CARE OF MOTHER, CHILD, & ADOLESCENT LEC

SMU – SHANS
2nd YEAR NURSING
FIRST SEMESTER, 2nd TERM
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LABOR AND DELIVERY PROCESS

- As the placenta reaches the set age,
LABOR (CHILDBIRTH)
decreased blood supply leads to uterine
- A series of events by which the uterine contraction
contractions and abdominal pressure expel a
fetus and placenta from the uterus. PRELIMINARY SIGNS OF LABOR
NURSING DIAGNOSIS 1. INCREASE IN ENERGY
1. Pain related to labor contractions - Due to increase in epinephrine level
2. Anxiety related to process of labor and birth
3. Health- seeking behaviors related to 2. LIGHTENING (10-14 DAYS BEFORE LABOR
management of discomfort of labor ONSET FOR PRIMI)
4. Situational low self-esteem related to
- Effects of lightening:
inability to use planned childbirth
o feeling of relief
frequent urination
THEORIES OF LABOR ONSET o
o shooting pain in the leg
1. UTERINE SRETCH THEORY o increase amount of vaginal discharge

- Any hollow body organ when stretched to 3. BRAXTON HICK’S CONTRACTIONS

capacity will necessarily contract and empty.
- Painless, irregular contractions
2. OXYTOCIN THEORY
4. RIPENING OF THE CERVIX
- Labor stimulates the hypophysis to produce
- From Goodell’s sign the cervix becomes
oxytocin from the PPG (posterior pituitary
“butter-soft”
gland) which will cause uterine contraction.
5. SLIGHT LOSS OF WEIGHT
3. PROGESTERONE DEPRIVATION THEORY
- Due to fall of progesterone
- Decreased amount will lead to uterine
contraction.
SIGNS OF TRUE LABOR
4. PROSTAGLANDIN THEORY 1. UTERINE CONTRACTIONS
- Release of arachidonic acid produced by
- Productive uterine contraction
steroid action on lipid precursors increase
o Regular, interval, intensity, &
prostaglandin synthesis which in turn causes
duration
uterine contraction.
o It should be increasing
5. THEORY OF THE AGING PLACENTA 2. SHOW
- As cervix softens and ripens, mucus plug is
expelled

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CARE OF MOTHER, CHILD, ADOLESCENT LECTURE KRISTINE BALER
CARE OF MOTHER, CHILD, & ADOLESCENT LEC
SMU – SHANS
2nd YEAR NURSING
FIRST SEMESTER, 2nd TERM
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o Brownish to pinking o the anteroposterior diameter in the

o At first, brown then pinkish to inlet
reddish o The narrowest diameter in the pelvic
inlet
3. RUPTURE OF MEMBRANES o 10.5-11cm
- Sudden gush or scanty seeping of clear fluid b. Transverse diameter
from the vagina. o The narrowest at the pelvic outlet

DIFFERENCES BETWEEN FALSE AND

TRUE LABOR PAINS
FALSE TRUE
CONTRACTIONS CONTRACTIONS
Remain irregular May be irregular at
first but become
regular and predictable
in a matter of hours
Generally confined in Start at the back and
the abdomen sweep around the
abdomen in a girdle like
fashion
No increase in duration, Increase in duration,
frequency, an intensity intensity, and
frequency
Often disappears if the Continue no matter
woman ambulates what the woman’s type
of activity
No cervical change Accompanied by
False pelvis
cervical effacement
and dilatation - supports the uterus during pregnancy and
Effacement directs the fetus towards the true pelvis
- measure in
percentage True pelvis
dilatation
- a bony canal through which the fetus must
- measure in
diameter pass during birth

COMPONENTS OF LABOR
1. THE PASSAGE
- refers to the route the fetus must travel
from the uterus to the external perineum

2 important Pelvic Measurements:

a. Diagonal Conjugate/conjugate vera

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CARE OF MOTHER, CHILD, ADOLESCENT LECTURE KRISTINE BALER
CARE OF MOTHER, CHILD, & ADOLESCENT LEC
SMU – SHANS
2nd YEAR NURSING
FIRST SEMESTER, 2nd TERM
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2. THE PASSENGER - Referred to as the bregma (diamond in

shape)
- Fetus - Lies at the junction of the coronal and
- The head has the widest diameter sagittal sutures
STRUCTURE OF THE FETAL SKULL - Closes between 12-18 months

Four superior bones B. Posterior Fontanelle

A. FRONTAL - Lies at the junction of the lambdoidal suture

and sagittal suture (triangle shape)
- The area over the frontal bone is referred - Closes between 2-3 months
to as the SINCIPUT
Note:
B. 2 PARIETAL The space in between is called the VERTEX

C. OCCIPITAL

- The area over the occipital bone is referred

to as the OCCIPUT

D. OTHER BONES:

- Sphenoid, ethmoid, temporal

The bones of the skull meet at suture lines

A. SAGITTAL SUTURE

- A membranous interspace, joins the parietal DIAMETER OF THE FETAL SKULL

bones
- The fetal skull causes it to be wider in its
B. CORONAL SUTURE anteroposterior diameter than in its
transverse diameter
- Line of the junction of the frontal bones and
- To fit through the inlet of the birth canal,
the two parietal bones
the fetus must present the smallest
C. LAMBDOID SUTURE diameter (transverse diameter) of the head
to the smaller diameter of the maternal
- Line of junction of the occipital bone and the
pelvis (diagonal conjugate)
parietal bones
TRANSVERSE DIAMETER
Note:
Suture lines and the fontanelles allow molding of i. Biparietal = 9.25 cm
the fetal head - smallest diameter

ANTEROPOSTERIOR DIAMETER
FONTANELLES
i. Suboccipitobregmatic
- membrane- covered spaces - from below the occiput to the anterior
A. Anterior Fontanelle fontanelle
- = 9.5 cm.; the narrowest AP diameter

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CARE OF MOTHER, CHILD, ADOLESCENT LECTURE KRISTINE BALER
CARE OF MOTHER, CHILD, & ADOLESCENT LEC
SMU – SHANS
2nd YEAR NURSING
FIRST SEMESTER, 2nd TERM
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ii. Occipitofrontal a. Complete flexion (Vertex presentation)

- From the occiput to the mid- frontal bone
- Very good attitude
- = 12 cm
- The spinal column is bowed forward, head is
iii. Occipitomental
flex forward and the chin touches the
- from the occiput to the chin
sternum
- = 13.5 cm.; widest AP diameter
- Normal or usual fetal position

b. Moderate flexion (Sinciput presentation/ Military

attitude)

- The chin is not touching the chest but in an

alert or military position
- Does not interfere with labor

c. Partial extension (Brow presentation)

- Brow present at the birth canal

d. Poor flexion (Face Presentation)

- The occipitomental diameter is the one

Molding presented at the birth canal (widest
- the change in the shape of the fetal skull diameter)
produced by the force of uterine
contractions pressing the vertex against the
not-yet dilated cervix.

FETAL LIE

- Relationship of the maternal long axis to the

fetal long axis

A. Longitudinal Lie – vertical position

- Cephalic (face, vertex, brow, mentum)

o Head is presenting part; usually
FETAL PRESENTATION AND POSITION
vertex (Occiput) which is the most
FETAL ATTITUDE favorable for birth. Head is flexed
with chin or chest.
- relationship of the fetal parts to one another
o Face
- degree of flexion of the fetal head

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CARE OF MOTHER, CHILD, ADOLESCENT LECTURE KRISTINE BALER
CARE OF MOTHER, CHILD, & ADOLESCENT LEC
SMU – SHANS
2nd YEAR NURSING
FIRST SEMESTER, 2nd TERM
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▪ When the head is completely B. TRANSVERSE LIE

extended, will. distend the
- Horizontal
vaginal orifice the rs are the
- The presenting part may be the shoulder,
SOB- 9.5 cm, BT- 8.2 cm, the
scapula and arms
SMV diameter 11.5 cm
o Vertex
▪ When the head is well flexed,
the suboccipitobregmatic
diameter and the biparietal
diameter present. When the
head is not flexed but erect,
the presenting diameters are
occipitofrontal, and the
biparietal (95%)
o Brow
▪ When the head is partially FETAL POSITION
extended, the mento vertical
- The relationship of the presenting part to a
diameter, 13.5 cm and the
specific quadrant of the of a woman pelvis.
bitemporal diameter, 8.2 cm.
If this presentation persists, i. Maternal quadrant
vaginal delivery is extremely
- L anterior
unlikely
- R anterior
- Breech (complete, frank, footling)
- L posterior
o Buttocks or lower extremities
- R posterior
present first
o Complete ii. Reference point
▪ Things and legs flexed,
buttocks and feet (Baby is - Occiput (O)
squatting position) - Mentum (M)
o Frank - Sacrum (S)
▪ Thighs flexed, legs extended
on anterior body surface,
buttocks presenting
o Footling
▪ One or both feet are
presenting

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CARE OF MOTHER, CHILD, ADOLESCENT LECTURE KRISTINE BALER
CARE OF MOTHER, CHILD, & ADOLESCENT LEC
SMU – SHANS
2nd YEAR NURSING
FIRST SEMESTER, 2nd TERM
_____________________________________________________________________________________________________________________________

Most common positions are: Notes:

1. LOA (Left Occiput Anterior)

Anterior – Nakahara sa spine
- Fetal occiput is on maternal left side and Posterior – nakatalikod sa spine
toward front, face is down- This is favorable
Breech – automatic reference point is sacrum
delivery position.
Cephalic – reference point is either occiput or
2. ROA (Right Occiput Anterior) mentum

- Fetal Occiput on maternal right side toward Occiput – head ang mauuna
front, face is down- This is favorable Mentum – chin ang mauuna
delivery position
Anterior – examiner can see the reference point
3. LOP (Left Occiput Posterior)
Posterior – examiner cannot see the reference
- Fetal occiput is on the maternal side and point
toward back, face is up Transverse – examiner can neither see the
reference point
- Mother experiences much back discomfort
during labor; Labor may be slowed; Rotation
ENGAGEMENT
usually occurs before labor to anterior
position or health care provider may operate - Refers to the settling of the presenting part
at the time of delivery. of the fetus into the pelvis

4. ROP (Right Occiput Posterior) Descent

- Fetal occiput is on maternal side and toward - The widest part of the fetus has pass
back, face is up. Presents problem similar to through the pelvis or pelvic inlet
LOP
Station

- Relationship of the presenting part to the

level of the ischial spine

Description:

Station 0 - synonymous engaged

- the presenting fetal part is at the level of

ischial spine

The presenting fetal part is above the level ischial

spine

- describe as minus station (-1 to -4)

The presenting fetal part is below level of ischial

spine

- describe as plus station (+1 to +4)

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CARE OF MOTHER, CHILD, ADOLESCENT LECTURE KRISTINE BALER
CARE OF MOTHER, CHILD, & ADOLESCENT LEC
SMU – SHANS
2nd YEAR NURSING
FIRST SEMESTER, 2nd TERM
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+3 to + 4 “Crowning”- presenting part is at the - Once the shoulder is born, the rest of the
perineum body is born easily because of its smaller size

- Note: (+) 4 = crowning

MECHANISM (CARDINAL MOVEMENTS OF 3. POWERS OF LABOR

LABOR) DFIREERE
- The force supplied by the fundus of the
DESCENT uterus and implemented by uterine
contractions.
- The downward movement of the Biparietal
diameter of the fetal head within the pelvic UTERINE CONTRACTIONS
inlet
- Begin at a “pacemaker” point located in the
FLEXION myometrium near one of the utero tubal
junctions
- As descent occurs, pressure from the pelvic
o Myometrium consists of uterine
floor causes the fetal head to bend forward
smooth muscle cells. Its main
onto the chest
function is to induce uterine
INTERNAL ROTATION contractions.
- Pain occurs from:
- The occiput rotates so the head is brought
o contraction of the uterine muscles
into the best relationship to the outlet of
when in an ischemic state
the pelvis
o pressure on nerve ganglia in the
EXTENSION cervix and lower uterine segment
o stretching of ligaments adjacent to
- As the occiput is born, the back of the neck
the uterus and in the pelvic joints-
stops beneath the pubic arch. The head
stretching and displacement of the
extends, and the foremost parts of the head,
tissue of the vulva and perineum
the face and the chin are born
Phases of uterine contraction
EXTERNAL ROTATION
Increment
- Immediately after the head is born, the head
rotates back to the diagonal or transverse - The first phase; also known as crescendo
position
Acme
EXPULSION
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CARE OF MOTHER, CHILD, ADOLESCENT LECTURE KRISTINE BALER
CARE OF MOTHER, CHILD, & ADOLESCENT LEC
SMU – SHANS
2nd YEAR NURSING
FIRST SEMESTER, 2nd TERM
_____________________________________________________________________________________________________________________________

- The height of uterine contraction (apex)

- Most painful part

Decrement

- Last phase, intensity decreases

(decrescendo)

4. PSYCHE
- refers to the psychological state of the
mother during labor and delivery
- Note:
o If the mother has a positive outlook
towards labor and delivery it would
Uterine contractions
really have a good effect unlike if the
Duration mother considers labor and delivery
as a stress and pain.
- Start to end of one uterine contraction

Interval
DANGER SIGNS
- MATERNAL:
Frequency 1. HIGH BP
- From the start of one uterine contraction to - Above 40/90 mmHg
the beginning of the next contraction - Systolic of above 30 mmHg
- Diastolic of above 15 mmHg
Intensity
* Decrease in BP indicates intrauterine hemorrhage
- Mild, moderate, or severe

CERVICAL CHANGES 2. ABNORMAL PULSE

Effacement
- Shortening and thinning of the cervical canal
it is expressed in percentage
Dilatation
- Widening of the external cervical os to 10
cm. As a result of uterine contractions and
pressure of the presenting part and the bow
- Above 100 beats per minute may indicate
hemorrhage
3. INADEQUATE PROLONG CONTRACTIONS
- Contractions lasting longer than 70 sec which
may interfere uterine artery filling
4. ABNORMAL ABDOMINAL CONTOUR
- May indicate pathologic retraction ring,
breech presentation etc.…

5. INCREASE APPREHENSION
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CARE OF MOTHER, CHILD, ADOLESCENT LECTURE KRISTINE BALER
CARE OF MOTHER, CHILD, & ADOLESCENT LEC
SMU – SHANS
2nd YEAR NURSING
FIRST SEMESTER, 2nd TERM
_____________________________________________________________________________________________________________________________

FETAL DANGER SIGNS 1. Overall appearance

2. Presence of lesion
1. High and low fetal heart rate- fetal distress 3. Palpate lymph node
2. Meconium staining 4. Inspect conjunctiva
3. Hyperactivity 5. Inspect for dental carries, inner lip
4. Low O2 saturation 6. Auscultate the lungs
7. Assess heart sound
THE STAGES OF LABOR 8. Palpate breast

1. FIRST STAGE (STAGE OF DILATATION) Abdominal and lower leg assessment:

- Begins with true labor pains and ends with a) Fundic height
complete cervical dilatation, takes about 12 b) Palpate and percuss the bladder
hrs. to complete. c) Auscultate the lungs
d) Determine fetal position, presentation and
Immediate assessment:
lie
a) EDC e) Do the Leopold’s maneuver
b) Time of contraction started f) Vaginal examination
c) Amount and characteristic of show g) Sonography
d) Rupture of membrane has occurred h) Assess rupture of membrane
e) Drug allergies
Assess pelvic adequacy
f) Use of drugs
g) History of past and pregnancy if prenatal Assess vital sign
record is not available
h) Birth plan - Temperature

i) Assess the following: V/S, nature of o Taken every 4 hrs.

contraction, her rating of pain on a 10-poit o Report temperature greater than
scale, urine specimen and the position and 37.2
presentation of the fetus - Pulse rate
o 70 to 80 bpm
Detailed assessment: - RR
o 18 to 20
a. History
- BP
1. Current pregnancy history (gravida, para, o Rise of 5-15mm during contraction
chief complain, plan of labor and childcare)
Laboratory Analysis
2. Past pregnancy (previous surgery, abortion,
type of complication and outcome, sex and - Blood
weight of previous children o HGB. HCT, VDRL, and HIV test
3. Past health history (previous surgery, heart o Urine
disease, DM, anemia, TB, STD and determine
the lifestyle of a woman Assessment of Uterine Contraction

4. Family Hx (hereditary diseases) a. Duration

b. Physical exam o Starts from the moment the uterus
first tenses until it has relaxed

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CARE OF MOTHER, CHILD, ADOLESCENT LECTURE KRISTINE BALER
CARE OF MOTHER, CHILD, & ADOLESCENT LEC
SMU – SHANS
2nd YEAR NURSING
FIRST SEMESTER, 2nd TERM
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b. Frequency
o Timed from the beginning of one
contraction to the beginning of the
next
c. Interval
o It is timed from the end of
contraction to the beginning of the
next contraction
d. Intensity (mild, moderate and strong)

Initial fetal assessment

A. Auscultation of fetal heart rate b. Late deceleration

o The onset and recovery of the
- q30 min (latent phase) deceleration occurs after the
- q15 min (active phase) beginning, peak and ending of the
- q5 min (second stage of labor) contraction
B. Fetal heart rate parameters o Suggest uteroplacental insufficiency
or decrease of blood flow through
Periodic changes the intervillous spaces of the uterus
- Changes in FHT due to contraction and fetal during uterine contraction
movement * Position the mother in a side lying position
- Describe in terms of acceleration and
deceleration

Acceleration

- Temporary normal increase FHT or cause by

fetal movement, change in fetal position and
administration of analgesic

Deceleration

- Usually apparent, usually symmetrical

periodic decrease in FHT resulting from c. Prolonged deceleration
pressure on the fetal head during o Deceleration that are decrease from
contractions the FHR baseline of 15bpm or more
and last longer than 2-3 times but
a. Early decelerations less than 10 mins
o Waveform of the FHR change is the o May indicate cord compression or
inverse of the contraction waveform maternal hypotension
or the lowest point of the
deceleration occurs with the peak of
contraction.

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CARE OF MOTHER, CHILD, ADOLESCENT LECTURE KRISTINE BALER
CARE OF MOTHER, CHILD, & ADOLESCENT LEC
SMU – SHANS
2nd YEAR NURSING
FIRST SEMESTER, 2nd TERM
_____________________________________________________________________________________________________________________________

2. Active
o Cervical dilatation reaches 4-7 cm.
o Duration of contraction is 40-60
seconds every 3-5 min.
o Irritable
o Bow may also rupture
o Encourage the mother to participate
by keeping active and assuming
whatever comfortable position she
wants

Variable deceleration
3. Transition
- Refers that occur at unpredictable times in o Mood: suddenly changes and the
relation to contraction contractions intensify
- Indicates compression of the cord o The maximum cervical dilatation is 8-
- Occurs after the rupture of membrane 10cm.
o Contraction occurs every 2-3 minutes
and lasts for 60-70 sec
o Profuse perspiration and distention
of neck veins are seen
o May experience nausea and vomiting
o May also experience feeling of loss
of control, panic, anxiety and
irritability
o There is irresistible urge to push

Interventions during the first stage

3 PHASES 1. Help empower women

2. Respect contraction time
1. Latent
3. Promote change in position
o Begins at the onset of regularly
4. Promote voiding and bladder care
perceived uterine contractions and
5. Respect and promote the support person
ends when rapid cervical dilatation
6. Support a woman’s pain management needs
occurs
o Cervix dilates at 0-3 cm only
o Contraction is mild and short lasting
20-40 sec 2. SECOND STAGE OF LABOR (STAGE OF
o There is feeling of excitement with EXPULSION)
some feeling of apprehension but still
- Starts from the full dilatation and
with ability to communicate
effacement of the cervix to the delivery of
o The woman is advised to continue
the infant
walking
- There is uncontrollable urge to push or bear
down

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CARE OF MOTHER, CHILD, ADOLESCENT LECTURE KRISTINE BALER
CARE OF MOTHER, CHILD, & ADOLESCENT LEC
SMU – SHANS
2nd YEAR NURSING
FIRST SEMESTER, 2nd TERM
_____________________________________________________________________________________________________________________________

- There is momentary nausea and vomiting - Show the baby to the mother, inform her of
- Anus may become everted the sex time of delivery. Put name tags
before giving to the circulating nurse.
Care of a woman during the second stage of labor

1. Preparing the place of birth

2. Positioning for birth
3. Promoting effective second stage of
pushing
4. Perineal cleaning and massage

Episiotomy

- A surgical incision of the perineum that is

made both to prevent tearing of the
perineum and to release pressure on the
fetal head with birth.
- Types:
o Midline
o Mediolateral

* At birth the following should be observed

Ritgen’s Maneuver

- The rectum is press forward in the fetal chin

and the other hand presses downward on the
occiput
- No pressure should be applied on the fundus
- Cutting and clamping of the cord
o Clamp until pulsation stop
o Count blood vessels (AVA)
- Dry the infant (place the bonnet) -
HYPOTHERMIA
- Infant remain in the abdomen for skin-to-
skin contact
3. THIRD STAGE (PLACENTAL STAGE)
- Eye prophylactic is delayed to facilitate eye - Begins with the delivery of the baby to the
to eye contact delivery of the placenta
- Breastfeeding is initiated - Perform Crede’s maneuver
o Exerting gentle pressure on the
contracted uterine fundus

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CARE OF MOTHER, CHILD, ADOLESCENT LECTURE KRISTINE BALER
CARE OF MOTHER, CHILD, & ADOLESCENT LEC
SMU – SHANS
2nd YEAR NURSING
FIRST SEMESTER, 2nd TERM
_____________________________________________________________________________________________________________________________

2 Phases - It includes the first few after birth

1. Placental separation Nursing Intervention

Signs of placental separation - Monitor V/S every 30 mins

- Monitor the uterus
- Calkin’s Sign
- Sudden gush of blood
- Lengthening of the cord

Types of Placental Delivery

a. Schultz Presentation (fetal side)

- Shiny/ separate first at the center/ 80%

b. Duncan Presentation (Maternal side)

- Rough/dirty- separate first at the edges

2. Placental expulsion

- Placenta is delivered either by natural

bearing
- Down effort of the mother or by Crede’s
maneuver
- Placenta should be delivered up to 30 mins
- Inspect the placenta for the abnormalities
and cotyledons
- Massage uterus to facilitate uterine
contraction
- Inspect perineum
- V/s q 15 mins. For the first hour
- Chills and sensation may be experienced by
the mother (provide blanket)

4. FOURTH STAGE
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CARE OF MOTHER, CHILD, ADOLESCENT LECTURE KRISTINE BALER