# 4 MCN 1 Lecture (Midterm)

CARE OF MOTHER,CHILD, ADOLESCENT
(WELL CLIENTS)
OBDULIA M. ALMAREZ, RN, MAEd, MAN

CARE OF MOTHER,CHILD, ADOLESCENT
(WELL CLIENTS)
Nursing care of a Family during Labor and Delivery
Nursing Care of a Family During Labor and Delivery
THEORIES OF LABOR ONSET
• Uterine muscle stretching (Uterine Stretch
Theory)
• Pressure on the cervix (Mechanical Irritation
Theory)
• Oxytocin stimulation ( Oxytocin Theory)
• Change in ratio of estrogen and progesterone
( Progesterone Deprivation Theory)
• Placental age
• Rising fetal cortisol level
• Seasonal and time influences
• Prostaglandin Theory
Preliminary signs of labor/ PREMONITORY SIGNS OF LABOR
1.LIGHTENING
It refers to the descent of the uterus as a result of the sinking of the fetal
presenting part into the pelvic inlet which occurs 2-3 weeks before term
2. FALSE LABOR PAIN/ (Braxton Hick’s )
These are merely an exaggeration of the relatively painless, intermittent uterine
contractions they may begin as early as 3-4 weeks before the onset of true
labor
3. PASSAGE OF SHOW
It refers to the small amount of usually blood tinged cervical mucus plug
4. RIPENING OF THE CERVIX
It is the softening of the cervix that takes place in late pregnancy
Preliminary signs of labor/ PREMONITORY SIGNS OF LABOR
Signs of True Labor
• Uterine contractions
- the surest sign that labor has begun
- make the mother feel that it is not that frightening and degree
of discomfort can be controlled
• Show
- as cervix softens and ripens, operculum is expelled
• Rupture of membranes
- there may be sudden gush or slow seeping of fluid from vagina
- prolapsed of umbilical cord and intra uterine infection are
possible risks
COMPONENTS OF LABOR
COMPONENTS OF LABOR
A. Passageway
• - refers to the route a fetus must travel from the uterus through
the cervix and vagina to the external perineum
- for a fetus to pass through the pelvis, it must be of adequate size
• Two pelvic measurements to determine the adequacy of the pelvic
size:
1. diagonal conjugate( anterior-posterior diameter of the inlet)
2. transverse diameter of the outlet
- both are the narrowest diameter in the inlet and outlet
respectively
A. Passageway
A. Passageway
A. Passageway
B. PASSENGER
• - the passenger is the fetus
- the head of the fetus has the widest diameter
among all its body parts
• - fetal head can pass depending upon the
following:
1. bones
2. fontanelles
3. suture lines
B. PASSENGER
B. PASSENGER
MOLDING
–the change in the shape of the fetal
skull produced by the force of uterine
contractions pressing the vertex of
the head against the not yet dilated
cervix
- pressure causes them to overlap and

causes the head to become narrower
and longer
B. PASSENGER
ENGAGEMENT
- the settling of the presenting part of a fetus into the ischial
spine
- it means that the widest part of the fetus has passed through
the pelvis and pelvic inlet is proven adequate for birth
- degree of engagement is assessed by vaginal and cervical
examination
-FLOATING- presenting part that is not engaged
- DIPPING- presenting part that is descending but has not yet
reached the ischial spine
B. PASSENGER
B. PASSENGER
B. PASSENGER
B. PASSENGER
B. PASSENGER
FETAL POSITION
- the relationship of the presenting part to a specific quadrant of a
woman’s pelvis
- 4 quadrants of the maternal pelvis according to the right and
left
a. right anterior
b. left anterior
c. right posterior
d. left posterior
B. PASSENGER
Fetal parts that serve as landmarks to describe the relationship of
the presenting part to one of the pelvic quadrants:
1. OCCIPUT- in vertex position
2. CHIN- in face presentation
3. SACRUM- in breech presentation
4. SCAPULA- in shoulder presentation
- position is indicated by an abbreviation of three letters
1st letter-defines whether the landmark is pointing to the
mother’s right or left
B. PASSENGER
Middle letter denotes the fetal landmark
O-for occiput
M-for mentum or chin
Sa-for sacrum
A-for scapula or acromion process
Last letter defines whether the landmark points anteriorly (A), posteriorly
(P). Or transversely (T)
- Position influences the process and efficiency of labor
- ROA or LOA fastest delivery
- ROP or LOP , labor is extended
- Posterior positions are more painful for the mother because the rotation
of the fetal head puts pressure on the sacral nerves causing sharp, back pain
B. PASSENGER
B. PASSENGER
B. PASSENGER
STATION
- refers to the relationship of the presenting part of a fetus to
the level of the ischial spine
0 station- presenting part is at the level of the ischial spine (
engagement)
-Minus stations if the presenting part is above the ischial spine
- Plus Stations if the presenting part is below the level of the
ischial spine
-Crowning if the presenting part is at the perineum and can be
seen if the vulva is separated
B. PASSENGER
B. PASSENGER
When the widest diameter of the fetal head successfully negotiates through the narrowest part
of the maternal bony pelvis, the fetal head is considered to be ‘crowning’. This is clinically
evident when the head, visible at the vulva,
B. PASSENGER
FETAL LIE
- relationship between the
long(cephalocaudal) axis of the fetal
body and the long axis of a woman’s
body
1. Horizontal- or transverse lie
2. Vertical- or longitudinal lie
B. PASSENGER
Fetal attitude refers to the posture of a fetus during labor
B. PASSENGER
Mechanisms of Labor
It refers to the series of changes in the attitude and position of the fetus so
that it may successfully pass through the irregularly curved birth canal
Engagement
It is the descent of the biparietal plane of the fetal head to a level at or below
that of the pelvic brim or inlet
Descent
Refers to the downward movement of the fetus in the birth canal
Flexion
Refers to the movement where to chin is brought into more intimate contact
with the fetal thorax and the shorter suboccipito- bragmatic diameter
B. PASSENGER
Internal rotation
This movement refers to the turning of the fetal head along its vertical axis
Extension- The occiput slips beneath the suprapubic arch allowing the head to
extend.
External rotation/ restitution - the head externally rotate to face the right or
left medial thigh of the mother.
Expulsion
B. PASSENGER
Cardinal Movements of Labor Mnemonic: EDFIEEE
Every Darn Fetus Is Extremely Eager to Exit
E: Every = Engagement
D: Darn = Descent
F: Fetus = Flexion
I: Is = Internal rotation
E: Extremely = Extension
E: Eager to = External rotation
E: Exit = Expulsion
B. PASSENGER
B. PASSENGER
C. Powers
POWERS - force expelling the fetus and placenta
A. PRIMARY - involuntary uterine contractions
3 PHASES:
1. INCREMENT - steep crescent slope from beginning of a
contraction until its peak
2. ACME/PEAK - strongest intensity
3. DECREMENT - diminishing intensity
B. SECONDARY - voluntary bearing-down efforts
C. Powers
C. Powers
C. Powers
CHARACTERISTICS OF CONTRACTION
a. FREQUENCY - times frame in minute from the beginning of one contraction to the beginning
of the next one
* frequency of less than Every 2 min. should be reported
b. DURATION - time frame in second from the beginning of a contraction to its
completion
* more than 90s should be reported because of potential risk of uterine rupture or fetal
distress
c. INTENSITY - the strength of a contraction at acme; may be assessed by subjective
description from the woman, palpation
• mild contraction would feel like the tip of the nose
• moderate contraction like the chin
• strong contraction like the forehead
Or electronic intrauterine pressure catheter (IUPC)
C. Powers
C. Powers
C. Powers
EFFACEMENT- it is the shortening and thinning of the cervical canal
DILATATION- refers to the enlargement or widening of the cervical
canal from an opening a few milliliters wide to one large enough
(approximately 10 cm.) to permit passage of a fetus
C. Powers
D. Maternal posture and position
D. Maternal posture and position
E. PSYCHE
- refers to the pychological state or feelings that a woman brings
into labor
- for some it could be a feeling of apprehension and fright
- for many, it is a feeling of excitement or awe
- self esteem and a support person can help mothers through
labor
- pre natal information and health education as well as attending
pre natal classes for for labor will provide a lot of help
E. PSYCHE
Stages of Labor
FIRST STAGE
From the beginning of labor to the full opening (dilation) of
the cervix—to about 4 inches (10 centimeters
Initial (Latent) Phase
Contractions become progressively stronger and more
rhythmic
Discomfort is minimal
cervix thins and opens to about 1½ inches (4 cm)
this phase lasts an average of 12 hrs in a first pregnancy
and 5 hrs in subsequent pregnancies
FIRST STAGE
Active Phase
cervix opens from about 1½ inches (4 cm) to the full 4
inches (8 cm)
presenting part of the baby, usually the head, begins to
descend into the woman's pelvis
woman begins to feel the urge to push as the baby descends
this phase averages about 3 hrs in a first pregnancy and 2
hrs in subsequent pregnancies
FIRST STAGE
Transition
(8-10cm )
contraction may be every 1.5 to 2 min and last 60-90 sec
more than 3 hrs for nulliparas or 1 hr for multiparas
* may be accompanied by irritability and restlessness,
hyperventilation and dark heavy show as well as leg cramps,
nausea/vomiting, hiccups, belching
* possible fetal pressure creating a desire to pulse, should
discourage before full dilation because it may cause maternal
exhaustion and cervical and fetal trauma
FIRST STAGE
PHYSIOLOGICAL CHANGES DURING THE 1ST STAGE OF LABOR
• Contraction and retraction of the uterine muscle
• Formation of the upper and lower uterine segment
• Polarity
• Taking up of the cervix or cervical effacement
• Cervical dilatation
• Presence of show
• Formation of the bag of water
• Rupture of the membranes
CARE OF THE PATIENT DURING THE FIRST STAGE OF LABOR
1. Psychologic preparation of the patient
• Instill to the patient confidence and trust
2. Maternal and fetal assessment
• A. Get the history
• Uterine contraction
• Passage of show
• Status of the membrane
• Fetal movement
• Sleep, rest, food
2. Maternal and fetal assessment

A. Physical Examination
• Vital signs
• Fundic height
• B. Vaginal Examination
Purpose of Vaginal Examination:
• To know the degree of cervical effacement and dilatation
• To verify the correctness of presentation and position as
gained during abdominal palpation
• The determine the station of the presenting part
• To determine if the forewater is intact, leaking or
absent
• To evaluate the capacity of the bony pelvis in relation to
the size of the baby
MANAGEMENT DURING THE FIRST STAGE OF LABOR
1. Physical preparation of the patient
• Vulvar and perineal shaving and scrubbing
• Cleansing enema
• Bath or shower
2. Obstetric nursing care
• During early labor and in the presence of intact
membranes, the patient may be allowed or encouraged to
walk
• Let the patient relax and rest if she is tired
• Left lateral recumbent position is recommended to
prevent the supine hypotensive syndrome and to
facilitate kidney function
• During the early stage of labor, the patient is allowed to
take liquid diet like milk, soup or fruit juices
• The stomach should be empty preferably 4-6 hours
before the expected time of delivery to avoid vomiting
and aspiration
• Empty the bladder every 2

hours
• Give emotional support by giving
encouragement and coaching
about the proper way to relax
• In early labor, the parturient is
excited, talkative and
apprehensive
3. Comfort and Supportive/ Protective Measures

• Relief of backache or pain by rubbing back
• Relief of leg cramps by extending the leg, putting
pressure on the knee and dorsiflexing the foot
• Attention to the personal hygiene of the patient by
washing or wiping her face and hands, helping her fix her
hair and keeping her clothing clean
• Relief of dryness of mouth cause by medications or mouth

breathing by giving ice chips or moistening the lips with
vaseline or lubricant to prevent cracked lips
• Helping the patient to use breathing and relaxation
technique to ease pain during contractions
• BEARING DOWN DURING THE FIRST STAGE OF LABOR
SHOULD BE DISCOURAGED:
• monitor uterine contraction:

frequency, interval, intensity
• monitor fetal condition: fetal
position, FHT,
• monitor maternal condition
• assess the progress of labor
by vaginal examination
SIGNS THAT MAY REQUIRE THE SERVICES OF A DOCTOR/HOSPITAL
• Passage of meconium
or meconium stained
fluid in a vertex
presentation
• Prolapse of the cord
• Unusual bleeding per
vagina
SECOND STAGE OF LABOR
DELIVERY
• 1. NORMAL SPONTANEOUS VAGINAL DELIVERY
• a. the mother is encouraged not to push as the head
is delivered; the infant cries for 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
2. ASSISTED DELIVERY
A difficult stage for the fetus because of possible trauma or
asphyxia as it passed though the birth canal
a. FORCEPS-TWO DOUBLE-CURVED, SPOONLIKE ARTICULATED
BLADES USED TO EXTRACT THE FETAL HEAD; indicated if mother
cannot push fetus out or compromised maternal/fetal status in late
second stage; contraincated in cephalopelvic disproportion (CPD)
b. VACUUM EXTRACTOR - delivery with use of suction device
that is applied to the fetal scalp for traction; used in prolonged
second stages; contraindicated in CPD and face/breech presentation
MANAGEMENT OF THE 2ND STAGE OF LABOR
Preparation for delivery
• Setting up of the delivery table
• Preparation of the patient
1. transporting the patient to the delivery room
2. positioning the patient
* lithotomy position on the hospital delivery table
* patient lies either in the left or right side , buttocks
at the edge of the bed, and legs slightly flexed
• Preparation for delivery
perineal prep ( vulvar scrubbing, painting with antiseptic
solution)
Draping
• Preparation of the nurse

Scrubbing
sterile gowning
sterile gloving
• Preparation for delivery
Observation
• Continue observing the contraction, maternal condition,
fetal condition
• AMNIOTOMY can be done if the bag of water has not
ruptured spontaneously at this time, it is punctured
by means of an allis forcep or amniotomy hook during
contraction
General Care and Assistance
• Bladder should not be allowed to be distended, if unable
to void, she should be catheterized aseptically
• No solid or liquid food is given by mouth
• Relief of leg cramps by changing the position of the legs
or by a brief massage
• Teaching the patient the proper way to bear down (when
and how to bear down)
METHODS OR MANUEVER WHICH MAY BE EMPLOYED iN DELIVERING THE HEAD
Modified Ritgen’s Maneuver
This is a method of delivery of the head by lifting it upward
through the vulva between pain by pressing with the
fingertips of one hand over the perineum and with the
fingers of the other hand over the vertex or occiput
exerting gentle downward pressure over it
METHODS OR MANUEVER WHICH MAY BE EMPLOYED iN DELIVERING THE HEAD
Kristeller’s Manuever
This is a method of expelling the fetus or the fetal head
when it is already at the vulva and the bearing down power
is insufficient
With the abdomen sufficient relaxed the nurse grasps
the uterine fundus between the fingers behind the thumb
in front and applies pressure at the fundus along the axis
of the birth canal during the acme of the contraction
Lacerations of the birth canal
Classification:
1ST Degree Laceration
one which involves the vaginal
mucosa, the fourchette, the
perineal skin, but not the muscle
it is superficial and may require a
few stitches or none at all
bleeding is minimal
2nd Degree Laceration
one which involves in addition to
the vaginal mucosa and perineal
skin, the fascia, and muscles of
the perineal body but not the
rectum or anus
it requires repair similar to an
episiotomy
3rd Degree Laceration
also known as THE COMPLETE
TEAR
it extend completely thru the
vaginal mucosa , the perineal skin,
the muscles of the perineal body
and in addition the, involves the
anal sphincter
4th Degree Laceration
which refers to the complete
tears which extends through
the anterior rectal wall to
expose the cavity of the
rectum; it requires extensive
repair
LACERATIONS OF THE BIRTH CANAL
CAUSES:
Rapid and sudden expulsion of the fetal head
Persistent occiput posterior position
Excessive size of the infant
Difficult forcep deliveries
Pelvic outlet contraction forcing the head posteriorly
Exaggerated lithotomy position
Rigid perineum in primigravidas and in multiparas where scar tissue
from a previous laceration or episiotomy is present
requires extensive repair
MEANS OF LESSENING THE OCCURRENCE OF PERINEAL LACERATION
Obtaining the patient’s cooperation
regarding bearing down or pushing
Having control of the advancing head
Preventing active extension before
crowning
Delivery of the head between
contraction
Taking care in delivering the shoulder
and body
EPISIOTOMY - incision of the perineum designed to

substitute a clean surgical incision for a ragged tear
Purposes:
To spare the fetal head from prolonged pounding against
the perineum which may cause brain injury
To shorten the 2nd stage of labor
In mediolateral episiotomy, to reduce the likelihood of a
third degree laceration
THIRD STAGE
• From delivery of the baby
to delivery of the placenta.
This stage usually lasts
only a few minutes but may
last up to 30 minutes.
• If more than 30mins,
placenta is considered
retained
THIRD STAGE
separation of placenta from the uterine wall
evidenced by
• a change in the placenta; if more than to globular
shape as it becomes firm and rises in the abdomen
• a sudden gush/trickle of blood and
• lengthening of the umbilical cord.
THIRD STAGE
Recognition of signs of placental
separation
A. Calkins sign ( refers to the change in
the shape and consistency of the
uterus from a flattened, discoid body to
a firmer globular mass
the earliest sign of placental separation
and results from an emptied uterus
contracting better)
THIRD STAGE
B. Expulsion of the placenta through the vagina by
uterine contraction and pushing by mother or by
gentle traction on the umbilical cord
THIRD STAGE
C. Contraction of the uterus following delivery
controls uterine hemorrhage and produces placental
separation;
if necessary Pitocin (oxytocin) or Methergine
(methylergonovine maleate) may be administered to
help contract the uterus
THIRD STAGE
Mechanisms of Placental Expulsion
1. SHULTZE’S MECHANISM
The placenta appears like an inverted umbrella as it is forced out with the
smooth glistening fetal surface of the placenta coming out first
This is the more common type of placental expulsion
2. DUNCAN MECHANISM
It occurs when the placenta is attached to the lateral wall of the uterus
particularly if relatively low
Separation occurs first at the periphery with the result that blood collects
between the membranes and the uterine wall
Rough maternal surface appears first at the vulva
THIRD STAGE
THIRD STAGE
Methods of placental expulsion
Ask the patient to bear down
Modified Crede’s Method
with one hand at the fundus, palm either facing downward or behind
the uterus with the thumb anterior to the uterus
downward pressure along the axis of the birth canal is applied to
the contracted uterus using this as a piston or plunger while
simultaneously tracting on the cord with the other hand to bring out
easy delivery of the placenta
THIRD STAGE
THIRD STAGE
Brandt Andrews method
Tension is applied to the umbilical cord with the one hand
While on the other hand , palm facing either the umbilicus or
symphysis pubis is placed over the lower abdomen approximately
between the upper segment and the lower segment , and made to
push the uterus upward in order to displace the placenta from the
lower segment into the vagina)
Examine the membranes
Examine it for completeness
THIRD STAGE
CONDITIONS THAT MAY REQUIRE REFERRAL TO THE PHYSICIAN
Profuse bleeding before placental separation or expulsion
Profuse bleeding from vaginal or perineal laceration
Retention of the placenta for 30 minutes or more
Atony of the uterus
Retention of placental cotyledons or membrane
Multiple perineal or vaginal laceration
Inversion of the uterus
Increase in maternal pulse rate (120/minute or above)
Lowering of maternal blood pressure
(90/50 mmHg)
Difficulty of breathing
Convulsions
SPECIFIC CONDITIONS AND THEIR EFFECT ON LABOR
Parity
Age of the Mother
Interval between birth
Size of the Baby

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# 4 MCN 1 Lecture (Midterm)

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CARE OF MOTHER,CHILD, ADOLESCENT

OBDULIA M. ALMAREZ, RN, MAEd, MAN

- pressure causes them to overlap and

2. Maternal and fetal assessment

• Empty the bladder every 2

3. Comfort and Supportive/ Protective Measures

• Relief of dryness of mouth cause by medications or mouth

• monitor uterine contraction:

• Preparation of the nurse

EPISIOTOMY - incision of the perineum designed to

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