NCM 107 MODULE 3F - Measure the FHR immediately after the rupture of
INTRANATAL CARE membrane to determine presence of cord prolapse and
ACME
- Phase of contraction when the contraction is at its
strongest
DECREMENT
- Phase of contraction when the contraction intensity
decreases
INCREMENT
- Phase of contraction in which it increases
DURATION
- Length of contraction
- Time start of contraction until end = duration
FREQUENCY
- Refers to how close together the contractions are
- From beginning of one contraction to the beginning of
the next
- Time of the second contraction minus time of the first
contraction
INTENSITY
- Strength of the contraction
LABOR
- Series of events by which uterine contractions and
abdominal pressure expel a fetus and placenta from
the uterus
- Normally begins within 37-42 weeks of pregnancy
- PRIMIPARA: 14-16 hours (first time mothers/ delivered
once)
- MULTIPARA: 6-8 hours (delivered multiple times)
TRIAL LABOR
- Attempt labor to determine whether labor will progress
normally
- Assess woman who underwent cesarean if it is possible
to deliver through normal vaginal delivery in the
present pregnancy;
- Done if the woman has borderline or adequate inlet
measurement and the fetal lie and position are good
Successful trial labor
- when the pregnancy terminates in the vaginal delivery
without causing a scar or rupture when the live fetus is
born
Fail trial labor
- Designated when vaginal delivery is arrested or scar
ruptures and emergency cesarean section is required
AMNIOTOMY
- Artificial rupture of membrane during labor
- Done if amniotic sac does not ruptures spontaneously
performed to allow fetal head to contact cervix more
directly which will possibly increase the efficiency of
contractions or therefore increases the speed of labor
- Can be performed using AMNIHOOK or HEMOSTAT/
kelly straight
- Important to perform only if fetal head is well applied
to the cervix
compression because it may cause deceleration or
decrease fetal heart rate of the baby
disadvantages
- Puts the fetus at risk for cord prolapse if a loop of cord
escapes to the vagina with a lot of fluid
INDUCTION OF LABOR
- Labor started artificially
- Labor not started yet
- Induction may initiate labor before spontaneous
occurrence
- Done through mechanically opening cervix through
amniotomy or use medication to start contractions like
oxytocin or pitocin
AUGMENTATION OF LABOR
- Assisting labor that has spontaneously started but is
not effective
- Uses oxytocin or amniotomy to strengthen labor
contractions
- Labor started already however contractions are
hypotonic or too weak or infrequent to be effective
that is why to make the contraction effective like
administration of medication such as oxytocin to
enhance uterine contraction
DYSFUNCTIONAL LABOR
- Sluggishness of contractions or the force of labor is
less than usual
- Augmentation of labor is less than usual
DYSTOCIA
- Difficult labor
- Ex: shoulder dystocia; wide fetal shoulders cannot pass
through the outlet of the pelvis
EPISIOTOMY
- Surgical incision made at the opening of the vagina
during childbirth to aid a difficult delivery and prevent
rupture of tissues
- Median and mediolateral
EUTOCIA
- Normal childbirth, characterized by uterine contractions
that result in progressive cervical dilatation and fetal
descent
THEORIES OF LABOR
● The uterine muscle stretches from the increasing size
of the fetus, which results in release of prostaglandins.
● The fetus presses on the cervix, which stimulates the
release of oxytocin from the posterior pituitary
● Oxytocin stimulation works together with
prostaglandins to initiate contractions
● Changes in the ratio of estrogen to progesterone
occurs, increasing estrogen in relation to progesterone,
which is interpreted as progesterone withdrawal
● The placenta reaches a set age, which triggers
contractions
● Rising fetal cortisol levels reduce progesterone
formation and increase prostaglandin formation
● Fetal membrane begins to produce prostaglandins,
which stimulates contractions
TRUE LABOR FALSE LABOR
PRELIMINARY/PREMONITORY SIGNS OF LABOR
● Lightening Begin irregularly but Begin and remain
● Increase in energy become regular and irregular
● Slight loss of weight predictable
● Backache
● Braxton Hicks contractions Felt first in the lower Felt first abdominally
● Ripening of the cervix back and sweep around and remain confined to
to the abdomen in the abdomen and groin
1. LIGHTENING wave
- Descend of the fetal presenting part to the
pelvis Continue no matter Often disappear with
- Occurs approximately 10-14 days before labor what the woman’s level ambulation or sleep
begins of activity
- Ishial spine, level 0
- Fetal descend changes the woman's Increases in duration, DO NOT increase in
abdominal contour and gives the woman relief frequency and intensity duration, frequency or
from diaphragmatic pressure and shortness of intensity
breath
- Woman may experience shooting leg pain Achieve cervical dilation DO NOT achieve
from the increases pressure on the sciatic cervical dilation
nerve, increase amount of vaginal discharge
and urinary frequency
COMPONENTS OF LABOR
2. INCREASE IN ENERGY 1. Passage - the woman's pelvis
- Woman may experience high energy the 2. Passenger - the fetus
morning of labor than chronic fatigue she felt 3. Powers of Labor - uterine factors (contractions)
from the previous months 4. Psyche - Woman’s psychological state
- Decreased progesterone production by the
placenta that boost of epinephrine release PASSAGE
that caused increased energy - Refers to the route a fetus must travel from the
uterus through the cervix and vagina to the
3. SLIGHT LOSS OF WEIGHT external perineum.
- Progesterone level falls then - In most instances, if a disproportion between the
- Bodily fluid is more easily excreted (increase fetus and pelvis occurs, the pelvis is a structure at
in urine production) then fault. If the fetus is the cause of the disproportion
- Weight loss to 1-3lbs it is often not because of the fetal head is too
large but because it is presenting to the birth
4. BACKACHE canal at less than its narrowest diameter.
- Labor contractions begins at the back
PASSENGER
5. BRAXTON HICK’S CONTRACTIONS - Refers to the fetus
- False labor uterine contractions - The head of the fetus is the body which has the
- Last week or days, woman may experience widest diameter
strong braxton hick’s contractions - Fontanelle spaces compress during birth to aid in
- Assure woman that misinterpreting labor molding of the fetal head
signals is common especially for first time
mothers Molding
- If contractions are strong enough to be - refers to the overlapping of skull bones along the
mistaken as true labor, true labor is not far suture line
away - This causes a change in the shape of the fetal skull
that facilitates passage through the rigid pelvis
6. RIPENING OF THE CERVIX - Nursing intervention: Assure the parents that it
- Internal sign seen only in pelvic examination will only last a day or two, and it will not be a
- Throughout pregnancy cervix feels softer than permanent condition.
usual through palpation similar consistency Take note: No skull molding happens when a fetus is in
with an earlobe/ GOODELL'S SIGN breech presentation.
- At term, the cervix becomes softer (butter
soft) Other factors that play a part in whether a fetus is
- Internal announcement that labor is very properly aligned to the pelvis and is in the best
close at hand position to be born:
 · Fetal attitude
· Fetal lie
· Fetal presentation
· Fetal position
Fetal attitude
- Attitude describes the degree of flexion a fetus
assumes during labor or the relation of the fetal
parts to each other
1. Good attitude (Complete flexion)
2. Moderate flexion
3. Poor flexion
4. Full extension
1. Good attitude (Complete flexion) / full flexion
- Spinal column is bowed forward that the head is
flexed forward
- The chin touches the sternum
- The arms are flexed and folded on the chest
- The thighs are flexed on to the abdomen
- The Calves are pressed against the posterior aspect
of the thighs
> Advantageous for birth
- Helps the fetus present the smallest
anteroposterior diameter of the skull to the pelvis and
also because it puts the whole body into an ovoid
shape, occupying the smallest space possible.
- Ideal
2. Moderate flexion
- The chin is not touching the chest but is in an alert or
military position
- This does not usually interfere with labor, however because
later mechanisms of Labor specifically descend and
flexion, will force the fetal head to fully flex.
Partial extension: Brow is presented in the birth canal
Complete extension: The back is arched, and neck is
extended, presenting the occipital mental diameter of the
head to the birth canal - which means the face is presented
to the birth canal
Fetal lie
- The relationship between the long axis of the fetal
body and the long axis of the woman's body.
- This depicts whether the fetus is in:
1. Horizontal position (transverse) shoulder
2. Vertical position (longitudinal)
2.1 Cephalic
2.2 Breech
Fetal Presentation
- Denotes the body part that will first contact the
cervix or which one will be born first.
- This is determined by the combination of fetal lie
and degree of fetal flexion (attitude)
1. Cephalic Presentation (Vertex, brow,
face, mentum, head)
2. Breech Presentation (Buttocks or feet)
3. Shoulder Presentation (one of the
shoulder, iliac crest, a hand or an elbow)
MENTUM:RO
Cephalic presentation
- Vertex, brow, face, mentum, head)
- The most frequent type of presentation and it
is the
- The area of the skull that contacts the cervix
often becomes edematous. This will result to
caput succedaneum - cone shaped head of
the baby
Vertex presentation
- Ideal presenting part because the skull bones
are capable of effectively molding to
accommodate the cervix.
Breech Presentation
- Buttocks or feet)
- Can cause a difficult type of birth
- Has three types of breech presentation:
1. Frank Breech
- Baby's legs are folded flat up against
his head and his bottom is closest to
the birth canal.
2. Complete breech
- Both of the baby's knees are bent
and his feet and bottom are closest
to the birth canal
3. Footling breech
- One or both feet are the presenting
parts during delivery
Shoulder Presentation
- One of the shoulder, iliac crest, a hand or an
elbow
- Fetus lies horizontally in the pelvis
- The contour of the mother’s abdomen at term
may appear fuller side to side, rather than top to
bottom
Fetal Position
- Relationship of the presenting part to a specific
quadrant and side of a woman’s pelvis
· LOA- Left Occipitoanterior (Most
common fetal position)
· ROA- Right Occipitoanterior (2nd Most
frequent fetal position)
- Important because it can influence both the
process and efficiency of labor.
- Fetus is born fastest in ROA or LOA position
- Labor can extended if position is posterior
(LOP, ROP) and may be more painful for a
woman because the rotation of the fetal head
puts pressure on sacral nerves.
- Intervention: Place woman in Sims position on
the same side of the fetal spine or use hands and
knees position (to encourage rotation from
occipitoposterior to occipitoanterior).
Engagement
 - Refers to the settling of the presenting part of the
fetus far enough into the pelvis that it rests at the
level of the ischial spines, midpoint of the pelvis
- In Primipara, nonengagement of the fetal
head at the beginning of labor suggests that a
possible complication such as an abnormal
presentation or position, abnormality of the fetal
head or cephalopelvic disproportion exists
- In multipara, engagement may or may not be
present at the beginning of Labor. Still considered
normal. If the presenting part is not yet engaged
at the beginning of Labor, it is still considered as
normal.
- The degree of engagement is established by
vaginal and cervical examination
During documentation:
Ø Engaged - when the presenting part already
rests at the level of the ischial spine.
Ø Floating - when the presenting part is not
engaged
Ø Dipping - when the presenting part is
descending but has not yet reached the
ischial spines
Station
-One of the things that you will really look into when you are
in the clinical area
- Anticipating for the delivery of the child and also when you
make your requirements for Friedman’s curve.
- Refers to the relationship of the presenting part of the fetus
to the level of the ischial spine
- When the presenting part is at the level of the ischial spine,
it is at 0 station (synonymous with engagement)
- Minus stations/ negative stations – presenting part is above
the ischial spine (negative 1- 4)
- Plus stations – presenting part is below the ischial spine
+ 3 and +4 – The presenting part is at the perineum
2. Passenger
Station- refers to the relationship of the presenting
part of the fetus to the level of ischial spines
- when the presenting part is at the level of the ischial
spine, it is at the 0 station
(synonymous with engagement)
-presenting part is above the ischial spine the distance
is measured and described as minus stations or
negative ones, ranges from -1 to -4
-if presenting part is below the ischial spines the
distance is stated as plus stations, ranges from +1 to
+4
→ if +3 and +4, the presenting part is at the
perineum and can be seen if the vulva is separated
Mechanism (Cardinal Movements) of
Labor
a. DESCENT
i. Downward movement of biparietal diameter of the fetal head
within the pelvic inlet
b. FLEXION
i. Head bends forward onto the chest (to present the smallest
anteroposterior diameter at the birth canal)
c. INTERNAL ROTATION
I. The occiput rotated on the head is bright into the best
relationship to the outlet of the pelvis. To make sure the
shoulder is in optimal position
d. EXTENSION
i. The head extends and the foremost parts of the head, the
face and the chin are born
e. EXTERNAL ROTATION
i. Almost immediately after the head of the infant is born, the
head rotates a final time back to the diagonal or transverse
position of the early part of labor
ii. The anterior shoulder is born first
f. EXPULSION
i. Once the shoulders are born, the rest of the baby is born
easily and smoothly because of its smaller size
ii. It is the end of the pelvic division of labor
3. Powers of Labor
-force applied by the fundus of the uterus and implemented by
uterine contractions
→Causes cervical dilation → expulsion of the fetus
from the uterus
-Secondary power source: The abdominal muscles
-do not burden muscles to push unless the cervix is fully dilated,
doing so impedes the primary force and could cause fetal and
cervical damage
3 Phases of contraction
1. Increment - intensity of the contraction increases
2. Acme - contraction is at its strongest
3. Decrement - intensity decreases
- As labor contraction progresses and become regular and
strong, the uterus gradually differentiates itself into 2 distinct
functioning areas:
→ an upper portion (thickness, active -bec. fundus serves as
the source of contraction)
→ lower segment (becomes thin-walled, supple and passive-
bec. There is no contraction in this part of the uterus and only
serves as passageway)
Effacement- the shortening and thinning of the cervical
canal
- Unit is in percent (100% - very thin)
-in primipara, effacement before dilation begins but in
multipara dilation may proceed before effacement is
complete
Dilation- enlargement of widening of the cervical canal
-from an opening of few millimeters to one large enough
(10cm) to permit passage of a fetus
4. Psyche
- Psychological outlook
-refers to the psychological state or feelings a woman
brings into labor
-a woman who manages best in labor typically are those
who have a strong sense of self-esteem and meaningful
support person with them
-woman who lack a strong sense of self-esteem and meaningful
support system may experience a frightening labor and later
have a possibility of showing symptoms of post-traumatic stress
disorder
Part 3
Stages of Labor
1st stage
-Begins with the initiation of true labor contractions
and end when the cervix is fully dilated
 - cervix is fully dilated (10cm)
-takes about 12 hours to complete
-divided into 3 segments:
- phases: Latent, active, transition
Latent: duration of contraction is 20-40 sec
- Encourage to walk around
-cervical effacement occurs and cervix dilates minimally
-begins at regularly perceived contractions and ends at
the beginning of cervical dilatation
Nursing Intervention:
● Encourage women to continue to
walk about
● Make preparations for birth such as
doing last minute packing for her
stay at the hospital or birthing center
● Preparing the older children for her
departure and the upcoming birth
● Giving instructions to the person who
will take care of them while she is
away
● The woman could begin alternative
methods of pain relief such as
aromatherapy, distraction or
acupressure
Active: duration of contraction is 40-60 sec
-cervical dilation occurs more of contraction: 3-5
minutes
Nursing Intervention:
● Encourage woman to be active participants in
labor by keeping active
● Assuming whatever position is most
comfortable for them during this time, except
flat on their back
● Back rubs
2nd stage
-from the time of full dilation until the infant is born
3rd stage
-placental stage
-from the time the infant is born until the delivery of
the placenta
4th stage
-the 1st-4 hours after birth of the placenta
Part 3 - 4 minutes till end
1st stage:
3. Transition Phase
- Contraction occurs every 2-3 minutes
- Duration of contraction last: 60 - 70 seconds
- In this phase a maximum of cervical dilation
of 8-10 cm occurs
- By the end of this phase, both full dilation and
complete cervical effacement have occurred
- A new sensation, the irresistible urge to push
usually begins
- In this phase, the women may experience
intense discomfort accompanied nausea and
vomiting, she may also experience a feeling of
loss of control, anxiety, panic and or irritability
1st Stage: Nursing Diagnosis and Related
Interventions
● Anxiety related to stress of labor
○ Offer support
○ Respect and support the support
person
○ Support a woman’s pain
management needs
○ Orient client to staff, environment
and procedure
○ Encourage client to verbalize feelings
○ Demonstrate breathing and
relaxation methods
2nd Stage of labor:
- The time span from full cervical dilation and
effacement to birth of the infant (fetal stage)
- The woman may experience momentary nausea or
vomiting because pressure is no longer exerted on her
stomach as a fetus descends into the pelvis the woman
pushes with such forces that she perspires and the
blood vessels in her neck become distended
- Crowning happens
- At this stage the baby is delivered that why this stage
is also called as fetal stage
- Possible nursing interventions when the
woman perspires
● As a support system during the actual delivery
of the baby aside from coaching the
expectant mother, you will also wipe the
perspiration of the patient. Fetus begins
descent and as the fetal head touches the
internal perineum to begin internal rotation
her perineum begins to bulge and appear
tense. The anus may become inverted and
still may be expelled as the fetal head pushes
against the vaginal introitus. This opens and
the fetal scalp appears at the opening of the
vagina and enlarges from the size of a dime
to a quarter then a half dollar, this is termed
as crowning
- Ritgen maneuver
- Pressing forward the fetal chin while the other
hand is pressed downward on the occiput
[this is the maneuver that the health care
provider has to apply in order to facilitate the
delivery of the baby.]
- childbirth pressure should never be applied on
the fundus of the uterus cause uterine
rupture could occur.
- check for nuchal cord
- Nuchal cord pertains to the loop of
cord encircling on the neck. We need
to check this one because this could
cause asphyxia or absence of oxygen
in the baby
- Child is considered born when the whole body
is already born (time should be noted and
recorded)
- Delayed umbilical cord cutting (physiologic
clamping) until pulsation ceases and
maintaining the infant at uterine level allows
as much as 100mL more of blood to pass
from the placenta into the fetus
- Vessels in the cord are then counted after
clamping and cutting
3rd stage of labor:
- The placental stage
- Begins with the birth of infant and ends with the
delivery of the placenta
- Placental delivery up to 30 minutes following childbirth
is considered normal
- during normal spontaneous vaginal delivery blood loss
for NSVD: 300-500mL because bleeding occurs as the
placenta separates
- Placenta delivers by either the natural-bearing down
effort or by applying gentle pressure on the contracted
uterine fundus (crede maneuver)
- If placenta does not deliver spontaneously, it could be
removed manually
- Take note: after the delivery of the placenta
the placenta needs to be inspected after
delivery to be certain that it is intact
- 2 separate phases are involved:
1. Placental separation
- Lengthening of the
umbilical cord
- Sudden gush of vaginal
blood
- The placenta is visible at
the vaginal opening (vaginal
entroitus??)
- The uterus contracts and
feels firm again
- Sudden rising of the
abdomen
2. Placental expulsion
● Mechanism of placental
expulsion or
presentation of placenta
upon delivery:
- Shultze
presentation:
- If the placenta
separates first at
its center and last
at its edges
- It tends to fold on
itself like an
umbrella and
presents at the
vaginal opening
with the fetal
surface evident
- The placenta
appears shiny and
glistening from the
fetal membranes
- Duncan
presentation:
- If the placenta
separates first at
its edges and
slides along the
uterine surface
and presents at
the vagina with
maternal surface
evident then the
presentation is
duncan.
- It looks raw, red
and irregular with
the ridges or the
cotyledons that
separates blood
specs
TAKE NOTE: pressure should never be applied to a uterus in a
non contracted state because doing so could cause the uterus
to evert (turn inside out) accompanied by massive hemorrhage.


This is an
example
of an
intact
placenta
upon
delivery


This is an example of a non-
intact placenta upon delivery
Why is it important to make sure
that there are no retained
placental fragments in the
uterus?
-It is because if there are
retained placental fragments attached to the wall of
the uterus, the uterus could not contract properly
which may lead to bleeding. That is why it is very
important to make sure that there are no retained
placental fragments in the uterus. One nursing
responsibility that you really need to look into the 3rd
stage of labor is to check the intactness of the
placenta, this is to prevent bleeding.
● After the placenta inspection, if the mother’s uterus
has not contracted firmly on its own, the primary care
provider will massage the fundus to urge it to contract.
● Oxytocin (pitocin) may be prescribed to be
administered IM or IV to also help uterine contraction
● If excessive bleeding with poor uterine contraction
remains, an injection of carboprost tromethamine
(hemabate) or methylergonovine maleate (methergine)
is another solution to increase uterine contraction and
to guard against hemorrhage.
remember the nursing responsibility:
- You need to check the blood pressure before
administering the medication. Because this
medication can cause vasoconstriction and
thereby will increase the blood pressure of the
patient and so you need to check the blood
pressure of the patient before giving these
medications because if the patient is already
hypertensive and these medications are
administered it can further increase the blood
pressure of the patient.
300- 500 mL- normal blood loss during
delivery
 ● After birth the uterus can be palpated as firm round
mass just below the level of umbilicus
● During this stage (3rd stage) you also need to do
perennial inspection and check for perineal tears, with
this you need to assess for the degree of perineal
laceration.
Below is the classification of perineal laceration

NURSING

INTERVENTIONS FOR 3RD STAGE OF LABOR:

● Take note of the time the placenta was out
● Check for intactness of placenta
● Check for bleeding
● Anticipate for the administration of medications to
promote uterine contraction. Check BP first!
● Assess the degree of perineal laceration

4TH STAGE OF LABOR:

- The first 4 hours after birth of the placenta
- High risk for hemorrhage
Nursing interventions for this stage:
● Obtain vital signs every 15 minutes for the
first hour
● Wash the perineum and apply perineal pad
● Palpate a woman’s fundus for size
consistency, and position
● Observe the amount and characteristics of
lochia each time you record vital signs
● Well contracted uterus = firm