CARE OF MOTHER, CHILD, AND ADOLESCENT SEM 01 | CYC 01

LECTURE / WELL-CLIENTS AUF-CON

NCM 0107 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON
a. Poor
OUTLINE b. Moderate
I Intrapartal Care c. Good
A Normal Labor and Delivery d. Excellent
i Methods for Pain Management, Relaxation and
Birth Settings
II Labor 6. When the fetal presenting part is at the level of the
A Theories ischial spine, the station is:
B Components
i Passageway
a. 0
ii Passenger b. -1
· Fetal Presentation and Position c. +2
iii Power
d. +3
· Premonitory Signs of Pregnancy
· Signs of True Labor
· Rupture of the Membrane 7. Which of the following is the most common type of
iv Psyche fetal presentation?
C Stages of labor
i First a. Military
· Latent, Active, and Transition b. Brow
ii Second c. Face
iii Third
· Placental Separation and Expulsion d. Vertex
iv Fourth
8. All of the following are methods that can determine
fetal position, presentation, and lie, EXCEPT:
PRE-TEST a. Abdominal x-ray
b. Auscultation of fetal heart tones
1. Labor pains are perceived more quickly if anxiety is
c. Leopold’s maneuver
present.
d. Sonography
a. True
b. False
9. One of the premonitory signs of labor onset is slight
decrease in maternal weight 1 or 2 days before the
2. This component of labor refers to the fetal position:
onset of labor.
a. Psyche
a. True
b. Passageway
b. False
c. Passenger
d. Power
10. In the mechanisms of labor, which of the following
will follow after fetal descent?
3. The suture which joins the occipital bone and two
a. Internal rotation
parietal bones:
b. Flexion
a. Frontal
c. Extension
b. Sagittal
d. External rotation
c. Coronal
d. Lambdoid
11. Effacement is a characteristic referable to the:
a. widening of the cervical canal
4. This refers to the intersections of the cranial sutures:
b. shortening and thinning of the cervical
a. Mentum
canal
b. Fontanelle
c. thickening of the uterine wall
c. Molding
d. formation of a ridge dividing the uterus into
d. Attitude
two segments

5. When the fetus presents the smallest

12. The relation of the long axis of the fetus to the long
anteroposterior diameter because it puts the whole
axis of the mother is termed:
body into an ovoid shape, occupying the smallest
a. Station
space as possible, the fetal attitude is:

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 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON

b. Position 18. In a vertex presentation and an LOA position, the

c. Presentation fetal heart rate can usually be heard at the:
d. Attitude a. RLQ
e. Lie b. LLQ
c. RUQ
13. The primary aim of doing a perineal incision or d. LUQ
episiotomy is to:
a. prevent lacerations* 19. Voiding every 2–3 hrs is encouraged in a woman in
b. reduce duration of second stage of labor labor to:
c. prevent prolonged and severe stretching of I. Facilitate fetal descent
muscles supporting the bladder II. Lessen the weight of her abdomen
d. spare the infant's head from prolonged III. Avoid UTI
pressure and pushing against the rigid IV. Stimulate contractions
perineum a. 1 and 2
b. 1 and 3
14. Crowning is best defined as: c. 2 and 3
a. accommodation of the fetal head to the d. 3 and 4
pelvic shape
b. encirclement of the largest diameter of the 20. Which of the following is a characteristic of true
fetal head by the vulvar ring* labor pains?
c. enlargement of the fetal head a. lack of cervical effacement or dilatation
d. appearance of the fetal head at the vagina b. cessation of uterine contractions
c. irregular, generally confined to the abdomen
15. Signs of placental separation include the following; d. intensification of uterine contractions with
I. Uterus becomes elongated walking
II. Uterus rises to the level of the umbilicus
(Calkin’s sign) 21. The beginning of the second stage of labor can be
III. Sudden gush of blood from vagina recognized by the patient's desire to:
IV. Shortening of the cord a. blow during contractions
a. 1 and 2 b. tense up during contractions
b. 1 and 3 c. push during contractions
c. 2 and 3 d. pant during contractions
d. 3 and 4
22. The average length of time a primipara patient will
16. Which of the following describes the Shultz be in labor is approximately:
mechanism of placental separation? a. 18
I. Placenta separates first from its center b. 20
II. The shiny surfaces presents at vaginal c. 24
opening d. 14* (Multipara)
III. Placenta separates first at its edges
IV. The raw, red, irregular surface presents at the 23. When the placenta has been delivered, the first
vaginal opening thing the nurse should do is to:
a. 1 and 2 a. palpate the uterus if it is contracted
b. 2 and 3 b. administer oxytocic agents as ordered
c. 1 and 3 c. inspect the placenta for completeness of the
d. 3 and 4 cotyledon
d. estimate the blood loss to detect any
17. Which of the following is the most common position bleeding
of the fetus at birth?
a. right sacroposterior (RSP) 24. It is the relation of the fetal presenting part of a
b. left occiput anterior (LOA) specific quadrant of the woman's pelvis.
c. right mentum transverse (RMT) a. Station
d. right acromion dorsoanterior (RADA) b. Position
c. Presentation

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 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON

d. Attitude ● 2. Impulses pass through a dense, interacting

network of cells in the spinal cord (substantia
25. It is the relation of the fetal presenting part to the gelatinosa)
level of the ischial spines. ● 3. A synapse occurs that returns the transmission
a. Lie to the peripheral site through motor nerve
b. Station ● 4. Impulse then continues in the spinal cord to
c. Presentation reach the hypothalamus and cortex of the brain
d. Position ● 5. Impulse is interpreted and perceived as pain

26. Stage of expulsion in labor PRINCIPLES

a. 1
b. 2 ● A woman needs to come into labor informed about
c. 3 what causes labor pain and prepared with
d. 4 breathing exercises to use to minimize pain during
contractions
27. Stage of dilatation in labor ● A woman experiences less pain if her abdomen is
a. 1 relaxed and the uterus is allowed to rise freely
b. 2 against the abdominal wall with contractions
c. 3 ● Using the gating control theory of pain perception:
d. 4 distraction techniques

28. Normal amount of blood loss during labor and METHODS FOR PAIN MANAGEMENT
delivery: A. GATE CONTROL MECHANISMS
a. 100 mL
b. 250–350 mL ● Involves halting an impulse at the level of the spinal
c. 600 mL cord so the impulse is never perceived at the brain
d. 1000 mL level as pain, a process similar to closing a gate
● Involves 3 techniques
29. It is the relation of the long axis of the fetus to the
long axis of the mother. CUTANEOUS STIMULATION
a. Presentation
b. Station ● Ability of the small nerve fibers at the injury site to
c. Position transmit pain impulses appears to decrease if the
d. Attitude large peripheral nerves next to the injury site are
e. Lie stimulated
● Examples
30. It is synonymous to crowning which is the ○ Rubbing an injured
encirclement of the largest diameter of the fetal part
head by the vulvar ring [station]. ○ Applying
a. +1 or +2 Transcutaneous
b. -1 or -2 Electrical Nerve
c. -3 or -4 Stimulation
d. +3 or +4 ○ Heat/cold compress
○ Effleurage: light abdominal massage
MODULE PROPER
DISTRACTION
NORMAL LABOR AND DELIVERY

PAIN PATHWAY
● 1. Endings of the small peripheral nerve fibers
detect a stimulus transmit to the cells in the dorsal
horn of the spinal cord
● If the cells of the brain stem that register an impulse
as pain are preoccupied with other stimuli, a pain
impulse will not register
● Examples
○ Breathing techniques: increases oxygenation
– decreasing pain

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 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON

○ Focusing/Imagery: sensate focus like ● Couple must be aware of these breathing exercises
photograph of her husband/children, a during prenatal care
graphic design, or something appealing to ● Ex: Unang Yakap
them
6 MAJOR CONCEPTS
REDUCTION OF ANXIETY
1. Labor should begin on its own, not induced
● Pain is perceived more quickly if anxiety is also 2. Woman should walk, move freely throughout the
present labor and change position
● Examples 3. Woman should bring loved one, friend for
○ Focusing/Imagery - sensate focus like continuous support
photography of her husband/children, a a. Woman should continuously receive support
graphic design, or something appealing to during labor
them b. DOULA: do not have any training in obstetrics
but hired to support the laboring mother
B. BRADLEY METHOD 4. Interventions that are not medically necessary
Partner-Coached should be avoided
a. No routine interventions such as IVF
● Developed by Robert Bradley
5. Women should be allowed to give birth in other
● Pregnancy is a joyful natural process and stresses
positions
importance of the husband
a. Allow woman to assume a non-supine position
● Pain is reduced by: abdominal breathing, walking
6. Mother and baby should be housed together
during labor
following birth
● Husband will coach the pregnant wife

C. PSYCHOSEXUAL METHOD RELAXATION TECHNIQUES

Sheila Kitzinger CONSCIOUS RELAXATION
● Stresses that pregnancy, labor and birth, and the Relax the body so the woman does not remain
●
early newborn period are important points in tense, have anxiety, unnecessary muscle strain and
woman’s life cycle fatigue during labor
● Program involves conscious relaxation and levels
of progressive breathing that encourages the CLEANSING BREATH
woman “to flow with” rather than struggle against
contractions of labor ● Woman breathes deeply and then exhale deeply

D. GRANTLY DICK-READ METHOD CONSCIOUSLY CONTROLLED

BREATHING
● Fear leads to tension and tension leads to pain
● Achieves relaxation and reduced pain in labor by LEVEL 1
using abdominal breathing during contractions
● Reduction/prevention of fear = no tension = no pain ● Slow chest breathing (comfortable but full
respirations 6-12 cpm)
E. LAMAZE METHOD ● Early labor
Ferdinand Lamaze
LEVEL 2
● Based on stimulus-response conditioning
○ To be effective, full concentration on ● Breathing lighter than level 1
breathing exercises during labor should be ● Rib cage expands lightly; the diaphragm barely
observed moves
● PSYCHOPROPHYLACTIC METHOD: preventing pain ● RR up to 40 cpm
during labor (prophylaxis) by the use of mind ● Good for contractions when cervical dilation is 4
(psyche) and 6 cm
● Teach the mother full concentration in breathing
exercises (mind over matter)

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 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON
LEVEL 3
● Breathing is shallow mostly at the sternum
● 50-70 cpm
● Keep the tip of the tongue against the roof of her
mouth
● Cervical dilation 7 and 10 cm (full dilation)
LEVEL 4
● Uses “pant-blow pattern”
○ 3-4 quick breaths then a careful exhalation
○ “choo-choo” “hee-hee-hee-hoo”
LEVEL 5
● Chest panting is continuous, very shallow, 60 cpm
Prevents pushing before dilation
●
TYPES OF BIRTH SETTING
● Besides how to prepare for labor, choosing a birth
setting is another important decision that a couple
needs to make during pregnancy
HOSPITAL BIRTH
● Labor, Birthing, Recovery, Postpartum room (LBRPs)
ALTERNATIVE BIRTHING
CENTERS
● Lying-in clinics
● Wellness-oriented childbirth facilities designed to
remove childbirth from the acute care hospital
setting while providing enough medical resources
for emergency care should complication of birth
arises
● Woman is encouraged to express her own needs
and wishes during labor, she can choose birth
position, bring her own music or distraction objects
and partner can perform such as cutting the cord,
woman remains 4–24 hours after birth
HOME BIRTH
● Allows for family integrity, puts the responsibility on
the woman to prepare the house and take care of
her infant after birth.
● Not allowed in the Philippines unless emergency
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ALTERNATIVE METHODS OF BIRTH
LEBOYER
● From a warm, fluid filled intrauterine environment to
a noisy, air filled brightly lit birth room creates major
shock
● Birthing room is darkened so there is no sudden
contrast in light, keep pleasantly warm, soft music
is played, infant handled gently
● Cord is cut late, placed in a warm-water bath
HYDROTHERAPY AND WATER BIRTH
● Reclining or sitting in warm water labor can be
soothing
○ Feeling of weightlessness and relaxation can
reduce discomforts
○ Ex: Labor in shower/spa tubs
● DIFFICULTIES
○ Water contaminated with feces, aspiration,
maternal chilling
● HYDROTHERAPY is done during labor only
UNASSISTED BIRTHING
● Free birthing or couple birth = woman giving birth
without healthcare provider supervision
● Differs from home birthing
● Needs no medical supervision
THE LABOR PHENOMENON
● Normally begins when a fetus is sufficiently mature
to cope with extrauterine life yet not too large to
cause mechanical difficulties in delivery
● A normal labor starts at 37-42 weeks AOG (term)
○ However, the trigger that converts the
random, painless Braxton-Hicks contractions
into strong, coordinated, productive labor
contractions is unknown.
○ Preterm Labor: occurs earlier than 37 weeks
● A series of events by which the uterine contractions
and abdominal pressure expel a fetus and
placenta from a woman’s body
● A series of continuous, progressive contractions of
the uterus which help the cervix to open (dilate)
and to thin (efface), allowing the fetus to move
through the birth canal
Full cervical dilation is 10 cm in primigravida; 7-8
●
cm in multigravida
 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON
THEORIES OF LABOR ONSET
UTERINE STRETCH
● Any hollow organ when stretched to capacity will
contract and empty because of the pressure on
nerve endings and increased irritability of the
uterine musculature
OXYTOCIN
● Oxytocin is an effective stimulant of uterine
contractions in late pregnancy and is commonly
used to induce labor
● Fetus’ presenting part presses the cervix → Nipples
are stimulated → Nerve impulses travel from nipple
to the hypothalamus → stimulates posterior
pituitary gland to produce oxytocin → causes
uterine contractions
PROGESTERONE DEPRIVATION
● Progesterone inhibits uterine contraction
● Onset of labor in humans might result from
withdrawal of progesterone at a time of relative
estrogen dominance
PROSTAGLANDIN
● The relative progesterone deprivation and estrogen
predominance set off production of corticosteroids
which act on lipid precursors to release arachidonic
acid, and in turn, increase the synthesis of
prostaglandins.
● Prostaglandins, like oxytocin, are known to
stimulate uterine contractions
AGING PLACENTA
● The decrease of nutrients and blood supply in the
aging placenta causes uterine contractions
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COMPONENTS OF LABOR
Will the patient undergo NSD or CS?
PASSAGEWAY
Route of Travel
● Route of the fetus to travel (maternal pelvis) from
the uterus through the cervix and vagina to the
external perineum
○ Dadaanan ng baby para mapanganak siya
○ Because these organs are contained inside
the pelvis, the fetus must also pass between
the pelvic ring.
● A favorable type of pelvis is the gynecoid
● Size of the maternal pelvis: diagonal conjugate (AP
diameter of the transverse diameter outlet)
○ Cephalopelvic disproportion: maternal pelvis
is not enough to deliver the fetus vaginally
● Ability of the cervix to dilate and efface
PELVIC INLET
● Top opening of the pelvis
● The part of the baby’s head which enters first
PELVIC OUTLET
● Where the baby’s head and body exits
● These dimensions need to be sized sufficiently to
allow the baby to maneuver comfortably through
the pelvis for birth
TAILBONE (SACRUM/COCCYX)
● Needs to be sufficiently mobile to be gently pressed
back out of the way when the baby moves through
SYMPHYSIS PUBIS
● A cartilaginous joint in the front of the pelvis
● Needs to be properly mobile to help the pelvis flex
to allow the baby to pass through
● The relaxin hormone in the body helps both the
tailbone and the symphysis pubis to become more
mobile to facilitate birth
PASSENGER
Fetal Position
● Checks if the fetus is of appropriate size and in an
advantageous position and presentation
● The baby needs to be positioned properly to make
it through the pelvis
● FETAL HEAD
○ Body part that has the widest diameter
 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON

○ Occiput Anterior (OA): part of the head which FONTANELLES

is the optimal position and presenting part for
birth ● The intersections of the cranial sutures
● Pinakamaliit na part ng head na dapat ● ANTERIOR FONTANELLE
nakalagay sa pelvis ni mother ○ Diamond shape
● Chin should be touching the chest ○ Permits the growth of the brain by remaining
(well-flexed) unossified for 12 -18 months
● Babies can be born vaginally in a number of ● POSTERIOR FONTANELLE
positions ○ Triangular-shaped
○ Closes within 8-12 weeks/ 3-4 months
FETAL SKULL ○ Lies in the junction of the lambdoidal and
sagittal sutures
STRUCTURE
OTHER IMPORTANT LANDMARKS
CRANIUM
● MENTUM
● Uppermost proportion of the skull ○ The fetal chin
● 8 bones ● SINCIPUT
○ Frontal, Two Parietal, Occipital: the four ○ Anterior area known as brow
superior bones ● VERTEX
○ Sphenoid, Ethmoid, two temporal bones: lies ○ Area between the anterior and posterior
at the base of cranium fontanelles
● OCCIPUT
SUTURES ○ Area of the fetal skull occupied by the
occipital bone, beneath the posterior
● Membranous spaces between the cranial bones
fontanelle
● Allow for molding (overlapping of the bones)
○ Molding: changes in shape of the fetal skull
DIAMETERS
produced by the force of the uterine
contractions pressing the vertex against the
● The shape of the skull causes it to be wider in its
not-yet-dilated cervix
anteroposterior diameter than in its transverse
● SAGITTAL SUTURE LINE
diameter to fit the birth canal
○ Joins the two parietal bones of the skull
● Measurement: AP diameter of the skull is wider
● CORONAL SUTURE
than the transverse diameter
○ Joins the frontal bone and the two parietal
bones
TRANSVERSE
● LAMBDOID SUTURE
○ Joins the occipital bone and the two parietal ● Bi-parietal: 9.25 cm
bones ● Bitemporal: 8 cm
● FRONTAL/MITOTIC SUTURE
○ Joins the two frontal bones ANTEROPOSTERIOR
○ Becomes the anterior continuation of the
sagittal suture ● SUBOCCIPITOBREGMATIC
○ Narrowest diameter is from the inferior
aspect of the occiput to the center of the
anterior fontanelle (approximately 9.5 cm)
● OCCIPITOFRONTAL
○ Measured from the bridge of the nose to the
occipital prominence (approximately 12 cm)
● OCCIPITOMENTAL
○ Widest AP diameter measured from the chin
to the posterior fontanelle (approximately 13.
5 cm)

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 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON

FACE PRESENTATION (Fig. D)

● Fetus is in poor flexion
● Back is arched
● Neck is extended
● Fetus is in complete extension
and presents a wide
(occipitomental) diameter
● This unusual position usually
presents too wide a skull diameter to the birth canal
FETAL PRESENTATION AND POSITION for vaginal birth
● May also reflect a neurologic abnormality in the
FETAL ATTITUDE fetus, causing spasticity

● Describes the degree of flexion a fetus assumes

FETAL LIE
during labor or the relationship of the fetal
presenting parts to each other
● The relationship of the cephalocaudal axis (spinal
column) of the fetus to the cephalocaudal axis of
GOOD ATTITUDE (well-flexed)
the woman
● The normal fetal position
● Advantageous for birth as it LONGITUDINAL LIE TRANSVERSE LIE
helps a fetus present the smallest Cephalocaudal axis of Cephalocaudal axis of the
anteroposterior diameter the fetus is parallel to fetus is at the right angles
● Complete flexion the woman’s spine to the woman’s spine
● Spinal column is bowed forward Fetus is in a vertical Fetus is in a horizontal
● The head is flexed forward so position position
much that the chin touches the Further classified as
sternum cephalic and breech
● The arms are flexed and folded on the chest
● The thighs are flexed onto the abdomen
● The calves are pressed against the posterior aspect
of the thighs

MILITARY POSITION (head is straight)

● LIE: longitudinal
● ATTITUDE: moderate flexion
● Chin is not touching the chest
but is in an alert
● Causes next-widest
FETAL PRESENTATION
anteroposterior diameter, the
● Determined by the fetal lie and by the body part of
occipital diameter to present to
the fetus that enters the maternal pelvis first
the birth canal
○ Combination of lie and attitude
● 12 cm; hard to deliver
● May be cephalic, breech, or shoulder

BROW AND FACE PRESENTATION (poor)

CEPHALIC PRESENTATION

● Most frequent presentation occurring as often as

BROW PRESENTATION (Fig. C) 95%
● The fetus is in partial extension
● Presents the brow of the head in VERTEX
the birth canal
● Most common type of presentation

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 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON

● Skull bones are capable of effective molding to PROBLEMS ENCOUNTERED

accommodate the cervix
● LIE: longitudinal
● ATTITUDE: good (full flexion)
● The fetal head is completely flexed onto the chest
● The smallest diameter of the fetal head
(suboccipitobregmatic) presents to the maternal
pelvis
● The occiput is the presenting part
MILITARY
● Fetal head is neither flexed or extended (straight)
● The occipitofrontal diameter presents to the
maternal pelvis
● The sinciput is the presenting part
CAPUT SUCCEDANEUM: During labor, the area of the
fetal skull that comes in contact with the cervix often
becomes edematous from the continued pressure
against it
● Not all babies have this, nangyayari lang kapag
hindi properly timed ‘yung pag-ire
● Normal and the edema will subside
CEPHALHEMATOMA: Happens when blood is
collected between the periosteum of the skull bone
and the skull bone itself; will subside after a few days

BROW

● The fetal head is partially extended

● The occipitomental diameter, the largest
anteroposterior diameter, is presented to the
maternal pelvis
BREECH PRESENTATION
FACE
COMPLETE
● The fetal head is hyperextended (complete
extension)
● Fetus has thighs tightly flexed on
● The face is the presenting part
the abdomen
● Both the buttocks and the tightly
flexed feet present to the cervix
● Good attitude and longitudinal lie

FRANK

● Attitude is moderate because the

hips are flexed but the knees are
extended to rest on the chest.
● Buttocks alone present to the
cervix
● Lies longitudinal and moderate
attitude

FOOTLING

● Neither the thighs nor lower legs are

flexed
● SINGLE FOOTLING: one foot is
present
● DOUBLE FOOTLING: both feet present
● Longitudinal lie, poor attitude

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 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON

SHOULDER PRESENTATION LEVELS

Level of the ischial spine (synonymous
● In transverse lie, a fetus lies horizontally in the pelvis 0
with engagement)
so that the longest fetal axis is perpendicular to that
of the mother -1 to -4 Above the ischial spine (descending)
● Presenting part is -4 Floating
usually one of the +1 to +2 Below the ischial spine (engaged)
shoulders (acromion
Synonymous to crowning; encirclement
process), an iliac crest, a
+3 to +4 of the largest diameter of the fetal head
hand or an elbow by the vulvar ring; nakikita na ‘yung FPP
● Caused by relaxed
abdominal wall from
grand multiparity, allows
unsupported uterus to fall
forward, pelvic contraction where the horizontal is
greater than the vertical space, placenta previa
(low implantation of placenta; limit a fetus ability to
turn), external version (delivery: CS)

FETAL POSITION

● Relation of the fetal presenting part to a specific

quadrant of the woman’s pelvis (right
anterior/posterior and left anterior/posterior)
NOTATIONS TO DESCRIBE FETAL POSITION
ENGAGEMENT
● Right (R) or Left (L) side of the maternal pelvis
● Settling of the presenting part of the fetus far ● O, M, Sa, A (Occiput, Mentum, Sacrum, Acromion
enough to the pelvis to be at the level of the ischial Process)
spine ○ Landmark of the presenting part
○ In a vertex presentation, the occiput (O) is the
STATION chosen point.
○ In a face presentation, it is the chin (mentum
● The relationship of the presenting part of a fetus to [M]).
the level of the ischial spine ○ In a breech presentation, it is the sacrum (Sa).
○ The ischial spines can be palpated at about a ○ In a shoulder presentation, it is the scapula or
finger-length into the vagina (felt as bony the acromion process (A).
prominences) ● A, P, T (Anterior, Posterior, Transverse)
○ Depending on whether the landmark is in front,
back, or side of the pelvis
● Positions are indicated by an abbreviation of three
letters
○ FIRST LETTER: whether the landmark is pointing
to the mother’s right or left
○ MIDDLE LETTER: fetal landmark (O, M, Sa, A)
○ LAST LETTER: whether the landmark points A, P,
or T
● NOTE: Fetal positions left and right occiput posterior
need surgery
○ This position is associated with more frequent
induction and augmentation of labor,
chorioamnionitis, postpartum hemorrhage,
third and fourth degree perineal tears, wound
infection and endometritis

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 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON

● LOA is the most common and favorable fetal
position followed by ROA (born and delivered the
fastest)
● Kapag occiput anterior, kita ang fetal back and
spinal area
● Kapag occiput transverse, medyo naka-side
naman si baby
● The triangular-shaped is the occiput while the
diamond-shaped is the anterior fontanel
● Kapag hindi LOA or ROA, mas matagal ang
pag-ikot ng occiput papunta sa vaginal canal and
mas matagal ang delivery
○ NURSING RESPONSIBILITY: lay the mother in a
side-lying position or bring the knees and
hands towards the abdominal chest to
compress the abdomen and help with fetal
positioning
WHY IS IT IMPORTANT TO DETERMINE FETAL
PRESENTATION AND POSITION?
● Determines the efficiency and duration of delivery
○ Positions other than the LOA and ROA might
extend the process of labor and put the
mother in pain because as the baby’s head
rotates, it presses on the mother’s sacral
nerve which would cause more discomfort
● Could put a fetus at risk due to proportional
differences between fetus and pelvis
● Membranes also are more apt to rupture early,
increasing possibility of infection
● Risk of fetal anoxia and meconium staining
leading to respiratory distress at birth
WAYS TO DETERMINE FETAL POSITION,
PRESENTATION, AND LIE
● Inspection and palpation (Leopold’s maneuver)
● Vaginal examination
● Sonography
● Auscultation of fetal heart tones

POWER

● The force supplied by the fundus of the uterus and

implemented by uterine contractions, which causes
cervical dilatation and then expulsion of the fetus
from the uterus
● After full dilatation of the cervix, the primary power
is supplemented by use of a secondary power
source, the abdominal muscles
● NURSING RESPONSIBILITY: Make sure that patients
understand that they should not bear down with
their abdominal muscles to push until the cervix is
fully dilated. Doing so impedes the primary force
and could cause fetal and cervical damage.

UTERINE CONTRACTIONS

● Braxton Hicks (False Labor)

○ The uterus begins to contract and relax
periodically as if it is rehearsing for labor
○ Usually mild but can be strong enough to be
mistaken for true labor
○ Usually irregular and are not painful, but they
do not cause cervical dilatation
● Comes from the uterine fundus and implemented
by uterine contractions, a process that causes
cervical dilatation and the expulsion of the fetus
from the uterus
○ Must be strong enough in order to cause
cervical dilatation so that it can aid in the
expulsion of fetus and placenta

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 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON
○ Need to be at regular intervals, moving closer
together and increasing in strength throughout
the labor
○ Dapat mula sa fundus, then pababa
● In some patients, contractions appear to
originate in the lower uterine segment
rather than in the fundus. These are
reversed and ineffective and may actually
cause tightening rather than dilatation of
the cervix.
● After dilatation of the cervix, the primary power is
supplemented by the use of abdominal muscles
PREMONITORY SIGNS OF PREGNANCY
1. LIGHTENING
● Descent of the fetal presenting part into the pelvic
inlet
● Happens 10-14 days before labor in primigravida
and 1 day before labor in a multipara.
● When the largest diameter of the presenting part
passes the pelvic inlet, the head is said to be
"engaged." However, lightening is heralded by the
following signs
○ Relief of dyspnea/SOB/diaphragmatic pressure
○ Relief of abdominal tightness
○ Increased frequency of voiding
○ Increased amount of vaginal discharges
○ Increased lordosis as the fetus enters the pelvis
and falls forward
● Walking is more difficult and leg cramping
may increase
○ Shooting leg pains (from the increased
pressure in the sciatic nerve)
2. SUDDEN BURST OF MATERNAL ENERGY/ACTIVITY
● Awaken full of energy epinephrine release initiated
by decrease in progesterone produced by the
placenta
● This is meant to prepare the body for the “labor”
ahead
3. BRAXTON HICKS CONTRACTIONS (PRACTICE
CONTRACTIONS)
● Happens in the last week or days before labor
● False, painless, irregular, abdominal contractions
and are relieved by walking
4. SLIGHT DECREASE OF MATERNAL WEIGHT
● Loss is about 2-3 lbs
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● One to two days before the onset of labor because
of decrease progesterone level and loss of appetite
5. SOFTENING/RIPENING OF THE CERVIX
● Butter-soft
SIGNS OF TRUE LABOR
UTERINE CONTRACTIONS
● The surest sign that labor has begun is the initiation
of effective, productive, involuntary uterine
contractions
TRUE CONTRACTIONS
● Increment/Crescendo: increasing in the
intensity/strength of the uterine contraction
○ Kapag naka-contract ang uterus, constricted
din ang blood vessels na nagbibigay ng
nutrients sa placenta
● Apex/Acme: the peak of the uterine contraction;
hard uterus; dilation
● Decrement/Decrescendo: decrease in the strength
of the uterine contraction; paglambot at pag-relax
ng uterus; refilling of blood
○ Contraction should be decreased because of
vasoconstriction
○ Rigid uterus: tuloy-tuloy na matigas ang uterus
and hindi nag-rerelax; need i-CS
📌
○ REMEMBER: Do not get the FHR if the uterus is
contracted (pwedeng mababa or possible ring
mataas ang HR because the baby is
compensating for the lack of blood supply)
HOW TO GET THE DURATION
● Place palm on the top of the patient’s abdomen
● Feel the contraction (start counting if hard)
● Stop counting (if abdomen softens)
CHARACTERISTICS OF CONTRACTIONS
● Frequency
○ Timed from the beginning of one contraction to
the beginning of the next
○ Contractions will be 3-5 times in every
10-minute period
● Duration
○ Timed from moment the uterus first begins to
tighten/contract until it relaxes again
○ 40-60 seconds duration
 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON
● Interval
○ Pagitan ng contraction
○ From the end of the previous contraction to the
beginning of the next contraction
● Intensity
○ Subjective
○ May be mild moderate or strong at its acme
○ The interval decreases as the labor progresses
INTENSITY OF UTERINE CONTRACTION
● Mild
○ The uterine muscle becomes somewhat tense,
but can be indented with gentle pressure (tip of
the nose)
● Moderate
○ The uterus becomes moderately firm and a
firmer pressure is needed to indent (forehead)
● Strong
○ Uterus becomes so firm that it has the feel of
wood like hardness, and at the height of the
contraction, the uterus cannot be indented
when pressure is applied (wood)
TRUE CONTRACTIONS
● Begin irregularly but become regular and
predictable
● Felt first in lower back and sweep around to the
abdomen in a wave
● Continue no matter the woman’s level of activity
● Increase in duration, frequency, and intensity with
movement
● Achieve cervical dilatation
● Fetus usually engaged
○ Nakakapa na ‘yung presenting part during IE
● There is bloody show (mucus + blood)
○ Operculum: mucus plug, protective layer of the
cervix
● Most sperm cells and microorganisms get
trapped in the operculum
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● Kinukuhang specimen during pap smear
● Natatanggal once the cervix opens
● Parang sipon na lumalabas three days
before menstruation
● Need na dalhin sa hospital
FALSE CONTRACTIONS
● Begin and remain irregular
● Felt first abdominally and remain confined to the
abdomen, groin, or Braxton Hicks
○ Hindi umaabot sa lower back
● Often disappear with ambulation and sleep
● Do not increase in duration, frequency, or intensity
● Do not achieve cervical dilatation
● Fetus is ballotable
UTERINE CHANGES
● Duration of the contraction increases from 20-30
secs to 60-90 secs
● As labor contractions progress, the uterus is
gradually differentiated into two distinct portions
● Distinguished by a ridge formed in the inner uterine
surface, the physiologic retraction ring by the
examiner’s finger
UPPER UTERINE SEGMENT (Fundus)
● Becomes thicker and active, preparing it to exert
the strength necessary to expel the fetus during
the expulsion phase
LOWER UTERINE SEGMENT
● Becomes thin walled, supple, and passive so that
the fetus can be pushed out of the uterus easily
CONTOUR OF THE UTERUS CHANGES
● From a round ovoid to a structure markedly
elongated in a vertical diameter rather than
horizontally
● This lengthening serves to straighten the body of
the fetus and place it in better alignment to the
cervix and pelvis
● As the uterus contracts, round ligaments move
keeping the fundus forward, assisting the fetus in
good alignment with the cervix
● Elongation of the uterus exerts pressure against the
diaphragm
● Uterus is taking control of a woman’s body
 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON
CERVICAL CHANGES
EFFACEMENT
● Shortening and thinning of the cervical canal to
paper-thin edges to primiparas
● PRIMIPARAS: Effacement is accomplished before
dilatation begins
○ NURSING RESPONSIBILITY: Inform the patient
of both effacement and dilatation following a
pelvic examination
● MULTIPARAS: Dilatation may proceed before
effacement is complete
○ Effacement must occur by the end of
dilatation, however, before the fetus can be
safely pushed through the cervical canal;
otherwise, cervical tearing can result.
● During labor, the longitudinal traction from the
contracting uterus shortens the cervix so much that
the cervix virtually disappears
DILATATION
● Enlargement of the cervical canal from an opening
a few millimeters wide to one large enough
(approximately 10 cm.) to permit passage of the
fetus.
● WHY DOES DILATATION OCCUR?
○ Uterine contractions gradually increase the
diameter of the cervical canal lumen by
pulling the cervix up over the presenting part
of the fetus
○ Fluid-filled membranes push ahead of the
fetus and serve as an opening wedge
● If they are ruptured, the presenting part
will serve this same function, although
maybe not as effectively
● SHOW
○ Blood-tinged mucus discharge from the
vagina because of pressure of the
descending fetal part on the cervical
capillaries, causing their rupture.
○ Capillary blood mixes mucus when
operculum is released
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RUPTURE OF THE MEMBRANE (BAG OF WATER)
● Sudden gush or a scanty slow seeping of amniotic
fluid from the vagina
● The color of the amniotic fluid should always be
noted
○ Clear: contains vernix
● At term, this is clear, almost colorless and
contains white specks of vernix caseosa
○ Green: contaminated with meconium (fetal
distress)
○ Yellow: blood incompatibility
○ Pink: bleeding
NURSING ACTIONS WITH RUPTURED MEMBRANE
● Once membranes have ruptured, labor is inevitable,
meaning to say that uterine contractions will occur
within the next 24 hours
● INITIAL NURSING ACTIONS
○ Notify the physician.
○ Lie the patient to bed to ensure that the fetus is
not impinging on the cord.
○ Check the fetal heart rate to determine for fetal
distress. (Normal: 120-160 bpm)
○ If she feels that the loop of the cord coming out
from the vagina (umbilical cord prolapse)
● Position the woman in Trendelenburg
(lower the head of the bed) in order to
release pressure on the cord
● Apply sterile saline saturated gauze to
prevent drying of the cord, if needed
PSYCHE
Psychological Outlook
● Psychological state or feelings a pregnant person
brings into labor
○ The woman’s psyche is preserved so afterward
labor can be viewed as a positive experience
○ If the mother is afraid, tense, stressed out,
angry, feels unsafe or unsupported, she will not
likely do well during birth
● GOOD EMOTIONAL STATE
○ Helps mother to cope with the pain effectively
○ Helps her tune in to her body
○ Helps guide her to her baby’s needs and allows
the other 3 P's to sync up effectively
○ A mom whose psyche is healthy, strong, and
who has good support during labor, will have a
good birth.
○ Regardless of the medical interventions she
may need, she will ride her labor to a birth
 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON

experience she will remember with a strong

heart and a peaceful mind
● NURSING RESPONSIBILITY A. FIRST STAGE (Dilatation)
○ Always coach and provide positive feedbacks
to the mother (responsibility of the assist) ● Begins with the initiation of true labor contractions
● Umiire kapag fully effaced and dilated and ends when the cervix is fully dilated (10cm)
lang. If relaxed ang uterus, mahihirapan and complete effacement (100%)
lang si mother
● Para maka-ire nang maayos si mother, LATENT/EARLY PHASE
itaas ang head part, instruct na i-dikdik
‘yung bottom niya sa bed (parang ● Begins at the
tumatae lang), and nakatingin sa tiyan onset of regularly
niya perceived uterine
● Effective ang pag-ire if lumalaki ang contractions and
butas ng anal area since nakalagay roon ends when rapid
ang pressure and dapat closed ang cervical dilatation
mouth begins
○ Direct the mother’s focus to the labor ● Lasts for 6 hours
for nullipara while
4.5 hours for multipara
STAGES OF LABOR
● WHAT HAPPENS DURING THIS PHASE?
○ Cervical effacement (stretching/thinning)
LENGTH OF LABOR
○ Minimal cervical dilatation (3 cm)
STAGE PRIMI MULTI ● A birthing parent who enters labor with a
1: Dilatation 12 1⁄2 hrs. 7 hrs. 20 mi “nonripe” cervix will probably have a longer
2: Expulsion 80 mins. 30 mins. than average latent phase
● Dilatation refers to enlargement/opening of
3: Placental Expulsion 10 mins. 10 mins.
the cervix
Total: 14 hrs. 8 hrs. ● CONTRACTIONS
○ Mild and short uterine contractions
● The 4th stage is included as the 1-4 hours after
○ INTERVAL: 10-20 mins apart
delivery (also considered critical)
○ DURATION: 20-40 secs
○ OVERALL AVERAGE TIME
● MANIFESTATIONS
● 18-20 hours: primipara
○ Low backaches (sign of true contractions;
● 12-14 hours: multipara
nagra-radiate na sa back)
○ Abdominal cramps
FALSE LABOR ○ Excited, alert, talkative, cooperative, and in
control
● Pain in the lower abdomen and groin
● NURSING RESPONSIBILITY: Encourage patients to
● Contractions do not increase in frequency, duration,
continue to walk about and make preparations for
and intensity; irregular
birth, such as doing last-minute packing for their
● No measurable progressive cervical change
stay at the hospital or birthing center, preparing
● Relieved by walking
older children for their departure and the upcoming
birth, or giving instructions to the person who will
TRUE LABOR
take care of them while they are away
● Pain in the lower back radiating to abdomen or ○ NONPHARMACOLOGIC MANAGEMENT:
from the fundus to the back aromatherapy, distraction, and accupressure
● Contractions increase in frequency, duration, and ○ NOTE: Analgesia can be given, but might
intensity prolong this phase when given too early in
○ Consistent regular rhythmic pattern labor
● Progressive cervical change ● Help with controlling breathing and walking
● Intensify with ambulation instead

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 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON
ACTIVE
● Begins at 6 cm
● Lasts for 3 hours for
nullipara while 2
hours for multipara
● TWO PERIODS:
○ Acceleration
(4-5 cm)
○ Maximum slope (5-9 cm)
● WHAT HAPPENS DURING THIS PHASE?
○ Complete effacement to more rapid cervical
dilatation (4–7 cm)
○ Show (increased vaginal secretions)
○ Spontaneous rupture of the membranes may
occur
● CONTRACTIONS
○ INTERVAL: 3–5 mins apart
○ DURATION: 40–60 secs
○ Stronger, longer, and begin to cause true
discomfort
● MANIFESTATIONS
○ Realizing that labor is truly progressing makes
this phase exciting and frightening
● MOST RAPID PACE: Average rate of 3.5 cm/hr in
nulliparas; 5–9 cm/hr in multiparas
● NURSING RESPONSIBILITY: Encourage patients to be
active participants in labor by keeping active and
assuming whatever position is most comfortable
for them during this time, except flat on their back
TRANSITION
● Peak of this phase can be identified by a slight
slowing rate of cervical dilatation when 9 cm is
reached (baby is moving hence the slowing rate;
baka magkaroon ng precipitous labor)
○ At 10 cm dilatation, an irresistible urge to push
begins to occur
● Focus of the mother is entirely inward on the task of
birthing the baby
● WHAT HAPPENS DURING THIS PHASE?
○ Full effacement and dilatation (8–10 cm)
○ If it has not previously occurred, show will occur
as the last of the mucus plug from the cervix is
released
○ If the membranes have not previously ruptured,
they will usually rupture at full dilatation (10 cm)
● CONTRACTIONS
○ Contractions reaches their peak of intensity
○ INTERVAL: 2–3 minutes
○ DURATION: 60–90 seconds
○ NOTE: Not to be mistaken for labor
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● MANIFESTATIONS
○ Experience feeling of loss of control
○ Anxiety, panic, and irritability (giving birth is the
mind’s focus; gusto na lang niya i-deliver)
○ Intense discomfort may cause N/V
NURSING DIAGNOSES RELATED TO LABOR
1. POWERLESSNESS R/T DURATION OF LABOR
● They feel na wala na silang choice but to go into
labor
● NURSING INTERVENTIONS
○ Help empower women
● Ask each woman what will make her feel
most comfortable
● Breathing with contractions, change of
position, passive and quiet environment
(shouting and crying are inevitable, but try
to provide a quiet environment to help the
mother gain control)
○ Respect contraction time
● Allow the patient to finish breathing with
contractions
○ Promote change of positions
● Either out of bed, kneeling, squatting,
walking, sitting, ballroom dancing, swaying,
soaking in warm water
● Active movement can shorten labor if it is
not contraindicated
○ Help with fetal alignment
● Squatting, all-fours position
○ Promote voiding and provide bladder care
● Void every 2–4 hours during labor
● Percussion of the bladder (dull and
resonant)
● If the mother is unable to void,
catheterization using French 12–14 is done
2. RISK FOR INEFFECTIVE BREATHING PATTERN R/T
BREATHING EXERCISES
● HYPERVENTILATION
○ Brought about by the deep exhalation, there is
too much loss of carbon dioxide leading to
respiratory alkalosis
○ Respiratory Alkalosis: lightheaded, numbness
at toes and fingertips, loss of consciousness
○ Paper bag/cupped hands covering the mouth
and the nose
● When the mother inhales, hindi nawawala
‘yung CO2, nare-rebreathe niya.
● The CO2 is now balanced
 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON

● Determined by the fetal lie and by the body part of

3. ANXIETY R/T STRESS OF LABOR the fetus that enters the maternal pelvis first
● Presenting part refers to the part of the fetus that
● Offer support
presents at the internal cervical os and may either
○ Respect and promote the support person
be the head, the buttocks, the shoulder, brow, chin,
(doula)
face or feet
● Hydrotherapy
● Cephalic, breech, and shoulder
○ Submerged in water while in labor
○ The feel/buoyancy of the water is relaxing for
4. FETAL ATTITUDE
the person in labor

4. RISK FOR FLUID VOLUME DEFICIT R/T PROLONGED ● Posture of a fetus during labor
LACK OF ORAL INTAKE AND DIAPHORESIS FROM THE ● FLEXION: Mammalian fetuses have a tendency to
EFFORT OF LABOR assume a fully flexed posture during development
and during parturition (also includes arms, legs,
● Glass of fluid every hour if permitted
and longitudinal posture)
● Offer ice chips, popsicles, and lollipops
○ Allows for the delivery of the head by its
● Isotonic sports drinks may be given to prevent
smallest bony diameter
dehydration, exhaustion, and uterine inertia
○ A loss of this flexed posture presents a
○ Isotonic dapat para hindi magkaroon ng
progressively larger fetal head to the bony
changes sa cell
pelvis for labor and delivery
● Lip balm to prevent cracking and drying of the lips

5. FETAL POSITION
NURSING CARE AND MANAGEMENT
● Relation of the fetal presenting part to a specific
HISTORY TAKING quadrant of the woman’s pelvis

● Review of the woman’s pregnancy, 6. STATION

(physical/psychological events) general health,
family medication information
● Confirm EDB/EDD, time when contractions began,
and amount/characteristics of any show
● Check for ROM if any, drug allergies, GPTPALM, and
birth plan
PHYSICAL ASSESSMENT
● Leopold’s maneuver and/or internal examination
are done to determine the following:
1. EFFACEMENT, DILATATION, AND CONDITION OF THE
MEMBRANES
2. FETAL LIE
● Relationship of the cephalocaudal axis (spinal
column) of the fetus to the cephalocaudal axis of
the woman
● LONGITUDINAL LIE: cephalocaudal axis of the fetus
is parallel to the woman’s spine
● TRANSVERSE LIE: cephalocaudal axis of the fetal
spine is at the right angles to the woman’s spine
3. FETAL PRESENTATION
● Relation of the fetal presenting part to the level of
the ischial spines
7. ENGAGEMENT
● Settling of the presenting part of a fetus far enough
to the pelvis to be at the level of the ischial spine
8. LOCATION OF FETAL HEART TONE IN RELATION TO
PRESENTATION
● VERTEX: area of the fetal back (LLQ or RLQ)
● BREECH: at or above the level of the umbilicus
● FACE: at the area of the fetal chest
● Average fetal heart rate is between 110 and 160 bpm
(can vary by 5–25 bpm)
● The fetal heart rate may change as your baby
responds to conditions in your uterus
○ An abnormal fetal heart rate may mean that
your baby is not getting enough oxygen or that
there are other problems
● With every contraction, there will be a fetal
response (seen in the fetal heart rate)
● WHAT CAN WE USE TO GET THE FHT?
○ Stethoscope and Doppler ultrasound
○ NOTE: Do not take the FHT once the uterus is
contracted as it will give you unreliable results.

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 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON

● You need to simultaneously get the fetal
heart tone and maternal pulse to
determine if the sound you are hearing
comes from the baby and not from the
mother’s heartbeat (maternal souffle)
● Do not artificially induce labor unless the fetus is in
distress
● Allow the patient to move freely during labor
● DOULA: caring support person during labor
● No need to insert IV and other interventions
● Position of choice during labor
● Non-separation of mother and baby after birth
unless contraindicated

ADDITIONAL INTERVENTIONS

● RAPPORT: Provide privacy and assurance; establish

therapeutic relationship
● HYGIENE:
○ Bath for comfort and relaxation
○ Wipe front to back to prevent contamination
○ Perineal preparation
● Shaving depends on the patient or on
hospital protocol
● FOOD AND FLUIDS:
○ NPO, start IVF, and monitor input and output
FETAL HEART RATE AND UTERINE CONTRACTION ○ Avoid solid foods as these can cause:
RECORDS
● Digestion: delays labor
100–109 bpm; vagal
response from compression ● Full stomach: interferes with proper bearing
Moderate Bradycardia down
of fetal head; vagus nerve
stimulation = bradycardia ● Aspiration
Marked Bradycardia <100 bpm; hypoxia ● BLADDER: must be emptied every 2–3 hours
○ Distended bladder may retard fetal descent,
Moderate Tachycardia 161–180 bpm
urinary stasis can lead to UTI, full bladder can
>180 bpm; hypoxia, be traumatized during delivery
maternal fever, fetal ● BEARING DOWN: done only during true labor
Marked Tachycardia
arrhythmia, maternal contractions (cervix fully dilated and effaced) to
anemia or hypothyroidism
minimize maternal exhaustion and possible
lacerations
9. VITAL SIGNS ● SIM’S POSITION: encourage to change and assume
comfortable position
● Assess between contractions for comfort and
○ Favors anterior rotation of the head (allows
accuracy
faster delivery)
● DO NOT TAKE during contractions as the blood
○ Promotes relaxation between contractions
vessels are constricted.
○ Prevents supine hypotension syndrome
○ INACCURACY: Pwedeng mababa or possible
● MONITORING:
ring mataas ang HR because the baby is
○ UTERINE CONTRACTION: every hour during
compensating for the lack of blood supply
latent phase and every 30 mins during active
● Check for frequency, duration, and intensity of
phase
contractions
● Should not be taken during contractions
● Use the pain scale to identify if the labor is
● During uterine contractions, no blood goes
progressing
to the placenta. The blood is pooled in the
○ Pain should be escalating
peripheral blood vessels which results in
● Check the urine specimen for presence of protein
increased blood pressure
and glucose
○ VITAL SIGNS: BP and FHR taken every hour
during the latent phase and every 30 mins.
10. LABOR AS A NATURAL PROCESS
during the active phase
● Must be a joyful and memorable experience

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 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON
● FHR tends to decrease during a contraction
because of the compression of the fetal
head.
○ When the fetal head is compressed by
the contracting uterus, the vagus nerve
is stimulated, thus causing
bradycardia.
● Normal FHR: 120–160 bpm
● DRUG ADMINISTRATION:
○ ANALGESICS: Demerol is usually given; acts to
suppress the sensory portion of the cerebral
cortex
● This way, the mother feels less pain
○ ANESTHETICS: regional anesthesia is preferred
over any other form as it does not enter
maternal circulation and therefore does not
retard labor contractions nor cause respiratory
depression in the newborn
● DANGER SIGNS: be aware of the danger signs of
labor and delivery (fetal/maternal distress)
○ FETAL DISTRESS
● Tachycardia: >160 bpm
● Bradycardia: <110 bpm
● Meconium: green-stained amniotic fluid
● Fetal thrashing or hyperactivity due to the
fetus struggling for more oxygen.
● Fetal Acidosis: blood pH below 7.2
○ MATERNAL DISTRESS
● BP over 140/90 or falling BP (associated with
clinical signs of shock e.g. pallor,
restlessness or apprehension, and
increased RR and PR)
● Hemorrhage: abnormal PR >100 bpm
● Inadequate/prolonged contractions
● Abnormal lower abdominal contour
● Oxygen deprivation/internal hemorrhage:
increasing apprehension
● TRANSFER: labor room to the delivery room when
cervix is dilated
○ Multiparas: cervical dilatation of 7-9 cms
○ Primiparas: full dilation
B. SECOND STAGE (Expulsion/Fetal Delivery)
● Time span from full dilatation and cervical
effacement to birth of the infant
● A patient typically feels contractions change from
the characteristic crescendo–decrescendo pattern
to an uncontrollable urge to push or bear down with
each contraction as if to move their bowels
● Momentary N/V
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○ This is because pressure is no longer exerted on
their stomach as the fetus descends into the
pelvis
● Perspiration and Distention of Vessels
○ Caused by forceful pushing
● The fetus begins descent and, as the fetal head
touches the internal perineum to begin internal
rotation, the perineum begins to bulge and appear
tense
○ The anus may become everted, and stool may
be expelled
○ CROWNING: As the fetal head pushes against
the vaginal introitus, this opens and the fetal
scalp appears at the opening to the vagina and
enlarges from the size of a dime, to a quarter,
then a half-dollar.
DECELERATION PHASE
● The progress of labor does not slow down
● The final degree of cervical dilation is achieved and
the cervix retracts over the presenting part
FETAL DESCENT PHASE
● Fetus descent in the pelvic ring, being pushed
beyond the open cervix, perineum begins to bulge
(labia), and vaginal introitus stretched apart
DFIERE: MECHANISMS OF LABOR
● Also known as the cardinal movements of labor
● Passage of a fetus through the birth canal involves
a number of different position changes to keep the
smallest diameter of the fetal head always
presenting to the smallest diameter of the birth
canal
● Only applicable to cephalic presentation
● Engagement, descent, and flexion → IR → ER
(restitution) → extension → ER (shoulder rotation)
→ extension complete → expulsion
DESCENT (D’RIERE)
● Downward movement
of the biparietal
diameter of the fetal
head within the pelvic
inlet
● Occurs because of
pressure on the fetus
by the uterine fundus
● FULL DESCENT
 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON

○ Occurs when the fetal head protrudes beyond EXTERNAL ROTATION

the dilated cervix and touches the posterior
vaginal floor ● RESTITUTION: Almost
● As the pressure of the fetal head presses on the immediately after the head
sacral nerves at the pelvic floor, the pregnant of the infant is born, the
person will experience the typical “pushing head rotates a final time
sensation,” which occurs with labor (from the anteroposterior
○ This pushing, which contracts the abdominal position it assumed to enter
muscles, aids descent the outlet) back to the
FLEXION diagonal or transverse
position of the early part of labor
● As descent is completed and the fetal head ● It would rotate 45 degrees to the left so that the
touches the pelvic floor, the head bends forward anterior shoulder is just below the pubic arch
onto the chest, causing the smallest
anteroposterior diameter (the ● SHOULDER ROTATION: The
suboccipitobregmatic diameter) to present to the after-coming shoulders are
birth canal brought into an
● Aided by abdominal muscle contraction during anteroposterior position, (best
pushing for entering the outlet)
● ATTITUDE: degree of flexion that the fetus assumed ● The anterior shoulder is
prior to delivery born first, assisted perhaps by
downward flexion of the
INTERNAL ROTATION infant’s head
● NOTE: Ask the mother not to push anymore but do
● During descent, the deep breathing
biparietal diameter of the fetal
skull was aligned to fit through EXPULSION
the wider anteroposterior
diameter of the pregnant ● End of the pelvic
person’s pelvis division of labor
● As the head flexes at the ● Once the shoulders are
end of descent, the occiput born, the rest of the baby is
rotates so the head is brought born easily and smoothly
into the outlet of the pelvis, or the anteroposterior because of its smaller size
diameter is now in the anteroposterior plane of the
pelvis
● This movement brings the shoulders into the
optimal position to enter the inlet, or puts the widest
diameter of the shoulders (a transverse one) in line
with the wide transverse diameter of the inlet
● SEQUENCE: occipitotransverse (LOT) → left
occipitoanterior (LOA) → occiput anterior (OA)
○ The occiput is now either superior to or just
below the symphysis pubis

EXTENSION

● As the occiput of the fetal head is born, the back of

the neck momentarily stops beneath the pubic
arch and acts as a pivot for the rest of the head ELECTRONIC FETAL MONITORING
● The head extends, and the foremost parts of the
head, the face and chin, are born
EXTERNAL FETAL MONITOR

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 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON

● Test used during pregnancy that is non-invasive,

easily applied, has less discomfort
○ Disadvantages: DOB, limited change of position
● Measures a baby's heart rate and the mother's
contractions
○ CONTRACTIONS: fundus of the mother
○ FHT: fetal back
● Uses instruments (electrodes) placed on the
mother's belly to make the measurements
● Results are viewed as graphs on a video screen

Upper grid is used for recording FHR and is vertically

scaled in bpm. The lower grid is for recording uterine
activity and is vertically scaled in mmHg

EXTERNAL UTERINE CONTRACTION MONITORING

TOCODYNAMOMETER

● Increased myometrial tension measured through

the abdominal wall

FLUCTUATIONS IN FHR
INTERNAL FETAL MONITOR

● Involves placing a electrode directly on the fetal

scalp through the cervix
● This test is performed to evaluate fetal heart rate
and variability between beats, especially in relation
to the uterine contractions of labor
● Invasive, 3cm dilation, ruptured membranes, more
discomfort
● For high risk labor; high chance of infection

ACCELERATIONS

● A short-term rise in the heart rate of at least 15

beats per minute, lasting at least 15 seconds
● Accelerations are normal and healthy. They tell the
doctor that the baby has an adequate oxygen
supply
● Non-periodic; increase in FHR; below 30 secs
● Caused by fetal movement, change in maternal
position, or analgesics
● BEFORE 32 WEEKS (PRETERM): 10 bpm; 10 seconds
● AFTER 32 WEEKS (8th month): 15 bpm; 15 seconds

EARLY DECELERATION [MIRRORING]

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 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON
● DECELERATION:
○ Temporary drops in the fetal heart rate
● Early decelerations are generally normal
and not concerning
● Late and variable decelerations can
sometimes be a sign the baby isn’t doing
well
○ Symmetrical; periodic lower in FHT
○ Caused by pressure on the fetal head during
contractions, stimulating the vagus nerve which
causes parasympathetic stimulation
● Follows pattern of uterine contraction
○ Begins at the onset of contraction and end as
the contraction ends
○ Just prior to or early in contraction
● Inverse of contraction waveform
○ Waveform consistently uniform; inversely
mirrors contraction
○ Peak of contraction = decrease in FHR
● <100 bpm and returns to normal at the end
of the contraction
● Caused by pressure on the fetal head as it
progresses down the birth canal
● Increased intracranial pressure stimulates
vagus nerve which slows the heart rate
● Usually seen in active labor when dilatation 4–7 cm
○ Baby is descending through the birth canal
● If early labor tapos may early deceleration, baka
may cephalopelvic disproportion si mother (needs
to undergo CS)
● Can be single or repetitive
● NURSING INTERVENTIONS
○ No intervention is needed
○ Continuous monitoring of the baby
LATE DECELERATION
● OCCURS LATE IN CONTRACTION: delayed 30–40
seconds after the onset of contractions and
continued beyond end of contraction
○ Consistently after the midpoint of the
contraction
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○ Occasional, consistent, gradually increase to
repetitive
● Due to uteroplacental insufficiency
○ Decrease blood flow impeding oxygen transfer
to the fetus through the intervillous space
during intense uterine contraction (hypoxemia)
● Supposedly by the end of the contraction,
magiging normal ulit kasi nare-reestablish
‘yung blood flow
● NURSING INTERVENTIONS:
○ Left-lateral position to supply oxygenation and
blood flow
○ IV and oxygen provision
○ CS: late decelerations that occur along with
tachycardia and very little variability can mean
that the baby is in fetal distress
PROLONGED DECELERATION
● Decrease in FHR of 15 bpm or more and lasts longer
from 2-3 minutes
● May be a sign of cord compression or maternal
hypotension
VARIABLE DECELERATION
● Decelerations at unpredictable times in relation to
contractions
● Due to umbilical cord compression, ROM, rupture
of BOW, or oligohydramnios (too little amniotic
fluid)
● Decreases amount of blood flow to the fetus
● Repetitive deceleration may indicate short cord or
nuchal cord
● CS, forcep births or vacuum extraction is indicated
● Waveform variable, generally sharp drops and
returns
● Abrupt with fetal insult: not related to contraction
● Not usually within normal range
● Variable-single around midpoint or repetitive
 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON
● NURSING INTERVENTIONS
○ Left-lateral position
○ Oxygen supplementation
○ Knee-chest position
NURSING CARE AND MANAGEMENT
1. PREPARING THE PLACE OF BIRTH
● Multipara: 7–8 cm dilation
● Primipara: crowning [10 cm] (quarter–half dollar)
● Table with instruments (with cover)
● Radiant heat warmer, equipment for resuscitation,
eye care (ophthalmia neonatorum), and
identification
2. PROPER POSITIONING ON THE DELIVERY TABLE
● Lithotomy: clear view of perineum, no slow fetal
descent, and no thrombophlebitis
● Alternative positions (lateral, Sim’s and dorsal
recumbent), semi-sitting, squatting
○ Favored because of less tension on the
perineum and results in fewer perineal tears
3. BEARING DOWN TECHNIQUE
● Best time to encourage pushing contractions, the
woman is asked to take two short breaths and bear
down the peak of the contraction
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○ Peak of contraction kapag matigas na ‘yung
abdomen
● No Valsalva maneuver → impaired blood return
○ Increases maternal abdominal pressure and
puts increased workload on the heart
○ Mag-de-decrease ang uterus and placental
blood flow
● Prolonged descent is associated with
chorioamnionitis, increased CS, and urinary
incontinence
● Assume any comfortable position (align fetal
presenting part with cervix, increase pelvic
diameters, use fetal weight to help with descent)
● Breathe naturally, use blow-blow breathing pattern
to prevent pushing between contractions and have
an effective support person
○ Do not go against uterine contractions
● FOR EFFECTIVE 2ND STAGE PUSHING:
○ Effective support person
○ Wait to feel for urge to push
○ Semi-fowler’s position with legs raised against
abdomen, squatting, all-fours (allow gravity to
aid the effort)
○ Short or long/sustained pushes (comfortable
for the mother; push as if defecating)
○ No Valsalva
○ Breathe out during a pushing effort
○ Multipara: pant breathe
4. PERINEAL CLEANING AND MASSAGE
● Massage the perineum
○ Done during internal examination
○ Para hindi nabibigla ‘pag delivery na
● Use warmed antiseptic solution
● Rinse the perineal area with sterile water and clean
the vagina from inner to outer part; clean compress
with each stroke
5. CARE OF THE EPISIOTOMY WOUND
● Episiotomy is a surgical incision of the perineum
made to prevent tearing of the perineum and to
release pressure on the fetal head during delivery
○ Bandage scissors is used to avoid causing
harm to the fetal head
 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON
○ No anesthesia is necessary during episiotomy
as the pressure of the fetal presenting part
against the perineum (crowning) is so intense
that the nerve endings for pain are
momentarily deadened, resulting in natural
anesthesia
● MEDIAN EPISIOTOMY: begun in the midline of the
perineum and directed toward the rectum
○ Appear to heal more easily, cause less blood
loss, and result in less discomfort to a woman in
the postpartum period.
● MEDIOLATERAL EPISIOTOMY: begun in the midline of
the perineum but directed laterally away from the
rectum
○ Have the advantage over midline cuts in that, if
tearing occurs beyond the incision, it will be
away from the rectum with less danger of
complication from rectal mucosal tears.
6. BREATHING TECHNIQUES
● As soon as the head crowns, the woman is
instructed not to push any longer as it can cause
rapid expulsion of the fetus. Instead, she could be
advised to pant (rapid and shallow breathing)
7. RITGEN’S MANEUVER
● Support the perineum during crowning by applying
pressure with the palm against the rectum with a
sterile towel or sanitary pad
○ Will not only prevent lacerations of the
fourchette but will also bring the fetal chin
down the chest so that the smallest diameter of
the fetal head is the one presented at the birth
canal.
● The head should be pressed gently while it slowly
eases out to prevent rapid expulsion of the fetus
○ Could result to not only to lacerations, abruptio
placenta, and uterine inversion but also shock
because of sudden decrease in intra
abdominal pressure
● As soon as the head has been delivered, the nurse
should insert two fingers into the vagina to feel for
the presence of a cord looped around the neck. If it
is loose, it should be slipped down the shoulder, be
clamped twice an inch part and cut in between.
● As the head rotates, give a gentle, steady
downward push in order to deliver the anterior
shoulder and then a gentle, upward lift to deliver
the posterior shoulder.
● While supporting the body’s head and neck, the rest
of the baby is delivered
● Time of delivery must be noted
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8. PROPER HANDLING OF THE NEWBORN
● Immediately after delivery, the newborn should be
held below the level of the mother’s vulva so that
blood from the placenta can enter the infant’s body
on the basis of gravity flow
9. CUTTING OF THE CORD
● Postponed until pulsations have stopped as
50–100ml of blood is flowing from the placenta to
the newborn at this time
● DELAYED CUTTING (PHYSIOLOGIC CLAMPING)
○ Continue to pulsate for a few minutes after birth
○ Delayed cutting can prevent polycythemia and
hyperbilirubinemia because of 50-100 mL of
blood from placenta to fetus
● (+) Adequate RBCs and WBCs
○ Clamp the cord 8–10 inches from the infant's
umbilicus with 2 hemostats then cut in the
middle of the hemostats (the partner may cut)
○ Check for 3 vessels
● AVA: 2 arteries, 1 vein (larger diameter)
● Wharton's jelly
10. INITIAL CONTACT
● If there is no complication after delivery,
maternal–infant bonding is initiated as soon as the
baby has been suctioned and provided warmth
● The mother is informed of the baby’s sex and
condition and allow her to hold onto her baby,
maybe put to breast to suck, it can help contract
the uterus as well as the weight of the baby on her
abdomen
C. THIRD STAGE (Placental Expulsion)
● Begins with the birth of the infant and ends with the
delivery of the placenta
● The placenta is a freely disc-like organ that is 15-20
cm in diameter and 2.3 cm in thickness and weighs
500 grams at term
○ A mature placenta has 16-30 separate
segments known as cotyledons
● After the birth of the infant, the uterus can be
palpated as a firm, round mass just below the level
of the umbilicus
● After a few minutes of rest, uterine contractions
begin again, and the organ assumes a discoid
shape
○ It retains this new shape until the placenta has
separated, approximately 5 minutes after the
birth of the infant
 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON

PLACENTAL SEPARATION ○ NOTE: Pressure should never be applied to a

uterus in a non-contracted state because
● Occurs because of the disproportion between the doing so could cause the uterus to evert (turn
placenta and the contracting wall of the uterus that inside out), accompanied by massive
happens as the uterus contracts down on an hemorrhage
almost empty interior ● If the placenta does not deliver spontaneously, it
● Active bleeding on the maternal surface of the can be removed manually.
placenta begins with separation, which helps to ○ It needs to be inspected after delivery to be
separate the placenta still further by pushing it certain it is intact and part of it was not
away from its attachment site retained (which could prevent the uterus from
● As separation is completed, the placenta sinks to fully contracting and lead to postpartum
the lower uterine segment or the upper vagina hemorrhage)
● SIGNS THE PLACENTA IS READY TO BE DELIVERED:
○ There is lengthening of the umbilical cord NURSING CARE AND MANAGEMENT
○ A sudden gush of vaginal blood occurs
1. PLACENTAL DELIVERY AS THE MAIN FOCUS
○ The placenta is visible at the vaginal opening
○ Calkin’s Sign: the uterus contracts and feels ● Never hurry the delivery of the placenta by
firm round in shape and rising high at the level forcefully pulling out the cord or by vigorous fundal
of the umbilicus push as this can lead to uterine inversion
● SCHULTZ PRESENTATION ● Encourage the mother to push with contractions to
○ Placenta aid in placental expulsion
separates ● BRANDT ANDREWS MANEUVER: wind the cord
first at its around the clamp, then deliver the placenta by
center and rotating it so that no placental fragments are left
lastly at its inside the uterus
edges
○ Presents at 2. TAKE NOTE OF THE TIME OF PLACENTAL DELIVERY
the vaginal
opening ● Should be delivered within 20 minutes after the
with the delivery of the baby
fetal ○ If the placenta is not delivered within this time,
surface evident the doctor should be immediately notified as it
○ Shiny and glistening could be a sign of uterine atony, a condition
○ Fetal surface that could lead to death due to hemorrhage
● DUNCAN PRESENTATION
3. COMPLETENESS OF COTYLEDONS
○ Placenta separates first at its edges and slides
along the uterine surface ● Incomplete cotyledons means that some placental
○ Presents at the vagina with the maternal fragments may have been retained in the uterus.
surface evident ● This will prevent the uterus from contracting well
○ Looks raw, red, irregular, with the ridges or and, therefore, cause excessive bleeding.
cotyledons evident
○ Dirty Irregular maternal surface 4. DETERMINE DEGREE OF UTERINE CONTRACTION
● NOTE: 300–500 mL blood loss may occur as
placental separation occurs before the uterus ● If relaxed, boggy or non-contracted, the
contracts sufficiently to seal maternal capillaries immediate nursing actions are: a) massage the
fundus gently and properly and/or b) apply an ice
PLACENTAL EXPULSION or ice cap over the abdomen.
● NOTE: Massage muna ‘yung uterus bago notify
● Placenta delivers either by the natural yung physician
bearing-down effort of the birthing parent or the
Crede’s maneuver (gentle pressure on the 5. ADMINISTRATION OF OXYTOCIC AGENTS
contracted uterine fundus by the primary
healthcare provider) ● Administered as ordered to ensure uterine
contractions, thus preventing hemorrhage

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 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON
● Methergine (0.2 mg/mL) and Syntocinon/Oxytocin
(10 u/mL): more commonly-given oxytocics; given
intramuscularly
● NOTE: Never administered oxytocics before
placental delivery, it may cause placental
entrapment.
● Hypertension: common side effect of oxytocins
○ The nurse should, therefore, assess or monitor
the blood pressure of mothers who have
received oxytocics
6. PERINEAL LACERATIONS
● Presence of bright red vaginal bleeding following
placental delivery and if the uterus is firm,
lacerations should be suspected
○ LACERATIONS: ragged edges which heal more
slowly and therefore predispose the mother to
infection
● CLASSIFICATIONS
○ FIRST DEGREE: involve the vaginal mucous
membrane and the skin of the perineum to the
fourchette
○ SECOND DEGREE: vagina, perineal skin, fascia,
levator ani muscle, and perineal body
○ THIRD DEGREE: entire perineum and external
sphincter of the rectum
○ FOURTH DEGREE: entire perineum, rectal
sphincter and some of the mucous membrane
of the rectum
7. EPISIORRHAPHY
● Repair of episiotomy or lacerations
● Xylocaine: local anesthetic given in order to
minimize pain during the procedure.
● Vaginal Packing: done to maintain pressure on the
suture line and, therefore, prevent bleeding. The
nurse should be aware that this packing is usually
removed after 24-48 hours.
8. ESTIMATE AMOUNT OF BLOOD LOSS
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● The normal amount of blood loss during labor and
delivery is around 300–500 mL
○ CS: 500-1000mL
● Any amount exceeding 500 mL is considered
hemorrhage.
9. PERINEAL CARE
● Provide comfort and perineal care, apply clean
sanitary
● Soiled napkins should be removed from front to
back.
10. VITAL SIGNS
● Take vital signs every 15 minutes for the first hour
and palpate the uterine fundus for size, and
position.
● Pulse may become rapid 80-90 min., respiration
20-24/min. and BP slightly elevated due to the
excitement of the mother and recent oxytocin
administration.
11. TRANSFER BACK TO ROOM
● Transfer back to room (recovery room if she had
undergone anesthesia) and position flat on bed
without pillows to prevent dizziness due to decrease
in intra-abdominal pressure
● Marks the start of the fourth stage of labor
D. FOURTH STAGE (1–4 hours after delivery)
● The stage refers to the first one to four hours
immediately after delivery when the VS are quite
unstable.
○ As critical as the other three stages of labor
● CRITICAL CONDITION: possibility of uterine atony
○ May lead to bleeding
NURSING CARE AND MANAGEMENT
ASSESSMENT
● FUNDUS: palpate every 15 minutes during the the
first hour and every 30 minutes for the next hours
○ Palpate at the midline of the umbilicus
○ Should feel firm
● BLADDER: checked every 2 hours during the 1st 8
hours and every 8 hours for 3 days
○ Suspect full urinary bladder if fundus is not well
contracted and is shifted to the right
○ A full bladder prevents good contraction of the
uterus and may cause hemorrhage
● VAGINAL DISCHARGE: checked every 15 minutes
and should be moderate
 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON
○ Saturated napkin every 30 minutes means
excessive bleeding
● BP AND PR: check every 15 minutes during the first
hour and then every 30 minutes until stable
● PERINEUM: inspect every 8 hours for 3 days
○ Note that the episiorrhaphy should be clean
and intact
COMFORT MEASURES
● Perform perineal care gently and apply napkin
● Lower legs simultaneously from the stirrups and
position the patient flat on the bed
○ To prevent dizziness
● Give the patient a soothing sponge bath then
change their linen and clothing
● Provide additional blankets
● Give them initial nourishment of coffee, tea, soup, or
milk
● Provide a quiet and restful environment
● Allow the patient to take enough rest and sleep in
order to regain energy
RESPONSES TO LABOR
MATERNAL PHYSIOLOGIC EFFECTS
CARDIOVASCULAR SYSTEM
● Cardiac output increases 40%–50% from prelabor
levels.
● Blood loss at birth is 300–500 mL on average.
● Blood pressure may rise with pain response and,
due to work of the system during contractions, by
an average systolic rise of 15 mm Hg per
contraction. Epidural anesthesia may cause
hypotension.
● HEMATOPOIETIC SYSTEM/BLOOD: During labor,
WBCs increase to a level of 25,000–30,000
cells/mm3 compared to 5,000–10,000 cells/mm3
(leukocytosis; response of stress and heavy
exertion)
● NURSING MANAGEMENT
○ Monitor closely for hemorrhage
○ Monitor for signs of pathology with hypertensive
episodes.
○ If allowed, increase fluid intake. If not, start IV
insertion
○ Ensure that patients are well hydrated prior to
epidural administration. This usually involves an
IV fluid bolus.
○ Put the patient on upright or side-lying position
RESPIRATORY SYSTEM
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● Increased respiratory rate to respond to increased
cardiovascular parameters
● Total oxygen needs increase 100% during the
second stage of labor
● NURSING MANAGEMENT
○ Monitor for any signs of hyperventilation
● If hyperventilation occurs, rebreathing into
a paper bag can be helpful
○ If needed, use appropriately patterned
breathing exercises to regulate respiratory rate
● Sabayan ang mother sa pag-inhale &
exhale
TEMPERATURE REGULATION
● Body temperature may increase up to 1°F
● Diaphoresis occurs with increased muscular
activity, accompanying evaporation to cool and
limit excessive warming
● NURSING MANAGEMENT
○ Monitor for any signs of infection
○ Offer cool washcloths for the patient’s forehead
for comfort if needed
FLUID BALANCE
● Insensible water loss increases during labor due to
diaphoresis and the increase in rate and depth of
respirations
● NURSING MANAGEMENT
○ Encourage patients to sip fluid during labor the
same as they would if they were exercising to
keep hydrated
○ If a patient is nauseated by labor, encourage
sips of fluid, ice chips, or hard candy to supply
some extra fluid
URINARY SYSTEM
● Pressure of the fetal head as it descends in the birth
canal against the anterior bladder reduces bladder
tone or the ability of the bladder to sense filling
● NURSING MANAGEMENT
○ Advise the mother to void every 2 hours to
avoid overfilling/distention as this can decrease
postpartum bladder tone
MUSCULOSKELETAL SYSTEM
● During pregnancy, relaxin is secreted from the
ovaries, causing the cartilage between joints to be
more flexible.
○ This allows the joints of the pelvis to be able to
open as much as 2 cm in labor to allow for fetal
passage
● NURSING MANAGEMENT
 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON
○ Monitor for appropriate mobility and be mindful
of fall risks
GASTROINTESTINAL SYSTEM
● Blood shunts to life-sustaining organs causing the
GI system to become fairly inactive during labor
● Digestive and emptying time of the stomach
becomes lengthened
● Some patients experience a loose bowel movement
as contractions grow strong
● NURSING MANAGEMENT
○ Recommend small but high caloric intake of
snacks (chocolate bars, sports drink, yogurt)
NEUROLOGIC AND SENSORY RESPONSE
● Increased pain and RR
● NURSING MANAGEMENT
○ Where pain registers is important in
appreciating why epidural anesthesia is
effective. For early labor, the anesthetic block
needs to suppress the lower thoracic synapses;
for birth, it needs to block sacral nerves.
○ Discuss nonpharmacologic pain techniques if
the patient does not desire medication.
MATERNAL PSYCHOLOGICAL EFFECTS
● Labor can lead to emotional distress because it is
not only painful and fatiguing but it also represents
the beginning of a major life change for a birthing
parent and partner
● NURSING MANAGEMENT
○ Offer expeditious care to the patient.
○ Continue to encourage the process of labor.
○ Prior to birth, a birthing parent can investigate
the services of a doula.
○ DOULA: an individual with specialized training
who provides physical, emotional, and
psychological support to laboring parents
● Does not perform clinical tasks
● Their presence has been shown to reduce
the need for analgesia and anesthesia
requests, shorten labor times, and increase
satisfaction with the birth experience
MATERNAL RESPONSES
PAIN
● Cultural factors can strongly influence a patient’s
experience and satisfaction with labor
● To make labor a positive experience, be prepared
to adapt care to the patient’s specific needs
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FATIGUE
● By the time the date of birth approaches, a birthing
parent is generally tired from the normal
discomforts of pregnancy and has not slept well for
the past month
● Sleep hunger from this type of discomfort can
make it difficult for a person to perceive situations
clearly or to adjust rapidly to new situations
● It can make the process of labor loom as an
overwhelming, unendurable experience unless the
patient has competent people to offer support,
reassurance, and comfort
FEAR
● Being taken by surprise—labor moving faster or
slower than anticipated or contractions harder and
longer than they remember from a previous
pregnancy—can lead a patient to feel out of control
and increase their level of pain
● This sense of lack of control combined with pain
may cause a patient to begin to worry for the infant
and fear they will not meet their own behavioral
expectations
● Contractions last a certain length and reach a
certain intensity but always have a rest period in
between, so patients can have a break from pain.
● Fear of labor this way releases adrenaline, and
adrenaline interferes with oxytocin release and so
can limit the effectiveness of uterine contractions
● NURSING INTERVENTION: Explain and repeat as
necessary that labor is predictable but also
variable
FETAL PHYSIOLOGIC EFFECTS
CARDIOVASCULAR SYSTEM
● HYPOXIA DURING A CONTRACTION
○ As the arteries of the uterus become sharply
constricted, and the filling of cotyledons almost
completely halts, the amount of nutrients,
including oxygen, exchanged during this time is
greatly reduced, causing a slight but
inconsequential fetal hypoxia.
● INCREASED BLOOD PRESSURE
○ Caused by increased intracranial pressure
raises blood pressure and keeps circulation
from falling below normal for the duration of a
contraction
NEUROLOGIC SYSTEM
 MODULE 04 & 05 – INTRAPARTAL CARE AND THE LABOR PHENOMENON

● Uterine contractions exert pressure on the fetal

head, so the same response that is involved with
any instance of increased intracranial pressure
occurs.
● FETAL HEART RATE
○ The fetal heart rate (FHR) decreases by as
much as five beats per minute during a
contraction, as soon as contraction strength
reaches 40 mm Hg; although not measurable,
fetal blood pressure also rises.
○ The decrease in FHR appears on a fetal heart
monitor as a normal or early deceleration
pattern.

INTEGUMENTARY SYSTEM

● The pressure involved in the birth process is often

reflected in minimal petechiae or ecchymotic areas
on a fetus (particularly the presenting part)
● There may also be edema of the presenting part
(caput succedaneum) from this pressure

MUSCULOSKELETAL SYSTEM

● The force of uterine contractions tends to push a

fetus into a position of full flexion or with the head
bent forward, which is the most advantageous
position for birth

RESPIRATORY SYSTEM

● The process of labor appears to aid in the

maturation of surfactant production by alveoli in
the fetal lung
● Both the pressure applied to the chest from
contractions and passage through the birth canal
help to clear the respiratory tract of lung fluid
○ For this reason, an infant born vaginally is
usually able to establish respirations more
easily than a fetus born by cesarean birth

REFERENCES
Synchronous Lecture: 07 & 17 Oct 2022 (CI: Dr. Angela
Gonzales/Ma’am Jennie Junio)
Module: NCM 0107 LEC Mod 04 and Mod 05
Presentation Deck: Module 04 Labor and Delivery
Book: Maternal and Child Health Nursing

NCM 0107 | Banaag, Cato, Diala, Mallari, Malonzo, Navarro, Paras|29