NUR 1210: MATERNAL AND CHILD NURSING

LECTURE | DR. WILFREDO QUIJENCIO – FACULTY OF NURSING

FAR EASTERN UNIVERSITY | BACHELOR OF SCIENCE IN NURSING | 1ST SEMESTER A.Y. 2023-2024

MODULE 4: NURSING CARE OF THE CLIENT DURING LABOR AND DELIVERY

DYSTOCIA FACTORS AFFECTING LABOR

• Abnormally slow progress of labor
• Most common contemporary indication of primary PASSENGER PASSAGEWAY POWERS PLACENTA PSYCHE POSITION OF
LABORING
WOMAN
cesarean section Fetal bones Gynecoid Strength, Site of Psychological LABOR:

• It is slower than the expected time frame Suture lines

Fontanels
Anthropoid
Android
Duration and
Frequency of
insertion of
the placenta
state of the
woman
Walking
Standing

• Can arise in the 4Ps of the labor process: Head Meas.

Fetal lie
Platypelloid uterine
contraction Stress factors
Leaning
Tailor sitting
o Power – force that propels the fetus (uterine Fetal attitude,
presentation,
Configuration
and diameter of
(primary
powers of
leading to
hypotonia
Semi-
recumbent
position, the maternal labor), hand knees
contractions) station pelvis involuntary Squatting
o Passenger (the fetus) distensibility of
the lower
urge to push
(secondary
Kneeling
Leaning
o Passageway (the birth canal) uterine
segments,
power)
Frequency
forward with
support
o Psyche (woman’s and family’s perception cervical
dilatation, and
Duration
Interval DELIVERY:
of the event) capacity
distention of
for Intensity Lithotomy
Semi-
the vagina and recumbent
introitus Lateral
DIAGNOSIS OF LABOR Recumbent

• Regular painful uterine contractions accompanied

by any of the following:
o Ruptured Membrane
o Bloody show
o Complete cervical dilatation and
effacement
PROBLEMS THAT DEVELOP DURING LABOR OR
DELIVERY
• LABOR: Series of events by which uterine
contractions and abdominal pressure expel the fetus
and placenta from the woman’s body
o Amniotic fluid embolism (fluid enters the
woman’s bloodstream – life-threatening to
the woman)
o Shoulder dystocia (shoulder lodges against
the pubic bone, and baby is caught in the
birth canal)
• DELIVERY: Actual event of birth
o Labor could start too early (umbilical cord
comes out of the birth canal before the
baby)
DYSTOCIA DUE TO ABNORMALITIES OF THE
PASSENGER
PASSENGER
• Abnormalities of Presentation and Position
o Occiput Posterior Position
o Breech Presentation
o Face Presentation
o Brow Presentation
• Macrosomia
• Conjoined Twins
• Multiple Pregnancy
POSITION
• Relationship of reference point on fetal presenting
part to maternal bony pelvis
o O (occiput) in vertex position
o M (mentum or chin) in face presentation
o S (sacrum) in breech position
o A (acromion) in shoulder presentation
• Maternal bony pelvis divided into four quadrants
(right and left anterior; right and left posterior)
o ROA
o LOA
o ROP
o ROA
• Transverse – Right acromio dorso posterior
(RADP). The shoulder of the fetus is to the mother’s
right, and the back is posterior.
• LOA/ROA – most common position favorable for
delivery
• LOP/ROP – usually causes back pain during labor;
may slow the progress of labor; usually rotates

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 MODULE 4: NURSING CARE OF THE CLIENT DURING LABOR AND DELIVERY

before delivery to anterior position; rotation may be • Dysfunctional labor

done by physician • Early rupture of the membrane

METHODS TO ESTABLISH FETAL CAUSES OF BREECH PRESENTATION

PRESENTATION AND POSITION • Gestational age less than 40 weeks
• Combined abdominal inspection and palpation • Abnormality in a fetus (Anencephaly,
(Leopold’s maneuver) Hydrocephalus, or Meningocele)
• Vaginal examination • Hydramnios that allows for free fetal movement
• Auscultation of fetal heart tones • Congenital anomaly of the uterus (mid-septum)
• Sonography • Any space-occupying mass in the pelvis (fibroid
• X-ray tumor of the uterus or a placenta pre-via)
• Pendulous abdomen. If the abdominal muscles are
TYPES OF PRESENTATION lax, the uterus may fall so far forward that the fetal
• CEPHALIC head comes to lie outside the pelvic brim, causing
o Vertex / Occiput a breech presentation.
o Brow • Multiple gestation. The presenting infant cannot
o Sinciput turn to a vertex position.
o Face • Unknown factors
• BREECH
o Frank VAGINAL BREECH DELIVERY
o Complete • No traction or manipulation of the infant is used
o Incomplete
• Occurs predominantly in very preterm deliveries
• SHOULDER (24 weeks and below)
• COMPOUND
ASSISTED BREECH DELIVERY
MALPRESENTATION
• Most common type of vaginal breech delivery
• Is presentation other than the vertex presentation • Spontaneously deliver up to the umbilicus
• Any malpresentation will lead to difficult labor and • Maneuvers are initiated to assist in the delivery of
delivery the remainder of the body, arms, and head
o Breech 3%
• If legs do not deliver spontaneously can be assisted
o Face 0.2%
by Pinard maneuver
o Brow 0.01%
o Shoulder 1:300
TOTAL BREECH EXTRACTION
o Compound 1:1000
• Fetal feet are grasped, and the entire fetus is
BREECH PRESENTATION extracted
• Buttocks or lower extremities present first. Types • Noncephalic second twin
are: • TBE for the singleton breech is associated with a
o FRANK: thighs flexed, legs extended on birth injury rate of 25% and a mortality rate of
anterior body surface, buttocks presenting approx. 10%
o FULL / COMPLETE: thighs and legs
flexed, buttocks and feet (squatting FACE PRESENTATION
position) • Asynclitism
o FOOTLING: one or both feet are • Condition of maximal deflexion/extension
presenting • Submentobregmatic diameter presented to pelvis
(9.5 cm)
PREDISPOSING FACTORS
• Placenta previa PREDISPOSING FACTORS
• Polyhydramnios (more than 1000 ml amniotic fluid) • Conditions which favour extension and reduce
/ Oligohydramnios (less than 500 ml amniotic fluid) flexion of the vertex
• Abnormal motor ability • Multiparity
• Anoxia from a prolapsed cord • Prematurity
• Traumatic injury to the aftercoming head • CPD
(intracranial hemorrhage or anoxia)
• Fracture of the spine or arm

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DIAGNOSED PREDISPOSING FACTORS

• In labor • Placenta previa
• Palpation of the eyes, nose, mouth • Multiple pregnancy
• Uterine anomalies
CLASSIFIED • Prematurity
• According to the position of the chin (mentum) • Polyhydramnios
• Mento-anterior – can be delivered vaginally • Multiparity
• 1/3 of face presentation begin as M-P and 2/3 of
these will rotate to M-A MANAGEMENT
• > 37 weeks without C/I consider ECV
MANAGEMENT • If in labor or C/I to ECV exists deliver by C/S
• Re-evaluate and make preliminary choice • Type of uterine incision is considered – classical,
• Vaginal delivery appropriate where labor low transverse with the primary purpose to avoid
progressing satisfactorily, average size baby and fetal trauma and asphyxia
adequate sized pelvis • External cephalic version
• Rotation to M-A may occur late in the second stage
• Maneuvers to manually flex the face to facilitate COMPOUND PRESENTATION
delivery abandoned in modern obstetric practice • Implies that another anatomic part, usually an
• Forceps rotation C/I extremity has entered the pelvis along the with
• Outlet forceps for M-A positions acceptable principal vertex or breech presentation
• C/S for persistent non-M-A positions
PREDISPOSING CONDITIONS
BROW PRESENTATION • Prematurity
• Moderate degree of deflexion • Abnormal lies
• Mento-occipital diameter presented to the pelvis • Fetal anomalies
(12.5 cm) • Large pelvic capacities
• May be a transient feature of labor
• 2/3 of the cases are unstable and convert MANAGEMENT
• 1/3 of all women going to labor and delivery has • Labor usually progresses normally
persistent brow • Problem usually solved with the head being forced
past the extremity
PREDISPOSING FACTORS • Cord prolapse a possible complication
• Conditions which favor extension and reduce • May encourage the fetus to remove the extremity
flexion of the vertex • Consider C/S for usual causes or arrest of labor
• Multiparity • Edema / Discoloration of the extremity quickly
• Prematurity resolve
• CPD
MULTIPLE PREGNANCY
DIAGNOSIS • When more than one fetus simultaneously develops
• Palpation of nose, eyes, orbital ridges in the uterus
• Simultaneous development of two fetuses (twins) is
MANAGEMENT the commonest
• Re-evaluate • Although rare
• Manual flexion and rotation to OA sometimes o Triplets (Three fetuses)
possible o Quadruplets (Four fetuses)
o Quintuplets (Five fetuses)
• C/S for persistent brow
o Sextuplets (Six fetuses)
TRANSVERSE / SHOULDER PRESENTATION
VARIETIES
• Long axis of the fetus is perpendicular to that of the
mother • DIZYGOTIC TWINS - most common (two-third);
• Shoulder is usually over the pelvic inlet, with the results from the fertilization of two ova
head lying in one iliac fossa and the breech in the • MONOZYGOTIC TWINS (one-third) results
other from the fertilization of single ovum

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TWIN PREGNANCY LABOR AND DELIVERY

• DIAMNIOTIC DICHORIONIC • Timing of delivery – the benefit of prolonging the
o 72 hours after fertilization pregnancy is outweighed the risk of stillbirth
o Two separate placenta, chorions, and • Uncomplicated dichorionic twins – managed
amnions expectantly and delivery can be around 38 weeks
• DIAMNIOTIC MONOCHORIONIC • Uncomplicated monochorionic twins – delivery at
o 4-8 day after inner cell mass when chorion around 37 weeks
had developed • In cases of prematurity and discordant fetal well
• MONOAMNIOTIC MONOCHORIONIC being exists, timing of delivery should be based on
o After 8th day of fertilization when amniotic parameters of healthy twin
cavity is formed • In case of discordant fetal well-being or an
anomaly, timing of delivery should be based on the
CONJOINED TWINS condition of compromise fetus
• Division occurs after 2 weeks of the development of
embryonic disc METHOS OF DELIVERY
• Siamese twins • CEPHALIC – cephalic presentation – vaginal
• Four types of fusion may occur delivery
o Thoracopagus (commonest) • CEPHALIC – non cephalic presentation –
o Pyopagus (posterior fusion) controversial
o Craniopagus (cephalic) o Vaginal delivery of second non cephalic
o Ischiopagus (caudal) twins whose birthweight <1500gm is safe
o 2nd twin – Breech extraction of non-
ETIOLOGY cephalic twin or internal podalic version of
• Maternal age an unengaged cephalic second twin
• Race and heredity: Black race followed by breech extraction
• Parity: Increasing parity (2.7% in 4th pregnancy) • CESAREAN SECTION
• Heredity o Breech presentation of the first twin –
• Pituitary Gonadotropin similar as singleton breech fetus
• ART – Assisted Reproductive Technology o Locked twins – first fetus breech and
o Ovulation induction with FSH and second cephalic, breech of the first twin
gonadotropin/chlomiphine descends through the birth canal, the chin
o Greater the number of embryos transferred locks between the neck and chin of the
the greater the risk of multiple pregnancy second cephalic presenting co-twin

MATERNAL COMPLICATIONS DYSTOCIA DUE TO ABNORMALITIES OF THE

DURING PREGNANCY DURING LABOR DURING PUERPERIUM PASSAGEWAY
- Nausea and vomiting - Early rupture of - Subinvolution
- Anemia membranes - Infection
- Preeclampsia (25%) - Cord prolapse - Lactation failure PASSAGEWAY
- Hydramnios (10%)
- Antepartum hemorrhage
- Prolonged labor • Refers to the route the fetus must travel from the
- Increased operative
- Malpresentation
interference
uterus through the pelvis
- Preterm labor (50%)
- Mechanical distress - Bleeding o Soft Tissue
- Postpartum hemorrhage o Pelvic Bone
• The soft tissues of the passage includes:
FETAL COMPLICATIONS o Distensible lower uterine segment
• Miscarriage o Cervix
• Prematurity (80%) o Vaginal canal
• Growth Problem (25%) o Pelvic floor muscle
• Intrauterine death o Introitus
• Asphyxia and still birth • Before labor, uterine is made up of the corpus and
• Fetal Anomalies the cervix
• Important factors in the passageway
o Types of pelvis
o Structure of the pelvis (true versus false
pelvis)
o Pelvic inlet diameters

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o Ability of the uterine segment and vaginal MEASUREMENTS

canal to distend, the cervix dilate • Two pelvic measurements are important to
determine the adequacy of the pelvic size
2 DIVISIONS OF THE PELVIS o Diagonal conjugate (AP diameter of the
1. False Pelvis inlet)
2. True Pelvis o Transverse diameter of the outlet
a. Pelvic Inlet • PELVIC INLET MEASUREMENTS
b. Pelvic Cavity o DIAGONAL CONJUGATE (12.5 – 13
c. Pelvic Outlet CM)
▪ from lowest margin of the
TYPES OF PELVIS symphysis pubis to sacral
• GYNECOID – the true female pelvis promontory
• PLATYPELLOID – wide but flat, kidney-shaped ▪ obtained by vaginal examination
brim ▪ Metal scale fastened to wall for
• ANTHROPOID – oval. Transverse diameter is measuring the diagonal conjugate
narrow, A-P is longer. Ape pelvis diameter as ascertained manually
• ANDROID – heart shape, male pelvis o OBSTETRIC CONJUGATE
(ESTIMATED SUBTRACTING 1.5 – 2
CM TO DIAGONAL CONJUGATION)
▪ From inner surface of symphysis
pubis, slightly below upper
border, to sacral promontory
▪ Shortest distance between sacral
promontory and symphysis pubis
▪ Most important pelvic
measurement
o TRUE CONJUGATE (10.5 – 11 CM)
▪ Conjugate vera
▪ From upper margin of symphysis
pubis to sacral promontory
COMPARISON OF PELVIC TYPES
▪ Maybe obtained by x-ray or
ultrasound
• MIDPELVIS MEASUREMENTS
o INTERSPINOUS DIAMETER /
BISPINOUS DIAMETER (10.5 cm)
▪ At the level of the ischial spine
▪ Importance: Engagement of the
fetal head
▪ The space between the inlet and
the outlet
▪ Extends from the lower margin of
the symphesis pubis through the
level of the ischial spines to the tip
the sacrum
o ANTEROPOSTERIOR
DIAMETER (11.5 cm)
▪ Through the level of ischial
spines
o TRANSVERSE OR
INTERSPINOUS (10.5 cm)
o POSTERIOR SAGITTAL (5 cm)
▪ From the midpoint of the
interspinous line to the same
point in sacrum

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o Above ischial spines, station is negative

number
o Below ischial spines, station is positive
number
o “High” or “floating” terms use to denote
unengaged presenting part

• PELVIC OUTLET MEASUREMENTS

o AP DIAMETER (11.5 cm)
▪ Extends from the lower margin of
the symphysis pubis to the tip of
the sacrum
o TRANSVERSE DIAMETER / INTER
ISCHIAL TUBEROUS DIAMETER (10
cm)
▪ Distance between the inner edges
of the ischial tuberosities
o POSTERIOR SAGITTAL DIAMETER
(7.5 cm)
▪ Extends from the tip of the sacrum
to a right-angled intersection with
a line between the ischial
tuberosities
• OUTLET
o Inferior portion of the pelvis, or that
portion bounded in the back by coccyx, on
the sides by the ischial tuberosities and in
the front by the symphysis pubis
o The greatest diameter of the outlet is its
anteroposterior diameter
DIAMETERS OF THE FETAL SKULL
• 2 TRANSVERSE DIAMETERS
o BIPARIETAL DIAMETER
▪ 9.5 cm between 2 parietal
eminences
o BITEMPORAL DIAMETER
▪ 8.2 cm between the furthest points
of the coronal suture of the
temples
• AP OR LONGITUDINAL DIAMETERS
o SUBOCCIPITOBREGMATIC
ENGAGEMENT ▪ 9.5 cm from inferior aspect of the
• Fetal presenting part enters true pelvis (inlet) occiput to the center of the anterior
fontanelle
• May occur two weeks before labor in Primipara;
o SUBOCCIPITOFRONTAL
usually occurs at beginning of labor for Multipara
▪ 10 cm from below the occipital
protruberance to the center of the
STATION
frontal suture
• Measurement of how far the presenting part has o OCCIPITOFRONTAL
descended into the pelvis. Referent is ischial spines, ▪ 11.5 cm bridge of the nose to the
palpated through lateral vaginal walls occipital prominence
• When presenting part is:
o At ischial spines, station is “O”

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o METROVERTICAL OR DISPROPORTION
OCCIPITOMENTAL • There is discrepancy, between the size of the fetus
▪ 13.5 cm measured from the chin to and that of the pelvis
the posterior fontanelle • Due to an average-sized baby in the woman with a
▪ The widest AP diameter small pelvis or a normal pelvis with a big baby or
o SUBMENTOVERTICAL due to a combination of these factors
▪ 11.5 cm from the point where the
chin joins the neck to the highest
point on the vertex
o SUBMENTOBREGMATIC
▪ 9.5 cm from the point where the
chin joins the neck the neck to the
center of the bregma

CONTRACTED PELVIS
ANATOMICALLY
• Defined as one in which the essential diameters of
one or more planes are shortened by at least 0.5 cm
PELVIC INLET CONTACTION
OBSTETRICALLY • Anteroposterior diameter is less than 10 cm
• Any alteration of size and shape of the pelvis • Greatest transverse diameter is less than 12 cm
• Diagonal conjugate < 11.5 cm
• Abnormal bony pelvis secondary to
o Malnutrition
o Kyphosis
o Scoliosis
o Trauma
• History of childhood tuberculosis, rickets, or
poliomyelitis
• Past obstetrical history for prolonged labor and
instrumental delivery
• In primigravida women, engagement is to occur by
the 37th week. Non-engagement or malpresentation
should warrant a suspicious pelvic contraction
OMINOUS SIGNS TO WATCH FOR INCLUDE:
CLINICAL PELVIMETRY • Dysfunctional labor
• Determination of the adequacy of the inlet reaching • Posterior parietal presentation with exaggerated
the promontory of the sacrum obliquity
• Early rupture of membranes
ASSESSMENT OF THE PELVIS
• Increasing of edema of the cervix
• Reaching the sacral promontory • Formation of caput and molding
• Feeling the lateral pelvis wall • Conversion from vertex to face presentation
• Determining the prominence of the ischial spines • Evidence of fetal or maternal distress
• Assessment of the pubic arch
MIDPELVIC INLET CONTACTION
• The sum of the interspinous diameter (10.5 cm) and
the postero sagittal diameter of the midpelvis (5 cm)
falls to 13.5 cm and below
• Inter spinous diameter is less than 10 cm
• When smaller than 8 cm then definite contraction
exists
• Ischial spines are prominent
• Sidewalls are convergent
• Sacrosciatic notch is narrow
• More common that inlet contraction with frequently
associated deep transverse arrest of the fetal head

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• Management of midpelvic contraction is to allow

for the normal forces of labor to push the biparietal
diameter of the head beyond the area of narrowing
• Use of oxytocin is contraindicated

CONTRACTED PELVIC OUTLET SUSPECT IF:

• Interischial tuberous diameter of less than 8 cm • Broadening of the uterine fundus
• Usually associated with midpelvic contraction and • Abnormal lie or presentation
it is the combination of the two • History of repeated abortions
• Produces perineal tears • Abnormal location of the cervix in the vaginal
vault

CERVICAL ABNORMALITIES
• Ff. extensive cauterization of the cervix, it may
become so stenosed that dilatation and effacement
may not take place during labor
• In cases of unyielded cervical stenosis, cesarean
section is carried out

VAGINAL ABNORMALITIES
• Septum can be present that divides that vagina
GENERALLY CONTRACTED PELVIS o LONGITUDINAL SEPTUM
• All the different planes are shortened ▪ cervix to vulva
o INCOMPLETE SEPTUM
• Molding and internal rotation results in arrests in
▪ Upper or lower portion of vagina
occipito posterior position due to associated mid
o TRANSVERSE SEPTUM
pelvic contraction
▪ Upper vagina divided from lower
• Termination by cesarean section is usually done
part
CONTRACTED PELVIS
PELVIC MASSES
• Contraction of pelvic inlet AP < 10 cm; transverse • Gartner Duct cyst may protrude into the vagina
<12 cm and through the introitus
• Contraction of mid pelvis Interischial spinous • Uterine myomas
diameter < 10 cm • Ovarian neoplasm
• Contraction of pelvic outlet Interischial tuberous
diameter < 8cm LOW LYING PLACENTA
• Marginal or low-lying placenta may prevent fetal
SOFT TISSUE DYSTOCIA descent, or worst may give rise to abnormal
• Anatomic abnormalities of the reproductive tract bleeding that cesarean section may be required
may cause abnormal or prolonged labor
• Due to abnormalities in the uterus, cervix, and the
vagina; the presence of pelvic masses; scarring of
the birth canal and low implantation of the placenta

UTERINE ABNORMALITIES
• Abnormal fusion of the Mullerian ducts
• Failure of absorption of the septum lead to a variety
of congenital malformations of the uterus

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DYSTOCIA DUE TO ABNORMALITIES OF THE INTENSITY OF CONTRACTIONS

POWER / EXPULSIVE FORCES
A. UTERINE CONTRACTION (INVOLUNTARY)
• FREQUENCY
o Timed from the beginning of one
contraction to the beginning of the next
• REGULARITY
o Discernable pattern; better established as
pregnancy progresses
• INTENSITY
o Strength of contraction; may be determined
by the “depressability” of the uterus during
a contraction.
o Describe as mild, moderate, or strong
• DURATION
o Length of contraction
o Contraction lasting more than 90 seconds
without a subsequent period of uterine
relaxation may have severe implications
for the fetus and should be reported
• MILD
o The uterus is contracting but does not
become more than minimally tense
• MODERATE
o The uterus feels firm
• STRONG
o So intense, the uterus feels as hard as
wooden board at the peak of contraction
B. VOLUNTARY BEARING DOWN EFFORTS
• After full dilatation of the cervix, the mother can use
her abdominal muscles to help expel fetus
• These efforts are similar to those for defection, but
the mother is pushing out the fetus from the birth
canal
• Contraction of levator ani muscles

LABOR AND DELIVERY

PHASES OF CONTRACTION
• INCREMENT STAGES OF LABOR
o When the intensity of the contraction • STAGE 1
increases o From onset of labor until full dilatation of
• ACME cervix
o When the contraction is at its strongest ▪ Latent phase: 0 - 4 cm
• DECREMENT ▪ Active phase: 4 – 8 cm
o When the intensity decreases ▪ Transition phase: 8 – 10 cm
• STAGE 2
o From full dilatation of cervix to birth of
baby
• STAGE 3
o From birth of baby to expulsion of placenta
• STAGE 4
o Time after birth (usually 1 – 2 hrs) of
immediate recovery

DURATION OF LABOR
• Depends on:
o Regular, progressive uterine contraction
o Progressive effacement and dilatation of
cervix
o Progressive descent of presenting part

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• Average length of Normal Labor: • TRANSITION PERIOD

o 8 – 10 cm cervical dilatation occurs
o The mood of the woman suddenly
changes, and the nature of contractions
intensify
• If cervix is intact, this period is marked by a
sudden gush of amniotic fluid as the fetus is
pushed into the birth canal. Show becomes
prominent.
• Uncontrollable urge to push contractions (a sign
that the second stage of labor is very near)
• Duration of contraction – 60 to 70 secs
• Interval – 30 to 90 seconds

STAGE OF DILATATION
• LATENT PHASE
o Early time in labor
o Cervical dilatation is minimal because
effacement is occurring
o Cervix dilates 0 – 4 cm
STAGE OF EXPULSION
• SECOND STAGE OF LABOR (STAGE OF
EXPULSION)
o Begins with the complete dilatation and
ends with the delivery of the infant
o PRIMI: 80 minutes
o MULTI: 30 minutes
o Power / forces at work: involuntary uterine
contractions of the diaphragmatic and
abdominal muscles
• ACTIVE OR ACCELERATED
o Cervical dilatation reaches 4 – 8 cm
o Rapid increase in duration, frequency, and
intensity of contraction
o Woman fears losing of herself

MECHANISMS OF LABOR / FETAL POSITION

• Changes: (ED FIRE ERE)
o ENGAGEMENT
▪ The head is fixed in the pelvis
o DESCENT
▪ Fetus goes down in the birth canal
o FLEXION
▪ Fetal chin bends toward the chest
o INTERNAL ROTATION
▪ From AP to transverse then AP to
AP

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o EXTENSION FUNCTIONAL DIVISION OF LABOR

▪ The head extends, the forehead, • PREPARATORY DIVISION
nose mouth and chin appears o Includes the latent and acceleration phases
o EXTERNAL ROTATION • DILATATIONAL DIVISION
(RESTITUTION) o labor during which time dilatation
▪ Anterior shoulder rotates proceeds at a rapid rate, occupies the phase
externally to AP position maximum slope of dilatation
o EXPULSION o This is unaffected by sedation or
▪ Delivery of the rest of the body conduction analgesia
• PELVIC DIVISON
o Encompasses both deceleration phase
o Second stage of labor, concurrent with the
maximum slope of descent
o Classical mechanisms of labor that the
involve the cardinal movements of the
fetus in cephalic presentation

PLACENTAL STAGE
• THIRD STAGE OF LABOR (PLACENTA
STAGE)
o Begins with the delivery of the baby and
ends with the delivery of the placenta PHASES OF THE ACTIVE PHASE
o PRIMI: 10 minutes • ACCELERATION PHASE
o MULTI: 10 minutes o Short and variable but is important in
determining the ultimate outcome of labor
POST-PARTUM STAGE o Low acceleration phase generally presages
• FOURTH STAGE OF LABOR (RECOVERY a lower maximum slope and therefore
STAGE) prolonged total labor
o First 2 hours post-partum is the most • PHASE OF MAXIMUM SLOPE
crucial stage of the mother due to unstable o Good measure of the overall efficiency of
vital signs the uterus
o Gives a clear idea of the effectiveness of
NORMAL LABOR PATTERN the force of uterine contraction in
• Friedman in 1954 begun studies to describe a producing dilatation
characteristic sigmoid pattern for labor when • DECELERATION PHASE
analyzed by graphing cervical dilatation against o Reflects fetopelvic relationship
time o Involves retraction of the cervix about the
fetal presenting part

• Friedman’s minimum criteria for subsequent entry

into the active phase of labor are cervical dilatation
rates of 1.2 cm per hour for multiparas. These rates
of dilatation do not start at a specific dilatation

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• Friedman’s data shows that normal labor is • Etiologic factors include excessive sedation or
characterized by rates of maximum descent conduction analgesia, unfavorable cervix (e.g.,
exceeding 1 cm per hour in nulliparas and 2 cm per thick, rigid, uneffaced, undilated), false labor, and
hour in multiparas uterine dysfunction

ABNORMAL LABOR PATTERNS, DIAGNOSTIC

CRITERIA AND METHOS OF TREATMENT
• Prolonged latent phase
• Protracted active phase dilatation
• Protracted descent
• Prolonged deceleration phase
• Secondary arrest of dilatation
• Arrest of descent
• Failure of descent

PROTRACTION DISORDERS
• PROTRACTED ACTIVE PHASE
DILATATION means that the maximum slope of
dilatation
o NULLIPAROUS: less than 1.2 cm per
hour
o MULTIPAROUS: 1.5 cm per hour
• PROTRACTED DESCENT means descent of the
fetal head
o NULLIPAROUS: less than 1 cm per hour
o MULTIPAROUS: 2 cm per hour

• NULLIPARA
o 2 hrs extended to 3 hrs when conduction
analgesia is used
• MULTIPARA
o 1 hour is the limit extended to 2 hrs with
conduction analgesia.
o Common cause of prolonged 2nd stage is
persistent occiput posterior position
• A prolonged latent phase is one longer than 20 hrs
in nulliparous or 14 hrs in multiparous women

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 MODULE 4: NURSING CARE OF THE CLIENT DURING LABOR AND DELIVERY

POWERS: FORCE OF LABOR • COMPLICATION

• Ineffective uterine force o Fetal Anoxia
o Hypotonic uterine dysfunction
o Hypertonic uterine dysfunction MANAGEMENT
o Uncoordinated contractions • Provide comfort measures
• Bedrest or position changes
• Hydration
• Mild sedation
• Tocolytics
• Caesarean delivery

PREVENTION OF DYSFUNCTIONAL LABOR

HYPOTONIC CONTRACTION • No CPD
• Maintain a serum glucose level
• NUMBER OF CONTRACTIONS
• Prevent fluid and electrolyte loss
o Not more 2 or 3 occurring in 10-minute
period • Reduce psychological stress
• RESTING TONE • Provide measures to reduce pain
o Less than 10 mmHg • Maintain a side lying position
• STREGTH OF CONTRACTIONS • Keeping the bladder empty
o Does not rise above 25 mmHg
• PHASE OF LABOR
o Active
• SYMPTOM
o Painless

ETIOLOGY
• Overstretching of the uterus – large baby, multiple
babies, polyhydramnios, multiparity
• Bowel or bladder distention, preventing descent
• Excessive use of analgesia

THERAPEUTIC INTERVENTIONS
• Oxytocin
• Ambulation
• Nipple stimulation
• Enema
• Amniotomy

HYPERTONIC CONTRACTIONS
• RESTING TONE
o More than 15 mmHg
• CONTRACTIONS
o Frequent prolonged contractions that are
not productive
• PHASE OF LABOR
o Latent
• SYMPTOM
o Painful
• CAUSE
o Occurs because the muscle fibers of the
myometrium do not repolarize or relax
after contraction, thereby “wiping it clean”
to accept a new pacemaker stimulus

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 MODULE 4: NURSING CARE OF THE CLIENT DURING LABOR AND DELIVERY

LABOR COMPLICATIONS fetal distress in 30 minutes → rate 16 – 20

gtts/min
UTERINE INERTIA • AMNIOTOMY
• Sluggishness of contraction o Done with Cervical Dilation = 4 cm; Check
FHR and quality of amniotic fluid
CAUSE
• Inappropriate use of analgesics NURSING CONSIDERATION
• Pelvic bone contraction • Monitor uterine contraction → potential for rupture
• Poor fetal position • Monitor flow rate regularly
• Overdistention – due to multiparity, multiple • Turn off IV with any abnormality in FHR or
pregnancy, polyhydramnios, or excessively large contractions
baby • Watch out for complications
• Prostaglandin administration
MANAGEMENT o Route: Oral or IV (never IM causes
• Stimulation of labor by oxytocin administration or irritation)
amniotomy o Effect is slower than oxytocin

PRECIPITATE DELIVERY INSTRUMENTAL DELIVERIES

• Labor and delivery that is completed in < 3 hrs due • Incidence: 4.5% of vaginal deliveries
to multiparity or following oxytocin administration • Forceps delivery: 0.8%
or amniotomy • Vacuum deliveries: 3.7%
• Success Rate: 99%
EFFECTS o Reflects appropriate choice of candidates
• Extensive lacerations
• Abruptio placenta FORCEPS DELIVERY
• Hemorrhage due to sudden release of pressure → • Use of metal instruments to extract the fetus from
shock the birth canal
• When at +3 / +4 and sagittal suture line is in an AP
INDUCED LABOR position in relation to the outlet (e.g., Simpson,
• Stages of labor and birth occurs due to chemical or Elliot, Piper for breech presentation)
mechanical
• Performed to save the mother or fetus from PURPOSES
complications which may cause death • Shorten second stage of labor because of fetal
distress; maternal exhaustion; maternal disease –
INDICATIONS cardiac, pulmonary complication
• Maternal – toxemia • Ineffective pushing due to anesthesia
• Placental accidents • Prevent excessive pounding of fetal head against
• Premature rupture of membrane perineum (low forceps for premature)
• Fetal: DM – terminated at about 37 weeks AOG if • Poor uterine contraction or rigid perineum
indicated
PREREQUISITES
• Excessive size
• Post maturity • Pelvis adequate, no disproportion
• Fetal head is deeply engaged
PREREQUISITES TO INDUCE LABOR • Cervix is completely dilated and effaced
• No Cephalon – Pelvic Dislocation • Membranes have ruptured
• Fetus is already viable > 32 weeks AOG • Vertical presentation has been established
• Single fetus in longitudinal lie and is engaged • Rectum and bladder are empty
• Ripe cervix – fully or partially effaced; Cervical • Anesthesia is given for sufficient perineal relaxation
Dilatation at least 1 – 2 cm and to prevent pain

PROCEDURE FOR INDUCED LABOR

• OXYTOCIN ADMINISTRATION
o 10 IU of Pitocin in 1000 ml of D5W at a
slow rate of 8 gtts/min given initially → no

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 MODULE 4: NURSING CARE OF THE CLIENT DURING LABOR AND DELIVERY

FORCEPS DELIVERY
• TYPES: Low or Mid Forceps Delivery

COMPLICATIONS
• Forceps marks – noticeable only for 24 – 48 hours
• Bladder or rectal injury
• Facial paralysis
• Ptosis
• Seizures
• Epilepsy TYPES
• Cerebral Palsy • LOW SEGMENT
o The method of choice
o Incision is made in the lower uterine
segment
o Thinnest and most passive part during
active labor
o ADVANTAGES:
▪ Minimal blood loss
RISKS: INSTRUMENTAL DELIVERY ▪ Incision is easier to repair
▪ Lower incidence of post-partum
MATERNAL RISKS infection
▪ No possibility of uterine rupture
• Perineal Injury (extension of episiotomy)
• Vaginal and Cervical lacerations
• Postpartum hemorrhage

FETAL RISKS
• Intracranial hemorrhage
• Cephalhematoma
• Facial / Brachial palsy
• Injury to the soft tissue of face and forehead
• Skull fracture • LOWER VERTICAL INCISION
o Recommended in:
CESAREAN DELIVERY ▪ Bladder or lower uterine segment
• CESAREAN SECTION ▪ Adhesions from previous
o Birth through a surgical incision on the operations
abdomen ▪ Anterior Placenta Previa
▪ Transverse lie
INDICATIONS
• Cephalon-pelvic disproportion (CPD)
• Severe Toxemia
• Placental Accidents
• Fetal Distress
• Previous classic CS – done prior to onset of labor
pains; scheduled birth

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 MODULE 4: NURSING CARE OF THE CLIENT DURING LABOR AND DELIVERY

PREOPERATIVE CARE • Age: Adolescent or 40 years old above

• Check vital signs, uterine contractions, and FHR primigravids
• Physical examination; routine laboratory tests;
blood typing and cross matching MANAGEMENT
• Abdomen is shaved from level of the xiphoid • If no bleeding; no CD, good FHT, medication is
process below the nipple line, extending out to the given
flanks on both sides up to the upper thirds of the o Ethyl alcohol IV – blocks release of
thighs Oxytocin
• Retention catheter is inserted to constant drainage o Vasodilan IV – vasodilator
to keep the bladder away from the operative site o Ritodrine – muscle relaxant per orem
• Preoperative medication is usually only atropine o Bricanyl – bronchodilator
sulfate • Pain meds are kept to a minimum to prevent
• No narcotics → causes respiratory depression in respiratory depression
the NB • Steroids (glucocorticoids) for maturation of fetal
lung → surfactant production
POSTOPERATIVE CARE • Anesthesia preferred – caudal, spinal or infiltration
• Deep breathing, coughing exercises, turning from – do not affect the infant
side to side
• Ambulate after 12 hours
• Monitor vital signs
• Watch for signs of hemorrhage – inspect lochia;
feel fundus
• Breastfeeding should be started 24 hrs after
delivery
• Most common complication: Pelvic thrombosis

AMNIOTIC FLUID EMBOLISM SHOULDER DYSTOCIA

• Forced into an open maternal uterine fluid flood • Inability to deliver a baby’s shoulders after its
sinus through some defect in the membranes or head has emerged
after partial premature separation of the placenta
• The baby’s shoulder has become impacted
• Solid particles in the amniotic fluid enter maternal
circulation and reach the lungs as emboli behind the mother’s pubic symphysis
• One that requires additional obstetrical
maneuvers ff. the failure of gentle downward
traction on the fetal head to effect delivery of
the shoulders
SIGNS AND SYMPTOMS
• Dramatic RISKS
• Sudden inability to breathe, sits up, grasps chest • Macrosomia
and sharp chest pain
• Turns pale then → bluish gray color • Gestational diabetes
• Death may occur in a few minutes • Previous shoulder dystocia
• Instrumental vaginal delivery
MANAGEMENT • Heightened awareness that a shoulder
• Emergency measures to maintain life: IV, oxygen, dystocia might occur in a particular case
CPR • Diagnosis
• Provide intensive care in the ICU • Operational control / situational awareness
• Keep family informed
• Maneuvers
• Provide emotional support
o McRoberts maneuver
PREMATURE LABOR AND DELIVERY o Suprapubic pressure
• Uterine contractions occur before 37th week of o Woods maneuver
gestation o Rubin’s maneuver
• Pre-eclampsia
• Placenta Previa

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 MODULE 4: NURSING CARE OF THE CLIENT DURING LABOR AND DELIVERY

CAUSES
• Malpresentation
• Prematurity
• Polyhydramnios
• Multiple pregnancy
MANAGEMENT • PROM
• CLEIDOTOMY • CPD
o Fracturing the fetal clavicle • Obstetric interventions
• SYMPHYSIOTOMY
o Cutting the pubic symphysis MANAGEMENT
• ZAVENELI • Cord pulsations
o Returning the fetal head to the pelvis for • CTG shows variable decelerations
delivery of the baby via caesarean section
• Fundal pressure causes bradycardia
o
• Meconium stained liquor
• Lift presenting part off the cord
• Instruct patient NOT to push
• Position
o Knee chest
o Trendelenburg
o Exaggerated position
• Vulvar pad
• Replacement of cord
• Tocolysis
• Funic reduction
o Manual replacement of cord into uterus
o Cord gently pushed above presenting part
• Expedite delivery
• Prepare for newborn resuscitation

PROM
• PREMATURE RUPTURE OF MEMBRANES
(PROM)
o Spontaneous rupture of fetal membranes
before onset of labor
• PRETERM PREMATURE RUPTURE OF
MEMBRANE (PPROM)
o Rupture of membranes before onset of
labor in pregnancies between 28 – 37
weeks
CORD PROLAPSE
• TERM PREMATURE RUPTURE OF
• In a prolapse, the umbilical cord drops (prolapses)
MEMBRANE (TPRM)
through the open cervix into the vagina ahead of the
o Rupture of membranes before onset of
baby
labor beyond 37 weeks
• The cord can then become trapped against the
baby’s body during delivery

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 MODULE 4: NURSING CARE OF THE CLIENT DURING LABOR AND DELIVERY

CAUSES
• Unknown but hypothesized
o Vaginal and cervical infections
o Incomplete cervix
o Nutritional deficiencies
o Polyhydramnios
o Fetal malpresentation
o Multiple gestation or a large baby
o Occupational fatigue
o Vaginal exams

RISKS
• Preterm labor
• Umbilical cord prolapse
• Umbilical cord compression
• Chorioamnionitis
• Pulmonary hypoplasia
• Placental abruption
• Neonatal infection UTERINE RUPRTURE
• Stillbirth / Neonatal death • Occurs when the uterus undergoes more straining
than it is capable of sustaining
SIGNS AND SYMPTOMS
• Vaginal discharge CAUSE
o Gush of fluid • Scar from previous CS
o Leaking of fluid • Unwise use of oxytocin
• Cramping • Overdistension
• Contractions • Faulty presentation
• Back pain • Prolonged labor
PRETERM PREMATURE RUPTURE OF
MEMBRANE (PPROM)
• Sudden gush of clear vaginal fluid with
oligohydramnios
• Speculum exam
• Pooling
• Nitrazine paper test
• Ferning

CHORIOAMNIONITIS
• Clinical diagnosis with all the ff: SIGNS AND SYMPTOMS
o Maternal fever • Sudden severe pain
o Uterine tenderness • Hemorrhage and clinical signs of stock
o Confirmed PROM • Change in abdominal contour
o Absence of URI or UTI
MANAGEMENT
MANAGEMENT OF PROM
• Hysterectomy
PREVIABLE < 24 weeks PULMONARY HYPOPLASIA
PRETERM
PREMATURITY
24 – 35 weeks
TERM
INFECTION
36+ weeks
BEFORE VIABILITY
INDUCE LABOR
< 24 weeks
HOME BED REST
(PULMONARY HYPOPLASIA)
HOSPITALIZE
PRETERM VIABLE
MATERNAL STEROIDS
24 – 35 weeks
CERVICAL CULTURES
(PREMATURITY)
7 DAYS AMPIC+ERYTHRO
AT TERM
36+ WEEKS PROMPT DELIVERY
(INFECTION)

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 MODULE 4: NURSING CARE OF THE CLIENT DURING LABOR AND DELIVERY

THIRD STAGE OF LABOR o Placental chorionic villi grow through the

• Remains most unpredictable and dangerous stage of uterine myometrium and often adhere to
labor from the mother’s point of view abdominal structures (bladder or intestine)
• Retained placenta / undelivered placenta – 1 – 2%

NURSING MANAGEMENT
RETAINED PLACENTA • Identify placenta accrete in the client
• If the placenta is undelivered at 30 minutes it should • Assist with rapid treatment and intervention
be considered to be “retained” • Provide physical and emotional support
• Provide client and family education
CAUSES OF RETAINED PLACENTA
ABNORMALITIES OF THE PLACENTA
• Placenta partly or wholly attached
• Placenta develops from the chorion frondosum, the
• Placenta separated but undelivered
part in contact with the most vascular decidua
• Any developmental abnormality may have a clinical
BRANDT-ANDREWS METHOD
significance
• Cord is pulled gently the other hand presses the
• More or less than whole chorion develops
uterus upwards to prevent inversion
functional villi and the placenta occupies the greater
• Slight see-sawing motion is imparted by both hands
part of the uterine
• PLACENTA BIPARTITA
PLACENTA ACCRETA
o Partly divided into two lobes, with
• Rare cause of retained placenta
connecting vessel
• Abnormal adherence of placenta to the uterine
• PLACENTA MEMBRANACEA
muscle due to a defect of decidual formation
o Unduly large and thin
• Can be partial or complete where bleeding is absent o Not only develops from chorionic
• Attempts at manual removal open the blood sinuses frondosum but chorionic levae so whole of
causing severe bleeding ovum is practically covered
• PLACENTA SUCCENTURIATA
o Vascular connection between main and
accessory lobes
o Accessory lobe is retained and manually
removed
• PLACENTA CIRCUMVALLATA
o Membranes appear to be attached
internally to the placental edge and on the
periphery there is a ring of thick whitish
tissue which is in fact a fold of infarcted
chorion
• PLACENTA VELAMENTOSA
o Distance away from the attachment of the
• PLACENTA ACCRETA cord and the vessels
o Placental chorionic villi adheres to the o Cord at the edge of the placenta
superficial layer of the uterine o Divide in the membranes
myometrium o If they cross the lower pole of the chorion
• PLACENTA INCRETA – yasa previa
o Placental chorionic villi invade deeply into • BATTLEDORE PLACENTA
the uterine myometrium o Cord has a marginal instead of a central
• PLACENTA PERCRETA insertion
o No clinical significance

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 MODULE 4: NURSING CARE OF THE CLIENT DURING LABOR AND DELIVERY

o Six or seven loops are drawn tightly round

the neck
o Fetus descends the cord tightens
o Blood supply is interrupted
o Baby is stillborn
o True knots are seen quite often but
Wharton’s jelly usually prevents actual
obstruction by kinking
o False knots are protuberances of
connective tissues matrix, sometimes
containing varices
• SINGLE UMBILICAL ARTERY
o Sometimes associated with congenital
abnormalities in the fetus

CLINICAL SIGNIFICANCE
• Post-partum hemorrhage
• Subinvolution
• Retained placenta
• Sepsis
• Abortion
• Premature labor
• Fetal malformation
• Fetal death

PLACENTA BIPARTITA PLACENTA MEMBRANACEA

PLACENTA SUCCENTURIATA PLACENTA CIRCUMVALLATA

PLACENTA VELAMENTOSA SINGLE UMBILICAL ARTERY

BATTLEDORE PLACENTA

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