5 Ps of Labor

Passenger, Passageway, Powers, Placenta, Psyche

PASSENGER
Engagement:
- Settling of the presenting part of a fetus far enough
into the pelvis to be at the level of the ischial spines, a
midpoint of the pelvis.
Molding:
- change in the shape of the fetal skull produced by the
force of uterine contractions pressing the vertex
against the not-yet-dilated cervix.
- Because the fetal skull is not yet completely ossified,
the bones overlap making the head narrower but
longer.
- Parents should be assured that this is not permanent FETAL LIE
and will last for a day or two. - Relationship of the long axis (spine) of the fetus
Diameter of the Fetal Skull: to the long axis (spine) of the mother
Longitudinal lie = if the two are parallel; nearly all (99.5%)
Transverse lie = if two are at 90° angles to each other
FETAL PRESENTATION
- The portion of the fetus that enters the pelvis first
and covers the internal os of the cervix, such as:
a. Cephalic (head): vertex, brow, face
b. Breech:
- Sacrum (frank) - legs are extended
- Foot (footling/incomplete) - may be single or
double
- Sacrum and feet (full/complete) - baby in
squatting position
- To fit through the birth canal, the fetus must present c. Shoulder or acromion, iliac crest, hand or below =
the smaller (transverse) diameter to the smaller transverse lie
diameter of the maternal pelvis.
- At the pelvic inlet, the fetus must present the narrowest If the baby is breech, his
diameter (biparietal diameter: 9.25cm) to the bottom is the part of his body
anteroposterior diameter (11cm) of the pelvis. closest to the birth canal. No
- The degree of flexion of the head determines which one is sure what causes a
anteroposterior diameter will be presented to the birth breech presentation, but it
canal. happens in 3%-5% of single-
- The anteroposterior diameter of the fetal head must fit baby deliveries.
through the transverse diameter (13.5cm) of the pelvic FETAL ATTITUDE
inlet, and through the anteroposterior diameter - The relationship of the
(11.9cm) of the outlet. fetal parts to one
another.
FETAL HEAD DIAMETER PRESENTED
- Universal flexion or
FLEXION @ BIRTH CANAL
general flexion
- The back is markedly
Full Suboccipitobregmatic
flexed, head is flexed on
Moderate Occipitofrontal the chin, thighs are
flexed on the abdomen,
Hyperextended Occipitomental legs are flexed at the
knee joints.
Diameters: FETAL POSITION
➔ Biparietal = 9.25cm - The relationship of the fetal reference point
➔ Anteroposterior = 11cm (occiput, mentum, sacrum or acromion process) to
➔ Suboccipitobregmatic = 9.5cm (narrowest) one of the 4 quadrants of the mother’s pelvis.
➔ Occipitofrontal = 12cm - 6 positions are usually defined for each
➔ Occipitomental = 13.5cm (widest) presentation except the shoulder presentation.
➔ Transverse diameter = 13.5cm

P a g e 1 | 14
 PASSAGEWAY
1. Soft tissues: includes
- Lower uterine segment
- Cervix
- Vaginal canal
2. Pelvis

IMPORTANT MEASUREMENTS
1. Diagonal Conjugate: measure between sacral
promontory and inferior margin of the symphysis
pubis.
- 11.5cm-12.5cm basis in getting true
conjugate.
- DC - 1.5cm = true conjugate
2. Obstetrical Conjugate: smallest AP diameter.
- Pelvis at 10 cm or more
3. True Conjugate/Conjugate Vera: measure
between the anterior surface of the sacral
promontory and superior margin of the symphysis
pubis.
- Measurement: 11.0cm
4. Tuberoischi Diameter: transverse diameter of the
pelvic outlet.
- Ischial tuberosity - approximated with use
of fist = 8cm & above

OUTLET CONTRACTION
MOST COMMON FETAL POSITION: LOA Ischial Tuberosity:
- The distance between ischial tuberosities or the
transverse diameter of the outlet
- Handspan or clenched fist measurement
- 11cm diameter is considered adequate to allow the
9cm head of the fetus to pass freely through the
outlet.
Occiput/Cephalic Posterior: - Narrowing of the transverse diameter at the outlet
- Sometimes, the baby is presenting head down as it to less than 11cm
should be but is facing the mother’s abdomen.
- This increases the chance of painful “back labor” and
prolonged delivery.
STATION
- Refers to the relationship of the presenting part to the
level of the ischial spines.
- When the presenting part is at the level of the ischial
spines, it is at station 0 (synonymous with
engagement).
- If the presenting part is above the spines, the distance
measured and described as station -1 or so if it is 1cm
or so above the ischial spines.
- Station +1 or so if it is 1 cm below the ischial spines
- At -4 station = “floating”
- At +4 station = “at outlet”
P a g e 2 | 14
 POWERS ● Can cause the uterus to not contract as effectively
Consists of: during the postnatal period.
- Involuntary uterine contractions (primary powers) ● Increase chance for infection (both fetus and
- Voluntary bearing down efforts uterus)
- Contraction of the levator ani muscles Management:
3 methods of assessing uterine contractions: - Vital signs and FHR monitoring, IVF
1. Subjective description given by the woman - Ultrasound:
2. Palpation and timing by the nurse or physician ➢ AMOL - active management of labor
- Fingertips are used ➢ Amniotomy, timed cervical examinations
- More accurate than the first method since the and augmentation of labor.
tensing of the uterus may be felt by palpation HYPERTONIC CONTRACTIONS
about 5secs before the woman is able to feel ● Resting tone >15mmHg
the contraction. ● Intensity not stronger than with hypotonic
3. Use of electronic monitoring devices that measure ● Most common in the latent phase of labor
the frequency and duration of contractions. ● Myometrium does not repolarize or relax after
contraction.
● More painful
● May not allow optimal uterine artery filling.
● Risks of hypertonic labor:
➢ Maternal:
- Increased discomfort
- Fatigue
Factor of prolonged labor: - Stress on coping abilities
● Fetus is large ➢ Fetal:
● Hypotonic - Non reassuring of fetal status
● Hypertonic - Prolonged pressure on the fetal
● Uncoordinated contractions head, which may result in:
Ineffective Uterine Force: ● Cephalhematoma
● Uterine contractions are the basic force moving ● Caput succedaneum
the fetus through the birth canal. ● Excessive molding
● Occurs because of the interplay of the: Management:
➢ Contractile enzyme: ADENOSINE ● Uterine and fetal external monitoring at least
TRIPHOSPHATE every 15mins
➢ Contractile proteins: Actin & Myosin ● Rest and pain relief:
➢ Influence of major electrolytes: Ca, Na, K ➢ MORPHINE SULFATE
➢ Epinephrine, Norepinephrine ➢ Changing linen and client’s gown
➢ Oxytocin, Estrogen ➢ Darkening the room lights
➢ Progesterone, Prostaglandins ➢ Decreasing noise and stimulation
● About 95% of labors are completed with ● Amniotomy
contractions that follow a predictable, normal ● C/S: deceleration of FHT, abnormal long first
course. stage of labor, lack of progress with pushing
● Abnormal, ineffective contraction can lead to PRECIPITATE LABOR
ineffective labor. ● Precipitous labor lasts <3hrs and results in rapid
HYPOTONIC CONTRACTIONS birth.
● Contractions are usually low or infrequent (not Contributing factors:
increasing beyond 2 or 3 in a 10-minute period). ➢ Multiparity:
● Resting tone of the uterus remains <10mmHg. ○ Large pelvis
● Strength of contractions does not rise >25mmHg. ○ Previous precipitous labor
● Usually develops in the active phase of labor. ○ Small fetus
● May occur after administration of analgesia. ○ + string contractions = PRECIPITATE
● Associated with: LABOR
➢ Multiple gestation Risks of Precipitous Labor:
➢ LGA (large for gestational age) or hydramnios ➢ Maternal:
(too much amniotic fluid around fetus) - Loss of coping abilities
➢ Lax uterus (weak pelvic muscles) from grand - Lacerations of the cervix, vagina, and
multiparity perineum due to rapid descent and birth of the
● Contractions are not exceedingly painful. fetus
● Hypotonic contractions increase length of labor.
P a g e 3 | 14
 - Postpartum hemorrhage due to undetected
lacerations or inadequate uterine contractions
after birth
- Can lead to premature separation of the
placenta
➢ Fetal-neonatal:
- Nonreassuring fetal status or hypoxia
- Cerebral trauma
- Pneumothorax
- Subdural hemorrhage
NURSING ASSESSMENT
● Intrapartum:
- Identify a woman at increases risk of
precipitous labor.
- During labor, one or both of the following
factors may indicate potential problem:
a. Accelerated cervical dilatation:
- > 2 cm/hr (multigravida)
- >1.2 cm/hr (primigravida)
b. Fetal descent
Management:
● A precipitous labor can be predicted from a labor
graph if:
➢ Active phase rate is:
- >5cm/hr - 1cm q12mins (nullipara)
- 10cm/hr - 1cm q6mins (multipara)
● Tocolytics can be given to reduce the force and
frequency of contractions.
● Promote comfort and rest
● Be alert of Pitocin overdose:
➢ Hyperstimulation of uterus:
- Discontinue immediately
- Turn the woman to her left side
- O2 administration
● Fetal monitoring
PHYSIOLOGIC RESPONSE
● Women who are relaxed, knowledgeable, and
capable of actively participating in the control of
the birth process usually experience shorter, less
intense labors.
THEORIES OF ONSET OF LABOR
Uterine Stretch Contraction
- The idea is based on the concept that any hollow
body organ when stretched to its capacity will
inevitably contract to expel its contents. In return,
the pressure increases causing physiologic
changes (uterine contractions) that initiate labor.
Oxytocin Theory
- Pressure on the cervix stimulates the release
oxytocin from the
- maternal posterior pituitary gland. As pregnancy
advances, the uterus becomes more sensitive to
oxytocin. The presence of this hormone causes the
initiation of contraction of the smooth muscles of
the body (uterus is composed of smooth muscles).
Progesterone Deprivation Theory
- It is believed that the presence of this hormone
inhibits uterine motility. As pregnancy advances,
changes in the relative effects estrogen and
progesterone encourage the onset of labor.
- A marked increase in estrogen level is noted in
relation to progesterone, making the latter
hormone less effective in controlling rhythmic
uterine contractions.
Prostaglandin Theory
- In the latter part of pregnancy, fetal membranes
and uterine decidua increase prostaglandin levels.
- This hormone is secreted from the lower area of
the fetal membrane.
- A decrease in progesterone amount also elevates
the prostaglandin level. Synthesis of
prostaglandin, in return, causes uterine
contraction thus, labor is initiated.
Theory of Aging Placenta
- Advanced placental age decreases blood supply
to the uterus. This event triggers uterine
contractions, thereby, starting the labor.
PREMONITORY SIGNS OF LABOR
1. Lightening
- Two to three weeks before labor, the lower
uterine segment expands allowing the fetal
head to sink deep. The descent of the head and
the body of the baby gives space to the lungs,
heart and stomach, which enables these
organs to function easily.
- The symphysis pubis widens, and the pelvic
floor softens and becomes more relaxed,
allowing further descent of the uterus into the
pelvis
2. Frequency of Micturition
- The descent of the fetal head increases
pressure within the pelvis. This limits the
capacity of the bladder, which can cause
irritation.
- The laxity of the pelvic floor muscles gives rise
to poor sphincter control causing a degree of
stress incontinence. This pressure results in the
congestion of circulation to the lower limbs.
Additionally, the relaxation of the pelvic joint
may give rise to backache.
3. Bloody Show - a discharge from the vagina of
mucus, and this is sometimes tinged with blood.
4. Braxton Hicks Contraction
5. Uterine contraction
6. Cervical Dilatation and effacement
P a g e 4 | 14
 PRELIMINARY SIGNS OF LABOR
Lightening:
- Or descent of the fetal presenting part into the pelvis
- Primiparas: occurs 10-14 days before labor begins.
- Changes a woman’s abdominal contour because it
positions the uterus lower and more anterior in the
abdomen.
- Lightening gives a woman relief from the
diaphragmatic pressure and shortness of breath that
she has been experiencing and “lightens” her load.
Increase in Level of Activity:
- This increase in activity is related to an increase in
epinephrine release initiated by a decrease in
progesterone produced by the placenta.
- This additional epinephrine prepares a woman’s body
for the work of labor ahead.
- This blood, mixed with mucus, takes on a pink tinge
and is referred to as “show” or “bloody show”.
- Women need to be aware of this event so that they do
not think they are bleeding abnormally.
Rupture of Membranes:
- Labor may begin with rupture of the membranes,
experienced either as a sudden gush or scanty, slow
seeping of clear fluid from the vagina.
- Early rupture of the membranes can be advantageous
as it can cause the fetal head to settle snugly into the
pelvis, shortens labor.
- Two risks associated with ruptured membranes are:
1. Intrauterine infection and
2. Umbilical prolapse (cut off oxygen supply to fetus)
- In most instances, if labor has not spontaneously
occurred by 24hrs after membrane rupture and the
pregnancy is at term, labor will be induced to help
reduce these risks.
STAGE 1: DILATION OF CERVIX
● Begins with the onset of true labor contractions
and ends with full or complete cervical dilatation.
True vs. False Labor
True Labor False Labor

- Contractions occur at - Contractions are

regular intervals irregular
- Intensity gradually - Intensity remains the
Slight Weight Loss: increases same
- As progesterone level falls, body fluid is more easily - Discomfort is in the back - Pain is confined on the
excreted from the body. and abdomen abdomen
- This increase in urine production can lead to weight - Cervix dilates - No cervical dilatation
loss between 1 and 3 pounds. - Discomfort is not - Discomfort relieved by
Braxton Hicks Contraction: stopped by sedation sedation
- Woman usually notices extremely strong Braxton Three Phases
Hicks contractions
Latent Phase Active Phase Transition Phase
Ripening of the Cervix:
- At term, the cervix becomes still softer (“butter-
- Contraction - Contractions - Contractions
soft”) and tips upward.
are mid and grow stronger reach their peak
- Cervical ripening this way is an internal
short lasting to lasting 40-60 duration 60-90
announcement that labor is very close at hand.
20-40 sec secs secs.
SIGNS OF TRUE LABOR
- 0-3 cm cervical - 4-7 cms - Dilatation 8-10
(Involves uterine and cervical changes.)
dilatation cervical cms
Uterine Contraction:
- interval: 5-10 dilatation - Interval 2-3
- The surest sign that labor has begun is productive
mins. - Increase mins.
uterine contractions. Because contractions are
- “Non-ripe” vaginal - At 9 cms there
involuntary and come without warning, their intensity
cervix analgesia secretions is a slight
can be frightening in early labor.
given too early - Bloody show slowing of
- Helping a woman appreciate that she can predict
cephalopelvic and dilatation
when her next one will occur and therefore can control
disproportion spontaneous - At 10 cm -
the degree of discomfort, she feels by using breathing
- Nullipara - 6 rupture of irresistible urge
exercises offers her a sense of well-being.
hrs. membranes may to push
Show:
- Multipara - 4-5 occur
- As the cervix softens and ripens, the mucus plug that
hrs. - Nullipara - 3
filled the cervical canal during pregnancy (operculum)
hrs
is expelled.
- Multipara - 2
- The exposed cervical capillaries seep blood as a result
hrs
of pressure exerted by the fetus.

P a g e 5 | 14
Remember to: 3. Perineal shaving and preparation
- Provide privacy - Done aseptically
- Provide reassurance - Use #7 method always from front to back
- Establish rapport 4. Pain Relief
- Inform pt. Of labor progress - Administer analgesic as ordered (Demerol,
- Check for show/rupture bow Meperidine, HCL)
Nursing Management - Give only when cervix is already 5-8 cms
Hospital admission dilated (25-100 mg/ml)
- Get history of the pt. Assess if BOW is still intact. If - Antidote: Narcan or Nalline (narcotic
it is ruptured as claimed by the patient, perform: antagonist)
NITRAZINE PAPER TEST 5. Anesthesia: Regional: Low spinal
Nitrazine Paper Test - Usually xylocaine given at 5th lumbar space
- Blue-green to deep blue: alkaline amniotic fluid - Post-spinal headache due to leakage of CSF
Fern Test (keep patient flat on bed for 13 hrs)
- (+) Ferning test: amniotic fluid - Patient kept on NPO with IVF of glucose
Color - Watch out for hypotension
- Yellow-stained - blood incompatibility 6. Positioning
- Green-stained - meconium staining - Assume Sim's position
- Breech: normal - It favors rotation of the head Promotes
- Vertex: fetal anoxia relaxation between contractions
Physical Examination - Prevent supine hypotension syndrome
Maternal V/S - Transfer of patient to DR:
- Temp: ruptured membranes: q 2 hours - Primipara: when fully dilated Multipara:
- Intact membranes: q 4hrs * respect time of when 7-9 cms dilated
contractions 7. Danger Signs
- BP,PR & RR: latent phase -q hour or PRN FETUS:
- Active phase - q 30 mins. MOTHER: BP > 140/90
- IE, LEOPOLD'S MANEUVER - Falling BP: with accompanying signs of cold,
Monitoring and Evaluating clammy skin / pallor / restlessness /
Uterine Contractions apprehension / Increase RR & PR -
- Frequency of contractions, duration/length of hypovolemic shock
contractions, intervals - Bright red vaginal bleeding
Intensity - Abnormal abdominal contour signal
- Mild: tense uterus but can be indented impending uterine rupture and possible fetal
- Moderate: firm uterus, difficult to indent distress
- Strong: board-like, cannot indent w/ fingers STAGE 2: DELIVERY OF THE BABY
Fetal Assessment ● As the fetal head touches the internal side of the
- FHT/Fetal Electronic Monitoring: Normal: 120- 160 perineum, the perineum begins to bulge and
bpm appears tense.
- Fetal distress: Fetal bradycardia < 100 bpm ● As the fetal head pushes against the perineum, the
- Fetal tachycardia > 180 bpm vaginal introitus opens and the fetal scalp appears
- Fetal thrashing-hyperactivity - meconium stained. at the opening of the vagina.
○ Should not be taken during contractions. ● ED FIRE ERE
○ Taken q 15 and immediately after rupture Nursing Management
of membranes. - Prepare the place of birth
HEALTH TEACHING & PREPARATIONS - Positioning for birth
1. Ambulation - Promoting effective second stage pushing
- Latent phase shortens the first stage of labor ○ Should push with contractions and rest
- C/I: Medications, Ruptured between them.
- membranes, Intravenous infusions ○ Holding breath during contractions can
2. Breathing Technique temporarily impede blood return to the heart.
- Abdominal breathing - panting during These could interfere with the blood supply to
contractions (reduce tension and prevent the fetus.
hyperventilation) Perineal Cleaning
Elimination: - Always clean from the vagina outward.
- Encourage to void q 2-3 hours by offering a - Include a wide area (vulva, upper thighs, pubis
bedpan and anus).
- Urinary stasis can lead to UTI • Full bladder may - Sponge away any fecal material may be expelled
be traumatized during delivery from the rectum.
P a g e 6 | 14
Episiotomy
- Pudendal block is given (lidocaine)
○ Prevent prolonged stretching of muscles (vaginal
prolapse)
○ Spare the infant's head from prolonged pressure
(brain damage)
○ May shorten the last portion of the second stage
of labor
Birth
- ED FIRE ERE
- Ritgen's Maneuver
○ To support the perineum and prevent
laceration.
○ Ease the head out and immediately wipe
the nose and mouth of secretions to ensure
a patent airway.
- Insert finger in the vagina to check for nuchal cord
- As the head rotates:
- Deliver the anterior shoulder - downward
push
- And then deliver the posterior shoulder-
upward lift;
- Place the newborn on the mother's
abdomen.
- Show the baby to the mother inform the sex and
time of delivery and has the baby to the circulating
nurse.
- Take note of the time when the whole body of the
infant is born.
Cutting and Clamping of the Cord
- Delay cutting until pulsation ceases and
maintaining the infant at a uterine level allows as
much as 100 ml of blood to pass from the placenta
into the fetus.
- Late clamping of the cord can cause over infusion
with the placental blood.
STAGE 3: PLACENTA DELIVERY
- Begins with the birth of the infant and ends with
the delivery of the placenta
- Signs of placental separation
○ Lengthening of the umbilical cord
○ Sudden gush of vaginal blood
○ Change in the size of the uterus
○ Firm contraction of the uterus
○ Appearance of the placenta at the vaginal
opening.
Types of Placenta:
1. SCHULTZE
- Placenta separates first at its center and
lastly to its edges, it tends to fold on itself
like an umbrella.
- Fetal surface ("shiny")
- 80% of placental separation
2. DUNCAN
- Separates first at its edges, it slides along
the uterine surface
- Maternal surface ("dirty") raw, red and
irregular
NSG. RESPONSIBILITIES (3rd Stage of Labor)
● DO NOT HURRY the delivery of the placenta
● Timing of placental delivery:
● Care after placental delivery:
○ Inspection of the placenta for the
completeness of cotyledons
○ Determine the degree of uterine
contraction by palpating the uterus
● Inspection of the perineum for lacerations:
○ 1st degree laceration - vaginal mucous
membrane and skin of perineum
○ 2nd degree laceration - plus the levator ani
muscle
○ 3rd degree laceration - plus the external
sphincter of the rectum
○ 4th degree laceration - plus mucous
membrane of the rectum
● Care during and after perineal repair
○ Administration of xylocaine/lidocaine
○ Episiorrhaphy
○ Vaginal packing is sometimes inserted to
prevent bleeding but must be removed after
24 hrs
○ Estimation of blood loss
STAGE 4: RECOVERY STAGE
● First 2 hours postpartum - most critical stage
● Monitor for signs for hemorrhage and other
complications.
Nursing Responsibilities
- Fundus- checked q 15 min for 1 hr and q 30 mins
for 4 hrs
- Lochia - should be moderate in amount.
Types of Lochia
1. Lochia rubra - 1-2 days postpartum. Lochia is red,
made up of blood endometrial decidua, fetal
lanugo, vernix.
2. Lochia serosa - after 3rd day, the placental site
exudes serous material and lochia becomes dark
and thinner.
3. Lochia alba - 3rd wk. And thereafter, lochia
decreases and gray-white color. - cessation of flow
of lochia at 6wks
P a g e 7 | 14
 ESSENTIAL INTRAPARTUM AND NEWBORN CARE
(EINC)
“Unang Yakap”

COMMUNITY HEALTH TEAMS (CHTS)

With the support of barangay leader,
● CHTs known before as “women’s health teams”
● Led by the public health midwife (CHT Team Leader)
● Members:
- RN HEALS
- Barangay nutrition scholars
- Barangay health workers
- Barangay service point officers
- Women’s groups
- TBAs as ‘trackers in some CHTs

NEWBORN CARE PACKAGE

Before Php 1,000
Php 250 (eye prophylaxis, umbilical cord care, vit. K,
thermal care, BCG vaccine, resuscitation of the NB)
Php 250 (Hep B vaccine)
Php 500 (NB screening)
Now Php 1,750 UNBUNDLED
Php 1000
Php 500 for caregiver plus, PE of NB, breastfeeding
support, 4 EINC core steps, eye prophylaxis, vit. K, BCG
vaccine, Hep B vaccine
Php 200 (Hearing Screen)
Php 550 (NB screening)

Luzon (8): QMMC, PGH, Fabella, Jose Reyes, East Ave,

Tondo Medical, San Lorenzo Ruiz, Jose Rodriguez
Visayas (1): EVRMC (Tacloban)
Mindanao (2): GSCH (General Santos), CRMC (Cotabato
City)

P a g e 8 | 14

ANTENATAL CORTICOSTEROIDS
Administer ANTENATAL STEROIDS to all patients who are
at risk for preterm delivery.
– with preterm labor between 24-34 weeks AOG
– or with any of the following prior to term:
● Antepartal hemorrhage/bleeding
● Hypertension
● (preterm) Pre-labor rupture of membranes
Betamethasone 12 mg IM q 24 hrs x 2 doses OR
DEXAMETHASONE 6 mg IM q 12 x 4 doses
Overall reduction in neonatal death
● Reduction in RDS
● Reduction in cerebroventricular hemorrhage
● Reduction in sepsis in the first 48 hours of life
DEXAMETHASONE PHOSPHATE
- 2ml ampules: 4mg/ml
- 6 mg – 1.5 ml injected intramuscularly.
- Even a single dose of 6 mg IM before delivery is
beneficial.
- Emergency drug should be available at the OPD
and ER
RECOMMENDED PRACTICES DURING LABOR
1. Admission to labor when the parturient is already in
the active phase.
Active phase labor:
● 2-3 contraction in 10 minutes
● Cervix is 4 cm dilated.
2. Continuous maternal support
● ↓ Need for pain relief by 10%
● Duration of labor SHORTER by half an hour
● ↑ spontaneous vaginal delivery by 8%
● ↓ Instrumental vaginal delivery 10%
● 5-minute APGAR < 7 ↓ by 30%
3. Upright position during first stage of labor
4. Routine use of WHO partograph to monitor progress
of labor.
5. Limit total number of IE to 5 or less
● No difference in endometritis
● UTI lower by 34%
● An observational study on 161,077 women (with or
w/o PPROM) who had < 5 exams
● ↓ Chorioamnionitis by 72%
● ↓ Neonatal sepsis by 61%
PRACTICES NOT RECOMMENDED DURING LABOR
1. Routine perineal shaving on admission for labor and
delivery
● No difference in rates of maternal fever, perineal
wound infection, and perineal wound dehiscence
● No neonatal infection was observed.
2. Routine enema during the first stage of labor.
● Fecal soiling during delivery reduced by 64%
● No difference in maternal puerperal infection,
episiotomy dehiscence, neonatal infection, and
neonatal pneumonia.
3. Routine vaginal douching
● No difference in chorioamnionitis, postpartum
endometritis, perinatal morality, neonatal sepsis
● No side effects reported.
4. Routine amniotomy to shorten spontaneous labor.
● ↓ Risk of dysfunctional labor by 25%
● No difference in duration of labor, CS rate, cord
prolapse, maternal infection and APGAR score <7
at 5 minutes.
PRACTICES RECOMMENDED DURING LABOR
1. Upright position during delivery
● More efficient uterine contractions
● Improved fetal alignment.
● Larger anterior-posterior and transverse
diameters of pelvic outlet
● Enhances fetal movement through the maternal
pelvis in descent for birth.
● Faster delivery
● Leads to less interventions, less episiotomies.
2. Selective (non-routine) episiotomy
PERINEAL SUPPORT AND CONTROLLED DELIVERY
OF THE HEAD
● Keep one hand on the head as it advances during
contractions while the other hand supports the
perineum.
● During delivery of the head, encourage woman to
stop pushing and breathe rapidly without mouth
open.
3. Use of prophylactic oxytocin for management of third
stage of labor
● OXYTOCIN 10 U
● Intramuscular palpation of abdomen to rule out a
second baby.
4. Delayed cord clamping
● Early clamping: <1 min after birth
● Delayed (properly timed): 1-3 minutes after
birth or when pulsations stop.
PROPERLY TIMED CORD CLAMPING
● Lower infant hemoglobin at birth and at 24 hrs
after birth prevented.
● Fewer infants require phototherapy for jaundice.
● No difference in rates of polycythemia, need for
neonatal resuscitation, and NICU admission.
5. Controlled cord traction with countertraction to
deliver the placenta.
6. Uterine massage after placental delivery
● Lower mean blood loss
● Less need for uterotonics
P a g e 9 | 14
 ACTIVE MANAGEMENT OF THE THIRD STAGE SKIN-TO-SKIN CONTACT
(AMTSL) ● General perception is purely for mother-baby
1. Administration of uterotonic within one minute of bonding.
delivery of the baby ● Other benefits
2. Controlled cord traction with counter traction on the ○ B - breastfeeding success
uterus ○ L - lymphoid tissue system stimulation
3. Uterine massage ○ E - exposure to material skin flora
○ S - sugar (protection from hypoglycemia)
ANTENATAL STEROIDS ○ T - thermoregulation
Betamethasone ● If breathing or crying:
● 12 mg IM q 24 hrs x 2 doses ○ Position prone on the mother’s abdomen
● May be the preferred drug – less PVL or chest
Dexamethasone ○ Cover the newborn.
● 6 mg IM q 12 hrs x 4 doses ○ Dry linen for back
● Have dexamethasone available in the E-cart ○ Bonner for head
● No additional benefit to using higher or more ○ Temperature check
frequent doses. ○ Room: 25-28 C
● Prednisone, methylprednisolone, cortisol are ○ Baby: 36.5-37.5 C
unreliable Question:
1. When should the cord be clamped after birth?
PROVIDING WARMTH: CHECK THE ENVIRONMENT
Check temperature of the delivery room PROPERLY-TIMED CORD CLAMPING
● Ideal temp.: 25-28 C ● Clamp cord using a sterile plastic clamp or tie
● Check for air drafts. the umbilical
● Turn air conditioner off at time of delivery. ● Clamp again at 5 cm from the base
○ Non-mercury thermometer ● Cut the cord close to the plastic clamp
Question:
1. After the baby is born, what should be the first CARE OF THE CORD
action performed? ● Do not milk the cord towards the baby.
● Observe for the oozing of blood. If the blood
IMMEDIATE THOROUGH DRYING oozes, place a second tie between the skin and the
● Immediate drying clamp.
● Stimulates breathing. ● Dry cord care is recommended.
● Prevents hypothermia. ● Do not apply any substance onto the cord.
● Coagulation defects ● Do not use a binder or “bigkis”.
● Acidosis Questions:
● Delayed fetal to newborn circulatory adjustment. 1. Bathing the baby in the first 6 hrs is protective.
● Hyaline membrane disease 2. What is the approximate capacity of a newborn’s
● Brain hemorrhage stomach?
● Dry the newborn thoroughly for at least 30 secs. 3. How long after birth is a newborn ready to
● Do a quick check of breathing while drying. breastfeed?
● >95% of newborns breathe normally after birth.
● Follow an organized sequence. NON-SEPARATION OF NEWBORN FROM MOTHER FOR
● Wipe gently, do not wipe off the vernix. EARLY BREASTFEEDING
● Remove the wet cloth, replace with a dry one. ● Weighing, bathing, eye care, examination,
● Drying should be the first action, IMMEDIATELY injections should be done after the first full
FOR A FULL 30 SECS unless the infant is both breastfeed is completed.
floppy/limp and apneic. ● Postpone bathing until at least 6 hours.
● If the baby is not breathing, STIMULATE by
DRYING. NON-SEPARATION OF NEWBORN FROM MOTHER
● Do not slap, shake or rub the baby. ● Never leave the mother and baby unattended
● Do not ventilate unless the baby is floppy/limp and ● Monitor mother and baby q15 mins. In the first 1-2
not breathing. hrs. Assess breathing and warmth
● Do not suction unless the mouth/nose are blocked ● Breathing: listen for grunting sounds, look for
by secretions. chest in drawing and fast breathing
Question: ● Warmth: check to see if the feet are cold to touch
1. During drying and stimulation of the baby, your if no thermometer
rapid assessment shows that the baby is crying.
What is your next action?
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 EARLY AND APPROPRIATE BREASTFEEDING
INIATION
● Leave the newborn be the mother’s breasts in
continuous skin-to-skin contact.
● The baby may want to rest for 20-30 mins and even
up to 120 mins before showing signs of readiness
to feed.
● Health workers should not touch the newborn
unless there is a medical indication.
● Do not give sugar water, formula or other
prelacteals.
● Do not give bottles or pacifiers.
● Do not throw away colostrum.
● Let the baby feed for as long as he/she wants on
both breasts.
● Help the mother and baby into a comfortable
position.
● Observe the newborn.
● Once the newborn shows feeding cues, ask the
mother to encourage her newborn to move
forward the breast.
BREASTFEEDING CUES
● Eye movement under closed lids
● Alertness, movements of arms and legs
● Tossing, turning or wiggling
● Mouthing, licking, tonguing movements
● Rooting
● Changes in facial expression
● Squeaking noises or light fussing
● CRYING IS THE LATE SIGN OF HUNGER
SUPPORT CONTINUED AND EXCLUSIVE
BREASTFEEDING
● After delivery, mother is moved onto a stretcher
with her baby and transported to recovery room.
● Breastfeeding support is continued.
● Counsel on positioning.
● Newborn’s neck is not flexed or twisted.
● Newborn is facing the breast.
● Newborn is close to mother’s body.
● Newborn’s whole body is supported.
● Counsel on attachment and suckling.
● Mouth wide open
● Lower lip turned outwards.
● Baby’s chin touching breast.
● Suckling is slow, deep with some pauses.
UNDERARM HOLD
● Football hold
● Baby is held like a clutch bag
● Nose further away from the breast
● Baby’s trunk is secure beside mother’s trunk
CRADLE HOLD
SIDE-LYING POSITION
LINEAR ARRANGEMENT OF INSTRUMENTS
● Eye prophylaxis
● IM injections
○ Vit K
○ Hepatitis
○ BCG
KMC Method: Fulfilling the essential needs of the
LBW/Preterm newborn.
1. Warmth
2. Nutrition
3. Protection
4. Stimulation
Accredited KMCP in Philippines Hospitals
● Dr. Jose Fabella Memorial Hospital
● Mariano Marcos Memorial Hospital (Ilocos)
● Southern Ph. Medical Center (Davao)
● Eastern Visayas Regional Medical Center (EVRMC)
● Gat Andres Bonifacio Memorial Medical Center
(Tondo)
FOUR CORE STEPS IN IMMEDIATE NEWBORN CARE
1. Immediate and thorough drying
2. Early skin-to-skin contact
3. Properly timed cord clamping
4. Non-separation of newborn from mother for early
breastfeeding
POSTPARUM PERIOD
● Known as the 5th stages of labor
● Involution - it is the return of reproductive organ
to its pre-pregnant state
PSYCHOLOGICAL CHANGES OF THE POSTPARTAL
PERIOD
Taking-in Phase (2-3 days)
- Time of reflection for a woman
- Wants to talk about her pregnancy (labor and
birth)
- Passive dependence
- Sense of wonder
- Encourage her to talk about the birth
Taking-hold Phase
- Beings to initiate action
- Begins to take a strong interest for her child
- Give the woman brief demonstration of baby care
- Allow her to care for the child herself with watchful
guidance
- Often feels insecure about the ability to care
Letting-go
- The act of ending old ways of thinking or believing
- The woman finally redefines her new role
- Gives up fantasized image of her child and accepts
the real one
- Gives up her old role of being childless or the
mother of only one or two
- Extended and continues during the child’s growing
years
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 REPRODUCTIVE SYSTEM CHANGES
UTERUS
● A well-contracted fundus should feel firm.
● Uterine atony - relaxed uterus, woman may loss
blood rapidly
● Involution of the uterus involves 2 main processes:
1. The areas where the placenta was implanted is
sealed off to prevent bleeding.
2. The organ is reduced to its approximate
pregestational size.
- Immediately after birth - 1,000g
- End of 1 wk - 500g
- 6 wks - 50g
● 1 cm or 1 fingerbreadths every postpartum day
● After 9-10 days the fundus is no longer palpable
● After pains - intermittent cramping of the uterus
○ Common in multiparas and those who have given
birth to a large baby.
○ Uterus contracts more forcefully.
○ Intense with breastfeeding (bcs of oxytocin).
CERVIX
● Immediately after birth, the cervix is soft and
malleable.
● Both the internal and external os are open.
● By the end of 7 days the external os is narrowed to
the size of a pencil opening and the cervix feels firm
and nongravid again.
● Does not return exactly to its prepregnant state.
VAGINA
● After a vaginal birth, the vagina is soft with fer rugae.
● Hymen is permanently torn and heals with small
separate tags of tissue.
● Gradually turns to its approximate prepregnant state.
● Vaginal outlet remains slightly more distended.
HORMONAL CHANGES
● HCG and HPL almost negligible by 24 hrs
● Progestin, estrone, and estradiol are at pre-pregnant
level by 7th day.
● FSH remains low for about 12 days then begins to rise
to initiate a new menstrual cycle.
● Pregnancy hormones begin to decrease as soon as
the placenta is no longer present.
URINARY SYSTEM
● Voiding is difficult because of the pressure on the
bladder and urethra making it edematous.
● To prevent permanent damage to the bladder from
over distention, assess the woman’s abdomen
frequently in the immediate postpartum period.
● From 1500ml/day to 3000ml/day during the second
to fifth day after birth.
GI SYSTEM
● Digestion and absorption begin to the active soon
after birth.
● Hemorrhoids that have been pushed out of the
rectum due to effort of pushing often are present.
● Bowel sounds are active, but passage of stool
through the bowel may be slow due to the effect of
relaxation.
INTEGUMENTARY SYSTEM
● Striae gravidarum still appear reddened.
● Linea nigra will be barely detectable in 6 wks time
TEMPERATURE
● Take during puerperium because of the danger of
vaginal contamination.
● Slight ↑ temp during the first 24 hrs
PULSE
● Slightly slower than normal in postpartal period
● By the end of the first week, the pulse returns to
normal.
BLOOD PRESSURE
● Should be monitored carefully .
● Should be compared to her blood pressure with
that pregnancy level.
● 140/90 may indicate development of postpartal
pregnancy induced HTN, unusual but serious
complication of the puerperium.
● ↓ BP indicates hemorrhage
FORMATION OF BREAST MILK
● Stimulate the growth of milk glands and growth in
breast size
● Stimulate the growth of milk glands and growth in
breast size
● Colostrum - thin, watery, prelactation secretion
begins to secrete since midway through
pregnancy (IgA)
● Continues to excrete this fluid the first 2 days
postpartum
● On the 3rd day, breast tends to become full and
feel tense or tender as milk forms within breast
ducts
● A fall in estrogen and progesterone levels causes
prolactin production and stimulates milk
production
● Primary engorgement - noted breast distention
often accompanied by a feeling of heat or
throbbing pain
● Let-down reflex - ability of the milk to come
forward in the breast
POSPARTUM HEMORRAGE
● Is the excessive bleeding following the birth of a
baby
● Any blood loss from the uterus greater than 500ml
with a 24 hrd period
● Hemorrhage may occur before or after the
placenta is delivered
● Early postpartum hemorrhage - >500 ml in first
24 hrs (blood loss often underestimated)
● Late postpartum hemorrhage - >500 ml after
first 24 hrs
● Uncontrolled bleeding (>2 pads/30 mins)
● ↓ RBC count (hematocrit)
● Swelling and pain in tissues in the vaginal and
perineal area
● Light headedness, nausea and visual disturbances
● Anxiety, pale and clammy skin
● ↑ PR ↑RR ↑HR
● ↓ BP = blood loss
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 UTERINE ATONY RETAINED PLACENTAL FRAGMENTS
● Failure of the uterus to stay or firmly contracted ● When a placenta does not deliver entirely
● The uterus must be contracted to allow the opne ● Keeps the uterus from contracting fully leading to
vessels at the placental site to seal hemorrhage
● Slow, steady or massive hemorrhage sometimes ● May be detected by sonography or on
underestimated or hidden behind a clot examination, the uterus is not fully contracted
● Dark red bleeding ● Every placenta should be inspected for
Causes of Uterine Atony completeness after delivery
● Multiple pregnancy Causes of Retained Placental Fragments
● Hydramnios ● Pulling the cord
● Large babies ● Uterine massage prior to separation
● Placental accidents ● Placenta Accreta — the placenta is abnormally
● Prolonged and diff labor attached to the inside of the uterus (a condition
● Prev uterine surgeries that occurs in one in 2,500 births and is more
● Deep anesthesia common if the placenta is attached over a prior
Nursing Management cesarean scar).
● Medication (to stimulate uterine contractions) Nursing management
○ IM methergine ● Assess the need for dilatation and curettage (D&C)
○ IV oxytocin (10-40U/1L Ds) to remove retained placental fragments
● Manual massage of the uterus (to stimulate ● Advise woman to observe color of lochia at home
contractions) and report any changes from serosa or alba, back
● Administer ice pack to rubra.
● Bimanual massage ● Methotrexate maybe prescribed for these
● Blood transfusion instances to destroy the retained placenta.
● Hysterectomy - surgical removal of the uterus IMMEDIATE NEW BORN CARE
● If with resp distress from decreasing blood ● The ABCDs in immediate newborn care
volume ○ A — Airway
○ Give O2 ○ B — Body temperature
○ Place in supine to allow adequate blood ○ C — Check / assess newborn
flow to brain and kidneys ○ D — Determine identification
A. Establish and Maintain a Patent Airway
LACERATIONS Effective Respiration
● Tears of the birth canal ● The most important nursing responsibility
● Uterus feels firm but bleeding persists where the survival of the NB greatly
● Causes: difficult or precipitate births; depends
primigravida, LGA, lithotomy position B. Breathing
Types of Lacerations ● Main purpose is to expand the lungs
1. Cervical Laceration ● Close the accessory fetal structures
- Arterial bleeding (bright red) Nursing Interventions
- Usually on the sides of the cervix, near the ● Wipe the mouth and nose of secretions after
branches of the uterine artery delivery of the head
2. Vaginal Laceration ● Suction mouth 1st obligatory nasal breathers until
- Easier to assess but harder to repair 2-3 wks old
- Vaginal tissues is friable so lacerations are ● If the nose is suctioned first: causes aspiration
harder to repair ● Too deep suctioning: vagal stimulation and
- Indwelling urinary catheter and packing bradycardia
may be inserted ● Stimulate the baby to cry if baby does not cry
- Doc packing and remove after 24 hrs to spontaneously.
prevent infection that may lead to toxic ● Effective cry means effective breathing.
shock syndrome ● Do not slap the buttocks but rub the soles of the
Nursing management feet or back.
● Repair as episiorrhaphy ● The normal infant cry is loud and lusty
● Document degree of laceration ○ High-pitched cry – hypoglycemia, ↑ ICP
● Provide increase fluid and stool softener for1 ○ Weak cry – prematurity
week ○ Hoarse cry – laryngeal stridor
● For 3rd and 4th degree: no enema, suppository or ● Place the infant in a position that would promote
rectal temperature drainage of secretions
● Trendelenburg position: head is lower than body

P a g e 13 | 14
 ● Side lying position. if Trendelenburg is
contraindicated
● Keep the nares patent.
● Give oxygen as needed, don’t give more than 40%
02 may lead to Retrolental Fibroplasia (blood
vessels of the eyes become spastic leading to
blindness
● If cyanotic or tachycardic after initial suctioning
and a stimulation give 02 for 20-30 mins
C. PERFORM INITIAL ASSESSMENT/APGAR
SCORING of the NB
● It is taken initially at 1 minute and then at
5 minutes after birth
● 1 min score — indicates the neonate's
general condition at birth and the need for
resuscitation
● 5 min score — determines how well the NB
is adjusting to extrauterine life
○ more reliable picture of the
neonate's overall status

Score interpretation:
● 0- No distress
● 1-3 _ Mild distress
● 4-6- Moderate respiratory distress
● 7-10 - Severe distress

Dubowitz/Ballard Gestational Age Assessment

APGAR SCORE
Interpretation:
7-10:
- very good condition at the moment regular
nursing care
4-6:
- fair/guarded condition
- moderately depressed infant
- baby needs more extensive clearing of the airway
and supplementary oxygen
- problems may still arise and maybe admitted to
neonatal Intensive Care Unit (NiCU)
- prepare baby for diagnostic tests
0-3:
- poor or serious condition
- severely depressed infant, needs immediate Vital Statistics
resuscitation, must be referred to the physician. ● Vital statistics measured in a newborn are weight,
PERFORM INITAIL ASSESSMENT length, and head and chest circumference. Be sure
The Silverman and Anderson Scoring System all health care providers involved with newborns
● Is a test used to evaluate or estimate respiratory are aware of safety issues specific to care when
distress in newborns or the respiratory status of taking these measurements such as not leaving a
premature infants. newborn unattended on a bed or scale.

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