Care of the Mother and Fetus during the Perinatal

Period (The Labor Process)

Lesson 11
LESSON: 11
DURATION: 5hours

Care of the Mother and Fetus during the Perinatal Period

(The Labor Process)

SPECIFIC OBJECTIVES:

At the end of the lesson, the students should be able to:

1. Discuss the theories of labor

2. Outline premonitory signs of labor
3. Explain the five factors that affect the labor process.
4. Describe the anatomic structure of the bony pelvis
5. Recognize the normal measurements of the diameters of the pelvic inlet, cavity, and outlet.
6. Explain the significance of the size and position of the fetal head during labor and birth.
7. Summarize the cardinal movements of the mechanism of labor for a vertex presentation.
8. Assess the maternal anatomic and physiologic adaptations to labor.
9. Describe fetal adaptations to labor.
10. Review the factors included in the initial assessment of the woman in labor.
11. Describe the ongoing assessment of maternal progress during each stage of labor.
12. Describe fetal assessment during labor

LESSON PROPER:

I. THEORIES OF LABOR ONSET (The Labor Phenomenon)

LABOR - is 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

1. Uterine Stretch Theory – any hollow organ when stretched to capacity will contract and
empty, which results in prostaglandin release
2. Oxytocin theory – works together with prostaglandin to initiate contractions
3. Progesterone deprivation – change in the ration of estrogen to progesterone (increasing
estrogen in relation to progesterone stimulates contraction)
4. Prostaglandin theory – deprivation of progesterone and estrogen predominance set off
production of cortical steroids, which act on lipid precursor to release arachidonic acid, and
in turn, increases the synthesis of prostaglandin. It acts like oxytocin
5. Theory of Aging Placenta – decreases nutrients and blood supply in the aging placenta
causes uterine contractions
  SIGNS OF LABOR

Preliminary Signs of Labor

1. Lightening- (descent of the fetal presenting part into the pelvis, 10-14 days before labor
begins. When the largest diameter of the presenting part passes the pelvic inlet, the head
is said to be “ENGAGED”

Woman’s experiences:
a. Relief SOB/ diaphragmatic pressure
b. Relief abdominal tightness
c. Increased frequency of voiding
d. Shooting leg pains (from the increased pressure in the sciatic nerve)
e. Increased amount of vaginal discharges
f. Increased lordosis as the fetus enters the pelvis and falls forward. Walking is more difficult
and leg cramping may increase

2. Increased Level of Activity –awaken full of energy (epinephrine releases initiated by in

progesterone produced by the placenta).

3. Braxton Hick’s Contractions (practice contractions) – these are false labor contractions,
painless, irregular, abdominal and relieved by walking.

4. Ripening of the cervix (butter-soft)

5. Slight decrease maternal weight – 2-3lbs one to 2 days before the onset of labor because of
decreases progesterone level and loss of appetite

Differentiation Between True and False Labor Contractions

FALSE LABOR TRUE CONTRACTIONS
Begin and remain irregular Begin irregularly but become regular and
predictable

Felt first abdominally and remain First felt in lower back and sweep around
confined to the abdomen and to the abdomen in a wave
groin
Continue no matter what the woman’s
Often disappear with ambulation level of activity
and sleep
Increase in duration, frequency, and
Do not increase in duration, intensity
frequency, or intensity

Do not achieve cervical dilatation Achieve cervical dilatation

COMPONENTS OF LABOR
1. Passageway – route the fetus must travel from the uterus to the external perineum. The
fetus must also pass the pelvic ring.
2. Passenger – the fetus
3. Power – supplied by the fundus of the uterus and implemented by uterine contractions. It
causes cervical dilatation and expulsion of the fetus
4. Psyche – refers to the psychological state or feeling that women bring into labor with them

 PASSAGEWAY
o Size of the maternal pelvis - diagonal conjugate (AP diameter of the inlet)
and transverse diameter of the outlet
o Type of maternal pelvis (gynecoid, android, anthropoid and platypelloid)
o Ability of the cervix to dilate and efface and ability of the vaginal canal and
the external opening of the vagina to distend
o Route of the fetus to travel

 PASSENGER
I. Fetal head – the body part that has widest diameter
II. Fetal skull
a. Cranium – uppermost portion of the skull
8 bones:
 Frontal
 Two parietal the four superior bones
 Occipital
 Sphenoid
 Ethmoid lies at the base of cranium
 Two temporal bones

b. Sutures- are membranous spaces between the cranial bones

- allow for molding (overlapping of the bones)

a. Sagittal suture line – joins the two parietal bones of the skull
b. Coronal suture – joins the frontal bone and the two parietal bones
c. Lambdoid suture – joins the occipital bone and the two parietal bones
d. Frontal (mitotic) suture – joins the two frontal bones, becomes the anterior
continuation of the sagital suture

c. Fontanelles – the intersections of the cranial sutures

a. Anterior fontanelle (Bregma) - diamond shape and it permits growth of the

brain by remaining for 12-18 months
b. Posterior fontanelle (Lambda) - lies in the junction of the lambdoidal and
sagittal sutures. Triangular-shaped and closes within 8-12 weeks/3-4 mos.

Other important landmarks of the fetal skull:

 a. Mentum – the fetal chin
b. Sinciput – the anterior area known as brow
c. Vertex – the area between the anterior and posterior fontanelles
d. Occiput – the area of the fetal skull occupied by the occipital bone, beneath the posterior
fontanelle

Diameters of the fetal skull

The shape of the skull causes it to be wider in its anteroposterior diameter than in its
transverse diameter to fit the birth canal. Measurement – AP diameter of the skull is wider than
the transverse diameter.

1. Transverse diameter
a. Bi-parietal – 9.25 cm
b. Bitemporal – 8 cm

2. Anteroposterior diameter
a. Suboccipitobregmatic – the narrowest diameter is from the inferior aspect of the occiput to
the center of the anterior fontanelle(approximately 9.5 cm)
b. Occipitofrontal – measured from the bridge of the nose to the occipital
prominence(approximately 12 cm)

3. Occipitomental – widest AP diameter measured from the chin to the posterior fontanelle
(approxiamately 13.5 cm)

FETAL PRESENTATION AND POSITION

• (Attitude) Fetal attitude – describes the degree of a flexion a fetus assumes during labor
or the relation of the fetal parts to each other

a. Good attitude – complete flexion

 spinal column is bowed forward
 the head is flexed forward so much that the chin touches the sternum
 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

A. Vertex (full flexion) : GOOD ATTITUDE: is the normal fetal position it is advantageous for
birth because of it helps a fetus present the smallest anteroposterior diameter because it puts the
whole body into an ovoid shape, occupying the smallest space as possible

B. Sinciput (moderate flexion; military attitude)

• The fetus is in moderate flexion the chin is not touching the chest but it is in an alert
• Causes next-widest anteroposterior diameter, the occipital diameter to present to the birth
canal.

C. Brow (partial extension)- the fetus is in partial extension presents the brow of the head in the
birth canal
D. Face (poor flexion, complete extension)- fetus is in poor flexion, the back is arched, the neck
is extended, and in complete extension

 Engagement- refers to the settling of the presenting part of a fetus far enough to the pelvis to
be at the level of the ischial spine.

 Molding - change in shape of the fetal skull produced by the force of uterine contractions
pressing the vertex of the head against the not-yet dilated cervix.

 Station - refers to the relationship of the presenting part of a fetus to the level of the ischial
spine

1. 0 – level of the ischial spine (synonymous w/engagement)

2. -1 to -4 ( above the spines)
3. +1 to +4(below the spines)
4. +3 to +4 (synonymous to crowning)

 Fetal Lie
- refers to the relationship of the cephalocaudal axis (spinal column) of the fetus to the
cephalocaudal axis of the woman
a. Longitudinal lie – cephalocaudal axis of the fetus is parallel to the woman’s spine
b. Transverse lie – cephalocaudal axis of the fetal spine is at the right angles to the woman’s
spine

FETAL PRESENTATION
- determined by the fetal lie and by the body part of the fetus that enters the maternal pelvis first.
It may be cephalic, breech or shoulder.

a. CEPHALIC PRESENTATION - is the most frequent presentation occurring as often as

95%
Caput succedaneum – during labor the area of the fetal skull that contracts the cervix often
becomes edematous from the continued pressure against it

1. Vertex presentation
 the most common type of presentation
 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

2. Military presentation
 The fetal head is neither flexed or extended
 The occipitofrontal diameter presents to the maternal pelvis
 The top of the head is the presenting part
3. Brow presentation
 The fetal head is partially extended
 The occipitomental diameter, the largest anteroposterior diameter, is presented
to the maternal pelvis
 The sinciput is the presenting part

4. Face presentation
 The fetal head is hyperextended (complete extension)
 The submentobregmatic diameter presents to the maternal pelvis
 The face is the presenting part
b. BREECH PRESENTATION

1. Complete breech
 The fetus has thighs tightly flexed on the abdomen; both the buttocks and the tightly
flexed feet present to the cervix
 Good attitude and longitudinal lie

2. Frank breech
 Attitude is moderate because the hips are flexed but the knees are extended to rest
on the chest. The buttocks alone present to the cervix.
 Lies longitudinal and moderate attitude

3. Footling Breech
 Neither the thighs nor lower legs are flexed. If one foot presents, it is a single-
footling breech; if both present, it is a double-footling breech
 Longitudinal lies, poor attitude

c. SHOULDER PRESENTATION
 In transverse lie, a fetus lies horizontally. The presenting part is usually one of the
shoulders (acromion process), an iliac crest, a hand or an elbow
 Caused by relaxed abdominal wall from grand multiparity, allows unsupported
uterus to fall forward, pelvic contraction the horizontal is greater than the vertical
space, placenta previa (limit a fetus ability to turn),

FETAL POSITION
 The relation of the fetal presenting part to a specific quadrant of the woman’s pelvis.

3 notations to describe the fetal position:

1. Right (R) or Left (L) side of the maternal pelvis

2. The landmark of the presenting part: Occiput (O), Mentum (M), Sacrum (S), or Acromion
process (A)
3. Anterior (A), Posterior (P), or transverse (T) depending on whether the landmark is in front,
back, or side of the pelvis

Importance of Determining Fetal Presentation and Position

  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

Four methods determining fetal position:

 Inspection and palpation (Leopold’s maneuver)
 Vaginal examination
 Sonography
 Auscultation of FHT

SIGNS OF TRUE LABOR

1. Uterine Contraction - surest sign that labor has begun. Initiation of effective, productive,
involuntary uterine contraction

3 phases of uterine contractions:

a. Increment/ Crescendo- intensity of the contraction increases
b. Apex/Acme- the height or peak of the contraction
c. Decrement/Decrescendo- intensity of the contraction decreases

Level of Intensity
a. Mild contraction - uterine muscle becomes somewhat tense, but can be indented with gentle
pressure
b. Moderate contraction - uterus becomes moderately firm and a firmer pressure is needed to
indent
c. Strong contraction - uterus become so firm that it has the feel of wood like hardness, and
uterus can’t be indented when pressure is applied

2. Uterine Changes - as labor progresses, the uterus is gradually differentiated into two distinct
portion– Physiologic retraction ring
a. Upper uterine segment = thicker and active
b. Lower uterine segment = thin, supple and passive
c. Contour of the uterus changes = from a round ovoid to a elongated in a vertical diameter

3. Cervical Changes

A. Effacement - shortening and thinning of the cervical canal to paper thin

• Primipara: Effacement ; Dilatation
• Multipara: Dilatation ; Effacement

B. Dilatation- enlargement of the cervical canal from an opening a few millimeters wide to
one large enough (approximately 10 cm)

4. Show – this is the blood-tinged mucus discharged from the vagina ----rupture of the cervical
capillaries
5. Rupture of the membranes of bag of water - this is the sudden gush or a scanty slow seeping
of amniotic fluid from the vagina.
1. Note for the color of the amniotic fluid
2. Normal color: clear with white specks of
vernix
3. Consequences: a. Infection
b.prolapse cord
Nursing Action with Ruptured Membrane:
1. Notify physician
2. Lie patient on bed to ensure that fetus is not impinging on the cord
3. Check FHR to determine fetal stress
4. If she feels, loop of the cord coming out from the vagina (umbilical cord prolapse), position
the woman in Trendelenburg

LENGTH OF LABOR:

Comparison:

Stage Primigravida Multigravida

First stage 12 ½ hours 7 hrs. 20 mins
Second Stage 80 mins 30 mins
Third Stage 10 mins 10 mins
Total 14 hours 8 hours

STAGES OF LABOR

A. STAGE OF DILATATION (1st Stage)

- Begins with first symptoms of true labor and ends with complete dilatation of the cervix
(10cms).

Different Phases of the FIRST STAGE

Duration Uterine Cervical

Contraction Dilatation
LATENT Primi:6 hrs Lasts 20 - 30 secs 0 - 3 cm
PHASE Multi: 4-5 hrs Every 5-20 mins
ACTIVE PHASE Primi: 3 hrs Lasts 30 – 45 sec 4 – 7 cm
Multi: 2 hrs Every 3 – 5 mins
TRANSITION Primi: 1 hr Lasts 45 – 70 secs 8 – 10 cm
PHASE Multi: 30 mins Every 2 - 3 mins

 EARLY DECELERATION: Pressure on the fetal head as it progresses down the

birth canal
• Usually seen in active labor when dilatation 4 to 7 cm
 • Increased intracranial pressure stimulates vagus nerve which slows the heart
rate

NURSING INTERVENTION:
- Do nothing

 LATE DECELERATION: Due to uteroplacental insufficiency

• Decrease blood flow impeding O2 transfer to the fetus
• During uterine contraction (hypoxemia)

NURSING INTERVENTIONS:
- Left lateral/ side lying
- O2 therapy
- CS delivery

 VARIABLE DECELERATION: umbilical cord compression

• Decreases amount of blood flow to the fetus

NURSING INTERVENTIONS:
- Left sidelying
- O2 therapy
- CS, forcep births or vacuum extraction is Indicated

NURSING CARE MANAGEMENT (1st Stage)

A. History taking, review of the woman’s pregnancy (physical/psychological events) general

health, family medical information

B. Physical assessment – Leopold’s, IE to determine:

 effacement, dilatation and conditions of membranes
 Lie (vertical or horizontal), presentation, presenting part
 Station
 Location of FHT – Vertex (LLQ); Breech (above level of umbilicus); Face (fetal chest)

C. Provide privacy and reassurance – rapport

D. Bath – comfort and relaxation

E. Perineal preparation

F. NPO, start IVF and monitor I & O

G. Avoid solid foods for the following reasons:

 Digestion delayed labor
 Full stomach interferes with proper bearing down
 Aspiration
 H. Empty bladder every 2 -3 hrs. – Because:
 Retards fetal descent,
 Urinary stasis can lead to UTI,
 Full bladder may have traumatized during delivery

I. Bear down only during true labor contractions – to minimize maternal exhaustion and
cervical edema

J. Encourage to change and assume comfortable position (Sim’s position)

 Favors anterior rotation of the head
 Promotes relaxation between contraction
 Prevents supine hypontensive syndrome

K. Monitor uterine contractions every hour during the latent phase and every 30 minutes
during active phase: Duration, Interval, Frequency, and Intensity

L. Monitor vital signs – BP and FHR taken every hour during the latent phase and every 30
minutes during the active phase. This should not be taken during contractions.

M. Administered of analgesics – analgesics (Demerol) acts to suppress the sensory portion of

the cerebral cortex.

N. Administration of anesthetics

O. Be aware of the danger signs of labor and delivery (fetal/maternal distress)

FETAL DISTRESS:
1. Tachycardia= more than 160 bpm
2. Bradycardia = less than 110
3. Meconium = stained amniotic fluid
4. Fetal trashing= hyperactivity
5. Fetal acidosis = ph below 7.2

MATERNAL DISTRESS
1. BP over 140/90 mmHg, with signs of shock
2. Abnormal pulse more than 100 bpm = hemorrhage
3. Inadequate or prolonged contractions
4. Increase apprehension = sign of 02 deprivation or internal hemorrhage

P. Transfer of patient from the labor room to the delivery room

 Multiparas (cervical dilatation 7-9cms)
 Primiparas (full dilatation)
 B. STAGE OF EXPULSION (2ND Stage)
- This stage begins from the time of full dilatation of the cervix and ends with the delivery
of the infant.

2 Phases:

1. Deceleration phase: the progress of labor does not slow down; the final degree of cervical
dilatation is achieved and the cervix retracts over the presenting part.

2. 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.

MECHANISMS 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. These position changes are termed the Cardinal Movements:

1. Descent- is the downward movement of the biparietal diameter of the fetal head within the
pelvic inlet. Full descent occurs when the fetal head extrudes beyond the dilated cervix
and touches the posterior vaginal floor. The pressure of the fetal head on the sacral nerves
at the pelvic floor causes mother to experience pushing sensation.

2. Flexion- as descent occurs the fetal head reaches the pelvic floor, the head bends forward
onto the chest, making the smallest anteroposterior the one presented to the birth canal.
3. Internal Rotation- occiput rotates until it is superior or just below the symphysis pubis
bringing the head into the best relationship to the outlet of the pelvis.

4. Extension- as the occiput is born, the back of the neck stops beneath the pubic arch and
acts as a pivot for the rest of the head. The head extends and foremost parts of the head,
face and chin are born.

5. External Rotation- immediately after the head of the infant is born, the head rotates from
the AP position assumed to enter the outlet back to the diagonal/transverse position of the
early part of labor.

6. Expulsion- once shoulders are born, the rest of the baby is born easily and smoothly
because of the smaller size. The end of the pelvic division of labor.

NURSING CARE MANAGEMENT (2nd Stage)

A. Proper positioning on the delivery table- 2 alternative positions

1. Sim’s and dorsal recumbent
2. Semi-sitting, squatting- less tension on the perineum to have fewer perineal tears.

B. Bearing down techniques – best time to encourage strong pushing with contractions, the
woman is asked to take two short breath and bear down the peak of the contraction.
 C. Care of use 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.
It has natural anesthesia

The two types of episiotomy are:

A. Median- begun in the midline of the perineum and directed
toward the rectum.
B. Mediolateral- begun in the midline of the perineum but directed laterally
away from the rectum

D. Breathing Techniques- as soon as the head crowns, the woman is instructed not to push any
longer because it can cause rapid expulsion of the fetus instead she should be advise to
pant ( rapid and swallow breathing).

E. Ritgen’s Maneuver
1. Support the perineum during crowning by applying pressure with the palm against
the rectum.
2. The head should be pressed gently while it slowly eases out to prevent rapid
expulsion of the fetus which could result to lacerations
3. As soon as the head as 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 so and is loose,
it should be slipped down the shoulder, be clamped twice an inch part and cut in
between.
4. 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.
5. While supporting the body’s head and neck, the rest of the baby is delivered.

F. Time of Delivery must be noted.

G. 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.

H. Cutting of the Cord – this is postponed until pulsations have stopped because 50-100 ml of
blood is flowing from the placenta to the newborn at his time.

I. Initial Contact
 Maternal- infant bonding is initiated as soon as the baby has been sanction and
provide warmth

C. PLACENTAL EXPULSION (3rd Stage)

- The stage begins with the delivery of the infant and ends with the delivery of the
placenta. It is divided into two phases:
A. Placental Separation phase – separation of the placental results from the disproportion
between the size of the placenta and the reduced size of the site of the placental attachment after
the delivery of the baby.

The sign of the placental separation are follows:

1. The uterus becomes more firm and round in shape and rising high at the level of the
umbilicus
2. Sudden gush of blood from the vagina
3. Lengthening of the umbilical cord.

B. Placental expulsion – placenta is delivered either by natural bearing down effort of the mother
or by gentle pressure on the contracted uterine fundus by the physician or
nurse (CREDE’s MANUEVER).

Two mechanisms by which placenta is expelled:

a. Schultz (shiny-fetal membrane) – placenta separates first from the center so that it
will folds itself like an umbrella and its shiny and glistening fetal surface is presented
at the vaginal opening.

b. Duncan (dirty – irregular maternal surface) – if the placenta separates first at the
edges, it slides along the uterine surface evident. It looks raw red and irregular with cotyledons
showing.

NURSING CARE MANAGEMENT (3rd Stage)

1. Never hurry the delivery of the placenta by forcefully pulling out the cord or by vigorous
fundal push as it can lead to uterine inversion
• Brandt Andrews Maneuver – wind the cord around the clamp, then deliver
the placenta by rotating it so that no placental fragments are left inside the
uterus.

2. Take note the time of placental delivery should be delivered 20-30mins after the
delivery of the baby.

3. Inspect for the completeness of the cotyledons

4. Palpate the uterus to determine degree of contraction if boggy/uncontracted – massage

fundus gently and properly, apply ice or ice cap over abdomen.

5. Administration of oxytoxic agents – Methergin (0.2mg/ml) and Syntocinon (10u/ml)

6. Inspect perineum for laceration

Classifications:
 a. First degree – involved vaginal mucous membrane and the skin of the perineum to
the fourchette
b. Second degree – vagina, perineal skin, fascia, levator animuscle, perineal body
c. Third degree – entire perineum, external sphincter of the rectum
d. Fourth degree - entire perineum, rectal sphincter and Some mucuos membrane of
the rectum

7. Assist doctor in doing episiorraphy, repair of the episiotomy or lacerations

8. Estimate amount of blood loss

9. Provide comfort and perineal care, apply clean sanitary

10. Vital signs every 15 minutes for the first hour and palpate uterine fundus for size and
position.

11. Transfer back to the RR or room and position flat on bed w/o pillows. To prevent
dizziness due to intra-abdominal pressure

D. One to 24 HOUR AFTER DELIVERY(4th Stage)

- The stage refers to the first one to four hours immediately after delivery when the VS are
quite unstable. *Critical condition possibility of uterine atony

NURSING CARE MANAGEMENT (4th Stage)

Assessment
a. Fundus – palpate every 15 minutes first hour; 30 mins for the next hours. Should be firm,
at the midline of the umbilicus
b. Bladder – check 2 hours during 1st 8 hours then every 8 hours for 3 days. Suspect full
urinary bladder if the fundus is not well contracted and is shifted to the right. A full bladder
prevents good contraction of the uterus and may cause hemorrhage
c. Vaginal discharge – checked every 15mins and should be moderate. Saturated napkin every
30 minutes – excessive bleeding
d. Check BP and PR every 15 minutes first hour then 30 minutes until stable
e. Inspect perineum every 8 hours for 3 days. Note the episiorraphy should be clean and
intact

Comfort Measures:

1. Perform perineal care gently and apply napkin

2. Lower legs simultaneously from the stirrups and position her flat on bed
3. Give mother soothing sponge bath changed linen and clothing
4. Provide additional blankets
5. Give the mother initial nourishment of coffee, tea, soup or milk
6. Provide a quiet and restful environment
7. Allow mother to take enough rest and sleeps in order regain energy.
REFERENCES/ADDITIONAL RESOURCES/READINGS:

Pillitteri, Adele (2018). Maternal and Child Health Nursing, Care of the Childbearing and
Childrearing Family, 8th edition.

Ricci, Susan (2007). Essentials of Maternity, Newborn and Women’s Health Nursing, Lippincott
Williams & Wilkins

Seeley, Rod R. (2005). Essentials of Anatomy and Physiology, 5th Edition

Wong, Donna, et.al.(2009). Maternal Child Nursing Care, 3rd edition, Elsevier (Singapore) Pte Ltd