topic-

obstetric & physiological changes during labour

gynecology nursing
Presented by -MRS. MAMTA YADAV
M. SC. NURSING PREVIOUS YEAR
 
Introduction
The physiological processes associated with birth. This begins in the final
weeks of pregnancy as changes occur to the uterus and cervix in
preparation for birth and continues through the processes associated with
the birth of the baby. The mechanism of labor describes the manipulations
the baby must make to negotiate the narrow pelvis and birth canal. Labor
is a physically demanding time that is supported by changes to metabolism
and probably changes to all body systems to maximize the efforts of the
woman. Parturition, typically occurs within a week of a woman’s due
date, unless the woman is pregnant with more than one fetus, which
usually causes her to go into labor early. As a pregnancy progresses into its
final weeks, several physiological changes occur in response to hormones
that trigger labor.
The increasing ratio of estrogen to progesterone makes the myometrium
more sensitive to stimuli that promote contractions.
Some women may feel the result of the decreasing levels of progesterone in
late pregnancy as weak and irregular peristaltic braxton hicks
contractions, also called false labor. These contractions can often be
relieved with rest or hydration.
 
DEFINITION OF NORMAL LABOUR
 WHO defines normal labor / birth as follows: “the
birth is onset & low risk at the start of labor &
remains so throughout labor & delivery.”
The infant is born spontaneously in vertex position
between 37 and 42 weeks of pregnancy.

 “Labor is the series of event that takes place in the

genital organs in an effort to expel the viable
product of conception out of the womb through the
vagina in to the outer world.”
Physiology of Labour-

 Labor, Childbirth, or parturition, is a process where

regular and coordinated muscular contractions of the
uterus lead to gradual effacement and dilation of the
cervix, followed by expulsive contractions which result in
the birth of the baby and placenta.
 A common sign that labor will be short is the so-called
“bloody show.” During pregnancy, a plug of mucus
accumulates in the cervical canal, blocking the entrance to
the uterus. Approximately 1–2 days prior to the onset of
true labor, this plug loosens and is expelled, along with a
small amount of blood.
For simplicity the physiological changes that occur
during this process can be divided into four stages.
1ST STAGE OF LABOUR/ CERVICAL
STAGE
 describes the time when uterine contractions are of sufficient frequency,
intensity and duration to cause effacement and dilation of the cervix.
 Prime 12 hrs
 Multi 6-8 hrs
 Latent (Preparatory) Phase:- starts from the onset of true labor

contractions to 3 cm cervical dilatation.

 Active Phase:- starts from 4 cm cervical dilatation to 7 cm cervical

dilatation. During this phase, contraction intensity is stronger, interval

shortens, and duration lengthens. This is where true discomfort is first
felt by the patient so she is dependent and her focus is on herself.
 Transition Phase:- starts from 8 cm cervical dilatation to 10 cm (full)

cervical dilatation and full cervical effacement. During this time, patient
may be exhausted and withdrawn or aggressive and restless. Patient’s
urge to push is noticeable.
Stages cont….
Physiological events in the first stage of labor
are –
 1. The first stage of labour is chiefly concerned with the
preparation of the birth canal so as to facilitate the expulsion of
the fetus in the second stage of labour. Physiological events in the
first stage of labor –
 Contraction & retraction uterine muscles
 Formation of upper & lower uterine segment
 Development of retraction ring
 Taking up or effacement of the cervix
 Dilatation of the cervix
 Show presentation
 Formation of bag of water
 General fluid pressure
 Rupture of membranes
 Fetal Axis pressure
I. UTERINE FACTORS

 1. UTERINE CONTACTION IN LABOR: - Uterine contractions are involuntary movements, which are
recurring with rhythmic & irregular intervals.  
 Nature of uterine contraction
1. Pain full uterine contraction
2. Fundal dominance
3. Raised intra amniotic pressure
4. Retraction
5. polarity
1. Painfull uterine contraction: - the contractions are intermittent and regular intervals which
are pain full. During contractions are not within the control of the patient & confines even
when the patient is unconscious sedation.
 Frequency: - contractions occur intermittently throughout labour. They begin at 20- 30 min.

apart & become closer together until, at height of the expulsive efforts, they are as frequent
as every 2 - 3 min. in 2nd stage.
 Regularity:- contractions occur more & more regularly as becomes well established.
 Duration: the length of the time a contraction lasts increase from 30 sec. to between 60-90

sec. near full dilation of the cervix. Then the duration becomes about 60sec. until delivery
of the fetus is accomplished.
 Intensity: the strength of the contraction also increase as labour progress, from weak

contractions noted early in labour strong expulsive contratraction( intrauterine pressure

measured at 50-70 mmHg).
CONT..

2. Fundal dominance:-Each contractions begins in the region of the ostia where

the pacemaker of the uterine contractions are probably situated and waves of
contractions are through midzone downward to lower segment. & most
effective when they are synchronous with fundal dominance.
3. Raised intra amniotic pressure: - there is some Intra-amniotic pressure during
pregnancy (3-5 mm of Hg). During contraction it increases up to 40- 50 mm
of Hg in the first stage & 80 – 100 mm of Hg in the second stage of labour.
4. Retraction: - Retraction is the progressive shortening of uterine smooth
muscle cells in the upper portion of the uterus as labour progress. the
retraction of the upper pole of the uterus causes smaller uterine cavity which
keeps pace with the gradual descent of the presenting part. Retractions are
progressive in nature & more pronounce in the second & 3 rd stage of labour
which is inevitable.
 The effects of retraction which is essential in normal labour are-

 Formation of upper & lower uterine segment.

 Help in dilatation and effacement of cervix.

CONTI… .

 Maintain the advancement of presenting part & help in expulsion of the fetus.
 Help to reduce the surface area of the uterus favoring separation of placenta

after birth of the baby.

 Maintain effective homeostasis after the separation o placenta.

5. Polarity:-during each contraction two

poles of uterus act harmoniously.
The upper pole contract strongly &
reacts to expel the fetus towards the
lower pole & the lower pole contract
slightly & help cervix to dilate in
response to the force o contraction
of upper segment. Thus the coordination between upper & lower segment called
polarity which brings cervical dilatation.Polarity of the uterus there is some
co-ordination between contraction & cervical dilatation called “polarity of
uterus”. While the upper segment contracts, retracts & pushes the fetus, the
lower segment & the cervix dilate in response to the force of contraction of
upper segment.
2. FORMATION OF THE LOWER UTERINE SEGMENT: -
by the end o pregnancy, the body of the uterus has divided into the anatomically distinct
segments. The lower segment is develops from the isthmus & are about 8 to 10 cm in length.
The upper segment becomes thicker and the progressive thinning of lower segment &
comparatively upper segment is active & lower segment is passive or relaxed to passed out
of product & expel out the baby. 
3. DEVELOPMENT OF RETRACTION RING: - as a result of the lower
segment thinning & concomitant upper segment thickening, a boundary between the two is
marked by a ridge on the inner uterine surface is known as the physiological retraction
ring. 
Bandl's ring (also known as pathological retraction ring) is the abnormal junction
between the two segments of the human uterus, which is a late sign associated with 
obstructed labor. Prior to the onset of labour, the junction between the lower and upper
uterine segments is a slightly thickened ring. In abnormal and obstructed labours, after the 
cervix has reached full dilatation further contractions cause the upper uterine segment
muscle fibres myometrium to shorten, so that the actively contracting upper segment
becomes thicker and shorter. The ridge of the pathological ring of Bandl's can be felt or seen
rising as far up as the umbilicus. The lower segment becomes stretched and thinner and if
neglected may lead to uterine rupture. It is Major pathology behind obstructed labor. A
circular groove encircling the uterus is formed between the active upper segment and the
distended lower segment. Due to pronounced retraction, there is fetal jeopardy or even death.
4. CERVICAL CHANGES IN PREPARATION OF LABOUR-

  Another region of the uterus that undergoes changes is the cervix.

 During pregnancy, the cervix serves as a protective barrier from invading

microorganisms.
 It is also important in retaining the fetus in the uterus.

 Stretching of the cervix is resisted due to its high content of connective tissue,

collagen-fiber bundles embedded in a proteoglycan matrix.

 Before effacement and dilation can occur, the cervix must change structure and

soften or ‘ripen’, and this occurs towards the end of pregnancy.

 The softening process is characterized by an infiltration of leucocytes, an increase

in water and a decrease in collagen content of the cervix.

 Increases in levels of glycoaminoglycans reduce the ability of collagen fibres to

bind together.
 The changes associated with cervical ripening are independent of myometrial

contractions.
 Increases in oestrogens relative to progesterone and increases in relaxin levels
promote collagen degradation.
 Once the cervix is prepared physiologically and structurally, labuor can begin.
5. EFFECMENT: -
 takeoff & reduce or thinning out & shortening of cervical
canal length & merge with the isthmus of uterus.
 During pregnancy, your cervix has been closed and
protected by a plug of mucus. When the cervix effaces, the
mucus plug comes loose and passes out of the vagina. The
mucus may be tinged with blood. Passing the mucus plug is
called "show" or " bloody show." You may notice when the
mucus plug passes. But you might not.
Effacement and dilatation allow a baby to be born through
the birth canal. Effacement means that the cervix stretches
and gets thinner. Dilatation means that the cervix opens.
6. DILATATION: -
Most of the time, the cervix is a small, tightly closed
hole. It prevents anything from getting into or out of
the uterus, which helps to protect the baby. After the
cervix begins to efface, it will also start to open. This is
called cervical dilatation.
Dilation cont…

 During labor, intense contractions of the uterus help move the

baby down and eventually out of the pelvis, and into the vagina.
These contractions put pressure on the cervix and cause it to
expand slowly. Contractions tend to get stronger, closer
together, and more regular as labor progresses.

 Cervical dilatation is described in centimeters from 0 to 10. At

0, the cervix is closed. At 10, it's completely dilated. The cervix
must be completely dilated before start the pushing stage.
7. SHOW PRESENTATION: -

As a result of the dilatation of the cervix, the

operculum, which formed the cervical plug during
pregnancy, is lost. The woman may see a blood stained
mucoid discharge a few hours before, or within a few
hours after, labour starts.
The blood comes from the ruptured capillaries in the
parietal decidua where the chorion has become
detached from the dilating cervix.
 
 
II. MECHANICAL FACTORS

1. Formation of Bag of fore water: - the increased

uterine pressure during contraction causes the loosened part
of the amniotic sac to herniated downwards into the dilating
internal OS & forms bag of membranes.well fitting
presenting part dividing the fore –water from hind water to
force into the bag of membranes during contraction which
may leads to its early rupture.
The intact bag of membranes is essential for effective dilation of cervix.
2. General fluid pressure: -
 When the membranes remain intact, the pressure of
each contraction is exerted on the fluid and, as fluid is
not compressible, pressure is equalized throughout the
uterus. This is known as general fluid pressure. If the
membranes are ruptured and amniotic fluid is reduced,
contraction pressure is
applied directly to the fetus.
3. Fetal axis pressure:-
 during each contraction the uterus rises forward and the
force of the fundal contration is transmitted to the
upper pole of the fetus & down the long axis of the
fetus , & applied by the presenting part to the cervix.
4. Rupture of membrane: -
 The optimal physiological time for the membranes to rupture spontaneously is at the end
of the first stage of labour when the cervix becomes fully dilated and no longer supports
the bag of forewaters.
The uterine contractions are also applying
increasing force at this time.
 If it ruptures before full dilation, is called early

rupture of membranes.
 If the membranes rupture before 37 weeks

of gestation & when mother is not in labour called PPROM.

When the membranes rupture before onset of labour it is called premature rupture of
membranes.
 If for any reason there is a badly fitting

presenting part, the forewaters are not cut

off effectively & the membranes rupture early
but in some causes no reason is apparent,
occasionally the membranes do not rupture
even in the second stage & appear at it is born,
this known as “Caul”. Amniotomy, also known
as artificial rupture of membranes (AROM) or colloquially known as "breaking the
water," is the intentional rupture of the amniotic sac by an obstetrical provider.
2ND STAGE OF LABOUR / CHILDBIRTH
STAGE
begins with the complete dilation of the cervix, decent and ends with delivery of
fetus through the birth canal.
Physiological events in the second stage of labor –
1. FULLY DILATATION OF CERVIX: - the first stage of labor ends when the
cervix is dilated 10cm & fully effaced.
2. CROWNING: - Signs in vaginal roots opening circular, stretching & thin off
the vaginal wall, with the pressure of presenting part & the hairs of fetus or
biparaital diameter 10.5 cm of skull is visible in the outlet of pelvic floor.
The internal rotation is followed by further descent until the occiput passes
beyond symphysis pubis in flexed attitude of fetal head. This causes a slight
twist in the neck of the fetus as the head is no longer in direct alignment with
the shoulders The anteroposterior diameter of the head now lies in the widest
diameter of the pelvis outlet. The maximum diameter (biparietal) of the head
stretches the vulval outlet without any recession of the head even after the
contraction is over is called crowning of the head.
3. SOFT TISSUE DISPLACEMENT: -
 The fetal head becomes visible at the vulva, advancing each contraction and receding between
contractions until crowning takes place. The head is then born. The shoulders and body follow
with next contraction, accompanied by gush of amniotic fluid and sometimes of blood. The
second stage culminates in the birth of the baby.
EXPULSION OF FETUS: - Uterine contraction and retraction become stronger with “bearing
down” efforts by mother. (Average duration is 2 hours in primigravida and 1 hour in
multipara).
Propulsive efforts: Propulsive phase-starts from full dilatation up to the descent of the
presenting part to the pelvic floor. Delivery of the fetus is accomplished by the downward
thrust offered by uterine contractions supplemented by voluntary contraction of abdominal
muscles against the resistance offered by bony & soft tissues of the birth canal.
Expulsive efforts/additional efforts: Expulsive phase- is distinguished by maternal bearing
down efforts and ends with delivery of the baby.
Endowed with power of retraction, the fetus is gradually expelled from the uterus against the
resistance offered by the pelvic floor.  
After the expulsion of the fetus, the uterine cavity is permanently reduced in size only to
accommodate the after –birth.
 
III. HORMONAL FACTORS
Prostaglandins-
 Prostaglandins are lipids that are synthesised in tissues throughout the body.
 They are act at or near the place where they are synthesised.
 Prostaglandins are uterotonins directly responsible for uterine contraction.

 Two prostaglandins are particularly important in labour: PGE  and PGF .

2 2α
 These prostaglandins stimulate smooth muscle fibres to contract, formation of gap junctions in

myometrial tissue.
 Increase calcium levels in mayometrial cells.
 As mentioned previously, prostaglandins also have a role in softening the cervix, enabling

effacement and dilation.

 

Oxytocin-
 Another hormone essential for labor is oxytocin.
 Oxytocin is released into the systemic circulation from the posterior pituitary in response to tactile

stimulation of the reproductive tract, particularly the cervix.

 This is known as the Ferguson reflex
 There is also a local (paracrine) release of oxytocin from the fetal membranes, decidua and placenta.
 It can only be used clinically to induce labor if the cervix is ripe.
 Plasma oxytocin levels do not increase physiologically until the second stage of labour.
 Oxytocin binds to these decidual receptors, stimulates the release of prostaglandins from the

decidua and stimulates uterine pacemakers.

Augmentation
 Augmentation is the process of stimulating the uterus to
increase the intensity and duration of contractions after
labour has begun. Several methods of augmentation are
commonly been used to treat slow progress of labour
(dystocia) when uterine contractions are assessed to be
too weak. Oxytocin is the most common method used to
increase the rate of vaginal delivery. The World Health
Organization recommends its use either alone or with 
amniotomy (rupture of the amniotic membrane) but
advises that it must be used only after it has been correctly
confirmed that labour is not proceeding properly if harm
is to be avoided. The WHO does not recommend the use
of antispasmodic agents for prevention of delay in labour.
MATERNAL PHYSIOLOGICAL Changes in SECOND STAGE OF LABOUR:

 cardiovascular system- The major anatomy-physiological

changes of the maternal cardiovascular system happen
throughout gestation and include an increase of blood volume,
cardiac output, maternal heart rate, decrease of arterial blood
pressure, and systemic vascular resistance. These changes are
almost fully reversed in the weeks and months after delivery.
During labor and delivery, there is further adaptation of cardiac
output which progressively rises in both stroke volume and
heart rate, peaking with contractions.
 BLOOD PRESSURE: B.P. may raise another 15 – 20 mmHg
with contraction during the 2nd stage of labour. Maternal pusing
effort affects the b.p. causing variation from an increase to a
decrease & ending at a level of slightly above normal.
 METABOLISM: A maternal pushing effort adds further skeletal
muscles activity that contributes to the increase in metabolism.
CONT….

 PULSE RATE: during maternal pushing effort. Elevated throughout the 2nd
stage with a definite tachycardia reaching a peak at the time of delivery.
 TEMPERATURE: the highest elevation is at the time of delivery &
immediately thereafter. An increase of 0.5 to 1 degree celsius is considered
normal.
 GASTRO INTESTINAL CHANGES: there is a reduction in gastric
motility & absorption continues through the 2nd stage. Usually nausea &
vomiting subside during this stage but may persist some women.
 RENAL & HEMATOLOGICAL CHANGES: there is increased filtration
& reabsorbtion because increase CO2, decreased renal vascular resistance,
plasma volume expansion, decrease viscosity of the blood, & other
endocrine changes.
 Hemodynamic changes include increase in Glomerulus filtration rate,
renal plasma flow (RPF), excretion of amino acids, & elimination of water
soluble vitamins.
THE MECHANISM OF LABOUR
 These are changes in the position of the fetus and movement
done by the fetus to navigate the birth canal. It is the relation
of the head and body of the fetus the maternal pelvis during
parturition. The mechanism comprises of
•Engagement
•Descent
•Flexion
•Internal rotation
•Extension
•Restitution
•External rotation
•Delivery of the shoulder and fetal body
THE MECHANISM OF LABOUR
ENGAGEMENT
the head of the baby enters into the mid pelvic cavity by passing through the
transverse pelvic diameter of the upper pelvic passage. Engagement happens
when the largest part of the presenting part (the part of the fetus occupying the
lowest portion of the uterus) has successfully passed through the upper pelvic
opening (inlet). Normally when this occurs only 2/5 of the fetal head is palpable
on abdominal examination.
DESCENT
this happens before the head is flexed in the mid cavity. Descent is usually
secondary to uterine contractions and also by pushing (valsalva manoeuvre).
FLEXION
As the fetal head descends into the narrow mid cavity it begins to flex due to
pressure by surrounding structures.
INTERNAL ROTATION
At this point the fetal chin is in contact with the chest, the face is turned to the
left. When internal rotation occurs the fetal head is turned to face forward with
the face intended to make its way out facing the gluteal region (buttocks). This is
so that the widest diameter or the fetal head passes the widest diameter of the
lower pelvic opening (pelvic outlet). This is also known as 'face to pubes'.
EXTENSION
As the fetal head makes its way through the vagina it begins to
extend in order to give room for the shoulders to make their way
through the bid cavity. The fetal head then distends the vulvar. This
is known as crowning.
RESTITUTION
As the head is delivered it relines itself with the shoulder. This
slight rotation is known as restitution.
EXTERNAL ROTATION
In order to be delivered, the shoulders have to be rotate into the
plane of the pelvic outlet. When this occurs the head rotates 1/8th of
a circle.
DELIVERY OF THE SHOULDER AND FETAL HEAD
when restitution and external rotation happen the shoulder would be
ready to be delivered. This process happens without assistance
sometimes traction may be needed. After this the rest of the body is
delivered with ease.
STAGE 3 / placental stage
 Third Stage of Labor or the placental stage starts
from birth of infant to delivery of placenta. It is divided
into two separate phases: placental separation and
placental expulsion. Five minutes after delivery of
baby, the uterus begins to contract again, and placenta
starts to separate from the contracting wall. Blood loss
of 300-500 mL occurs as a normal consequence of
placental separation. Placenta sinks to the lower uterine
segment or upper vagina. The placenta is then expelled
using gentle traction on the cord. finally its expulsion
with the membranes.
PHYSIOLOGICAL CHANGES DURING 3RD STAGE OF
LABOUR:
 The expulsion of placenta & fetal membranes by
mother additional efforts or manipulative methods.
 The plane of separation runs through deep spongy layer

of decidua basalis.
Two types of placental separation –
1). Central separation (Schultze):-

 detachment of the Placenta from

uterine attachment start at the
centre resulting in opening up
of few uterine sinuses &
accumulation of blood
behind the placenta
(retroplacental hematoma).
With increase contraction, more & more detachment
occurs. the placenta & retroplacental blood until whole
of placenta gets detached.
 
2). Marginal separation (Mathews-
Duncan):-
 separation/detachment at the margin
as it is mostly unsupported. With
progressive uterine contraction, more
& more areas of the placenta
gets separated.
Clinical significance of separation-

 Height of fundus below the umbilicus

 Discoiled
 Decent down
 Globular FSH
 Supra pubic bulge
 Permanent lengthening of cord
 Sudden gush of vaginal blood
 Change in the shape of uterus (globular in shape)
 Firm uterine contractions
 Appearance of placenta in vaginal opening
METHODS OF PLACENTA EXPULSION:

 The third stage of labor can be managed actively with several standard procedures,
or it can be managed expectantly, the latter allowing the placenta to be expelled
without medical assistance.
 A retained placenta is a placenta that doesn't undergo expulsion within a normal

time limit. Risks of retained placenta include hemorrhage and infection. If the
placenta fails to deliver in 30 minutes in a hospital environment, manual extraction
may be required if heavy ongoing bleeding occurs, and very rarely a curettage is
necessary to ensure that no remnants of the placenta remain (in rare conditions
with very adherent placenta, placenta accreta).
However, in birth centers and attended home birth environments, it is common for
licensed care providers to wait for the placenta's birth up to 2 hours in some
instances.
Active management
Methods of active management include
1. Umbilical cord clamping
2. Stimulation of uterine contraction
3. Cord traction.
4. Manual placenta removal
1. Umbilical cord clamping:-
Active management routinely involves clamping of the 
umbilical cord, often within seconds or minutes of
birth.
2. Uterine contraction
Uterine contraction assists in delivering the placenta.
Uterine contraction reduces the placental surface area,
often forming a temporary hematoma at their former
interface. Myometrial contractions can be induced with
medication, usually oxytocin via intramuscular
injection. The use of ergometrine, on the other hand, is
associated with nausea or vomiting and hypertension.
Breastfeeding soon after birth stimulates oxytocin
which increases uterine tone, and through physical
mechanisms uterine massage (the fundus) also causes
uterine contractions.
3. Cord traction
Controlled cord traction (CCT) consists of pulling on the
umbilical cord while applying counter pressure to help deliver
the placenta. It may be uncomfortable for the mother. Its
performance requires specific training. Premature cord
traction can pull the placenta before it has naturally detached
from the uterine wall, resulting in hemorrhage. Controlled
cord traction requires the immediate clamping of the 
umbilical cord.
4. Manual placenta removal

Manual placenta removal is the evacuation of the

placenta from the uterus by hand.It is usually carried
out under anesthesia or more rarely, under sedation
 and analgesia. A hand is inserted through the vagina
 into the uterine cavity and the placenta is detached
from the uterine wall and then removed manually. A
placenta that does not separate easily from the uterine
surface indicates the presence of placenta accreta.
STAGE 4 / puerperal stage
 refers to the first hour or two after birth when uterine
tone is established and recovery from labor begins.
Recovery begins during the first 2-3 hours after
delivery. During this time, the uterus contracts here and
there, pushing out what’s left inside and reestablishing
muscle tone.These contractions are hastened by 
breastfeeding, which stimulates the production of the
hormone oxytocin.
 LOCHIA
Although postpartum uterine contractions limit blood loss from the
detachment of the placenta, the mother does experience a
postpartum vaginal discharge called lochia.
LOCHIA RUBRA:- This is made up of uterine lining cells,
erythrocytes, leukocytes, and other debris. Thick, dark, typically
continues for 2–3 days,
LOCHIA SEROSA:- A thinner, pinkish-brown that continues until
about the 10th postpartum day.
LOCHIA ALBA:- A scant, creamy, or watery discharge may
continue for another 1–2 weeks.
NURSING MANAGEMENT OR NURSING
RESPONSEBILITIES DURING LABOUR

 Nursing responsibilities in first stage of labour:-

 Assess patient’s psychological readiness. Provide continuous
maternal support (compared to usual care).
 Conduct interviews and at this phase while the patient experiences
minimal discomfort and has control over contraction pains.
 Conduct health teaching on effective bearing down because during
this time, patient’s anxiety is controlled and she is able to focus on
nurse’s instructions.
 Educate patient on different relaxation techniques. As early as this
phase, encourage patient to begin alternative therapy of pain relief
(deep breathing, accupressure, music therapy, massage therapy etc.)
Nursing responsibilities CONT…..
 Ensure that the total number of internal examinations
the woman receives in the entire course of labor is
limited to 5 only.
 Inform patient on the progress of her labor to lessen

her anxiety and obtain her trust and cooperation.

 Start monitoring progress of labor with the use of

WHO partograph, 2-hour action line.

 Encourage patient to be continually active to

maximize the effect of uterine contractions. Upright

maternal positions are recommended if tolerated.
Nursing responsibilities CONT…
 Assist patient in assuming her position of comfort. For those who
can’t stay upright, left-side lying is recommended to avoid disruption
in fetal oxygenation.
 Monitor maternal vital signs and fetal heart rate every 2 hours,
Contraction monitoring is also continued, depending on the doctor’s
order.
 Determine when patient last voided because a full bladder can hinder
fast labor progress.
 When perineal bulging is noticeable, prepare for delivery. Check room
temperature (25-280C and free of air drafts). The nurse should also
notify staff and prepare necessary supplies and equipment, including
resuscitation machine. Lastly, perform hand washing and double
gloving.
Nursing responsibilities CONT….
 Nursing responsibilities  in second stage of labour:-
 Instruct patient on quality pushing. The abdominal muscles must
aid the involuntary uterine contractions to deliver the baby out.
 Provide a quiet environment for the patient to concentrate on
bearing down.
 Provide positive feedback as the patient pushes.
 Repeat doctor’s instructions. At this phase, the patient barely hears
the conversation around the room because all her energy and
thoughts are being directed toward giving birth.
 Take note of the time of delivery and proceed to initiate essential 
newborn care. Delayed cord clamping is recommended.
 Assist in restrictive episiotomy for patients who had vaginal births.
Nursing responsibilities cont…
 Nursing responsibilities in third stage of labour :-
 Coach in relaxation for delivery of placenta.
 Encourage skin-to-skin contact to facilitate bonding and
early breastfeeding.
 Administer prophylactic oxytocin as ordered.
 Utilize controlled cord traction technique for placental
expulsion.
 Utilize absorbable synthetic suture materials (over chromic
catgut) for primary repair of episiotomy or perineal
lacerations.
 
Nursing responsibilities cont….
 Nursing responsibilities in fourth stage of labour:-
 For immediate postpartum,
 The nurse checks the vital signs and monitors for

excessive bleeding. The first four hours after birth is

sometimes referred to as the fourth stage of
labor because this is the most critical period for the
mother. Also, they are being reminded of the
importance of breastfeeding, ambulation, and newborn
care.
Nursing responsibilities cont…
 Here are WHO recommendations for immediate
postpartum care:
 Early (<6 hours) resumption of feeding for patients

who have vaginal birth

 Prophylactic antibiotics for women who sustained third

to fourth degree of perineal tear during delivery

 In healthy women who delivered vaginally to term

neonate, early postpartum discharge is recommended.

SUMMARY

  Systemic plasma levels of hormones are not representative of

local changes that may initiate and maintain labour.
  During pregnancy, hormones such as progesterone, relaxin
and nitric oxide maintain the uterus in a quiescent state.
 Prior to labour, changes in the oestrogen-to-progesterone ratio
facilitate activation of the uterine muscle, and ripening of the
cervix occurs under the influence of prostaglandins, relaxin
and nitric oxide.
 Following activation of myometrial cells and cervical ripening
in the uterus, the myometrium responds to the uterotonins,
oxytocin and prostaglandins.
  Initiation of labour probably involves both fetal and maternal
influences.
 BIBLIOGRAPHY

 Bhaskar nima (2019) “Midwifery & gynecological nursing” 3 rd ed. Emmess

publisher .
 Datta D.C. (2004),’’Text book of obstetrics’’, 6th ed. New central book agency (P)
LTD New Delhi  
 Ghai Sandhya( 2019) “ Clinical Nursing procedure 2 nd ed. CBS publisher &
distributors pvt. ltd.
 Jacob Annamma,(2019) ‘’A comprehensive textbook of midwifery &
gynecological nursing” 5th ed. Jaypee brothers medical publishers New Delhi. 
 Jacob Annamma (2020) “Clinical Nursing Procedures the art of nursing practice”
4th ed. Jaypee brothers medical publishers New Delhi . 
 J.B. Sharma (2015).” Midwifery & gynecological nursing “1 st ed. Avichal
publishing company New Delhi. 
 Kumara Neelam, Shivani Sharma (2017)”A textbook of midwifery &
gynecological nursing”4th ed. S. Vikas and company (medical publisher) 
 Lata Sneh Manocha (2011)” Procedure & practices in midwifery” 1 st ed. Kumar
publisher New delhi.
THANKYOU