The Birth Process

Theories Onset of Labor

• Maternal Factors :
> Uterine Stretch Theory
- “any hallow organ when stretched to capacity will contract and
empty”
> Oxytocin Stimulation Theory
- Posterior Pituitary gland increase production but oxytocinase
produce by placenta decreases. Sensitive to oxytocin
> Progesterone Deprivation Theory
- “HELPS Maintain Pregnancy-progesterone (relaxant effect
smooth muscle) . Production of placenta for progesterone
decrease.
 Theories
• Fetal factors:
> Theory of Aging Placenta
- Placenta ages-less efficient = decrease progesterone.
Allows increase of prostaglandin and estrogen

> Fetal Adrenal Response Theory

- fetal cortisol increases and acts on placenta to
reduce progesterone & increase prostaglandin production
> Uterine decidua activation
- arachidonic acid released at term is converted to
prostaglandin
 Birth Classes
 Pain management
a. Bradley method- muscle toning exercise & avoidance of
food w/ preservative, salty, hi in fat.- abdominal
breathing, walking
b. Psychosexual method- by Kitzinger conscious relaxation &
progressive breathing.
c. Dick-Read method- break tension & pain thru focus on
abdominal breathing
d. Lamaze method-by controlled breathing
e. w/ the use of mind focus on preventing pain
f. Effleurage –massage, distraction technique
g. Imagery – focusing in other object during labor
 PREPARED CHILD BIRTH
Comparison DICK-READ LAMAZE Leboyer Method
METHOD METHOD
(Psychoprophyla
ctic childbirth)
Theoretical Tension (psychic & Pavlov Theory of Contrast of
Assertion muscular) is aroused Classical intrauterine
by fear & conditioning environment &
anticipation of pain (favorable external world
(sympathetic response & high causes Infant
stimulation) level of activity psychological
can excite brain shock during
inhibit pain delivery
Covers Prenatal courses Anxiety replace Gentle
:Deep breathing controlled useful controlled
techniques activity delivery
 Signs of Impending Labor
• Lightening – “the baby dropped”
– Settling of presenting part in the pelvic brim or inlet
– Results to: relief of dyspnea, inc. freq. of urination, vaginal discharge,
leg pains & dec. fundal ht
– Fetus –Floating, engagement & fixation
• Increasing braxton hicks contraction - painless irregular contractions
• . Increase Activity of the Mother- nesting instinct. Save energy, will be used
for delivery. Increase epinephrine
• Cervical changes
– Butter soft
• Bloody show
– Continuous pressure, operculum mixed with rapture blood vessels. –
pinkish vaginal discharge – blood & leukorrhea
• Rupture of Membranes
– Bag of water (avoid douching, coitus, enema), Check FHT
• Wt Loss – decline of progesterone (promotes fluid retention) 1.5 – 3 lbs
 III. PRELIMINARY OR PRODROMAL SIGNS
OF LABOR

A. LIGHTENING
 The settling of
the fetal head
into the pelvic
brim.
 Primis – 2wks
before EDC
 ENGAGEMENT

When the
presenting part
has descended
into the pelvic
inlet
 E. RIPENING OF THE CERVIX

From
Goodell’s sign,
the cervix
becomes
“butter-soft”.
Variables that affect Labor

“CLAPPS”
C – contraction
L – lie
A – attitude
P – presentation
P – position
S - station
 F. RUPTURE OF THE MEMBRANE

The membrane or
“bag of water”
(BOW) ruptures
 AMNIOTOMY

• Surgical rupture
of the fetal
membranes to
induce labor
amniotome.
 Important to remember once BOW has
been ruptured:
1. Labor is inevitable and occurs within
24 hours.
2. The integrity of the uterus has been
destroyed, therefore, infection can easily
sets in;
 Aseptic technique
 Less manipulation (IE)
 Enema is prohibited
3. Umbilical cord
compression or
cord prolapse can
occur (especially
in breech
presentation).
Nursing Actions:

Put mother on bed

immediately and monitor
FHT consequently.
If the mother in labor says that she
feels a loop of the cord coming out of
the vagina (cord prolapse);
 Remember:

Only 5 minutes of
cord compression
can already lead to
irreversible brain
damage or even
death.
 Nursing Action:
 Position: Trendelenberg position /
Modified knee chest position
to reduce pressure in the cord
 Apply warm saline-saturated OS
To prevent prolapse cord from
drying
POSITION FOR PROLAPSED CORD
G. SHOW  pinkish vaginal discharge

Due to the pressure ofBlood

the mixes with
descending presenting mucus when
part of the fetus which operculum is
causes rupture of the
released.
minute capillaries in the
mucous membrane of the
cervix.
BLOODY SHOW
 5 “P” of Labor
1. Passages
 Hard Passages – body pelvis
 Soft passages – lower uterine segment, cervix, vagina, pelvic
floor and perineum
2. Power
 Primary force – involuntary uterine contraction
 Secondary force – voluntary use of thoracic, diaphragm &
abdominal muscles when bearing down
3. Passenger
 Fetal position, presentation & attitude
4. Psyche/person – maternal attitude during labor
5. Position – maternal position during labor & delivery
 Passage
• 4 types of pelvis:
1. The Gynaecoid or genuine female pelvis
2. The Android pelvis It has a heart-shaped
brim and is quite narrow in front.
3. The Anthropoid pelvis It has an oval brim and
a slightly narrow pelvic cavity.
4. The Platypelloid pelvis It has a kidney-shaped
brim and the pelvic cavity is usually
shallow and may be narrow in the antero-
posterior (front to back) diameter. The outlet is
usually roomy
TYPES OF PELVIS
1. Android Pelvis – “male pelvis”. The pubic
arch in this pelvis type forms an acute
angle, making the lower dimension of the
pelvis extremely narrow. A fetus may have
difficulty exiting from this type of pelvis
2. Gynecoid Pelvis – “normal” female
pelvis. The inlet is well rounded
forward and backward, the pubic arch
is wide. This type is ideal for
childbirth.
3. Platypelloid Pelvis – “flattened pelvis”.
The inlet is oval, smoothly curved, but
the anteroposterior diameter is shallow.
A fetal head might not be able to rotate
to match the curves of the pelvis cavity
of this type.
4. Anthropoid Pelvis – “ape-like” pelvis. The
transverse diameter is narrow, and the
anteroposterior diameter of the inlet is
larger than normal. This does not
accommodate a fetal head as well as a
gynecoid pelvis
 Passageway – vagina & pelvis
Pelvis
4 main pelvic types
Gynecoid – Android – Anthropoid-Platypelloid
Problem :
» mother who encounter accident
» ↓ 4’9”
» ↓ 18y/o – R: pelvis not achieve its full pelvic growth

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FLORES,RN,MAN
 Passageway – vagina & pelvis
4 Bones of pelvis
1.2 hip bones – 2 innominate bones
3 Parts of 2 Innominate Bones
• Ileum – lateral side of hips Iliac crest – flaring superior
border forming prominence of hips
• Ischium – inferior portion - ischial tuberosity where we sit
– landmark to get external measurement of pelvis
• Pubis – ant portion – symphisis pubis junction between 2
pubis
2.1 sacrum – post portion – sacral prominence – landmark to
get internal measurement of pelvis
3.1 coccyx – 5 small bones compresses during vaginal delivery

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 Important Measurements

1. Diagonal Conjugate – measure between sacral

promontory and inferior margin of the symphysis
pubis.
Measurement: 11.5 cm - 12.5 cm basis in getting
true conjugate. (DC – 11.5 cm=true conjugate)
2. True conjugate/conjugate vera – measure between
the anterior surface of the sacral promontory and
superior margin of the symphysis pubis.
Measurement: 11.0 cm

3. Obstetrical conjugate – smallest AP diameter. Pelvis at

10 cm or more.

Tuberoischi Diameter – transverse diameter of the

pelvic outlet. Ischial tuberosity – approximated with
use of fist – 8 cm & above.

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 P-passageway : S-station
• Gynecoid pelvis
a. Inlet – AP diameter
> Diagonal conjugate : 12.5 cm
> Obstetric conjugate : 11 cm
> True conjugate : 11.5 cm
Transverse diameter : 13.5 cm
R or L Oblique diameter : 12.75 cm
 P-passageway : S-station
• c. Outlet – Transverse / bi-ischial diameter
> distance between ischial
tuberosities : 11.5 cm
AP diameter : 11.5 cm
Post sagittal diameter : 7.5 cm
 P-passageway : S-station
• d. Pelvic Articulations – joints w/c are points
of attachment b/w pelvic bones & allows
some degree of movement
> symphysis pubis joints
> sacroiliac joints
> sacrococcygeal joints
ENGAGEMENT

• Refers to the settling of the

presenting part far enough into the
pelvis to be at the level of ischial
spine.
Floating – presenting is not engage
Dipping - descending but has not yet
reached the ischial spine
STATION
• Refers to the relationship of the fetal
presenting part to the level of maternal
ischial spine

• 0 – synonymous with engagement

• -1 to -4 – refers as the minus station,
the presenting part is above the level
of ischial spine
• +1 to +2 – Plus station, the presenting
part is below the level of ischial spine
• +3 to +4 – presenting part is at the
perineum and can be seen if the vulva is
separated (crowning)
 P-passageway : S-station
• b. Pelvic canal – b/w inlet & outlet
curves at lower half below the ischial spine
> to control speed of descent
> for thoracic squeeze
AP diameter : 11.5 cm
Post sagittal diameter : 4.5 cm
Interspinous diameter : 10 cm
 P-power : C-contraction
Power
– the force acting to expel the fetus and placenta – myometrium – powers of labor

a. Involuntary Contractions
b. Voluntary bearing down efforts
c. Characteristics: wave like
d. Timing: frequency, duration, intensity
• Characteristics:
Frequency – report if less than 2 minutes
Duration – report if more than 90
seconds
Intensity – strength; increment-acme-
decrement
Contraction Cycle
3 Phases of Contraction

a. Increment or cresendo– contraction begins at the

fundus and spread throughout the uterus
b. Acme or Peak – contraction is most intense
c. Decrement or decresendo – uterine relaxation
Pattern:

1. Frequency – from the beginning of one

contraction to the beginning of the next
(A-C). Expressed in minutes and
fractions of minutes. (2-3 minutes)

2. Duration – from the beginning of one

contraction to the end of the same (A-
B).

early labor – 20-30 secs

late labor – 60-70 secs
3. Interval – from the end of one contraction to the
beginning of the next (B-C)

early labor – 40-45 mins

late labor – 2-3 mins
4. INTENSITY OF CONTRACTIONS

• Mild – the uterus is contracting but does

not become more than minimally tense.
Described as like tip of the nose

• Moderate – the uterus feels firm.

Described as like the chin

• Strong – the contraction so intense the

uterus feels as hard as a wooden board
at the peak of contraction. Described as
like the forehead
 3.Passenger
–is the largest presenting part – common presenting part – ¼ of its length.
Fetal head

Bones – 6 bones
E – ethmoid
S – sphenoid
O – occuputal – occiput
F – frontal – sinciput
T – temporal
P – parietal 2 x

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 1.Passenger
–is the largest presenting part – common presenting part – ¼ of its length.
Fetal head

Bones – 6 bones
E – ethmoid
S – sphenoid
O – occuputal – occiput
F – frontal – sinciput
T – temporal
P – parietal 2 x

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 I. THE FETAL SKULL
A. Importance: From an obstetrical
point of view the fetal skull is the
most important part of the fetus
because:
1. Largest part of the body
2. Most frequent presenting part
3. Least compressible of all parts
FONTANELS – significant membrane covered
spaces and found at the junction of the
main suture lines

A. Anterior (Bregma) – a diamond shape about

3 cm by 2 cm and lies at the junction of
the sagittal , coronal and frontal sutures.
Closes 18 mos after birth
B. Posterior – a triangular shape about 1 cm by
2 cm. lies at the junction of lambdoidal and
sagittal sutures of the parietal bones and
one occipital bone. Closes 6 to 8 weeks
after birth

• vertex – space between the 2 fontanels

Measurement fetal head
1. transverse diameter
biparietal – largest transverse 9.25cm
Bitemporal - 8 cm
bimastoid - 7cm smallest transverse
2.AP diameter
Suboccipitobregmatic– complete flexion
Occipitofrontal – partial flexion - 12cm
Occipitotemporal – largest AP diameter; hyperextended (13.5cm)
Submentobrgmatic - face presentation; poor
flexio
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 Sutures
intermembranous spaces that allow molding.
• sagittal suture – connects 2 parietal bones ( sagitna)
• coronal suture – connect parietal & frontal bone
(crown)
• lambdoidal suture – connects occipital & parietal
bone

Moldings
the overlapping of the sutures of the skull to permit
passage of the head to the pelvis
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 Fontanels
1. Anterior fontanel
• bregma, diamond shape
• 3 x 4 cm,( > 5 cm – hydrocephalus),
• 12 – 18 months after birth- close
2.Posterior fontanel or lambda – triangular shape
• 1 x 1 cm. Closes – 2 – 3 months.

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 C. MEMBRANE SPACES

• Suture lines
Is important because they allow
the bones to move and overlap,
changing the shape of the fetal
head in order to fit through the
birth canal, a process called the
molding.
FETAL LIE
The relationship of the long axis of the
fetus to the long axis of the mother

1. Longitudinal or vertical – long axis of the

fetus is parallel to the long axis of the
mother. Fetal presentation is either
cephalic or breech depending on the
fetal structures that first enters the
pelvis

2. Transverse or horizontal or oblique – long

axis of the fetus is lying at a right angle
diagonal or perpendicular to the long axis
of the mother (spine)
FETAL PRESENTATION

• Presentation – refers to fetal parts

that first enter the pelvic inlet first.
This is determined by the fetal lie
and the degree of flexion (attitude)
1. Cephalic – head is the body part that
first contacts the cervix. The most
frequent type of presentation,
occurring as often as 95%.

Advantages:
– Capacity of the fetal head to mold
– Fetal head effectively dilates the
cervix because it is smooth, round
and hard
– Fetal head as the largest single
part, allows easy delivery of
smaller parts
Variation

a. Vertex – longitudinal
lie and attitude is good
(full flexion). Fetal
head is fully flexed
making the parietal
bones or space
between the fontanels
(the vertex) the
presenting part. This
the most common
presentation and
allows the
suboccipitobregmatic
diameter to present to
the cervix
b. Brow – head is
partly extended.
The brow or
sinciput becomes
the presenting
part
c. Face – head is fully
extended and the
fetal occipital is near
the fetal spine
making the face the
presenting part.
Extreme edema and
distortion of the face
may occur.
Occipitomental as the
presenting diameter
d. Mentum – The fetus has complete
hyperextension of the head to present
the chin. The widest diameter
(occipitomental) presents which is
impossible to enter the pelvis
2. Breech - occurs when
fetal buttocks or feet
enters the pelvic inlet
Variation

a. Frank breech –
attitude is moderate
because the hips are
flexed but the knees
are extended to rest
on the chest. The
buttocks presents to
the cervix
b. Complete breech –
the head is flexed
and the hips and
knees are also
flexed. The thighs
are tightly on the
abdomen. Both the
buttocks and tightly
flexed feet presents
in the cervix.
Reverse of usual
cephalic
presentation
c. Footling breech –
one or both feet
are presenting
3.Shoulder– transverse
lie. The presenting part
is usually one of the
shoulder (acromion
process), an iliac crest,
a hand or an elbow
Cephalic

Type Lie Attitude

Vertex Longitudinal Good (full flexion)

Brow Longitudinal Moderate (Military)
Face Longitudinal Poor
Mentum Longitudinal Very Poor
Breech

Type Lie
Attitude

Complete Longitudinal Good flexion

Frank Longitudinal Moderate
Footling Longitudinal Poor
FETAL ATTITUDE

• Attitude – describes the degree

of flexion a fetus assumes during
labor or the relation of fetal
parts to each other. A fetus is in
good attitude
1. Complete Flexion
(Good Attitude) –
complete flexion: the
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 and the
calves are pressed
against the posterior
aspect of the thigh.
Normal fetal position
2. Moderate Flexion –
the chin does not
touch the chest but
is in alert or
“military position”.
This causes the
occipitofrontal
diameter (next
widest AP diameter)
to present
3. Poor Flexion –
presents the brow.
The back is
arched, the neck is
extended and a
fetus is in compete
extension,
presenting the
occipitomental
diameter of the
head. May occur if
there is less
normal amount of
amniotic fluid
present which
does not allow
adequate fetal
movement
• Partial extension –
Presents the brow of
the head
FETAL POSITION

• Describes the location of the fixed

reference point on the presenting
part in relation to 4 quadrants of the
maternal pelvis
Maternal pelvis is
divided into 4
quadrants

– Right anterior
– Left anterior
– Right
posterior
– Left posterior
Four parts of the fetus chosen as a
landmark

• Vertex – occiput
• Face – mentum
• Breech - sacrum
• Shoulder – scapula or acromion
process
Position is marked by three letters

1. First Letter – defines whether the

landmark is pointing to the mother’s
right R or left (L)
2. Middle letter – denotes fetal landmark.
(O) occiput, (M) mentum or chin, (Sa)
sacrum and (A) acromion process
3. Last letter – defines whether the
landmark is in front (A) anterior, (P)
posterior and (T) –transverse
POSSIBLE FETAL POSITION

Vertex Breech Face Shoulder

(Occiput) (Sacrum) (Mentum) (Acromion)

LOA LSaA LMA LAA

LOP LSaP LMP LAP
LOT LSat LMT RAA
ROA RSaA RMA RAP
ROP RSa RMP
ROT RSaT RMT
Consequences of Malpresentation

1. Presentation other than the cephalic

may affect the laboring woman, the
fetus and the powers of labor
2. The presenting part tends to
descend longer into the pelvis, the
cervix may dilate slowly and
incompletely, uterine contraction
tend to be irregular and less strong
3. Fetus is subjected to trauma as a
result of obstetric intervention
4. Greater incidence of premature rupture
of membrane
5. Increased need for operative delivery
6. The mother experienced prolonged labor
with accompanying exhaustion
7. Necessitates greater uterine contractile
efforts and the mother must push
harder
8. Mother’s soft tissues and perineum must
undergo more stretching, increasing the
incidence of laceration
9. Presentation of the body parts other
than the cervix puts the fetus at
risk
10. Prolonged labor increase fetal
compromise (prolapsed cord,
asphyxia or intrauterine death
 P-passenger : P-position /
S-station
• Vertex : Flexed – O (occiput); bregma
Mod Extension – B (brow);
sinciput, lambda
Full Extension – M (mentum); face
or chin
• Breech : S (sacrum)
• Shoulder : Sc (scapula) or Ac (acromion
process)
 P-passenger : L-lie / A-attitude /
P-presentation
• Lie : Longitudinal – parallel
Transverse – perpendicular / right
angle
Oblique – 45 degree angle
• Attitude : Flexed or Extended
• Presentation : cephalic; breech; shoulder
*** face, brow
 P-passenger : P-position
• LOA : left occiput anterior vertex w/ fetal
occiput towards mother’s front
• LOP : left occiput posterior
• ROA : right occiput anterior
• ROP : right occiput posterior
• LSA : left sacrum anterior
• RSA : right sacrum anterior
 Psyche
• Refers to the clients’s:
> psychological state
> available support system
> preparation for childbirth
> experiences
> coping strategies
 Position of mother
• Especially during delivery
> supine lithotomy
> hands and knees position
> upright sitting position
 Placenta
• Refers to the site of placental implantation
> low-lying
> marginal
> partial
> complete
 Partograph
• The partograph is a graphical presentation of the
progress of labour, and of fetal and maternal
condition during labour. It is the best tool to help
you detect whether labour is progressing
normally or abnormally, and to warn you as soon
as possible if there are signs of fetal distress or if
the mother’s vital signs deviate from the normal
range
First Stage of Labor

Cervical Dilatation
 TRUE VS FALSE LABOR

TRUE FALSE

CONTRACTION REGULAR Irregular

INCREASE FREQUENCY, No changes in
DURATION & INTENSITY, Frequency, duration &
SHORTENING OF INTERVALS intensity

DISCOMFORT RADIATES FROM BACK AROUND Pain at abdomen

THE ABDOMEN

REST/ACTIVITY CONTRACTION DOES NOT Contraction may lessen

INCREASE WITH REST OR with activity or rest
ACTIVITY/WALKING

CERVIX PROGESSIVE EFFACEMENT & Cervical changes does

effacement - shortening of the DILATATION OF CERVIX not occur yet
uterine cervix and thinning of
its walls as it is dilated during
 ESSENTIAL INTRAPARTUM & NEWBORN
CARE (EINC)
Practices:Unnecessary:
• Enema – target: decrease risk of infections, shorten
duration of labor and make cleaner for Obstetrician
/med team but cause discomfort to mothers and
increase pain. If only requested
• Shaving –(pubic hair) target : minimize infection if
perineal tear & facilitate easier repair of these tears
but could only protect against bacterial colonization,
there was no effect on perineal would infection. There
is no significant difference in the incidence of
postpartum maternal morbidity. Embarrassment
during shaving and discomfort during hair re-growth.
 ESSENTIAL INTRAPARTUM & NEWBORN
CARE (EINC)
• Restrict intake of food and fluids – NPO during active labor due to
Practices:Unnecessary:
possible risk of aspirating gastric contents during anesthesia
administration but it is distressing and can increase the length of
labor. ENERGY is needed. It is more traditional but it decrease
mother satisfaction , increased cost (CS) & diminished the quality
of birth experience. Easy to digest food and fluids during labor.
• Routine intravenous infusion – routine to hydrate woman who
were restricted from foods and fluid. It is questioned since life-
threatening emergencies are rare in low risk laboring women. IVF
is stressful, painful and disrupts the natural birthing process by
hindering freedom to move in labor (mother). Justified as stressful,
increase risk of fluid overload and does not ensure nutrient. Also
interfere with glucose and insulin level of both mother and infant.
 ESSENTIAL INTRAPARTUM & NEWBORN
CARE (EINC)
• Fundal Pressure – belief that helps expulsion of fetus but this
Practices:Unnecessary:
evidence of maternal morbidities such as perineal tears,
uterine rupture, uterus inversion, hypotension & respi distress
and effects to newborn: brachial plexus, spinal cord and liver,
rib, humeral, and clavicular fracture, hypoxemia, asphyxia,
intracranial pressure, cord compression and hemorrhage.

• Routine episiotomy – performed to protect the perineum,

pelvic floor and fetus from injury during child birth and
thought that improve neonatal outcome and prevent urinary
incontinence in mother but it is more associated with more
pain, incontinence and sexual problem than spontaneous
tearing
 ESSENTIAL INTRAPARTUM & NEWBORN
CARE (EINC)
• Practices:NECESSARY:
Contineous support during childbirth – better that analgesia
administration. Studies show that it resulted shorter labor,
less likely to undergo CS or instrumental vaginal birth,
regional anesthesia or APGAR score lower than 5 with in 5
minutes.

• Mobility during labor – supine position traditionally does not

prove any advantages to mother but only staff monitoring
labor status. Walking and upright position at 1st stage labor
with freedom to move is effective means to distract mother
to pain and labor thus lessening pain medication (most
comfortable but safe position)
 ESSENTIAL INTRAPARTUM & NEWBORN
CARE (EINC)
• Practices:NECESSARY:
Pain relief in labor- non drug method such as continuous
support during labor, walking, moving around, massage,
verbal and physical assurance and qui environment. If
anesthesia is required(mother low threshold to pain) –
epidural anesthesia is used but lead to instrumental delivery.

• Partograph use to monitor progress of labor – tool that can

be used to assess the progress of labor and identify necessary
interventions. Reduce complications such as post partum
hemorrhage, sepsis, uterine rupture with newborn asphyxia,
infection and death.
 ESSENTIAL INTRAPARTUM & NEWBORN
CARE (EINC)
• Spontaneous Practices:NECESSARY:
pushing semi-upright position – spontaneous
pushing rather direct bearing down that prevent trauma and
oxygen sparing for the fetus contrast that direct bearing down
once cervix fully dilated is ineffective, result to maternal
exhaustion and greater need for operative interventions.
Upright position during 2nd stage of labor enhance descent of
fetal head because of additional gravity

• Hand Hygiene – most effective prevent nosocomial infection

and antimicrobial resistance. (hand washing, antiseptic hand
wash, antiseptic handrub or surgical antisepsis
 ESSENTIAL INTRAPARTUM & NEWBORN
CARE (EINC)
Practices:NECESSARY:
• Active management of the third stage of labor
(AMTSL) – post partum hemorrhage leading case of
maternal mortality. Administration of oxytocin after
delivery of fetus, controlled cord traction (counter
traction) and uterine massage after delivery of
placenta. Much effective than preventing blood loss
measure, severe postpartum hemorrhage, low
maternal Hgb after birth and prolonged 3rd stage of
labor
.
 ESSENTIAL INTRAPARTUM & NEWBORN
CARE (EINC)
• Practices:NECESSARY:
Antenatal steroids in Preterm labor – (RDS – respi
distress syndrome, most serious complication
premature babies and primary cause of early neonatal
morbidity and disability) .Best premature rupture of
membrane (PROM) and pregnancy related
hypertension syndromes. Treatment with antenatal
corticosteroids is reduction of neonatal death,
cerebroventricular hemorrhage, necrotizing
enterocolitis, respi support, systemic infection in the 1st
and neonatal intensive care admissions. FETAL LUNG
MATURITY acceleration .
 STAGES OF LABOR
1ST STAGE PHASES DILATION DURATION/INT INTENSITY
OF LABOR ERVALS

I – LATENT 0-3cm 20-40 secs / 5- Mild to

30 mins moderate

II – ACTIVE 4-7cm 40-60 secs / Moderate to

3-5mins strong

III- TRANSITION 8-10cm 60-90 secs / Strong

2-3 mins
 Latent Phase
• Latent : 0-3cm dilatation
10-30 sec duration
5-30 mins interval
mild to moderate intensity
Assessment : VS q 4hr; if PROM Tq2hr
FHT q 1-2 hr
Primi/Nulli 8.5 hrs ; Multi 5.5 hrs
(average length)
 Latent phase
• Client is still talkative, happy, excited
• Establish rapport; obtain maternal history
• Health teachings :
– Review client’s prep & expectations of how
delivery will be handled (goals & learning
needs)
– Breathing techniques; slowed, deep; shallow;
pant-blow
– Empty bladder q 2 hrs; enema (saline or fleet)
 Latent Phase
– Ambulate if (+) BOW
– Do not allow to lie flat on her back to prevent
supine hypotensive syndrome
– Place pads under buttocks to absorb drainage
– Change linens, relaxing environment, oral care and
perineal care
– Provide pain relief options
 Active Phase
• Active : 4-7 cm dilatation
30-40 sec duration
3-5 mins interval
moderate to strong intensity
• P/N : 4 hrs ; M : 2 hrs
• VS q 1hr ; FHT q 30 mins-1 hr
• Client has varying degree of discomforts
• Focus on breathing techniques
 Active Phase
• Less talkative, apprehensive, helpless, anxious, fears
abandonment
• Inform progress of labor, let listen to FHT
• Promote comfort by giving praise & encouragement,
• Coach on breathing techniques
• Moisten lips : lip balm, gargle water, candy, or ice
chips
• Back rub, cool cloth, position change, warm tubs
 Active Phase
• Discourage from bearing down
• Empty bladder q 2 hrs
• Stay on bed if (-) BOW or analgesia was given
or intolerable to sit
• Back rubs
 Transition Phase
• Transition : 8-10 cm dilatation
45-90 sec duration
2-3 min interval
strong intensity
• P/N : 1-3 hrs ; M : 15-30 mins
• VS q 30 mins ; FHT q 15-30 mins
• Most difficult period
• Easily irritated and does not want to be touched
• Mother feels an urge to push or to have a BM
 Transition Phase
• Reassure though most difficult, it is the shortest
period
• Reinforce breathing & relaxation techniques
• No narcotics because too close to delivery, baby may
become too sedated to be able to breathe effectively
• Discourage bearing down coz it can lead to cervical
lacerations and edema – may prolong labor – pant
blow breathing
 Transition Phase
• If client experience N&V, let woman lie on her
side to prevent aspiration
• If client falls asleep, awaken at the beginning
of contraction to institute breathing
techniques
• If w/ hyperventilation, let woman breathe on
cupped hand or paper bag
ASPECTS OF CONTRACTION

A B C D
 Blood Pressure

 Should not be taken during

contraction as it tends to increase.

 Beacause NO blood supply goes to the

placenta during contaction, all of the
blood is in the periphery that’s why
there is increased BP during
contraction.
BP readings should be taken every
half hour during active labor.
When a woman in labor complains
of headache, the first nursing action
is to take BP.
 Normal = stress headache
 Increased = refer to the doctor
asap, could be a
sign of
toxemia
 Fetal heart rate
 should not be mistaken for uterine
souffle (synchronize with maternal pulse rate)

–Normally 120-160 per minute

–During contraction = decreased
–During contraction, compression of
the head stimulates vagal reflex,
causing, bradycardia.
• Should be taken:
Every hour during the latent
Every 30 minutes during
active labor
Every 15 minutes during the
transition phase

 For any abnormality in FHR =

change the mother’s position
 SIGNS OF FETAL DISTRESS

• BRADYCARDIA (FHR <100/minute) /

TACHYCARDIA (FHR >180/minute)
• MECONIUM-STAINED amniotic fluid in
non-breech presentation

• FETAL TRASHING – hyperactivity of the

fetus as it struggles for more oxygen
 Monitoring of fetal status

• Assess changes in FHT

a. Early deceleration
• Decreasing FHT early in the contraction
• Benign
• Mirrors the contraction
• Indicates : HEAD COMPRESSION
• B. Late deceleration
• Begins at the peak of contraction and ends after the
contraction ends
• Indicates : FETAL HYPOXIA due to placental
insufficiency
• PIH, Placenta previa, Ablatio placentae, hypertonic
contractions
• Position on left side, Oxygen thru face mask at 8
liters/min, dc IV oxytocin, may give tocolytics or
analgesia
• NOTIFY PHYSICIAN
• C. Variable deceleration
• Transient decrease in FHT before, during, or after
contraction
• Has an erratic and jagged pattern (V,U,or W shape)
• Indicates CORD COMPRESSION
• Do IE and check for cord prolapse
• If (+) cord prolapse, relieve pressure by change in
maternal position : knee chest, modified sim’s
• Oxygen by face mask
• NOTIFY PHYSICIAN
• D. Bradycardia
• Less than 100 b/m or a drop of 20 b/m below
baseline
• Assess for cord prolapse, left side position, oxygen
administration
• Indicates :
» Fetal hypoxia from analgesia or anesthesia
» Maternal hypotension
» Prolonged cord compression
» Vagal stimulation due to compression of fetal
» Placental separation
• E. Tachycardia
• FHT greater than 160 b/m
• Indicates fetal distress if it persists for more than 1
hr or is accompanied by late deceleration
• Caused by:
– Maternal infection
– Dehydration
– Hyperthyroidism
– Drugs : atropine, vistaril, ritodrine, terbutaline,
epinephrine, caffeine, theophylline, cocaine
 Fetal Heart Tone
• Baseline rate is 120-160 b/m.
• Rates of 110-120 are normal if all other
signs are reassuring.
• Baseline must be measured between
uterine contractions for a full 10 minute
period.
 E. HEALTH TEACHINGS

Bath

 Advisable if contractions are

tolerable or not too close to one
another.
 Make the mother feel
comfortable
Ambulation

 During the latent phase of labor, it

helps shorten the first stage of labor.
 But not allowed if membranes have
rupture
 Digestion is delayed during labor.
 A full stomach interferes with
proper bearing down
 May vomit and cause aspiration
 Enema
 ENEMA – not routinely done

• SOAP SUDS
ENEMA
 PURPOSES:

A full bladder hinders the progress of

labor  effectiveness of enema in
labor is shown by evaluating the
change in uterine tone and amount
of show.
Expulsion of feces on the second
stage of labor predisposes mother
and baby to infection.

Full bladder predispose to

postpartum discomfort.
 PROCEDURE OF ENEMA
 Enema solution may either be
soap suds or fleet enema
 Optimal temperature 105 F -115 F
( 40.1C-40.6 C)

 Side- lying postion

 (+) resistance during catheter insertion,
withdraw the tube slightly while letting
small amount of solution enter.
 Clamp rectal tube during contraction
 IMPT: Check FHR after enema
administration to determine fetal distress
CONTRAINDICATIONS:
Vaginal bleeding
Premature labor
Abnormal fetal presentation or
position
Ruptured membranes
Crowning
Encourage the mother to void every 2-3
hours by offering bedpan

 Full bladder:
Retards fetal descent
Urinary stasis can lead to UTI
Can be traumatized durig delivery
 Perineal prep
done aseptically using “No. 7
stroke”. Always front to back
Perineal shave
 done to provide
clean are for
delivery
 Razor moved
along the
direction of the
hair growth
 Woman in labor should not be allowed
to push or bear down on the first stage
of labor because:

 Leads to unnecessary
exhaustion
 Strong pounding of the
fetus against the pelvic
floor
 Cervical edema
 Abdominal breathing

 On the first stage

of labor to reduce
tension and
prevent
hyperventillation.
F. ADMINISTER ANALGESICS AS
ORDERED

• Dosage is based on:

Patient’s weight
Status of labor
Stage of gestation
Narcotics are the most commonly used,
specifically Demerol

• Pharmacologic effect:
Depresses the sensory portion of
the cerebral cortex
Sedative and antispasmodic
 Demerol

Not given in early labor because it can

retard labor progress
Not given also one hour before delivery
because it causes respiratory depression
in the newborn
Can only be given if cervical dilatation is
6-8 cms.
 Demerol

Takes effect in 20
mins. patient
experiences a sense
of well-being and
euphoria.

Antidote:
 Narcan/Nalline
G. ASSIST IN REGIONAL ANESTHESIA

 Does not enter maternal circulation,

thus, does not affect the fetus.

 Patient is completely awake and

aware of what is happening

 Does not depress uterine tone

 XYLOCAINE
 Anesthesia of choice

Patient on NPO and with IV to prevent:

Dehydration
Exhaustion
Aspiration
Glucose aids in uterine muscles in
proper functioning
 TYPES OF ANESTHESIA:

PARACERVICAL
 Transvaginal
injection of either
side of the cervix.
 Painless childbirth
 Px: Lithotomy
position
PUDENDAL
 Through sacrospinous
ligament into the
posterior areolar tissues
to reduce perception of
pain during 2nd stage of
labor and make mother
comfortable.
 Px.: Lithotomy
position
Side effect: PUDENDAL
 Ecchymosis /
hematoma in the
right of the
perineum

 Management:
Ice pack on the
area to reduce
swelling
 LOW SPINAL

EPIDURAL

 Injection of local
anesthesia at the
lumbar level
outside the dura
mater
 SADDLE BLOCK
 Injection into the 5th lumbar space,
causing the anesthesia into the parts
that come in contact with the saddle
(perineum, upper thighs and lower
pelvis)
 Blocks nerves that transmit pain of
first stage of labor.
 Px.: Sitting or side-lying position with
back flexed
TYPES OF ANESTHESIA
 FORCEPS Postspinal Headaches
Due to leakage of
DELIVERY anesthesia into the CSF
or injection of air at time
• Done in patient of needle insertion
under anesthesia
because of loss of Management:
coordination in
second stage  Flate on bed for 12 hours
pushing and increase fluid intake
FORCEPS
 Common side effects of Anesthesia:

Hypotension
 Because xylocaine is a vasodilator
 Mangement:
Turn to side;
Prompt elevation of legs
Administration of vasopressor and
oxygen as ordered
Fetal bradycardia
Decreased maternal respirations
 H. SURE SIGN of delivery

Bulging of the
perineum

 Primis: LR to DR
cervix is fully
dilated
 Multis: 7-8 cms.
Cervical dilatation
 c. Transition Period

• The mood of the

woman suddenly
changes and the
nature of the
contractions
intensify
 1. Characteristics:

A. If membrane is intact, this period is a

sudden gush of amniotic fluid as fetus is
pushed into the birth canal.
 If (-) spontaneous rupture,
amniotomy is done to prevent fetus
from aspirating amniotic fluid.
B. Show becomes more prominent
C. There is
uncontrollable urge to
push with
contractions,
impending sign of 2nd
stage of labor.
(+) Profuse
perspiration and
distended neck
veins.
 D. Nausea and vomiting

Reflex reaction due to decreased

gastric motility and absorption.

E. Primis = baby is delivered within

20 contractions (40 minutes)
Multis = in 10 contractions (20
minutes)
 2. Nursing Actions: Comfort
measures
Sacral Pressure
 Applying pressure with
the heel of the hand on
the sacrum
 Relieves discomfort from
contractions
Proper bearing
down techniques:

 Push with
contraction
Controlled chest
(costal) breathing

during contraction
Emotional
support
 SECOND STAGE
OF
LABOR
(FETAL STAGE)
Complete dilatation
and
Effacement to birth MICHELLE E.
11/7/2019 171
FLORES,RN,MAN
 STAGES OF
LABOR
2nd STAGE OF PHASES STATION CONTRACTION
LABOR

I 0 to (+) 2 2-3 mins apart

II (+) 2 to (+) 4 2- 2.5 mins apart

with urgency to
bear down

III (+) 4 to birht 2mins apart, fetal

head visible,
increased
 Birth of the baby
• VS q 5-15 mins; P/N : 30-50 mins ; M : 20 mins
• 2-3 mins frequency, 60-90 secs duration, strong
intensity
• Bulging perineum due to pressure of the fetal head
• Crowning – largest part of the head is past the vulva
• Multi are moved to DR once 8 cm dilatation
• Episiotomy may be done to facilitate delivery
• Coach mother to push effectively : open-glottis
• Breathing techniques to avoid exhaustion
• If w/ leg cramps, provide relief
• Ritgen’s maneuver
– Place a sterile towel over rectum & apply
forward pressure on the chin while the other
hand presses downward on the occiput
– Purpose:
• Facilitate extension
• Slows down delivery of the head
• Lets the smallest diameter of the head to be born
• After delivery of the head, suction may be
applied using bulb syringe
• Insert fingers into vagina and check for
nucchal cord
• Then hold the sides of baby’s head then
apply a slight downward push to deliver the
anterior shoulders first then the posterior
shoulder.
• Take note of exact time of delivery
• Place infant in dependent position to
facilitate drainage of secretions
• Place infant on top mother’s uterus
• Clamp the cord twice then cut in between
• After cutting, check for cord vessels
• Stabilize infant’s condition, perform 1
minute post delivery APGAR, wrap with
sterile draw sheet then let mother hold the
baby and establish eye contact before
bringing to the nursery
Giving Birth
Giving Birth
Giving Birth
E• Mechanisms of Labor
Engagement – widest diameter of fetal head enters the
inlet & passage of fetus into pelvis
D• Descent – progress of presenting part through pelvis;
F aided by ROM & more rapid at end of active labor
• Flexion – further contact of fetal chin to chest when
I head meets resistance from the pelvic floor
R• Internal Rotation – process from which the long axis of
the fetal skull changes from transverse to AP diameter
E• Extension – birth of fetal head as it leaves the outlet
• External Rotation – realignment of the head with the
E back & shoulders; Restitution ( return to or restoration of a
previous state or position, especially the return of the rotated head of a fetus
R to its natural alignment with the body after delivery)

• Expulsion – delivery of the shoulders, trunk, &

E extremities
 SECOND STAGE OF LABOR (FETAL STAGE)
• PRIMI – transfer to DR @ 10 cm dilatation
• MULTI – transfer to DR @ 7 – 8 cm dilatation
Position in lithotomy both legs at the same time
BULGING OF PERENIUM  surest sign of delivery initiation
PANT & BLOW Breathing- fetal pushing should be done on an open glottis

Mechanism of Labor (ED FIRE RERE)

E -ngagement
D-escent
F-lexion
I-nternal R-otation
E-xtension
R-estitution
E-xternal R-otation
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MICHELLE E.
FLORES,RN,MAN
 C. SECOND STAGE
(Stage of expulsion)
 begins with 1.Powers/forces:
complete
dilatation of the  Involuntary uterine
cervix and ends contractions and
with the delivery contraction of the
of the baby diaphragmatic and
abdominal muscles
 MECHANISM OF LABOR (d fire ere)

Descent

 Preceeded by
engagement
Flexion

 Pressure
from the
pelvic floor
causes the
chin too
bend forward
onto the
chest
 Internal Rotation

• From AP to
transverse, the AP
to AP
 Extension

• As head comes
out, the head back
of the neck stops
beneath the pubic
arch.
• Head extends,
forehead, nose,
mouth and chin
appear
 External Rotation

• Restitution-
anterior
shoulder rotates
externally to the
AP position.
 Expulsion

• Delivery of the
rest of the body
 Nursing Care:

a. When positioning legs on lithotomy

position, put them up at the same time
to prevent injury

b. As soon as the fetal head crowns,

instruct mother not to push, but pant
(rapid and shallow breathing) to prevent
rapid expulsion of the baby.
  If panting is deep and rapid
(hyperventillation), the patient will
experience lightheadedness and
tingling sensation of fingers leading
to carpopedal spasm due to respiratory
alkalosis.

c. Assist in episiotomy (incision made in

the perineum primarily to prevent
laceration.
 PURPOSES:
Prevent prolonged and severe
stretching of muscles supporting
bladder or rectum
Reduce duration of the 2nd stage when
there is hypertension and fetal distress
Enlarged outlet, as in breech
presentation or forceps delivery
 TYPES OF EPISIOTOMY:

MEDIAN MEDIOLATERAL

 From middle  Begun in the

portion of the midline but
lower vaginal directed laterally
border directed away from the
toward the anus. anus.
EPISIOTOMY
 Respiratory alkalosis
– Due to incorrect breathing
– Hyperventilation
– S/sx
•  RR
• Lightheadedness
• Tingling sensation
• Carpopedal spasm
• Circumoral numbness

Episiotomy
• Prevent laceration
• Widen the vaginal canal
• Shortens the 2nd stage of labor
2 types
– MEDIAN
• Less bleeding
• Less pain
• Easy repair
• Possible urethroanal fistula  major disadvantage
– MEDIOLATERAL
• More bleeding
• More pain
• Hard to repair and slow healing

MICHELLE E.
11/7/2019 196
FLORES,RN,MAN
•
 Natural anesthesia

Pressure of the fetal

presenting part against
the perineum is so
intense that nerve ending
for pain are momentarily
dreadened
 d. Apply the modified Ritgen’s
maneuver

Cover the anus with sterile towel and

exert upward and forward pressure on
the fetal chin, while exerting gentle
pressure with two fingers on the head to
control emerging head
Modified Ritgen’s maneuver
Insert 2 fingers into the vagina so as to
feel for the presence of a cord looped
around the neck (nuchal cord)

 If so, but loose, slip it down the

shoulder or up over the head; but if
tight, clamp cord twice, an inch apart,
and then cut in between.
As the head rotates, deliver the anterior
shoulder by exerting a gentle downward
push and then slowly lift to deliver the
posterior shoulder.

While supporting the head and the neck,

deliver the rest of the body.

Take note of the exact time of delivery of

the baby.
e. Immediately after delivery,
newborn should be held below
the level of the mother’s vulva
for a few minutes to encourage
flow of blood from the placenta
of the baby.
f. The infant is held with his head in a
dependent position

Head is lower than the rest of the

body to allow for drainage of
secretions.

Remember: Chilling increases the

body’s need for oxygen
h. Put the baby on
the mother’s
abdomen.

 The weight of the

baby will help
contract the
uterus
i. Cutting of the cord is postponed until the
pulsations have stopped because it is
believed that 50-100 ml. of blood is
flowing from the placenta to the baby.

After cord pulsations have stopped,

clamp it twice, an inch apart, and
then cut in between.
Cutting of the umbilical cord
THIRD STAGE OF LABOR
(PLACENTAL STAGE)

Birth of Infant
to

Placental Expulsion
3 – 10 minutes after child birth
207
MICHELLE E.
11/7/2019 FLORES,RN,MAN
CALKIN’S SIGN - 1st sign  Fundus rises 
Signs of Placental Separation
– Fundus becomes globular and rises  calkin’s sign
– Lengthening of the cord
– Sudden gush of blood
BRANT – ANDREW’S MANEUVER
– slowly pulling the cord and wind at the clamp
– rapidly  may cause uterine inversion
Types Placental Delivery
SHULTZ (Shiny)
– From center to the edges
– Presenting fetal side
DUNCAN (Dirty)
– Form edges to center
– Presenting the maternal side
•
MICHELLE E.
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FLORES,RN,MAN
 MICHELLE E.
11/7/2019 209
FLORES,RN,MAN
Nursing Considerations during placental delivery
Check - placental completenes
Check -Fundus – Massage if Boggy
Check -BP
M-ethergine, methylergonovine mallate (IM)
O-xytocin (IV) if methergine is not present
C-heck perenium for lacerations
A-ssist in episioraphy
V-aginoplasty/ Vaginal Landscape – Virgin again
E-ncourage Flat on bed

11/7/2019 Chills-due dehydration.

210
MICHELLE E.
FLORES,RN,MAN
j. Show the baby to
the mother,
inform her of the
sex and time of
delivery then give
to the circulating
nurse.
 D. THIRD STAGE
(Placental Stage )

Begins with the delivery of the

baby and ends with thee
delivery of the placenta
 1. SIGNS OF PLACENTAL
SEPARATION

• Calkin’s sign (earliest sign)

Uterus becound round and firm and
rising high on the level of the
umbilicus.
• Sudden gush of blood from the vagina
• Lengthening of the cord from the vagina
2. TYPES OF PLACENTAL DELIVERY:

SCHULTZE
 Placenta separates first at the center
and last at its edges.
 It tend to fold itself like an umbrella
and presents the fetal surface which
is shiny and 80% separate in this
manner
Schultze = Shiny
DUNCAN

 Placenta separates first at the edges

 it slides along the uterine surface and
presents with maternal surface which is
raw, red beefy, irregular and dirty.

 Only 20% of placenta separates this way

Duncan = dirty
 Nursing Care

A. Do not hurry the expulsion of

the placenta by forcefully
pulling out the cord or doing
vigorous fundal push as this can
cause uterine inversion
B. Brand-Andrews
maneuver – tract the
cord slowly, winding
it around the clamp
until placenta
spontaneously
comes out, rotating
it slowly so that no
membranes are left
inside the uterus.
C.Take note of the
placental delivery;
and should be D. Inspect for
delivered within completeness of
20 mins. cotyledons; any
retained placental
fragments can
cause severe
bleeding and
possible death.
Placental Cotyledons
E. Palpate the uterus to determine the
degree of contraction
 If boggy or non-contracted, nursing
actions:
Massage gently and properly
Ice cap over abdomen
Tickle the nipple
F. Inject oxytocics (Methergin=0.2mg/ml
or
Syntocinon = 10 U/ml ) IM/IV  to
maintain uterine contractions,
thus prevent hemorrhage.

Not given: before placental delivery

because it will cause placental
entrapment.
If the parturient still has continuous oozing of
bright red blood, suspect lacerations; to stop
bleeding, this must be repaired.

• Classifications:
a. First degree – fourchette, vaginal mucous
membrane, perineal skin
b. second degree – plus muscles of perineal
body
c. third degree – plus anal sphincter
d. fourth degree – plus mucous membrane
of rectum
 Categories of lacerations:
 ragged edges tend to heal more
slowly.
1.FIRST DEGREE
 Involves the
vaginal mucous
membranes and
skin
2. SECOND DEGREE
 Involves not only the
vaginal mucous
membranes and skin,
but also the muscles.
3. THIRD DEGREE
 Invoves not only the
muscles, vaginal
mucous membranes
and skin, but also
the external
sphincter of the
rectum
Care of Woman during Third Stage of
Labor

• At the end of the second stage of

labor, the fundus is usually 2.5 cm
below the level of the umbilicus or
about 15 cm above symphisis pubis.
The normal uterus should be firm and
contracted. If after the birth of the
baby, the fundus is more than 2.5 cm
above the umbilicus, the following
possible cause must be considered
• there is another fetus in the utero
• the placenta is usually big
• blood clots are present in the
uterus
• distended bladder
A. Examination of the Membranes, Placenta
and Umbilical Cord

1. Membrane carefully examined for the

following
• Completeness – the state of membrane
must be properly recorded in the chart as
either complete, incomplete or ragged –
refers to torn out apparently complete
membrane
• Presence of blood vessel in the
membrane
• Site of rupture of the membrane – refers
to hole in the membrane through which
the baby was born
2. Placenta both maternal and fetal
surface are examined
3. Umbilical Cord – the following are
noted
– length of the cord
– number of arteries and vein
– any abnormalities like presence of
knots
Intervention to prevent bleeding
during third stage of labor

– slow delivery of the shoulder and body

of the baby – to allow the uterus to
contract and retract its diminishing
content
– shortening the duration of the third
stage by expelling the placenta as soon
signs of placental separation appears
– preventing the occurrence of laceration
– administration of oxytocic
• Watchful waiting:
– No fundal push
– No uterine massage
– No pulling of the cord
– Rest one hand over the fundus to make sure it
is firm while waiting for placental separation
– Place the hand above symphysis pubis and
push uterus upwards while the other hand
slowly and gently rotate the cord around the
clamp until complete delivery
Oxytoxic – substance which stimulates
contraction of the uterine musculature
and is therefore useful in the prevention
and control of bleeding

a. Syntocinon – synthetic oxytocin

(Methylergonovine Maleate)
b. Methergin – a semi synthetic
derivatives of Ergonovine
Conditions that requires referral to the
physician

– Profuse bleeding before placental

separation
– Profuse bleeding from vaginal or
perineal laceration
– Retained placenta
– Uterine atony
– Retained placental
cotyledons/membrane
• Multiple perineal vaginal
lacerations
• Inversion of uterus due to strong
traction to umbilical cord
• Increase or decease vital signs
• Dyspnea
• Convulsion
Complication of Third Stage of Labor
Retained placenta
1. Placenta Accreta- refers to abnormal
firm adherence of placenta to the
uterine wall because of the subnormal
amount or complete absence of
deciduas. Cannot be removed manually.
– Placenta Increta- actually invade
the myometrium
– Placenta percreta- Penetrate the
myometrium
2. Prolapsed of the uterus- rare case
Etiologic Factors

– over a previous caesarian section scar

– uterine curettage
– placental previa
– gravida 6 or more

Treatment: hysterectomy
Forceps Delivery
– Obstetrics forceps is an instrument
designed to delivery the head of fetus
when fatal or maternal indications for
prompt delivery develop.
– Forceps consist of 2 blades that maybe
solid or fenestrated (windowed). The
blades are
– Curved to fit the sides of the fetal head
and most blades are curved to fit the
cavity of the pelvis
Danger of forceps delivery
Mother
– Extensive laceration
– Hemorrhage
– Infection
Fetus
– Intracranial injuries
– Disfigurement
Vacuum Extractor

– Suction is applied to the fetal head and

the traction gained thereby is
synchronized with the uterine
contraction
– There has been report of the fetal
damage to the scalp and skull and of
intracranial hemorrhage
Caesarian Operation

• Delivery of fetus through incision in

the abdominal wall and the uterine
wall
Types
1. Classical CS – the incision is made through
the body and the fundus. This operation is
not considered as safe as other types but
is slightly easier to perform and still used
by the operator. It maybe employed if
there is urgent need to deliver the baby
quickly. It is safest if performed before
the onset of labor and when the
membranes are intact
2. Low cervical operation – the incision is
made on the lower uterine segment. It
may be performed before labor or when
the labor has continued for number of
hours.
Indication:
– Toxemia
– Placenta previa
– Abruption placenta
– Prolapsed of umbilical cord
– Previously extensively vaginal repair
– First baby in elderly woman
– Breech presentation
– Fibroids or ovarian cyst
– Malposition of the fetus
Complications

1. Hemorrhage
2. Shock
3. Infection
4. FOURTH
DEGREE
 Involves not only the
external sphincter of
the rectum, the
muscles, vaginal
mucous membranes
and skin, but also the
mucous membranes
of the rectum
 Assist the doctor in doing episiorrhapy
• Repair of episiotomy
or lacerations.
• Vaginal packing is
done to maintain
pressure in the
suture line, to
prevent bleeding;
removed after 24-48
hours
H. Make mother comfortable by perineal
care and applying clean sanitary napkin
to prevent its moving forward from the
anus to the vagina.

Soiled napkins should be removed

from front to back
I. Position the newly-
delivered mother flat
on bed without
pillows to prevent
dizziness due to
decrease in intra-
abdominal pressure.
J. The newly-delivered mother suddenly
complain of chills due to the rapid
decrease of pressure, fatigue or cold
temperature in the delivery room.

 Management:

Provide additional blankets to keep

her warm
K. Give initial nourishment
eg. Milk, coffee or tea // DAT // diet at
minimal

L. Allow patient to sleep in order to

regain lost energy.
FOURT STAGE OF LABOR
(Recovery Stage)

Immediate post Partum

First 1 – 2 hours after

delivery of placenta
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• Maternal observation – body system stabilize
– 1st hour – q15 min 2nd hour - q 30 min
• Placement of fundus
– In between umbilicus and pubis symphysis
– Check bladder, assist in voiding, May lead to uterine
atony  hemorrhage
Types Color Day Composition
Rubra Red 1-3 days Blood,WBC,Decidua, Some
microorganism
Serosa Pink 4-9 days Blood,mucus, tissue and WBC
Lochia
Alba White 10-21days Mucus

MICHELLE E.
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Perineum
E - dema
R - edness
E - cchymosis
D - ischarge
A – pproximation

• Fully saturated – 30 – 40 cc

• Weighing – 1 cc = 1 gram Common Board

Question
MICHELLE E.
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FLORES,RN,MAN
 Nursing Consideration during Recovery
F - lat on bed to prevent dizziness
I - f with Chills  give blanket due to dehydration
N - ourishment (progression of meal)
– Clear liquids – gatorade, ginger juice, gelatins
– Full liquid – milk, ice cream
– Soft diet
– Regular diet
C - heck VS/ Pain
Bonding – interaction between mother and
newborn
Strict – 24 hours with mother
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MICHELLE E.
FLORES,RN,MAN
 E. FOURTH STAGE
(Post Partum Stage)

First 1-2 hours after delivery

which is said to be the most
critical stage for the mother
because of unstable vital
signs.
 Post-Partum Assessment
• B
• U
• B
• B
• L
• E
• S
• H
• E
 1. ASSESSMENT

FUNDUS
Check every:
 15 mins=1hour
 30 mins = next 4
hours
 Fundus should be
firm, in the midline
and during 1st 12  Non-contracted
hours postpartum, is uterus
a little above the
umbilicus
 Action:
 Massage
B. LOCHIA –moderate in amount

Immediately after
delivery, a perineal pad
can be completely
saturated after 30
minutes.
RUBRA – red, moderate 1-3 days
postparum

SEROSA – pinkish, slighly moderate, 3-5

days

ALBA – colorless or whitish, 5-8 days or

onwards
 C. BLADDER

 A full bladder is evidenced by

a fundus which is to the right
of the midline; dark-red
bleeding with some clots
 D. PERINEUM

 Normally tender,
discolored and
edematous.
 It should be clean,
with intact sutures
E. BLOOD PRESSURE & PULSE
RATE

 Slightly increased from

excitement and effort of
delivery, but normalize within
one hour
2. Lactation-suppressing Agents

 Estrogen-androgen preparation
Given within first hours
postpartum to prevent
breastmilk production in mothers
who will not breastfeed.
»Diethylstilbestrol
»Deladumone
Post partum Psychological response according to
Reva Rubin Characteristic
Phase Nursing Care
Taking In Reflection/Dependent Phase •Encourage to tell story about
2-3 days childbirth experience
Client is Passive •Encourage rest
Taking Hold Dependent to Independent Phase •Positive reinfircement
Start to make decision Emphasize on the care of the
Active new born
4-5 days •Initiate Family Planning Method

Letting Go Independent phase Encourage Prenatal Love and

Redefining the New Role positive Family relationShip

MICHELLE E.
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 3. Rooming-in concept

• Mother and baby are together

while in the hospital.

• Eye-to-eye contact is immediately

established, releasing maternal
caretaking responses
Rooming-in concept
• Massage uterus to keep it contracted, make
sure it will not be displaced laterally
(FUNDAL MASSAGE)
• Oxytocic given is Methyl ergonovine
maleate
– A powerful stimulant of uterine
contractions with an effect that may
persists for hours, it becomes a very
effective drug to control postpartum
hemorrhage
• Nursing Care:
–Never leave client unattended
–Have oxygen & emergency
equipment available
–VS q 15 mins for 2 hrs
–WOF boggy uterus; profuse
bright red bleeding with a
contracted uterus;
 Care of Parturient
• Prevent bleeding from uterine atony and birth
canal lacerations
• Uterus must be contracted in the midline of
the abdomen about the level of umbilicus
• Normal blood loss is 250 to 500 ml
• Episiorraphy is done right after delivery of
placenta; may use LA
 Documentation
• Exact date and time of delivery
• Sex of the infant
• Condition of the infant (APGAR) after birth
• Position of the infant at delivery
• Type of episiotomy, degree of lacerations
• Spontaneous or forceps or vacuum-assisted
• Use of oxygen & suction on infant
 Documentation
• Number of vessels in the cord
• Any other pertinent acts about delivery
• Time placenta was delivered
• Mechanism of placental delivery
• Spontaneous or manually removed
• Type, amount, time, & route of administration of
oxytocics.
• Record uterine condition, and characteristics of
lochial flow.
Women in labor : DO SCREAM
• D – escent & engagement of fetus into
pelvis
• O – pening cervical OS

• S – oftening of cervix
• C – ontraction of the uterus that are regular
• R – upture of membranes
• E – ffacement or thinning & shortening of
the cervix
• A – pprehension
• M – ucus plug expulsion - BLOODY SHOW
Progress of Labor : ED FIRE ERE
• E – ngagement
• D – escent
• F – lexion
• I - nternal R - otation
• E – xtension
• E – xternal R – otation
• E - xpulsion
 Danger Signs of pregnancy : SHAVVVE

• S – welling of face, finger, legs

• H – ead ache, continuous & severe
• A – bdominal pain / chest pain
• V – aginal bleeding
• V – omiting, persistent
• V – isual changes
• E – scape of vaginal fluids
 OBSTETRICS
• O – xytocin is used to Induce uterine
contractions
• B – leeding disorders : Previa & Ablatio
• S – ubstance abuse during pregnancy
can cause fetal alcohol
syndrome (SGA), restlessness
in infants among cocaine-addicted
mothers
• T – eratogens must be avoided
• E – xercises : squatting, abdominal
muscle contraction, Kegel’s, Pelvic
rocking
• T – rue labor is differentiated from
Nursing Care Management
 Initial Assessment
1. Pre-natal record
2. Vital signs
3. Leopold’s maneuver
4. FHR
5. Contractions for frequency, duration & intensity
6. Nitrazine Test
7. Vaginal Exam
8. Inspection for signs of edema of face, hands,
legs
 Analysis
• Anxiety
• Impaired Verbal Communication
• Ineffective Coping
• Interrupted Family Processes
• Fatigue
• Fear
• Risk for Deficient Fluid Volume
 Analysis
• Gas Exchange Impaired (fetal)
• Risk for Infection
• Risk for Injury
• Deficient Knowledge
• Pain
• Impaired Physical Mobility
• Social Isolation
• Ineffective Tissue Perfusion (Maternal)
• Impaired Urinary elimination
 Planning
1. demonstrate expected progress through labor
2. express satisfaction w/ the assistance provided
by support person & staff
3. maintain adequate hydration
4. void at least every 2 hrs
5. actively participate in the labor progress
6. not experience any injury during the labor &
birthing process
 Interventions
1. Continuous assessment of Labor & Fetal well-
being
2. Providing maternal Physical care
• 2.1 Comfort measures
• 2.2 Hygienic measures
• 2.3 Ambulation & Position
• 2.4 Food & Fluid Intake
• 2.5 Elimination
3. Assisting Client & Support Person
 Interventions
1. Provide Pharmacological Comfort Measure
• 1.1 Systemic Medications
• 1.2 Regional Blocks – blocks neural impulses
– 1.2.1 Epidural Block
– 1.2.2 Intrathecal Block – SAB
– 1.2.3 Local Infiltration – blocks nerve
fibers impulses electrical
– 1.2.4 Pudendal Block – inject into
pudendal nerve to provide
perineal external genitalia, &
lower vaginal anesthesia
• 1.3 General Anesthesia
 HIGH RISK
LABOR & DELIVERY
 Preterm labor
• - onset of regular contractions of uterus
that cause cervical changes b/w 20 to 37
weeks of gestation
• - contraction less than 10 min apart,
leading to 2cm cervical dilatation and 75%
effacement
Risk factors:
P - revious PTL
A – bdominal surgery
Y – ounger than 17
O – lder than 35
L – ow socio-economic class
A – bnormality of fetus or placenta

M – ultiple gestation
E – motional & physical stress
N – utritional deficiency
 Conditions to halt labor :

• Intact membrane
• Good FHT
• No bleeding
• Cervix not dilated more than 4 cm
• Effacement is less than 50%
(if any of these conditions is not present, delivery,
regardless of fetal age is inevitable)
 Prevention:
•  minimize or stop smoking, substance abuse,
chemical dependency
•  early & consistent prenatal care
•  appropriate diet & weight gain
•  minimize psychological stressors
•  minimize or prevent exposure to infections
•  learn to recognize signs & symptoms of
PTL
 Medical Management :
•  Tocolysis of beta2 adrenergic
receptors (Ritodrine, Terbutaline)
• * SE : Tachycardia, Hypotension,
hypokalemia, hyperglycemia, headache
• * baseline data of : serum electrolytes, ECG,
uterine & fetal monitoring
• * Mg SO4 is also effective
• * Dexamethasone is given also for 24 hours
for effective therapy
 Nursing Interventions:
•  CBRsBRP on left side-lying position
•  Maintain continues maternal & fetal
monitoring
•  Administer drugs as ordered
•  Monitor I&O
•  Keep client informed of all progress &
changes to relieve anxiety
•  Identify side effects & complications as
early as possible
 PROM
• - loss of amniotic fluid before labor begins
• - dangers a/w this event are prolapsed cord,
infection, & potential need for premature
delivery
• - Full term – contractions begin w/in 24 hours
• - Pre term – labor may start for a week or more
 Nursing Interventions :
•  monitor maternal & fetal VS & FM count
•  calculate AOG; CBR
•  Observe for signs of infection & labor onset
•  Observe & record color, odor, amount of
amniotic fluid
•  Examine mother for signs of prolapsed cord
•  Provide explanations of procedures &
findings & support mother & family
•  Prepare mother & family for early birth if
indicated; avoid nipple stimulation & sex
 Dystocia
• any labor & delivery that is prolonged & difficult
• Assessment findings :
•  progress of labor slower than
expected rate
•  length of labor prolonged
•  maternal exhaustion
•  fetal distress
 causes :
• Pelvic Structure Variations – CPD, myoma
• Fetal Variations – malpresentation
• Mother’s Responses – lack of readiness
• Dysfunctional Labor
> hypertonic : intense, high tonus; painful;
fetal hypoxia; sedation
> hypotonic : weak, ineffective; painless;
sepsis; augment labor
 Complications:
• Maternal exhaustion
• Intrapartum
infection
• Traumatic operative
delivery
• Uterine rupture
• Fetal demise
 Nursing Interventions :
• Provide comfort measures
• Monitor mother & fetus continuously
• Administer analgesia if ordered
• Prepare oxytocin infusion for induction of
labor if ordered
• Prepare for CS if needed
 Precipitate Labor & Delivery
• - labor of less than 3 hrs
• - emergency delivery w/o client’s physician
or midwife
• - Assessment findings :
•  history of previous precipitate labor &
delivery
•  desire to push
•  observe status of membranes, perineal area
for bulging & for signs of bleeding
Emergency Delivery of an
• 
infant:
Stay with client at all times
•  Do not prevent birth of baby
•  Maintain sterile environment if
possible
•  Rupture membranes if necessary
•  Support baby’s head as it emerges,
preventing too rapid delivery w/
gentle pressure
•  Check for nucchal cord, slip over
head if possible
Emergency Delivery of
• 
an infant:
Use gentle aspiration w/ bulb syringe to
remove blood & mucus from mouth &
nose
•  Deliver shoulders after external rotation,
asking mother to push gently if needed
•  Provide support for baby’s body as it is
delivered
•  Hold baby in head-down position
•  Promote cry by gently rubbing over back &
soles of feet
•  Again, suction the mouth, throat & nose of
infant
 Emergency Delivery of an
infant:
•  Dry the infant to prevent heat loss &
place the infant on the mother’s abdomen.
Cover with a dry blanket
•  Document on the birth record : fetal
position, nucchal cord, time of birth, Apgar
score, gender, time & method of placental
expulsion, & mother’s condition.
 Prolapsed Umbilical Cord
• - displacement of cord in a downward
direction, near or ahead of the presenting part, or
into the vagina
• - may occur when membranes rupture
• - associated with breech presentations,
unengaged presentations and premature labors
• - Obstetric emergency : if compression of the
cord occurs, fetal hypoxia may result in CNS
damage or death.
• - Assessment findings : vaginal exam
identifies cord prolapsed into vagina
• - Nursing Interventions :
•  check FHT immediately after membranes
rupture & again after next contraction
or within 5 minutes, report
decelerations
•  if fetal bradycardia, perform vaginal exam
& check for prolapsed cord
•  if cord prolapsed into vagina, exert upward
pressure against presenting part to lift
part off cord to reduce pressure
•  get help to move mother into a position
where gravity assists in getting
presenting part off cord (knee-chest
position, T-burg position, modified
sim’s position)
•  Administer oxygen & prepare for
immediate CS
•  If cord protrudes outside vagina, cover with
sterile gauze moistened with sterile
saline. Do not attempt to replace cord.
•  Notify physician.
 Postmature Pregnancy
• - defined as those pregnancies lasting
beyond the end of 42nd week
• - fetal jeopardy may exist because of
decrease efficiency of placenta
resulting risk of hypoxia & fetal weight loss
• - decreased amounts of vernix allows drying of
fetal skin resulting in dry, parchment-like skin
condition
 Medical Management :

•  ascertain precise AOG & condition

& detemine fetal ability to tolerate
labor
•  Induction of labor & possibly CS
 Nursing Interventions :
•  Continuous monitoring of maternal
& fetal VS
•  Support mother through all testing &
labor
•  Prepare mother for possible
emergency interventions
 Fetal Distress
• - common contributing factors are cord
compression, placental abnormalities,
preexisting maternal disease.
• - Assessment findings :
• a. decelerations in FHT
• b. meconium-stained amniotic fluid w/
vertex presentation
 Nursing Interventions :

•  Check FHT, institute fetal monitoring

•  Vaginal exam for presentation & position
•  Place mother on left side lying, administer
oxygen, check for prolapsed cord, notify
MD
•  Prepare for emergency birth if indicated
 Induction of labor
• - deliberate stimulation of uterine
contractions before the normal occurrence of
labor
• - may be accomplished by amniotomy &
oxytocin infusion
• - Indications : postmature infants,
preeclampsia/eclampsia, DM, PROM, fetal demise
• - Condition of fetus : mature, engaged vertex
fetus in no distress
• - Condition of mother : cervix ripe for
induction, no CPD
 Nursing Interventions :

•  Explain all procedures to client

•  Prepare appropriate equipment &
medications
•  Continuous monitoring of maternal
& fetal VS including progress of labor
 Augmentation of Labor
• - stimulation of uterine contractions
after spontaneously beginning but the
progress of labor is unsatisfactory
Obstetric Procedures
 Cesarean Birth
• - birth of an infant though an incision in
the abdomen & uterus
• - indications : placenta previa, abruptio
palcenta, CPD, prolapsed cord, breech
presentation, active genital herpes, dystocia,
PIH, hydrocephaly, multifetal pregnancy,
repeat CS
 Incisions:
• skin – transverse or vertical
• Uterus – vertical in either the upper (classic)
or lower uterine segment
- Transverse in the lower uterine
segment
Forceps - assisted birth
- obstetrician’s use of special spoon-
shaped instruments to effect the
delivery of the baby & shorten the 2nd
stage of labor
- Types :
• outlet forceps – crowning
• Low forceps - +2 station
• Mid forceps – above +2 station
Indications :
– > exhausted mother
– > fetal distress
– > arrested rotation
– > maternal heart disease
– > poor descent of fetus
 Requirements
• fully dilated cervix,
• presenting part engaged,
• vertex or face
presentation,
• ruptured membranes,
• no CPD,
• bowel & bladder emptied,
• station must be known
• Make sure the cord will not be
compressed
• Traction is applied only during
contractions
• Assess mother for vaginal & cervical
lacerations, hematoma & bruising
 Vacuum – assisted birth
• - a cup connected to suction is placed
over the occiput of fetal head, after suction,
traction is applied in a downward &
outward direction during contractions.
• - Maternal risks : vaginal & rectal
lacerations
• - Fetal risks : cephalhematoma,
brachial plexus palsy, retinal & intracranial
hemorrhage, hyperbilirubinemia
 Episiotomy
• - incision made in the perineum to
enlarge opening for delivery
• - types : midline or median
mediolateral