INTRODUCTION TO

NORMAL LABOUR

Ms Kairu &
By
Jonah
 COURSE OUTLINE- 3 RD & 4TH MONTHS
COURSE OUTLINE- 3RD & 4TH MONTHS
1. THE NORMAL LABOUR:
Preliminaries/ preambles:
Review of definitions
Causes associated with onset of labour
Clinical features of true labour
Analysis of labour stages
First stage of labour
Transition and 2nd stage of labour
Physiology & management of 3rd stage of labour
The 4th stage of labour
2. NORMAL NEONATE:
APGAR scoring
Immediate care of the neonate
Physiology of the normal neonate
First/initial examination
Daily/routine examination
Minor disorders of the neonate
3. NORMAL PUERPERIUM:
Physiology
Prime health messages
Daily/ six weeks examination
Targeted post-natal care
Minor disorders in puerperium
 DEMONSTRATIONS: 3rd & 4th MONTHS
1. Preparation-Delivery trolley & role play in
conducting 2nd stage
2. APGAR Scoring
3. First examination of a neonate
4. Placenta examination- already done.
5. Daily & six weeks examination of the postnatal
mother
INRODUCTORY BLOCK MIDWIFERY
WORK SCHEDULE
MONTH III & IV
 WEEK 1 WEEK 2
1. THE NORMAL LABOUR: Ct’ First stage of labour
Preliminaries/ preambles: Specific management
 Review of definitions Vaginal examination
 Causes associated with Partographing
onset of labour Artificial rupture of the
 Clinical features of true
membranes
labour
The transition & 2nd stage
 Analysis of labour stages
of labour
First stage of labour
 Introduction
 Physiology
 WEEK 3 WEEK 4
Ct’ Second stage of labour NORMAL NEONATE:
Recognition APGAR scoring
Physiology of 2nd stage
Immediate care of the
Mechanism of labour
neonate
Management of 2nd stage
Physiology of the normal
The 3rd stage of labour
neonate
Features
First/initial examination
Active management
Specific management Daily/routine examination
Delivery of the placenta Minor disorders of the
4th stage of labour neonate
WEEK 5 WEEK 6
THE NORMAL PUERPERIUM: DEMONTRATIONS:
Physiology Preparation-Delivery trolley
Prime health messages & role play in conducting 2nd
Daily/ six weeks stage
examination APGAR Scoring
Targeted post-natal care First examination of a
Minor disorders in neonate
puerperium Daily & six weeks
examination of the
postnatal mother
REFERENCE MATERIALS
Myles textbook for Midwives, African edition
National guidelines for Quality obstetrics and
perinatal care
Myles textbook for Midwives, 15th edition
 BROAD OBJECTIVE
By the end of these session(s), the KRCHN student
will be able to correctly diagnose and manage a
mother in labour, normal puerperium and manage
a normal neonate with an aim of ensuring safe
motherhood, to promote safe labour and delivery.
 SPECIFIC OBJECTIVES
At the end of these sessions, the KRCHN students will be able to:
1. Define and describe the process of labour
2. Describe the factors influencing labour
3. Describe physiology of 1st stage of labour
4. Explain the management of a mother in 1st stage of labour
5. Describe the physiology and management of 2nd stage of labour
6. Describe the physiology and management of 3rd &4th stages of labour
7. Keep accurate records of labour
8. Manage a normal newborn
9. Manage normal puerperium
 DEFINITION
INTRODUCTION- DEFINITION OF TERMS:
• LABOUR is described as the process whereby the foetus,
placenta and membranes are expelled through the birth
canal after 28 weeks of gestation. Labour, can be either
normal or abnormal.
• Labour is a physiological process, characterized by rhythmic
regular uterine contractions increasing in frequency and
intensity, accompanied by progressive cervical effacement
and dilatation, and descent of the presenting part. Labour
may be spontaneous or induced.
 DEFINITION OF NORMAL LABOUR
• Normal labour is a physiological process, which commences
spontaneously at term (after 37 completed weeks of
gestation) with rhythmic regular uterine contractions of
increasing intensity and frequency, accompanied by
progressive cervical effacement and dilatation, and descent of
the presenting part (cephalic), resulting in expulsion of a
healthy foetus, a complete placenta and membranes and a
healthy mother.
 CHARACTERISTICS OF NORMAL LABOUR:
• Normal labour has several important characteristics. These
are:
Duration - completed within 18 hours (from 1st stage to 4th
stage)
Occurs at term between 38 and 40 weeks of gestation
Is spontaneous, i.e. not induced
The foetus presents by the vertex
Has no complications to either mother or baby
The newborn child requires minimal or no resuscitation at
birth
Changes during the last few weeks
of pregnancy

• The physiological transition from being a pregnant

woman to becoming a mother means an enormous
change for each woman, both physically &
psychologically
• During the last few wks of pregnancy, a number of physical &
psychological changes occur:
• Mood swings are common and a surge of energy may be
experienced.
• 2-3 wks prior to onset of labour, the lower uterine segment
expands and allows the foetal head to sink lower and it may
engage in the pelvis, especially in 1st time mothers. When
this happens, the fundus of the uterus descends & there is
more room for the lungs, breathing is easier & the heart
and stomach can function more easily. The woman may
experience relief known as lightening
• Walking may become more difficult for some women at
the end of pregnancy because the symphysis pubis is
more mobile and relaxation of the sacroiliac joints may
give rise to backache
• Relief of pressure at the fundus results in an increase in
pressure within the pelvis, which may be accounted for by
the presence of foetal head causing venous congestion of
the whole pelvis. Vaginal secretions may also increase at
this time
 Onset
Onsetof
ofspontaneous
spontaneousphysiological
physiological
labour
labour
• A midwife should ensure women have sufficient information
to assist them to recognize the onset of true labour. A
pregnant woman would be best placed to diagnose the
onset of labour herself.
• Some young women, especially the primigravidae, may fail
to recognize true labour. It is important that you help them
differentiate between false and true labour signs. The
contractions of true labour are regular and intense. In false
labour, the contractions are sporadic. False contractions
occur during the last weeks of pregnancy.
CLINICAL FEATURES OF NORMAL LABOUR
• Contractions of the uterus, which are increasingly strong,
painful and regular
• The cervix is taken up into the lower uterine segment
causing dilatation of the cervix
• There is a mucoid blood stained discharge, which is called
show
• Sometimes there is rupture of membranes with drainage of
liquor amnii (amniotic fluid)
 Spurious labour
• Refers to false labour symptoms experienced by most
women commonly 2-3 weeks prior to onset of true labour
• Many women experience contractions prior to onset of
labour which may be painful and may even be regular for
some time, causing the woman to think that labour has
started
• The two features of true labour that are absent in spurious
labour are effacement and dilatation of the cervix
• Reassurance should be given to the woman
DIFFERENCES BETWEEN TRUE & FALSE LABOUR
FACTORS TRUE LABOUR FALSE
LABOUR

Contractions Regularly spaced Irregularly spaced

Interval Gradually shortens Remains long
between
contractions
Intensity of Gradually increases Stays the same
contractions
Location of pain Back and abdomen Mostly lower abdomen
Effect of Do not abolish Often abolish the pain
analgesics the pain
Cervical Progressive effacement No changes
changes and dilation
FACTORS INFLUENCING THE ONSET OF
LABOUR
 There are many theoretical explanations as to why labour
starts.
 It appears to be as a result of a combination of factors.
 Medical researchers describe hormonal and mechanical
factors as the chief factors which influence onset of labour.
◦ Hormonal factors
◦ Mechanical factors
◦ Other factors
 HORMONAL FACTORS INFLUENCING THE ONSET OF SPONTANEOUS
LABOUR
The hormones include:
◦ Oxytocin
◦ Progesterone & Oestrogen
◦ Prostaglandins
 Close to term, progesterone levels in the body fall, while at the same

time levels of oestrogen (which is responsible for sensitizing the

uterine muscles) rise.
 The fall in progesterone levels is important because it has effect on

muscle contractions.
 The rise in oestrogen levels meanwhile triggers the release of

oxytocin, from the posterior pituitary gland, which causes uterine

contractions, hence contributing to maintenance of labour.
 Oxytocin stimulates the release of prostaglandins from
the myometrium which facilitate in initiation of labour
by causing the cervix to soften (cervical ripening) in
preparation for normal labour.
 The foetal hypothalamus produces releasing factors,

which stimulate the anterior pituitary gland to

produce adrenocorticotrophic hormone (ACTH). ACTH
stimulates the foetal adrenal glands to secrete cortisol,
which causes relative levels of placental hormones to
rise. These cause further uterine contractions.
 MECHANICAL FACTORS
1.Increased contractility of the uterus
 As the pregnancy advances, there is an increase in

contractibility of the uterus which becomes more

susceptible to stimulation as term approaches
2.Pressure of the presenting part
 The presenting part stimulates nerve endings in the cervix

resulting in initiation of labour

3.Over distention/overstretching of the uterus
 It increases contractility of the uterus thus prompting onset

of labour
 This explains why patients with certain conditions tend to go

into premature labour eg. Polyhydramnious and multiple

pregnancy
Other factors
 that have been associated with onset of labour:-

hyperpyrexia, cyanosis, emotional upset

 PRE-LABOUR OR PREMONITORY SIGNS OF
LABOUR
 Synonym: Warning signs indicating the onset of labour
 This is the period two to three weeks prior to the onset of labour

when a number of changes take place;

1)Lightening
 Two to three weeks before labour (at around 38 weeks in

primigravida), the lower uterine segment expands allowing the foetal

head to sink deep into the pelvic cavity. The descent of the head and
the body of the baby gives space to the maternal lungs, heart and
stomach, which enables these organs to function easily.
 The symphysis pubis widens and the pelvic floor softens and becomes

more relaxed, allowing further descent of the uterus into the pelvis
 Factors that bring about lightening
 The symphisis pubis widens
 The softened pelvic floor relaxes
 The lower uterine segment stretches and foetus

sinks further down in the uterus

 Lightening may also bring the following maternal
symptoms:
o Leg cramps or pains
o Increased pelvic pressure
o Increased urinary frequency
o Increased venous stasis, causing edema in the lower

extremities
o Increased vaginal secretions, due to congestion in the

vaginal mucosa
2)Frequency of Micturition
 The descent of the foetal head increases pressure

within the pelvis. This limits the capacity of the urinary

bladder, which can cause irritation. The laxity of the
pelvic floor muscles gives rise to poor sphincter control
causing a degree of stress incontinence.
 This pressure results in the congestion of circulation to

the lower limbs. Additionally, the relaxation of the

pelvic joint may give rise to backache
3. Weight Loss – A slight decrease in weight (about 0.5 to 1.5
kg) occurs around 1-2 days before onset of labor due to
decreased water retention as a result of decreased
progesterone
4. Increased Activity Level= ENERGY SPURT
 - Toward the end of the pregnancy, some women experience

a sudden increase in energy coupled with a desire to

complete household preparations for the new baby.
-    Increased secretion of adrenaline in preparation for much
work ahead = labor.
-    Should be reserved for labor
 5. Increased Braxton Hick’s Contractions
-    B-H is irregular painless practice contractions,
which may appear even on 6th month. Usually felt
in the abdomen or groin region and patients may
mistake them for true labor
-   It may reach an uncomfortable level.
-   Will not dilate cervix but ripen it, in preparation
for spontaneous labour onset.
6. Cervical changes.
 Ripening of Cervix: Cervix becomes butter-soft and may

dilate 1-2 cm.

 The cervix softens (“cervical ripening”), stretches, and thins,

and eventually is taken up into the lower segment of the

uterus. This softening and thinning is called cervical
effacement.
7. Backache due to fetal descent, as a consequence of
lightening.
8. Gastrointestinal disturbances: diarrhea, nausea, vomiting
or indigestion occur as a result of increased nerve
innervation due to descent of the presenting part.
 STAGES OF LABOUR
 Labour is divided into four stages, although in real practice, the
process is a continuous one and change from one stage to the other
may not be clearly obvious.
 The four stages of labour are known as First stage, Second stage,
Third stage and Fourth stage
 1st Stage: from onset of labour to full dilatation of the cervix. This
is the stage of dilation of the cervical os (upto 10cm)
 2nd Stage: from full cervical dilatation to expulsion of the foetus.
Begins when the cervix is fully dilated until when the baby is born
 3rd Stage: The stage of separation and expulsion of the
placenta and foetal membranes

 It begins after the birth of the baby until the placenta and
membrane are completely expelled
 4th Stage: This is the period of observation after the 3rd stage
of labour
This stage is described inorder to stress the importance of close
observations for the 1st 2-4 hours after the 3rd stage because of
the risk of P.P.H
 OUTCOME OF LABOUR
 The outcome of labour depends on various factors, which
include:-

 The Passage(Birth canal)

– Size of the pelvis(diameters of the inlet, cavity and
outlet)
– Type of pelvis
– Stretching/yielding of cervix and vaginal canal and
pelvic floor
 The passenger(Mainly the foetus, placenta and
foetal membranes)

– Foetal head (size and presence of moulding)

– Foetal attitude (Flexion or extension of the head)
– Foetal lie
– Foetal presentation
– Foetal position
 The powers(primary and secondary powers)
– Primary powers-the contractions and retractions of the
uterine muscle fibres
Are in force mainly in the 1 st stage of labour
– Secondary powers-the contractions of the abdominal
muscles and the diaphragm
 General health of the mother
o Physical preparation for child birth
o Previous childbirth experience
o Emotional integrity of the woman
 FIRST STAGE OF LABOUR
• This is known as the stage of cervical dilatation. This stage
begins when regular, painful uterine contractions start and is
detected clinically by the thinning and effacement of the
cervix, followed by its dilatation.
• The normally thick cervix becomes thinned out and stretched
over the presenting part.
• The first stage is completed when the cervix is fully dilated
and the presenting part starts being expelled.
• This stage has two phases;
 Latent phase
 Active phase
Latent phase
- Slow period of cervical dilatation from 0-4cms
- It is the period of gradual shortening of the cervix
(cervical effacement) where the cervix shortens from 3
cm to <0.5 cm long.
- Lasts for 6-8 hours in primigradivae
Active phase
-Faster/rapid period of cervical dilatation from 4-10cms or
full cervical dilatation, with rhythmic regular uterine
contractions.
 ASSIGNMENT
• CASE
A woman who is 36/40 weeks gestation calls her midwife
and report back pain and fluid leakage which was not sure if
is amniotic fluid or urine incontinence.
a) Explain health messages to give to the woman on
recognition of true signs of labour?
PHYSIOLOGY OF 1ST
STAGE OF LABOUR
 INTRODUCTION.
OBJECTIVE
To equip the learner midwife with the relevant
knowledge on normal labour so as to be able to
diagnose and manage any abnormal findings in the
course of care of the laboring woman.
 1. DURATION:
• Length of labour varies widely & is influenced by the parity,
birth interval, psychological state, presentation & position of
the fetus, maternal pelvic shape and size and the character
of uterine contractions.
• A greater part of labour is taken up by first stage.
• Active phase is completed within 6-12 hrs. Duration of latent
phase of labour should not be longer than 8hrs.
• During active phase, it is expected that a multiparous ought
to dilate at a rate of 1.5cm per hr & a primigravida at a rate of
1cm per hr.
 2. UTERINE ACTION
i) CONTRACTION & RETRACTION
• Uterine muscle has a unique property. During labour, the
contraction does not pass off entirely, but the muscle fibers
retain some of the shortening of contraction instead of
becoming completely relaxed. This is called retraction.
• It assists in progressive expulsion of the fetus; the upper
segment of the uterus becomes gradually shorter & thicker
& its cavity diminishes
• The contractions of the uterus are coordinated by two
pacemakers in the region of the cornua. These are located
where the fallopian tubes join the uterine body.
• The muscle contractions start at the top corner of the uterus,
spread to the fundus, and then downward. During normal
pregnancy, the uterus contracts intermittently but the
contractions are not strong enough to overcome the
resistance of a normal cervix and do not lead to its dilation.
• The contractions of pregnancy become more frequent
towards term and get more painful and noticeable.
• When talking about contractions, you as a midwife are concerned
with three factors, namely:
– The strength,
– The duration and
– The frequency of the contraction.
• When you talk of the strength of a contraction, you identify it as one
of three categories: Mild, moderate & severe.
• The strength of a contraction is measured according to the time it
has taken.
• Thus, a contraction which takes <20 seconds is said to be mild, one
that takes 20 to 40 seconds is said to be moderate or fairly strong
and one that lasts for 40 to 60 seconds is said to be strong or
severe contraction.
• The duration refers to the time taken by a contraction
(time between the start and end of a contraction), for
example a mild contraction lasts for 10 to 20 seconds.
• Frequency, on the other hand refers to the number of
contractions per 10 minutes duration. The frequency is
low at the start of 1st stage but increases at the end of 1st
stage (normally 3-4 contractions in 10 minutes). If a
mother has three contractions in every 10 minutes, the
frequency is written as 3:10.
 (ii) POLARITY
• Polarity describes the neuromuscular harmony between
the two poles or segments of the uterus throughout labour.
• The upper pole contracts strongly and retracts to expel the
fetus. The lower pole contracts slightly and dilates to allow
expulsion of the fetus to take place.
• If polarity is disorganized, then the progress of labour is
inhibited.
 (iii: ) FUNDAL DOMINANCE
• During a contraction the uterus feels hard to touch. At the
beginning of the process, contractions are painless and
involuntary, and are controlled by the nervous system under
the influence of endocrine hormones.
• The contraction starts at the upper part of fundus, spreading
across, and by the time they reach the lower fundus, they
last longer and are very intense. The peak of the contraction
is reached simultaneously over the whole uterus and fades
from all parts together. This pattern allows the cervix to
dilate and the contracting fundus to expel the foetus.
Fundal dominance
 iv) FORMATION OF THE UPPER & LOWER
UTERINE SEGMENTS

• By the end of pregnancy, the uterus is divided into two

anatomically distinct segments, known as the upper and
the lower uterine segments.
• The upper uterine segment is a thick muscular, contractile
area from where the contractions begin. The longitudinal
fibres retract, pulling on the lower segment and causing it
to stretch, pushing the head down.
Uterine segments.
• The lower uterine segment is thinner and develops from the
isthmus of the uterus about eight to ten centimeters in
length and is prepared for distension and/or dilatation. The
lower segment stretches when being pulled by the
longitudinal fibres.
• When labour begins, the retracted longitudinal fibres in the
upper segment pull on the lower segment causing it to
stretch.
• The force applied by the descending head or breech also aids
the stretching.
 v) THE RETRACTION RING
• A retraction ring which is an imaginary ridge, forms between the
upper and the lower uterine segment. It is present in every
labour and is perfectly normal as long as it is not marked
enough to be visible above the symphysis pubis.
• When retraction ring is seen above the symphysis pubis, it
indicates obstructed labour when lower segment thins
abnormally. May also indicate fetal compromise.
• The physiological ring gradually rises as the upper uterine
segment contracts and retracts and the lower uterine segment
thins out to accommodate the descending fetus. Once the
cervix is fully dilated and the fetus can leave the uterus, the
retraction ring rises no further.
 vi) CERVICAL EFFACEMENT
• ‘Effacement’ refers to the inclusion of the cervical canal into
the lower uterine segment.
• This process takes place from above downward; i.e. the
muscle fibres surrounding the internal cervical os are drawn
upwards by the retracted upper segment and the cervix
merges into the lower uterine segment
• The cervical canal widens at the level of the internal os
whereas the condition of the external os remains unchanged
• Effacement may occur late in pregnancy, or it may not take
place until labour begins
Cervical canal before effacement
Partial effacement
Effacement almost complete
Effacement fully complete
 vii) CERVICAL DILATATION
• Dilatation of the cervix is the process of enlargement of the
os uteri from a tightly closed aperture to an opening large
enough to permit passage of the fetal head
• Cervical dilatation is measured in centimeters & full dilatation
at term is 10 cm
• Cervical dilatation occurs as a result of uterine action & the
counterpressure applied by either the intact bag of
membranes or the presenting part, or both.
• A well flexed fetal head closely applied to the cervix favours
efficient dilation. Pressure applied evenly to the cervix causes
the uterine fundus to respond by contraction & retraction.
 viii) SHOW
• Throughout pregnancy the cervical canal is sealed by a
plug of mucus known as an operculum. Together with
the intact membranes this prevents organisms ascending
into the uterine cavity.
• When labour starts, the internal Os is pulled away from
the fetal membranes and the canal is opened up. This
releases the mucous plug which oozes out of the vagina
mixed with a little blood. This is called the 'show'.
 FURTHER DESCRIPTION OF TERMS
Contraction:-The uterine muscles contract repeatedly,
becoming progressively shorter and thicker.
Retraction:-A unique property of uterine muscle fibre
• it means the contraction does not pass over entirely;
• the muscle fibre does not return to its original length;
• it retains some of the contraction, thus becoming
progressively shorter and thicker
• this progressively reduces the capacity of the uterine cavity
• NB: The muscle fibre of the upper segment mainly contracts
and retracts-relaxes slightly
• Relaxation:-relaxation of the muscle fibres of the lower
segment results in progressive thinning and lengthening of
this segment and subsequent dilation of the cervical os
• When these processes are normal, the result is good
outcome of labour in that:-
– Contraction and retraction provide sufficient force to
expel the foetus without overtiring the uterus
– Relaxation-Ensures an adequate oxygen supply to the
foetus since during a contraction the blood supply is
diminished as the placenta is squeezed
 3. MECHANICAL FACTORS
a) FORMATION OF THE FOREWATERS:
• As the lower uterine segment forms & stretches, the chorion
becomes detached from it & the increased intrauterine pressure
causes this loosened part of the sac of fluid to bulge downwards into
the internal os to the depth of 6-12 mm.
• The well flexed head fits snugly into the cervix & cuts off the fluid in
front of the head (forewaters) from that which surrounds the
body(hindwaters)
• The effect of separation of the forewaters prevents the pressure that
is applied to the hindwaters during uterine contractions from being
applied to the forewaters. This may help keep the membranes intact
during the 1st stage of labour and be a natural defence against
ascending infections.
b) GENERAL FLUID PRESSURE
• While the membranes remain intact, the pressure of the
uterine contractions is exerted on the fluid & as fluid is not
compressible, the pressure is equalized throughout the uterus
& over the foetal body. This is known as general fluid pressure
• When the membranes rupture & a quantity of fluid emerges,
the placenta, fetal head, and umbilical cord are compressed
between the uterine wall & the foetus during contractions &
the oxygen supply to the foetus is thereby diminished.
Preserving the integrity of the membranes, therefore,
optimizes the oxygen supply to the foetus & helps prevent
intrauterine fetal infection especially in longer labours.
c) RUPTURE OF THE MEMBRANES

• The optimum physiological time for the membranes to

rupture spontaneously is towards the end of the first stage
of labour after the cervix becomes fully dilated & no longer
supports the bag of forewaters. The uterine contractions are
also applying increasing expulsive force at the time.
• Occasionally, the membranes do not rupture even in the
second stage & appear at the vulva as a bulging sac covering
the foetal head as it is born. This is known as the ‘caul’
d) FOETAL AXIS PRESSURE
• During each contraction, the uterus rises forward & the
force of the fundal contraction is transmitted to the
upper pole of the foetus, down the long axis of the
foetus & applied by the presenting part to the cervix.
This is known as ‘foetal axis pressure’ & becomes more
significant after rupture of the membranes & during
second stage of labour
Fetal axis pressure
 CHANGES DURING 1 STAGE OF ST

LABOUR
CARDIOVASCULAR CHANGES
 During each contraction, about 400ml of blood is emptied
from the uterus into the maternal vascular system. This
increases cardiac output by 10-15% during first stage of labour
& 30-40% during second stage of labour
 BP rises & pulse rate increases. Bp should be assessed
between contractions
 The BP increases even more in 2nd stage and therefore there’s
need for vigilant observation
 RESPIRATORY CHANGES
 There is increased respiratory rate due to increased physical activity &
increased oxygen consumption
 Patient experiences mild hyperventilation & decrease in carbon
dioxide tension
GASTROINTESTINAL SYSTEM
 Gastric motility & absorption of solid foods are reduced.
 Gastric emptying time is prolonged & gastric volume remains over
25ml regardless of the time the last meal was taken
 The acidity of gastric contents increases.
 Nausea & belching usually occurs as a reflex response to full cervical
dilatation
INITIAL MEETING WITH THE MIDWIFE
& CARE IN LABOUR

 BETTER BIRTH INITIATIVES(BBI)

 BBI is a focused set of standards that aim to improve the
quality & the humanity of obstetric care. The standards are
based on the best available evidence & can be implemented
using existing resources
 PRINCIPLES OF BBI
 Humanity-treat women with respect
 Benefit-care that is based on the best available evidence
 Commitment-health professionals are committed to
improving care
 Action-effective strategies to change current practice
 SPECIFIC MANAGEMENT OF 1ST STAGE OF
LABOUR
INTRODUCTION
 The aim of management is to prevent/ detect complications as
early as possible so that the necessary interventions are put into
place to deliver a healthy neonate and end up with a healthy
mother.
 The proper management of labour is essential, if you are to
avoid problems or to detect them early when they occur. The
patient will come to you believing she is in labour. You should
be able to assess and decide whether she is in labour or not. The
patient may be in early labour, but often she might arrive in the
late second or even third stage.
 Ifyou are sure she is not in labour send her home to wait.
If she is in labour, keep her in the ward and continue
monitoring her progress.
Note: No labour should be assumed normal until the
fourth stage has successfully concluded
 ADMISSION
 Activities to be carried out on admission;
 History Taking
 A detailed personal history should have been taken during
pre-natal care. However, if this has not been done, this is
a good time to get it recorded. Make sure the names are
correctly spelled because this can eventually result in
problems when registering the baby.
Review the last date of menstruation to calculate the
expected date of delivery.
Check her age, parity and contraceptive history.
Assuming that a detailed personal history had been
taken during pre-natal care, you should now take
information about the following:
Any presence of show
Presence or absence of contractions
Onset of contractions and their characteristics
Activity of the foetus
Rupture of the membranes
Any treatment given
Food taken in the last four hours
 HEAD TO TOE PHYSICAL EXAMINATION
 Start by explaining to the mother that you want to
examine her. The health care provider should appreciate
the psychological aspect of a woman in labour, respect her
feelings and the need for company or privacy. They
should support the woman and her partner or family
during labour, birth and the immediate postpartum period
 How to Examine the Mother Systematically
When examining her, check on her general condition.
Check if she is exhausted, anaemic, in great pain,
dehydrated, or with generalized oedema. You should
also check her height. This will enable you to exclude
any risk factors.
You should also take her vital measurements including
her blood pressure, pulse, temperature, and respiratory
rate
Conduct an abdominal examination checking for:
 Height of fundus
 Over-distension of the abdomen, scars or other
abnormality
 Over-distension of bladder
 Possible presence of twins or multiple pregnancy
 Contractions - frequency, length, type and strength
 Lie of foetus - this is the relation of the long axis of the
foetus to the long axis of the uterus (it can be longitudinal,
oblique or transverse)
 Rate and rhythm of the foetal heart
VAGINAL EXAMINATION IN LABOUR
 Thisis an important examination as it can give you a lot of
information, which you might not get from an abdominal
examination. On the other hand, if you do it often it is
uncomfortable for the woman and you might introduce an
infection into the uterine cavity, especially if the membranes
have ruptured.
Note: Do not do a vaginal examination if the mother has an
ante-partumhaemorrhage, because if there is placenta
praevia, severe haemorrhage will occur
 INDICATIONS FOR A VE
These are to;
 Make a positive identification of presentation
 Determine whether head is engaged incase of doubt
 Ascertain whether the forewaters have ruptured or to
rupture them artificially
 Exclude cord prolapse after rupture of the forewaters
especially if there is an ill-fitting presenting part or the foetal
heart rate changes
Assess progress or delay in labour
Confirm full cervical dilatation
Confirm the axis of the foetus & presentation of
the second twin in multiple pregnancy
 METHOD/PROCEDURE OF PERFORMING A
VAGINAL EXAM
VE during labour is an aseptic procedure
Explain procedure to the patient & give her an
opportunity to ask questions.
Observe patient’s privacy & avoid unnecessary
exposure by screening the bed & closing the nearby
windows
Ensure that her bladder is empty
Bring the trolley and dirty bin near
 Perform abdominal palpation to assess the fundal height,
lie, position & FHR
 Scrub your hands for at least five minutes & Glove
yourself methodically to prevent contamination.
 Explain the semi-lithotomy position that should be
maintained during the examination to the mother.
 Check vaginal loss for its type and colour
 Swab the vulva with antiseptic lotion with the left hand
 Lubricate the 1st and 2nd fingers of the gloved hand with
hibitane obstetric cream
 Inspect the vulva and perineum for warts, varicose veins or scars
 With the right hand, gently insert the lubricated fingers
obliquely inside the vagina with the thumb, facing the symphysis
pubis and note the condition of the following:
 Vagina- check for texture and temperature
 Cervix- check for position, length, texture and dilatation
 Membranes- check whether intact or ruptured
 Forewaters- whether formed, forming, already formed and shape
 Check for level of presenting part
 Confirm position, degree of moulding and caput succedaneum

NB: Your left hand should be on the mother’s abdomen during

the procedure.
The fingers to be introduced are held on a higher
level than the vaginal orifice during insertion to avoid
contact with the anus. Fingers should not be
withdrawn until the required information has been
obtained.
The fingers are directed along the anterior wall of the
vagina. The wall should feel soft and dilatable while
the vagina should be warm and moist.
The fingers are then directed upwards to the position
of the cervical Os.
 At times the Os is not felt readily, the fingers should then
be directed backwards and upwards
 Depending on the level of the presenting part, reach the
promontory of the sacrum
 Check the ischial spines: whether prominent or blunt
 Check the pubic arch: whether it can accommodate two
fingers (90˚)
 Withdraw the fingers slowly and note the discharge on
them
Assess the intertuberous diameter by fitting four
knuckles of the closed fist of the gloved hand
Clean and dry the mother and leave her comfortable
Check the foetal heart rate
Communicate the findings to the mother
Unscreen the bed, open the windows, remove the
trolley and dirty bin for clearance.
 IN SUMMARY, THE FOLLOWING ARE THE
FINDINGS OF A VE WHICH SHOULD BE
DOCUMENTED:
 Observe the labia for any sign of varicosities, oedema or
vulval warts or sores
 Note whether perineum is scarred from a previous tear or
episiotomy
 Note any discharge or bleeding from the vaginal orifice
 If membranes have ruptured, colour & oduor of any
amniotic fluid or discharge are noted
THE CERVIX
Is it bruised or oedematous?
Is it firm or soft?
Is it taken up, that is effaced?
How much is the Os dilated?
THE MEMBRANES
After deciding the state of the cervical Os, check
for presence of membranes. Note the following:
Are they ruptured or intact?
If intact are they bulging?
THE CORD
Is it presenting or prolapsed?
If prolapsed is it pulsating?
THE PRESENTING PART
Next, determine the level of the presenting part. The
station or level of the presenting part is the level to
which the presenting part has descended in the pelvis.
The level of the presenting part is expressed in
relation to the easily palpable ischial spines. state if it
is above the brim, at the brim, in the cavity or at the
outlet
POSITION
 Observe the position of the presenting part.
This is the position of the foetal parts in relation to the
parts of the pelvis. A point on the foetus, such as  the
occiput in a vertex presentation, is usually  used as
a reference point.
 To get the position right, you have to palpate the sutures
and fontanel to determine their position relative to the
pelvis.
In a cephalic presentation, you will feel the hard
head sutures and fontanel. Determine whether it is
the anterior or posterior fontanel by its shape. If it is
the posterior fontanel, then the position is
occipito-anterior. If it is the anterior fontanel
then the position is occipital-posterior
Illustration of baby in mothers womb showing
normal presentation
 MOULDING
 Check for moulding or caput succedaneum
 Moulding is when the diameters of the foetal skull are reduced
in size. During labour the bones of the foetal skull tend to
overlap at the sutures so that the head can easily pass through
the birth canal
 Moulding is judged by feeling the amount of overlapping of
the skull bones. The parietal bone overrides the occipital bone
& the anterior parietal bone overrides the posterior
During a vaginal examination this is how you should check for
moulding:
 In cephalic presentation, run the finger on the head feeling for
the sutures
 Judge the degree of moulding by feeling the amount of
overlapping of skull bones & determine whether the skull
bones are:-
Not overlapping/ not touching each other = o
Just touching each other = +
Slightly overlapping = ++
Severely overlapping = +++
 Check for caput succedaneum
 THE VAGINAL DISCHARGE
Withdraw the fingers and check if there is:
Any vaginal discharge
Any smell
Any liquor or meconium staining
Any bleeding
The following steps should further be taken as part of your
investigation:
 Take a urine sample for albumin and sugar
 Check for acetone, especially if the patient is in prolonged
labour
 Take blood for haemoglobin and cross matching if the
patient is anaemic or might need an operation
 By this time you will have gathered enough information as
to the stage of labour and whether the patient belongs to
the ‘at risk’ category and needs referral or not.
 CLEANLINESS AND COMFORT
Bowel preparation
If there has been no recent bowel
action( depending on the woman’s normal
bowel habits), or the rectum feels loaded on
vaginal examination, the woman should be
consulted and asked if she would like an
enema or supporsitories. This is never done
as a routine procedure
 EMTCT DURING LABOUR
ELIMINATION of mother to child transmission of HIV during
labour and delivery
Goals of interventions: these are to:
 Identify HIV-positive women
 Provide adequate EMTCT coverage
 Continuity of care of prophylactic and treatment
antiretroviral regimens
 Reduce maternal nevirapine resistance
 Initiate neonates born to HIV-positive mothers with
antiretroviral prophylaxis immediately at birth
 MEASURES TO BE TAKEN TO PREVENT HIV
TRANSMISSION DURING LABOUR:
 Use universal precautions for all patients. These include:
Protective gear
Safe use and disposal of sharps
Sterilization of equipment
Safe disposal of contaminated materials
 Minimize vaginal examination by performing them only when
necessary and recording all vaginal examinations performed
 Use of the partograph: Proper and consistent use of the
partograph in the monitoring progress of labour will
improve the management and reduce the risk of prolonged
labour in all women.
 Avoid artificial rupture of membranes unless necessary
 Avoid unnecessary trauma during delivery.
Avoid invasive procedures, such as using scalp
electrodes or scalp sampling
Avoid routine episiotomy
Minimize the use of forceps or vacuum extractors
 Minimize risk of postpartum haemorrhage through:
 Active management of the third stage of labour
 Carefully remove all products of conception
 Carefully repair genital tract lacerations and tears
 Use safe blood transfusion practices
Minimize use of blood transfusions
Use only blood screened for HIV , Syphilis, malaria ,hepatitis
B and C
 Elective C/S. Caesarean section performed before the onset of
labour or membrane rupture has been associated with
reduced MTCT of HIV.
HIV TESTING DURING LABOUR
 A woman of unknown HIV status at labour should be
offered HIV testing and counseling.
 ARV prophylaxis, when initiated during labour for the
woman and just after birth for the infant, can reduce
MTCT by as much as 50%
 PERINEAL SHAVE
 Not a routine procedure as research has shown that perineal
shaving is unnecessary and does not improve infection rates
Bath or shower
 For women in normal labour, a warm bath( or birthing pool)
can be an effective form of pain relief that allows increased
mobility with no increased incidence of adverse outcome for
the mother or baby
Clothing
 The woman should be given a clean, loose gown to wear or
one that she feels comfortable in immediately upon
admission
 RECORDS
 The
midwife’s record of labour is a legal document and must
be kept meticulously/accurately. The records may be
examined by any court for up to 25 years, they may go b4
the nursing council professional conduct or health
committee and may be examined
Half hourly- maternal pulse, contractions for length,
strength and frequency, FHR
Every 1 1/2 - 2 hours check bladder
Every 4 hours – B/P. Temperature, abdominal
examination for descent, V.E, urine test acetone,
albumin
THE PARTOGRAPH
THE PARTOGRAPH
 PARTOGRAPH SYMBOLS
FETAL HEART

LIQUOR I = Intact

C = clear
M= meconium stained

B= blood stained

MOLDING O= Bones are separated & sutures can be felt easily

+= Bones are just touching each other.

++= Bones are overlapping but can be separated easily with pressure from
your fingers.

+++ = Bones are severely overlapping but cannot be separated easily with
pressure from your fingers

118
 Partograph symbols ct’
Dilatation X

Descent O  

......
Dots = mild contractions
......
< 20 seconds
......
Diagonal Lines = Moderate
Contractions
contractions 20 - 40 seconds
Completely filled in = strong
contractions > 40 seconds

BP
119
 PARTOGRAPH
Definition of partograph
 A tool developed by the World Health Organization (WHO) to
monitor, document and manage labour. It gives a complete
picture of maternal and fetal well-being and labour progress at a
glance & provides guidelines on when labour is no longer
normal.
 The partograph is a graphic presentation of the progress of
labour, which outlines the progress of a woman in active labour
including the foetal and maternal condition.
The partograph serves as an ‘early warning system’
& assists in early decision on transfer,
augmentation & termination of labour.
It also increases the quality & regularity of all
observations on the fetus and the mother in labour
and aids in early recognition of problems with
either.
 OBJECTIVES OF PARTOGRAPHING
These are to:
 Detect abnormal progress of labour as early as possible so that
appropriate intervention(s) are taken e.g. emergency caesarean section
 Monitor & prevent prolonged labour thru’ accurate charting and
interpreting the partograph
 Recognize cephalopelvic disproportion long before obstructed labour

 Assist in early decision on transfer, augmentation or termination of the

labour process
 Increase the quality and regularity of all observations of mother and
foetus
 Recognize maternal or foetal related health problems as early as
possible
NOTE:- The partograph, if correctly and can
highly effective in reducing the complications
related to prolonged labour for the mother
( PPH, puerperal sepsis, uterine rupture and
its sequelae) and for the newborn ( neonatal
infections e.t.c.)
CONDITIONS FOR STARTING A PARTOGRAPH
 A Partograph chart must only be started when a woman is in
active phase of labour (from 4 cms)
Points to remember
 The partograph is only started when the mother is in the active
phase of the first stage of labour, i.e. cervical dilatation of 4cm &
above
 The latent phase is from 0-4cm dilatation & is accompanied by
gradual shortening of cervix. It should normally not last longer
than 8 hrs.
 The active phase is from 4-10cms & dilatation should be at the
rate of at least 1cm/hr in a primigravida.
 When labour progresses well, the dilatation should not
move to the right of the alert line.
 When admission to hospital takes place in the active
phase, the cervical dilatation is immediately plotted in the
alert line
 When labour goes from latent to active phase plotting of
the dilatation is immediately transferred from the latent
phase to the alert line.
Plottingthe partograph helps alert the provider
to problems and needed action in time for a
prompt life-saving intervention to occur.
 OBSERVATIONS CHARTED ON THE
PARTOGRAPH
a) The progress of labour
- Cervical dilatation
- Descent of fetal head
 Descent: abdominal palpation of fifths of head felt above the pelvic brim

 Uterine contraction

- Frequency per 10 min

- Duration /shown by different shading
b) The fetal condition
- Fetal heart rate & rhythm
- Membranes & liquor (whether ruptured or intact)
- Moulding of the fetal skull
c) The maternal condition
- Pulse, B/P temperature
- Drug and IV fluids given
- Urine /volume, protein, acetone/
- Oxytocin regimen

*** EXERCISE ON PARTOGRAPHING

SPECIFIC MANAGEMENT OF FIRST STAGE OF
LABOUR CNTD’
 Admit the patient to the waiting room, reassure her and
introduce her to other patients
 Reassure her and explain what is being done at every stage
 Give her an enema only if she is in early labour (this will
reduce the risk of faecal soiling and infection at delivery)
 The patient may have a warm bath and change into a clean
hospital gown
COMMUNICATION
 The culmination of pregnancy is an event with great
psychological, social & emotional meaning for the
mother and her family. The woman may experience
stress and physical pain.
 The MW should display tact and sensitivity, respect
the needs of the individual and provide an
environment within which each woman will deliver
with dignity
 ENVIRONMENT
It is important that the woman is welcomed and made to
feel at ease and that the mw spends time actively
listening as the woman recounts the details of the onset
of labour
She should be nursed in a clean environment
EMOTIONAL SUPPORT
 The MW has a traditional role to fulfil. i.e. being
‘with woman’ by monitoring the progress of labour
and assessing the physical state of mother and foetus
 Emotional support is provided by imparting
confidence, expressing caring, dependability and
being an advocate for the child bearing woman
COMPANIONSHIP IN LABOUR
 Research has shown that continous one to one support of
a woman during labour creates a strong feeling of
security & satisfaction & is associated with a reduction
in the length of labour, fewer perinatal complications
and a reduced incidence of oxytocin augmentation
 Admission to hospital is always a traumatic experience
& the company of a supportive companion can help
reduce the anxiety. Sometimes, the mw may double as
the companion since not all women are glad to have a
husband or companion present
MANAGEMENT OF FIRST STAGE OF LABOUR
CTND…
 Encourage her to walk about and empty her bladder
frequently
 Encourage the woman to take fluid diet soup, fruit
juice, salt lemon juice or plain water
 Do not allow any solid foods as the stomach takes a
long time to empty in labour
Check the following regularly:
 Check the foetal heart rate half hourly or more often if you
suspect foetal distress
 Check uterine contractions ½ hourly (strength, type, frequency
and duration) as well as maternal pulse.
 Four hourly, BP and temperature.
 Check the urine output and check for albumin and acetone.
 Every four hours check the level of the presenting part
and the degree of dilatation of the cervix
 Constantly check the woman's reaction to labour and be
aware of her needs, especially for pain relief.
 You can repeat pethidine 50 mg IM if cervical dilatation is
still 5 cm or less. Do not give more pethidine if delivery is
imminent as it depresses the baby's respiration
 Towards the end of the first stage, she can rest on her side,
or in any position she finds comfortable, for example,
squatting
 Discourage early pushing or bearing down before the cervix
is fully dilated. Early pushing only exhausts the woman and
will cause oedema of the cervix and interfere with normal
cervical dilatation
 If the bladder is full and she cannot empty it on her own,
catheterize her using aseptic technique
 When the membranes rupture, usually at the end of the
first stage, check the colour of the liquor for meconium
staining, the foetal heart rate and do a vaginal
examination to exclude prolapse of the foetal umbilical
cord
 The descent of the presenting part can be noted by abdominal
palpation or vaginal examination
 After conducting a thorough examination of the mother and
recording your observations in the partogram, there are a
number of things you can do to make her feel comfortable
during her labour i.e.. allow her to change position and move
around, use back massage, have a chosen companion with her
during labour, allow her to take fluids as required and return
the placenta to parents if so desired and directed by the
culture.
 However do not forget to check on the foetus especially if you
suspect foetal distress.
Control of pain may be achieved by:
Change of position/ moving around,
Touch and back massage from a companion or the MW
Breathing techniques e.g. breathing in/out through an
open mouth
Verbal coaching and relaxation to help draw her attention
away from labour pain (diversional mthds of pain mgt)
 Warm bath or shower
 Use of pharmacological agents e.g. tramadol 100mg IM or
slow IV 6-8 hourly, pethidine 50-100 mg IM or IV slowly 6-
8 hourly, inhalational nitrous oxide combined with 50%
oxygen (Entonox) or epidural analgesia where available,
however, exercise much caution when using
pharmacological agents for pain relief in labour becoz of
the risk of foetal distress
Examples of Positions during Labour
 Note!
* Discourage supine position!
The supine position causes compression of the client’s aorta and
inferior vena cava by the fetus. This, in turn, inhibits maternal
circulation, leading to maternal hypotension and, ultimately, fetal
hypoxia
The other positions promote comfort and aid labor progress. For
instance, the lateral, or side-lying, position improves maternal and fetal
circulation, enhances comfort, increases maternal relaxation, reduces
muscle tension, and eliminates pressure points.
The squatting position promotes comfort by taking advantage of gravity.
The standing position also takes advantage of gravity and aligns the
fetus with the pelvic angle.
 Role of the midwife in caring for a woman in 1 st
stage of labour.
Admitting client to birthing area after determining that client is in labor
Determining if client's membranes have ruptured
Encouraging family participation as appropriate with the labor process
Performing Leopold maneuver and vaginal exams as appropriate
Monitoring maternal vital signs and fetal heart rate and patterns,
reporting any deviations or abnormalities
Applying electronic fetal monitor as appropriate
Assessing pain level, instituting positioning, breathing, relaxation, and
other methods for pain control; administering analgesics as ordered
Role of the midwife in caring for a woman in 1st stage
of labour ct’
Encouraging voiding at least every 2 hours
Assisting with amniotomy with assessment of fetal heart rate, fetal
positioning, and fetal cord after amniotomy
Cleansing perineum and assisting with pad changes regularly
Monitoring progress including vaginal discharge, cervical dilation and
effacement, position, and fetal descent
Performing vaginal examinations as necessary
Preparing supplies and equipment for delivery
Verifying maternal and fetal heart rate response to uterine contractions
during intrapartal care
 ARTIFICIAL
ARTIFICIALRUPTURE
RUPTUREOF
OFTHE
THE
MEMBRANES
MEMBRANES
Also referred to as amniotomy & is abbreviated as ARM
(acronym)
DEFINITION
It is a procedure aimed at tearing the fetal membranes
resulting in drainage of liquor amnii
NOTE: the procedure is contraindicated in all HIV positive
clients becoz of the risk of increased transmission of the
virus to the fetus
 INDICATIONS OF AMNIOTOMY:
To induce labour. Only recommended after ensuring that the
cervix is ready for labour but contractions fail to start
spontaneously as in a case of prolonged pregnancy
To augment (accelerate) labour. Contractions are weak in the
active phase. Engagement must have occurred
Presence of caul. Failure for spontaneous rupture of membranes to
occur in early 2nd stage
To visualize the colour of liquor especially if fetal compromise is
suspected
To allow application of fetal scalp electrode hence continuous fetal
heart rate monitoring
 PREPARATION
MOTHER (CLIENT)
Explain the procedure briefly & obtain an informed verbal consent
Instruct her to empty her urinary bladder and remove inner wear if
not in labour
Instruct her to lie on the couch in lateral position
EQUIPMENT
This is a sterile procedure
Have a sterile vaginal examination pack
Add a sterile pair of an amniohook/ amniotic hook
A sanitary towel
ENVIRONMENT
For any sterile exam
SELF (MIDWIFE)
Initially, handwashing, later surgical hand scrubbing and wear
gloves correctly
PROCEDURE
While the client is in supine position, perform an abdominal
examination to assess specifically;-
Presentation & engagement- whether it has occurred. If not
don’t do ARM
Auscultate the fetal heart sounds
Thereafter perform a VE & assess the following:
 State of the cervix & its application to the presenting
part
The presentation and descent
Establish the state of membranes & shape of the
forewaters
Assess for cord presentation, if present, abandon the
procedure
If all factors are favourable, pick the amniohook with the
left hand and insert it into the vagina while still closed
Open it near the membranes & guide the hook with the 2
fingers in the vagina to pierce the membranes
Observe some fluid come out- note the coluor
Confirm the presentation, position and application of
the presenting part to the cervix. If poor, ask the
mother to bear down (push) during a contraction in
order to improve it hence prevent the hindwaters from
running out quickly
Make her comfortable
Instruct her to wear a sanitary towel & change as soon
as it gets soiled
Record the findings in terms of:-
1. Indication for ARM
2. Time and date carried out
3. State of liquor
4. State of cervix, dilatation, its application
5. Presentation, position and descent
6. Fetal heart sounds after the procedure
 COMPLICATIONS OF ARM
1. Cord prolapse. Due to undiagnosed malpresentation or if
the head had not yet fully engaged
2. Intrapartum haemorrhage. Premature separation of the
placenta, following fast drainage of hindwaters
3. Fetal hypoxia. Due to severe compression of the placenta
during each contraction
4. Intra-uterine infection. From digital or contaminated
instruments due to failure to strictly observe aseptic
technique
 ASSIGNMENT:
 Read& make notes on pain management in labour
 REFERENCE:
MYLES TEXTBOOK FOR MIDWIVES, AFRICAN
EDITION PG.485-500
COMPLICATIONS OF 1ST STAGE OF LABOUR
1. Prolonged labour
2. Obstructed labour
3. Fatal hypoxia/ distress
4. Maternal distress
5. Cord presentation/ prolapse
6. Uterine rupture
7. Sudden intra-uterine fetal death
8. Intrapartum haemorrhage
9. Pre-eclampsia/ eclampsia

END
THE 2 STAGE OF
ND

NORMAL LABOUR
 THE TRANSITION & SECOND STAGE OF
LABOUR
DEFINITION OF 2ND STAGE
• This is the stage that begins with full dilatation of the cervix (10
cm) & ends with complete expulsion of the foetus.
• It is the stage of descent and expulsion of the baby.
• The contractions become stronger, lasting 40 to 60 seconds,
with a one minute recovery interval.
DURATION OF 2ND STAGE
• It normally lasts from 1 to 2 hours on average in primigravida,
and half an hour in multipara (but can be as litle as 5 minutes).
If this stage goes beyond two hours, it is considered abnormal.
 DEFINITION OF THE TRANSITION PERIOD
• The period between full cervical dilatation and the time
when active maternal pushing efforts begin
• It is considered as part of the last phase of the active 1st stage
of labour & marks the shift to the 2nd stage of labour.
• It’s characterized by maternal restlessness, discomfort, desire
for pain relief, a sense that the process is never ending and
demand to the attendants to end the whole process hence
regarded as the most intense part of active labour
• This period lasts for 30 minutes- 1.5 hrs.
 PHYSIOLOGY OF SECOND STAGE
OBJECTIVES OF LEARNING
1. To be ready to conduct the delivery on time
2. To conserve maternal energy which is only needed during the
perineal phase
3. To prevent occurrence of intracranial injury thru’ accurate
timing of 2nd stage + early intervention thru’ proper control of
the head during delivery
4. Prevent/ minimize the soft tissue trauma
 SPECIFIC CHANGES
1. CONTRACTIONS: strengthen, become more frequent and expulsive
in nature. Strengthening results after the membranes rupture becoz;-
– Fetal head is directly applied to the vaginal tissues
– The uterus is closely applied to the fetus (uterus moulds around
the fetus)
• Finally the contractions intensify i.e. strengthen & become more
frequent (lasting between 40- 60 seconds)
• Expulsive nature occurs as descent continues, whereby pressure from
the presenting part stimulates nerve receptors in the pelvic floor
leading to ferguson reflex
• The mother then experiences a great urge to bear down
• Initially, the reflex is controllable to some extent but later
becomes compulsive (irresistible) during each contraction
2. Abdominal muscles and diaphragm become active:
• Are also referred to as secondary powers/ maternal efforts
• This is in response to the compulsive and expulsive uterine
actions which come into action on order to reinforce the
contractions which are already in place
• Finally, the pelvic outlet and floor resistance is overcomed
3. Displacement of the pelvic floor
Also referred to as soft tissue displacement. Occurs as follows as the
fetal head continues to descend:-
• Anteriorly; the urinary bladder is pushed upwards into the abdomen
to prevent its injury, while the urethra is stretched & thinned out,
reducing its lumen. This makes catheterization difficult
• Posteriorly; the rectum is compressed alongside the sacral curve.
Pressure of the advancing head leads to expulsion of the residual
fecal matter
• Laterally; levator ani muscles are pushed sideways as they dilate and
thin out. The perineal body is flattened, stretched and thinned to
allow maximum opening of the vagina and the fetal head becomes
visible
4. Expulsion of the fetus
• The fetal head advances gradually as contractions continue,
receeds between contractions until crowning occurs.
• Finally the head is born, followed by the shoulders and the
body. The hind fluid drains out and second stage is
completed
 PRESUMPTIVE SIGNS OF 2ND STAGE OF
LABOUR
 Expulsive uterine contractions-the woman feels the urge to
bear down as the contractions are expulsive in character
 Trickle of blood through the vagina- from slight laceration of
the cervix when fully dilated, laceration from vaginal mucosa
caused by the advancing head
 Anus dilatation/ gaping-due to pressure exerted by the head
as it reaches the pelvic floor\woman feels the urge to open
bowels as the head exerts pressure on the rectum
• Appearance of anal cleft line: also called the ‘purple line’
appears as a pigmented mark in the cleft of the buttocks
which creeps up the anal cleft as the labour progresses
• Appearance of the rhomboid of michaelis: this is sometimes
noted when a women is in position where her back is visible.
Appears as dome shaped curve in the lower back, & is held
to indicate the posterior displacement of the sacrum &
coccyx as the fetal occiput moves into the maternal sacral
curve
• Gaping of vulva-more pronounced in primigravida than
in a multigravida because it is distended by the
presenting part.
• Visible presenting part-visible at the vagina. It is almost
a positive sign except in excessive moulding and in
breech presentation
• Bulging of the perineum- a sign that delivery is
imminent/ about to occur
 CONFIRMATORY EVIDENCE OF THE 2ND STAGE OF
LABOUR
Full cervical dilatation on vaginal examination.
Therefore, vaginal examination must always be
performed as a confirmatory evidence of onset of 2nd
stage.
 PHASES OF THE SECOND STAGE OF LABOUR
• Two distinct phases:
The latent/ Passive phase
The active/perineal phase
1. The latent phase: the phase in which descent and rotation of
the fetal head occurs.
• In some women, the cervix may be fully dilated but the
presenting part may not have fully descended & there4
pushing at this phase does not yield much, apart from
exhausting & discouraging the mother
2. The active phase
• Also known as perineal phase or imminent 2nd stage
• Delivery is expected to occur in the next 5-15 minutes.
• is characterized by a compulsive urge to push once the head is fully
visible
• Specific features of the perineal phase are:
Contractions are expulsive and compulsive
Secondary powers become active i.e. mother pushes with each
contraction
Perineum bulges excessively becoz the presenting part is directly
applied on the pelvic floor
Excessive gaping of the anus, vagina and vulva due to severe pressure
on the pelvic floor
Presenting part is visible at the vulva
 Positions for the 2nd stage of labour
• The second stage begins when the cervix is fully dilated,
the baby has moved deep into the pelvis, and the mother
is ready to push.
• During the tiring second stage of labor, effectiveness of
pushing can be aided with body positions such as
kneeling, upright squatting, and being on all fours.
Kneeling
On all fours
Squatting
 MECHANISM OF THE SECOND STAGE OF
MECHANISM OF THE SECOND STAGE OF
NORMAL
NORMALLABOUR
LABOUR
DEFINITION
• The mechanism of labour refers to a series of
movements the foetus has to make to pass
through the birth canal.
 COMMON PRINCIPLES
1. Descent takes place all through
2. Whichever part leads and 1st meets the resistance
of the pelvic floor will rotate forwards 1/8 of a
circle (45 degrees) until it comes under the
symphysis pubis
3. Whatever emerges from the pelvis will pivot
around the pubic bone
 Common principles ctd’
4. Whichever mechanism/movement that the head
makes will be the same movement that the
shoulders will follow
5. Internal rotation of the shoulders will always take
place at the same time with external rotation of the
head.
BASIC FACTORS
1) LIE
• Lie means the relation of the long axis of the foetus to
the long axis of the uterus. It may be longitudinal, oblique
or transverse
• In cephalic presentation, the lie is longitudinal
2) PRESENTATION
• The presenting part of the foetus is that part which is in
or over the pelvic brim. Its position is examined in
relation to the cervix. It could be vertex, face, or a
breech.
• The presentation is cephalic, and the presenting part is
usually the posterior part of the anterior parietal bone.
3) POSITION
• The position describes the relationship of a selected part of the
foetus to the maternal pelvis. For example, in a vertex
presentation the selected part is the occiput. With face
presentation it is the chin, and with a breech presentation, it is
the sacrum
• The position in normal labour is right occipito-anterior (ROA) or
LOA (left occipito-anterior)
4) ATTITUDE
• The pelvis is a curved passage with different diameters at the
inlet, mid-cavity and outlet . The foetus, therefore, has to adapt
itself to the shape, size, and curve of the pelvis at different
levels as it descends. Therefore, ATTITUDE IS ONE OF
COMPLETE FLEXION
• To be able to manage labour skillfully, you need to
understand the natural movements made by the baby so
that, when assisting in delivery, you can follow the
movements rather than oppose them.
• The factors, which influence the mechanism of labour,
are known as the three 'Ps': power, passage, and
passenger.
5) DENOMINATOR
• Refers to the part of presentation that indicates the
position. Or
• Part of presentation, used when referring to a fetal
position.
**E.g , In vertex presentation, denominator is the occiput.
• In normal labour ( cephalic presentation), denominator is the
occiput
 POWER
• The stronger the contraction in a well prepared
mother, the better the outcome of labour.
 PASSAGE
• The size, shape and resistance of the birth canal
including the bony pelvis, cervix, vagina and pelvic
floor may speed up or slow down the process of
delivery. A gynaecoid pelvis and a fully dilated
cervix speed up the process.
 PASSENGER
• This refers to the size, lie and presentation of the foetus,
as well as the placenta and membranes. For the foetus, a
vertex presentation makes labour shorter as the
presenting part fits well on the cervical Os and stimulates
the cervix to dilate faster
• It is important to remember that descent occurs
throughout.
• In order to present with the smallest diameter, the head
must be well flexed on the neck with the chin touching the
chest. As the leading part meets resistance of the pelvic
floor, it rotates 1/8th forwards until it comes under the
symphysis pubis.
 Therefore,
• The lie is longitudinal
• Presentation is cephalic
• Position is right or left occipitoanterior
• Attitude is one of complete flexion
• The denominator is the occiput
• The presenting part is the posterior part of the anterior
parietal bone
The mechanism of labour in a cephalic vertex presentation
includes the following steps (MAIN MOVEMENTS OF THE
FOETUS):
• Descent and flexion
• Internal rotation of the head
• Birth by extension of the head
• Restitution of the head
• Internal rotation of the shoulders & External rotation of
the head
• Lateral flexion of the body
 ENGAGEMENT, DESCENT & FLEXION OF THE HEAD
• Engagement is the descent of the presenting diameter
through the pelvic brim. The head usually engages late in
pregnancy in the primigravida while in the multipara it does
not engage till labour starts.
• The head enters the pelvic brim in oblique diameter with
sub occipital frontal diameter (10cm)-The presenting
diameter in a cephalic presentation. With good uterine
contraction, there is more flexion of the head.
• The head engages with sub occipital bregmatic (9.5 cms)
oblique diameter of the pelvis brim.
 INTERNAL ROTATION OF THE HEAD
• The occiput rotates 1/8th of a circle anteriorly, to lie under
the symphysis pubis. Such a rotation is achieved by the
action of the uterine muscles pushing downwards.
• The pointed vertex presents on the broad levator ani muscle.
When the vertex reaches the perineum, the occiput turns
from the posterior to the anterior position.
• Anteriorly there is more room for further descent. When the
occiput is below the symphysis pubis, crowning takes place.
Internal rotation of the foetus
 BIRTH BY EXTENSION OF THE HEAD
Once the occiput has escaped from under the
symphysis pubis, the head extends forward. The
nape of the neck is pressed firmly against the pubic
arch.
This extension of the head causes the anterior part
to stretch the perineum gradually.
Further extension allows the sinciput, face and
chin to sweep the perineum and the head is born
by extension.
Extension is the result of action from two
forces. The abdominal and thoracic muscles
exert downward pressure. The pelvic floor and
perineum resist this pressure and push the head
forward and upward through the weak area,
which is the vagina.
Sinciput and face delivered
 RESTITUTION
• The head turns 1/8 of the circle, back to where it
was before internal rotation took place.
• This rotation takes place to undo the twist in the
neck of the fetus, which occurred during the
previous internal rotation of the head. This 'undoing
of the twist' is known as restitution.
 INTERNAL ROTATION OF THE SHOULDERS
• When the head is passing through the level of the ischial
spines and the outlet in anterior posterior position, the
shoulders enter in the oblique diameter of the pelvis.
• The anterior shoulder reaches the pelvic floor first & therefore
rotates anteriorly 1/8th of a circle to lie directly below the
symphysis pubis
• The shoulders are now in the anterior posterior diameter of
the outlet.
• The anterior shoulder escapes the symphysis pubis while the
posterior shoulder sweeps the perineum.
 EXTERNAL ROTATION OF THE HEAD

• As the internal rotation of the shoulders takes place, the

head, which has already been born, rotates externally 1/8
of a circle in the same direction as restitution. The
occiput of the fetal head now lies in the lateral position.
External rotation of the head
 LATERAL FLEXION OF THE BODY
• Following these movements the body bends sideways to
follow the curve of the birth canal.
The anterior shoulder escapes under the symphysis pubis
and the posterior shoulder sweeps the perineum. The body
of the baby is born by lateral flexion.
• To recap, the cardinal movements of labour in a vertex
presentation are:
– Engagement
– Descent and
– Flexion
– Internal rotation of the head
– Extension of the head
– restitution of the head
– Expulsion of the body
• An easy way to remember these movements is by use of
the mnemonic device -'Every Decent Family In Europe Eats
Eggs'.
SPECIFIC
SPECIFICMANAGEMENT
MANAGEMENTOF
OFTHE
THESECOND
SECOND
STAGE OF NORMAL LABOUR
STAGE OF NORMAL LABOUR
Equipment needed during the second stage of labour:
( see procedure manual pg241)
• On the top shelf make sure you have:
– Sterile delivery pack( list the contents of a
delivery pack from procedure manual)
• On the bottom shelf you should have the following:
– Suturing pack
– Antiseptic solution
– Draw sheet and mackintosh
– Syntocinon drawn, in a receiver
– Lignocaine
– 5% dextrose solution 500mls
– Needles
– Branulars
– Syringes (for emergency)
– Sterile gloves
 Extras
– Small bucket with 0.5% jik for decontaminating
instruments
– Bucket with 0.5% jik for
decontaminating linen
–  A bucket with plastic bag for used swabs and
gloves
The role of nurse in caring 4 the woman in the second stage of labour

• Notifying the delivery team

• Setting up trays for delivery
• Providing a warm environment for the newborn
• Checking for the working condition of the neonatal resuscitation
• Preparation of delivery room
• To assist in the natural expulsion of the fetus slowly and steadily.
• To prevent perineal injures.
• To assist labour under aseptic precautions
• Vigilant monitoring of maternal vital sign and fetal heart
rate.
• Encouraging spontaneous bearing-down efforts for second
stage
• Evaluating pushing efforts and length of time in second
stage
The following steps are suggested in the management of the second
stage of labour:
• Explain the procedure to the mother and reassure her
• Ask your assistant to open and arrange the delivery pack while you
scrub up
• Gown and glove yourself methodically 
• Swab the mother methodically
• Lubricate your two fingers and perform vaginal examination to confirm
second stage
• instruct your assistant to check the foetal heart beat after every
contraction, the mother's pulse after every ten minutes and to
administer syntocinon after the delivery of the baby
Flexing of the head and guarding
of the perineum
• Tell the patient to wait for a contraction. When it comes, she
should take in a full breath, close her mouth and bear down
as strongly as she can, then quickly take in another breath
and bear down again.
• She should be able to make at least two efforts during each
contraction and relax between contractions. Encourage her
all the time and explain the progress being made towards the
birth of her baby
• Place the baby towel on the bed, with the scissors and
two forceps for clamping the cord. Prepare two pieces of
cotton wool for wiping the newborn’s eyes, some gauze
for cleaning the airway and for a covering when cutting
the cord.
• At this stage the head might start distending the
perineum. The anus starts dilating and the head is seen at
the vulva. It keeps receding between contractions.
• When the head distends the perineum check if the
perineum is stretching well.
• Place the left hand on the advancing head with fingers
spread equally over the vertex towards the bregma to
stop any sudden explosive effort during and after
crowning of the head. With the right hand guard the
perineum, holding it with the pad.
• Check if the perineum is stretching. If not, give an
episiotomy at the height of a contraction if there is any
indication that the head is about to crown.
 Crowning of the Head
• Next is the crowning of the head. The parietal eminences
pass through the bony outlet. At this stage the head no
longer recedes between contractions
-During crowning of the head,
• Tell the mother to stop pushing as this might lead to a rapid
delivery of the head and consequent brain damage.
• Ask her to pant thru’ an open mouth.
• Research has shown that a series of short pushes are more
effective than a long push. Encourage her as she pushes
 Extension of the head
• Assist the extension by gently grasping the parietal
eminences with your left hand. Let the head come out
slowly and naturally.
• Feel for the cord around the baby's neck. If it is there, slip
it from the baby's neck over the head. If it is too tight,
place two artery forceps on the cord and cut it between
them.
• When the nose and mouth come out, wipe away the
mucus with a sterile swab. By this point the whole head
should be out.
• The head will have restituted and rotated
spontaneously to face the mother’s left or right
thigh. This shows you that the shoulders have
descended and rotated to the anterior posterior
diameter of the pelvic outlet.
 Delivering the Shoulders by Lateral Flexion of the
Body
The following procedure should be followed when
delivering the shoulders by lateral flexion of the body:
• Place one hand above and one below the foetal head
• Depress the head gently towards the anus/neck,
making sure it is neither twisted nor bent sideways till
the anterior shoulder is free under the syphysis pubis
• Remind your assistant to prepare to give syntocinon
10 I.U intramuscularly (in a single dose) after
delivery of the baby.
• Guide the head upwards in the direction of the
mother's abdomen to deliver the posterior shoulder
and the rest of the body.
The delivering of posterior shoulder
• The posterior shoulder will sweep the perineum smoothly
and be born & the rest of the body will be born by lateral
flexion.
• Ask your assistant for the time and note the time of birth & to
administer syntocinon (oxytocin) to the mother 10 I.U
intramuscularly.
NOTE: -Syntocinon injection is provided as a sterile solution for
intravenous or intramuscular administration & is indicated to
produce uterine contractions during the third stage of labor and
to control postpartum hemorrhage.
• Place the baby on the mother’s abdomen at a slight slant to
drain the mucous
• Put the baby on the baby towel, clamp and cut the cord
• NB:
1) It’s encouraged to practice delayed cord clamping (usually
2-4 minutes)unless under these circumstances:
– Where the mother is rhesus negative
– Where the mother is HIV positive
2) Delayed cord clamping enables the baby be born with a high
h.b, increases the iron stores in the newborn and lowers the
level of early childhood anaemia.
• Give the APGAR score to the baby a one minute.
• Show the baby to the mother & let her identify the sex of
the baby by saying loudly for the attendants in the labour
ward to hear and confirm.
• Ask your assistant to continue with the immediate care of the
neonate.
• Continue with the delivery of the placenta by using controlled
downward traction (CDT).
• Check the placenta for completeness and/or malformation.
• Measure/estimate the blood loss and intervene where necessary.
• Do the first/initial examination of the baby
• Weigh the baby
• Do a post natal examination on the mother and record all the
findings
• Give the mother a free hot drink and transfer her to the postnatal
ward
 EPISIOTOMY
EPISIOTOMY
Definition
This is an incision made through the perineal tissues
which is used to enlarge the vulval outlet during
delivery
This is a technique each midwife should master while
in the labour ward.
This competence is achieved through observing an
experienced midwife conducting the procedure. It is
an aseptic procedure
 INDICATIONS OF AN EPISIOTOMY
 Rigid perineum, mostly in primigravidae
 Poor maternal effort or maternal distress in perineal phase of
second stage
 Prolonged 2nd stage of labour with foetal head bulging the
perineum
 In case of foetal distress in second stage, to hasten delivery
 When the perineum threatens to tear, for example, in persistent
occipito posterior position
 Prior to assisted vaginal delivery such as in low forceps or vacuum
delivery
 Pre-eclamptic mother- in order to hasten the delivery
 In mothers who have medical conditions such as cardiac
disease or diabetes mellitus, where rapid delivery is
required
 In premature labour to minimize the risks of intracranial
injury to the baby since malpresentations are common in
preterm labour & the fetal head does not mould easily.
 In case the mother has had previous third degree tears
which had been repaired
 In malpresentations like breech delivery to prevent risks
of intracranial injury to the baby
 ADVANTAGES OF EPISIOTOMY
 Fetal acidosis and hypoxia are reduced since the delivery is
hastened.
 Over stretching of the pelvic floor is lessened due to timely
administration of the episiotomy
 Bruising of the urethra is avoided, hence prevents birth
complications e.g. VVF (Vesico-vaginal fistula).
 In severe pre – eclampsia or cardiac disease, episiotomy
reduces the effort of bearing down.
 A previous third degree tear which may occur again because
of the scar tissue which does not stretch well is prevented.
 TYPES OF EPISIOTOMY INCISIONS
1. Mediolateral Episiotomy
 This is the most commonly performed episiotomy due to its safety

record. However, it is difficult to repair.

 It begins at the centre of the fourchette, directed posteriorly and

laterally.
 The incision is not more than 3cm & is made at 45° to the midline.

Move towards a point midway between ischio-tuberosity and the anus.

This is to avoid damaging the anal sphincter and the Bartholin’s glands
Advantages
 Bartholin glands are not affected

 Anal sphincters are not injured

Mediolateral episiotomy
 2. Median Episiotomy
 This begins at the fourchette, is directed posteriorly for
approximately 2.5cms and stops just before the anal sphincter.
 It follows the insertion of perennial muscles and has minimal

bleeding due to few blood vessels in this area.

 It is easy to repair & less painful.

 However, there is the danger of the incision extending to the anal

sphincter
Advantages:
 It is associated with less bleeding

 More easily and successfully repaired

 Greater subsequent comfort for the women

Median episiotomy
 3. J Shaped Episiotomy
 Not commonly performed.
 The incision begins at the centre of the fourchette, is

directed posterior for about 2cm and then it is extended

latero-posteriorly to avoid damage to the anal sphincter.
 Suturing of this episiotomy is very difficult.

Disadvantages
 The suturing is difficult

 Shearing of the tissue occurs

 The repaired wound tends to be pucked

J shaped episiotomy
 4. Lateral episiotomy
 Not used now.
 Unlike in all the other types, the incision does not begin at the

centre of the fouchette but on the side of the vaginal opening.

 The incision may extend leading to a severe vaginal tear and

excessive bleeding
Disadvantages
 Bartholins duct may be involved

 The levator ani muscle is weakened

 Bleeding is more profuse

 Suturing is more difficult

 The woman experiences subsequent discomfort

Lateral Episiotomy
 Performing an Episiotomy
 The timing of the incision is very important. It is best timed
when the presenting part is directly applied to the perineum
& he contractions are at their pick.
 If the episiotomy is performed too early, it exposes the
mother to a lot of bleeding. If performed too late, there will
not be enough time to infiltrate the anaesthesia. A tear may
already have developed before the midwife gives an
episiotomy.
 The main requirement for the procedure is a trolley with:
 Suture pack
 10mls syringes and needles
 Lignocaine ( 0.5% 10ml or 1% 5mls)
 Chromic catgut (an absorbable suture).
 One Needle holder
 Artery forceps
 Toothed dissecting forceps.
 Mayo scissors for shortening the thread during the repair of the
episiotomy.
 Procedure
 When the head reaches the pelvic floor, two fingers of the left
hand are inserted between the perineum and the foetal head.
 Lignocaine, 0.5%, is infiltrated into the area where the incision
has to be made.
 Using the right hand, the midwife places the tip of the opened
scissors and makes an incision at the height of a contraction.
 Delivery of the head should follow immediately
and it should be controlled to avoid extension of the
episiotomy.
 If there is delay before the head emerges, apply
pressure at the episiotomy site between
contractions to minimize bleeding. Use aseptic
techniques all through.
Infiltrating the perineum
Performing an episiotomy
 Procedure cntd…
 Direct your needle 4.5cm beneath the skin of the
proposed site of injection
 Ensure the needle is not in the blood vessel by drawing
back the piston
 If you withdraw blood, redirect the needle
 Inject the lignocaine as you withdraw the needle
 Distribute the anaesthesia by changing the direction of
the needle to two or more areas on the proposed
injection site
 Toxic signs of local anaesthesia that you should be
aware of:
 Drowsiness
 Twitching of the face/lips

 Tingling in the area of the mouth

 Convulsion

 Circulatory collapse

 Respiratory collapse

If the above signs are noted, call for medical help

(anaesthetist) and resuscitate the mother
 Repair of the Episiotomy
 The episiotomy should be repaired as soon as possible
(immediately after the third stage) before oedema sets in and
while tissues are still anaesthetised. You will need a good source
of direct light.
 The patient is placed in the dorsal recumbent position. The
midwife should be seated comfortably during the procedure.
 An aseptic technique must be maintained throughout the
procedure.
 The vagina and the episiotomy site are cleaned with antiseptic
lotion and the midwife should have a sterile gown and gloves
on.
 Sterile gauze is inserted into the vagina to absorb blood
and keep the operation site dry. Absorbable sutures are
used.
 The repair begins at the apex of the vaginal wound. A
continuous or interrupted stitch is used, started from the
apex to the fourchette bringing the two edges of the
wound together. The perineal muscles are then sutured
and finally the skin is sutured= a total of three (3) layers
are sutured.
 The stitches should just be firm enough. If they are too
loose, they may cause oedema and if they are too tight,
the mother will be very uncomfortable.
 After suturing, remove the pack from the vagina and note
on the mother’s card that the pack has been removed.
 Insert the little finger into the anal orifice to make sure
the two orifices have not been stitched together and the
vaginal orifice is still patent.
Hints on repairing the perineum
 Should be sutured with in one hour after local analgesia is

given
 The area is cleansed with savlon solution

 For any leakage from the uterus, vaginal tampon or pack

should be inserted
 Good light is essential

 The extent of the laceration should be determined

Layers to be repaired
 Vaginal wound

 a) Deep and superficial tissue

 b) Vaginal mucosa

 Perineal muscles and fascia

 Perineal skin and subcutaneous tissue

 The first stitch inserted at the apex of the incision

 The most commonly used suturing material is 2/0 chromic

catgut.
 Complications of episiotomy
 Infections leading to broken episiotomy
 Haematoma formation at the site of the
episiotomy haemorrhage
 VAGINAL TEARS
• Vaginal tears during childbirth are relatively
common.
• Vaginal tears that involve only the skin around the
vagina typically heal within a few weeks. Some
vaginal tears are more extensive and take longer to
heal.
• Advise the patient to seek help If the pain seems
excessive or gets worse. Excessive pain could be a
sign of infection.
 Types of tears
First-degree vaginal tear
• First-degree vaginal tears are the least severe,
involving only the skin around the vaginal opening.
• Although the pt might experience some mild burning
or stinging with urination, first-degrees tears aren't
severely painful and heal on their own within a few
weeks, so they don’t need any suturing.
 Second-degree vaginal tear
• Second-degree vaginal tears involve vaginal tissue and
the perineal muscles — the muscles between the vagina
and anus that help support the uterus, bladder and
rectum i.e. bulbocavenosus & the transverse perineal
muscles and in some cases, the pubococcygeus.
• Second-degree tears typically require stitches and heal
within a few weeks.
 Third-degree vaginal tear

• Third-degree vaginal tears involve the vaginal

tissues, perineal muscles and the muscle that
surrounds the anus (anal sphincter).
• These tears sometimes require repair in an operating
room — rather than the delivery room — and might
take months to heal.
• Complications such as fecal incontinence and painful
intercourse are possible outcomes.
To ease discomfort, advice the mother to:
• Sit on a pillow or padded ring.
• Pour warm water over the vulva as she is passing
urine, and Press a clean pad firmly against the wound
as she bears down for a bowel movement.
• Cool the wound with an ice pack, or place a chilled
witch hazel pad between a sanitary napkin and the
wound.
• Take pain relievers or stool softeners
 Fourth-degree vaginal tear
• Fourth-degree vaginal tears are the most severe.
• They involve the perineal muscles and anal sphincter as
well as the tissue lining the rectum.
• Fourth-degree tears usually require repair in an operating
room — rather than the delivery room — and might take
months to heal.
• Should be repaired by an experienced obstetrician
• Complications such as fecal incontinence and painful
intercourse are possible.
THE 3RD STAGE OF
LABOUR
PHYSIOLOGY AND MANAGEMENT OF 3RD STAGE OF LABOUR

DESCRIPTION OF 3RD STAGE:

• This is the stage that commences immediately after the birth of
the baby & involves delivery of the placenta & the membranes up
to when bleeding is completely controlled.
• It includes the delivery of the placenta and membranes as well as
the complete control of hemorrhage from the placenta site.
DURATION:
• The third stage lasts between 5-15 minutes but any period upto 1
hour is normal. If it lasts more than 1 hr, it is considered as
retained placenta, hence prolonged 3rd stage of labour thus
posing a risk for possible postpartum haemorrhage (PPH).
• At this stage, the uterus contracts down to follow the body
of the foetus as it is being born.
• As the cavity of the uterus becomes smaller, the area of the
placental site is diminished. The placenta is then cut off
from the spongy layer of the decidua basalis.
• Further uterine contractions expel the placenta from the
upper segment into the lower segment and through the
vaginal vault.
• This process, whereby the placenta leaves the upper
segment to the lower segment and through the vagina, is
referred to as separation and descent of the placenta.
 Principles of the Third Stage of Labour
Physiology of Third Stage
1. Separation of the placenta
2. Descent of the placenta
3. Expulsion of the placenta
4. Control of bleeding
The Mechanical Factors:
During the third stage, the following mechanical factors come into
play:
• The uterus reduces in size 2.5cm below the umbilicus, or 15cm
above the symphysis pubis after the expulsion of the foetus
• The contraction and retraction of the uterine muscles continues.
The placental site is reduced to half
• The placenta becomes compressed & blood in the intervillous
spaces is forced into the spongy layer of the decidua.
• Retraction of the oblique uterine muscle fibres exerts pressure
on the blood vessels so that blood does not drain back into the
maternal system.
• Since the placenta is inelastic, it does not contract, so it
detaches from the shrinking uterine wall
• The placenta is pushed further to the lower uterine segment
by the weight of the retro-placental clot. This is the
accumulated blood from the separated placenta
• With the next contraction the placenta is pushed into the
vagina and expelled
 METHODS OF PLACENTA SEPARATION
• There are 2 methods of separation of the placenta:
– Matthew-Duncan method
– Schultz Method.
 Matthew-Duncan method
• A method of placenta separation whereby the placenta is
expelled with the maternal side first exposed.
• The placenta slides down sideways & comes thru’ the
vulva with the lateral border first, like a button thru’ a
buttonhole
• In this case, the placenta begins to detach unevenly at one
of its lateral borders so the placenta descends, slipping
sideways, maternal surface first
• Maternal surface is first seen
• In this method, the process of separation takes longer &
blood loss is greater than in Schultz method
 Schultz Method
• The most common method of placenta separation whereby
the placenta is expelled with the fetal surface first exposed.
• Placenta detaches from a central point & slips down into the
vagina thru’ the hole in the amniotic sac
• The fetal surface first appears at the vulva with the
membranes trailing behind like an inverted umbrella as they
are pilled off the uterine wall
• The maternal surface of the placenta is not seen & any blood
clot is inside the inverted sac
 Signs of placental separation
• Elongation of the cord at the vulva which does not recede
on pressing at the symphysis pubis
• A sudden gush of blood through the vulva
• The uterus contracts and feels hard like a cricket ball.
• Uterus rises in the abdomen as the placenta descends to the
lower uterine segment or vagina and displaces the uterus
upward
 Descent of the placenta
• When the placenta has completely separated, the contracting
uterus pushes it down into the lower uterine segment and into the
vagina. The weight of the placenta itself pulls the chorion off the
uterine wall.
SIGNS OF PLACENTAL DESCENT
• The uterus becomes hard, round and movable.
• The fundus rises to the level of the umbilicus.
• The cord seems to lengthen at the vulva.
• There is a gush of blood through the vulva
• When you apply suprapubic pressure, the cord will not receed back
• Placenta can be felt or seen on vaginal examination.
 CONTROL OF BLEEDING
The control of bleeding is achieved through the following:
• The uterine muscles contraction and retraction causes the placental
site to reduce into half, consequently forming a retro-placental clot
which pushes the placenta further down into the vulva
• Retraction of the oblique uterine muscle fibres exerts pressure on
the blood vessels so that blood does not drain back into the
maternal system.
• Criss-cross fibres in the uterus control bleeding by compressing the
blood vessels. These fibres are also known as ‘living ligatures’
• Clotting of blood takes place in the sinuses thus sealing the bleeding
points a few hours later when uterine contractions are less vigorous.
 The time interval between the delivery of the baby and
delivery of the placenta is a dangerous period, in which one
of the greatest complications of pregnancy and labour can
occur.
 This complication is excessive bleeding or postpartum

haemorrhage (PPH). You should never leave the mother

alone even for a short while during this stage.
 The third stage of labour can be managed either passively

or actively.
 The Passive or Natural Method of
Managing the 3rd Stage of Labour
 The passive or natural method occurs naturally, that is
without any interference. For example, in a normal
delivery, if oxytoxic drugs are not used, the uterus
generally remains inactive for a few minutes after the
delivery of the baby, after which regular contractions then
begin again.
 Physiology of the third stage takes place, the placenta is

expelled and bleeding is controlled.

 ACTIVE MANAGEMENT
- Giving uterotonic Drugs.
• Oxytocin, ergometrine or syntocinon stimulate uterine
contraction during the third stage of labour.
• Ergometrine 0.5mg given IM causes a uterine contraction to
occur five to seven minutes after the injection. Given
intravenously, it acts within 45 seconds.
• Syntometrine is a mixture of oxytocin and ergometrine 0.5ml
given IM acts within two to three minutes.
• Usually syntocinon (oxytocin) is the preferred uterotonic drug
& is given immediately after delivery of the baby, at a dosage
of 10 I.U intramuscularly.
 DELIVERY OF THE PLACENTA AND THE MEMBRANES
- Methods of Delivery of the placenta and membranes
a) Controlled Downward Traction(CDT) method.

• Controlled downward traction involves traction on the umbilical

cord downward and forward, combined with counterpressure
upwards on the uterine body by a hand placed immediately above
the symphysis pubis.
• CDT is used in conjunction with drugs that speed up the separation
process i.e.. syntocinon.
 PRE-REQUISITES PRIOR TO APPLICATION OF
CDT METHOD TO DELIVER THE PLACENTA
ENSURE THAT:
• A uterotonic drug (syntocinon) has already been administered
• The uterotonic drug has been given time to act
• The uterus is well contracted
• Counter-traction is applied.
• Signs of placenta separation have already been observed-Not
mandatory so long as oxytocin has already been administered
and given at least 3-5 minutes to work
• After the syntocinon is given (with consent) –
intramuscularly, you MUST wait for signs of
placenta separation, this will be blood loss and
lengthening of the umbilical cord, use the clamps
as a guide to cord lengthening.
• Maintain your abdominal hand or non-dominant
hand over the uterus, using your flattened fingers
just above the pubic bone to aid the placenta as it
exits the cervical os into the vagina.
• Place your right hand fingers in the clamp at the
point where the cord is attached, and apply steady
cord traction with a downward and forward motion,
STOP IF YOU FEEL RESISTANCE.
• Wait a minute or two and then try again, gently, if
you do not feel resistance then continue traction but
upward along the curve of Carus as the placenta
becomes visible at the the introitus.
• When the placenta is visible at the introitus,
lift it partially through with the hand holding
the clamp
• Remove your other hand from the abdomen and
let the placenta fall into your hands.
• At this point drop the cord and the clamp.
• Move the placenta up and down and rotate it gently
to bring it through the os. This has been called
'feathering'.
• Continue to rotate the placenta to make a thick
cord of the trailing membranes, if necessary.
• If this is not sufficient, grasp the membranes with
the clamp to encompass them laterally.
• Rotate the ring forceps to make a thicker cord of
membranes and then gently tease the membranes
through the introitus by a slight up and down
movement.
Important Note: Remember: slow controlled
delivery to avoid tearing the cord or membranes.
 b) Maternal Effort

• This method is not commonly used.

• When the placenta has separated and descended, the
palm is placed downwards on the mother’s abdomen to
provide a backup that the mother can push against.
• During a contraction, the mother should be asked to
push down the placenta.
• The placenta will be pushed out of the vagina. This
method is useful in the event of a macerated birth
 c) Fundal Pressure
• This method should be used in case of a macerated
or pre-term baby as the strength of the cord is
reduced.
• You should wait for the signs of placental
separation b4 applying fundal pressure
 Procedure
• Make sure the bladder is empty.
• Instruct the mother to breathe through an open mouth slowly and
quietly.
• When there is a contraction, grasp the uterus with your left hand
fingers behind the uterus. Thumb in the anterior surface.
• Apply pressure to the pelvic inlet in downward and backward
direction.
• Receive the placenta with both hands.
• If the membranes do not slip out, turn the placenta around and
deliver the membranes slowly with an upward movement.
• Rub the uterus and expel the clots.
• Once the placenta is out, you will need to examine the birth canal.
• Explain to the mother that you need to check if she has any
tears, warn her it will be a bit painful but the worst part has
passed, you will be very gentle and quick and that she needs
to cooperate
• Change the gloves, roll gauze over pointing and middle fingers
of the right hand
• Insert middle fingers of left hand facing upwards pushing the
upper vaginal wall.
• With the right hand press down the lower vaginal wall
exposing the cervix
• Check the cervix for bleeding, oedema or tears
• Check for any tears with the two fingers of your right hand,
mop both sides of the vaginal wall, finish with the fourchette
• Reassure the mother in case there is any tear for suturing
• Cover the perineum with the folded pad into a half
• Wipe the buttocks from the fourchette towards the rectum
cover the perineum completely
• Collect any blood loss from the bed
• Change the bed linen with the help of an assistant
• In case of episiotomy or a tear, scrub your hands while your
assistant is setting a sterile suturing pack and repair the
tear
• Ask the mother to lie on her back with her legs crossed on
each other
• Ask the assistant to hand over the baby to the mother
• Leave the mother to rest while you go to examine the
placenta
 Complications of the 3rd stage of labour
POSTPARTUM HAEMORRHAGE(PPH)
• PPH can be defined as excessive bleeding of more than 500mls
of blood from the genital tract after the birth of a baby or any
amount that may lead to deterioration in the mother’s
condition.
• If it occurs during the 3rd stage of labour or within 24hrs of
delivery, this is known as primary PPH
• If the condition occurs after 24 hours of, and within six weeks
after, delivery it is known as Secondary PPH.
 Retained placenta
The placenta remains inside the uterus for longer than 30 minutes
after delivery of the baby, usually due to one or more of the
following:
• Uterine contractions may be inadequate to expel the placenta
• The cervix might have retracted too fast and partially closed,
trapping the placenta in the uterus
• The bladder may be full and obstructing placental delivery.
 Acute Uterine inversion

• The uterus is pulled ‘inside out’ as the baby or the

placenta is delivered, and partly emerges through
the vagina.

End
FOURTH STAGE OF NORMAL LABOUR
DESCRIPTRION:

 This is the period of maternal physiological adjustment that occurs after

delivery of the placenta and membranes to the end of the first 1-2 hours
postpartum, until the uterus remains firm on its own.
 During the 4th stage of labour, mother remains in labour ward where her
condition is assessed after delivery.
 In this stabilization phase, the uterus makes its initial readjustment to the
non- pregnancy state.
 The primary goal of the above is to prevent haemorrhage from uterine atony
& the cervical or vaginal lacerations
NOTE: Atony is the lack of normal muscle tone thus uterine atony is failure of
the uterus to contract, leading to postpartum haemorrhage.
 The uterus is firm at level of two fingers breadth below the
umbilicus.
 Restoration of physiological stability is established.
 During this period myometrial contractions and
retraction, accompanied by vessel thrombosis, operate
effectively to control bleeding from the placenta site.
Failure of this mechanism could result in excessive
blood loss (postpartum haemorrhage (PPH)) that could
be life threatening.
 The mother should be closely observed for
haemorrhage, urine retention or hypotension.
 The mother and child relationship should be initiated
and encouraged, as it has an effect to the subsequent
quality of their relationship and bonding
 SPECIFIC NURSING/ MIDWIFERY CARE
DURING THE FOURTH STAGE OF
LABOR

 Transfer the patient from the delivery table.

Remove the drapes and soiled linen. Remove both legs from the
stirrups at the same time and then lower both legs down at the same
time to prevent cramping. Assist the patient to move from the table to
the bed.
 Provide care of the perineum.
An ice pack may be applied to the perineum to reduce swelling
from episiotomy especially if a fourth degree tear has occurred
and to reduce swelling from manual manipulation of the
perineum during labor from all the exams
 Transfer the patient to the recovery room.
This will be done after you place a clean gown on the patient,
obtained a complete set of vital signs, evaluated the fundal height
and firmness, and evaluated the lochia.
 Ensure emergency equipment is available in the recovery
room for possible complications. E.g.
– Suctioning machine and oxygen
– Syntocinon in the fridge
– IV remains patent for possible use if complications develop
 Check the fundus.
(1) Ensure the fundus remains firm.
(2) Massage the fundus in a smooth circular motion until it is firm
if the uterus should relax
Massaging the fundus
(3) Massage the fundus every 15 minutes during the first
hour, every 30 minutes during the next hour, and then,
every hour until the patient is ready for transfer.
(4) Chart fundal height. The fundus should remain in the
midline. If it deviates from the middle, identify this and
evaluate for distended bladder.
(5) Inform the Charge Nurse or physician if the fundus
remains boggy after being massaged.
NOTE: A boggy uterus many indicate uterine atony or
retained placental fragments.
Boggy refers to being inadequately contracted and
having a spongy rather than firm feeling. This is
descriptive of the post delivery of the uterus.
 Monitor lochia flow.
Lochia is the maternal discharge of blood, mucus, and tissue from the
uterus. This may last for several weeks after birth.
1) Keep a pad count. Record the number of pads soaked with lochia
during recovery
2) Identify presence of bright red bleeding or clots
3) Document thick, foul smelling lochia
4) Observe for constant trickle of bright red lochia as this may
indicate lacerations
 Observe the mother for chills.
The cause of the mother being chilled following birth is
unknown. However, it refers primarily to the result of circulatory
changes after delivery. The best means of relief is to cover the
mother with a warm gown.
 Monitor the patient's vital signs and general condition

1) Take BP, P and R every 15 minutes for an hour, then every 30

minutes for an hr and then every hr as long as the patient is
stable. Take temperature every hrly.
2) Observe for uterine atony or haemorrhage
3) Allow patient time to rest
4) Offer a free hot drink
 Observe patient's urinary bladder for distention.
Be able to recognize the difference between a full bladder and a
fundus.
 Characteristics of a full bladder.

1. Bulging of the lower abdomen

2. Spongy feeling mass between the fundus and the pubis.
3. Displaced uterus from the midline, usually to the right.
4. Increased lochia flow.
Bulging of the lower abdomen= full bladder
 Observe for signs of hemorrhage. These include:-
1. Uterine atony
2. Vaginal or cervical lacerations.
3. Retained placental fragments.
4. Bladder distention
5. Severe haematoma in vagina or surrounding perineum
 Assess for ambulatory stability.
Patient is at risk of fainting on initial ambulation after delivery due to
hypovolaemia from blood loss at delivery & hypoglycaemia from
prolonged nil by mouth (NPO) status thus should be accompanied on
initial ambulation
 Instruct the patient in the proper perineal care.

Should wipe from front to back to avoid contamination after voiding,

and apply the perineal pad from front to back.
 Discontinue IV infusion on a normal patient once she is stable
and the physician has ordered removal
 Complete notes and transfer the stable patient to the postnatal
ward
 Post natal discharge instructions
AREA INSTRUCTIONS
Work • All women should avoid heavy work (lifting or straining) for at least
the first three- four weeks following delivery

Rest • The women should plan at least one rest period a day and try to get a
good night sleep

Exercise • The women should limit the number of stairs she climbs to 1
flight/day for the first week at home.
• Beginning the second week, if her lochia discharge is normal, she
may start to expand this activity. She should continue with muscle-
strengthening exercise, such as sit-ups and leg raising
Hygiene • The women may take either tub baths or shower, and continue to
cleanse her perineum from front to back
Coitus  Coitus is safe as soon as the woman’s lochia is over and if she
has an episiotomy, it is completely healed (about the fourth
week after delivery)

Contraception  The women should begin contraception measures with the

initiation of coitus (if she desires contraception).
 If she wishes an IUCD, this may be fitted immediately following
delivery or at the first postnatal check up (after 2 weeks)
 Oral contraception are begun about 2-3 weeks after delivery
 All women should be counseled on Lactation amenorrhoea method
by emphasizing on exclusive breastfeeding.

Follow up  The women should notify her physician or midwife if she notices
an increase in lochia discharge, or if lochia serosa or lochia alba
becomes lochia rubra as these are signs of secondary P.P.H
THE
THE NORMAL
NORMALNEONATE
NEONATE

Welcome…
 BROAD OBJECTIVE
To provide the learners with knowledge, skills and attitudes on
management of the normal neonate
SPECIFIC OBJECTIVES
By the end of this unit, the learners will be able to:-
Describe the immediate and subsequent care of the normal
neonate, including APGAR scoring, initial examination and daily
routine examination
Describe the physiology of the normal neonate
Describe the minor disorders of the normal neonate.
 DEFINITION OF TERMS
a) A NEONATE:
Also known as a newborn, is a child from birth up to 28 days
of life.
b) A NORMAL NEONATE:
A neonate born at term ( at approximately 40 weeks
gestation)
Has no physical or physiological features suggestive of an
emergency or warranting immediate resuscitation
Has got all the features/ characteristics expected of a
healthy neonate
 GENERAL CHARACTERISTICS OF A NORMAL
NEONATE
A normal term baby weighs appx 2.5-3.5 kgs at birth
When fully extended, measures 45-55cm from the crown of
the head to the heels
Has an occipito-frontal head circumference of 34-37cm or
35-38cm
Appears plumpy and abdomen is prominent
Lies in an attitude of flexion, so as to prevent heat loss
When the arms are extended, their fingers reach the upper
thigh level
 APGAR SCORING
The Apgar score was devised in 1952 by Dr. Virginia
Apgar as a simple and repeatable method to quickly and
summarily assess the health of newborn children
immediately after birth.
Apgar was an anesthesiologist who developed the score
in order to ascertain the effects of obstetric anesthesia
on babies
The Apgar score is determined by evaluating the
newborn baby on five simple criteria on a scale
from zero to two (2), then summing up the five
values thus obtained. The resulting Apgar score
ranges from zero to 10.
After delivering the baby, an assessment of the general
condition is done after one minute, after five minutes &
again after 10 minutes.
This involves the consideration of five specific signs and the
degree to which they are present or absent. The factors
assessed are:
Appearance – Colour of the neonate at birth
Pulse - Heart rate of the newborn
Grimace - good grimace =reflex response to stimulation
Activity - Muscle tone of the neonate
Respiratory efforts – vigorous crying or spontaneous
respiration
 THE COMPONENTS OF THE APGAR SCORE
HEART RATE.
Is the priority assessment of the newborn after birth.
On auscultation or palpation, the nurse recognizes an absent heart
rate or heart rate less than 100 bpm as a signal for resuscitation.
RESPIRATORY EFFORT.
The newborn’s vigorous cry best indicates adequate respiratory
effort, the next most important assessment after birth.
A weak or absent cry is a signal for intervention.
MUSCLE TONE.
The nurse determines the newborn’s muscle tone by assessing the
response to the extension of the extremities. Good muscle tone is
noted when the extremities return to a position of flexion.
REFLEX IRRITABILITY. The nurse assesses reflex irritability by
observing the newborn’s response to stimuli such as a gentle
stroking motion along the spine or flicking the soles of the feet.
When this stimulation elicits a cry, the score is 2. A grimace in
response to stimulation scores 1, and no response is a score of 0.
COLOR. The nurse assesses skin color for pallor and cyanosis.
Most newborns exhibit cyanosis of the extremities at the 1-
minute Apgar check, and this normal finding is termed
acrocyanosis. A score of 2 indicates that the infant’s skin is
completely pink.
. Newborns with darker pigmented skin are assessed for pallor
and acrocyanosis
A score of 0, 1, 2 is awarded to each of these
signs in accordance with the APGAR Score
Chart.
 THE APGAR SCORE TABLE
SIGN  SCORE 0 SCORE 1 SCORE 2
Appearance( skin Pale or blue Body pink, extremities Pink all over
colour complexion) blue
Pulse/ heart rate Absent Less than 100/min More than 100/min
Grimace( reflex No response to Grimace/feeble cry Cry or pull away when
Response to stimulation when stimulated stimulated
stimuli)
Activity (muscle Limp Some Spontaneous
tone) flexion/movement movements/active(flex
ed arms and legs that
resist extension
Respiratory None Weak or slow/gasping Good/vigorous cry
effort( breathing)
A normal infant in good condition at birth will achieve
an APGAR score of 7 to 10. A score of 1 to 3 is severe
birth asphyxia and 4 to 6 is moderate birth asphyxia,
both of which require immediate resuscitation of the
baby
 IMMEDIATE CARE OF THE NEONATE
GOALS
To establish, maintain and support respirations.
To provide warmth and prevent hypothermia.
To ensure safety, prevent injury and infection.
To identify actual or potential problems that may require
immediate attention
 i) Establish and maintain clear airway
The most important need for the newborn immediately after birth is a
clear airway to enable the newborn to breathe effectively since the
placenta has ceased to function as an organ of gas exchange
Check breathing (Baby should be crying or breathing quietly and easily)
To establish & maintain clear respirations:-
a) Wipe mouth and nose off secretions after delivery of the head.
b) Suction secretions from mouth and nose. Suction mouth first, then,
the nose
c) Stimulate the baby to cry if baby does not cry
spontaneously, or if the cry is weak. The normal infant cry
is loud and husky. Observe for the following abnormal
cry:-
High, pitched cry – indicates hypoglycemia, increased

intracranial pressure, maternal (illicit) drugs

withdrawal.
Weak cry – prematurity

Hoarse cry – laryngeal stridor

 Immediate care cntd’
ii) Place the infant in a position that would promote drainage of
secretions:
Trendelenburg position – head lower than the body
Side lying position – If trendelenburg position is contraindicated,
place infant in side lying position to permit drainage of mucus from
the mouth. Place a small pillow or rolled towel at the back to
prevent newborn from rolling back to supine position
iii) Keep the nares patent. Remove mucus and other particles that may
be cause obstruction. Newborns are obligatory nose breathers until they
are about 3 weeks old.
iv) Care of the eyes.
It is part of the routine care of the newborn to give prophylactic eye
treatment against gonorrhea conjunctivitis or ophthalmia neonatorum. 
 Administer tetracycline ophthalmic eye ointment (T.E.O).
 Apply over lower lids of both eyes, starting from the inner canthus to
the outer canthus then, manipulate eyelids to spread medication over
the eyes.
v) Vitamin K administration.
The newborn has a sterile intestine at birth, hence, the newborn does not
possess the intestinal bacteria that manufactures vitamin K which is necessary
for the formation of clotting factors. This makes the newborn prone to bleeding.
So, as a preventive measure, 5mg (preterm) and 1 mg (full term) Vitamin K or
aquamephyton is injected IM in the newborn’s vastus lateralis (lateral anterior
thigh) muscle.
 Vi) Care of the cord
Ligate the cord and make sure the ligature is very tight
before you cut the cord.
Clamp and cut the cord (DO NOT MILK THE CORD)
Artificial cord clamp is applied a least 3-4cm from the
abdomen
The manner of cord care depends on hospital protocol.
Cord should be cleansed three times daily with an
antiseptic solution.
 INSTRUCTIONS TO THE MOTHER ON CORD CARE:
No tub bathing until cord falls off. Do not sponge bath to clean
the baby. See to it that cord does not get wet by water or urine.
Do not apply anything on the cord such as baby powder or
antibiotic, except the prescribed antiseptic solution
Avoid wetting the cord. Fold diaper below so that it does not
cover the cord and does not get wet when the diaper soaks with
urine.
Leave cord exposed to air. Do not apply dressing or abdominal
binder over it.
If you notice the cord to be bleeding, apply firm pressure and
check cord clamp if loose and fasten.
 Cord care cntd’
Report any unusual clinical features which
indicates infection on the cord:
Foul odor in the cord
Presence of discharge
Redness around the cord
The cord remains wet and does not fall off within 7
to 10 days
Newborn fever
Cord care
vii) Wipe the baby’s head and the body and wrap to keep
warm.
viii) Record the following information about the baby:
Label the baby with the mother’s name and I.P.
number
Write the date and time of delivery
Sex of the baby
Birth weight
Immediate care of the newborn cntd’
ix) Encourage breastfeeding and routine newborn care
x) Anticipate the need for neonatal resuscitation and
prepare in advance for it
Clamped umbilical cord
Keep the baby warm
 IDENTIFICATION
Name bands should be applied legibly on the
infant’s wrist or ankle
Should include:-family name, sex of the infant,
date and time of birth.
They should be fastened securely and should not
be too tight or too loose
Care for the baby
Check frequently for bleeding.
daily Change napkin whenever wet or soiled & have mother
do it.
Take temperature twice daily or & hourly if necessary
If the baby’s condition is good mother should be allowed to
feed, as often as she wishes to do so.
Test breast feeding and body activity of the child.
Check cord for bleeding and signs of infection,
 xi) INFANT-PARENT BONDING
The baby should remain with his mother during
the first few hours of life whenever possible,
provided the mother and baby are in good
condition. This facilitates the attachment
process.
 EMTCT OF HIV-NEONATAL CARE
= Elimination of mother to child transmission of HIV/AIDS during
the neonatal period
Specific measures include:-
Wipe the mouth and nostrils with sterile gauze at delivery of the
head.
Clamp and cut cord immediately after birth and avoid milking
the cord. Cover with gauze before cutting the cord
Avoid suctioning unless there is a meconium or excess
secretions. If you must suction, use low pressure or bulb suction.
Avoid beating or turning baby upside down
Wipe baby dry with particular attention to the
mucous membranes. Wiping should be done
carefully to avoid trauma to the skin. The
preterm infant's skin bruises more easily.
Feed the baby within one hour to avoid infection.
Umbilical cord requires good hygiene; the mother should be
instructed on how to clean the cord as per the recommended
guidelines
Prophylaxis for all HIV exposed infants is recommended with
nevirapine syrup for 6 weeks
All HIV exposed infants are given cotrimoxazole prophylaxis
(septrin) starting from 6 weeks. This is stopped when the
child is confirmed HIV negative and no longer breastfeeding
 INFANT FEEDING RECOMMENDATIONS
For HIV infected mothers
Exclusive breastfeeding is recommended for HIV-infected
women for the first 6 months of life unless replacement
feeding is Acceptable, Feasible, Affordable, Sustainable
and Safe (AFASS) for them and their infants
WHO recommends continued breastfeeding for up to 12
months with ARV prophylaxis until one week after
breastfeeding ceases
When replacement feeding is AFASS, avoidance of
all breastfeeding by HIV-infected women is
recommended
These mothers should receive counseling
concerning:
Information about risks and benefits of each
option
Specific guidance on selecting option most
suitable for their situations
 PHYSIOLOGY
PHYSIOLOGY OF
OF THE
THE NORMAL
NORMAL
NEONATE
NEONATE
1. THE SKIN
The skin of a newborn is covered with vernix caseosa in utero to
protect and help retain heat and also act as a lubricant during delivery.
Has an important role in temperature regulation, acts as a barrier to
infections, balances electrolytes, stores fat & insulates against the cold
The sebaceous glands cease to produce vernix after birth, which may
lead to dryness of the skin. The vernix caseosa peels off within three
days of delivery if left alone.
There is also plenty of fine hair (lanugo) on the skin which falls off in
the first month of life.
The skin of the newborn baby is thin, delicate & easily
traumatized by friction, pressure or substances with a
different PH thus rendering it prone to blistering, excoriation
& infection.
Sterile at birth but colonized with micro-organisms within 24
hours
PH reduces from 6.4 at birth to about 4.9 over 3-4 days
A mature baby has many creases on the palms of the hands
& soles of the feet
Nails are fully formed & adherent to the tips of the fingers
Sensitivity to touch & pressure, heat and cold and pain are
mediated through the skin.
2. THERMO (HEAT) REGULATION

Thermal control in the neonate is initially poor for

some time
The neonate leaves a thermo constant environment of
37.1 degrees Celsius, where they have survived for nine
months and enters a much cooler atmosphere at
delivery. This affects the neonate in various ways.
Firstly, heat regulation in the neonate is poor because of
their inefficient heat regulating centre/immaturity of the
hypothalamus.
The subcutaneous fat layer of the neonate is thin and
provides poor insulation, allowing the transfer of core
heat to the environment and also cooling of the baby’s
blood.
A baby’s normal core temperature is 36.5- 37.3˚C thus a
normal baby is able to sustain these temperatures so long as
the environmental temperature is sustained between 18˚C &
21˚C
 Reasons as to why neonatal physiology
predisposes to poor thermoregulation.
Wet skin at birth and high surface area to body ratio thus
lost heat via skin surface.
Immature hypothalamus
Lack of enough subcutaneous fat (term) and/or adipose
tissue or brown fat (preterm)
Poor energy stores and limited brown fat which leads to
limited thermogenesis (heat production)
METHODS OF HEAT LOSS IN NEONATES
EVAPORATION – heat loss through wet skin
CONVECTION – heat loss from cooler air circulating
around warmer skin particularly when exposed
CONDUCTION – heat loss through direct contact with a
cold surface (e.g. scales, unwarmed mattress)
RADIATION – heat loss from heat radiating towards a
cooler surface (e.g. a cold window, wall or incubator wall)
This baby will lose heat by evaporation through a wet
skin after birth. Drying and wrapping OR skin to skin
contact plus a hat is required
 Preventing hypothermia
Sources of heat Preventive measures
loss  
Conduction Warming blanket, Drapes or blanket, Head covering &
Warmed solutions

Convection Room temperature to 26.6ºC, Keep neonate covered

 
radiation Radiant warmer, Wrap neonate, Warm room
 
Evaporation Heated, humidified inspired gases, AND body humidification
Plastic bags / wrap for preterm (<28-30 weeks)
 3. RESPIRATORY SYSTEM
At birth, the respiratory system is developmentally incomplete,
growth of new alveoli continuing for several years
The lumen of the peripheral airways is narrow, which
predisposes to atelectasis (a complete or partial collapse of a
lung or a lobe of a lung)
Respiratory secretions are more than in an adult. Their mucous
membranes are delicate and sensitive to trauma
Normal respirations in a neonate is 20- 60 (average 44 b/min)
Their breathing is diaphragmatic, chest and abdomen rising and
falling synchronously
Their respirations are shallow and irregular, interspersed
with brief 10-15 seconds of periods of apnoea (a period of
cessation of external breathing) hence periodic
breathing.
Babies are obligatory nose breathers and do not convert
automatically to mouth breathing when nasal obstruction
occurs
 4. CARDIOVASCULAR SYSTEM
Foetal type of circulation ceases as the respiration
commences
Normal circulation starts when the temporary structures
stop functioning. These temporary structures are:-
Foramen ovale
Ductus arteriosus
Ductus venosus
Umbilical vein and hypogastric arteries
At birth, the baby takes a breath and blood is drawn to
the lungs and then to the left atrium.
The placental circulation ceases and less blood returns
to the right side of the heart.
The pressure in the left side is greater while that in the
right side is less
Functional closure of the foramen ovale occurs
Anatomical closure of the ductus arteriosus and
formation of ligamentum arteriosum.
As the placental circulation ceases soon after birth when the
umbilical cord is ligated, the blood flow to the right side of
the heart decreases and the blood on the left side increases
causing the foreman ovale to close.
With the establishment of pulmonary respiration, the ductus
arteries close. Complete closure happens within eight to ten
hours of birth.The cessation of placental circulation will result
in the collapse and subsequently drying of the umbilical veins,
the ductus venosus and the hypogastric arteries
Initially, the heart rate is rapid; 120- 160 beats per minute.
Peripheral circulation is sluggish thus resulting in mild
cyanosis of the hands, feet and circumoral areas
The total circulating blood volume at birth is 80 ml/kg body
weight. This volume is usually raised where there’s delay in
clamping of the cord at birth
The h.b is high (13-20 g/dl) of which >50% is fetal
haemoglobin. Conversion from fetal to adult h.b is completed
within the first 1-2 years of life
Breakdown of the excess r.b.cs in the liver & the spleen
predisposes to jaundice in the 1st week
 5. THE RENAL SYSTEM
Though the kidneys are functional in foetal life, their workload is
minimal until after birth
The glomerular filtration rate is low & tubular reabsorption
capabilities are limited.
The baby is not able to concentrate or dilute urine very well in
response to variations in fluid intake, nor compensate for high or
low levels of solutes in the blood. This results in a narrow margin
btwn homeastasis & fluid imbalance
The ability to excrete drugs is also limited & the baby’s renal
system is vulnerable to physiological stress
The first urine is passed at birth or within the 1st
24hrs & thereafter with increasing frequency as fluid
intake rises
The urine is dilute, straw coloured & odourless
 6. GASTROINTESTINAL SYSTEM
The G.I.T of the neonate is structurally complete, although
fuctionally immature in comparison with that of the adult. The
mucous membrane of the mouth is pink & moist &The teeth are
buried in the gums
The stomach has a small capacity(15-30ml), which increases
rapidly in the 1st wks of life. The cardiac sphincter is weak,
predisposing to regurgitation
The gut is sterile at birth but is colonized within a few hrs. bowel
sounds are present within one hr of birth
Bowel sounds are present within 1 hour of birth
 LIVER FUNCTION
Physiological jaundice is usually seen in 50% of normal
neonates from the third to the sixth day of life. This is
due to excessive break down of red blood cells resulting
from a high haemoglobin level (Hb of 14 -
18mgs/100mls).
The process of breaking down red blood cells leads to
formation of bilirubin. The liver is not able to conjugate
the excess bilirubin to enable its secretion through the
kidneys. This leads to physiological jaundice.
STOOLS
The neonate is capable of passing the first stool, known
as meconium, within the first two to three days of life.
This is because the foetus swallows liquor amnii in utero.
Thus, their sucking and swallowing reflexes are usually
present at birth.
The colour of the meconium is dark greenish for the 1st
48-72 hours and later changes to a mustard (yellowish)
colour from the 3rd-5th day. The bowels may be opened
three to five times daily.
 Note:
The consistency and frequency of stools reflect the type
of feeding
Breastmilk results in loose, bright yellow and inoffensive
acid stools
The stools of a bottle fed baby are paler in colour,
semiformed, less acidic and have slightly sharp smell
 7. IMMUNOLOGICAL ADAPTATION
Neonates demonstrate a marked susceptibility to infections,
especially those gaining entry thru the mucosa of the
respiratory & gastrointestinal systems
The baby has some immunoglobulins at birth but the
sheltered intrauterine existence limits the need for learned
immune responses to specific antigens. There are 3 main
immunoglobulins, igG, igA and igM and of these, only igG is
small enough to cross the placental barrier
At birth, the baby’s levels of igG are equal to or
slightly higher than those of the mother. This provides
passive immunity during the last few months of life.
 8. REPRODUCTIVE SYSTEM
In boys, the testes are descended into the scrotum,
which has plentiful rugae, the urethral meatus opens
at the tip of the penis & the prepuce is adherent to the
glans
In girls both at term, the labia majora normally cover
the labia minora, the hymen and the clitoris may
appear disproportionately large
In both sexes, withdrawal of maternal oestrogens
results in breast engorgement with a nodule of breast
tissue around the nipple
 9. MUSCULOSKELETAL SYSTEM
The muscles are complete, subsequent growth
occurring by hypertrophy rather than by hyperplasia
Long bones are incompletely ossified to facilitate
growth at the epiphyses
 10. PSYCHOLOGY AND PERCEPTION
Newborn babies at birth are alert and aware of their
surroundings and they have long periods( 60%) of
‘quiet alert state’ & react to stimuli
 i) Special senses
a) VISION
Though immature, the structures necessary 4 vision
are present & functional at birth. Babies are sensitive
to bright light which cause them to frown or blink.
They demonstrate a preference for bold black & white
patterns and the shape of the human face
 b) HEARING
Newborn babies’ eyes turn towards sound. On hearing
a high pitched sound, they 1st blink or startle then
become agitated and are comforted by low pitched
sounds
c) SMELL & TASTE
Babies prefer a smell of milk to that of other
substances & show a preference for human milk
 d) TOUCH
Is the most highly developed sense in a neonate at
birth. Neonates respond well to touch. The senses of
taste, smell, and hearing are functional in the
newborn; however, not to the extent of touch.
 ii) SLEEP AND AWAKENING
Following initiation of respirations at birth, the baby
remains alert & reactive for a period of at least 1 hr,
then relaxes & sleeps
The baby goes into 2 sleep states, namely; deep sleep
and light sleep
 11. GROWTH & DEVELOPMENT
Babies are dependent on their mothers 4 continued
survival, growth & dvpt. These will progress
satisfactorily if the baby is physiologically &
neurologically normal, is in a safe envt, nutritional
needs are met & physiological dvpt is promoted by
appropriate stimulation & loving care
WEIGHT
The average normal birth weight ranges from 2.5 - 3.5
kilograms. During the first three days of life, the baby
loses approximately 10 - 20% of their birth weight but
regains it again within one to two weeks.
 POSSIBLE REASONS FOR WEIGHT LOSS IN A
NEWBORN
Due to tissue fluid loss during the heat loss when the baby
is born
When the baby opens their bowels, the meconium which
was present in the gut is lost, leading to weight reduction
Poor sucking on the breast due to tiredness incurred
during the baby’s passage through the birth canal during
labour will affect the baby’s weight since they are not
getting enough fluid intake
 FIRST EXAMINATION OF THE NEONATE
This is the first/ initial physical examination that is done to a
newborn baby
Examination whenever possible should be done near the
parents and findings explained to them
OBJECTIVES OF THE FIRST EXAMINATION:-
To rule out external congenital malformations
To determine maturity of the neonate and rule out
prematurity
To rule out birth trauma or injury
A thorough physical examination is done during the 1st 4 hours after
birth
In order to carry out this examination, you need to have with you the
following equipment in a tray:-
Tape measure
Second hand watch
Gloves
Weighing scale
Clinical thermometer
Swabs
Stethoscope
 PREPARATION PRIOR TO FIRST EXAMINATION
The midwife should first perform hand hygiene:-This is to prevent the
spread of infections.
The midwife’s hands should be warm:-This is to avoid chilling of the
infant
The neonate should be in a warm, draught (windy) free environment
There should be enough light to allow the midwife to see the neonate
clearly
The examination is performed in an orderly manner from head to
toes
EVALUATE THE BABY
 APPEARANCE
The baby should be pink in colour.
Note any abnormal facies
Lies in an attitude of flexion
Vernix caseosa-a white, sticky substance is present on the
skin. It has a protective function and is absorbed within a
few hours
Residual vernix in the axillae and groin predisposes to
excoriation of the skin
Vernix caseosa
 THE SKIN
Sterile at birth and is colonized by micro-
organisms within 24 hours
General colour of the skin depends on the baby’s
ethnic origin
Lanugo,downy hairs cover the skin and are
plentiful over the shoulders, upper arms and thighs
Mature baby has plentiful skin creases on the
palms of his hands and soles of his feet
 Examine
Vital signs the baby
- heart systematically
rate (120-160/min),inrespiration
the following manner:
(20-60 average
44/min), and temperature (36.5-37.3 degrees centigrade).
Head - Check the shape to see if there is excessive moulding, caput
succedaneum or depressed fractures to exclude head injury,
microcephalus or hydrocephalus.
On palpation of the vault of the skull:
The bones should feel hard in a full term infant
It may also be done to determine the degree of moulding
Take the occipital-frontal head circumference (Approximately 34-37
cm).
 HEAD CNTD’
Fontanels should be flat, soft, & firm. They
bulge when the baby cries or if there is increased
in ICP( Intracranial pressure).
Wide anterior fontanelle or splayed sutures may
indicate hydrocephalus or immaturity
Sunken fontanelles denote dehydration
MEASURING OCCIPITO-FRONTAL CIRCUMFERENCE
 EYES
No tears are present in the eyes of a baby and they become
easily infected
Each eye should be visualised to confirm that it is present
and the lens is clear
The baby may open his eyes spontaneously if held in an
upright position
Any slight bleeding or oedema is noted
Observe for jaundice,
The normal space between the eyes is upto 3cms
The inner canthal distance averages 2.5-3cms
Normal eye
Eyelid edema
EARS
Placement and position:-
Draw an imaginary line from the outer canthus of the
eye to the occiput and the top of the pinna should meet
or cross this line.
The upper notch of the pinna should be level with the
canthus of the eye
Abnormal:-low set ears Down’s syndrome, renal
anomalies
Down syndrome
Normal ear Ear tag
 THE MOUTH
The mouth can be easily opened by pressing against the
angle of the jaw. This allows visual inspection of the
tongue, gums and palate.
The palate should be high arched, intact and the uvula
central
The midwife uses her little finger to feel the palate for any
submucous cleft.
Inspect for cleft lip and palate
A normal baby responds by sucking the finger
Precocious teeth may protrude through the central part of
the lower gum
Though usually covered by epithelial
tissue, such teeth may have erupted and be
loose, requiring extraction in the early
neonatal period to prevent their
inhalation.
Inspect for ankyloglossia (tongue tie)
Precocious /natal teeth
CLEFT LIP CLEFT PALATE
Normal tongue Ankyloglossia
Nostrils - Check for patency with no polyps or flaring.
Neck - Check for congenital goitre or enlarged glands.
Limbs and digits - Check for equality, free movement,
fractures, webbed fingers, extra digits and any bony
tissues. Extra digits can be ligated with silk and will fall off
(with the parents permission). Check for Erb's palsy.
The digits should be counted and separated to ensure
webbing is not present
Normal flexion and rotation of the ankle and wrist joints
should be confirmed
Normal nose Dislocated nasal septum
Extra Digits
Webbed fingers
 THE HIPS
Specific exams are done to detect
developmental dysplasia of the hips
NOTE:-care must be taken to avoid producing
an iatrogenically unstable hip
Exams done are:-Ortolani’s test
- Barlow test
 ORTOLANI’S TEST
The baby’s legs are grasped with the flexed knees in the
palms of the examiner’s hands
Femur is splinted between the index and middle fingers
and the thumb
From an adducted position, baby’s thighs are flexed on to
the abdomen and rotated and abducted through an angle
of 70-90 degrees towards the examining surface, while
lifting the trochanter anteriorly.
NO FORCE SHOULD BE EXERTED
If the hip is dislocated,a clunk sound will be felt
Ortolani’s test
 Barlow’s test
Baby’s legs flexed, then, the thigh is grasped loosely
with the examiner’s index and middle finger along
the greater trochanter and the thumb on the inner
thigh.
As hip is gently adducted to 70 degrees, gentle
pressure is exerted in a backwards and lateral
direction
A ‘clunk’ is felt as head of femur dislocates out of
the acetabulum
Chest - Check for continuity of sternum and the shape
of rib-cage, respiratory rate, enlarged breast or absence
of breast tissue .
Abdomen - Should be intact and firm, check for
umbilical hernia and exomphalus (protrusion of
abdominal organs through a defect in the anterior wall).
Abdominal distension is present in hydrops foetalis.
Check for blood oozing from the cord and clamp again if
necessary (cord shrivels within 24 hours, falls off within
6-10 days).
Exomphalus
External genitalia - Confirm the sex of the baby
to rule out pseudo-haemophrodism or intersexes.
In males, check for undescended testes,
hypo/hyperspadias and phimosis.
In females, check for bleeding from urethral and
vaginal orifice. Vaginal bleeding may be due to
excessive hormones from the mother
 THE SPINE
The baby lies prone and midwife examines the back
The spinal column should be continuous
Any swellings, dimples or hairy patches may signify
an occult spinal defect
Neurological Assessment
This entails the checking of reflexes, which deal with the
function of the baby’s nervous system as well as physical
and behavioural assessments.
At the beginning of the examination, observe the baby’s
movements. These movements involve all extremities and
should be random and symmetrical but never
stereotyped
 a) Moro
Support the baby’s head Reflex
and body in supine position about a
centimetre from the cot. Allow the head to drop back. Look at the
baby’s response.
The baby throws out his arms extending the elbows and fingers with
embracing movements of the arms.
The Moro reflex is symmetrical in a normal baby at birth and
disappears after four (4) months.
It is incomplete in the pre-term baby and absent in the baby with
intra-cranial injury.
NB// >>> If the Moro reflex is still present after the age of 6 months,
neurological maturity may be delayed or another neurological disorder
may be present thus the need for further evaluation/ assessment of the
child.
The Moro reflex
 b) TONIC NECK REFLEX
Also known as the ‘FENCING REFLEX’
A fencing position is assumed, that is, the baby lies on the
back, head rotated to one side with one arm and leg partially
or completely extended.
The opposite arm and leg are flexed. This is a manifestation
of the immaturity of the newborn’s nervous system.
Disappears at 6 months of age
Tonic neck reflex
 c) Rooting Reflex
To test for the rooting reflex, gently touch the corner of
the baby’s mouth with clean fingers.
The baby will open his/her mouth turning towards the
stimulus in anticipation of the mother’s nipple.
To check for;
d) Sucking reflex
Place a clean finger in the baby’s mouth noting the sucking
strength.
The sucking reflex is poor in pre-term babies.
 e) Stepping Reflex

The stepping or dancing reflex is present at birth

but disappears soon after.
Once this reflex diminishes, the infant does not
attempt a stepping motion until he/she starts to
walk.
 Hold the infant up, with the feet touching a
surface. The infant will attempt to make some
steps or pressing movements.
Stepping reflex
 f) Grasp Reflex
At birth, the grasping reflex of both hands and feet is present.
The infant will grasp any object you place in their hand, and then
let it go.
They are able to hold on to a finger so securely, that you can lift
them to a standing position.
Stroking the soles of the feet causes the toes to turn downwards
trying to grasp.
By applying traction to the baby's wrists raise them to a sitting
position.
A full term infant will offer a strong resistance while a pre-term
does not resist the pull.
 g) Protective Reflex
Other reflexes include protective reflexes such as:
The blinking reflex, which protects the eyes from bright
light
Sneezing and coughing reflexes used to clear the
infant’s throat
The yawn reflex, which draws additional oxygen
Cry reflex, which helps to withdraw from painful stimuli
Once this examination is completed, the baby
can be placed on the cot for transfer to the
nursery or given to the mother.
After completing the delivery of the baby, you
should transfer the mother to the postnatal ward
where she will rest.
DAILY EXAMINATION OF A NEWBORN
Similar to the first exam but concerned with monitoring daily
changes in the baby and detecting any signs of infection.
OBJECTIVES OF DAILY EXAMINATION OF NEWBORN
To detect any neonatal complications the baby might have
developed since birth and take appropriate action
To detect and rule out any internal congenital anomalies
Assess growth and development of the baby
Monitor progress of the baby
 Procedure of daily examination
PREPARATION:
Review guidelines for daily examination of the newborn
Explain the procedure briefly to the mother to gain her verbal
consent. Wash and dry hands, clean the tray and place cotton wool
swabs in a container, spirit swabs, clamp remover, tape measure,
stethoscope and receiver for used swabs
Have a weighing scale in good working order & Ensure clean, warm
and well ventilated environment. Have a cot ready
Obtain brief history on labour, date and time of birth and birth
order
Ask on immediate condition of the baby after birth and initial
examination findings
 PERFORMANCE:-
Ask the mother to undress the baby but wrap up warmly
Wash hands and expose the baby briefly for general
inspection and cover it as soon as possible
Note the posture, breathing pattern, general color, rash and
skin changes then examine systematically as follows:
The head:
 Examine for resolution of birth injuries, abnormal size
of the head and take head circumference if applicable
 Examine for presence of cradle cap, signs of
dehydration and increased intracranial pressure
(denoted by bulging of the fontanelles).
Eyes: examine for signs of infection e.g eye discharge,
jaundice and resolution of subconjuctival haemorrhage
Ears: observe for signs of infection e.g. leakage of fluid and
note the hygiene behind the ears
Nose: observe for signs of infection and presence of dry mucus
Mouth: observe for cyanosis on the lips, sucking blisters and
signs of oral thrush. Dry lips denote dehydration status.
Neck: assess for hygiene, peeling of the skin at the folds and
presence of a heat rash
Chest: assess for ease of breathing, count the respiratory rate
& the heart rate, presence of breast engorgement, skin
condition e.g. pemphigus neonatorum (excoriation of the skin
because of an infection)
Abdomen: assess for tenderness, the state of the
cord and listen to the bowel sounds ( should be
present)
Genitalia: assess for hygiene on the skin folds, for
females, check for pseudomenses and for males,
enquire for any problem
Buttocks: assess for hygiene, nappy rash and
excoriation of the skin
Limbs( upper and lower): assess for hygiene,
oedema and note movement
Take vital signs e.g. apex beat, temperature and respirations
Take weight and comment accordingly
Make the baby comfortable & communicate your findings to
the mother and advise her accordingly throughout the
examination
Clear the tray and wash hands
Record the examination on the relevant charts and
communicate any abnormal findings to the staff in charge of the
shift
Enquire from the mother the baby’s feeding habits, elimination
and sleeping pattern and interpret accordingly & thank the
mother and leave them comfortable
MINOR
MINORDISORDERS
DISORDERSOF OFAANEWBORN
NEWBORN&&
THEIR
THEIRSPECIFIC
SPECIFICMANAGEMENT
MANAGEMENT
Vomiting
Rash:-
Heat rash
Nappy rash
Mastitis neonatorum
Pseudo-menstruation
Constipation
Oral thrush
Sticky eyes
Moulding
 VOMITING:
Vomit on first day due to irritation of stomach
by swallowed amniotic fluid. Vomiting soon after
feed is due to faulty technique of feeding. If
vomiting persists for longer it leads to some
other conditions
Eruption of papules andHEATblisters
RASH
when baby is kept too
warm.
It occurs when pores in the skin get clooged and sweat cant
get out hence, heat rash develops.
MANAGEMENT
The parents should be advised to:-
Loosen or remove extra clothing from the baby
Let him air dry rather than rubbing him with a towel
NAPKIN RASH
More common in artificially fed babies.
It can be prevented by frequent care and
attention to the napkin area along with
immediate changes of the napkins after each
soiling.
 MASTITIS NEONATORUM
The enlargement of breasts occurs in full term babies of
both sexes on 3rd or 4th day and may last for few days or even
weeks.
Lack of inactivation of progesterone and estrogen after birth
due to immaturity of neonatal liver, leads to further rise in
their levels thus resulting in hypertrophy of breasts.
The local massage, fomentation should be curbed and
mother reassured.
 PSEUDO MENSTRUATION
The development of menstrual like withdrawal
bleeding may occur in above ¼ of female babies after
3 to 5 days of birth.The bleeding is mild and lasts for
2 to 4 days. The local aseptic cleaning of genitals is
advised.
Caused by the withdrawal of maternal hormones
CONSTIPATION

It is commonly met in artificially fed babies.

Management :Correction of the diet and extra
water is usually effective 
ORAL THRUSH
1% gentian violet solution or nystatin
suspension, applied to each side of the mouth
with a cotton swab 3-4 times a day.
STICKY EYES
It may be due to a chemical irritant or bacterial
conjunctivitis due to Staphylococcus.
Rx: Erythromycin (0.5%) ointment every 6 hrs
for 7-10 days.
MOLDING
The head may appear asymmetric in the
newborn of a vertex birth.
Caused by the overriding of the cranial bones
during labor and birth.
Diminishes within few days after birth, so just
reassure the mother.

End
THE NORMAL
PUERPERIUM

Finally…
 NORMAL PUERPERIUM & ITS SPECIFIC
MANAGEMENT
SPECIFIC OBJECTIVES:
At the end of these sessions, students will be able to:
 Define normal puerperium
 State physiological changes that take place in the
mother during peurperium
 Describe the postnatal care given for mother and
baby.
 Describe & manage the maternal minor disorders
during puerperium
 Introduction;
Definitions:
 i) Puerperium is the period immediately following
labour during which, the reproductive organs
return to their pre pregnant stage. Lactation is
initiated, and the mother recovers from the
physical and emotional experiences of parturition.
 Puerperium begins as soon as the placenta is
expelled and lasts for 6 weeks (42 days). It’s the
process whereby the genital organs revert back to
their original pre-pregnancy state (involution).
The puerperium period covers six to eight
weeks following delivery or abortion and is
characterized by:
General organs return to their pre-
gravida state( involution)
Initiation of lactation
General recuperation (recovery) of the
mother
 ii) Post-natal care
The care given by a skilled attendant to
meet the needs of both the mother and the
baby after birth to reduce their risk of
morbidity and mortality as well as to
promote the health and wellbeing of the
mother and baby.
Postpartum care is care given to the mother
from the time of placental expulsion up to 6
weeks after delivery.
 Incidence of maternal & newborn
mortality
 Globally, over 500,000 women die as a result of
pregnancy related conditions. About 60% of these
deaths occur within the first week following
childbirth.
 One million newborn deaths occur within the first
24 hours after birth and 75% of neonatal deaths
occur during the first week of life
 In Kenya, most maternal and newborn deaths
occur in the early postnatal period.
Currently in Kenya, Neonatal mortality
rate is contributing to 60% of infant
mortality rate.
The above rates/incidences therefore
emphasize the importance of
midwives and other involved parties
to offer quality post natal care to the
clients.
THE CARE WHICH IS REQUIRED DURING
PUERPERIUM IS BASED UP ON THE FOLLOWING
PRINCIPLES:-
 Promotion of physical well-being by good nutrition,
adequate fluid intake, comfort, cleanliness, and
sufficient exercises to ensure good muscle tone.
 Early ambulation is insisted to prevent deep vein
thrombosis.
 Establishment of emotional well-being.
 Promotion of breast-feeding/ sound methods of
infant feeding.
 Prevention of possible puerperal complications
 CLASSIFICATION OF PUERPERIUM
Immediate: First 24 hours after child
birth
Early: Includes the first postpartum
week
Remote : Traditionally until the sixth
week post-partum
 Anatomic changes during puerperium
 Uterus: The uterus in pregnancy enlarges by
about 11x its non pregnant weight. Its
growth is influenced by progesterone and
estrogen, which cause hyperplasia and
hypertrophy
 Uterine involution occurs mainly by decrease
in myometrial size and is complete by the 6 th
postpartum week
 LOCHIA
Lochia are the discharges from the
uterus, cervix and vagina for the first
fortnight (14 days) during puerperium.
They are alkaline in reaction and
contain blood, debris of deciduas, and
liquor amnii, lanugo, vernix caseosa and
meconium.
 THE SEQUENTIAL CHANGES IN LOCHIA
 Lochia rubra (red) lasts from the 1st -4th days post-
partumly. Consists of blood, chorion, decidua,
amniotic fluid, lanugo, vernix caseosa and meconium.
 Lochia serosa – lasts from 5th -9th days post-partumly.
Colour is yellowish or pink or pale browne. contains
less blood, more serum as well as leukocytes &
organisms
 Lochia alba- (pale white) lasts from 10th -15th day
post- partumly.
The character of the lochia gives useful information
about the abnormal puerperal state.
 CHARACTERISTICS OF LOCHIA
Should not be excessive in amount
Should never have an offensive odor
Should not contain large pieces of tissue/
debris
Should not be absent during the first 3 weeks
Should proceed from rubra -- serosa – alba
sequentially
 Cervix,vagina, muscular walls, fallopian tubes,
ovaries
Cervix closes during puerperium to remain as a
slit
Inflammatory changes with no clinical signs of
salpingitis occur
The vagina returns to its antepartum state by
the third week
The torn hymen heals and is known as the
carunclae myrtiformes
The voluntary muscles regain tone during
puerperium
Abdominal muscle involution may take
about 6-7 weeks
 The vagina

Although the vagina may never return to its

prepregnancy state, the supportive tissues of the
pelvic floor gradually regain their former tone.
Women who deliver vaginally should be taught
and encouraged to perform Kegel exercises
(intermittent tightening of the perineal muscles)
to maintain and improve the supportive tissues of
the pelvic floor by tightening the perineal
muscles.
 Physiologic changes
Fluid and electrolyte balance
The baby and placenta weigh about 5kg
After their delivery about 4kg is lost in form
of fluid
Electrolyte balance is back to normal by the
end of the first week
 Metabolic and chemical changes
During early puerperium blood sugar
falls to below that in pregnancy,
especially the 2nd and 3rd day
There is an increase in free amino acids
 Cardiovascular changes
 Immediately following delivery, there is a marked
increase in peripheral vascular resistance due to
the removal of the low-pressure uteroplacental
circulatory shunt.
 The cardiac output and plasma volume gradually
return to normal during the first 2 weeks of the
puerperium. As a result of the loss of plasma
volume and the diuresis of extracellular fluid, a
marked weight loss occurs in the first week.
 Cardiovascular changes cntd…
There is an increase in
thromboxane(vasoconstrictor or that of
prostacyclin(vasodilator)
Blood volume decreases from 5-6 l to 4l by the
third week.
Mean loss is 500ml in vaginal birth and 1500ml by
cesarean section or delivery of twins or triplets
Haematopoesis: During pregnancy there is an
increase of haematocrit by 30% about 15 % of
this is lost after delivery
 Return of Menstruation and
ovulation
 In women who do not nurse, menstrual flow
usually returns by 6 to 8 weeks, although this is
highly variable.
 Although ovulation may not occur for several
months, particularly in nursing mothers,
contraceptive counseling and use should be
emphasized during the puerperium to avoid an
undesired pregnancy.
 The Psychology of the Mother
During Puerperium
 During the puerperium the mother is subjected to
emotional turmoil and you must be supportive and
observant. She should be allowed to cuddle her baby
and express her love as she wishes. This maternal
instinct is at times delayed.
 The midwife should be kind, patient, and
compassionate towards the mother and give her the
necessary education concerning her and the baby.
Each mother should be taken as an individual based
on her maternal experience, educational background,
maturity and parity.
 Mothers should be given all the information
necessary to ensure they know how to care for
their babies.
 ‘Rooming in’ is the term given when a hospital
plans for the mother to stay with the baby for
most of the 24 hours in a day. It is highly
recommended because it has been seen to have
great psychological advantages for both mother
and baby.
 Bonding commences immediately and demand
breast-feeding can be successfully practiced
 General Involution
 Every system in the body is affected during this
process, including the heart and circulatory system.
With the cessation of the utero-placental
circulation, the work done by the heart decreases.
The quantity of blood required also gradually
returns to normal. The renal and musculo-skeletal
systems also return to normal.
 Involution of the Uterus
DEFINITION
 The uterus returns to its normal site, tone &
position of non pregnant state Mechanism
 The size of the pregnant uterus is 30 x 22 x 20cm
and it weighs 1000gms at the end of labour. It is
15 x 11 x 7.5cm by the end of puerperium.
 Involution takes place, by which point it measures
7.5 x 5 x 2.5cm and weighs 60gms.
 Involution is the return of the uterus to its normal
size, position and tone and is brought about by
autolysis and ischaemia.
Autolysis is a process by which muscle
fibres are digested by the proteolytic
hormone. The muscle fibres have to
dissolve a large amount of their protein in
order to achieve this reduction in size.
This means that a great deal of nitrogen is
excreted by the body in the urine together
with the excess fluid retained during
pregnancy.
This is why a lot of urine containing large
amounts of nitrogen is excreted during the
first few days after delivery. In addition, the
epithelial lining of the uterus, other cellular
debris, and red blood cells are expelled as
lochia from the uterus.
 Ischaemia is localized anaemia of the uterus,
which occurs when the placenta is expelled. Blood
vessels are constricted, which results in the
reduction of the blood supply to the uterus. The
phagocytes dispose of the redundant muscle fibre
and elastic tissue. The vagina, ligaments of the
uterus and muscle of the pelvis also return to
their pre-gravida state. If not, prolapse of the
uterus may occur later.
 Lining of the uterus is cast off and is replaced first
by granular tissue and then by endometrium
PROGRESS OF CHANGE IN THE UTERUS AFTER DELIVERY

WEIGHT OF DIAMETER OF CERVIX

UTERUS PLACENTAL SITE

END OF 900GMS 12.5CMS SOFT,

LABOUR
END OF 1 WK 450GMS 7.5CMS 2CMS

END OF 2 200GMS 5CMS 1CM

WKS
END OF 6 60GMS 2.5CM
WKS
 Onset of Lactation
 Lowered oestrogen levels trigger the production of
prolactin from the anterior pituitary gland, which
initiates lactation.
 The maintenance of lactation depends on putting
the baby on the breast, but secretion of milk
commences on the third to fourth day.
 The baby should be put on the breast immediately,
which leads to oxytocin release and assists in
keeping the uterus well-contracted & also triggers
the milk let down reflex
 Specific Management of Normal
Puerperium
The aim of managing the puerperium is to:
Maintain the mother’s good health
Aid involution of the pelvic area
Promote exclusive breast-feeding
Prevent infection and other puerperium
complications
Educate the mother on the proper care of
her own health and the baby
 Care of the mother
After the birth of the baby & expulsion of the
placenta:
Clean perineum & apply sterile pad
Make her comfortable
Give her a cup of tea and something light to
eat (immediate)
Allow her to rest
Record vital signs:
4 hourly for the 1st & 2nd day
then twice daily
if elevated as doctor ordered
Check for any bleeding & intervene
appropriately
The mother and the baby should be
examined daily and if any abnormality is
noted, the doctor should be informed.
Perform a daily post natal examination of
the mother as described below:
 PERFORMING DAILY POST NATAL
EXAMINATION OF THE MOTHER.
 Briefly explain the procedure to the mother and ask
her to empty the bladder.
 Have the environment prepared i.e. close the
nearest window and screen the bed
 Assemble the necessary equipment i.e. vital signs
tray, tape measure& clean gloves
 Wash hands and wear gloves
 Instruct the mother to lie on the bed with only one
pillow under her head
 Examine the head for hygiene and general neatness
of the hair
 Examine the eyes for anaemia, jaundice and sight
problems
 Examine nose and ears for signs of infection, hygiene
and hearing problems
 Examine the mouth for signs of dehydration and
general oral hygiene
 Neck, check for hygiene, enlargement of the thyroid
and lymph glands
 Check the chest for breathing, breasts for signs of
infection and success of lactation
 Examine the abdomen for size, shape and
organomegally. Examine for involution of the
uterus i.e. size, consistency and take the fundal
height. The fundal height should reduce by 0.5 - 1
centimeter daily.
 Examine the upper limbs for hygiene, pallor,
oedema, muscle wastage and tremors
 Examine the lower limbs for hygiene, oedema,
muscle wastage, signs of varicosity and D.V.T.- by
checking on the calf muscles
 Instructthe mother to remove pad. Inspect lochia
for colour, consistency, amount, smell and compare
the findings with expectation. Check perineum for
hygiene, oedema, healing of laceration, episiotomy
or tear.
Ifthere is persistent lochia rubra, this points to
the need for further investigation. Offensive
lochia odour denotes infection.
Advise the mother to wash the episiotomy at
least four times a day with salt water and
change the pad as soon as it is soiled and after
she goes to the toilet.
 Take the vital signs and enquire on the feeding
habits, elimination and the sleeping pattern of the
neonate
 Advice the mother accordingly during the
examination and congratulate her appropriately
 Leave the mother comfortable; communicate
your findings in simple terms. Allow the mother
to ask questions
 Clear the trolley or tray & un-screen the bed
 Record the findings on the relevant charts and
report any abnormalities for further
intervention(s).
 Specific management of puerperium ctd’
Ambulation is important to prevent deep
venous thrombosis. Encourage the mother
to walk around and keep the bladder
empty.
Take her temperature, pulse, respiration
and blood pressure twice daily.
Check the breasts and if she is not lactating,
express colostrum.
 Increase expressing on the second day and milk should
be sufficiently established by the fourth day.
 Advise the mother on how to feed the neonate.
 When fixing the baby on the breast she should put
the whole areola in the baby’s mouth.
 She should initially breast feed the baby for three
minutes to prevent cracked nipples and empty the
breast in cases where the baby does not feed a lot.
This is especially important in the first days to
prevent engorgement.
 THE 6 WEEKS POST NATAL EXAMINATION
 This is carried out during the sixth post-partum week
PURPOSE
 Toassess the general physical & emotional health of the
mother
 To assess whether the reproductive organs have gone
back to their pre-gravid state
 To evaluate family planning needs
REQUIREMENTS
A trolley containing:
Top shelf: a vaginal examination pack containing speculum
Bottom shelf:
A bowl with cotton wool swabs
Antiseptic lotion in a bucket of warm water
Transport media container
Lubricant
Sanitary pads
Bed linen
A clean gown
Vital signs tray
Sterile gloves
Clean gloves
Clock
 Accessories:
Mother’s notes
Coded bin
Potarble light
Weighing scale
Baby cot
FP devices
Urine jug
 Collect information on:
Mother’s health status & menses
Baby’s feeding, sleeping, growth & immunization status
Explain the procedure to the mother
Ensure that the bladder is empty
Assist the woman in supine position on the
couch
Screen the bed
Take vital signs
Assess the state of health & note whether calm,
happy or depressed
 Exclude pallor of the conjuctiva, tongue, palm &
fingers
 On the chest note;
Respirations, size & shape of the breasts
State of nipples, whether cracked, sore, flat,
inverted or prominent
Examine breasts for lumps
Educate her on breast examination
 Abdomen: inspect firmness of the muscles & palpate
for uterine involution
 Genitalia: inspect for cleanliness, discharge, oedema,
sores, warts and note state of episiotomy & tears
 Perform a digital vaginal or speculum examination.
A pap smear should also be done for detection of
cancerous cells on the cervix
 Dry the vulva and leave her comfortable
 Examine the legs for varicose veins, oedema and
tenderness
 Highlight important findings and inform the mother
 Counsel the mother on FP & Future pregnancies
 Share health talks with the mother on exclusive
breastfeeding, hygiene e.t.c.
 EMTCT OF HIV IN PUERPERIUM
Goals of interventions:
These are to:
 Provide follow-up post-partum care including a postnatal visit
within 3 days
 Improve the quality of the mother’s health and reduce mortality
by including family planning counseling and cervical cancer
screening where applicable
 Provide post-exposure prophylaxis for exposed infants
 Reduce postnatal HIV transmission through breastfeeding
 Identify all HIV-exposed infants
 Reduce mortality in HIV-exposed infants
 Identify all HIV-positive infants and start ART early
SPECIFIC POSTPARTUM CARE IN EMTCT INCLUDES:-
 Ongoing treatment, care and support for new HIV-
positive mother, including referral for ARV therapy
if eligible
 EID (early infant diagnosis) for HIV exposed infants
 Education on personal hygiene to prevent
contamination of baby with maternal blood and
other secretions
 Nutritional counseling and support for both
 Early detection and seeking care for HIV-related
conditions, including TB and malaria.
 Family planning options including the need for dual
protection
 Advice on breast care depending on her feeding
option
 Discuss partner Counseling &Testing
 Cervical cancer screening at 6 weeks

###
 TARGETED
POSTNATAL CARE
Definition of targeted post natal care

 Targeted postnatal care is an approach,

which defines a set of postnatal care
services delivered to both the mother and
baby in a minimum of four visits spread
throughout the first six months following
delivery.
 Elements of targeted postnatal care
These include the following:
a) Maternal care:
 Health promotion using health messages and counselling (e.g.
on nutrition and resumption of sexual activity)
 Assist the mother and her family to develop a personalized PNC
(post-natal care) plan
 Provision of Essential postpartum care by a skilled attendant
 Early detection of post-partum danger signs and treatment of
problems
 Elimination of mother to child transmission of HIV (EMTCT)
 Emergency Preparedness and Complication
readiness post-partumly
 Counselling and service provision for
Postpartum FP / healthy timing and spacing
of pregnancy
 Screening for other conditions e. g cervical
cancer, breast cancer, STI/RTI’s
 Ct… Elements of targeted postnatal care
b) Newborn care
 Provision of Essential Care of the Newborn.
 Counselling on infant and young child feeding
 Early detection of major neonatal danger signs
and treatment of problems
 Immunization.
 Schedule of targeted postnatal care
visits
The recommended schedule for Kenya is as
follows:
1. Within 24-48 hours = visit 1
2. 1 to 2 weeks = visit 2
3. 4 to 6 weeks = visit 3
4. 4 to 6 months = visit 4
 1st VISIT i.e. within 1ST 24-48 hours
 NOTE:
The initial assessment should be carried out as
soon as possible after delivery.
In case of a facility birth, the mother and baby
should be checked again before discharge.
Where delivery has occurred at home, both
mother and baby should be reviewed by a skilled
provider as soon as possible within 24/48 hours
 1st visit. Check /perform:
Mother Baby
• Physical assessment: Pallor, • Apgar scoring
Temperature, Blood Pressure, • Take temperature
uterine involution, • Take and record birth weight
• Inspection of the C/S wound- if • Head to toe examination
present- for bleeding
• Assess for danger signs for baby
• Assess lochia and blood loss
• Observe a breast feed &
• Breast examination for
interpret appropriately
establishment of lactation,
• Calf tenderness to rule out DVT
 Danger signs in newborns
There are 8 major danger signs in newborns:
1.Poor feeding
2. Lethargy
3. Convulsions
4. Hypothermia
5. Hyperthermia
6. Chest indrawing
7. Fast breathing (>60 breaths/min)
8. Neonatal Jaundice
 2nd visit. Check /perform:
Mother Baby

• Mental status • Growth monitoring; chart

• Pallor, BP, temperature, pulse rate weight
• Lochia loss- (Colour, amount, • Head to toe examination
smell) • Assess for danger signs for baby
• Assess for calf tenderness • Check eyes for discharge
• Infection /pus from C/S site or • Immunization status
perineal wound
• Observe a breast feed
• Breast condition
• Uterine involution
• Observe a breast feed
 3rd visit. Check /perform:
Mother Baby

• General condition of mother, • Growth monitoring; chart

head to toe physical exam weight
• Mental status • Head to toe examination
• BP, Weight, temperature • Assess for danger signs for baby
• Uterine involution • Immunization status
• Lochia (amount /Colour)
• Observe a breast feed
 4th visit. Check /perform:
Mother Baby
Check:
• Check the general health of mother • Growth monitoring; chart weight
Provide:
• Head to toe physical
• FP method of choice
examination
• Screening for RTI /STI
• Assess for danger signs for baby
• Screening for cervical cancer –if not
done • Immunization status
• Screening for TB
• Clinical Breast examination
• Treat or refer any complications that
are detected
Minor ailments/ disorders of puerperium &
Their specific management
 Postpartum blues
 After pains
 Sub-involution
 Pain on the perineum
 Breast related disorders- breast engorgement,
sore & cracked nipples
 Postnatal diuresis
 Constipation
 Postpartum Tears or Fourth Day Blues
A minor disorder during puerperium
This condition is characterized by mild
depression and mood swings due to a
temporary endocrine hormonal imbalance
following childbirth.
It occurs in fifty 50% of post-natal mothers on
around the fourth day.
 CLINICAL FEATURES OF POST PARTUM BLUES
INCLUDE:-
 Inappropriate guilt or negative feeling towards self
 Decreased interest or pleasure in normal activities
 Mother feels tired and /or agitated all the time
 Disturbed sleep (too much or too little, waking early)
 Diminished ability to think or concentrate
 Marked loss of appetite, loss of libido
 Rejection of the baby and
 Mother cries easily
 SPECIFIC MGT OF POST PARTUM
BLUES
 A midwife should try to prevent the 'blues' by educating
the mother during the pre-natal period on how to take
care of herself and the baby to build up her confidence
 The woman needs to be assured that the experience is
quite common and that many women experience the
same thing.
 Theprovider should listen to her concerns and give her
emotional encouragement and support.
 The partner and family need to be counselled to provide
assistance to the woman.
 Management of post-partum blues
cntd’
 Teach the mother how to check for minor
discomfort and the relevant remedies to
reduce the feeling of anxiety that the baby is
ill whenever they cry.
 She should be followed up in two weeks and
referred if no improvement is noted to
prevent occurrence of major depression.
Note:
Any prolonged episodes of depression
during or after pregnancy should receive
urgent psychiatric attention.
 AFTERPAINS
 It is the spasmodic, intermittent pain felt in the
back and lower abdomen after delivery for a
variable period of 2-4 days.
 It is often felt more frequently while breast-
feeding. Presence of blood clots or bits of the
after the birth leads to spasmodic hypertonic
contractions of the uterus in an attempt to expel
them out.
 MANAGEMENT

 Massage the uterus with expulsion of the

clot.
 Administer analgesics (ibuprofen) and
antispasmodics
 SUBINVOLUTION

Term used to describe a uterus that remains

large and fails to reduce in size and in mass
following child birth.
It may result from retained placental
fragments, infection and myoma.
 Sub-involution is suspected if the following
occurs:
The lochia fails to progress from rubra to
serosa
The woman gives a hx of excessive bleeding
Uterus is tender on palpation (suggests
endometritis)
Leucorrhoea and backpain
Enlarged uterus is palpable
 MGT OF SUB-INVOLUTION

Evaluate for the cause and manage

appropriately e.g. completely remove all
products of conception
oral antibiotics : usually effective in metritis
 PAIN IN THE PERINEUM

 Some degree of pain is felt in the

stitches.
 Abnormal pain should be investigated to
diagnose vulvo-vaginal hematoma or
infection is developing.
 RELIEVING MEASURES
 After using the bathroom, spray or pour warm
water over the entire vaginal area.
 Encourage mother to pat the area dry, making
sure to start at the front and end at the back to
avoid spreading germs from the rectum to the
vagina.
  
To reduce the swelling; 
Apply Ice packs
 Wrap the ice pack in a washcloth or
other soft or absorbent material. Do not
directly apply the ice
 Sitz bath

Encourage the mother to sit in a tub with

2-3 inches of warm salty water for about
15 minutes, three times in a day
 Care of perineal stitches
Clean and dress the perineal area daily
and cover with sterile pad.
Swabbing should be done from above
downwards
 Breast related disorders
BREAST ENGORGEMENT
 May occur about the third day postpartum and is
often regarded by mothers as the result of the milk
coming in.
 It is due to exaggerated normal venous and
lymphatic engorgement of the breasts which
precedes lactation.
 The mother approaches with pain and tense
feeling of the breasts, generalized malaise and
painful breastfeeding
 SPECIFIC mgt
 Encourage the mother to consume lots of fluids.
 Support the breasts with a binder or brassiere.
 Apply hot bags on breast before nursing and ice
bags after.
 Express the milk manually.
 The baby should be put to breast regularly after
the expression of milk.
 Analgesics may also be prescribed to relieve pain
 Sore, cracked and damaged nipples

Caused by trauma from the baby’s mouth and

tongue which results from incorrect
attachment of the baby to the breast.
Nipples should be kept dry and exposed to air
Other causes of soreness is infection with
candida albicans and both baby and mother
should receive concurrent fungicidal
treatment.
 Recommended Methods of Treatment
for Cracked Nipples
Rest the breast for 24 hours or until the
crack is healed
Meanwhile express the milk manually
Expose the breast to the air for 20 minutes
six hourly or to an electric lamp 30cm
distance to promote healing
 Prevention of Breast Complications
 Encourage breastfeeding by providing information on
the advantage of breastfeeding.
 Educate the mother during prenatal care on the
prevention of breast complications. Help her to fix
the baby properly on the breast.
 Stress the importance of emptying the breast by
manual expression in case of excess milk, to avoid
engorgement.
Emphasise the importance of infection
prevention, including prompt treatment
of any members of the family with boils,
burns or any skin lesions.
 Postnatal diuresis
 Within 12hrs of the birth the women
begins to lose excess tissue fluid
accumulated during pregnancy.
 The profuse diaphoresis occurs
especially at night for the first 2-3 days
after childbirth
 Causes of post natal diuresis
 Decreased estrogen levels
 Removal of increased venous pressure in
the lower extremities
By the above mechanisms the body rids itself
of excess fluid in the body
 SPECIFIC mgt
Keep the mother clean and dry
Change her dress frequently
Change the bed sheets frequently
Care must be taken to ensure that the
mother is well hydrated.
 CONSTIPATION
The problem is much less because of
early ambulation and liberalisation
of dietary intake.
Encourage the mother to take a diet
containing sufficient amount
of roughage and fluids is enough to
move the bowel.
 Post-partum danger signs to be
reported immediately
 Increased vaginal bleeding (more than 2 or 3 pads
soaked in 20-30 minutes after delivery OR bleeding
increases rather than decreases after delivery)
 Fits (convulsions)
 Fast or difficult breathing
 Fever and Excessive body weakness (e.g. too weak to
get out of bed)
 Severe abdominal pain
 Severe headaches with blurred vision
 Swollen, red or tender breasts or nipples
 Problems urinating, or leaking of urine and/or
faeces
 Increased pain in the perineum
 Infection in the area of the wound (redness,
swelling, pain, or pus in wound site)
 Foul smelling vaginal discharge.
 Major Complications of
puerperium
 Postpartum haemorrhage
 Deep Venous thrombosis
 Pulmonary embolism
 Retention of urine or retention with overflow
 Urinary tract infection
 Puerperal sepsis and pyrexia
 Puerperal psychosis

END
 SUMMARY-
SUMMARY- 3 & 4THMONTHS
3 RD
RD & 4 TH
MONTHS
1. NORMAL LABOUR: Specific management of first
Preliminaries/ Preambles: stage of labour
Review of definitions (labour Physiology & specific mgt of
& normal labour) second stage of labour
Causes associated with onset Physiology & specific mgt of
of labour third stage of labour
Clinical features- premonitory The 4th stage of labour & the
& true signs of labour specific management
Physiology of first stage of
labour
 2. NORMAL NEONATE: 3. NORMAL PUERPERIUM:
• APGAR scoring • Physiology & specific
• Physiology of the normal management of a
neonate puerperal mother
• First/initial examination • Daily & six weeks post
• Daily/routine examination natal examination of the
• Minor disorders of the mother
neonate • Targeted post natal care
• Minor disorders in
puerperium
###
THANKYOU...