True and False Labor

TRUE FALSE
Location back to abdomen groin to abdomen
Regularity regular irregular
Intensity increases mild to tolerable
Frequency more frequent changing frequency
Pain can’t be relieved can be relieved
Show bloody/pinkish none
Amniotic Fluid rupture w/ amniotic fluid present none
Cervical Dilation effacement & dilation none
Ambulation contraction continues no matter what position contractions fade on ambulation

Stages of Labor
First Stage (Bearing Stage)
• Begins w/ true labor contractions and ends w/ the cervix in
full dilation (10cm)
• Objectives: to provide comfort to the mother
• Latent / Resting / Preparatory Phase
o Nullipara: 6 hours
o Multipara: 4.5 hours
o Dilation: 0-3cm
o Contraction Duration: 20-40 seconds
o Contraction Frequency: 5-7min
o Woman can still walk around doing last minute things
• Active / Descent Phase
o Nullipara: 3 hours
o Multipara: 2 hours
o Dilation: 4-7cm
o Contraction Duration: 40-60 seconds
o Contraction Frequency: 3-5min
o Contractions start to be stronger and woman realizes
that labor is truly progressing
• Transition / Advance Active Phase
o Nullipara: 2 hours
o Multipara: 1 hour
o Nullipara: effaced before dilated
o Multipara: dilated before effaced
o Dilation: 8-10cm
o Contraction Duration: 60-90 seconds
o Contraction Frequency: 2-3min
o Woman is fully concentrated on pushing and will push
away any person trying to provide support to her
Second Stage (Fetal/Pushing Stage)
• Begins when the cervix is fully dilated and effaced up to the
birth of the infant
• Objectives: to deliver the fetus safely and maintain the
mother’s safety
o Crowning – vaginal introitus opens and fetal scalp
appears at the opening
o Episiotomy incision is made
o Ritgen’s Maneuver –pressing forward on the fetal chin
while pressing downward on the occiput
o Crede’s Maneuver – applying gentle pressure on the
contracted uterine fundus (never apply pressure on an
uncontracted uterus)
• Nursing Management
o Suction baby’s mouth then nose
o Clamp cord
o Assess AVA
o Trendelenburg position for baby
o Uterine contractions palpated continuously
Third Stage (Placental Stage)
• Begins with the birth of the infant up to the delivery of the
placenta (5-20 min)
• Objectives: delivery of the placenta and prevention of
infection and complications
o Placental Separation – signified by lengthening of
umbilical cord, sudden gush of blood (300-500mL)
uterus rise and becomes globular
o Placental Expulsion – delivered either by natural
bearing-down effort of the mother or by Crede’s
Maneuver
o Methergine and/or oxytocin may be given to stimulate
contractions further
• Nursing Management
o Note time of delivery of placenta
o Assess uterus, fundal height, and consistency
o Fundus should be in line with umbilicus
o Inspect perineum for lacerations

Fourth Stage (Recovery Stage)

• 1-4 hours after placental delivery
• Objectives: prevent complications
• Most dangerous stage for mother
• NSVD Blood Loss: 300-500mL
• CS Blood Loss: 500-1000mL
• Monitor maternal V/S continuously
Immediate Newborn Care
1. Promotion of Mother-Infant Bonding
Once the baby’s cord is cut, place the baby on the mother’s abdomen where a sterile cloth has
been placed ready for the baby. Then wrap the baby exposing the face for transfer to the
bassinet.

2. Promotion of Patent Airway

Place the baby in the bassinet with the head lower than the feet. Using the bulb syringe or suction
bulb, remove the mucus from the mouth then t the nose. In suctioning, press the bulb before
inserting into the intended cavity and allow bulb to go back to its original form. You may stimulate
the baby to cry by rubbing the back.

3. General Assessment using APGAR Scoring

Appraise the infant’s condition based on the following five signs: heart rate, respiratory effort,
muscle tone, reflex irritability, and skin color. Evaluate each criterion for one minute of life. Repeat
the process after five minutes and then after ten minutes. Score each sign using the correct form
guided by the APGAR chart. Add the scores of each sign to get the total APGAR score.

4. Provision of Cleansing Bath

Get sterile gauze soaked in container with antiseptic solution. Cleanse the baby starting from the
face, back portion of the head down to the lower extremities. Pay particular attention on the skin
folds. Change gauze once it is soaked with blood, tissues, and vernix caseosa. Once the baby is
clean, wipe the skin with dry sterile gauze following same sequence – head to toe.

5. Application of Eye Prophylaxis

Instill 1-2 drops of 1% Silver Nitrate / Garamycin / Gentamicin / Neosporin into the conjunctival
sac of each by separating the eyelids making sure that the tip of the container will not contact with
the baby’s eye.

6. Provision of Cord Care

Change gloves to a new pair after preparing the needed materials to be used. Then clean the
cord three times using cotton pledgets soaked with betadine starting from the base of the cord up
to 4-5 inches. Repeat the procedure using pledgets with alcohol. Clamp the cord one inch from
the base using a cord clamp and cut the cord half inch from the clamp using a surgical scissors.
Press the stump with sterile gauze until there is no bleeding. Then clean the cord stump three
times using cotton pledgets soaked with betadine starting from the stump to the base. Repeat the
procedure using the pledgets with alcohol. Include the clamp in the application of the antiseptic.

7. Provision for Temperature Taking

Lubricate a clean rectal thermometer with baby oil. Insert it in the baby’s rectum in a rotating
manner just enough that the bulb is inside by lifting the legs to expose the anal sphincter for 2-3
minutes. Take note of the result. Other parts of the body should be wrapped with dry cloth.

8. Provision for Measurement & Weight Taking

Using a tape measure, take the height of the baby from the tip of the head to the tip of the heel.
For the head circumference, make sure that the tape measure is placed just above the eyebrows.
For the chest circumference, place the tape measure at the nipple line. Take the mid-arm
circumference by placing the tape measure in the middle part of the upper arm. Measurement
should be in centimeters. Then weight the baby by placing him on the weighing scale without any
clothes on. Convert the results from pounds/ounces to grams/kilograms.

9. Provision of Parenteral Administration of Vitamin K

Prepare drug for IM administration. Expose one led and disinfect upper 1/3 of the lateral aspect of
the femoral muscles following the correct technique. Inject 0.1cc of the drug if the baby is mature,
and 0.05cc of the drug if premature (based on hospital policy). Follow correct principles in
injecting the drug.
10. Provision for Identification
Fill up the identification bracelet properly and place it around the baby’s wrist. Make sure that it is
not too tight or loose. Do foot printing. Wrap the baby properly.