PAIN PATHWAY

Endings of the small peripheral nerve fibers detect a stimulus

Transmit to the cells in the dorsal horn of the spinal cord

Impulses pass through a dense, interfacing network of cells in the

spinal cord (substantia gelatinosa)

A synapse occurs that returns the transmission to the

peripheral site through motor nerve

Impulse then continues in the spinal cord to reach

the hypothalamus and cortex of the brain

Impulse is interpreted and perceived as pain

 Principles
• A woman needs to come into labor
informed about what causes labor pain
and prepared with breathing exercises to
use to minimize pain during contractions
• A woman experiences less pain if her
abdomen is relaxed and the uterus is
allowed to rise freely against the
abdominal wall with contractions
 Principles
• Using the gating control theory of pain
perception – distraction techniques
 METHODS FOR PAIN MANAGEMENT
A.GATE CONTROL MECHANISMS – involves halting an
impulse at the level of the spinal cord so the impulse is
never perceived at the brain level as pain – a process
similar to closing a gate occurs
3 TECHNIQUES
1. Cutaneous stimulation- ability of the small nerve fibers
at the injury site to transmit pain impulses appears to
decrease if the large peripheral nerves next to the
injury site are stimulated.
Ex. Rubbing an injured part; applying TENS; heat/cold;
effleurage
2. Distraction – if the cells of the brain stem that register
an impulse as pain are pre-occupied with other stimuli,
a pain impulse will not register. Ex. Breathing
techniques – increases oxygenation– decreasing pain
3. Reduction of anxiety – pain are perceived more quickly
if anxiety is also present.
Focusing/Imagery

• Focusing/Imagery –
sensate focus like
photograph of her
husband/children, a
graphic design, or
something appeals to
them
B. Bradley Method (Partner-coached) Method:
- pregnancy is a joyful natural process and stresses
importance of the husband
- Pain is reduced by: abdominal breathing, walking
during labor

C. Psychosexual Method (Sheila Kitzinger):

- stresses that pregnancy, labor and birth and the
early newborn period are important points in woman’s
life cycle
- program involved conscious relaxation and levels
of progressive breathing that encourages the woman
“to flow with” rather than struggle against contractions
of labor.
D. Grantly Dick-Read Method:
- fear leads to tension and tension leads to pain
- achieves relaxation and reduced pain in labor by using
abdominal breathing during contractions

E. Lamaze Method (Ferdinand Lamaze):

- based on stimulus-response conditioning. To be effective,
full concentration on breathing exercises during labor
should be observed.
- psychoprophylactic method: preventing pain during labor
(prophylaxis) by the use of mind (psyche)

6 Major concepts:
1. Labor should begin on its own
2. Woman should move freely throughout the labor
3. Woman should continuously receive support during labor
4. No routine interventions such as IVF
5. Allow woman to assume a non-supine position
6. Mother and baby should be housed together following birth
 Relaxation Techniques:
1. Conscious relaxation – relax the
body so woman does not remain
tense and unnecessary muscle
strain and fatigue during labor.

2. Cleansing breath – woman

breaths deeply and then exhales
deeply
 Relaxation Techniques:
3. Consciously controlled breathing
Level 1: slow chest breathing (comfortable but full
respirations 6 - 12 bpm)
Level 2: breathing lighter than level 1. rib cage expands
lightly the diaphragm barely moves. RR up to
40/min
– good for contractions when cervical dilation
is 4 & 6 cms.
Level 3: Breathing is shallow mostly at the sternum, rate
50 –70 bpm. Keep the tip of the tongue against
the roof of her mouth. Cervical dilation 7 & 10
cms.
 Relaxation Techniques:
Level 4: uses “pant-blow pattern”- 3-4
quick breaths then a forceful
exhalation. “choo-choo”
“hee-hee-hee-hoo”

Level 5: chest panting is continuous, very

shallow, 60 bpm. Prevents pushing
before dilation
1. Hospital birth:
(LBRPs)
2. Alternative Birthing Centers:
- are wellness-oriented childbirth facilities designed to
removed childbirth from the acute care hospital setting
while providing enough medical resources for emergency
care should complication of labor and birth arises.
- woman is encouraged to express her own needs and
wishes during labor, she can choose a birth position, bring
her own music or distraction objects and partner can
perform such tasks such as cutting the cord, woman
remains 4 to 24 hours after birth.
3. Home Birth:
- it allows for family integrity, puts the responsibility on the
woman to prepare the house and take care of her infant
after birth.
4. Alternative Methods of Birth:
a. Leboyer – (from a warm, fluid filled intrauterine environment
to a noisy, air filled brightly lit birth room creates
major shock.)
- the birthing room is darkened so there is no sudden
contrast in light, keep pleasantly warm, soft music is
played, infant handled gently, cord is cut late, placed
in a warm-water bath.

b. Hydrotherapy and Water Birth:

- reclining or sitting in warm water labor can be
soothing, feeling of weightless and relaxation can
reduce discomforts, ex. Labor in shower, spa tubs
- difficulties water contaminated with feces,
aspiration, maternal chilling.
• 5. Unassisted Birthing – freebirthing or
couple birth = woman giving birth without
healthcare provider supervision
• It differs from home birth…
• It needs no medical supervision
 LABOR
a series of continuous,
is a series of events by the progressive contractions
which the uterine of the uterus which help
contractions and the cervix to open (dilate)
abdominal pressure expel and to thin (efface),
a fetus and placenta from a allowing the fetus to move
woman’s body. through the birth canal
Theories of Labor Onset

Uterine any hollow organ when

Stretch Theory stretched to capacity will
contract and empty
 Nipples are stimulated
Nerve impulses travel from
nipple to the hypothalamus
Stimulates posterior pituitary
gland to produce oxytocin
Causing uterine contraction
2nd Theory of
Labor Onset
Oxytocin theory –
oxytocin is an effective
stimulant of uterine
contractions in late
pregnancy and is
commonly used to induce
labor
 3rd Theory of Labor Onset

PROGESTERONE – inhibits uterine contraction

Progesterone deprivation

Onset of labor

Withdrawal of progesterone

At a time estrogen predominance (uterine contraction)

4th Theory of Labor Onset PROSTAGLANDIN
THEORY
PROGESTERONE DEPRIVATION and
ESTROGENPREDOMINANCES

Set-off production of cortical steroids

Act on lipid precursors

Releases arachidonic Acid

Increases synthesis of prostagladins (uterine contraction)

 Theory of
Aging
Placenta

Decrease
5th Theory of Labor Onset nutrients

UTERINE
CONTRAC- Decrease
blood supply
TIONS
 COMPONENTS OF LABOR:

• Passageway •Passenger

Route of Fetal
travel position

Uterine
Positive contraction
experience (Cervical
dilatation &
• Psyche •
expulsion) Power
Size of the maternal Type of maternal
pelvis -diagonal pelvis
conjugate (AP
diameter of the
inlet) and transverse
diameter outlet
Passageway

Route of the fetus

Ability of the cervix
to travel to dilate and efface
PASSENGER
I. Fetal head – the body part that has widest
diameter
II. Fetal skull
a. Cranium – uppermost portion of the skull
8 bones:
 Frontal
 Two parietal the four superior bones
 Occipital
 Sphenoid
 Ethmoid lies at the base of cranium
 Two temporal bones
Fetal skull (vertex view)
Sutures– are membranous spaces between
the cranial bones
- allow for molding (overlapping of
the bones)
a. Sagittal suture line – joins the two
parietal bones of the skull
b. Coronal suture – joins the frontal bone
and the two parietal bones
c. Lambdoid suture – joins the occipital
bone and the two parietal bones
d. Frontal (mitotic) suture – joins the two
frontal bones, becomes the anterior
continuation of the sagittal suture
Fetal skull (vertex view)
Molding - changes in shape of the fetal skull produced
by the force of the uterine contractions pressing the
vertex against the not-yet dilated cervix.
BRAIN EXERCISE
• Your skull sutures are still open at this
point?
• A. TRUE
• B. FALSE
• Your skull sutures are still open at this
point?
• A. TRUE
• B. FALSE
Fontanelles – the intersections of the cranial
sutures

ANTERIOR FONTANELLE

Diamond Shape

It permits growth of the brain

by remaining unossified for
12-18 months
 POSTERIOR FONTANELLE

lies in the junction of the

lambdoidal and sagittal
sutures

triangular-shaped and
closes within 8-12 weeks/3-
4 mos.
Other important landmarks of the fetal skull:
a. Mentum – the fetal chin
b. Sinciput – the anterior area known as
brow
c. Vertex – the area between the anterior
and posterior fontanelles
d. Occiput – the area of the fetal skull
occupied by the occipital bone, beneath
the posterior fontanelle
Fetal skull (lateral view)
 Diameters of the fetal skull

The shape of the skull causes it to be wider in its

anteroposterior diameter than in its transverse diameter to
fit the birth canal.

Measurement – AP diameter of the skull is wider than the

transverse diameter.
1. Transverse diameter
a. Bi-parietal – 9.25 cm
b. Bitemporal – 8 cm
2. Anteroposterior diameter
a. Suboccipitobregmatic –
the narrowest diameter is
from the inferior aspect of
the occiput to the center
of the anterior fontanelle
(approximately 9.5 cm)

b. Occipitofrontal –
measured from the bridge
of the nose to the
occipital prominence
(approximately 12 cm)
3. Occipitomental – widest AP diameter measured
from the chin to the posterior fontanelle
(approxiamately 13.5 cm)
 Fetal Presentation and Position
(Attitude) Fetal attitude – describes the degree of flexion a fetus
assumes during labor or the relation of the fetal parts to each other

a. Good attitude –
complete flexion
 spinal column is bowed
forward
 the head is flexed forward
so much that the chin
touches the sternum
 the arms are flexed and
folded on the chest
 the thighs are flexed onto
the abdomen
 the calves are pressed
against the posterior aspect
of the thighs
GOOD ATTITUDE: is the
normal fetal position it is
advantageous for birth
because of it helps a fetus
present the smallest
anteroposterior diameter
because it puts the whole
body into an ovoid shape,
occupying the smallest
space as possbile
Military Position
• The fetus is in moderate
flexion the chin is not
touching the chest but
it is in an alert
• Causes next-widest
anteroposterior
diameter, the occipital
diameter to present to
the birth canal.
 BROW - the fetus is in partial
extension presents the brow
of the head in the birth
canal

Face Presentation – fetus is in

poor flexion, the back is
arched, the neck is extended,
and in complete extension
Engagement – refers to the settling of the
presenting part of a fetus far enough to the
pelvis to be at the level of the ischial spine.

Station - refers to the relationship of the

presenting part of a fetus to the level of the
ischial spine
0 – level of the ischial spine (synonymous w/
engagement)
-1 to -4 ( above the ischial spine)
* -4 (floating)
+1 to +4(below the ischial spine)
* +3 to +4 (synonymous to crowning)
Fetal lie
Refers to the relationship of the cephalocaudal axis
(spinal column) of the fetus to the cephalocaudal axis
of the woman

Longitudinal lie –
cephalocaudal
axis of the fetus
is parallel to the
woman’s spine
 Refers to the relationship of the cephalocaudal axis (spinal
column) of the fetus to the cephalocaudal axis of the woman

Transverse lie –
cephalocaudal
axis of the fetal
spine is at the
right angles to the
woman’s spine
VARIATION IN FETAL PRESENTATIONS

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

a. CEPHALIC PRESENTATION - is the

most frequent presentation occurring as
often as 95%
CEPHALIC PRESENTATION
1. Vertex presentation
- the most common type of presentation
- the fetal head is completely flexed onto
the chest
- the smallest diameter of the fetal head
(suboccipitobregmatic) presents to the
maternal pelvis
- the occiput is the presenting part
2. Military presentation
- the fetal head is neither flexed or extended
- the occipitofrontal diameter presents to the
maternal pelvis
- the top of the head is the presenting part

3. Brow presentation
- the fetal head is partially extended
- the occipitomental diameter, the largest
anteroposterior diameter, is presented to the
maternal pelvis
- the sinciput is the presenting part
4. Face presentation
- the fetal head is
hyperextended
(complete extension)
- the face is the
presenting part
 Cephalic
Presentation
• Caput succedaneum – during labor the
area of the fetal skull that comes in contact
with the cervix often becomes edematous
from the continued pressure against it
• Cephalhematoma - is when blood is
collected between the periosteum of the
skull bone and the skull bone itself, so it
does not cross suture lines.
 BREECH PRESENTATION

1. Complete breech
- The fetus has thighs
tightly flexed on the
abdomen; both the
buttocks and the
tightly flexed feet
present to the cervix
- Good attitude and
longitudinal lie
2. Frank breech -
-Attitude is moderate
because the hips are
flexed but the
knees are extended to
rest on the chest. The
buttocks alone present to
the cervix

- Lies longitudinal and

moderate attitude
3. Footling Breech
- Neither the thighs
nor lower legs are
flexed. If one foot
present, it is a single-
footling breech; if both
present, it is a
double-footling
breech
- Longitudinal lie, poor
attitude
 Shoulder Presentation
In transverse lie, a fetus lies
horizontally in the pelvis so
that the longest fetal axis is
perpendicular to that of the
mother. The presenting part
is usually one of the
shoulders (acromion
process), an iliac crest, a
hand or an elbow
Caused by relaxed abdominal
wall from grand multiparity,
allows unsupported uterus to
fall forward, pelvic
contraction the horizontal is
greater than the vertical
space, placenta previa (limit a
fetus ability to turn),
Fetal position
- the relation of the fetal presenting part to a
specific quadrant of the woman’s pelvis.
3 notations to describe the fetal position:
1. Right (R) or Left (L) side of the maternal pelvis
2. The landmark of the presenting part: Occiput
(O), Mentum (M), Sacrum (Sa), or Acromion
process (A)
3. Anterior (A), Posterior (P), or transverse (T)
depending on whether the landmark is in front,
back, or side of the pelvis
Positions – indicated by an abbreviation
of three letters

Middle letter – denotes fetal landmark (O,M Sa, A)

First letter – defines whether the landmark is
pointing to the mother’s R or L
Last letter – whether the landmarks points A, P, T
 Importance of Determining Fetal
Presentation and Position

• Could put a fetus at risk due to proportional

differences between fetus and pelvis
• Membranes also are more apt to rupture early,
increasing possibility of infection
• Risk of fetal anoxia and meconium staining leading
to respiratory distress at birth
4 methods determining fetal position, presentation &
lie:
• Inspection and palpation (Leopold’s maneuver)
• Vaginal examination
• Sonography
• Auscultation of fetal heart tones
 MECHANISMS of LABOR
Passage of a fetus through the birth canal
involves a number of different position
changes to keep the smallest diameter of
the fetal head always presenting to the
smallest diameter of the birth canal. These
position changes are termed the:
Cardinal Movements
DESCENT
EXTERNAL
FLEXION
ROTATION

INTERNAL
EXTENSION
ROTATION
COMPLETE

EXTENSION EXPULSION
BEGINS
 D’FIERE

DESCENT
is the downward
movement of
the biparietal
diameter of the
fetal head within
the pelvic inlet
FLEXION fetal head reaches
the pelvic floor, the
head bends forward
onto the chest,
making the smallest
anteroposterior the
one presented to the
birth canal.
 the head enters the
INTERNAL pelvis with fetal
ROTATION anteroposterior head
diameter in a
diagonal or transverse
position. The head
flexes as it touches
pelvic floor and the
occiput rotates until it
is superior or just
below the symphysis
pubis
EXTENSION the occiput is
born, the back of
the neck stops
beneath the pubic
arch and acts as
a pivot for the
rest of the head
EXTERNAL immediately after the
ROTATION head of the infant
is born, the head
rotates from the AP
position assumed to
enter the outlet back
to the diagonal/
transverse position
EXPULSION once shoulders
are born, the rest
of the baby is
born easily and
smoothly because
of the smaller size
 POWERS OF LABOR

Implements Causing
Expulsion
uterine cervical
Fundus fetus &
contraction dilatation placenta

• After dilatation of the cervix, the primary

power is supplemented by the use of
abdominal muscles.
 C. Premonitory Signs of Pregnancy
1. Lightening- (descent of the fetal presenting part
into the pelvis, 10-14 days before labor begins.

Woman’s experiences:

a. Relief SOB/ diaphragmatic pressure

b. Relief abdominal tightness
c. Increased frequency of voiding
d. Shooting leg pains (from the increased pressure in
the sciatic nerve)
e. Increased amount of vaginal discharges
f. Increased lordosis as the fetus enters the pelvis
and falls forward. Walking is more difficult and leg
cramping may increase
2. Increased Level of Activity – awaken full of energy
epinephrine release initiated by in progesterone
produced by the placenta.
3. Braxton Hick’s Contractions (practice
contractions) – these are false labor contractions,
painless, irregular, abdominal and relieved by
walking
4. Ripening of the cervix (butter-soft)
5. Slight decrease maternal weight – 2-3lbs one to 2
days before the onset of labor because of decrease
progesterone level and loss of appetite
 APEX/ACME

I D
Three N E
Phases of C C
Uterine R R
Contraction E E
M M
E E
N N
T T
 Strong
(wood)
Intensity of
Uterine
Moderate
Contraction (forehead)

Mild
(tip of the nose)
Duration of the contractions increases from 20-30 secs to 60-90 secs

Contour Changes: upper uterine portion becomes thicker and active

Preparing it to be able to exert strength necessary to expel the fetus

Expulsion phase of labor is reached

The lower uterine segment becomes thin-walled, supple, and passive

to pushed out the fetus easily in the uterus

The upper/lower segment becomes marked a ridge on the inner

uterine surface (PHYSIOLOGIC RETRACTION RING)

The contour of the overall uterus changes from a round, ovoid

structure to elongated -- vertical diameter greater than horizontal

This lengthening serves to straighten the body of the fetus

Placing better alignment with the cervix and pelvis

As the uterus contracts, round ligaments move keeping the fundus forward,
assisting the fetus in good alignment with the cervix

Elongation of the uterus exerts pressure against the diaphragm

Uterus is taking control of a woman’s body

Cervical Changes: Effacement (shortening and thinning of the cervical

canal)

Dilatation: enlargement and widening of the cervical canal

Show: blood-tinged mucus discharged from the vagina due to the pressure
of the descending fetal part on the cervical capillaries

(clear-contains vernix; green-contaminated with meconium; yellow- blood

incompatibility; pink-bleeding)
Effacement
 Lie patient on bed so
that fetus is not
Notify physician impinging on the
cord

Nursing Action
with Ruptured
Membrane

Trendelenburg
Check FHR (Umbilical Prolapse)

• If she feels, loop of the cord coming out from the vagina
(umbilical cord prolapse). Position the woman in Trendelenburg
LENGTH OF LABOR:
Comparison :
Stage Primi Multi
First stage 12 ½ hours 7 hrs. 20 mins
Second Stage 80 mins 30 mins
Third Stage 10 mins 10 mins
Total 14 hours 8 hours
 STAGES OF LABOR

A. STAGE OF DILATATION (1st Stage)

B. STAGE OF EXPULSION (2ND Stage)
C. PLACENTAL EXPULSION (3rd Stage)
D. One to FOURS HOURS AFTER
DELIVERY (4th Stage)
 True
Labor
FIRST
STAGE OF
LABOR
(Stage of
Full Dilatation)
Dilatation
and
Complete
Effacement
 A. FIRST STAGE
- begins
with first symptoms of true labor and ends with
complete dilatation of the cervix (10cms).

3 PHASES:
 PHASE ONSET MINUTES OF Manifestations
CONTRACTIONS
LATENT begins with onset Mild uterine Low backache,
(6 hours – of the regular contractions 10- abdominal
nullipara and contractions and 20mins apart and are cramps, excited,
4.5 hours for ends with short duration 20-40 alert talkative and
multipara) complete secs in control
effacement
(100%) and
cervical dilatation
of 3 cm
ACTIVE Begins with Uterine contractions Begin to cause
(3 hours in complete occur at 3-5minutes discomfort,
nullipara and effacement and apart and last 40-60 exciting,
2 hours in cervical dilatation secs. Contractions frightening, labor
multipara) of 4-7cms are stronger, last is progressing
2 Periods: longer
Acceleration
(4-5cm)
Maximum
slope (5-9cm)
 PHASE ONSET MINUTES OF Manifestations
CONTRACTIONS
Transition Maximum Maximum dilatation Experience feeling
(peak of this dilatation until of 8-10cm occurs of loss of control,
phase can be contractions and contractions anxiety, panic,
identified by reaches their reached their peak of irritability
a slight peak of intensity intensity occurring 2-
slowing rate 3mins with duration
of cervical of 60-90secs
dilatation
when 9cm
reached and
10cm
dilatation an
irresistible
urge to push
begins to
occur
 Nursing Care Management (1st Stage)

a. History taking, review of the woman’s pregnancy

(physical/psychological events) general health,
family medical information
b. Physical assessment – Leopolds, IE to determine:
 effacement, dilatation and conditions of
membranes
 Lie (vertical or horizontal), presentation,
presenting part
 Location of FHT – Vertex (LLQ); Breech (above
level of umbilicus); Face (fetal chest)
 Station
 Position – 4 quadrants; 4 parts – O,M,Sa,A
 LOCATIONS OF FHT

LOA LOP

ROA

ROP LSA
Station
 Nursing Care Management (1st Stage)

c. Provide privacy and reassurance – rapport

d. Bath – comfort and relaxation
e. Perineal preparation
f. NPO, start IVF and monitor I & O
g. Avoid solid foods ff. reasons:
 Digestion delayed labor
 Full stomach interferes with proper bearing down
 Aspiration
h. Empty bladder every 2 -3 hrs. – because: retards
fetal descent, urinary stasis can lead to UTI, full
bladder can be traumatized during delivery
i. Bear down only during true labor contractions – to
minimize maternal exhaustion
 Nursing Care Management (1st Stage)
j. Encourage to change and assume comfortable position (Sim’s
position)
a. Favors anterior rotation of the head
b. Promotes relaxation between contraction
C. Prevents supine hypontensive syndrome
k. Monitor uterine contractions every hour during the latent phase and
every 30 mins during active phase: Duration, Interval, Frequency,
Intensity
l. Monitor vital signs – BP and FHR taken every hour during the latent
phase and every 30 mins during the active phase. This should not
be taken during contractions.
m. Administration of analgesics – analgesics (Demerol) acts to
suppress the sensory portion of the cerebral cortex.
n. Administration of anesthetics
o. Be aware of the danger signs of labor and delivery (fetal/maternal
distress)
Tachycardia, Bradycardia, Meconium, Fetal trashing, Fetal acidosis
k. Transfer of patient from the labor room to the delivery room
Multiparas (cervical dilatation 7-9cms) Primi (full dilatation)
Pressure on the fetal head as it
Progresses down the birth canal

Begins at the onset of contraction and

End as the contraction ends

Usually seen in active labor when

Dilatation 4 to 7 cm

Increased intracranial pressure

stimulates vagus nerve which slows
the heart rate
 Due to uteroplacental insufficiency

Decrease blood flow impeding O2 transfer

To the fetus through the intervillous space
During uterine contraction (hypoxemia)
 Umbilical cord compression

Decreases amount of blood flow to the

fetus

Repetitive deceleration may indicate

short cord or nuchal cord

CS, forcep births or vacuum extraction

is Indicated

Repositioning the woman corrects this

type of pattern
Full Dilatation
and Complete
Effacement

SECOND
STAGE OF
LABOR
(Fetal
Delivery)
Delivery
of the
baby
 SECOND STAGE
- this stage begins from the time of full dilatation of
the cervix and ends with the delivery of the infant.
2 Phases:
1. Deceleration phase: the progress of labor does not
slow down; the final degree of cervical dilatation is
achieved and the cervix retracts over the
presenting part.
2. Fetal descent phase: fetus descent in the pelvic
ring, being pushed beyond the open cervix,
perineum begins to bulge (labia), and vaginal
introitus stretched apart.

Mechanisms of labor:
 Nursing Care Management (2nd Stage)
a. Proper positioning on the delivery table- 2 alternative
positions (Sim’s and dorsal recumbent), semi-sitting,
squatting. Less tension on the perineum to have fewer
perineal tears.
b. Bearing down techniques – best time to encourage
strong pushing with contractions, the woman is asked
to take two short breath and bear down the peak of the
contraction.
c. Care of Episiotomy Wound – Episiotomy is a surgical
incision of the perineum made to prevent tearing of the
perineum and to release pressure on the fetal head
during delivery. It has natural anesthesia

The two types of episiotomy are:

a. Median- begun in the midline of the perineum and

directed toward the rectum.
b. Mediolateral- begun in the midline of the perineum
but directed laterally away from the rectum
d. Breathing Techniques- as soon as the head crowns, the
woman is instructed not to push any longer because it can
cause rapid expulsion of the fetus instead she should be
advise to pant ( rapid and shallow breathing).
e. Ritgen’s Manuever – the basic steps in applying this
method of delivery are as follows:
1. Support the perineum during crowning by applying
pressure with the palm against the rectum.
2. The head should be pressed gently while it slowly
eases out to prevent rapid expulsion of the fetus
which could result to not only to lacerations,
abruptio placenta, and uterine inversion but also
shock because of sudden decrease in intra
abdominal pressure.
3. As soon as the head as been delivered, the nurse
should insert two fingers into the vagina to feel for
the presence of a cord looped around the neck. If
it so and is loose, it should be slipped down the
shoulder, be clamped twice an inch part and cut in
between.
4. As the head rotates, give a gentle, steady
downward push in order to deliver the anterior
shoulder and then a gentle upward lift to deliver
the posterior shoulder.
5. While supporting the body’s head and neck, the
rest of the baby is delivered.
f. Time of Delivery must be noted.

g. Proper Handling of the newborn – immediately

after delivery, the newborn should be held below
the level of the mother’s vulva so that blood from
the placenta can enter the infant’s body on the
basis of gravity flow.
h. Cutting of the Cord – this is postponed until
pulsations have stopped because 50-100 ml of
blood is flowing from the placenta to the newborn
at this time
I. Initial Contact
Maternal- infant bonding is initiated as soon as
the baby has been suctioned and provided
warmth
Delivery of
the baby
THIRD
STAGE OF
LABOR
(Placental
Delivery)
Delivery
of the
placenta
PLACENTA - a freely disc like organ that is 15 – 20
cm in diameter 2.3 cm in thickness and weighs 500
gms at term. A mature placenta has 16 – 30 separate
segments known as COTYLEDONS
 THIRD STAGE
The stage begins with the delivery of the infant and ends with
the delivery of the placenta. It is divided into two phases:

a. Placental Separation phase – separation of the placental results

from the disproportion between the size of the placenta and
the reduced size of the site of the placental attachment after
the delivery of the baby. The sign of the placental separation
are follows:

 The uterus becomes more firm and round in shape and

rising high at the level of the umbilicus – CALKIN SIGN
 Sudden gush of blood from the vagina.
 Lengthening of the umbilical cord.
2. Placental expulsion –
placenta is delivered either by
natural bearing down effort of
the mother or by gentle
pressure on the contracted
uterine fundus by the
physician or nurse (CREDE’s
MANUEVER). Two
mechanisms by which
placenta is expelled:
a. Schultz (shiny-fetal
membrane) – placenta
separates first from the center
so that it will folds itself like an
umbrella and its shiny and
glistening fetal surface is
presented at the vaginal
opening.
b. Duncan (dirty –
irregular maternal
surface) – if the
placenta separates
first at the edges, it
slides along the
uterine surface
evident. It looks raw
red and irregular with
cotyledons showing.
 Nursing Care Management (3rd Stage)

1. Never hurry the delivery of the placenta by forcefully pulling

out the cord or by vigorous fundal push as it can lead to
uterine inversion
Brandt Andrews Maneuver – wind the cord around the clamp,
then deliver the placenta by rotating it so that no placental
fragments are left inside the uterus.
2. Take note the time of placental delivery should be delivered
20-30mins after the delivery of the baby.
3. Inspect for the completeness of the cotyledons
4. Palpate the uterus to determine degree of contraction
if boggy/uncontracted – massage fundus gently and
properly, apply ice or ice cap over abdomen
5. Administration of oxytoxic agents – Methergin (0.2mg/ml) and
Syntocinon (10u/ml)
 Nursing Care Management (3rd Stage)
6. Inspect perineum for laceration
Classifications:
a. First degree – involved vaginal mucous membrane and
the skin of the perineum to the fourchette
b. Second degree – vagina, perineal skin, fascia, levator
animuscle, perineal body
c. Third degree – entire perineum, external sphincter of
the rectum
d. Fourth degree - entire perineum, rectal sphincter and
some mucuos membrane of the rectum
7. Assist doctor in doing episiorraphy, repair of the episiotomy
or lacerations
8. Estimate amount of blood loss
9. Provide comfort and perineal care, apply clean sanitary
10. Vital signs every 15 minutes for the first hour and palpate
uterine fundus for size and position.
11. Transfer back to the RR or room and position flat on bed w/o
pillows. To prevent dizziness due to intra-abdominal
pressure
Delivery of
the
placenta
FOURTH
STAGE OF
LABOR
(Placental
Delivery)
First 1 to 4
hours after
delivery
 FOURTH STAGE
The stage refers to the first one to four hours immediately
after delivery when the VS are quite unstable. Critical
condition - possibility of uterine atony.
Nursing Care Management (4th Stage)

Assessment

a. Fundus – palpate every 15 minutes first hour; 30 mins

for the next hours. Should be firm, at the midline of
the umbilicus
b. Bladder – checked every 2 hours during 1st 8 hours
then every 8 hours for 3 days. Suspect full urinary
bladder if the fundus is not well contracted and is
shifted to the right. A full bladder prevents good
contraction of the uterus and may cause
hemorrhage.
 c. Vaginal discharge – checked every 15mins and should be
moderate. Saturated napkin every 30 mins – excessive
bleeding.
d. Checked BP and PR every 15 mins first hour then 30 mins
till stable
e. Inspect perineum every 8 hours for 3 days. Note the
episiorrhaphy should be clean and intact
Comfort Measures:
a. Perform perineal care gently and apply napkin
b. Lower legs simultaneously from the stirrups and position
her flat on bed
c. Give mother soothing sponge bath changed linen and
clothing
d. Provide additional blankets
e. Give the mother initial nourishment of coffee, tea, soup or
milk
f. Provide a quiet and restful environment
g. Allow mother to take enough rest and sleep in order regain
energy.