INTRAPARTUM

Process of Labor & Delivery

Labor
- Refers to the series of processes by
which product of conception are expelled
from the mother.

• PHYSIOLOGY OF LABOR
- Estrogen stimulate uterine muscle
contractions to permit softening, stretching
and eventually thinning of the cervix.
THEORIES OF LABOR ONSET
1. UTERINE STRETCH THEORY
 Any hollow organ when stretched to capacity will necessarily
contract and empty because of the pressure on nerve endings
and increased irritability on the uterine musculature

2. OXYTOCIN STIMULATION THEORY (Ferguson’s

reflex)
 A reflex release oxytocin by cervical distention
 Because labor is considered a stressful event, the hypophysis
is stimulated to initiate production of oxytocin by the pituitary
gland.
 Oxytocin is known to stimulate uterine contractions.
3. THEORY OF PROSTAGLANDINS
 prostaglandin from amnion and decidua, stimulate uterine
contraction.
 Prostaglandin

4. PROGESTERONE WITHDRAWAL/
DEPRIVATION THEORY
 decreasing progesterone level leads to uterine contraction.

5. THEORY OF AGING PLACENTA

 life span of placenta is 42 weeks, once this decreases of
nutrients and blood supply and degenerates it stimulates uterine
contraction.
SIGNS OF LABOR
1. LIGHTENING
 the settling of the fetal head into the pelvic brim
which occurs 2-3 weeks before onset of labor.
 results into:
a. relief of abdominal tightness and
diaphragmatic pressure so that respiration
becomes easier.
b. shooting pains down the legs because of
pressure on the sciatic nerve.
c. increased lordosis as the fetus enters the
pelvis and falls farther forward.
2. INCREASED LEVEL OF ACTIVITY “NESTING
BEHAVIOR”
 Sudden burst of energy is believed to be due to increase in
epinephrine in response to stress brought about by the
approaching delivery. The pregnant woman should be
cautioned not to use this energy to carry out household
chores to because it is meant to prepare the body for the
“Labor” ahead.

3. BRAXTON HICK’S CONTRACTIONS

 Painless, irregular, intermittent contractions also known as
practice contractions
4. RIPENING OF THE CERVIX
 Softening of the cervix
 Described as “butter soft”``

5. SHOW
 Discharge of blood tinge mucus secretion from the vagina
caused by the pressure of the descending fetal part on the
cervical capillaries causing their rupture.
 Capillary blood mixes with the mucus when the plug
(operculum) is released.
 NOTE: distinguished the show from the discharge of bright
red blood because it is a sign of bleeding, a danger sign in
pregnancy.
6. RUPTURE OF THE MEMBRANE
 also called rupture of the bag of waters.
 seen as a sudden gush of fluid (amniotic fluid) from the
vagina.
Fluid is CLEAR, ALMOST COLORLESS, CONTAINS
WHITE SPECS OF VERNIX CASEOSA.(Normal)
 NOTE: Green stain – fluid is contaminated with
meconium, a sign of fetal distress.
 Yellow stain – may indicate blood incompatibility.
 Pink stain – may indicate bleeding
7. UMBILICAL CORD COMPRESSION (Prolapse of
the cord) may occur.
 a condition where the umbilical cord presents itself at the birth
canal and precedes the fetal presenting part, and the
presenting part compresses the umbilical cord.
 5 minutes compression may damage the fetus.
 NURSING RESPONSIBILITIES:
• Place the patient in bed to ensure that the fetus is not impinging on
the cord.
• Take the FHT to determine hat the fetus is not in distress.
• If there is cord prolapse (cord is felt coming out of the vagina) – place
the patient in tredelenberg position (head is lower than the body) to
release the pressure on the cord.
- apply sterile saline saturated gauze to prevent drying of the cord.
- monitor FHT regularly.
SIGNS OF TRUE LABOR
1. UTERINE CONTRACTION:
 The initiation is effective, productive and involuntary.
 The tightening discomfort or actual pains. The uterus feels
hard and firm.
 PHASES:
a. CRESCENDO / INCREMENT – the intensity of the
contraction increases. This phase is longer than any of
the 2 phases combined.
b. ACME – height or the peak of the contraction.
c. DECRESCENDO / DECREMENT – intensity of the
contraction decreases.
Things to consider regarding rupture of
membranes:
1. Once the membrane have ruptured, labor is
inevitable, uterine contractions will occur within
24 hours.
2. If labor will not occur the woman should be
induced to go into labor by administration of IV
drip oxytocin.

 Predisposes the mother and the fetus to

intrauterine infection, thus strict asepsis should
be observed in assisting internal examination
and perineal care.
 Vital signs should be taken regularly in order
to determine signs of infection.
Differences between True Labor
TRUE LABOR PAINS FALSE LABOR PAINS
- regular, increasing
- Irregular, no change in
frequency, duration and
CONTRACTION frequency, duration and
intensity
intensity
- Shortening interval
- Radiates from back
- Pain generally confined
DISCOMFORT around the abdomen in
in the abdomen
girdle – like fashion
- Contraction may
- Contraction does not
lessen with activity or
REST/ ACTIVITY decreases with rest or
walking
activity/walking

- Presence of cervical
changes progressive - Cervical changes does
CERVIX
effacement and not occur yet
dilatation.
- Descent of the - No descent of
DESCENT
presenting part. presenting part.
2. UTERINE CHANGES
 The uterus is differentiated into two distinct portions
(segments) distinguished by a ridge formed of the inner
uterine surface, the physiologic retraction ring.

a. UPPER UTERINE SEGMENT – the portion from the

isthmus up to the fundus. It becomes thick and active and
the only part of the uterus which contracts in order to expel
the fetus from birth canal.
b. LOWER UTERINE SEGMENT – the portion from the
isthmus down to the cervix. This becomes thin-walled,
supple and passive so that the fetus can be easily pushed
out of the birth canal. There is no contraction in the lower
segment.
• EFFACEMENT:
 the shortening and the thinning of the cervical canal.
 Inclusion of the cervical canal into the lower uterine segment.
 In primigravidas, effacement occurs before dilatation, however,
in multigravidas dilatation may precede effacement.

• DILATATION:
 the process by which the external cervical os enlarges from
few mm wide to 10 cm full dilatation, large enough for the
passage of the baby.
LENGTH OF LABOR
 In general, multigravida delivers 6 hours earlier than
primigravida
 If primigravida complete labor on more than 18
hours and multigravida in more than 12 hours. It is
referred to as prolonged labor.
 Labor completed in less than 3 hours is precipitate
labor.
STAGES OF LABOR PRIMIGRAVIDAS MULTIGRAVIDAS

1ST STAGE 12 ½ Hours 7 hours, 20 minutes

2ND STAGE 80 minutes 30 minutes

3RD STAGE 40 minutes 10 minutes

TOTAL 14 hours 8 hours

FACTORS AFFECTING LABOR &
DELIVERY PROCESS

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FACTORS AFFECTING LABOR &
DELIVERY PROCESS

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PASSAGE involves:
• The size of the pelvis
• The shape of the pelvis
• The ability of the cervix to dilate and the vagina to
stretch

- It refers to the route a fetus must travel from the

uterus through the cervix and vagina to the external
perineum.
PELVIS
Functions:
• It provides protection to the organs found within
the pelvic cavity
• It provides attachment to muscles, fascia and
ligaments
• It supports the uterus during pregnancy
• It serves as birth canal
 TYPES OF PELVIS
TYPES FEATURES
GYNECOID Typical female pelvis
Adequate for labor and delivery
ANDROID Typical male pelvis
Narrow dimension
Slow descent of the fetal head
Associated with halting of labor
Forceps delivery often required
Found in 20% of woman
TYPES FEATURES

ANTHROPOID Apelike pelvis

Adequate for labor and birth

Found in 25% women

PLATTYPELLOID Unfavorable for labor

Frequent delay in descent

Found in 5% women
DIVISION OF PELVIS
• FALSE PELVIS – there is ample space. It is the
upper portion. Its functions are to provide support to
the uterus during pregnancy and to direct the fetus
to the true pelvis during labor.

• TRUE PELVIS – it forms the passageway of the

fetus during labor
- It is divided into three key areas:
• INLET
• CAVITY
• OUTLET
Ways to evaluate the adequacy of the
pelvis
1. CLINICAL PELVIMETRY
• estimation of pelvic shapes and dimensions by the
examiner
• wide margin of error depending in examiners skill.
2. X-RAY PELVIMETRY
• can provide critical pelvic diameters not otherwise
obtainable
• potential fetal exposure to low dose radiation
• has been replaced by other pelvic imaging methods
3. MAGNETIC RESONANCE IMAGING
• Offers accurate pelvic measurements and
complete fetal imaging
4. ULTRASONOGRAPHY
• uses sound waves, not ionizing energy
•Useful for precisely measuring fetal biparietal
diameters and fetal head circumferences.
•Not useful for measuring maternal pelvic
measurement.
5. CT SCAN
• has replaced x-ray pelvimetry in some institution
• accuracy has improved over conventional x-ray
pelvimetry
• involves a lower fetal exposure than x-ray
• maternal movements during exposure needs to be
minimal to prevent distortion
•Expense is similar to that of conventional x-ray
FACTORS AFFECTING LABOR &
DELIVERY PROCESS

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PASSENGER involves:
• the fetal head size
• The fetal attitude describes the relation of the fetal
head
• The fetal lie refers to the relationship of the long
axis of the fetus to the ring the long axis of the
mother
• The fetal presentation describes the part of the
fetus entering the pelvis first
• The fetal position refers to the direction toward
which the presenting part is pointing first – front,
side or back of the maternal pelvis
STRUCTURE OF FETAL SKULL
- The fetal skull is composed of the following cranial
bones:
• 1 frontal bone
• 2 parietal bones
• 1 occipital bone
• 2 temporal bones
• 1 sphenoid bone
• 1 ethmoid bone
SUTURE LINES
- They are important because they allow the skull
bones to overlap, called MOLDING during delivery
in order to reduce the size of the fetal head. It also
provide allowance for further brain development.

• SAGITTAL SUTURE – located between 2 parietal

bones
• FRONTAL SUTURE – located between 2 frontal
bones
• CORONAL SUTURE – located between frontal and
parietal bones
• LAMBDOID SUTURE – located between parietal
and occipital bones.
FONTANELS
- Membrane covered spaces located between the
intersections of suture lines. The location of
fontanels can help to determine the position and
presentation of the fetus.
• ANTERIOR FONTANEL or BREGMA – formed by
the intersection of sagittal, frontal and coronal
sutures. It is diamond shaped and closes between
12 to 18 months of age.
• POSTERIOR FONTANEL or LAMBDA – is formed
by the intersection of sagittal and lambdoid sutures.
It is triangular in shape and closes by 2 to 3 months
of age.
DIAMETERS OF THE FETAL SKULL
- The fetal head is wider in its anteroposterior (front to
back) diameter than its transverse (side to side)
diameter.
TRANSVERSE DIAMETERS
• BIPARIETAL: most important. Average measurement is
9.25 cm.
ANTEROPOSTERIOR DIAMETER
• SUBOCCIPITOBREGMATIC: smallest AP diameter.
Average measurement is 9.5 cm.
• OCCIPITOFRONTAL: measured from the bridge of the
nose to the occipital prominence. Average measurement
is 12 cm.
• OCCOPITOMENTAL: measured from the chin to the
posterior fontanel. Average measurement is 13.5 cm.
FETAL ATTITUDE
- The degree of flexion a fetus assume during labor or
the relation of the fetal parts to each other.
LIE PRESENTATION ATTITUDE
A. LONGITUDINAL LIE
1. CEPHALIC Vertex Complete Flexion

Sinciput Partial Flexion

Brow Moderate Flexion
Face Extension
Chin Hyperextension
2. BREECH Complete Good Flexion
Frank Moderate Flexion
Footling Very poor flexion
B. TRANSVERSE Shoulder Flexion
FETAL LIE
- Refers to the relationship of the long axis of the
fetus to the long axis of the mother.
FETAL PRESENTATION
- Denotes the body parts that will first contact the
cervix or be born first.
CEPHALIC PRESENTATION
BREECH PRESENTATION
FETAL POSITION
- Refers to the relationship of the presenting part to
one of the quadrants of the mother’s pelvis.
- Maternal pelvis is divided into four quadrants
according to the mother’s right and left:
• right anterior
• left anterior
• right posterior
• left posterior
- Four parts of fetus have been chosen as landmarks:

VERTEX Occiput
FACE AND CHIN Mentum
BREECH Sacrum
SHOULDER Scapula or acromion

POSITION is indicated by an abbreviation of three letters

First letter defines whether the landmark is pointing to the
mother’s right (R) or left (L)

Second letter Denotes the fetal landmark

Third letter Defines whether the landmark points anteriorly
(A), posteriorly (P), or transversely (T)
FETAL STATION
- The relationship of the presenting part of the fetus to
an imaginary line drawn at the level of the ischial
spines of the mother.
- When the presenting part is above the ischial spine
spines, it is at minus station and below the ischial
spines it is referred to +1 to +5.
- Zero station (0) is when the presenting part is at the
level of ischial spines.
- +1 station -> fetus is engaged
FACTORS AFFECTING LABOR &
DELIVERY PROCESS

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POWER
PRIMARY POWER: UTERINE CONTRACTIONS
- Causes the cervix to dilate and efface.

Characteristic of Uterine Contractions

• INVOLUNTARY – uterine contractions are
involuntary and independent of extrauterine control.
• INTERMITTENT – characterized by alternating
period of contraction and relaxation.
• INVOLVES DISCOMFORT
PHASES OF UTERINE CONTRACTION
• INCREMENT or CRESENDO: the time when contraction
is starting and intensity is building up.
• ACME or APEX: the peak of contraction
• DECREMENT or DECRESENDO: the time when
muscles start to relax.
o INTENSITY – the strength of uterine contraction
o FREQUENCY – refers to the rate at which
contraction are occurring. It is measured from the
beginning of a contraction to the beginning of the next
contraction.
o DURATION – the length of contraction. It is
measured from the beginning of contraction to the
end of the same contraction.
o INTERVAL – the time that lapse between two
uterine contraction. It is measured from the end of
contraction to the beginning of the next contraction.
SECONDARY FORCES
• The force created by increased inta-abdominal
pressure which is achieved when the mother “bears
down” or “pushes”.
FACTORS AFFECTING LABOR &
DELIVERY PROCESS

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PSYCHE involves:
• The mother’s physical, emotional and intellectual
preparation.
• Her previous childbirth experiences
• Her cultural attitude
• Support from significant people in the mother’s life.
MECHANISMS OF LABOR
(Cardinal Movement)
E - Engagement
D - Descent
F - Flexion
IR - Internal Rotation
E - Extension
ER - External Rotation
E - Expulsion
 S
T
A
G
E
S
of
LABOR
 73

Stages of Labor
• Regular uterine contractions / start of active labor
1st until full cervical dilatation

• Full cervical dilatation until baby is delivered

2nd

• After baby is delivered until placental delivery

3rd

• The hour immediately after delivery

4th
FIRST STAGE OF LABOR
• Known as the stage of dilatation
• Very important stage in so far as the assessment of
maternal and fetal well-being is concerned.
• starts with true labor contraction and ends with the
complete effacement (100%) and full dilatation of
the cervix (10cm)

• PHASES:
1. LATENT PHASE:
- Cervical dilatation is approximately 0-3cm
- contraction occur regularly 5-30 min. apart and of
short duration of 10-30 seconds
• Intensity of contractions is from mild to moderate
• The woman experience low back pains, abdominal
cramps and is generally excited, alert, talkative and
in control.
• This threshold may be clinically useful, for it defines
cervical dilatation limits beyond which active labor
can be expected.
2. ACTIVE PHASE
• Cervical dilatation is approximately 4-7 cm
• 3-5 minutes interval, 30-40 seconds duration
• Intensity of contractions is from moderate to strong.
3. TRANSITION
• 8-10 cm dilatation
• Interval of contraction is 2-3 mins
• Duration of contraction is 45 – 90 seconds
• Intensity of uterine contraction is strong.
INTRAPARTUM CARE
During the 1st Stage of Labor
× Routine enema Enema per request
× Perineal shaving Allow woman to eat
× Routine IVF and drink during labor
× Keep the woman in Mobility and position of
SUPINE position choice
× Routine analgesia Continuous maternal
and anesthesia support during labor
× Early amniotomy to Amniotomy only when
hasten labor indicated
× Oxytocin Oxytocin augmentation
augmentation as needed
SUPPORTIVE CARE THROUGHOUT LABOR
• COMMUNICATION
- Explain all procedures, seek permission and discuss
findings with the woman.
- Keep her informed about the progress of labor
- Praise her, encourage and reassure her that things
are going well
- Ensure and respect privacy during examinations
and discussion
- If known HIV positive, find out what she has told the
companion. Respect her wishes.
• PHYSICAL ASSESSMENT
- General PE to include Leopold’s maneuver and
internal examination to determine the following:
a. Status of dilatation, effacement and condition of
membranes.
b. Lie or presentation
c. Location of FHT in relation to the presentation
d. Station
 80

INTERNAL EXAMINATION
DURING LABOR
 81

WHEN to do an I.E.
• ONLY DURING LABOR
• When the BOW ruptures (to rule out cord prolapse)
• If malpresentation is suspected on abdominal
examination
• Before transferring a woman to another facility to
ensure she is not likely to deliver on the journey.
• In the 3rd stage, if there is postpartum
> 8 cm hemorrhage,
caused by retained placenta or suspected
laceration.
 82

If the woman has had vaginal bleeding after 5th month

of pregnancy

NEVER do an I.E. unless you have > 8acm

good indication
for doing so. Every I.E. may bring INFECTION to
the woman and her baby.
 83

Procedure for internal examination

• Explain to the woman what you are going to do.
• Take full aseptic precautions
• Rinse the vulva with clean water.
• Wear clean gloves
• INSPECT THE VULVA:
• Is there amniotic fluid? Is it clear or meconium stained?
• Is there any abnormal discharge, blood or pus?
• Feel inside the vagina with the> middle
8 cm and index
fingers.
 84

What to note during internal examination

• Cervix
• Dilatation
• Thickness or Effacement
• Bag of waters
• Presenting part
> 8 cm
 85

What is cervical dilatation?

• Gradual opening of the cervix
• Measured in centimeters
• Feel with your 2 fingers
• The fully dilated cervix is 10 cm open.
 86

Assessing cervical
dilatation.
• Insert the middle and
index finger into the open
cervix and gently open
them to the cervical rim.
The distance between the
outer rim of both fingers
is the cervical dilatation
 87

Determine status of Bag of Waters (BOW)

• Is BOW intact or ruptured?
• Is there amniotic fluid leaking?
• Clear or meconium stained?
 88

• BE CAREFUL NOT TO RUPTURE THE BAG OF

WATER IF THE PRESENTING PART IS
FLOATING OR NOT ACCESSIBLE
> 8 cm
 89

Determine the presenting part

Cephalic: Feels hard. Sutures and
fontanelles of the baby’s head are felt
Malpresentation: Hardness of the
baby’s head is not felt but soft
buttocks or extremeties (foot or
hand).
 90

Determine presenting part

• What is the presentation?
• Is the cord palpable?
• What is the level of the presenting part?
 91

What to note during internal examination

• Cervix
• Bag of waters
• Presenting part

> 8 cm
SUPPORTIVE CARE THROUGHOUT LABOR
• CLEANLINESS
- Encourage the woman to bathe or shower or wash
herself and genitals at the onset of labor
- Wash the vulva and perineal areas before each
examination.
- Wash your hands with soap before and after each
examination. Use clean gloves for vaginal
examination
- Ensure cleanliness of labor and delivery area
- Clean up spills immediately
SUPPORTIVE CARE THROUGHOUT LABOR
• MOBILITY
- Encourage the woman to walk around freely during the
first stage of labor
- Support the woman’s choice of position

• URINATION
- Encourage the woman to empty her bladder frequently.
Remind her every 2 hours.

• EATING, DRINKING
- Nutritious liquid drinks are important, even in late labor
- if the woman has visible severe wasting or tires during
labor, make sure she eat and drinks.
There is no evidence supporting strict
bed rest in supine position during the
first stage of labor. In the absence of
complications, women should be
encouraged to change to positions or
move around during labor.
• BREATHING TECHNIQUE
- Teach her to notice her normal breathing
- Encourage her to breathe out more slowly, making
sighing noise and to relax with each breath.
- To prevent pushing at the end of first stage of labor,
teach her to blow, to breathe with an open mouth, to
take in 2 short breaths followed by a long breath out.
- During delivery of the head, ask her not to push but
to breathe steadily.
• PAIN AND DISCOMFORT RELIEF
- Suggest change position
- Encourage mobility as comfortable for her
- Encourage companion to:
a. Massage the woman’s back if she finds this
helpful.
b. Hold the woman’s hand and sponge her face
between contraction.
- Encourage her to use breathing technique
- Encourage warm bath or shower, if available.
• MONITOR FIRST STAGE OF LABOR: NOT IN
ACTIVE LABOR
EVERY HOUR EVERY 4 HOURS
For emergency signs Cervical dilatation
Frequency, intensity, and duration Temperature
of contraction
Fetal Heart rate Pulse
Mood and behaviour Blood pressure
ASSESS PROGRESS OF LABOR
AFTER 8 HOURS IF;
- Contractions stronger and
more frequent but no
progress in cervical dilatation
with or without membranes
ruptured
AFTER 8 HOURS IF:
- No increase in contraction
- Membranes are not ruptured
- No progress in cervical
dilatation
CERVICAL DILATATION 4 CM
OR GREATER
TREAT AND ADVISE
refer
Discharge the woman and
advise to return if:
- pain/discomfort increases
- Vaginal bleeding
- Membrane rupture
Begin plotting the partograph
and manage the woman as in
Active labor
• MONITOR FIRST STAGE OF LABOR: IN ACTIVE
LABOR
EVERY 30 MINUTES EVERY 4 HOURS
For emergency signs Cervical dilatation
Frequency, intensity, and duration Temperature
of contraction
Fetal Heart rate Pulse
Mood and behaviour Blood pressure
 100

Stages of Labor
• Regular uterine contractions / start of active labor
1st until full cervical dilatation

• Full cervical dilatation until baby is delivered

2nd

• After baby is delivered until placental delivery

3rd

• The hour immediately after delivery

4th
 101

Care during 2nd stage of labor

THEN NOW
Routine catheterization Encourage woman to void spontaneously (1st
to empty bladder stage of labor)
Assist into a comfortable position, as
Lithotomy position UPRIGHT as possible

Fundal pressure Do not do this!

Allow her to push as she wishes with

Urge her to push
contractions
Perineal support and controlled delivery of
Massage perineum
the head

Routine episiotomy Restrictive episiotomy

Diagnosis of the 2nd Stage of Labor
Traditional Non-Traditional

• Defined by a “fully • Redefined as “complete

dilated cervix” cervical dilatation” +
“spontaneous explusive
• “To push” or “not to
efforts” (Simkin, 1991)
push”
 Pelvic phase of passive
• Coached to push descent
though out-of-phase  Perineal phase of active
with her own sensation pushing
 Time Mother Baby
Support the perineum with Call out time of birth and sex
Delivery
controlled delivery of the head
First 30 Dry, check breathing
secs Put in skin-to-skin contact
Give Oxytocin IM Feel for cord pulsation ,
After excluding a 2nd baby Clamp, cut cord
1 minute to
3 minutes Do controlled traction of cord Return baby to prone position
with counter-traction
Massage the uterus gently
Examine the placenta

Support FIRST FULL BREASTFEED. Monitor as a DYAD q15 minutes

15-90 Continue uterine massage; Do PE, weigh, measure, eye
minutes Monitor every 15 minutes care, inject Vit K, Hep B, BCG
Transport to room TOGETHER
> 6 hours BREASTFEEDING SUPPORT Optional: Bathing
DELIVER THE BABY
• Implement he 3 CLEANS
- Clean hands. Wear double gloves
- Clean delivery surface
- Clean cutting and care of the cord

• Ensure all delivery equipment and supplies,

including resuscitation equipment are
available and place of delivery is clean and
warm (25⁰C)
 Prepare for Delivery
• Two clean and warm towels or cloth
• Self inflating bag and mask (normal and small
newborn)
• Suction device
• Sterile cord clamp or ties
• Sterile forceps and scissors
• Rolled up piece of cloth
• Bonnet
• Clean dry warm surface

L3
Immediate and Thorough
Drying Early Skin to Skin
Contact Properly-timed
Clamping Non-Separation
of Mother and
Baby
• Ensure bladder is empty. Encourage the woman to
urinate. If unable to pass urine, empty bladder with
catheter.
• Stay with the woman and encourage her.
• Assis the woman into a comfortable position of her
choice, as upright as possible.
• Stay with her and offer her emotional and physical
support. If the woman is distressed, encourage pain
discomfort.
• Allow her to push as she wishes with contractions.
• PERINEAL CLEANING
- Cleanse perineum, anus and upper inner things
with an antiseptic technique.
Controlled Delivery of the Head
During delivery of the
head, encourage woman
to stop pushing and
breathe rapidly with
mouth open.

Keep one hand on the

head as it advances
during contractions while
the other hand supports
the perineum.
 120

Stages of Labor
• Regular uterine contractions / start of active labor
1st until full cervical dilatation

• Full cervical dilatation until baby is delivered

2nd

• After baby is delivered until placental delivery

3rd

• The hour immediately after delivery

4th
THIRD STAGE
- Known as placental stage
- Begins with the birth of the infant and
the ends of the placenta.
- Two Phases
• Placental Separation
• Placental expulsion
Approaches in the Mgt of the 3rd
Stage of Labor
Physiologic (Expectant) Active
(AMSTL)
Uterotonic NOT GIVEN before placenta GIVEN within 1 min. of
is delivered baby’s birth
Signs of placental WAIT DON’T WAIT
separation
Delivery of the By gravity with maternal CCT with
placenta effort countertraction on the
fundus
Uterine massage After placenta is delivered After placenta is
delivered
3rd Stage of Labor
• ACTIVE MANAGEMENT OF THIRD
STAGE OF LABOR
• Oxytocin 10 u IM after delivery of the baby (exclude the possibility of a 2 nd
baby)
• Controlled cord traction with counter traction on the uterus
• Uterine massage
POPPHI. Prevention of Postpartum Hemorrhage: Implementing Active Management of the Third Stage of Labor
(AMTSL): A Reference Manual for Health Care Providers. Seattle: PATH; 2007.

123
• Call out sex of baby
and the time of birth.
• Place the baby on the mother’s
abdomen.
• Thoroughly dry the baby, assess the
baby’s breathing and perform
resuscitation if needed;
• Place the baby in skin-to-skin contact
with the mother
• Keep the baby warm.
Discard the wet cloth
used to dry the baby.
Maintain skin-to-skin
contact. Wrap mother and
baby with linen, Put
bonnet on baby.
PLACENTAL SEPARATION
• Signs of Placenta Separation
- Lengthening of the umbilical cord
- Sudden gush of vaginal blood
- Change in the shape of the uterus
- Firm contraction of the uterus
- Appearance of the placenta at the vaginal
opening
METHODS OF PLACENTA SEPARATION
• SCHULTZE PRESENATION
o separation of the placenta starts at the center.
The shiny and smooth fetal side is delivered first
in this type of separation.
o 80% of placenta separates and present in this
way.
• DUNCAN PRESENTATION
o separation begins from the edges of
placenta.
o The maternal side is delivered first.
o it looks raw, red and irregular, with ridges or
cotyledons that separate blood collection
spaces.
• Perform controlled cord traction (CCT)
with counter-traction on the uterus
Place the palm of the other hand on the
LOWER abdomen
• Support the placenta with both hands.
• Gently move membranes up and
down until delivered
• Massage the uterus

• Examine
the
placenta
and the
membran
es
 • Examine the lower vagina and the
perineum.
• Provide immediate care to the
mother-baby dyad.
• Monitor the mother and baby
immediately after the delivery of the
placenta.
POPPHI. Prevention of Postpartum Hemorrhage: Implementing ActiveManagement of the Third Stage of Labor (AMTSL): A
Reference Manual for Health CareProviders. Seattle: PATH; 2007.
 139

Stages of Labor
• Regular uterine contractions / start of active labor
1st until full cervical dilatation

• Full cervical dilatation until baby is delivered

2nd

• After baby is delivered until placental delivery

3rd

• The hour immediately after delivery

4th
FOURTH STAGE OF LABOR

POSTPARTUM CARE
- The main danger during this stage is hemorrhage.
- The goal of nursing care during this period is to
prevent bleeding.
FIRST DEGREE Involves fourchette, vaginal mucous membrane,
perineal skin
SECOND Involving fourchette, vaginal mucous membrane,
DEGREE perineal skin, muscles of perineal body
THIRD DEGREE Involves fourchette, vaginal mucous membrane,
perineal skin, muscles of perineal body and anal
sphincter
FOURTH Involves fourchette, vaginal mucous membrane,
DEGREE perineal skin, muscles of perineal body, anal
sphincter and mucuous membrane of rectum.
• REPAIR OF LACERATION
• REPAIR OF 4TH DEGREE LACERATION
CARE OF MOTHER AND NEWBORN WITHIN
FIRST HOUR OF THE DELIVERY
CARE OF MOTHER ONE HOUR AFTER THE
DELIVERY
RESPONDS TO PROBLEMS IMMEDIATELY
POSTPARTUM
PUERPERIUM
- Also known as postpartal period
- Refers to the 6-week period after childbirth

PHASES OF PUERPERIUM
• Taking-in phase
• Taking- hold phase
• Letting-go phase
TAKING-IN PHASE
- A time of reflection
- 2 to 3 day period
- The woman is passive
- She is dependent

TAKING-HOLD PHASE
- Woman begins to initiate action

LETTING-GO PHASE
- Woman finally redefines her new role, as a mother
to her child
 MATERNAL CONCERNS AND FEELINGS IN THE
POSPARTAL PERIOD

• ABANDONMENT

• DISAPPOINTMENT

• POSTPARTAL BLUES
- Feeling of overwhelming sadness
- Caused by hormonal changes
 PHYSIOLOGIC CHANGES OF THE POSTPARTAL
PERIOD
INVOLUTION
- The process whereby the reproductive organs return
to their nonpregnant state.
- Involves two main process:
• the area where the placenta is planted is sealed
off to prevent bleeding.
•The organ is reduced to its approximate
pregestational size.
- the uterus, after birth weighs about 1000g. At
the end of the first week, it weighs 500g. By the
involution is complete(6 weeks) it weighs
approximately 50g.
LOCHIA
- Uterine discharges similar to a menstrual flow.
- This flow is consists of blood, fragments of decidua,
white blood cells, mucus and some bacteria