Labor

NCM 107 (Maternal and Child Health Nursing) - MIDTERMS
Labor Does coitus help induce labor?

 is the series of events by which uterine  Semen contains prostaglandins, which
contractions and abdominal pressure can be helpful in softening also known as
expel a fetus and placenta from a “ripening” of the cervix, if a cervix is
woman’s body. ready to ripen, semen prostaglandins
 Regular contractions cause progressive could possibly stimulate the beginning of
dilatation (enlargement or widening of contractions.
the cervical canal) and create sufficient SIGNS OF LABOR
muscular force to allow a baby to be Preliminary Signs of Labor
pushed from the birth canal (or vagina). It
is a time of change, both an ending and a 1. Lightening
beginning, for a woman, a fetus, and her  In primiparas, lightening, or descent of the
family. fetal presenting part into the pelvis, occurs
approximately 10 to 14 days before labor
Theories Why Labor Begin begins. This fetal descent changes a
 Labor normally begins between 37 and 42 woman’s abdominal contour, because it
weeks of pregnancy, when a fetus is positions the uterus lower and more
sufficiently mature to adapt to extrauterine anterior in the abdomen.
life, yet not too large to cause mechanical  Lightening gives a woman relief from
difficulty with birth. the diaphragmatic pressure and
shortness of breath that she has been
 Preterm Birth - labor begins before a experiencing and, in this way,
fetus is mature “lightens” her load.
 Post Term Birth - labor is delayed until
the fetus and the placenta have both  In multiparas, it is not as dramatic and
passed beyond the optimal point for birth. usually occurs on the day of labor or
even after labor has begun. As the fetus
 Although in animals it has been shown sinks lower into the pelvis, a woman may
that progesterone withdrawal is the trigger experience shooting leg pains from the
that stimulates labor, the association that increased pressure on her sciatic nerve,
converts the random, painless Braxton increased amounts of vaginal discharge,
Hicks contractions of pregnancy into and urinary frequency from pressure on
strong, coordinated, productive labor her bladder.
contractions in women is still largely  Lightening heralded by the following
undocumented (Bernal & Norwitz, 2012). signs:
1. Relief of dyspnea
Different Theories 2. Relief of abdominal tightness
 Uterine muscle stretching, which results 3. Increased frequency of voiding
in release of prostaglandins 4. Increased varicosities and pedal
 Pressure on the cervix, which stimulates edema
the release of oxytocin from the 5. Shooting pain down the legs/leg
posterior pituitary cramps
 Oxytocin stimulation, which works
together with prostaglandins to initiate 2. Increase Level of Activity
contractions  A woman may awaken on the morning of
 Change in the ratio of estrogen to labor full of energy, in contrast to the
progesterone (increasing estrogen in feeling of chronic fatigue she felt during
relation to progesterone, which is the previous month.
interpreted as progesterone withdrawal)  This increase in activity is related to an
 Placental age, which triggers contractions increase in epinephrine release initiated
at a set point by a decrease in progesterone produced
 Rising fetal cortisol levels, which by the placenta. This additional
reduces progesterone formation and epinephrine prepares a woman’s body for
increases prostaglandin formation the work of labor ahead.
 Fetal membrane production of  This increased maternal activity supports
prostaglandin, which stimulates the mother’s nesting behavior.
contractions (Impey & Child, 2012).  Nesting behavior is a psychological sign
of approaching labor.
Transcribed by: Cloine Marcel Callanta
 The woman is busy preparing for the therefore can control the degree of
arrival of the baby: sewing diapers, discomfort, she feels by using breathing
buying stuff (crib, layette, mittens, exercises offers her a sense of well-being.
bonnets), decorating a spare room for the
baby and the like. 2. Show
 As the cervix softens and ripens, the
3. Slight Loss of Weight mucus plug that filled the cervical canal
 As progesterone level falls, body fluid during pregnancy (operculum) is expelled.
is more easily excreted from the body.  The exposed cervical capillaries seep
This increase in urine production can blood as a result of pressure exerted by
lead to a weight loss between 1 and 3 the fetus. This blood, mixed with mucus,
pounds. takes on a pink tinged and is referred to as
“show” or “bloody show.”
4. Braxton Hicks Contractions  Within 24 to 48 hours from expulsion of
 In the last week or days before labor bloody show, labor usually starts
begins, a woman usually notices (Littletton & Engebretson, 2006).
extremely strong Braxton Hicks  Signs and Symptoms:
contractions (3-4 weeks before labor). - Cough of two weeks or more
 These are false labor contractions. They - Fever
are confined to the abdomen, are - Chest or back pains not referable
painless, irregular, and relieved by to musculoskeletal disorders
walking. - Hemoptysis or recurrent blood-
 For relief of discomfort: Encourage the streaked sputum
woman to walks as it relieves Braxton - Significant weight loss
Hicks contractions - Other signs and symptoms such as
sweating, fatigue, body malaise
5. Ripening of The Cervix and shortness of breath.
 Ripening of the cervix is an internal sign
seen only on pelvic examination. 3. Rupture of The Membranes Or Bag Of
Waters (Bow)
Cervical Consistencies:  Labor may begin with rupture of the
1. As soft as the nose tip: non-pregnant membranes, experienced either as a
cervix sudden gush or as scanty, slow
2. As soft as the earlobe: pregnant cervix “ seeping of clear fluid from the vagina.
Goodell’s sign”  Some women may worry if their labor
3. As soft as whipped butter: cervix ripe for begins with rupture of the membranes,
labor because they have heard that labor will
then be “dry” and that this will cause it to
be difficult and long.
 B. Signs and Symptoms:
o Fever
o patch or patches of grayish
membrane in the throat, nose,
larynx.
 C. Mode of Transmission: Contact with a
patient or carrier, or with articles soiled
with discharges of infected persons. Milk
has served as a vehicle.
 D. Agent: Corynebacterium Diphtheria
SIGNS OF TRUE LABOR ( Klebs – Loeffler Bacillus )
1. Uterine Contractions  E. Period of Communicability: variable
 The surest sign that labor has begun is until virulent bacilli has disappeared from
productive uterine contractions. secretions and lesions; usually 2 weeks
Because contractions are involuntary and and seldom more than 4 weeks.
come without warning, their intensity can
be frightening in early labor.
 Helping a woman appreciate that she can
predict when her next one will occur and
Rupture of the Bow
 Preterm rupture of the BOW (PROM):
when the bag ruptures before 37 weeks
gestation
 Premature rupture of the BOW (PROM):
when the bags ruptures before labor
 Early rupture of the BOW (EROM): when
the bag ruptures during the early first
stage of labor, usually before the active
phase
 The most common time for the BOW to

rupture is the early second stage or
labor, when the cervix is fully dilated.
 Tetanus is a rare but often fatal disease

that affects the central nervous system by
causing painful and often violent muscular
contractions. The earliest descriptions of
the disease can be found in the medical
papyri of ancient Egypt. The disease
begins when the tetanus bacterium
(Clostridium tetani ) enters the body,
usually through a wound or cut that has
 Actually, amniotic fluid continues to be come in contact with the spores of the
produced until delivery of the membranes bacterium. Tetanus spores are commonly
after the birth of a fetus, so no labor is found in soil, dust, and animal manure.
ever “dry.” Tetanus is a noncommunicable disease,
 Early rupture of the membranes can be meaning that it cannot be passed directly
advantageous as it can cause the fetal from one person to another.
head to settle snugly into the pelvis,  Signs and Symptoms
shortening labor. - Tetanus toxin affects the nerve
 commonly known as whooping cough, is a
endings, causing a continuous
highly contagious disease caused by the
stimulation of the muscles. Initial
bacteria Bordatella pertussis. It is
symptoms may include
characterized by classic paroxysms
restlessness, irritability, a stiff
(spasms) of uncontrollable coughing,
neck, and difficulty swallowing. In
followed by a sharp intake of air which
about half of all cases, the first
creates the characteristic "whoop" from
symptom is a stiff or "locked" jaw,
which the name of the illness derives.
which prevents patients from
 B. Signs and Symptoms:
opening their mouths or
- Fever swallowing. This symptom is also
- cough with whoop called trismus and results in a
 C. Mode of Transmission: facial expression called risus
- Direct spread through respiratory sardonicus, which is a Latin phrase
and salivary contacts. Crowding meaning "sardonic smile." Trismus
and close association with patients is often followed by stiffness of the
facilitate spread. neck and other muscles throughout
 D. Agent: Hemophilus pertussis, Bordet the body as well as uncontrollable
Gengou Bacillus, Bordetella Pertussis or spasms. Sometimes these
Pertussis Bacillus convulsions, known as
 E. Period of Communicability: opisthotonos, are severe enough
- In any catarrhal stage, paroxysmal to cause broken bones. Other
cough confirms provisional clinical symptoms of tetanus include loss
diagnosis 7 days after exposure to of appetite and drooling. People
3 weeks after onset of typical with localized tetanus experience
paroxysms. pain and tingling only at the wound

site and spasms in nearby rarely produces clinical symptoms. Less
muscles. than 1 percent of infections will result in
 C. Mode of Transmission: paralysis. Death may result, however,
- Usually occurs through especially if respiratory muscles are
contamination of the unhealed affected.
stump of the umbilical cord.  B. Signs and Symptoms:
- The infection is usually transmitted - Fever
through deep puncture wounds or - malaise
through cuts or scratches that are - anorexia
not cleaned well. Many people - nausea
associate tetanus with rusty nails - headache
and other dirty objects, but any - abdominal pain followed by
wound can be a source. Less soreness and stiffness of the trunk,
common ways of getting tetanus neck, and limbs that progresses to
are animal scratches and bites; flaccid paralysis
surgical wounds; dental work;  C. Mode of Transmission: Direct contact
punctures caused by glass, thorns, with infected person, fecal-oral and
needles, and splinters; and oropharyngeal routes.
therapeutic abortion. Rare cases  D. Agent: Enterovirus
have been reported in people with  E. Period of Communicability: Not
no known wound or medical known, approx. 4-6 weeks.
condition
 D. Agent: Tetanus Bacillus Caution
 E. Period of Communicability: Varies  The spontaneous rupture of the BOW is
from 3 days to 1 month or more, between always an indication for hospitalization. In
7 and 14 days in high proportion of cases. institutional settings, the FIRST NURSING
ACTION after the rupture of the BOW is to
Membranes and Liquor (Amniotic Fluid) check the fetal heart tones.
 The state of the membranes and color of  The expectant mother should be
amniotic fluid is assessed at every vaginal counseled that the moment
examination and recorded immediately premonitory signs are noted, she
below the FHR recordings. should:
 Four ways of recording membranes 1. Refrain from engaging long trips
and liquor: 2. Have someone with her always in
the home
INTACT membranes I 3. In case of a ruptured BOW,
Ruptured membranes, CLEAR liquid C promptly report to the healthcare
Ruptured membranes, MECONIUM- M provider or transport to a
stained liquid healthcare facility.
Ruptured membranes, BlOOD-stained B 4. The cervix is open and increasingly
fluid dilates and effaces.
 Poliomyelitis, or infantile paralysis, is a

highly infectious disease caused by three
serotypes of polioviruses. These viruses
belong to the Enterovirsus genus of the
family Picornaviridae. The infection is
transmitted from person to person and
 The powers of labor (uterine factors) are
adequate. (The powers of labor are
strongly influenced by the woman’s
position during labor.)
4. PSYCHE
 A woman’s psychological outlook is
preserved, so that afterward labor can be
viewed as a positive experience.
PASSAGE
 The passage refers to the route a fetus
must travel from the uterus through the
cervix and vagina to the external
perineum. Because the cervix and vagina
are contained inside the pelvis, a fetus
must also pass through the bony pelvic
ring.
Bony Pelvis
 Hepatitis B is a disease of the liver which False Pelvis
can be caused by viruses, bacteria,  Above Linea terminalis
protozoa, toxic chemicals, drugs, and  is the expanded portion of the cavity
alcohol. situated above and in front of the pelvic
 B. Signs and Symptoms: brim.
- Loss of appetite True Pelvis –
- Easy fatigability  Below linea terminalis; the part most
- Malaise important to birth
- Joint and muscle pain
- Low grade fever
- Jaundice
- Dark colored urine
 b. Parenteral transmission through:
- Blood and blood products (blood
transfusion.
- Use of contaminated instruments
for injection, ear piercing,
etc.
- Use of contaminated hospital and
laboratory equipment such
as dialysis apparatus and
others.
 C. Perinatal Transmission through:
- occurs during labor and delivery
through leaks across the placenta
and can be precipitated by injury
during delivery.
Components Of Labor At the Pelvic Inlet

A successful labor depends on four integrated  Diagonal conjugate – is the distance
concepts: from the lower border of the symphysis
1. Passage pubis to the sacral promontory which
 A woman’s pelvis (the passage) is of makes it an anteroposterior diameter of
adequate size and contour. the pelvic inlet.
2. Passenger o A diagonal conjugate
 The passenger (the fetus) is of appropriate measurement of greater than
size and in an advantageous position and 11.5cm assures a pelvic inlet of
presentation.
3. POWER
adequate size for vaginal  Sacrum: A good sacrum is deep and
delivery of a normal-sized fetus. well-curved, as in the ideal female pelvis
 Obstetric conjugate (OC) – is the the GYNECOID pelvis.
smallest anteroposterior diameter of the  Coccyx: The mobility of the coccyx is
pelvic inlet. detected by palpating it and attempting to
o If the diagonal conjugate move it to and from.
measurement is known, the
obstetric conjugate can be 2 Pelvic Measurements
indirectly measured by subtracting 1. 1.DIAGONAL CONJUGATE
1.5 to 2 cm from the diagonal  the anteroposterior diameter of the
conjugate. inlet
2. TRANSVERSE DIAMETER of the outlet
At the Pelvic Outlet  In most instances, if a
 Ischial spines – are blunt and somewhat disproportion between fetus and
widely separated, as in the gynecoid pelvis occurs, the pelvis is the
(circular) platypelloid (flat) pelves. structure at fault. If the fetus is the
 Bi-ischial diameter – smallest transverse cause of the disproportion, it is
diameter often because the fetal head is
presented to the birth canal at less
 It can be estimated using the attendant’s than its narrowest diameter, not
knuckles or clenched fist placed across because the fetal head is too large.
the perineum at the level of tuberosities.
With a fist size of at least 8 cm. the 4 BASIC PELVIC SHAPES
knuckles usually do not touch the left and  Gynecoid
right tuberosities simultaneously,  Most common pelvic shape (50%
indicating a diameter of 8cm or greater. of women)
 Best for vaginal delivery
 Oval-shaped inlet (wider form side
to side than from the back
 Parallel sides, dull ischial pines,
and a pubic arch that is 90
degrees or wider.
 ANTHROPOID
 Oval inlet but is wider from front to
back than from the side to side
 Sidewalls are parallel or flare
outward.
 Back part is roomy enough to fit
the back of the fetus head (25% of
women)
 Often results in occiput posterior
birth
 Diluents – a substance used to
dilute something.
 ANDROID
 Male type pelvis (20% of women)
 Small inlet that is somewhat heart-
shaped
 Sidewalls converge, the ischial
spines are prominent, and the
pubic arch is narrow
 Birth might occur, but more likely it
will not progress to a vaginal
 Pelvic side walls: good side walls are birth
straight and nor convergent (as seen in
gynecoid pelvis)  PLATYPELLOID
 Oval-shaped inlet that is is the head, so this is the part least likely
compressed from front to back. to be able to pass through the pelvic ring.
 Results in a fetus that traverses Whether a fetal skull can pass depends on
the pelvis with its head in a both its structure (bones, fontanelles, and
transverse or sideways position. suture lines) and its alignment with the
 Occurs in 5% if women pelvis.
 NOT CONDUCIVE to a vaginal
birth Structure of the Fetal Skull
 The cranium, the uppermost portion of the
skull, is composed of eight bones.
Measuring The Diagonal Conjugate
 The diagonal conjugate measures 12.5 cm  The four superior bones—the frontal
to 13 cm. (actually two fused bones), the two
 The diagonal conjugate is 1.5cm – 2cm parietal, and the occipital—are the
greater than the obstetric conjugate bones that are important in childbirth. The
other four bones of the skull (sphenoid,
FORMULA: ethmoid, and two temporal bones) lie at
DC – 1.5 to 2 cm = Obstetric conjugate the base of the cranium so are of little
significance in childbirth because they are
EXAMPLE never presenting parts. The chin, referred
PROBLEM: Given a diagonal conjugate to by its Latin name mentum, can be a
measurement of 12 cm, what is the obstetric presenting part.
conjugate?
SOLUTION: 12 cm 12 cm
- 1.5 cm - 2cm
10.5 cm 10cm
ANSWER: The obstetric conjugate is about
10cm-10.5 cm
The bones of the skull meet at suture lines.
 The sagittal suture joins the two parietal

bones of the skull.
 The coronal suture is the line of juncture
of the frontal bones and the two parietal
bones.
 The lambdoid suture is the line of
juncture of the occipital bone and the two
parietal bones.
 The suture lines are important in birth

because, as membranous interspaces,
they allow the cranial bones to move
and overlap, molding or diminishing the
size of the skull so that it can pass through
the birth canal more readily.
 Significant membrane-covered spaces

called the fontanelles are found at the
junction of the main suture lines. The
Passenger anterior fontanelle (sometimes referred to
 The passenger is the fetus. The body part as the bregma) lies at the junction of the
of the fetus that has the widest diameter
coronal and sagittal sutures. Because the is taken. The narrowest diameter
frontal bone consists of two fused bones, (approximately 9.5 cm) is from the inferior
four bones (counting the two parietal aspect of the occiput to the center of the
bones) are actually involved at this anterior fontanelle (the
junction so the anterior fontanelle is suboccipitobregmatic diameter).
diamond shaped. Its anteroposterior
diameter measures approximately 3 to 4
cm; its trans-verse diameter, 2 to 3 cm. It
closes when the infant is 12 to 18 months
of age.
 The posterior fontanelle lies at the

junction of the lambdoidal and sagittal
sutures. Because three bones—the two
parietal bones and the occipital bone—
are involved at this junction, the posterior
fontanelle is triangular shaped. It is
smaller than the anterior fontanelle,
measuring approximately 2 cm across its  The occipitofrontal diameter, measured
widest part. Because of its small size, it from the occipital prominence to the
closes when an infant is about 2 bridge of the nose, is approximately 12
months of age. cm. The occipitomental diameter which is
the widest anteroposterior diameter
 Fontanelle spaces compress during birth (approximately 13.5 cm), is measured
to aid in molding of the fetal head. Their from the posterior fontanelle to the chin.
presence can be assessed manually  If a fetus presents the anteroposterior
through the cervix after the cervix has diameter of the skull (a measurement
dilated during labor. wider than the biparietal diameter) to the
anteroposterior diameter of the inlet,
 Palpating for them during a pelvic engagement, or the settling of the fetal
examination helps to establish the position head into the pelvis, may not occur. If
of the fetal head and whether it is in a the fetus does not rotate so the
favorable position for birth. anteroposterior diameter of the skull is
presented to the transverse diameter of
the outlet, arrest of progress may occur.
Diameters of the Fetal Skull

 The shape of a fetal skull causes it to be Molding
wider in its anteroposterior diameter than  is a change in the shape of the fetal skull
in its transverse diameter. To best fit produced by the force of uterine
through the birth canal, a fetus must contractions pressing the vertex of the
present the smaller diameter (the head against the not-yet-dilated cervix.
transverse diameter) to the smaller Because the bones of the fetal skull are
diameter of the maternal pelvis; otherwise, not yet completely ossified and
progress can be halted and birth may not therefore do not form a rigid structure,
be accomplished. pressure causes them to overlap and
 The diameter of the anteroposterior fetal molds the head into a narrower and
skull depends on where the measurement

longer shape, a shape that facilitates
passage through the rigid pelvis.
 Molding is commonly seen in infants just

after birth.
Caput Succedaneum
 Is the swelling or edema of the scalp in a
newborn that appear as a lump on the
head after childbirth.
Cause
 From external pressures on the baby’s  A fetus in good attitude is in complete
head during delivery. flexion: the spinal column is bowed
Primary Symptoms forward, the head is flexed forward so
 Swollen, puffy area of the head under the much that the chin touches the
skin of the scalp sternum, the arms are flexed and
folded on the chest, the thighs are flexed
onto the abdomen, and the calves are
pressed against the posterior aspect of the
thighs.
 A fetus is in moderate flexion if the chin is

not touching the chest but is in an alert or
“military position”. This position causes
the next-widest anteroposterior diameter,
the occipital frontal diameter, to present to
the birth canal. A fair number of fetuses
assume a military position during the early
part of labor.
 This does not usually interfere with labor,

because later mechanisms of labor
Molding is recorded immediately beneath the (descent and flexion) force the fetal head
state of amniotic fluid or liquor. to fully flex.
Four ways of recording molding A fetus in partial extension presents the

“brow” of the head to the birth canal. If a fetus is
in complete extension, the back is arched, and
the neck is extended, presenting the
occipitomental diameter of the head to the birth
canal.
This unusual position presents too wide a skull

diameter to the birth canal for normal birth. Such
a position may occur if there is less than the
normal amount of amniotic fluid present
Fetal Presentation and Position (olighydramnios), which does not allow a fetus
adequate movement. It also may reflect a
Attitude neurologic abnormality in the fetus causing
 describes the degree of flexion a fetus spasticity.
assumes during labor or the relation of the
fetal parts to each other

Minus stations (-)
 Presenting part above the levels of the
ischial spines
Station -1 : 1cm above the level of the ischial
spines
Station -2 : 2 cm above the level of the ischial
spines
Station -3 : 3 cm above the ischial spines
Plus stations (+)

 Presenting part below the ischial spines
Engagement Station +1 : 1 cm below the level of the ischial
 refers to the settling of the presenting part spines
of a fetus far enough into the pelvis to be Station +2 : 2 cm below the ischial spines
at the level of the ischial spines, a Station +3 : 3 cm below the level of the ischial
midpoint of the pelvis. spines
 Descent to this point means that the In station +3, the presenting part can be seen at
widest part of the fetus (the biparietal the perineum (Cunningham et al., 2001).
diameter in a cephalic presentation; the
intertrochanteric diameter in a breech
presentation) has passed through the
pelvis inlet or the pelvic inlet has been
proved adequate for birth.
 The degree of engagement is assessed by

vaginal and cervical examination. A
presenting part that is not engaged is said
to be “floating.” One that is descending
but has not yet reached the ischial spines
is said to be “dipping.”
Lie
 is the relationship between the long
(cephalocaudal) axis of the fetal body
and the long (cephalocaudal) axis of a
woman’s body; in other words, whether
the fetus is lying in a horizontal
(transverse) or a vertical
(longitudinal)position.
Station
 refers to the relationship of the
presenting part of a fetus to the level of
the ischial spines.
 When the presenting fetal part is at the

level of the ischial spines, it is at a 0
station (synonymous with engagement).
 At a 3 or 4 station, the presenting part is at

the perineum and can be seen if the vulva
is separated (i.e., it is crowning).
4 Types of Cephalic Presentation

1. Vertex - is the ideal presenting part
because the skull bones are capable of
effectively molding to accommodate the
cervix.
2. Brow - moderately extended head, with
the brow presenting
3. Face - sharply extended fetal neck that
the occiput and back come in contact and
the face is nearest the birth canal
4. Mentum
During labor, the area of the fetal skull that

contacts the cervix often becomes edematous
from the continued pressure against it. This
edema is called a caput succedaneum. In the
newborn, the point of presentation can be
analyzed from the location of the caput.
 Longitudinal lies are further classified as

cephalic, which means the head will be
the first part to contact the cervix, or
breech, with the breech, or buttocks, as
the first portion to contact the cervix.
Types of Fetal Presentation

 Fetal presentation denotes the body part
that will first contact the cervix or be born
first. This is determined by a combination
of fetal lie and the degree of fetal flexion
(attitude).
Cephalic presentation
 is the most frequent type of presentation
 With this type of presentation, the fetal
head is the body part that will first
contact the cervix.

Breech presentation
 means that either the buttocks or the feet Shoulder Presentation (Transverse Lie)
are the first body parts that will contact the  a fetus lies horizontally in the pelvis so
cervix. that the longest fetal axis is perpendicular
to that of the mother. The presenting part
Three types of breech presentation is usually one of the shoulders
1. Complete (acromion process), an iliac crest, a
2. Frank hand, or an elbow.
3. Footling
Causes Of Transverse Lie
 relaxed abdominal walls from grand
multiparity, which allow the unsupported
uterus to fall forward.
 pelvic contraction, in which the
horizontal space is greater than the
vertical space.
 Placenta previa - in which the placenta is
located low in the uterus, obscuring some
of the vertical space
 With a transverse lie, the usual contour
of the abdomen at term is distorted or is
fuller side to side rather than top to
bottom.
 If an infant is preterm and smaller than
usual, an attempt to turn the fetus to a
horizontal lie may be made.
Position
1. Dorsoanterior – which is common
(60%). The flexor surface of the fetus is
better adapted to the convexity of the
External Cephalic Version maternal spine.
 Performed after 36 or 37 weeks of 2. Dorsoposterior
pregnancy 3. Dorsosuperior
 Non-surgical method 4. Dorso-inferior
 Medicine is given to relax the uterus
 Ultrasound is done before & after the ECV
to check baby’s heart beat and position  In dorsoposterior, chance of fetal
 Success rate is 40% to 50% extension is common with increased risk
 Procedure usually lasts for a few minutes of arm prolapse.
 ECV can be uncomfortable and painful at  According to the position of the head, the
times fetal position is term right or left, the left
one being commoner than the right
Danger of Transverse Lie

Maternal
1. Prolong labor
2. Obstructed labor
3. Rupture of uterus
4. Hemorrhage & Shock
5. Maternal death
Fetal
1. Cord prolapse
2. Hand prolapse
3. Intrauterine Demise (IUD)
4. Fetal distress
5. Still birth

Treatment  In this position, the fetus is facing toward
 CS should be performed in persistent the mother’s back
transverse lie LOP (Left occipito-posterior)
 Internal podalic version in delivery of the  the head is acutely flexed and the occiput
second twin points toward the right maternal abdominal
 External cephalic version may be tried in wall.
selected cases before labor or early in
labor
 In advanced labor or in case of ruptured
membranes CS is safer even in case of
fetal death.
Fetal Position and Cardinal Movements of

Labor
Types of Fetal Position

Position ROA (Right occipito-posterior)
 is the relationship of the presenting part to  the head is acutely flexed and the occiput
a specific quadrant of a woman’s pelvis. points toward the right maternal abdominal
 Maternal pelvis is divided into four wall.
quadrants according to the mother’s pelvis ROP (Right occipito-posterior)
right and left:  the head is acutely flexed, and the occiput
a. right anterior is pointing toward the right maternal back
b. left anterior or sacrum.
c. right posterior LOT or ROT (Left or Right occipito-transverse)
d. left posterior.  the head is acutely flexed and the occiput
points to either left or right side of the
4 important denominators mother.
 Occiput (O) : in cephalic vertex
presentation
 Mentum (M) : in cephalic face
presentation
 Sacrum (S) : in breech presentation
 Acromio-dorso (AD) : in shoulder
presentation
 The position is recognized by the Positions in Breech Presentation

differentiation of the various sutures and LSA Left sacro-anterior
fontanels (Cunningham et al., 1989).  position in which the fetal sacrum points
 If the head presents, the sagittal suture towards the left maternal abdominal wall.
is located and traced to the triangular- RSP Right sacro-posterior
shaped posterior fontanel if the head is  position in which the fetal sacrum points
flexed or to the diamond-shaped anterior towards the right maternal back or sacral
fontanel if the head is extended (Jensen & region.
Bobak, 1985). LST left sacro-transverse
 The sagittal suture is the space between  position in which the fetal sacrum points
two parietal bones of the skull and is towards the left side of the mother.
considered the most important suture.
 The sagittal suture can serve as a guide in
determining anterior, transverse, or
posterior positions.
Varied Positions in Cephalic Presentation

LOA (Left occipito-anterior)
 is the most common and ideal position.
 In this position, the head is acutely flexed
and the fetal occiput (O) points toward the
left (L) maternal abdominal wall (anterior).
Flexion
 As descent occurs and the fetal head
reaches the pelvic floor, the head bends
forward onto the chest, making the
smallest anteroposterior diameter (the
suboccipitobregmatic diameter) present
to the birth canal. Flexion is also aided by
abdominal muscle contraction during
pushing.
Positions in Shoulder Presentation

LADA Left acromio-dorso-anterior
 is the position in which the acromio-dorso
points towards the left maternal abdominal
wall.
RADP Right-acromio-dorso-posterior
 is the position in which the acromio-dorso
points towards the right maternal back or
sacral region.
Internal Rotation
 During descent, the head enters the pelvis
with the fetal anteroposterior head
diameter (suboccipitobregmatic,
occipitomental, or occipitofrontal,
depending on the amount of flexion) in a
diagonal or transverse position. The head
flexes as it touches the pelvic floor, and
the occiput rotates to bring the head into
Mechanisms (Cardinal Movements) of Labor the best relationship to the outlet of the
 Passage of a fetus through the birth canal pelvis (the anteroposterior diameter is now
involves several different position changes to in the anteroposterior plane of the pelvis).
keep the smallest diameter of the fetal head  This movement brings the shoulders,
coming next, into the optimal position to
(in cephalic presentations) always presenting
enter the inlet, putting the widest diameter
to the smallest diameter of the pelvis. These
of the shoulders (a transverse one) in line
position changes are termed the cardinal with the wide transverse diameter of the
movements of labor: descent, flexion, internal inlet.
rotation, extension, external rotation, and
expulsion Extension
 As the occiput of the fetal head is born,
Descent the back of the neck stops beneath the
 is the downward movement of the pubic arch and acts as a pivot for the rest
biparietal diameter of the fetal head to of the head. The head extends, and the
within the pelvic inlet. foremost parts of the head, the face and
 Full descent occurs when the fetal head chin, are born.
extrudes beyond the dilated cervix and
touches the posterior vaginal floor. External Rotation
Descent occurs because of pressure on  In external rotation, almost immediately
the fetus by the uterine fundus. The after the head of the infant is born, the
pressure of the fetal head on the sacral head rotates (from the anteroposterior
nerves at the pelvic floor causes the position it assumed to enter the outlet)
mother to experience a pushing sensation. back to the diagonal or transverse position
Full descent may be aided by abdominal of the early part of labor. This brings the
muscle contraction as the woman pushes. aftercoming shoulders into an
anteroposterior position, which is best for
entering the outlet. anterior shoulder is contractions, a natural process that
born first, assisted perhaps by downward causes cervical dilatation and then
flexion of the infant’s head. expulsion of the fetus from the uterus.
After full dilatation of the cervix, the
Expulsion primary power is supplemented by use of
 Once the shoulders are born, the rest of the abdominal muscles.
the baby is born easily and smoothly  It is important for women to understand
because of its smaller size. This they should not bear down with their
movement, called expulsion, is the end of abdominal muscles until the cervix is fully
the pelvic division of labor. dilated. Doing so impedes the primary
force and could cause fetal and cervical
damage.
Uterine Contractions
 The mark of effective uterine contractions
is rhythmicity and progressive lengthening
and intensity and accompany dilatation of
the cervix.
Origins
 Like cardiac contractions, labor
contractions begin at a “pacemaker” point
located in the uterine myometrium near
one of the uterotubal junctions. Each
contraction begins at that point and then
sweeps down over the uterus as a wave.
After a short rest period, another
contraction is initiated, and the downward
sweep begins again.
 In early labor, the uterotubal pacemaker
may not be working in a synchronous
manner. This makes contractions
Importance of Determining Fetal Presentation sometimes strong, sometimes weak, and
and Position perhaps irregular. This mild incoordination
 It helps predict if the presentation of a of early labor improves after a few hours
body part other than the vertex could be as the pacemaker becomes more attuned
putting a fetus at risk. If a body part other to calcium concentrations in the
than the vertex presents to the cervix, myometrium and begins to function
labor is invariably longer because of smoothly.
ineffective descent of the fetus, ineffective  In some women, contractions appear to
dilatation of the cervix, or irregular and originate in the lower uterine segment
weak uterine contractions. It may also lead rather than in the fundus. These are
to early rupture of membranes, increasing reverse, ineffective contractions, and they
the possibility of infection, fetal anoxia, may actually cause tightening rather than
and meconium staining, complications that dilatation of the cervix. That contractions
lead to respiratory distress at birth and are being initiated in a reverse pattern is
may require cesarean birth. difficult to tell from palpation. It can be
suspected if the woman tells you she feels
Four methods are used to determine fetal pain in her lower abdomen before the
position, presentation, and lie contraction is readily palpated at the
a. combined abdominal inspection and fundus. It is truly revealed only when
palpation, called Leopold’s maneuvers cervical dilatation does not occur. Some
b. vaginal examination women seem to have additional
c. auscultation of fetal heart tone pacemaker sites in other portions of the
d. ultrasound. uterus.
Powers of Labor Phases
 this is the force supplied by the fundus of  A contraction consists of three phases: the
the uterus, implemented by uterine increment, the acme, and the decrement.
provider determines whether it is mild,
A. Increment – is the “building up” of moderate or strong.
contraction (period of increasing 1. MILD: the uterine wall can be indented
contraction) and is the longest phase. with ease.
B. Acme – is the peak of a contraction; it is 2. MODERATE: the uterine wall can be
the most painful period. indented with difficulty.
C. Decrement – is the period of “letting up” 3. STRONG: the uterine wall can no longer
or decreasing contraction. be indented
Characteristics Of Uterine Contractions An intrauterine catheter measures intensity of

A. Duration contraction more accurately:
 refers to the length of time a contraction 1. Normal resting tonus pressure (between
lasts; the time from the start of increment contractions): 10mmHg
(increasing contraction) of one contraction 2. During peak of contraction (acme): 30-55
to the end of decrement (decreasing mmHg; varies depending on the phase of
contraction) of the same contraction. labor
 Duration is expressed in seconds.
B. Frequency
 is the time interval between the start of
one contraction to the start of the next
contraction.
 Frequency is expressed in “every___
minutes”.
C. Interval or Resting Period Differentiating Between True And False Labor
 denotes the time from the end of one Contractions
contraction to the start of the next
contraction.
 It is expressed in minutes.
 To compute interval: Frequency –
Duration = Interval
Correct Palpation Of Uterine Contractions

A. Use fingertips (not the palmar surface),
and the fingers must be kept moving. The
fingertips are the most sensitive part of the
hand.
B. Apply pressure lightly on the abdomen.
The interval of the contractions is the best time to:
C. The uterine fundus is the best site to
1. Auscultate the FHT
palpate when detecting the start of
2. Check maternal blood pressure
increment.
3. Deliver the fetal head in extension
Cervical Changes
The interval between contractions diminishes
 Even more marked than the changes in
gradually from about 10 minutes at the onset of
the body of the uterus are two changes
the first stage of labor so as little as one minute or
that occur in the cervix: effacement and
less in the 2nd stage (Cunningham et al., 1989).
dilatation.
Effacement - is shortening and thinning of the
Intensity
cervical canal. All during pregnancy, the canal is
 refers to the strength of a contraction at
approximately 1 to 2 cm long.
acme.
 During labor, the longitudinal traction from
 It is usually estimated by palpating the
the contracting uterus shortens the cervix
contraction. Judging the amount of
so much that the cervix virtually
indentability of uterine wall during the
disappears.
acme of a contraction, the healthcare
 In primiparas, effacement is accomplished  As dilatation begins, there is an increase
before dilatation begins. in the amount of vaginal secretions (show)
 In multiparas, dilatation may proceed because minute capillaries in the cervix
before effacement is complete. rupture and the last of the mucus plug that
 Effacement must occur by the end of has sealed the cervix since early
dilatation, however, before the fetus can pregnancy is released.
be safely pushed through the cervical  Closed Cervix: one finger cannot be
canal; otherwise, cervical tearing can accommodated through the cervical os.
result.  Open Cervix: At least 1 finger can pass
through the cervical os.
Effacement Of Cervical Canal  Cervical dilatation is expressed in
 Uneffaced: long and thick centimeters (cm), one fingerbreadth is
 Effaced: short and thin approximately 1.0 to 1.5 cm in width.
 Degree Of Thickness  A fully dilated cervix is approximately
o 0% - cervical canal uneffaced with 10cm.
original length of 2cm  Full dilatation is the end of the first stage
o 25% - cervical canal ¾ of its of labor and the start of the second stage.
original length (about 1.5cm)
o 50% - cervical canal ½ of its
original length (now about 1 cm)
o 75% - cervical canal ¼ of its
original length (now about ½ cm)
o 100% - no more canal or “paper-
thin”, this is fully effaced cervix.
Psyche Or Psychological Outlook

 refers to the psychological state or
feelings a woman brings into labor.
 Women who manage best in labor
typically are those who have a strong
sense of self-esteem and a meaningful
support person with them. These factors
allow women to feel in control of
sensations and circumstances they have
never experienced before, and which may
Dilatation not be what they pictured.
 refers to the enlargement or widening of  Women without adequate support can
the cervical canal from an opening few have a labor experience so frightening and
millimeters wide to one large enough stressful that they develop symptoms of
(approximately 10 cm) to permit passage posttraumatic stress disorder (PTSD)
of a fetus. (Beck, 2016)
 Dilatation occurs first because uterine
contractions gradually increase the Stages Of Labor
diameter of the cervical canal lumen by Labor is traditionally divided into three stages:
pulling the cervix up over the presenting  First stage: which begins with the initiation
part of the fetus. of true labor contractions and ends when
 Secondly, the fluid-filled membranes push the cervix is fully dilated
ahead of the fetus and serve as an  Second stage: extending from the time of
opening wedge. If they are ruptured, the full dilatation until the infant is born
presenting part will serve this same  Third or placental stage: lasting from the
function, although maybe not as time the infant is born until after the
effectively. delivery of the placenta
The first 1 to 4 hours after birth of the placenta is
Dilatation Of The Cervical Os sometimes termed the “fourth stage” to

emphasize the importance of close maternal Transition Phase
observation needed at this time.  contractions reach their peak of intensity
 If it has not previously occurred, show will
The First Stage occur as the last of the mucus plug from
 The first stage, which takes about 12 the cervix is released.
hours to complete, is divided into three  If the membranes have not previously
segments: a latent, an active, and a ruptured, they will usually rupture at full
transition phase. dilatation (10 cm).
 Duration: 45 – 90 seconds, average 60
1.Latent Phase or early phase seconds (cervix 8-10 cm)
 begins at the onset of regularly perceived  Frequency: every 2-3 minutes
uterine contractions and ends when rapid  Intensity: Strong
cervical dilatation begins.  During this phase, a woman may
 Contractions during this phase are mild experience intense discomfort that is so
and short, lasting 20 to 40 seconds strong, it might be accompanied by
 Duration: 15-30 seconds (cervix 0-3 cm) nausea and vomiting.
 Frequency: Every 5-8 minutes; greater  She may also experience a feeling of loss
than 10 minutes early in labor of control, anxiety, panic, and/or irritability.
 Intensity: Mild
The Second Stage
Latent Phase  It is the time span from full dilatation and
 A woman who enters labor with a cervical effacement to birth of the infant.
“nonripe” cervix will probably have a  A woman typically feels contractions
longer than average latent phase. change from the characteristic crescendo–
 In a woman who is psychologically decrescendo pattern to an uncontrollable
prepared for labor and who does not tense urge to push or bear down with each
at each tightening sensation in her contraction as if to move her bowels
abdomen, latent phase contractions cause  A woman pushes with such force that she
only minimal discomfort and can be perspires and the blood vessels in her
managed by controlled breathing. neck become distended.
 The fetus begins descent and, as the fetal
Interventions head touches the internal perineum to
 Encourage women to continue to walk begin internal rotation, her perineum
about and make preparations for birth begins to bulge and appear tense
 If desired, she could begin alternative  As the fetal head pushes against the
methods of pain relief such as vagina introitus, this opens and the fetal
aromatherapy, distraction, or acupressure scalp appears at the opening to the vagina
and enlarges from the size of a dime to a
Active Phase quarter, then a half-dollar. (Crowning)
 Cervical dilatation occurs more rapidly  As the fetal head is pushed out of the birth
 Contractions grow stronger, lasting 40 to canal, it extends and then rotates to
60 seconds, and occur approximately bring the shoulders into the best line
every 3 to 5 minutes with the pelvis. The body of the baby is
 Duration: 30- 45 seconds (cervix 4 – then born.
7cm)
 Frequency: every 3-4 minutes The Third Stage
 Intensity: Moderate  begins with the birth of the infant and
 Show (increased vaginal secretions) ends with the delivery of the placenta.
 Spontaneous rupture of the membranes  Two Phases: placental separation and
may occur placental expulsion.
 After the birth of the infant, the uterus can
Interventions be palpated as a firm, round mass just
 Encourage women to be active below the level of the umbilicus. After a
participants in labor by keeping active and few minutes of rest, uterine contractions
assuming whatever position is most begin again, and the organ assumes a
comfortable for them during this time, discoid shape.
except flat on their back.
Placental Separation
 As the uterus contracts down on an almost
empty interior, there is such a
disproportion between the placenta and
the contracting wall of the uterus that
folding, and separation of the placenta
occur.
 Active bleeding on the maternal surface of
the placenta begins with separation, which
helps to separate the placenta still further
by pushing it away from its attachment Placental Separation
site. As separation is completed, the This stage can take anywhere from 1 to 30
placenta sinks to the lower uterine minutes and still be considered normal.
segment or the upper vagina. Because bleeding occurs as the placenta
separates, before the uterus contracts sufficiently
Signs Of Placental Separation to seal maternal capillaries, there is a blood loss
 There is lengthening of the umbilical cord. of about 300 to 500 ml, not a great amount in
 A sudden gush of vaginal blood occurs. relation to the extra blood volume that was
 The placenta is visible at the vaginal formed during pregnancy.
opening.
 The uterus contracts and feels firm again. Placental Expulsion
It becomes globular (from discoid). This is  Once separation has occurred, the
called Calkin’s sign. placenta delivers either by the natural
 Uterus rises in the abdomen as it is being bearing-down effort of the mother or by
displaced and pushed up by the gentle pressure on the contracted
descending placenta. uterine fundus by the primary healthcare
provider (a Credé maneuver).
Schultze presentation  Pressure should never be applied to a
 Appearing shiny and glistening from the uterus in a noncontracted state because
fetal membranes (Shiny) doing so could cause the uterus to evert
(turn inside out), accompanied by massive
Duncan presentation hemorrhage (Bienstock et al., 2015).
 It looks raw, red, and irregular, with the
ridges or cotyledons that separate blood
collection spaces (Dirty)
Completeness of cotyledons – 15-20 ( If placenta

is complete)
The Maternal Physiologic Effects and

Psychological Responses
Physiological Effects Of Labor

Cardiovascular System
 Cardiac output increases 40%–50% from
pre-labor levels.
 Blood loss at birth is 300–500 ml on
average.
 Blood pressure may rise with pain
response and, due to work of the system
during contractions, by an average systolic
rise of 15 mmHg per contraction. Epidural
anesthesia may cause hypotension.
 Nursing Actions
o Monitor closely for hemorrhage bladder reduces bladder tone or the ability
o Monitor for signs of pathology with of the bladder to sense filling.
hypertensive episodes  Nursing Action
o Ensure that patients are well o Ask the birthing parent to void
hydrated prior to epidural approximately every 2 hours during
administration. This usually labor to avoid overfilling because
involves an IV fluid bolus. overfilling can decrease postpartal
bladder tone.
Hematopoietic system
 During labor, WBCs increase to a level of Musculoskeletal System
25,000–30,000 cells/mm3 compared to  During pregnancy, relaxin is secreted
5,000–10,000 cell/mm3 from the ovaries causing the cartilage
 Nursing Action between joints to be more flexible. This
o Continue to monitor for any signs allows the joints of the pelvis to be able to
of infection open as much as 2 cm in labor to allow for
fetal passage.
Respiratory System  Nursing Action
 Increased respiratory rate to respond to o Monitor for appropriate mobility
increased cardiovascular parameters and be mindful of fall risks.
 Total oxygen needs increase 100% during
the second stage of labor. Gastrointestinal (GI) system
 Nursing Action  Blood shunts to life sustaining organs
o Monitor for any signs of causing the GI system to become fairly
hyperventilation. If hyperventilation inactive during labor.
occurs, rebreathing into a paper  Digestive and emptying time of the
bag can be helpful. If needed, use stomach becomes lengthened.
appropriately patterned breathing  Some women experience a loose bowel
to regulate respiratory rate. movement as contractions grow strong.
 Nursing Action
Temperature Regulation o Although many hospital protocols
 Temperature may increase up to (1°F). dictate that women who present in
 Diaphoresis occurs with accompanying labor should not partake of oral
evaporation to cool and limit excessive nutrition, there is little evidence to
warming support this restrictive practice.
 Nursing Action
o Monitor for any signs of infection. Neurologic and Sensory Response
o Offer cool washcloths for the  Increased pain
patient’s forehead for comfort if  Increased respiratory rate
needed.  Nursing Actions
o Where pain registers is important
in appreciating why epidural
Fluid Balance anesthesia is effective.
 Insensible water loss increases during o For early labor, the anesthetic
labor due to diaphoresis and the increase block needs to suppress the lower
in rate and depth of respirations. thoracic synapses; for birth, it
 Nursing Action needs to block sacral nerves.
o Encourage women to sip fluid o Discuss nonpharmacologic pain
during labor the same as they techniques if the patient does not
would if they were exercising to desire medication.
keep hydrated.
o If a woman is nauseated by labor,
encourage sips of fluid, ice chips, Psychological Responses
or hard candy to supply some extra  Labor can lead to emotional distress
fluid. because it is not only painful and fatiguing
but it also represents the beginning of a
Urinary System major life change for a woman and her
 Pressure of the fetal head as it descends partner.
in the birth canal against the anterior  Nursing Actions:
o Offer expeditious care to the  Fear of labor this way releases adrenaline,
patient. and adrenaline interferes with oxytocin
o Continue to encourage her process release and so can limit the effectiveness
of labor. of uterine contractions (Rouhe, Samelo-
o Prior to birth, a woman can Aro, & Toivanen, 2015).
investigate the services of a doula.
Fetal Reponses to Labor
A doula is an individual with specialized training Neurologic System
who provides physical, emotional, and  Uterine contractions exert pressure on the
psychological support to laboring parents. A doula fetal head, so the same response that is
does not perform clinical tasks. However, the involved with any instance of increased
simple gift of presence has been shown to reduce intracranial pressure occurs. The fetal
the need for analgesia and anesthesia requests, heart rate (FHR) decreases by as much as
shorten labor times, and increase satisfaction with 5 beats/min during a contraction, as soon
the birth experience. as contraction strength reaches 40 mmHg;
although not measurable, fetal blood
The Response to Pain pressure also rises.
 Cultural factors can strongly influence a  The decrease in FHR appears on a fetal
woman’s experience and satisfaction with heart monitor as a normal or early
labor. deceleration pattern.
 To make labor a positive experience, be
prepared to adapt care to the woman’s Cardiovascular System
specific needs. If a woman has traditions  During a contraction, as the arteries of the
that run counter to hospital protocols, uterus become sharply constricted, and
address these differences and make the filling of cotyledons almost completely
arrangements to accommodate her halts, the amount of nutrients, including
desires, beliefs, or customs, if possible, oxygen, exchanged during this time is
such as advocating for special foods to greatly reduced, causing a slight but
eat, or saving the placenta for the mother inconsequential fetal hypoxia.
to take home.  The increase in blood pressure caused by
increased intracranial pressure raises
The Response to Fatigue blood pressure and keeps circulation from
 By the time the date of birth approaches, a falling below normal for the duration of a
woman is generally tired from the normal contraction.
discomforts of pregnancy and has not
slept well for the past month (Nazik & Integumentary System
Eryilmaz, 2014).  The pressure involved in the birth process
 For example, a side-lying position caused is often reflected in minimal petechiae or
backache; when she turned onto her back, ecchymotic areas on a fetus (particularly
her fetus kicked and wakened her; when the presenting part). There may also be
she turned back to her side, her back edema of the presenting part (caput
ached again. Sleep hunger from this type succedaneum) from this pressure.
of discomfort can make it difficult for a
woman to perceive situations clearly or to Musculoskeletal System
adjust rapidly to new situations.  The force of uterine contractions tends to
push a fetus into a position of full flexion or
The Response to Fear with the head bent forward, which is the
 Women appreciate a review of the labor most advantageous position for birth.
process early in labor as a reminder that
childbirth is not a strange, bewildering Respiratory System
event but a predictable and well  The process of labor appears to aid in the
documented one. maturation of surfactant production by
 Being taken by surprise—labor moving alveoli in the fetal lung. Both the pressure
faster or slower than the woman thought it applied to the chest from contractions and
would or contractions harder and longer passage through the birth canal help to
than she remembers from last time—can clear the respiratory tract of lung fluid.
lead a woman to feel out of control and
increase the level of pain she experiences.
 For this reason, an infant born vaginally is Increasing Apprehension
usually able to establish respirations more  Warnings of psychological danger during
easily than a fetus born by cesarean birth. labor are as important to consider in
assessing maternal well-being as are
Maternal Danger Signs Of Labor physical signs. As she approaches the
 A systolic pressure greater than 140 second stage of labor, a woman who is
mmHg and a diastolic pressure greater becoming increasingly apprehensive
than 90 mmHg, or an increase in the despite clear explanations of unfolding
systolic pressure of more than 30 mmHg events may not be “hearing” because she
or in the diastolic pressure of more than has a concern that has not been met.
15 mmHg (the basic criteria for gestational  Increasing apprehension also needs to be
hypertension), should be reported. investigated for physical reasons because
 Decrease BP - may be the first sign of it can be a sign of oxygen deprivation or
intrauterine hemorrhage, although a falling internal hemorrhage.
blood pressure from hemorrhage is often
associated with other clinical signs of High or Low Fetal Heart Rate
hypovolemic shock, such as  As a rule, an FHR of more than 160
apprehension, increased pulse rate, and beats/min (fetal tachycardia) or less than
pallor. 110 beats/min (fetal bradycardia) is a sign
of possible fetal distress. An equally
Abnormal Pulse important sign is a late or variable
 Most women during pregnancy have a deceleration pattern revealed on a fetal
pulse rate of 70 to 80 beats/min. This rate monitor.
normally increases slightly during the  Frequent monitoring by a fetoscope,
second stage of labor because of the Doppler, or a monitor is necessary to
exertion involved. A maternal pulse rate detect these changes as they first occur.
greater than 100 beats/min during labor is
unusual and should be reported because it Meconium Staining
may be another indication of hemorrhage.  Meconium staining, a green color in the
amniotic fluid, reveals the fetus has had a
Inadequate or Prolonged Contractions loss of rectal sphincter control, allowing
 Uterine contractions normally become meconium to pass into the amniotic fluid. It
more frequent, intense, and longer as may indicate a fetus has or is experiencing
labor progresses. If they become less hypoxia, which stimulates the vagal reflex
frequent, less intense, or shorter in and leads to increased bowel motility.
duration, this may indicate uterine  Although meconium staining may be usual
exhaustion (inertia). in a breech presentation because
 This problem may be correctable but pressure on the buttocks causes
needs augmentation or other interventions meconium loss, it should always be
to accomplish this. reported immediately even with breech
 uterine contractions lasting longer than 70 presentations so its cause can be
seconds are becoming long enough to investigated.
compromise fetal well-being because this
interferes with adequate uterine artery Causes: Foetal
filling.  Response to acute hypoxic events
 Relaxation of anal sphincter
Abnormal Lower Abdominal Contour  Increasing the production of motilin, which
 If a woman has a full bladder during labor, promotes peristalsis.
a round bulge appears on her lower
anterior abdomen. This is a danger signal
for two reasons: First, the bladder may be
injured by the pressure of the fetal head
pressing against it; and second, the
pressure of the full bladder may not allow
the fetal head to descend.
 To avoid a full bladder, ask women to try
to void about every 2 hours during labor.

 Before cutting, the cord is clamped with

two hemostats placed 8 to 10 in. from the
infant’s umbilicus.
 The timing of cord clamping, however, is
individualized because late clamping of
the cord this way could cause over
infusion with placental blood and the
possibility of polycythemia and
hyperbilirubinemia in a susceptible
Hyperactivity newborn (Preterm infant).
 Ordinarily, a fetus remains quiet and  A cord blood sample is often obtained to
barely moves during labor. Fetal provide a ready source of infant blood if
hyperactivity may be a subtle sign that blood typing or other emergency
hypoxia is occurring because frantic measures, such as establishing whether
motion is a common reaction to the need fetal acidosis was present, needs to be
for oxygen. done.
 A cord blood sample is often obtained to
Low Oxygen Saturation provide a ready source of infant blood if
 Normal fetal oxygen saturation – 40-70% blood typing or other emergency
 A fetus can be assessed for this by a measures, such as establishing whether
catheter inserted next to the cheek (under fetal acidosis was present, needs to be
40% oxygenation needs further done.
assessment). If fetal blood is obtained by  The vessels in the cord are then counted
scalp puncture, the finding of acidosis to be certain three are present and an
(blood pH lower than 7.2) suggests fetal umbilical clamp is applied to replace the
well-being is becoming compromised and forceps.
that further investigation is also necessary.
Introducing The Infant
 After the cord is cut, it is time for the new
parents to spend quality time with their
newborn.
 The infant can remain on the mother’s
Intrapartum and Newborn Care abdomen for skin-to-skin contact. If the
Cutting And Clamping The Cord woman’s partner or support person wants
 The timing of cord clamping, however, to hold the infant, dry the infant well with a
varies depending on the parent’s warmed towel, wrap him or her in a sterile
preference and the maturity of the infant. blanket, and cover the head with a
 The umbilical cord continues to pulsate wrapped towel or cap.
for a few minutes after birth and then  Be certain to handle newborns gently but
the pulsation ceases. Delaying cutting firmly as they are slippery from amniotic
(also called physiologic clamping) until fluid and vernix
pulsation ceases and maintaining the  Most newborns receive prophylactic eye
infant at a uterine level allows as much as ointment against the possibility of a
100 ml more of blood to pass from the chlamydia infection.
placenta into the fetus than if the infant  Don’t administer this until after the parents
were held in a superior position or the cord have had this chance to see their infant for
was immediately cut the first time (and the infant has had a
chance to see them).

 This initial contact is also the optimal time  Wiping or removal of vernix caseosa if
for a mother to begin breastfeeding present
because an infant seems to be hungry at  Foot printing
birth and sucking at the breasts stimulates  Bathing earlier than 6 hours of life
the release of endogenous oxytocin,  Unnecessary separation of the newborn
encouraging uterine contraction and primarily for weighing, anthropometric
involution, or the return of the uterus to its measurements, intramuscular
prepregnant state administration of vitamin K, Hepatitis B
vaccine and BCG vaccine
 Transferring of the newborn to the nursery
or neonatal intensive care unit without any
indication
Essential Intrapartum Newborn Care

 It is a package of evidence – based
practices recommended by the DOH,
PhilHealth, and WHO as the standard of
care in all births by skilled attendants in all
government and private settings
 It is the basic component of DOH’s
Maternal, Newborn and Child Health and
Nutrition (MNCHN)strategy.
 EINC practices for newborn care
constitute a series of time-bound,
chronologically ordered, standard
procedures that baby receives at birth.
What do these four (4) time-bound
interventions do to the newborn? The Care Of Woman During The Third Stage
1. Immediate and thorough drying of the Of Labor
newborn prevents hypothermia which is
extremely important to newborn survival The Delivery Of The Placenta
2. Keeping the mother and baby in  The placenta will deliver spontaneously
uninterrupted skin-to-skin contact prevents following most births (Begley, Gyte,
hypothermia, hypoglycemia, and sepsis, Devane, et al., 2015). Although this is true
increases colonization with protective in most cases, up to 30 minutes is
bacterial flora and improved breastfeeding considered normal.
initiation and exclusivity  After delivery, the placenta is inspected to
3. Properly timed cord clamping and cutting be certain it is intact without gross
until the umbilical cord pulsation stops abnormalities and that no cotyledons
decreases anemia in one out of every remain in the uterus.
seven term babies and one out of every  Normally, a placenta is one sixth the
three preterm babies. It also prevents weight of the infant. If it is unusually large
brain (intraventricular) hemorrhage in one or small, you may be asked to weigh it.
of two preterm babies.  Mature placenta
4. Breastfeeding initiation within the first hour  After the placenta inspection, if the
of life prevents an estimated 19.1% of all mother’s uterus has not contracted firmly
neonatal deaths. on its own, the primary care provider will
massage the fundus to urge it to
What newborn care practices in the delivery contract. Oxytocin (Pitocin 10 units)
room should no longer be continued? may be prescribed to be administered
The following practices should never be done intramuscularly (IM) or per 1,000 ml fluid
anymore to the newborn: intravenously (IV) to also help contraction
 Manipulation such as routine suctioning of (Karch, 2013).
secretions if the baby is crying and  If excessive bleeding with poor uterine
breathing normally. Doing so may cause contraction remains, an injection of
trauma or introduce infection. carboprost tromethamine (Hemabate)
 Putting the newborn on a cold or wet or methylergonovine maleate
surface. (Methergine) is yet another solution to
increase uterine contraction and to guard sutures just enough to achieve co-potation
against hemorrhage of tissues is more beneficial.
The Perineal Inspection Techniques Of Infiltration Of Local Anesthetic

 To be certain a woman’s perineum did not Agents
tear from the pressure of the fetal head,  Prior to the commencement of perineal
the perineum is carefully inspected after repair, infiltration of the traumatized tissue
birth. with local anesthetic agents is required.
 About 3% of women do have a small tear  Lidocaine 1% us used and time must be
extending backward from the vagina. Most allowed for it to take effect before repair is
are small enough that no suturing is started.
needed (Dudley, Kettle, & Ismail, 2013).
 If a tear is large enough to require 1. Put a 22 gauge, 1 ½ inch (3cm) needle on
suturing, a woman usually has enough a 20-cc syringe.
natural perineal anesthesia from pressure 2. Fill the syringe with lidocaine.
of the fetal head or enough effect from 3. Insert the whole length of the needle up
epidural anesthesia, she will not feel pain the vaginal tear just below the skin. Pull
from the suturing. back on the plunger of the syringe and
check for blood to ensure that blood
Degree Of Perineal Lacerations vessels have been avoided.
Perineal lacerations are classified according to 4. Do this on both sides of each vaginal tear.
their depth: 5. Repeat the procedure on both sides of the
1. First degree laceration: involves the perineal tear.
fourchette, perineal skin and vaginal
mucous membrane but not the underlying
fascia and muscle.
2. Second-degree laceration: involves the Caution
fascia and muscles of the perineal body:  If lidocaine is injected directly into a
a. bulbocavernosus perineal muscles blood vessel, it can cause heart
b. transverse perineal muscles irregularity. If blood is aspirated, pill the
c. pubococcygeus muscles in some needle, repeat the procedure with new set
cases of syringe and needle. To prevent any
3. Third-degree laceration: involves allergic reaction to lidocaine, do sensitivity
damage to the anal sphincter, in addition testing to the drug before use.
to the damage of the above structure
4. Fourth-degree laceration: involves Physiologic Changes of the Postpartal Period
massive trauma which extends into the Postpartum Period
rectal mucosa exposing the lumen of the  It is the interval between the birth of the
rectum. newborn and the return of the reproductive
organs to their normal nonpregnant state
Third and fourth-degree tears often needing  It lasts for 6 weeks, with some variation
epidural or spinal anesthesia, at times general among women.
anesthesia should be repaired by experienced
obstetrician. Reproductive system
Uterine changes
Principles Of Repair  The fundus is usually midline and
1. Adequate Hemostasis approximately at the level of the woman's
 Identify and apply pressure on small umbilicus after delivery.
bleeding areas. If unsuccessful, the  Within 12 hours of delivery, the fundus
bleeders with absorbable material. may be ½ inch (1 cm) above the
2. Anatomic Restoration umbilicus.
 Put together the anatomic structure that  After this, the level of the fundus descends
have been injured. The muscle should co- approximately 1 fingerbreadth (½ inch)
optate with muscle and the skin to skin. each day, until by the 10th to the 14th day,
3. Minimum Suture Materials it has descended into the pelvic cavity and
 Since it takes time for the suture materials can no longer be palpated
to be absorbed and since sutures elicit a
foreign body reaction, using minimum
INVOLUTION - is the return of the uterus to a  Exogenous oxytocin is usually
nonpregnant state after childbirth administered immediately after expulsion
 Involution process begins immediately of the placenta to maintain the uterus firm
after expulsion of the placenta with and contracted.
contraction of uterine smooth muscles  Mothers are encouraged to put the baby to
 At the end of third stage of labor, the breast immediately after birth to stimulate
uterus is in the midline, about 2cm below the release of oxytocin.
the level of the umbilicus and weighs
1000g Afterpains
 By 24 hours postpartum the uterus is  Are uncomfortable cramping that persist
about the same size it was at 20 throughout the early puerperium
gestational weeks  Afterpains are more noticeable after births
 The fundus descends about 1 to 2cm in which the uterus was greatly distended
every 24 hours, and by the sixth (e.g., large baby, multifetal gestation)
postpartum day it is located halfway  Breastfeeding and exogenous oxytocin
between the symphysis pubis and the cause these afterpains to intensify.
umbilicus.
 The uterus lies in the true pelvis within 2 Placental site
weeks after childbirth.  Immediately after the expulsion of the
 It involutes to about 500g by 1 week after placenta and membranes, vascular
birth, 350g by 2 weeks, and at 6 weeks it constriction and thrombosis cause the
has returned to its nonpregnant size 50- placental site to be reduced to an irregular
60g nodular and elevated area.
 Upward growth of endometrium causes
Autolysis – It is a self-destruction of excess the sloughing of necrotic tissues and
hypertrophied tissue. prevents scar formation.
 Endometrial regeneration is completed by
Subinvolution – Is the failure of the uterus to postpartum day 16, except the placental
return to a nonpregnant state. site is not complete until 6 weeks after
The most common causes of subinvolution are birth.
retained placenta fragments and infection
Lochia
 It is accompanied by prolongation of  It is the uterine discharge that occurs after
lochial discharge and irregular or birth.
excessive uterine bleeding, which  Lochia is initially bright red changing later
sometimes may be profuse. to a pinkish red or reddish brown
 On bimanual examination, the uterus is  For the first 2 hours after birth the amount
larger and softer than would be expected. of lochia should be about that of a heavy
menstrual period, after that time the lochial
 Ergonovine (Ergotrate) or flow should steadily decrease.
methylergonovine (Methergine), 0.2 mg  Lochia passes through 3 stages:
every 3 to 4 hours for 24 to 48 hours, is 1. lochia rubra
recommended  It consists of blood, decidual and
 On the other hand, metritis responds to trophoblastic debris
oral antimicrobial therapy.  It lasts 3-4 days after childbirth
 A third of cases of late postpartum uterine 2. lochia serosa
infection doxycycline therapy may be  It consists of old blood, serum, leukocytes,
appropriate and tissue debris, the flow becomes pink
or brown.
Contractions  It is expelled 3-10 days postpartum
 The hormone oxytocin strengths and 3. lochia alba
coordinates uterine contraction, which  it consists of leukocytes, decidua,
compress blood vessels and promotes epithelial cells, mucus, and bacteria.
homeostasis  it is yellow to white in color.
 During the first 1 to 2 postpartum hours,
uterine contractions may decrease in
intensity and become uncoordinated

dryness and dyspareunia may persist until
ovarian function returns and menstruation
resumes.
 Initially the introitus is erythematous and
edematous especially in the area of the
episiotomy or laceration repair.
 If episiotomy and laceration have been
carefully repaired, hematomas are
prevented or treated early.
 Usually, healing should occur within 2-3
weeks
 Hemorrhoids usually decrease in size
 Lochia alba may continue to drain for up to within 6 weeks of childbirth.
and beyond 6 weeks after childbirth.
 The amount of lochia is usually increases Pelvic Muscular Support
with ambulation, and breastfeeding.  The supporting structure of the uterus and
 Persistence of lochia rubra early in the vagina may be injured during childbirth.
postpartum period suggests continued  The supportive tissues of the pelvic floor
bleeding as a result of retained fragments that are torn or stretched during childbirth
of the placenta or membranes. may require up to 6 months to regain tone.
 Another common source of vaginal  Women are encouraged to do Kegel
bleeding is vaginal or cervical laceration. exercises after birth to strengthen perineal
 Nonlochial bleeding muscles and promote healing.
 Bloody discharge spurts from the vagina.
The amount of bleeding continues to be Placental hormones
excessive and bright red.  Expulsion of the placenta results in
 Lochia usually trickles from the vaginal dramatic decreases of hormones
opening; the steady flow is greater as the produced by placenta.
uterus contracts. A gush of lochia may  The placental enzyme insulinaze causes
result as the uterus is massaged. the diabetogenic effects of pregnancy to
be reversed, resulting in significantly lower
Cervix blood sugar levels in the immediate
 it is soft immediately after birth postpartum period
 The cervix up to the lower uterine segment  Estrogen and progesterone levels
remains edematous, and thin for several decrease markedly after expulsion of the
days after birth. placenta, reaching their lowest levels 1
 The cervical os which is dilated to 10cm week into the postpartum period.
during labor closes gradually, it may still  Decreased estrogen level associated with
be possible to introduce 2 fingers into breast engorgement, and diuresis of
cervical os for the first 4-6 postpartum excess extracellular fluid that has
days. accumulated during pregnancy
 The external cervical os never regains its  The estrogen levels in nonlactating
pre-pregnancy appearance, it is no longer women begin to increase by 2 weeks after
shaped like a fish mouth. birth, and higher by postpartum day 17.
Pituitary hormones and ovarian function.
Vagina and perineum  Lactating and nonlactating women differ in
 The greatly distended, smooth walled the time of the first ovulation.
vagina gradually returns to its pre-  The persistence of elevated serum
pregnancy size by 6-10 weeks after prolactin levels in breast feeding women
childbirth. appears to the responsible for suppressing
 The mucosa remains atrophic in lactating ovulation
woman at least until menstruation begins  In women who breast feed, prolactin levels
again. remain elevated into the sixth week after
 Thickening of vaginal mucosa occurs with birth.
the return of ovarian function.  Serum prolactin levels are influenced by
 The reduced estrogen levels also the frequency of breastfeeding, the
responsible for causing a decreased duration of each feeding, and the degree
amount of vaginal lubrication, so localized
to which supplementary feedings are uterus from firmly contracting which may
used. cause excessive bleeding.
 Prolactin levels decline in nonlactating  Bladder tone is usually restored 5-7days
women, reaching the prepregnant range after childbirth
by third week
 About 70 of nonlactating women resume Gastrointestinal System
menstruation by 3 months after birth. Appetite
 The resumption of ovulation and the return  The mother is usually hungry shortly after
of menses in lactating women are giving birth.
determined by breastfeeding patterns. Bowel Evacuation
 The first menstrual flow after childbirth is  A spontaneous bowel evacuation may be
usually heavier than normal, within 3-4 delayed until 2-3 days after childbirth.
cycles, the amount of menstrual flow  This can be explained by decreased
returned to woman prepregnant volume muscle tone of the intestines during labor
Urinary system and the immediate puerperium, prelabor
 The diminishing steroids levels after birth diarrhea, lack of food, or dehydration
may explain the reduced renal function
that occurs during the puerperium. GI/hepatic function
 GI tone and motility decreases in the early
Urine components postpartum period, commonly causing
 BUN level increases during puerperium as constipation.
autolysis of the involuting uterus occurs.  Normal bowel function returns
This breakdown of excess protein in the approximately 2 to 3 days postpartum.
uterine muscle cells results in a mild (1)  Liver function returns to normal
proteinuria for 1-2 days after childbirth approximately 10 to 14 days postpartum.
 Gall bladder contractility increases to
Postpartal diuresis normal, allowing for expulsion of small
 Within 12 hours of birth, women begin to gallstones
lose the excess tissue fluid that has
accumulated during pregnancy. Breasts
 One mechanism responsible for reducing Breastfeeding mothers
these retained fluids is the profuse  Before lactation begins the breast feel soft
diaphoresis that often occurs for the first and yellowish fluid (colostrum) can be
2-3 days after childbirth expressed from the nipple .
 The fluid loss through increased urinary  After lactation, the breast feel warm and
output accounts for weight loss of firm.
approximately 2.25kg during the  Tenderness may persist for about 48
puerperium hours after the start of lactation.
 The nipples are examined for erectility and
Urethra and bladder signs of irritation such as cracks, blisters.
 If trauma to the urethra and bladder occur
during the birth process, the bladder wall Non-breastfeeding mothers
becomes hyperemic and edematous, often  Prolactin levels decline rapidly, colostrum
with small areas of hemorrhage. is expressed for the first few days after
 Birth-induced trauma increased bladder childbirth.
capacity and the effects of conduction  On the third or fourth postpartum day
anesthesia combine to cause a decrease engorgement may occur the breasts
in the urge to void. become distended, firm, tender, and warm
 In addition to pelvic soreness from the to touch.
forces of labor, vaginal laceration, or an  Engorgement resolves spontaneously,
episiotomy which they reduce the voiding and discomfort usually decreases within
reflex. 24 to 36 hours
 A tight bra, icepacks, or mild analgesics
Urethra and bladder may be used to relieve discomfort
 Decreased voiding, along with postpartal
diuresis may result in bladder distention. Cardiovascular function
 Distended bladder pushes the uterus up  Most dramatic changes occur in this
and to the side and this prevents the system.
 Cardiac output decreases rapidly and  Afterpains and discomfort from the
returns to normal by 2 to 3 weeks delivery, lacerations, episiotomy, and
postpartum. muscle aches are common.
 Hematocrit increases and increases red  Frontal and bilateral headaches are
blood cell (RBC) production stops. common and are caused by fluid shifts in
 Leukocytosis with increased white blood the first week postpartum.
cells  The elimination of physiologic edema
 (WBCs) common during the first through the diuresis that occurs after
postpartum week. childbirth relieves carpal tunnel syndrome
by easing the compression of the median
Blood volume nerve.
 The blood volume which increase during
pregnancy is eliminated within the first 2 Musculoskeletal function
weeks after birth, with return to  Generalized fatigue and weakness is
nonpregnant values by 6 weeks common.
postpartum.  Decreased abdominal tone is common.
 Diastasis recti heals and resolves by the
Cardiac Output 4th to 6th week postpartum.
 Immediately after the birth, the pulse rate,  Until healing is complete, abdominal
stroke volume and cardiac output remain exercises are contraindicated
elevated or increase for 30 to 60 minutes
as the blood that shunted through Integumentary system
uteroplacental circuit suddenly returns to  Chloasma of pregnancy usually
the maternal systemic venous circulation. disappears at the end of pregnancy.
 Hyperpigmentation of the areolae and
Vital Signs linea nigra may not regress completely
 Temperature may increase to 38c during after childbirth, and it may be permanent
first 24 hours as a result of dehydration. in some women.
 After 24 hours the woman should be  Stretch marks on breasts, abdomen, hips,
afebrile and thighs may fade but usually do not
 Respiratory function returns to disappear
nonpregnant state by 6-8 weeks after  Hair growth slows during postpartum
birth. period, and some women may actually
 A small transient increase in both systolic experience hair loss.
and diastolic blood pressure lasting about
4 days after birth Immune system
 Pulse, it returns to nonpregnant rate by 8-  No significant changes occur during
10 weeks after childbirth. postpartum period
 Hematocrit and hemoglobin, they
increased in level by the seventh day after A good method to remember how to check the
birth. postpartum changes is the use of the acronym
 WBCs, they increased in values of BUBBLERS
between 20.000 and 25.000/mm, during B - Breast.
the first 10-12 days after childbirth U -Uterus.
 Marked leukocytosis and thrombocytosis B - Bladder.
occur during and after labor B - Bowel.
L - Lochia.
Respiratory function E - Episiotomy.
 Returns to normal by approximately 6 to 8 R - Emotional response.
weeks postpartum. S - Homans' sign.
 Basal metabolic rate increases for 7 to 14 Summary
days postpartum, secondary to mild  Postpartum physiologic changes allow the
anemia, lactation, and psychological woman to tolerate considerable blood loss
changes at birth
 The uterus involutes rapidly after birth
Neurologic function returning to true pelvis within 2 weeks
 Discomfort and fatigue are common.  The rapid decrease in estrogen and
progesterone levels after the expulsion of
the placenta is responsible for triggering mother of only one or two (or however
many of anatomic and physiologic many children she had before this birth).
changes in postpartum  This process requires some grief work and
readjustment of relationships, similar to
Psychological Changes of the Postpartal what occurred during pregnancy. It is
Period extended and continues during the child’s
 The postpartum period is a time of growing years. A woman who has reached
transition, during which a couple gives up this phase is well into her new role
concepts such as “childless” or “parents of
one” and moves to not only trying out their  When a woman has successfully linked
new role but also determining whether with her newborn, it is termed attachment
they “fit” their new role. Nurses can help or bonding.
couples acknowledge the extent of the  Although a woman carried the child inside
change so that they can gain closure on her for 9 months, she often approaches
their previous lifestyle. her newborn not as someone she loves
but more as she would approach a
Behavioral Adjustment: Phases Of The stranger.
Puerperium  The first time she holds the infant, she
Taking-In Phase may touch only the blanket. If she unfolds
 is largely a time of reflection. the blanket to examine the baby or count
 During this 1- to 3-day period, a woman is the fingers or toes, she may use only her
largely passive. She prefers having a fingertips for touch.
nurse attend to her needs and make  Skin-to-skin contact soon after birth
decisions for her rather than do these facilitates the early attachment and
things herself. binding phase. This should ideally occur
 This dependence results partly from her within the first hour of any birth, even
physical discomfort because of afterpains cesarean deliveries, as soon as the
or hemorrhoids, partly from her uncertainty mother and baby are stable and last until
in caring for her newborn, and partly from completion of the first breastfeeding
the exhaustion that follows childbirth. (Moore, Bergman, Anderson, et al., 2016).
 Gradually, as a woman holds her child
Taking-Hold Phase more, she begins to express more
 After a time of passive dependence, a warmth, touching the child with the palm of
woman begins to initiate action (the her hand rather than with her fingertips.
taking-hold phase). She prefers to get her  She soothes the baby’s hair, brushes a
own washcloth or to make her own cheek, plays with toes, and lets the baby’s
decisions. fingers clasp hers. Soon, she feels
 Women who give birth without any comfortable enough to press her cheek
anesthesia may reach this second phase against the baby’s or kiss the infant’s
in a matter of hours after birth. nose; she has successfully bonded or
become a mother tending to her child.
 During the taking-in period, a woman may Looking directly at her newborn’s face,
have been too tired to care for her child. with direct eye contact (termed an en
 Now, she begins to take a stronger face position), is a sign a woman is
interest in her infant and begins maternal beginning effective attachment.
role behaviors.
 As a rule, it is usually best to give a Engrossment - this action alerts caregivers to
woman a brief demonstration of baby care how actively the father, as well as the mother, is
and then allow her to care for her child beginning bonding.
herself—with watchful guidance—as she
enters this phase.  The length of time parents take to bond
with a child depends on the circumstances
Letting-Go Phase of the pregnancy and birth, the wellness
 In this third phase (the letting-go phase), a and ability of the child to meet the parents’
woman finally redefines her new role. expectations, reciprocal actions by the
 She gives up the fantasized image of her newborn, and the opportunities the
child and accepts the real one; she gives parents have to interact with the child.
up her old role of being childless or the
 When pregnancy or newborn pregnancy, they pictured a chubby-
complications lead to separation of the cheeked, curly-haired, smiling girl or boy.
mother from her newborn, it places the  They may have instead a thinner baby,
woman at greater risk for developing without any hair, who seems to cry
posttraumatic stress disorder and constantly, or may have a congenital
interferes with the usual process of condition. This can make it difficult to feel
bonding (Dale-Hewitt, Slade,Wright, et al., positive immediately toward a child who
2012). does not meet their expectations.
 It can cause parents to remember their
Maternal Concerns And Feelings In Postpartal adolescence, when they felt gangly and
Period unattractive, or to experience feelings of
 Typical issues identified by postpartal inadequacy all over again.
women that they would like to hear
discussed are breast soreness; Interventions
regaining their figure; regulating the  Handle the child warmly, to show you find
demands of a job, housework, their the infant satisfactory or even special.
partner, and their children; coping with  Comment on the child’s good points, such
emotional tension and sibling jealousy; as long fingers, lovely eyes, and healthy
and how to combat fatigue appetite.
Abandonment  Be aware, however, that, culturally, some
 Many mothers, if given the opportunity, groups are fearful for the baby if these
admit to feeling abandoned and less types of comments are made because
important after giving birth than they they could draw evil influences toward the
did during pregnancy or labor. Only child.
hours before, after all, they were the
center of attention, with everyone asking Postpartal Blues
about their health and well- being. Now,  During the postpartal period, as many as
suddenly, the baby is everyone’s chief 50% of women experience some feelings
interest. of overwhelming sadness or “baby blues”
 Relatives ask about the baby’s health; the (Baselice & Lawson, 2012).
gifts are all for the baby. Even a woman’s  They may burst into tears easily or feel let
primary healthcare provider, who has down and irritable. This phenomenon may
made her feel so important for the last 9 be caused by hormonal changes,
months, may ask during a visit, “How’s particularly the decrease in estrogen and
that healthy 8-pound boy?” Comments progesterone that occurred with delivery of
such as this can make a woman the placenta. Breastfeeding has been
experience a sensation very close to shown to help elevate baby blues and
jealousy. And how can a good mother be counteract the effects of the hormonal
jealous of her own baby? drop that occurs after childbirth.
 For some women, it may be a response to
Interventions dependence and low self-esteem caused
 You can help a woman move past these by exhaustion, being away from home,
feelings by verbalizing the problem: “How physical discomfort, and the tension
things have changed! Everyone’s asking engendered by assuming a new role,
about the baby today and not about you, especially if a woman is not receiving
aren’t they?” These are reassuring words support from her partner. In addition to
for a woman and help her realize that, crying, the syndrome is evidenced by
although uncomfortable, the feeling she is feelings of inadequacy, mood lability,
experiencing is normal. anorexia, and sleep disturbance.
 Pointing out positive parenting behaviors,
positive self-care behaviors, and the warm Interventions
infant response to their behaviors.  Be certain support persons also receive
assurance of this type, or they can think
Disappointment the woman is unhappy with them or the
 Another common feeling parents or new baby or is keeping some terrible news
partners may experience is about the baby secret.
disappointment in the baby. All during  Give the woman a chance to verbalize her
feelings and make as many decisions as
she wants to help her gain a sense of
control and move past this strange
postpartal emotion.
 Encouraging women to talk about their
postpartal feelings helps to differentiate
between problems that can be handled
best with discussion and concerned
understanding and those that should be
referred to a social service department or
a community health agency for additional
support.

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NCM 107 (Maternal and Child Health Nursing) - MIDTERMS

Labor Does coitus help induce labor?

 The most common time for the BOW to

 Tetanus is a rare but often fatal disease

Transcribed by: Cloine Marcel Callanta

 Poliomyelitis, or infantile paralysis, is a

Components Of Labor At the Pelvic Inlet

The bones of the skull meet at suture lines.

 The sagittal suture joins the two parietal

 The suture lines are important in birth

 Significant membrane-covered spaces

 The posterior fontanelle lies at the

Diameters of the Fetal Skull

Transcribed by: Cloine Marcel Callanta

 Molding is commonly seen in infants just

 A fetus is in moderate flexion if the chin is

 This does not usually interfere with labor,

Four ways of recording molding A fetus in partial extension presents the

This unusual position presents too wide a skull

Transcribed by: Cloine Marcel Callanta

Plus stations (+)

 The degree of engagement is assessed by

 When the presenting fetal part is at the

 At a 3 or 4 station, the presenting part is at

4 Types of Cephalic Presentation

During labor, the area of the fetal skull that

 Longitudinal lies are further classified as

Types of Fetal Presentation

Transcribed by: Cloine Marcel Callanta

Danger of Transverse Lie

Transcribed by: Cloine Marcel Callanta

Fetal Position and Cardinal Movements of

Types of Fetal Position

 The position is recognized by the Positions in Breech Presentation

Varied Positions in Cephalic Presentation

Positions in Shoulder Presentation

Characteristics Of Uterine Contractions An intrauterine catheter measures intensity of

Correct Palpation Of Uterine Contractions

Psyche Or Psychological Outlook

Transcribed by: Cloine Marcel Callanta

Completeness of cotyledons – 15-20 ( If placenta

The Maternal Physiologic Effects and

Physiological Effects Of Labor

Transcribed by: Cloine Marcel Callanta

 Before cutting, the cord is clamped with

Transcribed by: Cloine Marcel Callanta

Essential Intrapartum Newborn Care

The Perineal Inspection Techniques Of Infiltration Of Local Anesthetic

Transcribed by: Cloine Marcel Callanta

Transcribed by: Cloine Marcel Callanta

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