STAGES OF LABOR
1st stage of labor -exciting and frightening time
➢ Stage of Dilatation-begins with the
initiation of true labor contractions and
ends when cervix is fully dilated
➢ Takes about 12 hours to complete the
stage
Phases:
➢ Latent phase (cervix 1-4 cm) (Early
Labor)
- begin at the onset of regular uterine
contraction
- ends when rapid cervical dilatation
mild and short contraction lasts 20 to
40 seconds
-cervical effacement occurs, cervix
dilates minimally
-Controlled breathing
-encourage to walk and make
preparation for birth
- alternative pain therapy such as
aromatherapy, distraction, acupressure
-be active
-use nonpharmacotherapeutic
measures
➢ Active phase (4-7cm ,last for 4-8hrs)
-Cervical dilatations occurs rapidly
-Contractions grow stronger, lasting 40
to 60 seconds and occur approx. every
3 to 5 minutes
-show increases
-rupture of membranes
contractions grow stronger and last
longer
-encourage woman to be active participant
in labor
-assume comfortable position except flat
➢ Transition phase (8-10cm)
-Contractions reach its peak of intensity
occurring every 2 to 3 minutes with
duration of 60 to 70 seconds
-cervical dilatation of 8 to 10 cm
- show occur as the last mucus plug
-membrane rupture at full dilatation
- both dilatation (10cm) and complete
cervical effacement occurred
-signs of true labor
-an irresistible urge to push begins
- forehead wipe with cool cloth
-back rubbed
Care of woman on 1st stage of labor
Six major concepts to make labor and birth
natural as possible:
1. Labor should begin on its own, not
artificially induced
2. Women should be able to move freely
3. Should receive continuous support
4. No IV fluids should be used routinely
5. Assume a nonsupine position such as
upright and side lying for birth
6. Mother and baby should be housed
together after birth with unlimited
breast feeding
Nursing Care (1st stage of labor)
1. Respect contraction time
2. Promote change of position
o Squatting position
o Left side lying position
3. Promote voiding and provide bladder
care
4. Offer support
5. respect and promote the support
person’s activities
6. Support the woman’s pain management
efforts
7. Amniotomy
2nd stage of labor
➢ Stage of Expulsion- From the time of
full dilatation until the infant is born
-complete dilatation and cervical
effacement to birth of the infant
contraction from crescendo-
decrescendo pattern
- uncontrollable urge to push or bear
down as if to move bowel
-experience nausea and vomiting
perspires and blood vessels become
distended
- fetus begin to descend into the pelvis
fetal head touches the internal
-perineum to begin internal rotation
-perineum begins to bulge and appear
tense
-anus becomes everted and stool may
be expelled
-fetal scalp appears at the opening to
the vagina
crowning
become unaware of the conversation
pain may disappear, thoughts are
directed towards giving birth
body of the baby is born
Nursing Care (2nd stage of labor)
1. Preparing the place of birth or
birthing room
2. Positioning for birth
o Raise both legs at the same
time to prevent strain on
the woman’s back and
lower abdominal muscles
o Pad the stirrups if a woman
has ankle edema to
prevent thrombophlebitis
3. Prevent from lying for more than 1
hour in lithotomy position
o Lead to pelvic congestion
4. Promoting effective second stage
pushing
o Push with contractions and
rest between them
5. Perineal cleaning and massage
6. Episiotomy
o Surgical incision of the
perineum
o Prevent tearing of the perineum
o Release pressure of the fetal
head
Types:
➢ Midline episiotomy
-Appear to heal more easily
-Cause less blood loss
-Less postpartum discomfort
Mediolateral episiotomy
-Begin in the midline but
directed laterally away from the
rectum
-Less danger of complication
from rectal mucosa tears
Advantages of Episiotomy
-Substitute a clear for a ragged
tear
-Minimizes pressure on the
fetal head
-Shortens the last portion of the
second stage of labor
-May be done without
anesthesia
-Slight blood loss
-Pudendal block
-Numb the lower vaginal area
and perineum
6. Birth
Ritgen maneuver
o Approximately 8 cm across
o Physician or nurse midwife may place a
sterile towel over the rectum and press
forward on the chin while the other
hand is pressed downward on the
occiput
o Helps the fetus achieve extension
- so the head is born with the
smallest diameter presenting
o A child is considered born when the
whole body is delivered
o A child is considered born when the
whole body is delivered
7. Cutting and clamping of cord
-Delayed cutting ensures adequate RBC and
WBC
➢ Hyperbilirubinaemia
➢ Polycythaemia
-Introducing the infant
3rd stage of labor
➢ Placental stage- time the infant is born
until delivery of placenta
-begins with the birth of the infant and
end with the delivery of the placenta
- after birth, uterus is firm , round mass
just below the umbilicus
-after few minutes, uterine contraction
begin, and organ assumes a discoid
shape
-retain the shape until the placenta has
separated, aprox 5 mins after birth of
the infant
Phases
1. Placental separation
-Normal blood loss
-300ml to 500ml
-The placenta has loosened and is ready
to deliver when: LESPU
1. Lengthening of the cord
2. Sudden gush of blood
3. Placenta is visible at the vaginal
opening
4. Uterus contracts and feels firm again
Types of placental separation
➢ Schultze’s placenta
-Placenta separates first at the center and last
at its edges
-Shiny and glistening from the fetal membrane
-80% separates this way
➢ Duncan placenta
-Placenta looks “dirty” irregular maternal
surface
-Raw, red and irregular with the ridges of
cotyledons
2. Placental expulsion
Crede maneuver
-Natural bearing down effort of the mother
-Gentle pressure on the contracted uterine
fundus by the physician or nurse
-5 to 30 mins after delivery
-Pressure should never be applied to a uterus in
a noncontracted state because doing so could
cause the uterus to evert (turn inside out),
accompanied by massive hemorrhage
4th stage
➢ First 1 to 4 hours after the birth- of
placenta, emphasize the importance of
close observation
➢ High risk for hemorrhage
➢ Fundus is firm at the midline and at or
slightly above the umbilicus
➢ lochia rubra- Scanty vaginal discharge
➢ Fatigue, thirst, chills, nausea excitement
and intermittent dosing
Nursing Care:
➢ Oxytocin
-Administered IM or IV
-increase uterine contractions
-minimize uterine bleeding
- do not give if the bp is high, because it
can stimulate the bp to increase
➢ Placental delivery
-delivery up to 30 mins is considered
normal
-Inspection
✓ Intact
✓ no gross abnormalities
and no cotyledons
retain
-Normal in appearance and weight
-massage the fundus to contract
-oxytocin (Pitocin) Im or IV
-carboprost tromehamine (hemabate)
excessive bleeding and poor uterine
contraction
-Methergine to increase uterine
contraction and to guard against
hemorrhage
NOTE: Monitor blood pressure prior to
administer the medication, due to
hypertension by vasoconstriction
➢ Perineal repair
EPISIORRHAPY
-Repair of episiotomy or lacerations
Fetal Condition
Fetal Heart Rate Parameters
● Baseline rate fetal heart rate
1. Variability
• Difference between the highest
and the lowest heart rate is one
of the most reliable indicator of
fetal well-being
• Variation of differing
rhythmicity in the heart rate
• Reflected in the FHR tracing as a
slight irregularity or “jitter” to
the wave
• Baseline variability increases
when the fetus is stimulated
and slows when the fetus
sleeps
• Baseline variability
◦ long term
◦ short term
2. Periodic changes in the rate
• Acceleration and deceleration
in response to fetal movement
and contractions

Immediate postpartal assessment and

nursing care
-Vital signs every 15 mins for 1 hour
-Palpate the fundus for size, consistency
and position
-Observed the amount and
characteristics of lochia
-Perform perineal care and apply
perineal pad
-Offer clean gown or warm blanket
 Periodic Changes 2. Change the woman’s position from
supine to lateral
-Occur in response to contractions and fetal
3. Administer IVF or oxygen as prescribed
movement 4. Prepare for possible prompt birth of the
-Last from a few seconds to 1 to 2 minutes infant if late deceleration persist or if
FHR variability becomes abnormal
4 responses: (absent or decreased)
1. Acceleration ➢ Early deceleration

-Nonperiodic accelerations are temporary - Pattern of contractions, beginning when

normal increase in FHR contractions begin and ending when
contractions end
-caused by fetal movement , change in maternal
position or administration of analgesic Normal: early deceleration late in labor when
head descended fairly low
-Abrupt increase in baseline heart rate of
›15bpm for 15 secs. Abnormal: if occur early in labor, before head
fully descended can be due to cephalopelvic
-Antenatally there should be at least 2 disproportion
accelerations every 15 mins.
➢ Late deceleration
-Nonperiodic accelerations are temporary
normal increase in FHR visually apparent, gradual decrease in the fetal
heart rate typically following the uterine
-caused by fetal movement , change in maternal contraction.
position or administration of analgesic
➢ Variable deceleration
2. Decelerations
-An abrupt* decrease in FHR below the baseline
-Periodic decrease in FHR due to pressure on
the fetal head during contractions - The decrease is ≥15 bpm, lasting ≥15 secs and
<2 minutes from onset to return to baseline.
- Parasympathetic stimulation in response to
vagal nerve
-compression brings about a slowing of FHR
-Decrease in FHR 30 to 40 seconds after the
onset of a contraction and continue beyond the
end of the contraction
-The lowest point of deceleration (nadir) occurs
near the end of the contraction instead of at its
peak
-Due to marked hypertonia or with abnormal
uterine tone caused by administration of
oxytocin
-Suggests uteroplacental insufficiency
Nursing interventions:
1. Stop or slow the rate of administration
 Amnioinfusion
-Addition of sterile fluid into the uterus to
supplement the amniotic fluid
-Prevents additional cord compression
Fetal Heart Rate Pattern
1. Baseline rate
2. Variability in the baseline rate
o Long term and short term
3. Periodic changes in the rate
o Acceleration and deceleration
Nursing diagnosis:
- Powerlessness related to duration of labor.
✓ Interventions: Respect Contraction
Time
✓ Promote Change of Position
✓ Promote Voiding and Provide Bladder
Care
-Risk for ineffective breathing pattern related
to breathing exercises
✓ Interventions: urge the woman to keep
a paper bag nearby when doing
breathing exercises.
Anxiety related to stress of labor
✓ Intervention: Offer support. Personal
touch…
✓ Respect and promote the support
Person’s activities.
✓ Support a Woman’s Pain management
Efforts
Risk for full volume deficit related to
prolonged lack of oral intake and diaphoresis
from the effort of labor.
✓ Interventions: Apply cream to her lips.
✓ Suggest to suck on hard candy or ice
chips to relieve this discomfort
Anxiety related to lack of knowledge about
labor experience
✓ Interventions: Reduce anxiety with
explanations of the Labor Process
Ineffective coping related to combination
of uterine contractions and anxiety
✓ Interventions: Help the woman
identify coping strategies
✓ Provide Comfort Measures
Pain related to labor contractions
✓ Interventions: Encourage
comfortable positioning
✓ Assist the woman with prepared
childbirth method
✓ Provide Pharmacologic Pain Relief
Operative Obstetrical Procedures
➢ Episiotomy
➢ Assisted delivery
➢ Cesarean birth
Types of Delivery
➢ Spontaneous Delivery
Vaginal birth occurring without the assistance of
forceps, vacuum
➢ Cesarean Delivery
Incision made on the abdomen primarily
because of cephalo-pelvic disproportion
➢ Forceps Delivery
Use of metal instrument (Simpson, Elliot, Piper
for breech presentation) to extract fetus from
the birth canal
Essential Intrapartum and Newborn Care (EINC)
Every Newborn Has Needs:
✓ To breathe normally
-95% of Newborn breath normally after birth
✓ To be warm
-Drying for 30 seconds
-to prevent hypothermia
- thru uninterrupted skin to skin contact for 90
minutes
To be protected
-against diseases and infection (vaccination)
To be fed
- exclusive breast feeding for 6 months, and
with complimentary feeding from 6 months
onward
4 Phases that can save life
1. Immediate and thorough drying of the
newborn skin
✓ Dry the newborn thoroughly for at least
30 seconds
Remember: do quick check of breathing
while drying
✓ Follow an organized sequence when
drying
Remember: face, head, trunk (back
then front body part), arms, lower limb
(30 seconds)
✓ Wipe gently, do not wipe off vernix
Remember:
Vernix -keeps the baby warm
-serves as skin protection
-serves as protective barrier to E.coli
and Group B Strep
Early washing
-Hinders crawling reflex
-Can lead to hypothermia
-infection, coagulation defects, acidosis,
delayed fetal to newborn circulatory
adjustment, hyaline membrane
disease,brain hemorrhage
✓ Remove the wet cloth, replace with a
dry one (cover only the back of the
baby)and place bonnet
2. Skin to Skin Contact
Drying should be the first action
immediately for a full 30 seconds,
unless the infant is floppy/limp and
apneic
3. Properly – Timed Cord Clamping
4. Non- Separation of the Newborn from
the Mother for early initiation of
Breast feeding
Immediate Thorough Drying
-If baby not breathing, STIMULATE by DRYING! -
-Do not slap, shake or rub the baby
-Do not ventilate unless the baby is floppy/limp
and not breathing
-Do not suction unless the mouth/nose are
blocked by secretions
Immediate drying:
-Stimulates Breathing
-Prevents hypothermia
Hypothermia can lead to
1. Infection
2. Coagulation defects
3. Acidosis
4. Delayed fetal to newborn circulatory
adjustment
5. Hyaline membrane disease
6. Brain hemorrhage
Properly-Timed Cord Clamping
-Prevents anemia in both term and preterm
babies
-Prevents bleeding in the brain in premature
babies
-When preparing for delivery, don 2 pairs of -
gloves after thorough hand washing
-Remove the first set of gloves
-Palpate the umbilical cord
-Wait 1-3 minutes or until cord pulsations have
stopped.
-Clamp cord using a sterile plastic clamp or tie
at 2 cm from the umbilical base
-Clamp again at 5 cm from the base
-Cut the cord close to the plastic clamp
Care of the Cord
-Do not milk the cord towards the baby
-Observe for the oozing of blood. If blood oozes,
place a second tie between the skin and the
clamp
-DRY cord care is recommended
-Do not apply any substance onto the cord
-Do not use a binder or “bigkis”
Non- Separation of Newborn from Mother for
Early Breast feeding
-Weighing, bathing, eye care, examinations,
injections should be done after the first full
breastfeed is completed
Remember:
Postpone bathing until at least 6 hours
-Never leave the mother and baby unattended
-Monitor mother and baby q15 minutes in the
first 1-2 hrs. Assess breathing and warmth.
-Breathing: listen for grunting, look for chest in-
drawing and fast breathing (inform the
physician)
-Warmth: check to see if feet are cold to touch
if no thermometer
Early and Appropriate Breastfeeding Initiation
-Leave the newborn between the mother’s
breasts in continuous skin-to-skin contact
-The baby may want to rest for 20-30 mins. and
even up to 120 minutes before showing signs of
readiness to feed
-Health workers should not touch the newborn
unless there is a medical indication
-Do not give sugar water, formula or other
prelacteals
-Do not give bottles or pacifiers
-Do not throw away colostrum
-Let the baby feed for as long as he/she wants
on both breasts
-Help the mother and baby into a comfortable
position
-Observe the newborn
-Once the newborn shows feeding cues, ask the
mother to encourage her newborn to move
toward the breast
Breast Feeding Cues
-eye movement under closed lids
-alertness, movements of arms and legs
-tossing, turning or wiggling
-mouthing, licking, tonguing movements
-rooting
-changes in facial expression
-squeaking noises or light fussing
-Crying is a late sign of hunger
Support Continued and Exclusive Breastfeeding
Counsel on positioning
– Newborn’s neck is not flexed or
twisted
– Newborn is facing the breast
– Newborn is close to mother’s
body
– Newborn’s whole body is
supported
Counsel on attachment and suckling
– Mouth wide open
– Lower lip turned outwards
– Baby’s chin touching breast
– Suckling is slow, deep with
somepauses
Proper BF Hold
-Look for a quiet place
-Find a most relaxed position for mother
-Provide adequate back support
-Support feet
-Do not hunch shoulders
-Do not “scissor” the breast
Types of Hold
1. Cradle Hold
2. Cross Cradle Hold
3. Cradle vs. Cross Cradle Hold
4. Underarm Hold
5. Football hold
-Baby is held like a clutch bag
-Nose further away from breast
-Baby’s trunk is secure beside
mother’s trunk
Vaccines to be given after birth
1. Hepa B
2. BCG
Vitamin K- helps in clotting the blood; helps the
baby to avoid bleeding after cutting the cord
Brandt-Andrews maneuver
technique for expressing the placenta from the
uterus during the third stage of labor
1:6- weight of the placenta compared to the
baby’s weight
maternal cotyledons- 30
Exclusive breastfeeding- 6 months
- Do not give milk formula
Oxygen toxicity- can cause blindness