STAGES OF LABOR & DELIVERY

ESSENTIAL INTRAPARTUM and NEWBORN CARE

(EINC)
Evidenced-based standards for safe and quality care of
birthing mothers and their newborns, within the 48 hours of
Intrapartum period (labor and delivery) and a week of life for the
newborn

Mother= Essential Intrapartum Care (EIC)

Newborn= Essential Newborn Care (ENC)

ESSENTIAL INTRAPARTUM and NEWBORN CARE
(EINC)
December 2009

DOH Secretary Francisco Doque signed

Administrative order 2009-0025
• mandates implementation of EINC protocol in public and private
hospitals

Unang Yakap campaign was launched

 STAGES OF LABOR

Stage 1 = Stage of Cervical Dilatation

Stage 2 = Stage of Fetal Expulsion

Stage 3 = Stage of Placental Expulsion

Stage 4 = Stage of Puerperium

STAGE PRIMIS MULTIS

1ST STAGE 10-12 hours 6-8 hours

2ND STAGE 2 hrs. average 50 20 to 90 minutes
minutes average 20 minutes
3RD STAGE 30 minutes 30 minutes
4TH STAGE 1 to 4 hours 1 to 4 hours
FIRST STAGE OF LABOR
 FIRST STAGE OF LABOR
“STAGE OF CERVICAL
DILATATION”
• From the onset of true
labor contractions &
ends with complete or
full cervical dilatation
(10 cm)
 DILATATION
Progressive, opening/widening of the cervical canal

Expressed in centimeters

(cms)

10 cm = fully dilated cervix

Primigravida= 1.2 cm/hr

Multigravida= 1.5 cm/hr

 EFFACEMENT
shortening and thinning of the cervical canal

Expressed in percentage(%)
EFFACEMENT
 100% • fully effaced cervix
effaced • cervical canal become paper-thin

75% • cervix become ¼ of its original

effaced length

50 % • cervix become ½ of its original

effaced length

25 %
• cervix is ¾ of its original length
effaced
CLOSED CERVIX
 PHASES OF THE FIRST STAGE OF LABOR
LATENT ACTIVE TRANSITION
DILATATION 0-3 cms 4-7 cms 8- 10 cms
DURATION 20-40 sec. 40-60 sec. 60-90 sec.
INTERVAL 5-10 min. 3-5 min. 2-3 min.
INTENSITY Mild, short & Moderate to Strong
irregular strong
FREQUENCY > 10 min 3-5 min 2-3 min
 LATENT ACTIVE TRANSITIONAL
MATERNAL • Minimal • Increasing • Increased
DISCOMFORT discomfort discomfort, perspiration
• backache trembling of • Nausea & vomiting
• abdominal thighs and legs • Strong uterine
cramps • Pressure on the contractions
• rupture of bladder and • Backache
membrane rectum • Pressure on
bladder and rectum
• Leg trembling,
Cramps
 LATENT ACTIVE TRANSITIONAL
MATERNAL • Excited & • Fear of losing • Restlessness
BEHAVIOR alert control, • Panic and anxious
• Talkative, • Irritable, Restless • Irritability
able to • Less talkative, • Has lost control
laugh More anxious of labor
• Pain is • Skin warm and • irresistible urge
controlled flushed to push
paleness of the skin area around the mouth,
• able to walk • May • circumoral pallor
hyperventilate • resist being
touched and
push person
away
ANALGESIA COMMONLY USED DURING CHILDBIRTH

Narcotic Analgesics Example:

• may be given during • Meperidine

labor because of Hydrochloride (Demerol)
their potent • Nalbuphine (Nubain)
analgesic effect • Fentanyl (Sublimaze)
• Butorphanol tartrate
(Stadol)
 Meperidine Hydrochloride (Demerol)
most commonly used
promoting calm or inducing sleep
Has sedative and antispasmodic effect (Relieves pain and helps relax
reduce excessive GI smooth muscle contractility and spasm.
the cervix)

given either intramuscularly or intravenously

Dose : 25 –100 mg depending on woman’s weight & route of

administration.
Onset of action:
• 30 minutes after intramuscular (IM) injection
• 5 minutes after intravenous (IV) administration.
Duration of action : 2 - 3 hours
 SPECIAL CONSIDERATIONS IN GIVING DEMEROL:

• Not given early in labor due to possible effect on contractions (delays

progress)
• Given if cervical dilatation is 6 – 8 cms.(more than 3 hours away from
birth)
• Not given too late (1-2 hours before delivery) because it can cause
respiratory depression in the newborn
• Narcotic Antagonist:
drug that produces analgesia (pain relief), narcosis (state of stupor or sleep), and addiction (physical dependence on the drug)
❖Naloxone Hydrochloride (Narcan)- used to counteract newborn
respiratory depression when a mother has received a narcotic
analgesic during labor.
ESSENTIAL INTRAPARTUM CARE (EIC)
PRACTICES DURING FIRST STAGE OF LABOR
Mobility= allow the mother to walk to increase the
descent of fetus only if BOW is intact

Food and drinks= light carbohydrates food

Non pharmacologic pain relief (effleurage, positioning)

is a massage technique in which
long, light strokes are used over
areas of the body.

Companion in labor= shorter labor

Use of partograph (begins at 4cm (active labor), IE

done every 4 hours (not to exceed 5x because it might
lead to infection)
 NOT RECOMMENDED PRACTICES

• No perineal shaving
• No enema
• No IV fluids
• No NPO
• No lying down
• No artificial rupture of membrane or BOW/ Amniotomy
• No drug induce labor
SECOND STAGE OF LABOR
 SECOND STAGE OF LABOR
( STAGE OF FETAL EXPULSION / DELIVERY STAGE)
from complete cervical dilatation ( 10 cm)
& ends with the delivery of the fetus.

Primigravida: 30 minutes to 2 hrs.

Multigravida: 20 minutes to 1 hr.

Crowning is the • Newborn’s head or presenting part

hallmark appears at the vaginal opening
 Engagement
Descent

CARDINAL MOVEMENTS IN
THE SECOND STAGE OF LABOR Flexion

• ED FIRE ERE Internal rotation

Extension
Descent
External rotation

Expulsion
MECHANISMS (CARDINAL MOVEMENTS) OF LABOR

ENGAGEMENT

• synonymous to station 0
• Passage of the biparietal
diameter of fetal head
through the maternal
ischial spine/pelvic inlet
 DESCENT

• downward movement
of the biparietal
diameter of the fetal
head to the pelvic
inlet.
• Measured by “station”
 FLEXION

• Fetal head bends forward unto the

chest
• Presenting diameter changes from
Occipitofrontal (11cm) to the
smallest AP diameter
suboccipitobregmatic diameter (9.5
cm) to present in the pelvic outlet.
 INTERNAL ROTATION

• fetal skull rotates from transverse to

anteroposterior diameter at pelvic
outlet; associated with descent
• Occiput rotates 45 degrees; is just
under the symphysis pubis
• Sinciput near the sacrum
 CROWNING
Fetal head is visible at
vaginal outlet

Encirclement of the largest

diameter of the fetal head
in the vulvar ring
 EXTENSION

• fetal head reaches the

perineum
• occiput passes under the
lower border of the
symphysis pubis first
• head emerges by extension:
first occiput, next face, finally
the chin
 • sterile towel over the perineum
and press forward on the fetal chin
while the other hand is pressed
RITGEN’S
downward on the occiput
MANEUVER
• helps fetal extension
• controls the rate at which the head
is born
 (EXTERNAL
ROTATION/RESTITUTION)
• After head is delivered, it
rotates briefly to the position it
occupied when it was engaged in
the inlet
• 45-degree turn realigns
fetal head with his back and
shoulders
• anterior shoulder descends
first followed by posterior
shoulder
 EXPULSION

• head and shoulders are lifted up

toward the mother’s pubic bone
and the trunk of the fetus is
born by flexing it laterally in the
direction of the symphysis pubis.
PERINEAL ASSESSMENT DURING 2ND STAGE OF LABOR

LACERATIONS

• Injury or tear in the vaginal

canal and perineum that
occurs during delivery of the
fetus
 First Degree Laceration
• A tear on the fourchette, perineal skin, vaginal
mucous membrane
 Second Degree Laceration
• tear on the fourchette, perineal skin, vaginal mucous
membrane, fascia and perineal muscles
 Third Degree Laceration
• A tear on the fourchette, perineal skin, vaginal mucous membrane,
fascia and perineal muscles, perineal body, anal sphincter
 Fourth Degree Laceration

• tear on the fourchette, perineal skin, vaginal mucous membrane, fascia

and perineal muscles, perineal body, anal sphincter and rectum
 Episiotomy

• surgical incision into the

perineum to enlarge the
vaginal opening
• to prevent tearing of the
perineum and release
pressure on the fetal head
with birth
• done during or prior crowning
 Midline/Median episiotomy
• incision is made straight in the
midline of the perineum
• Easily repaired, less discomfort
• allows faster and less painful
healing
• DISADVANTAGE: may extend up
to rectum
Mediolateral episiotomy
• incision directed laterally
away from the rectum
• rectal structures are
avoided
• cause more pain during
healing
 Episiorrhaphy

• Repair of perineal
laceration or of
episiotomy
• stitching together
the margins of a
tear in the tissues
lacerated during
vaginal delivery
EIC PRACTICES DURING SECOND STAGE OF LABOR

Spontaneous bearing down/pushing of the

mother

Place mother on semi upright

Restrictive episiotomy/indicated
episiotomy(do not do as a routine in Primi)
NOT RECOMMENDED PRACTICES:

•No perineal sweeping

•No fundal pushing
THIRD STAGE OF LABOR
 THIRD STAGE OF LABOR
(STAGE OF PLACENTAL EXPULSION)
begins with the delivery of the fetus
to the delivery of the placenta.

Occurs within 30 minutes

 SIGNS OF PLACENTAL SEPARATION
Calkin’s sign
• earliest sign ; uterus becoming firm, round, globular again
• Immediately after delivery fundus at midway between the
symphysis pubis and umbilicus, then rises to the level of the
umbilicus-midline.
sudden gush of blood
lengthening of the umbilical cord

Firm contraction of the uterus

Appearance of the placenta at the vaginal opening

TYPES OF PLACENTAL PRESENTATION
 SCHULTZE PRESENTATION

• Fetal side out first

• “ Shiny/Clean Side First”
• Common (80%)
• placenta separates first at its center & last at its edges
• Folds like an inverted umbrella
 DUNCAN PRESENTATION

• Maternal side out first

• Rough, “dirty”, reddish, irregular, with ridges or cotyledons
• Less common(20%)
• placenta separates first at its edges and last at its center
 TECHNIQUES FOR PLACENTAL EXPULSION
CREDE’S MANEUVER AND
BRANDT ANDREW MANEUVER
• gentle pressure is exerted with the hand on the
contracted uterine fundus and the placenta is
gently guided out of the vagina
• Gentle traction is made on the 4 fingers
pressed the midline of the contracted uterus
pushing it upward
• slowly pull cord and wind the cord around the
clamp until placenta is delivered
• Placenta is held and rotated gradually to ensure
that no membranes are retained
 EIC PRACTICES DURING THE THIRD STAGE OF LABOR
Wait for placental separation, deliver the placenta only if the
uterus is contracted

Expel placenta via BAM (Crede’s Maneuver and Brandt Andrew

maneuver); Use of controlled traction

Inject oxytocin (Check BP first )

Gentle Massage of the uterus

 AMTSL
(Active Management of Third Stage of Labor)
After delivery of baby check if there is a second baby
If none, oxytocic drugs are given IM or IV
Oxytocics-drugs that contracts the uterus thereby controls uterine bleeding
• Oxytocin, Pitocin, Syntocinon
• Ergotrate Maleate, Methergine
• Carboprost (given if uterus is still unable to contract after oxytocin
is given)
Note: Check first the Blood Pressure before giving these Oxytocic drugs
 FOURTH STAGE OF LABOR
(Immediate Postpartum Period)

First 1-4 hours after delivery

Period of recovery, stabilization or homeostasis

Follows placental expulsion and lasts until maternal vital

signs and conditions are stable
 Uterus

• Immediately
after delivery-
midway
between the
umbilicus and
symphysis
pubis.
 KEEP THE UTERUS FIRM IF UTERUS IS DISPLACED TO THE SIDE

• If relaxed, soft and not contracted,

gently massage until it contracts and • First action: Check
becomes firm. bladder distention
• Do not OVER MASSAGE as this can tire
the uterine muscles, causing relaxation • feel the lower
• A boggy uterus many indicate uterine abdomen for a
atony or retained placental fragments.
• Boggy - being inadequately contracted distended bladder
and having a spongy rather than firm
feeling. • When the bladder is
• Administer oxytocin medications if distended, stimulate
ordered.
• Check BP, uterine contraction and
voiding.
lochia after administration
 DOCUMENT LOCHIA FLOW
WHEN THE FUNDUS IS MONITOR VITAL SIGNS
MASSAGED
• Every fifteen (15) minutes • every 15 minutes for the
for the first hour. first one hour
• Every thirty (30) minutes • Every 30 minutes for the
for the next one hour. next two hours
• Every hour until ready for • Every hour until thereafter
transfer. until stable
 CHECK EPISIOTOMY MONITOR BLOOD
CHECK PERINEUM OR LACERATED LOSS DURING
WOUND DELIVERY
• appearance • Bleeding • Normal
• redness, swelling, • Hematoma Spontaneous
bruising • edema Vaginal Delivery
• vaginal & suture line (NSVD): 300-500 ml
bleeding average 250 ml
• Cesarean Birth :
<1000 ml
 ASSESS LOCHIA
• the maternal discharge of blood,
mucus, and tissue from the uterus
• Bright red and can saturate 1 to 2
perineal pads in one hour
• If Reddish persists more than 2
weeks, it indicates either retention
of small portions of the placenta or
imperfect involution of the
placental site
ASSESSMENT
• Keep a pad count. Record the
number of pads soaked with lochia
during recovery.
• Identify presence of bright red
bleeding or blood clots.
• Document thick, foul-smelling
lochia.
• Observe for constant trickle of
bright red lochia. This may indicate
lacerations.
• Identify lochia amounts as small,
moderate, or heavy (large)
 PROMOTE SLEEP PROVIDE PROMOTE
AND COMFORT NOURISHMENT BONDING
• Keep warm. Chills • the woman may be • Early feeding can
are common in thirsty and hungry contract the uterus
fourth stage of and promote
labor bonding (LATCH-
• Give partial bath, ON)
perineal care( front • Breastfeeding
to back) change started: 30
wet linens. minutes after a
• Assess afterpains normal delivery
 STABLE MATERNAL CONDITION
Firm fundus

Lochia moderate in amount

No bladder distention

Alert and responsive

Stable vital signs

No signs of bleeding
 REFERENCES
❖ Pillitteri, Adele. Maternal and Child Health Nursing, Care
of the Childbearing & Childrearing Family. 7th Edition.
Copyright 2014. Lippincott William and Wilkins
❖ Murray, Sharon Smith. Foundations of Maternal-Newborn
Women’s Health Nursing 6th Edition. Copyright
2014.Elsevier(Singapore)
❖ Salustiano,Rosalinda Parado. Essential Procedures for
Safe Maternity Care. 3rd Edition. Copyright 2011 C&E
Publishing, Inc.
HAVE FUN IN LEARNING!
KEEP SAFE & GODBLESS