Nursing Care of a

Family During Labor

and Birth
Theories Why Labor Begins
 The uterine muscle stretches from the
increasing size of the fetus, which
results in release of prostaglandins.
 The fetus presses on the cervix, which
stimulates the release of oxytocin from
the posterior pituitary.
 Oxytocin stimulation works together
with prostaglandins to initiate
contractions.
 Changes in the ratio of estrogen to
progesterone occurs, increasing
estrogen in relation to progesterone,
which is interpreted as progesterone
withdrawal.
 The placenta reaches a set age, which
triggers contractions.
 Rising fetal cortisol levels reduce
progesterone formation and increase
prostaglandin formation.
 The fetal membrane begins to produce
prostaglandins, which stimulate
contractions
 Semen does contain prostaglandins,
which can be helpful in softening, also
known as “ripening,” of the cervix; if a
cervix is ready to ripen, semen
prostaglandins could possibly stimulate
the beginning of contractions.
Labor- series of events by which uterine
contractions and abdominal pressure expel a
fetus and placenta from the uterus
Components of labor
 Passage: Woman’s Pelvis
 Passenger: Fetal attitude(flexion or
extension), fetal lie(transverse or
longitudinal), fetal presentation(cephalic
or breech)
 Power of labor: uterine contractions
 Psyche: Psychological state of mother
Passage
 route of a fetus must travel from the
uterus through cervix and vagina to
external perineum
Passenger
 It is the fetus
 Head has the wider diameter
 Cranium(upper most layer of the skull)
composed of eight bones
 Four superior bones: Frontal(two
fused bones), two parietal, and
occipital
 Other bones of skull: sphenoid,
ethmoid, two temporal bones, which
lies at the base of the skull
 Fontanelle spaces compress during the
birth to aid in molding of fetal head.
Palpating for fontanelle spaces during a
pelvic examination helps to establish the
position of the fetal head
2 fontanels are palpable
Anterior Fontanel(bregma)
 Diamond in shape,2-3cm
 Permits growth of the brain by
remaining ossified for as long as
18months
 Closes at 12-18months or 1year to
1year and 6months
Posterior Fontanel(lambda)
 Triangular, 1x1 cm
 Closes at 2-3months or 8-12weeks
 Smallest diameter of the fetal skull-
biparietal diameter or transverse
diameter(9.25cm)
 Smallest anteroposterior diameter:
Suboccipitobregmatic(9.25cm)(complete
flexion)
 Widest anteroposterior diameter:
occipitomental (13.5cm) (hyperextension)
 Head is held in moderate flexion the
Occipitofrontal diameter present (12 cm)
 At the outlet, the fetus must present this
narrow fetal head diameter (biparietal
diameter) to maternal transverse diameter
 Molding
 overlapping of skull bones along the
suture lines, which causes a change in
the shape of fetal skull to one long
and narrow, to permit passage
through the rigid pelvis.
 Molding is caused by uterine
contraction as vertex of the head
pressed into not dilated cervix
 No skull molding occurs when a fetus
is in breech, because the buttocks
present first
 Babies born by cesarian have no
molding because there is no
procedure of labor

̶ T
Transverse Diameter (TD)
a. Biparietal – 9.25 cm (largest
transverse)
b. Bitemporal – 8.0 cm
c. Bimastoid – 7.0 cm (smallest
Fetal Attitude
 Degree of flexion a fetus assumes
during labor or relation of the fetal
parts to each other.
 Vertex- full flexion,
suboccipitobregmatic
 Sinciput-moderate flexion, military
attitude, occipitofrontal
 Brow- partial flexion
 Face-poor flexion, complete
extension, occcipitomental
 Good attitude is complete flexion: The
spinal column is bowed forward, head
is flexed forward that the chin
touches the sternum, the arms flexed
and folded on the chest, the thighs
are flexed on the abdomen,and calves
pressed against the posterior of the
thighs
 Fetus in a moderate flexion if the chin
is not touching the chest but is not
alert or “military position”.
 Fetus is in complete extension, the
back arched and the neck is extended
presenting the occipitomental
diameter of the head into the birth
canal. It can be an indication of
oligohydramnios nand may also
reflect a neurologic abnormality in
fetus causing spasticity
Fetal Lie
 Relationship between the
long(cephalocaudal) axis of fetal body and
the long(cephalocaudal) axis of the
woman’s body.
 Longitudinal(vertical)
 long axis of the fetal body is parellel to the
long axis of the woman.
 Cephalic or breech(foot or buttocks) will be
the presenting part.
 Transverese(Horizontal
 longest fetal axis is perpendicular or at the
right angle of the woman’s spine or long
axis.
 Acromion process, shoulder, elbow, hand,
iliac crest will be the presenting part.
 The usual contour of the mother’ss
abdomen at term may appear fuller side
to side
 Infants in transverse lie must be born by
cesarian birth
 It may be caused by placenta privia, pelvic
contractions
Fetal presentation
 Body parts that will first contact the cervix
or be born first and is determined by fetal
lie and fetal attitude
 Cephalic “head is the presenting part”
 Breech “ buttocks or feet is the presenting
part”
Types of Cephalic Presentation
Vertex
 the ideal presenting part
 Head is sharply flexed(full flexed)
 Suboccipitobregmatic diameter
Brow “military”
 Head is moderately flexed
 Brow or sinciput are the presenting part
Face “poor flexion”
 Fetus extended the head to make the face
the presenting part
 Extreme edema or distortion of face may
occur
Mentum “very poor flexion”
 Occipitomental diameter
 The fetus has completely hyperextended
the head
Types of Breech Presentation
Complete
 The fetus has the thighs tightly flexed on
the abdomen; both the buttocks and the
tightly flexed feet present to the cervix.
Frank presentation
 Hips are flexed but the knees are extended
to the rest of the chest
 Buttocks present 1st to the cervix
Footling breech
 Neither thigh nor lower legs are extended
 Feet present 1st to the cervix
 Single footling or double footling
Fetal position
 relationship of the presenting part to a
specific quadrant and side of a woman’s
pelvis.
 Maternal pelvis is divided into 4 quadrants:
right anterior, right posterior, left anterior,
left posterior
 1st letter denotes whether the landmark is
on mothers right or left
 Middle letter denote fetal landmarks
 Vertex presentation- occiput(O)
 Shoulder presentation- acromion
process(A)
 Breech presentation-sacrum(S)
 Face presentation- mentum(M)
 Last letter denotes whether the landmark
points Anteriorly(A) or posteriorly (P)
 Example: is the occiput of the fetus point
to left anterior quadrant in a vertex
position it will be called Left
occipitoanterior (LOA)
 LOA is the most common position
 ROA is the 2nd most frequent position
 Fetus is born fastest from LOA or ROA
position
 Labor can be extended if position is
posterior(ROP or LOP) and may be more
painful for woman because rotation of
fetal head puts pressure on sacral nerves
 Encourage woman to rest in SIMS position
on the same side of fetal spine or use
hands and knees position may encourage
rotation from an occipitoposterior to an
occipitoanterior position prior to and
during labor
ENGAGEMENT
 Settling of presenting part of a fetus into
the pelvis that it rests at the level of ischial
spines
 It typically occurs 2-3 weeks before labor
begins
 In a primipara, nonengagement of the
head at the beginning of labor suggests
that a possible complication such as an
abnormal presentation or position,
abnormality of the fetal head, or
cephalopelvic disproportion exists.
 In multiparas, engagement may or may
not be present at the beginning of labor.
STATION
 Relationship of the presenting part of the
fetus to the level of ischial spines
 Station -4, the head is floating
 Station 0, the head is engaged
 Station +4, the head is at the outlet
 -1 station or -4 station, the presenting part
is above the ischial spine
 +1 to +4 station, the presenting part is
below the ischial spine
 +3 or +4 station, the presenting part is at
the perineum(crowning)
Mechanism(cardinal movements) of labor
“D-FIRE”
 Descent: downward movement of fetus
 Flexion- chin against chest as resistance
from pelvic floor
 Internal rotation: fetal shoulders internally
rotates
 Extension- fetal head turns from flexion to
extension and emerge from vagina
 Restitution: Head eternally rotates
 Expulsion: anterior shoulder slip under
symphysis pubis and posterior shoulder
and the rest of the body. Once the
shoulders are born, the rest of the baby is
born easily and smoothly because of its
smaller size.
Power of labor
 This is the force supplied by the fundus of passage of a fetus. As dilattion begins
the uterus and implemented by uterine there is an increase in vaginal secretions
contractions, which causes cervical because minute capillaries in the cervix
dilatation and then expulsion of the fetus rupture
from the uterus  Primipara: effacement is accomplished
 Braxton hicks: “false contraction” irregular before dilation begins
and painful contractions but do not cause  Multipara: Dilation may proceed before
cervical dilation. effacement complete
FALSE CONTRACTION TRUE CONTRACTION Psyche
Begin and remain irregular Begin irregular but become  psychological state or feelings a woman
regular and predictable brings into labor
Felt first abdominally and STAGES
Felt first in lower back then OF LABOR
remained confined to the sweep around the abdomen  inFIRST STAGE: Effacement and dilation
abdomen and groin a wave  SECOND STAGE: Birth of the fetus
Often disappear with Continue no matter whatthe THIRD STAGE: separation and Expulsion of
ambulation or sleep woman’s level of activity the placenta
Do not increase in Increase in duration, FIRST STAGE
duration, frequency, or frequency, intensity  It takes about 12hrs to complete
intensity  It begins with the initiation of true labor
Do not achieve cervical Achieve cervical dilation contractions and ends when cervix is
dilation dilated
Origin of contractions  Divided into three segments: Latent phase,
 Labor conttraction begin at “pacemaker” Active phase, Transitional Phase
point located in the uterine myometrium LATENT PHASE
near one of re uterotubal junctions.  Begins at the onset of regularly perceived
 contractions appear to originate in the uterine contractions and ends when rapid
lower uterine segment rather than in the cervical dilations occurs
fundus. These are reversed and ineffective  Mild and short contractions, last for 20-40
and may actually cause tightening rather seconds every 5 to 30 minutes
than dilatation of the cervix  Cervix effacement occurs and minimal
Phases of Contraction cervical dilation (0 to 3cm)
 Increment: the intensity of the contraction  No fetal descent
increases  Phase last for 6hrs in nullipara
 Acme: the intensity of the contraction is at  Phase last for 4.5hrs in multipara
its strongest ACTIVE PHASE
 Decrement : the intensity of the  Contractions grow stronger, lasting 40 to
contraction decreases. 60econds for every 3 to 5 minutes
 As the labor progress, the relaxation  Dilation occur more rapid
interval of contraction decreases from  Cervix dilates for 4 to 7cm
10minutes early in labor to 2-3minutes  Fetal descent is progressive
 As the labor progress, the duration of  Phase last for 3 hrs in nullipara
contractions increases from 20-30seconds  Phase last for 2hrs in multipara
at the beginning to a range of 60-70  (increased vaginal secretions) and perhaps
st
seconds by the end of 1 stage. spontaneous rupture of the membranes
Cervical changes TRANSITIONAL PHASE
 Effacement is shortening and thinning of  Fetal descent increases
the cervical canal. All during pregnancy,  Contractions reach their peak of intensity
the canal is approximately 1 to 2 cm long.  Contractions last for 60-90 seconds, every
During labor, the longitudinal traction from 2 to 3 minutes
the contracting uterus shortens the cervix  Maximum dilation(8-10cm) and complete
so much that the cervix virtually effacement of cervix.
disappears.  Phase last for 3hrs in nullipara
 Dilation is the enlargement or widening of  Phase last for 1hr in multipara
the cervical canal from an opening a few  Loss of control, anxiety, panic, and
millimeters wide to one large irritability
enough(approximately 10cm) to permit  Intense discomfort, accompanied by
nausea and vomiting
SECOND STAGE
 From full dilation and effacement of the
cervix to birth of the infant
 Contractions change from the
Characteristic crescendo–decrescendo
pattern
 Fetus descent and touches the perineum
to begin internal rotation,her perineum
begins to bulge and appear tense. The
anus may become everted, and stool may
be expelled
 CROWNING- fetal head pushes into the
vaginal introitus, this opens and the fetal
scalp appears at the opening of the vagina
and enlarges.
 As the fetal head is pushed out of the birth
canal, it extends and then rotates to bring
the shoulders into the best line with the
pelvis. The body of the baby is then born.
THIRD STAGE
 begins with the birth of the infant and
ends with the delivery of the placenta
 Placental separation and expulsion
 Contractions will begin five to thirty
minutes after the birth, signaling that its
time to deliver the placenta, cord, and
membranes
 Primigravida- 15minutes
 Multigravida- 5 minutes
 Generally not longer than 30 minutes
Expectant Management during Third stage
 Signs of placental separation
 Mechanism of placental separation
 Method of placental separation
Signs of placental separation
 Lengthening of the visible portion of the
cord
 Trickling(Gush) of blood
 Rising of the fundal height: Fundus become
round and firm. Mobile from side to side.
Height rises from the level of umbilical
Mechanism of placental separation
 Uterine muscle contracts
 Placenta sheared from the uterine wall
 Pushing it into the lower segment or upper
part of the vagina
Methods of Placental Separation
Schultz “shiny” method
 placenta separates first at its center and
lastly at its edges, it tends to fold on itself
like an umbrella and presents at the
vaginal opening with the fetal surface
evident
 Minimal blood loss
 Retroplacental clot contained within
membrane
 Appearing shiny and glistening from the
fetal membranes
Duncan “dirty” Method
 Placental separation starts at the lower
edge of the placenta
 It is full of 30 cotyledons and sulci which
give this site its brain-like structure
 There is no retroplacental clot formed
 Accompanied by more bleeding from
placental site due to slower separation
Schultz Method Duncan Method
ADMINISTRATION OF OXYTOCIN
 Within one minute of birth, palpate
abdomen to rule out presence of another
baby
 Giving uterotonic drug help to contract the
uterus
 Give 10 IU of oxytocin via IM in women
without IV access
 Can be given per 1000ml of IV fluid
 Oxytocin given to a woman during or
immediately after the birth of her baby is
effective reducing excessive bleeding after
vaginal birth
 If excessive bleeding with poor contraction
remains after administration of oxytocin,
an injection carboprost thromethamine
(hemabate) or methylergonovine
maleate(methergine) is another solution to
increase uterine contractin and guard
against hemorrhage
 Pitocin(Oxytocin) Causes vassoconstriction,
be certain to obtain a baseline blood
pressure measurement before
administration.
UMBILICAL CORD CLAMPING AND CUTTING
Umbilical cord
 1 vein, 2 arteries: Covered in thick
gelatinous substance known as Wharton’s
jelly
 Lotus Birth- cord is left attached to the
placenta until naturally separates from the
navel in 3 to 10 days
 Clamp and cut the cord after cord
pulsation has stopped
 Place two sponge forceps to clamp the
umbilical cord roughing in the middle,
leaving a 2-3cm space between the
forceps, and 2cm away from the abdomen.
 Cut the cord with a piece of gauze under it.
The gauze keeps the excess blood from
splattering
 Do not milk the cord towards the newborn
DELAYED CORD CLAMPING
 Delayed cord clamping allows extra blood to
flow from the placenta to the baby and can
have various benefits
 American College of Obstetricians and
Gynecologists (ACOG) recommends a delay
of 30 to 60 seconds between delivery and
cord clamping for healthy, full-term babies;
 World Health Organization (WHO)
recommends one to three minutes
 Many midwives and physicians may
recommend a delay of two to five minutes,
especially for premature babies.
ADVANTAGE OF DCC IN FULL TERM INFANTS
 Increases hemoglobin levels at birth
 Improves iron stores in the 1st several
months
ADVANTAGE OF DCC IN PRE-TERM INFANTS
 Improves transitional circulation
 Better establishment of RBC volume
 Decreased need for blood transfusion
 Lower incidence of necrotizing
enterocolitis(inflammation and death of
intestine tissue) and intraventricular
hemorrhage(bleeding into cerebral
ventricular system)
RISK ASSOCIATED WITH DCC
 Hyperbilirubinemia, a form of jaundice
 Respiratory distress
 Polycythemia, when there’s an excess RBC
in circulation
CORD BANKING
 Cord blood banking involves collecting the
blood left in your newborn's umbilical cord
and placenta following birth and storing it
for future medical use.
 Cord blood is a rich source of blood stem
cells. These stem cells are the building
blocks of the circulatory and immune
systems. They have the ability to develop
into other types of cells, which in various
ways help the body repair tissues, organs,
and blood vessels and can be used to treat a
host of diseases.
 Normal blood loss during cesarian delivery
is 1000ml
 Normal blood loss during vaginal delivery is
300-500ml
 After placenta is delivered, applying
massage to the abdomen for a few minutes
every 15minutes for 1st two hours
 The massage helps uterus to continue to
contract which in turn helps to stop the
bleeding
CONTROLLED CORD TRACTION (CCT)
 Traction applied to the umbilical cord once
the mother’s uterus has contracted after
the birth of the baby.
 Signs of placental separation must be
present before doing CCT to prevent uterine
inversion
CONTROLLED CORD TRACTION PROCEDURE
1. Clamp the cord close to the perineum(once
pulsation stops or after 3 minutes in a
healthy newborn), hold it in one hand.
2. Palmar surface of one hand is placed on the
woman’s abdomen, gently put firmly
pushing the uterus upward and backward.
3. At the same time, steady but not too strong
traction is applied on the umbilical cord in a
direction that is downward and backward,
and then only downwards until the placenta
and membranes are expelled completely.
4. Counter force applied on the abdomen
should be equal to pulling force on the cord.
5. If the placenta does not descend during 30-
40 seconds of CCT, do not continue to pull
on the cord. Gently hold the cord and wait
until uterus is well contracted again. With
the next contraction, repeat CCT with
counter force
6. Counter-force applied on the abdomen,
helps to prevent uterine inversion
7. CCT reducing blood loss(post-partum
hemorrhage) and incidence of retained
placenta.
Perineal inspection
 1st degree- vaginal mucosa torn and
perineal skin
 2nd degree- perineal muscle torn
 3rd degree- anal sphincter torn
 4th degree- rectum torn
Types of Episiotomy  Palpate a woman’s fundus for size,
Median consistency, and position and
 Middle portion of the lower vaginal border
directed towards the anus
observe the amount and
 Less bleeding, less pain, easy to repair and characteristics of lochia each time
heals faster but there is a risk that it may you record vital signs.
extend to the rectum creating a urethro and
fistula A fetus is in potential danger when the
Mediolateral membranes rupture because of the
 Begin in the middle but directed away from
possibility of cord prolapse
the anus
 More bleeding, more pain, hard to repair,
and slow to heal
 It is done, if the perineum is very short, and
if a lot of room is needed for a large baby.

Immediate post partum assessment

 Obtain vital signs every 15 minutes for the
1st hour
 Pulse rate (80-90bmp) and respiration(20-
24) may be fairly rapid after birth
 Blood pressure may be slightly elevated due
to oxytocin administration

Most newborns receive prophylactic

eye ointment against the possibility of
a chlamydia infection

IMMEDIATE POSTPARTUM
ASSESSMENT AND NURSING
CARE
 Obtain vital signs (pulse,
respirations, and blood pressure)
every 15 minutes for the first hour
and then according to agency
policy or the woman’s condition.
 Pulse and respirations may be
fairly rapid immediately after birth
(80 to 90 beats/min and 20 to 24
breaths/min), and blood pressure
may be slightly elevated
 Wash the perineum with the
agency-designated solution and
apply a perineal pad.