

CMCA MIDTERMS Show- rupture of minute capillaries in the mucous

membrane of the cervix, a pinkish vaginal discharge.
REPRO NOTES 5  Rupture of the Membrane- labor is inevitable- it will
occur within 24 hours, the integrity of the uterus has
THEORIES OF LABOR ONSET been destroyed, umbilical cord compression and/or
cord prolapse can occur.
Labor usually begins when a fetus is sufficiently mature to
cope with extra uterine life, yet not too large to cause COMPONENTS OF LABOR
mechanical difficulties with birth.
Passage. It refers to the route the fetus must travel from
 Braxton Hicks- painless, irregular contractions the uterus through the cervix and the vagina to the
 Pre-term birth- labor begins before the fetus will external perineum.
mature.
 Post-term birth- delayed labor until the fetus and 2 Pelvic measurements:
the placenta have both passed beyond the
optimum point for birth. Diagonal conjugate (anterior-posterior diameter of inlet)
 Labor- is influenced by a combination of factors Transverse diameter (outlet)
from the mother and fetus.
At the pelvic inlet the anteroposterior diameter is the
These factors includes: narrowest diameter; at the outlet, the transverse
diameter is the narrowest.
1. Uterine muscles stretching-resulting in the
prostaglandins release Passenger. The passenger is the fetus. The body part of
2. Pressure on cervix- stimulating neural the fetus that has the widest diameter is the head.
release of oxytocin
3. Oxytoxin stimulation- working together with Structure of the fetal skull
prostaglandins to initiate contractions.
4. Change in ratio of estrogen and Cranium- the uppermost portion of the skull, is
progesterone- increasing estrogen in comprised of eight bones. The four superior bones –
relation to progesterone stimulates uterine the frontal (actually two fused bones), the two parietal
contractions. and the occipital –are the important bones in childbirth.
5. Placental age- triggering contractions.
6. Rising fetal cortisol levels- reducing siniciput - The area over the frontal bone
mentum- Chin (presenting part)
progesterone formation and increasing
sagittal suture- membranous interspace, joins the two
prostaglandins.
7. Seasonal and time influences- Cagnacci parietal bones of the skull.
coronal suture- is the line of the junction of the frontal
bones and the two parietal bones.
SIGNS OF LABOR lambdoid suture- is the line of the junction of the
occipital bone and the two parietal bone.
A. PRELIMINARY SIGNS OF LABOR fontanelle- Significant membrane-covered spaces

Lightening. The settling of the fetal head into the pelvic bregma -The anterior frontanelle, lies at the junction of
brim. the coronal and sagittal sutures. Its anteroposterior
diameter measures approximately 3 to 4 cm; its
Results of lightening are: transverse diameter, 2 cm to 3 cm.

1. Increase in urinary frequency Posterior fontanelle- lies at the junction of the

2. Relief of abdominal tightness and diaphragmatic
pressure
3. Shooting pains down the legs because of pressure
on the sciatic nerve
4. Increase in the amount of vaginal discharges.
Engagement- occurs when the presenting part has
descended into the pelvic inlet.
Increased Activity Level. Due to increase in epinephrine
secreted to prepare the body for the coming work ahead.
Braxton Hicks Contraction. Painless, irregular practice
contractions.
Ripening of the Cervix. From Goodell’s sign, the cervix
becomes “butter-soft”.
B. SIGNS OF TRUE LABOR
 Uterine Contractions- the surest sign that labor.
lambdoidal and sagittal sutures, triangular, smaller than
the anterior fontanelle, 2 cm across its widest part.
Vertex- The space between the fontanelle.
Diameter of the fetal Skull
 Narrowest diameter- (approx. 9.5 cm)
suboccipitobregmatic
 occipitofrontal diameter- 12cm measures
from the bridge of the nose to the occipital
prominence.
 occipitomental diameter-which is the widest
anteroposterior diameter (approximately 13.5
cm), is measured from the chin to the posterior
fontanelle.
 biparietal diameter (narrowest diameter)-
approximately 9.25 cm to the anteroposterior
diameter of the pelvis, a space approximately 11
cm wide.
 If the anteroposterior diameter of the skull (a
measurement wider than the biparietal diameter) is
presented to the anteroposterior diameter of the inlet,
engagement, or the settling of the fetal head into the
pelvis, may not occur. If the anteroposterior diameter of
the skull is presented to the transverse diameter of the
outlet, arrest of progress may occur at a point.
Full flexion- the head flexes so sharply that the chin rest
on the thorax.
moderate flexion- the occipitofrontal diameter will be
presented.
Molding- It is the change of the fetal skull, commonly
seen in newborns.
III. FETAL PRESENTATION AND POSITION
Attitude- used to describe the degree of flexion the fetus
assumes.
Complete flexion- fetus in good attitude, the spinal
column is bowed forward, the head is flexed forward, the
chin touches the sternum, the arm are flexed and folded
on the chest, the thighs are flexed onto the abdomen
and the calves of the legs are pressed against the
posterior aspect of the thighs.
Moderate flexion- the chin is not touching the chest but
is in an alert or military position.
Partial flexion- the brow of the head to the birth canal.-
Poor flexion- the back is arched, the neck is extended,
and the fetus is in complete extension, face presentation.
Oligohydrammios- less than normal amniotic fluid
present which does not allow the fetus adequate
movement. It may also reflect a neurologic abnormality
that is causing spasticity.
Engagement- It refers to the settling of the presenting
part of the fetus.
Primipara- non-engagement of the head at the beginning
of labor indicates a possible complication.
Multiparas- engagement may or may not be present at
the beginning of the labor.
Floating -presenting part that is not engaged.
Dipping- descending but has not yet reached the iliac
spines.
At 0 station- when the presenting part is at the level of
the ischial spines.
Minus station- If the presenting part is above the spines,
the distance is measured range from 1 cm to 4 cm.
Plus stations- if the presenting part is below the ischial
spines, the distance is (+ 1cm to + 4cm).
Fetal lie. Lie is the relationship between the long
(cephalocaudal) axis of the woman’s body, that is
whether the fetus is lying in a horizontal (transverse) or
a vertical (longitudinal) position.
Cephalic- the head as the first part to contact the cervix
breech- buttocks is the first portion to contact the cervix.
TYPES OF FETAL POSITION
POSITION. The relationship of the presenting part to a
specific quadrant of the woman’s pelvis.
Four quadrants according to the mothers right and left:
right anterior, left anterior, right posterior, left posterior.
Vertex presentation- the occiput is the chosen point.
Face presentation- it is the chin (memtum)
Breech presentation- it is the sacrum
Shoulder presentation- it is the scapula or the acromion
process.
Cephalic Presentation- It means that the head is the
body part that first contact the cervix.
Caput succedaneum- edema, cervix often becomes
edematous from the continued pressure against it.
Breech presentation- the buttocks or feet are the first
body parts to contact the cervix, types of breech
presentation – complete, frank, footling are possible.
Shoulder Presentation- transverse lie, the fetus is lying
horizontally in the pelvis, presenting parts becomes one of
the shoulders (acromion process), an iliac crest, a hand,
or an elbow.
IMPORTANCE OF DETERMINING FETAL
PRESENTATION AND POSITION
Abdominal inspection and palpation
Vaginal examination
Auscultation of fetal heart tones
Sonography
The presentation of the body part other than the vertex
puts the fetus at risk.
MECHANISM (CARDINAL MOVEMENTS) OF LABOR
Descent- downward movement of the biparietal diameter
of the fetal head to within the pelvic inlet.
Full descent- occurs when the fetal head extrudes
beyond the dilated cervix and touches the posterior
vaginal floor. (Pushing sensation and abdominal muscle
contraction).
Flexion- A descent occurs; pressure from the pelvic floor
causes the fetal head to bend forward onto the chest.
Internal Rotation- the occiput rotates until it is superior
or just below the symphysis pubis, bringing the head into
the best diameter for the outlet of the pelvis (the
anteroposterior diameter is now in the anteroposterior
plane of the pelvis). This movement brings the shoulder,
coming next, into the optimum position to enter the inlet or
puts the widest diameter of the shoulders (transverse one)
in line with the wide transverse diameter of the inlet.
Extension. As the occiput is born, the back of the neck
stops beneath the pubic arch and acts as a pivot for the
rest of the head. Head must extend and the foremost parts
of the head, the face and chin are born.
External Rotation. Almost immediately after the head of
the infant is born, the head rotates back to the diagonal
or transverse position of the early part of labor.
Expulsion. Once the shoulders are delivered, the rest of
the baby is delivered easily and smoothly because of its
smaller size. This is expulsion and is the end of the
pelvic division of labor.
IV. POWERS OF LABOR
After full dilation of the cervix, the primary power is
supplemented by the use of the abdominal muscle. It is
important for women to understand they should not bear
down with their abdominal muscles until the cervix is
fully dilated. Doing so will impede the primary force or
could cause fetal and cervical damage.
UTERINE CONTRACTION
STATION- It refers to the relationship of the presenting
part to an imaginary line drawn between the ischial spines
of the maternal pelvis.
Differentiation between True & False Labor

Origins- Labor contractions begin at a pacemaker points

located in the myometrium near one of the uterotubal
junctions.
In early labor, the uterotubal pacemaker may not be
working in a synchronous manner. This makes contraction
sometimes strong, sometimes weak, and irregular.
PHASES of CONTRACTIONS
Increment- when the intensity of the contraction
increases.
Acme- when the contraction is at its strongest.
Decrement- when the intensity decreases.
Between contractions the uterus relaxes. As labor
progresses, the relaxation interval decrease from 10
minutes early in labor 2 to 3 minutes. The duration of
contractions also changes, increasing from 20 to 30
seconds to a range of 60 to 90 seconds.
STAGES OF LABOR
I. FIRST STAGE OF LABOR
Primi = 12 ½ hours, Multis = 7 hours & 20 minutes.
Latent- early time in labor, cervix dilates 3 – 4 cm only,
contractions occur regularly 5 – 10 minutes apart and
period averages ranges from 6 to 8 hours.
Active / Accelerated- cervical dilatation reaches 4- 8cm,
rapid increase in duration, frequency and intensity of
contractions (40-60 sec.) 2 to 5 minutes apart. Fetal
descent is progressive. Contractions are stronger. This
phase last approximately vaginal secretion.
Transition Phase- cervical dilatation from 8-10 cm.
contractions are strongest, longest (50-90 sec) lasting
for 2 minutes and 1-3 minutes apart.

Contour changes General Physical Examination: VS (esp. BP)

The upper portion becomes thicker and active,
preparing it to exert the strength necessary to expel the
fetus when the expulsion phase of labor is reached.
The lower segment becomes thin walled, supple, and
passive so the fetus can be pushed out of the fetus easily.
Physiologic retraction ring- the boundary between the
two portions.
Pathologic retraction ring or Bandl’s ring- is a danger
sign that signifies impending rupture of the lower uterine
segment if the obstruction to labor is not relieved.
CERVICAL CHANGES
Note: BP should not be taken during contraction because
it tends to increase, BP reading should be taken every
30minutes during ACTIVE LABOR & monitor FHR (120 –
160/min)
Note: Should not be taken during contraction –it tends to
decrease (compression of the fetal head when the uterus
contracts stimulates the VAGAL REFLEX- Bradycardia)
Note: FHR should be taken: Latent – every hour, Active-
every 30 minutes, Transition- every 15 minutes.
The peak of the transition phase can be identifies by a
slight slowing in the rate of cervical dilation when 9 cm is
reached termed deceleration.

Effacement- Is a shortening and thinning of the cervical Signs of Fetal Distress:

canal. 1 to 2 cm long.
Bradycardia- less than 100/min
In primiparas, the effacement is accomplished before Tachycardia- more than 180/min
dilation begins. Be sure to inform the woman about this. Meconium- stained amniotic fluid
False Labor Pains True Labor Pains
In multiparas, dilation may proceed before effacement is
1. Remain irregular May be slightly irregular at first
complete. Effacement must occur at the end of dilation.
but become regular and
predictable in a matter of
Dilation- It refers to the enlargement of the cervical canal
hours.
from the opening few millimeters wide to one enlarge
enough (approx. 10 cm) to permit passage of the fetus. 2.Generally confined to the First felt in the lower back and
abdomen sweep around to the abdomen
As dilation begins, there is an increase in the amount in a girdle-like fashion
of vaginal secretion (termed show), because the last of 3.No increase in duration, Increase in duration,
the operculum or the mucus plug in the cervix are frequency & intensity frequency & intensity
dislodged and minute capillaries in the cervix rupture. 4.Often disappears if the Continue no matter what the
woman ambulates woman’s level of activity is.
V. PYCHE 5. Absent cervical changes Accompanied by cervical
effacement & dilatation (most
“P” or psyche- refers to the psychological state feelings important difference)
that women brings in to labor with them. For many women,
this is a feeling of apprehension or fright. For almost
everyone, it includes as sense of excitement or awe.
Hyperactivity of the Fetus
Encourage taking a bath if BOW is not yet ruptured and if
contractions are tolerable; encouraging ambulation: NPO:
Enema, Note: during enema, clamp rectal tube during
contraction, check FHR after enema administration.
Contraindications of Enema are: vaginal bleeding,
premature labor, abnormal fetal presentation/position,
ruptured membranes, crowning. Encourage to void every
2-3 hours
 Perineal prep
 Perineal shaving
 Encourage Sim’s position
 Advise not to bear down unnecessarily
II. SECOND STAGE OF LABOR
Second stage of labor is the period of dilation and
cervical effacement to birth of the infant. Contraction
change from the characteristics crescendo-decrescendo
pattern to an overwhelming, uncontrollable urge to push or
bear down with contraction as if she were moving her
bowels.
Begins with complete dilatation of the cervix and ends with
delivery of the baby.
Signs:
o (+) urge to push and to defecate from pressure
of the presenting part on the rectum.
o Increase bloody show and rectal pressure
o Primi = 80 minutes
o Multi = 30 minutes
Nursing Care:
o Place on lithotomy position
o (+) crowning
o instruct mother not to push
o Assist in episiotomy
EPISIOTOMY- Incision made in the perineum
PURPOSES:
1. To prevent laceration
2. Prevent prolonged and severe stretching of
muscles supporting bladder or rectum
3. Reduce duration of second stage
Types:
1. Median - from middle portion of the lower vaginal
border directed towards the anus.
2. Medio-lateral- beginning at the midline but
directed laterally away from the anus.
Nursing Care:
 Apply the modified RITGEN’S MANEUVER.
 To support perineum, to prevent laceration
 To favor flexion
 Ease the head out and immediately wipe the nose
 Insert 2 fingers into the vagina to feel for the
presence of a cord loop around the neck (nuchal
cord)
 Take note of the exact time of the baby’s delivery
 Wrap the baby in a sterile drapes to keep him warm
 Place baby on the mother’s abdomen
 Cut the cord
Note: Cutting of the cord is postponed until the
pulsation has stopped
 ( 50-100ml of blood is flowing from the placenta to
the baby.)
 Show the baby to the mother; inform her of the
gender & time of delivery.
THIRD STAGE OF LABOR
Placental Separation- It begins with the birth of the infant
to the birth of the placenta. Two separate phases are
involved, 1) placental separation, 2) placental
expulsion.
Placental separation- occurs automatically as the uterus
resumes contractions down on an almost empty interior.
Active bleeding on the maternal surface of the placenta
begins with separation: the bleeding helps to separate the
placenta still further by pushing it away from its attachment
site. As separation is completed, the placenta sinks to the
lower uterine segment or the upper vagina.
The following signs indicate that the placenta has
loosened and is ready to deliver:
 Lengthening of umbilical cord
 Sudden gush of vaginal blood
 Change in the shape of the uterus
Types:
 SCHULTZ Mechanism
o Placenta separates first at its center and last at
its edge
o Fetal surface comes first.
o 80% of placenta separate in this manner.
o Schultze’s placenta, shiny and glistening from
the fetal membranes
 DUNCAN Mechanism
o Placenta separates first at its edge and slides
along the uterine surface.
o Maternal surface is the presenting part
o Raw, red, beefy, irregular, & dirty
o 20%
Bleeding occurs as part of the normal consequence of
placental separation, before the uterus contracts
sufficiently to seal maternal sinuses. The normal blood
loss is 300- 500 ml.
Nursing Care:
 Watch for signs & symptoms of placental separation.
Separation:
 Uterus becoming round, firm, rising high to
the level of umbilicus (CALKIN’S SIGN)
 Sudden gush of blood
 Lengthening of the cord
 Note:
 Do not hurry the expulsion of the placenta.
  Tract the cord slowly, winding it around the
clamp until placenta spontaneously comes
out, rotating slowly so that no membranes
are left (BRANDT-ANDREW’S MANEUVER)
 Take note of the time of placental delivery.
 Check for completeness of cotyledons.
 Palpate the uterus to determine degree of
contraction.
 Administration of methergine.
 Note: Not to be given before placental
delivery.
 Inspect perineum for lacerations.
Categories of Lacerations:
o 1st degree – vaginal mucous
membrane and skin
o 2nd degree – (+) muscles
o 3rd degree –(+) external
sphincter of the rectum
o 4th degree – (+) mucous
membrane of the rectum
 Assist the doctor in doing episiorrhapy (repair of
episiotomy or lacerations)
 Note:
 In vaginal episiorrhapy, packing is done to
maintain pressure on the suture line to prevent
further bleeding.
 Packing has to be removed after 24 - 48 hrs
 Make mother comfortable by doing perineal care
& applying clean sanitary napkin snugly to
prevent it from moving forward from the anus to
the vagina.
 Soiled napkins should be removed from front to
back
 Position flat on bed with pillows to prevent
dizziness due to decrease in intra abdominal
pressure
 May complain of chills due to rapid decrease of
pressure, fatigue or cold temperature. Provide
additional blanket to keep her warm.
 Give initial nourishment e.g. milk
 Allow patient to sleep in order to regain lost of
energy.
Placental Expulsion- The placenta is delivered either by
the natural bearing down effort of the mother or by gentle
pressure on the contracted uterine fundus by the physician
or nurse midwives (Credes Maneuver).
FOURTH STAGE OF LABOR
- first 1 - 2 hours after delivery is the MOST CRITICAL
stage: UNSTABLE VITAL SIGNS
Management:
Assessment
a. Fundus
 Should be checked every 15 minutes for 1
hour then every 30 minutes for the next 4
hours.
 Should be firm in the midline
 Should be a little above the umbilicus
during the first 2 hours post partum.
b. Lochia
 Should be moderate in amount
 Perineal pad can be completely saturated
after 30 minutes.
c. Bladder
 Full bladder pushes the fundus to the right.
 Dark-red bleeding with some clots.
d. Perineum
 Normally tender, discolored & edematous
 Should be clean with intact sutures.
e. BP & PR
 Slightly high due to excitement & effort of
delivery, but normalize within one hour
Unang Yakap
 mother & baby are together while in the hospital
 Provide opportunity to develop a positive relationship
between parents & newborn.
 Eye-to-eye contact is immediately established
releasing maternal caretaking responses.
PERINEAL CLEANING- Perineum is cleaned with a
warmed antiseptic (cold causes cramping) and then rinsed
with a designated solution before birth by the physician,
nurse-midwives or nurse according to agency policy.
PHYSICAL PREPARATIONS FOR DELIVERY
POSITIONING FOR BIRTH
Lithotomy position- major position for birth.
Alternative birth position include the lateral or Sim’s
position, dorsal recumbent, semi-sitting and
squatting. Pushing becomes less effective in lithotomy
position; top portion of the table can be raised to a 30 – 60
degree angle so the woman can continue to push.
Cleaning should be done from the vagina outward
(microorganism are moved away from the vagina), using a
clean compress for each stroke. A wide area including
vulva, upper inner thighs, pubis and anus are included.
After cleaning sterile drapes are placed around the
perineum. Pressure of the fetal head may cause fecal
material to be expelled from the rectum. This is sponged
away as it occurs to prevent contamination of the birth
canal.
POSTPARTUM CARE
Reproductive Changes- Pain in perineal region may be
relieved by:
 Sim’s Position – minimizes strain on the suture
line
 Perineal heat lamp or warm sitz baths twice a
day
 Application of topical analgesics or
administration of mild oral analgesics, as ordered
Sexual Activity
  Maybe resumed by the third or fourth week her a bath towel or a clean nightgown, and make
postpartum if bleeding has stopped and decision for her. This dependence is due partly to
episiorrhaphy has healed. her physical discomfort from possible perineal
 Decreased physiologic reactions to sexual stitches, after pains or hemorrhoids: partly to her
stimulation are expected for the first 3 months uncertainty in caring for a newborn: and partly
postpartum because of hormonal changes and from extreme exhaustion that allows childbirth.
emotional factors. B. Taking-hold Phase- Begins to initiate action and
make decisions. Postpartum Blues (an
Menstruation overwhelming feeling of sadness that cannot be
 If not breastfeeding, return of menstrual flow is accounted for) may be observed. Could be due
expected within 8 weeks after delivery. to hormonal changes, fatigue or feelings of
 If breastfeeding, menstrual return is expected in inadequacy in taking care of a new baby.
3 – 4 months; in some women, no menstruation
occurs during the entire lactation period.
Management: Explain that it is normal and that crying is
Postpartum Check up therapeutic.
 Should be done after the 6th week postpartum
to assess involution. C. Letting-Go Phase- The woman redefines her new
role. She gives up the fantasized image of her child and
Urinary Changes accepts the real one. Give up his old role of being
 There is marked diuresis within 12 hours childless or the mother of only one or two.
postpartum to eliminate excess tissue fluid
accumulation
 Some newly-delivered mothers may complain of
frequent urination in small amounts
 Explain that it is due to urinary retention with
overflow.
 Difficulty voiding
1. Decreased abdominal pressure or
trauma to the trigone of the bladder.
2. Voiding maybe initiated by pouring
warm and cold water alternately over
the vulva
3. Encouraging patient to go to the comfort
room and let her listen to the sound of
running water.
If these measures fail, catheterization, done gently and
aseptically, is the last resort on doctor’s order.

Gastrointestinal Changes
 Delayed bowel evacuation postpartally due
to:
o Decreased muscle tone
o Lack of food + enema during labor
o Dehydration
o Fear of pain from perineal tenderness
due to episiotomy, lacerations, or
hemorrhoids.

Vital Signs
Temperature may increase because of the dehydrating
effects of labor.

1. Bradycardia is common for 6 – 8 days

postpartum
2. No change in respiratory rate.

Weight
1. There is an immediate weight loss of 10 –
12 lbs. Represents the weights of the fetus,
placenta, amniotic fluid and blood.
2. Further weight loss will occur during the
next days due to diaphoresis.

PHASES OF PUERPERIUM

A. Taking-in Phase- a time of reflection for a

woman. During this period, she is largely passive.
She prefers having a nurse minister to her, to get