LABOR & DELIVERY

 COMPONENTS OF LABOR

A. PASSAGE – the woman’s pelvis needs adequate size & contour

B. PASSENGER – the fetus is of appropriate size & in an advantageous position & presentation
C. POWER – uterine factors are adequate
D. PSYCHE – refers to the psychological state or feelings that women bring into labor with them

 THE FETAL SKULL

A. Importance: from an obstetrical point of view, the fetal

skull is the most important part of the fetus because:
 It is the largest part of the body
 It is the most common presenting part
 It is the least compressible of all parts

B. Structure of the Fetal Skull

1. Cranial Bones
a. Sphenoid d. Frontal
b. Ethmoid e. Occipital
c. Temporal f. Parietal
2. Membrane Spaces
 They are important because they allow the bones to
move & overlap changing the shape of the fetal
head in order to fit through the birth canal, a
process called “molding”
 Molding – the change in shape of the fetal skull
produced by the force of uterine contractions
pressing the vertex against the birth canal
 Suture Lines:
a. Sagittal – the membranous interspace which
joins the 2 parietal bones
b. Coronal – the membranous interspace which
joins the frontal bone & the parietal bones
c. Lambdoid – the membranous interspace which
joins the occiput & the parietals
3. Fontanelles: membrane-covered spaces at the
junction of the main suture lines
a. Anterior – the larger, diamond-shaped fontanelle which closes between 12-18 months in an infant
b. Posterior – the smaller, triangular-shaped fontanelle which closes between 2-3 months in an infant

C. Measurements
 The shape of the fetal skull causes it to be wider in its
anteroposterior (AP) diameter than in its transverse
diameter
 Transverse Diameter:
a. Biparietal = 9.25cm
b. Bitemporal = 8cm
c. Bimastoid = 7cm

 AP Diameter:
a. Suboccipitobregmatic – from below the occiput to the
anterior fontanelle = 9.5cm (the narrowest AP
diameter)
b. Occipitofrontal – from the occiput to the midfrontal
bone = 12 cm
c. Occipitomental – from the occiput to the chin =
13.5cm (the widest AP diameter)

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  Which one of the AP diameters is presented at the birth canal depends on the degree of flexion the fetal
head assumes prior to delivery

 FETAL PRESENTATION & POSITION

 Definition of Terms:

 Attitude – the degree of flexion the fetus assumes during labor or the relation of the fetal parts to each other
o Full or Complete Flexion - very good attitude; seen when the chin of the fetus is flexed on the chest; the
smallest suboccipitobregmatic diameter is the one presented at the birth canal
o Moderate flexion – the occipitofrontal diameter is the presenting part
o Poor flexion – the widest occipitomental diameter is the presenting part; will give the mother & the baby
problems at birth

 Station – refers to the relationship of the presenting part of the fetus to the level of the ischial spines
o Station 0 – when the presenting part is at the level of the ischial spine; synonymous with engagement
o Minus Stations – when the presenting part is above the ischial spine (-1cm to -4 cm); -4cm means the
presenting part is still “floating”
o Plus Stations – when the presenting par is below the ischial spine (+1cm to +4 cm); at +3 to+4, the
presenting part can be seen at the perineum & can be seen if the vulva is separated – this is synonymous to
“crowning”

 Lie – is the relationship between the long (cephalocaudal) axis of the fetal body & the long (cephalocaudal)
axis of the woman’s body
o Transverse Lie – horizontal
o Longitudinal Lie – vertical

 Fetal Presentation – denotes the body part that

will first contact the cervix or deliver first;
determined by fetal lie & the degree of flexion
(attitude)

 Types of Fetal Presentation:

 Cephalic Presentation – the head is the

body part that first contacts the cervix

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 TYPES OF CEPHALIC PRESENTATIONS

TYPE LIE ATTITUDE DESCRIPTION

Vertex Longitudinal Good (full The head is sharply flexed, making the parietal bones or
flexion) the space bet fontanelles (the vertex) the presenting part.
This is the most common presentation & allows the
suboccipitobregmatic diameter to present to the cervix
Brow Longitudinal Moderate Because the head is only moderately flexed, the brow or
(military) the sinciput becomes the presenting part
Face Longitudinal Poor The fetus has extended the head to make the face the
presenting part; from this position, extreme edema &
distortion of the face may occur; the presenting diameter
(occipitomental) is so wide, birth may be impossible
Mentum Longitudinal Very Poor The fetus has completely hyperextended the head to
present the chin. The widest diameter (occipitomental is
presenting; as a rule, the fetus cannot enter the pelvis in
this presentation

 Breech Presentation – either the buttocks or the feet are the first body parts to contact the cervix

TYPES OF BREECH PRESENTATIONS

TYPE LIE ATTITUDE DESCRIPTION

Complete Longitudinal Good (full flexion) The fetus has thighs tightly flexed on the abdomen; both
the buttocks are tightly flexed feet present to the cervix

Frank Longitudinal Moderate Attitude is moderate because the hips are flexed but the
knees are extended to rest on the chest; the buttocks alone
present to the cervix

Footling Longitudinal Poor Neither the thighs nor lower legs are flexed. If one foot
presents, it is a single-footling breech; if both are present, it
is a double-footling breech

 Shoulder Presentation – the presenting part is one of the shoulders (acromion process), an iliac crest, a
hand or an elbow
o The fetus is in a transverse lie lying horizontally in the pelvis so that its long axis is perpendicular to
that of the mother
o May be caused by:
 Relaxed abdominal walls from grand parity allowing the uterus to be unsupported & fall forward
 Pelvic contraction in which the horizontal space is greater than the vertical space
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  Placenta previa could obscure some of the
vertical space that may limit the fetus’ ability to
turn
o When this occurs, the usual contour of the abdomen
at term is distorted or is fuller side to side rather
than top to bottom
o If an infant is preterm & smaller than usual, an
attempt to turn the fetus may be made
o Infants in this presentation must be delivered by
cesarean birth

 Fetal Position
 It is the relationship of the presenting part to a specific
quadrant of the woman’s pelvis
 Maternal pelvis is divided into four quadrants according
to the mother’s right & left:
o Right Anterior
o Left Anterior
o Right Posterior
o Left Posterior
 Fetal landmarks to describe the relationship of presenting
part to one of the pelvic quadrants:
o Vertex Presentation – occiput (O)
o Face Presentation – chin or mentum (M)
o Breech Presentation – sacrum (S)
o Shoulder Presentation – scapula or the acromion
process (A)
 Position is marked by an abbreviation of three letters; the
first letter defines whether the landmark is pointing to the
mother’s right (R) or left (L); the middle letter denotes
the fetal landmark; the last letter defines whether the
landmark points anteriorly (A) or posteriorly (P) or
transversely (T)
o Example: When the occiput of the fetus points to the left
anterior quadrant in a vertex position, what is the fetal
position?
o Answer: LOA; the fetus is in good attitude in a vertical
cephalic lie; this is the most common fetal position
 Position is important bec it influences the efficiency of labor.
Fetus ins ROA or LOA positions are delivered faster than
posterior positions (ROP & LOP); posterior positions may also
be more painful for the mother bec the rotation of the fetal head
puts pressure on the sacral nerves causing sharp back pains
 Possible Fetal Positions:
o Vertex – LOA, LOP, LOT, ROA, ROP, ROT
o Breech – LSA, LSP, LST, RSA, RSP, RST
o Face – LMA, LMP, LMT, RMA, RMP, RMT
o Shoulder – LADA, LADP, RADA, RADP

 THEORIES OF LABOR ONSET

A. Uterine Stretch Theory – any hollow body organ when stretched

to capacity will necessarily contract & empty
B. Oxytocin Theory – labor, being considered a stressful event,
stimulates the hypophysis to produce oxytocin from the posterior
pituitary gland; oxytocin causes contraction of the smooth
muscles of the body
C. Progesterone Deprivation Theory – progesterone, being the
hormone designed to promote pregnancy is believed to inhibit
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 uterine motility, thus, if its amount decreases, labor pains can occur
D. Prostaglandin Theory – initiation of labor is said to result from the release of arachidonic acid produced by
steroid action on lipid precursors. Arachidonic acid is said to increase prostaglandin synthesis which in turn
causes uterine contraction
E. Theory of Aging Placenta – because of the decreased blood supply, the uterus contracts

 PRELIMINARY/PRODROMAL SIGNS OF LABOR:

A. Lightening
 The settling of the fetal head into the pelvic brim
 In primis, it occurs 2 weeks before EDC; in multis, it occurs on or before labor onset
 Lightening should not be confused with engagement; engagement occurs when the presenting part has
descended into the pelvic inlet far enough to be at the level of the ischial spine
 Results of Lightening:
 Increase in urinary frequency
 Relief of abdominal tightness & diaphragmatic pressure
 Shooting pains down the legs bec of pressure on the sciatic nerve
 Increase in the amount of vaginal discharges
B. Increased Activity Level
 Usually happens 2-3 days before labor
 Due to the increased epinephrine secreted to prepare the body for the coming “work” ahead
 Advise the pregnant woman not to use this increased energy for doing household chores
C. Loss of Weight – of about 2-3 lbs, 1to2 days before labor onset, probably due to decrease in progesterone
production leading to decrease in fluid retention
D. Braxton Hicks Contraction – painless, irregular practice contractions
E. Ripening of the Cervix – Goodell’s sign; the cervix becomes “butter soft”
F. Rupture of the Membrane
 It is important to remember that once membranes have ruptured:
 Labor is inevitable; it will occur within 24 hours
 The integrity of the uterus has been destroyed; infection therefore can easily set in
 Aseptic techniques should be observed in all procedures
 Doctors do less obstetric manipulations (ex. IE) & enema is no longer ordered
 Umbilical cord compression &/or cord prolapse can occur especially in breech position
 Nursing Action depends on the specific situation:
o A woman in labor seeking admission to the hospital and saying that her BOW has ruptured should be
put to bed immediately & the fetal heart tones taken consequently
o If a woman in the labor room says that her membranes have ruptured, the initial nursing action is to
the take the fetal heart tones
o If a woman in labor says that she feels a loop of the cord coming out of the vagina (cord prolapse), the
first nursing action is to put her on Trendelenburg position (lower the HOB) in order to reduce
pressure in the cord; remember: only 5 minutes of cord compression can already lead to irreversible
brain damage or even death. In addition, apply a warm saline-saturated OS on the prolapsed cord to
prevent drying of the cord.
G. Show – due to pressure of the descending presenting part of the fetus which cause rupture of minute
capillaries in the mucous membranes of the cervix. Blood mixes with mucus when operculum is released;
show therefore, is only a pinkish vaginal discharge

 SIGNS OF TRUE LABOR

A. Uterine Contractions
 The surest sign that labor has begun is the initiation of an effective, productive uterine contractions
 Pain in uterine contractions results from:
 Contraction of the uterine muscles when in an ischemic state
 Pressure on the nerve ganglia in the cervix & lower uterine segment
 Stretching of ligaments adjacent to the uterus & in the pelvic joints
 Phases of Uterine Contractions:
 Increment – first phase during which the intensity of the contraction increases; aka “Crescendo”
 Acme – the height of the uterine contractions; aka as “Apex”

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  Decrement – last phase during which the intensity of the contraction decreases; aka “Decrescendo”

B. Effacement
 Shortening & thinning of the cervical canal as distinct
from the uterus exists
 Expressed in percentage:
 25% - ¾ inch cervical canal
 50% - ½ inch cervical canal
 75% - ¼ inch cervical canal
 100% - none
C. Dilatation
 Enlargement of the external cervical os to 10cm primarily
as a result of uterine contractions & secondarily as a result
of pressure of the presenting part & the BOW
D. Uterine Changes
 The uterus is gradually differentiated into distinct
portions:
 Upper Uterine Segment – becomes thick & active to
expel out fetus
 Lower Uterine Segment – becomes thin-walled, supple
& passive so that fetus can be pushed out easily
 Physiologic retraction ring is formed at the boundary of
the upper & lower uterine segments
 In difficult labor when fetus is larger than the birth canal,
the round ligaments of the uterus become tense during
dilatation & expulsion causing an abdominal indentation called “Bandl’s Ring”
 Bandl’s Ring – is a pathologic retraction ring; it is a danger sign that signifies impending rupture of the
lower uterine segment if the obstruction to labor is not relieved.

FALSE LABOR VS. TRUE LABOR

PARAMETERS FALSE TRUE

Uterine Changes
Duration Short 30-45 seconds Long 50-70 seconds
Interval Long, Irregular Short, Regular
Intensity Mild Moderate to Strong

Cervix Closed Open, Effaced & Dilated

Show Absent Present
Location of Discomfort Hypogastrium Hypogastrium radiation to
lumbosacral area
Effect of Walking Relieves the pain Intensifies

 Duration – from the beginning of one contraction to the end of the same contraction; during early labor –
20 to 30 seconds; late in labor – 60 to 70 seconds (should never be longer)
 Interval – from the end of one contraction to the beginning of one contraction; during early labor – 40 to
45 minutes; during late labor – 2 to 3 minutes
 Frequency – from the beginning of one contraction to the beginning of the next contraction; time 3 to 4
contractions to have a good picture of the frequency of the contractions
 Intensity – the strength of contractions; maybe mild, moderate or strong; intensity is measured by the
consistency of the fundus at the acme of the contraction; when estimating intensity, check fundus at the
end contractions to determine whether it relaxes

 LENGTH OF NORMAL LABOR

Primis Multis
First Stage 12 ½ hours 7 hours & 20 minutes
Second Stage 80 minutes 30 minutes
Third Stage 10 minutes 10 minutes
Total 14 hours 8 hours

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 STAGES OF LABOR

A. First Stage: Dilatation Stage

 Begins with true labor pains & ends with complete dilatation of the cervix
 Phases:
1. Latent Period
 Early time in labor
 Cervical dilatation is minimal bec effacement is occurring
 Cervix dilates 3-4 cm. only
 Contractions are of short duration & occur regularly 5-10 minutes apart
 At this time, the pregnant woman may seek admission to the hospital
 Mother is excited with some degree of apprehension but still with ability to communicate
 Takes up to 8 of the 12-hour first stage
2. Active/Accelerated Period
 Cervical dilatation reaches 4-8 cm.
 Rapid increase in duration, frequency & intensity of contractions
 Contractions are usually every 2 to 5 minutes; lasting 30 to 50 seconds and of mild to moderate
intensity
 Mother fears losing control of herself
3. Transition Period
 The nature of contractions intensifies
 Dilates from 8 to 10 cm.
 Contractions are every 2 to 3 minutes, lasting 50 to 60 seconds and of moderate to strong intensity.
Some contractions may last up to (but not exceed) 90 seconds.
 If membranes are still intact, this period is marked by a sudden gush of amniotic fluid as fetus is
pushed into the birth canal
 If spontaneous rupture does not occur:
o Amniotomy (snipping of BOW with a sterile pointed instrument such as Kelly or Allis forceps to
allow amniotic fluid to drain)
o This is done to prevent fetus from aspirating the amniotic fluid as it makes different fetal position
changes
o However, amniotomy cannot be done if station is still “minus” as this can lead to cord prolapse
 Show becomes more prominent
 There is an uncontrollable urge to push with contractions, a sign of impending second stage of labor
 Profuse perspiration & distention of neck veins are seen
 Nausea & vomiting is a reflex reaction due to decreased gastric motility & absorption
 In primis, baby is delivered within 20 contractions (= 40 minutes); in multis, in 10 contractions (= 20
minutes)
 Nursing Care in Different Phases:
1. Latent Period & Active Period
 Hospital Admission
o Obtain personal data – name, age, address, civil status
o Obtain obstetrical data – determine EDC, amount & character of show, whether or not membranes
have ruptured
 General physical examination, internal examination, Leopold’s Maneuver are done to determine
effacement, dilatation, station, fetal position & presentation
 Monitor & Evaluate Important Aspects:
o Uterine Contractions (duration, interval, frequency, intensity)
o Blood Pressure
 Should not be taken during a contraction as it tends to increase bec no blood supply goes to the
placenta during a contraction, all of the blood is in the periphery
 BP readings should be taken at least every half an hour during active labor
 When a woman in labor complains of headache, the first nursing action is to take the BP; if it is
normal, it is only stress headache; if it is increased, refer immediately to the DR (it could be a sign
of toxemia)
o Fetal Heart Rate
 Should not be mistaken for uterine soufflé (synchronizes with maternal pulse rate)

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  Should not be taken also during contractions as it tends to increase; compression of the fetal head
when the uterus contracts stimulates the vagal reflex which in turn causes bradycardia
 Should be taken every hour during the latent phase of labor; every half an hour during the active
phase & every 15 minutes during the transition period
 For any abnormality in FHR, the initial nursing action is to change the mother’s position
 Signs of Fetal Distress:
 Bradycardia or Tachycardia (less than 100 or more than 180)
 Meconium-stained amniotic fluid in non-breech position
 Fetal thrashing – hyperactivity of the fetus as it struggles for more oxygen
 Emotional support is provided for the woman in labor keeping her constantly informed of the progress
of labor
 Health Teachings:
o Bath is advisable if contractions are tolerable or not too close to one another; this will make the
mother feel comfortable
o Ambulation during the latent phase of labor helps shorten the first stage of labor; but definitely not
allowed anymore if membranes have ruptured
o Solid & liquid foods are to be avoided bec:
 Digestion is delayed during labor
 A full stomach interferes with proper bearing down
 Woman may vomit & cause aspiration
o Enema is not a routine procedure but it serves the ff advantages:
 A full bowel hinders the progress of labor; the effectiveness of enema in labor is shown by
evaluating change in uterine tone & amount of show
 Expulsion of feces during second stage of labor predispose mother & baby to infection
 Full bowel predisposes to postpartum discomfort
♣ Procedure for enema administration:
♠ Enema solution may either be soap suds or fleet enema
♠ Optimal temperature of the enema solution should be 40 to 46°C
♠ Patient placed on side-lying position
♠ When there is resistance while inserting the rectal catheter, withdraw the tubes slightly while
letting a small amount of solution enter
♠ Clamp rectal tube during contraction
♠ Important: check FHR after enema administration to determine fetal distress
♣ Contraindications to enema in labor:
♠ Vaginal bleeding
♠ Premature labor
♠ Abnormal fetal presentation or position
♠ Ruptured membranes
♠ Crowning
o Voiding should be encouraged every 2-3 hours by offering the bedpan for the ff reasons:
 A full bladder retards fetal descent
 Urinary stasis can lead to urinary tract infection
 A full bladder can be traumatized during delivery
o Encourage Sim’s position because:
 It favors anterior rotation of the fetal head
 It promotes relaxation between contractions
 It prevents continual pressure of the gravid uterus on the inferior vena cava (the blood vessel
which brings unoxygenated blood back to the heart); pressure results to hypotensive syndrome
(aka “Vena Cava Syndrome”)
o A woman in labor should not be allowed to push or bear down unnecessarily during contractions in
the first stage bec:
 It leads to unnecessary exhaustion
 Repeated strong pounding of the fetus against the pelvic floor will lead to cervical edema thus
interfering with dilatation
o Abdominal breathing is advised for contractions during the first stage in order to reduce tension &
prevent hyperventilation
 Perineal Prep – done aseptically; use the “No. 7” method; always from front to back
 Perineal Shave – maybe done to provide a clean area for delivery; muscles at the symphisis pubis
should be kept taut & razor should move along the direction of hair growth
 Administer analgesics as ordered
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 o The dosage is based on the patient’s weight, status of labor & size & stage of gestation
o Narcotics are the most commonly used, specifically Demerol
o Pharmacologic Effect: depresses sensory portion of the cerebral cortex; it is not a potent analgesic; it
is also a sedative & an antispasmodic
o It is not given early in labor bec it can retard labor progress (bec of antispasmodic effect)
o It cannot also be given if delivery is only one hour away bec it can cause respiratory depression in
the newborn
o It is only given if cervical dilatation is 6-8cm
o Given 25-100mg depending on the body weight
o Takes effect in 20 minutes; patient experiences well-being & euphoria
o Narcotic antagonist (ex. Narcan) is given to counteract the toxic effects of Demerol
 Assist in the administration of regional anesthesia
o Preferred over any other form of anesthesia bec it does not enter maternal circulation & thus does
not affect the fetus.
o Patient is completely awake & aware of what is happening
o It does not depress uterine tone, thus optimal uterine contraction is achieved
o Xylocaine is the anesthesia of choice
o Patient is NPO with IV to prevent dehydration, exhaustion & aspiration & bec glucose aids uterine
muscles in proper functioning
o Types of Anesthesia:
 Paracervical
♣ Transvaginal injection into either side of the cervix
♣ Patient is on lithotomy position
♣ Coupled with a local anesthetic, results in “painless childbirth” (contractions are not felt by
mother)
 Pudendal
♣ Administered through the sacro-spinous ligaments into the posterior areolar tissues to reduce
perception of pain during second stage of labor & make mother comfortable
♣ Patient is on lithotomy position
♣ Side effect is an ecchymotic area or hematoma in the right of the perineum; needs no special
treatment; ice bag applied to the area on the first day may reduce swelling
 Low Spinal
♣ Epidural – injection of a local anesthetic at the lumbar level outside the dura matter; patient is
on fetal or shrimp position
♣ Saddle Block
♠ Injection into the 5th lumbar space causing anesthesia to penetrate into the parts of the body
that come in contact with a saddle (perineum, upper thighs & lower pelvis)
♠ Blocks nerves that transmit pain of first stage of labor
♠ Patient is on sitting or side-lying position with back flexed
o Forceps are generally needed in delivery of patient under anesthesia because of loss of coordination
in second-stage pushing
o Postspinal headaches may be experienced due to leakage of anesthetic into the CSF or injection of
air at the time of needle insertion; Mgt: keep patient flat on bed for 12 hours & increase fluid intake
o Common side effects of anesthesia
 Hypotension – because Xylocaine is a vasodilator; Mgt: turn to side; prompt elevation of the legs,
administration of vasopressor & oxygen as ordered
 Fetal bradycardia
 Decreased maternal respirations
3. Transition Period – nursing actions are primarily comfort measures:
 Sacral pressure with the heel of the hand to relieve discomfort from contractions
 Proper bearing down techniques - push with contractions
 Controlled chest (costal) breathing during contractions
 Emotional support

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B. Second Stage: Expulsion Stage

Descent: As the fetal head engages

and descends, it assumes an
occiput transverse position because
that is the widest pelvic diameter
available for the widest part of the
fetal head.

Flexion: While descending through

the pelvis, the fetal head flexes so
that the fetal chin is touching the
fetal chest. This functionally creates
a smaller structure to pass through
the maternal pelvis. When flexion
occurs, the occipital (posterior)
fontanel slides into the center of the
birth canal and the anterior fontanel
becomes more remote and difficult
to feel. The fetal position remains
occiput transverse.
Internal Rotation: With further
descent, the occiput rotates
anteriorly and the fetal head
assumes an oblique orientation. In
some cases, the head may rotate
completely to the occiput anterior
position.

Extension: The curve of the hollow

of the sacrum favors extension of
the fetal head as further descent
occurs. This means that the fetal
chin is no longer touching the fetal
chest.

External Rotation: The shoulders

rotate into an oblique or frankly
anterior-posterior orientation with
further descent. This encourages the
fetal head to return to its transverse
position. This is also known as
restitution.

 Begins with the complete dilatation of the cervix & ends with the delivery of the baby
 The second stage may last from 1 to 4 hours in the nullipara and from 20 to 45 minutes in the multipara.
 Mechanisms of Labor:
 Different position changes during the passage of the fetus through the birth canal
 The position changes are termed the “Cardinal Movements of Labor”
 (E)D FIRE ERE
o Engagement – could precede descent

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o Descent
The downward movement of the biparietal diameter of the fetal head into the pelvic inlet
Full descent occurs when the fetal head extrudes beyond the dilated cervix & touches the posterior
vaginal floor
The pressure of the fetus on the sacral nerves causes the mother to experience a pushing sensation
o Flexion
Pressure from the pelvic floor causes the fetal head to bend forward onto the chest
o Internal Rotation
The occiput rotates until it is superior or just below the symphisis pubis bringing the head into the
best diameter for the outlet of the pelvis
This movement brings the shoulders into the optimal position to enter the inlet or puts the widest
diameter of the shoulders 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 & acts as a pivot for the
rest of the head
The head thus extends & the foremost parts of the head, the face & chin are born
o 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
Anterior shoulder rotates externally to the AP position
o Expulsion
Delivery of the rest of the body

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  Nursing Care:
 When positioning legs on lithotomy, put them up at the same time to prevent injury to the uterine
ligaments
 As soon as the fetal head crowns, instruct the mother not to push but to pant instead (rapid, shallow
breaths) to prevent rapid expulsion of the baby;
 If panting is deep & rapid (hyperventilation), the patient will experience light-headedness & tingling
sensation of the fingers leading to carpopedal spasms bec of respiratory alkalosis
 Management: let the patient breathe into a brown paper bag to recover lost carbon dioxide; a cupped
hand will serve the same purpose
 Assist in episiotomy
o Episiotomy is an incision made in the perineum primarily to prevent lacerations
o Other Purposes of Episiotomy:
 Prevent prolonged & severe stretching of muscles supporting the bladder or rectum
 Reduce duration of second stage when there is hypertension or fetal distress
 Enlarge outlet such as in breech position or forceps delivery
o Types of Episiotomy:
 Median – from middle portion of the lower vaginal border directed towards the anus
 Mediolateral – begins in the middle line but directed laterally away from the anus
o Natural anesthesia is used in episiotomy that is, no anesthetic is injected bec the pressure of fetal
presenting part against the perineum is so intense that nerve endings are momentarily deadened
 Apply the Modified Ritgen’s Maneuver:
o Cover the anus with sterile towel & exert upward & forward pressure on the fetal chin while exerting
pressure with two fingers on the head to control emerging head; this will not only support the
perineum (thus preventing lacerations) but will also favor flexion so that the smallest
suboccipitobregmatic diameter of the fetal head is presented
o Ease the head out & immediately wipe the nose & mouth of secretions
 Remember the first principle in the care of the newborn is establish & maintain a patent airway; the
head should be delivered in between contractions
o Insert 2 fingers into the vagina so as to feel for the presence of a cord looped around the neck (nuchal
cord)
 If nuchal cord is present but loose, slip it down the shoulders or up over the head; but if tight, clamp
cord twice, an inch apart, & then cut in between
o As the head rotates, deliver the anterior shoulder by exerting a gentle downward push & the slowly
give an upward lift to deliver the posterior shoulder
o While supporting the head & the neck, deliver the rest of the body; take note of the exact time of
delivery of the baby
 Immediately after delivery, newborn should be held below the level of the mother’s vulva for a few
minutes to encourage the flow of blood from the placenta to the baby
 The infant is held with his head in a dependent position (head lower than the rest of the body) to allow
drainage of secretions; remember, never stimulate a baby to cry unless you have drained him out of his
secretions first
 Wrap the baby in a sterile diaper to keep him warm; remember, chilling increases body’s need for
oxygen
 Put the baby on the mother’s abdomen; the weight of the baby will help contract the uterus
 Cutting the cord is postponed until the pulsations have stopped bec it is believed that 50-100ml of blood
is flowing from the placenta to the baby at this time
 After the cord pulsations have stopped, clamp it twice, an inch apart & then cut in between
 Show the baby to the mother, inform her of the sex & the time of delivery then give the baby to the
circulating nurse or the assist

C. Third Stage: Placental Stage

 Begins with the delivery of the baby & ends with the
delivery of the placenta
 The third stage may last from a few minutes to 30 mins.
 Signs of Placental Separation:
 Calkin’s Sign – uterus becomes round & firm rising high
to the level of the umbilicus; the earliest sign of placental
separation
 Sudden gush of blood from the vagina
 Lengthening of the cord from the vagina
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  Types of Placental Delivery:
 Schultz
o If placenta separates first at its center & last at its
edges it tends to fold on itself like an umbrella
o Presents the fetal surface which is shiny
o 80% of the placenta separates in this manner
o Schultz – Shiny
 Duncan
o If placenta separates first at its edges, it slides along
the uterine surface
o Presents with the maternal surface which is raw,
red, beefy, irregular & dirty
o Only about 20% of placenta separates in this
manner
o Duncan – Dirty

 Nursing Care:
 Do not hurry the expulsion of the placenta by forcefully pulling out the cord or doing vigorous fundal
push as this can cause uterine inversion; just watch for the signs of placental separation
 Do the “Brandt-Andrews Maneuver” - tract the cord slowly, winding it around the clamp until the placenta
spontaneously comes out, rotating it slowly so that no membranes are left inside the uterus
 Take note of the time of placental delivery; it should be delivered within 20 minutes after the delivery of
the baby; otherwise, refer immediately to the doctor as this can cause severe bleeding & possible death
 Palpate the uterus to determine the degree of contraction. If relaxed, boggy or non-contracted, first
nursing action is to massage gently & properly; an ice cap over the abdomen will also help contract the
uterus since cold causes vasoconstriction
 Inject oxytocin (Methergine 0.2mg/ml or Syntocinon 10U/ml) IM to maintain uterine contractions thus
prevent hemorrhage
 Note: Oxytocin is not given before placental delivery bec placental entrapment could occur
 Inspect the perineum for lacerations:
 Anytime the uterus is firm following placental delivery, yet bright, red vaginal bleeding is gushing
forth from the vaginal opening, suspect lacerations
 Lacerations tend to heal more slowly bec of ragged edges
 Categories of Lacerations:
o First Degree – involves the vaginal mucous membranes & skin
o Second Degree – involves not only the vaginal mucous membranes & skin but also the muscles
o Third Degree – involves not only the muscles, vaginal mucous membranes & skin but also the
external sphincter of the rectum
o Fourth Degree - involves not only external sphincter of the rectum, muscles, vaginal mucous
membranes & skin but also the mucous membranes of the rectum
 Assist the doctor in doing episiorrhaphy (repair of episiotomy or lacerations):
♠ Packing is done to maintain pressure on the suture line thus prevent bleeding
♠ Vaginal packs have to be removed after 24-48 hours
 Make the mother comfortable by perineal care & applying clean sanitary napkin snugly to prevent its
moving forward from the anus to the vagina; soiled napkins should be removed from front to back
 Position the newly-delivered mother flat on bed without pillows to prevent dizziness due to decrease intra-
abdominal pressure
 The mother may suddenly complain of chills due to the rapid decrease of pressure, fatigue or cold
temperature in the DR; provide additional blankets to keep her warm
 Allow patient to sleep in order to regain lost energy

D. Fourth Stage: First 1 to 2 hours after delivery

 The most critical stage for the mother because of unstable vital signs
 Assessment:
 Fundus
o Should be checked every 15 minutes for 1 hour, then every 30 minutes for the next 4 hours
o It should be firm, in the midline & during the first 12 hours postpartum, is a little above the umbilicus
o First nursing action for a non-contracted uterus is massage or nipple stimulation

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 Lochia
o Should be moderate in amount
o Immediately after delivery, a perineal pad can be completely saturated after 30 minutes
o Types of Lochia: (RSA)
 Rubra – Red; 1-3 days; composed of blood, fragments of decidua & mucus
 Serosa – Pink; 3-10 days; composed of blood, mucus & invading leukocytes
 Alba – White; 10-14 (lasts 6 weeks); composed largely of mucus; leukocyte count is high

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  Bladder – a full bladder is evidenced by a fundus which is to the right of the midline, dark-red bleeding
with some clots
 Perineum – is normally tender, discolored & edematous; it should be clean with intact sutures
 BP & PR – may be slightly increased from excitement & effort of delivery but normalizes within one
hour
 Rooming-In Concept:
 Mother & baby are together while in the hospital
 The concept of the family therefore is felt at the very beginning bec parents have the baby with them
 This provides the opportunity for developing a positive relationship between parents & newborn baby
 Eye to eye contact is immediately established, releasing maternal caretaking responses

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