ASSESSMENT DURING LABOR

FETAL ASSESSMENT
Auscultation
-FHR: normal is 120-160 bpm
-best recorded during the 30 secs. Immediately
following the contraction

Palpation
-to assess the intensity of the contraction by normal
palpation of the uterine fundus
a. mild: tense fundus, difficult to indent w/ fingertips
b. moderate: firm fundus, diff. to indent w/ fingertips
c. strong: very firm fundus cannot be indent
add. Info:
Electronic Fetal Monitoring (EFM)
- used to monitor and record fetal heart beat
and uterine contractions and display them on a special
graph paper for comparison and identification of normal
and abnormal patterns.

a. External
-less precise
-non-invasive, rupture membrane is not required
B. Internal
-more precise
-invasive, rupture membrane is required
 DANGER SIGNS OF LABOR
Fetal Danger Sign
a. high or low FHR - indicates fetal distress

b. meconium staining -green color of the amniotic fluid

results to loss of sphincter control, fetus
experience hypoxia

c. fetal hyperactivity – hypoxia

d. fetal acidosis – sign of compromised fetal wellbeing

Maternal Danger Signs
a. rising or falling of BP

b. abnormal pulse

c. inadequate prolonged contraction

d. abnormal lower abdominal contour

e. increasing apprehension
( sign of O2 deprivation and internal
hemorrhage)
 PREPARATION FOR LABOR
*- natural childbirth: one approach of giving birth, to
some natural childbirth meant w/o the use of analgesic
or anesthesia.
- so certain preparation gave the woman a method of
coping with the discomforts of labor and delivery.

Method of Grantly Dick-Read

- this method is based in an idea that fear and
anticipation of pain arouse natural protective tension in
the body, both psychic and muscular.
- fear stimulates the SNS and cause the circular muscle
of the cervix
Psychoprophylactic or Lamaze Method
- based on Pavlov’s concept of perception
- woman is taught to replace response of restless, fear,
and loss of control with more useful activity like
exercises that strengthen abdominal muscles and
deep breathing exercise.

The Leboyer Method of Delivery

- based on the premise that infant suffers psychological
shock at the time if delivery.
- an effort is made to remove contract between the
intrauterine environment and the outside world
- emphasis onn providing the craniosacral axis by
supporting the baby’s head, neck and sacrum.
 OPERATIVE OBSTETRICS PROCEDURE
*-operative obstetric- refers to a number of procedures that
may be used to assist the mother in labor and delivery

() EPISIOTOMY
- is an surgical incision of the perineum during delivery
to enlarge the vaginal opening
Purpose:
-facilitate repair laceration and to promote
healing
-to spare the infants head from prolonged
pressure and pushing against the rigid perineum
 TYPES OF EPISIOTOMY

a. Median or midline
-incision is made in the middle of the perineum and
directed towards the perineum

b. Mediolateral
- incision is made laterally in the perineum to avoid the
anal sphincter if enlargement is needed
() FORCEPS DELIVERY
*- obstetrician’s use a special spoon-shaped instrument
to effect the delivery of the baby and shorten the 2nd
stage of labor
TYPES
a. low or outlet: presenting part at vaginal introitus
b. mid forceps: presenting part is at below the ischial
spine: rarely done
c. high forceps: presenting part above the ischial
spines. This procedure has been replaced
by cesarean birth
 Requirements for application of forceps
1. Fully dilated cervix
2. Presenting part engaged
3. Vertex or face presentation
4. Ruptured membranes
5. No pelvic contraction pr disproportion
6. Bowel and bladder emptied
() CAESAREAN BIRTH
-delivery of the baby through incision into the
abdominal wall and uterus.
TYPES
a. classical: vertical incision is made into both
abdomen and uterus
: used when rapid delivery is important as
in fetal distress, prolapsed cord,
placenta abruptio
b. low cervical/low segment
: transverse incision in the abdomen and
in the uterus. MOST COMMON USED.
() VAGINAL DELIVERY AFTER CAESAREAN (VBAC)

-woman should be offered opportunity for

vaginal delivery even after Caesarean Section

- should be prepared to have another section if

labor does not progress
 INDUCTION DURING LABOR
Candidates for induction of labor
-1 or 2 previous low transverse incision
- pelvis evaluated for adequacy
- no other uterine scars or previous uterine ruputures

Maternal/Fetal Contraindications
-Cesarean with a classical incision
-previous hysterectomy and myotomy
- uterine rupture
-placenta previa
-multiparty
-malpresentation
-fetal distress
- cancer of the cervix
1. Induction by Amniotomy
- involves artificial rupturing of the membrane by
the sterile instrument

- indicated to patients when internal fetal

monitoring is desired

- when oxytocin is contraindicated

ADVANTAGE
-facilitate fetal status monitoring using a external scalp
electrode, catheter, or scalp blood sampling
-assess the amniotic fluid’s color and composition

DISADVANTAGE
-increases the risk for infection
-increases the incidence of fetal compression
2. Induction by way of oxytocin infusion
-involves in the administration of I.V. oxytocin 10 IU in
1000ml of Ringer’s Lactated thru an infusion pump

- indicated to patients with prolonged rupure of

membrane and post maturity
ADVANTAGE
-predictable
-doesn't directly affect the baby
-stimulates contractions efficiently and effectively
DISADVANTAGE
-increases the risk for titanic uterine contractions
-risk for over stimulating the uterus, that lead to fetal
distress
3. Induction by way of prostaglandin
-this drug initiates the breakdown of collagen that
keeps the cervix tightly closed. Gel application of this
softens the cervix
- indicated for post maturity and long thick cervix
ADVANTAGE
-decreases the likelihood for cesarean delivery
-requires lower dose of oxytocin
-shortens labor
DISADVANTAGE
-increases the risk of uterine hyperstimulation
4.Induction by way of membrane stripping or cervical
ripening
-a nonpharmacologic method used by physicians bi
inserting a gloved finger into the in tinterbal cervical os and
rotates the finger (360 degrees) twice, to separate the
amniotic fluid from the lower uterine segment and that are
lying against the cervix, it releases prostaglandin thus uterine
contraction happens.
OBSTETRIC ALNALGESIA AND ANESTHESIA
- PAIN PERCEPTION THEORIES
-SPECIFICITY: a specific pain system that carries
message from pain receptors in the body to a pain center
in the brain

-PATTERN: network of nerves impulses produced by

sensory input at the dorsal horn cells; pain results if this
exceeds to critical level

-GATE CONTROL: closing a hypothetical gate

mechanism in the spinal cord that blocks pain signals fron
reaching the brain
 CIRCUMSTANCES AFFECTING PAIN
+ Cultural background
-some react to pain by being silent and avoiding
interaction with other individuals
+ Personal Significance
-self- concept is closely aligned with how an individual
regards to pain
+ Fatigue and Sleep deprivation
-a tired individual has less energy and can’t focus on
such strategies as distraction
+ Attention and Distractions
-preoccupation with another activity( such as breathing
techniques) lessens perceived pain
 PAIN RELIEF MANAGEMENT DURING LABOR
AND DELIVERY
A.NONPAHARMALOGICAL MEASURES
+relaxation
-position the woman where she is most
comfortable of. A change in position form back or
side lying position to one on the hands and knees
with the head lower than the hips usually helps
ease the pain
+ focusing
-use of distractions (photos: pictures important to
them)
-patient concentrates intently on the object during
contractions
+ imagery (visualization)
-involves mental concentration on person, place or
thing
+ therapeutic touch and massage
-a laying on of hands to redirect the energy fields that
lead to pain( Krieger)
-massage helps release endorphins (happy hormone)
( Lothian)
+ distraction
+effleurage
+lamaze breathing techniques
involves 3 patterns of controlled chest breathing
-slow breathing
-accelerated breathing
pant-blow
+transcutaneous electrical nerve stimulation
-stimulation of large neural fibers through the use of electrical impulses
to alter pain perception
+hypnosis
+acupuncture
+yoga
+herbal preparation
+heat and cold application
+reflexology
B. Pahrmacological management
ANALGESICS
+opioids
- meperidine (Demerol), nalbuphine (Nubain)

+sedatives
-midazolam (Versed)
-maternal-fetal-neonatal adversed reactions include
transient decrease in variability, neonatal respiratory
depression and decrease level of alertness
ANESTHETICS
+general anesthesia
-adm. By IV or inhalation resulting in unconsciousness
-used if regional anesthesia is contraindicated
IV: reserved for patients with massive blood loss,
thiopental (Pentothal), ketamine (Ketalar)

+regional anesthesia
-local anesthesia- blocks pain form the uterus to the
spinal cord
-lumbar anesthesia-to the epidural space to the lumbar
region
- spinal anesthesia- into the cerebrospinal fluid in the
spinal canal
 NURSING INTERVENTION
1. Have nalaxone (Narcan) antidote for patients possible for
opioid toxicity
2. Always check the 5 rights
3. Have a good knowledge in the meds you are giving.
4. Explain the purpose of giving such med.
5. Closely monitor the mother and the fetus for any kind of
distress
6. Take swift action if adverse effects happens
 NURSING CARE DURING POSTPARTUM
# SPECIFIC BODY SYSTEM CHANGES
 uterus: rapid reversal in size
: regress aprox. 1-2 fingerbreadths (1cm) per
day
() lochia rubra- dark red color, 1-3 days after delivery
() lochia serosa-pinkish red, 3-10 days after delivery
() lochia alba-yellowish white, 10-14 days after delivery

 cervix: flabby immediately after delivery; closes slowly

 vaginal/perineum: edematous after delivery
: have small lacerations
: smooth-walled for 3-4 weeks, then
rugae reappear
 breats
* nonlactating woman
-prolactin level fall immediately
-may still secrete colostrum 2-3 days
-engorgement of breast tissue resulting from
temporary congestion of veins
-client should wear tight bra to compress the
ducts and used cold application to reduce
swelling
* lactating woman
-high level of prolactin
-initial secretion of colostrums, with increasing
amount of true breast milk
- milk “let-down” reflex caused by oxytocin form
pituitary gland released by sucking
-successful lactation results from sucking reflexes and
maternal production and let down of milk
Abdominal skin
-may need 6 weeks to reestablish good muscle tone. Time
were sexual intercourse can resume
CV system
-normal blood loss in delivery in single infant is 500cc upto
1000 cc for Caesarean Section and 300-500cc to vaginal
birth
Urinary system
-difficulty voiding in immediate postpartum periods as a
result of urethral edema
- lactosuria found in nursing mother
GI system
-hungry after delivery; good appetite is expeced
-may still experience constipation from lack of muscle tone
in abdomen and intestinal tract
 POSTPARTAL PSYCHOSOCIAL CHANGES
1.Adaptation to parenthood
Motor Skills
-new parents must learn new physical skills to care for
infant (e.g. feeding, holding, burping,changing diapers and
skin care)

Attachment Skills
a. bonding
b. sensual response: use of senses; how you look, touch
feel tour baby
2. Maternal Adjustment
3 Phases
a. dependent “taking in”
-1-2 days after delivery
-mother is passive and dependent
-food/sleep is important
b. dependent/independent “taking hold”
-3-7 days after
-mother begin to reassert herself
-identifies own needs
- mother is active, assume independent role and
participative
c. independent “ leeting go”
-evident by 7th day or sixth week
-show pattern of lifestyle
-reestablishment of father-mother bond seen in this
period
-mother redefines new role, assumes interdependent
role and responsible
FAMILY PLANNING
 BASIC PRINCIPLES
1. Family planning is defined as the voluntary and moral
management of all the process of family life including
human reproduction.
2. The nurse should know the advantages and
disadvantages regarding different methods on
contraception
3. Woman are entitled to contraceptive devices as apart of
good health care without the burden of moral judgmnet
4. Feeling about contraception must be explored in a
nonjudgmental way and the variety of choices must be
summarized to allow selection oa method that fits the
unique circumstances of the person or couple
 TYPES OF FAMILY PLANNING
1. NATURAL Family Planning (NFP)
a. periodic abstinence
-abstention from sexual intercourse during fertile
period of each cycle
-abstaining from about 7-18 days
b. Cervical Mucus Method (CMM)
-requires a woman to examine the mucus from
her cervix to determine fertile period
-consistency and amnt. of the mucus depends
as hormonal levels vary during the menstrual cycle
-after 3-4 days of the menstrual period, little or
no mucus is discharged (dry days). To avoid
pregnancy, intercourse is allowed in this period
(safe days)
 -during the peak of ovulation, the mucus
becomes wet, slippery, abundant, clear,
stretchable like “egg white” ( Spinnbarkheit)
which can be stretched 2.5 cm and normally
from 8-10 cm. this means “wet day” and signals
“unsafe”
c. Calendar Method
-a woman keeps a record of at least 6 memstrual
cycles and uses the record to determine which
days is most likely to be fertile during an average
menstrual cycle
d. Basal Body Temperature
-measures variations in body temperature to determine
where ovulation begins
-normal: temp decreases slightly just before ovulation
and begin to rise several days afterwards
- progesterone influences the rise of temperature
during after ovulation
e. coitus interruptus (withdrawal)
- this is the effective withdrawal of the penis from the
vagina when ejaculation is imminent
- contraindicated when male is not able to exert self-
control
-ineffective when premature ejaculation occurs
- may result to psychological ill to both the male and
the female
f. Coitus Resevatus: sexual intercourse without ejaculation
g. Coitus Interfemora: sexual intercourse where penis is
wrapped between the femur
h. Coitus Intermammas: sexual intercourse where penis is
wrapped between the
mammary gland
ARTIFICIAL Family Planning
a. condom
- use of stretchable rubber sheath that civers the penis
to prevent the sperm in entering the vagina after
ejaculation
b. diaphragm
-shallow dome fits over the cervix, blocking passage of
sperm to the cervix
c. Hormonal Control Therapy (oral contraceptives, birth
control pills)
-ingestion of estrogen and progesterone on a specific
schedule to prevent the release of FSH and LH, thus
preventing ovulation and pregnancy
d. Cervical Cap
- cup-shaped device that is placed over the cervical os and held
in place by suction
- spermicadal increases the effectiveness and may left in place
from 24-48 hours

e. Contraceptive Sponge
-small, soft insert, with identation on one to fit the cervix
- it contains spermocide, moisten with water

f. Intrauterine Device (IUD)

-placement of plastic or noncreative device into the uterine c
avity during menstruation or after delivery

g. Steroid Implants
-biodegradable rods containing sustained release, low dose of
progesterone
-inhibits LH release for ovulation

h. injectable progestin: same as steroids

PERMANENT Family Planning
a. Bilateral Tubal Ligation
-blocking the isthmus of the fallopian tubes to prevent
the passage of ova and is done after menstruation

b. Bilateral Vasectomy
-the male will be incapable of fertilizing his partner
after all viable sperm ejaculated from the vas deferens
(6weeks or 10 ejaculations)
ESSENTIAL PROCEDURE IN THE CARE OF
NORAML NEWBORN