Care and Management of the Intrapartal

Woman

Ariel l. Tamayo
Antepartum/prenatal care
 starts when the woman’s pregnancy is

diagnosed and ends just before the baby is

delivered.
 From pregnancy diagnosis to beginning of

the contraction that cause cervical

dilatation
Intrapartum Care
-extends from the beginning of the contractions
that cause cervical dilatation to the first 1-4
hours after delivery of the newborn and
placenta.
-refers to the medical and nursing care given to
the pregnant woman during labor and delivery.
Admitting the laboring mother
-Personal data - physical exam
-baseline data -Pelvic exam
-obstetrical data
LABOR & DELIVERY
 What is labor?
TRUE or FALSE LABOR?

Theory of Labor Onset?

Stages of labor?
 Labor or Parturition
 It Is the process where by painful ,
regular uterine activity (contraction) with
progressive cervical effacement and
dilatation accompanied by decent of the
presenting part leads to expelled of the
fetus from the uterus at or beyond 24 (or
28) completed weeks of pregnancy.
 Term
Labour
PTL prolonged

24 W 28 W 37 W 40W 42W
1 LNMP
 Theories of Labor onset
1. Uterine Stretch theory
The idea is based on the concept that any hollow
body organ when stretched to its capacity
will inevitably contract to expel its contents .
The uterus, which is a hollow muscular organ,
becomes stretched due to the growing fetal
structures.
* the pressure increases causing physiologic
changes (uterine contractions) that initiate labor.
 2. Oxytocin Stimulation theory
Pressure on the cervix stimulates the
hypophysis(PG) of the pregnant woman to
release oxytocin (APG)
- As pregnancy advances, the uterus becomes
more sensitive to oxytocin. Presence of
oxytoxin hormone causes the initiation of
contraction of the smooth muscles of the
body (uterus is composed of smooth muscles).
3.Progesterone deprivation theory
Progesterone is the hormone designed to
promote pregnancy. It is believed that presence
of progesterone hormone inhibits uterine
motility.
As pregnancy advances, changes in the relative
effects estrogen and progesterone encourage
the onset of labor. A marked increase in
estrogen level is noted in relation to
progesterone, making the progesterone
hormone less effective in controlling rhythmic
uterine contractions.
Also, in later pregnancy, rising fetal cortisol levels
inhibit progesterone production from the
placenta. Reduce progesterone formation initiates labor.
4.Prostaglandin theory
*In the latter part of pregnancy, fetal
membranes and uterine decidua increase
prostaglandin levels. This hormone is
secreted from the lower area of the fetal
membrane (forebag).
*A decrease in progesterone amount also
elevates the prostaglandin level.
*Synthesis of prostaglandin, in return,
causes uterine contraction thus, labor is
initiated.
5. Theory of Aging Placenta
Advance placental age decreases blood
supply to the uterus. This event triggers
uterine contractions, thereby, starting
the labor.
-as the placenta begins to degenerate by 36
weeks, the body perceives it as a foreign
body hence makes its own defense to
expel it by contraction of the uterus.
 The 5 “Ps” of Labor:
5 Components of Labor
1.Passenger (fetus)
2.Powers (uterine contractions)
3.Passage (the pelvis & maternal soft parts)
4.Psyche (maternal psychological status)
5. Position (maternal)*********
 1. The Passenger(fetus)
 Fetal head (size and presence of
molding)”overlapping of the sutures”
 Fetal attitude(flexion or extension)

 Fetal lie(horizontal or vertical)

 Fetal presentation(cephalic, breech,

shoulder
 Placenta (implantation site)
 Fetal head:
-largest part of the newborn’s body- representing ¼ of
the newborn’s length, it is firm
The cranium, the uppermost portion of the skull,
comprises eight bones.
-4 superior bones(frontal-2 fused bones, two parietal,
occipital-important in childbirth)
Other 4 bones of the skull
1.Sphenoid
2.Ethmoid
3.Temporal(2)
Sutures -Membrabous space between the bones of
the fetal head
Suture lines- where bones of the skull meet
1.Sagittal suture lines
-connects 2 parietal bones
2.Coronal suture lines
-connects parietal and frontal bones
3. Lamboidal suture lines
-connects parietal and occipital bones

Molding- the overlapping of the sutures of the

skull to permit passage of the head to the pelvis
Fontanelles are areas of the head where suture lines
intersect.
2 fontanels are palpable
1.Anterior Fontanel(Bregma)
-diamond in shape, measures 2-3 cm
-permits growth of the brain by remaining unossified for
as long as 18 months
-closes at 12-18 months or 1 year -1 yr and 6 months
2. Posterior Fontanel (lambda)
-triangular in shape, 1x1 cm
-closes at 2-3 months/ 8-12 weeks
Fontanelle
Landmarks:
Head is divided into designated areas
1. the sinciput or brow portion;
2.the vertex, or top of the head between the 2
fontanelles;
3. the occiput or back of the head over the
occipital bone.
 Important Measurement of fetal head
Transverse Diameter(TD)
1.Biparietal – 9.25 cm(largest transverse)
2.Bitemporal – 8.0 cm
3.Bimastoid – 7.0 cm(smallest)
Antero-Posterior Diameter(APD)
1.Occipitomental – 13.5 cm(hyperextension)
2.Occipitofrontal-12.0 cm (partial flexion)
3. Submentobregmatic (face presentation)9.5 cm
4. Suboccipitobregmmatic -9.5 cm(complete
flexion)
 SIZE-LARGE BABIES MAY NOT BE
ABLE TO BE DELIVERIED VAGINAL.

 FETAL HEAD-DIAMETERS OF THE

FETUS HEAD
Diameters: During birth it is desirable that the
smallest diameter of the fetal head move
through the maternal bony pelvis. The
diameter that presents through the pelvis
depends on the amount of flexion or extension
of the head (attitude).
 The fetal skull or cranium consists of the face, the
base of the skull and the vault of the cranium or roof.
 The bones of the face and cranial base are well fused
and essentially fixed
 Molding refers to the cranial bones overlapping
under pressure during labor
 Sutures of the fetal skull are membranous spaces
between the cranial bones.
 Fontanelles are the intersections of the cranial
sutures. These sutures allow for molding of the fetal
head.
 Fetal attitude:
- is the relation of the fetal parts to one
another.
-The normal attitude of the fetus is one
of moderate flexion of the head,
flexion of the arms onto the chest,
and flexion of the legs onto the
abdomen
Attitude
-describes the degree of flexion a fetus asssumed
duting labor or the relationship of the fetal parts
to each other
Good attitude
-complete flexion: the spinal column is bowed
forward, the head is flexed forward so much that
the chin touches the sternum, the arms are
flexed and folded on the chest, the thighs are
flexed onto abdomen, and the calves are pressed
against the posterior aspect of the thighs
 Fetal lie:
- refers to the relationship of the cephalocaudal
(spinal column) axis of the fetus to the
cephalocaudal axis of the woman.
 A longitudinal lie(vertical) (occurs when the

cephalocaudal axis of the fetus is parallel to

the woman’s spine
 A transverse lie(horizontal) occurs when the

cephalocaudal axis of the fetus is at a right

angle to the woman’s spine
cephalic presentation breech presentation shoulder presentation
Fetal lie? Attitude?
Fetal lie? Attitude?
Fetal lie? Attitude?
*Fetal presentation
-Denotes the body part that will first contact the
cervix or be born first.(cephalic, breech,
shoulder)
*Fetal position
-the relationship of the presenting part to a
specific quadrant of the woman’s pelvis
a.L or R Occipito-anterior position
b.L or R Occipito-posterior position
(approximately one tenth of all labors)
4 quadrants of the maternal pelvis
1.Right anterior
2.Left anterior
3.Right posterior
4. Left posterior
Vertex-occiput
Face –chin(momentum)
Breech-sacrum
Shoulder – scapula or acromion process
*Station
-the relationship of the presenting part of a fetus
to the level of the ischial spines.
-3 to -4
= fetus is 3 to 4 cm above the ischial
spine and still floating(NC: therapeutic rest)
-1
= presenting part is 1cm above the ischial sspine
0
=fetus at the level of schial spines/engaged
*Engagement
-seetling of the presenting part into the pelvic
inlet.
+1 to + 2
=fetus is 1 to 2 cm below the ischial spines
+3 to +4
= fetus is at 3 to 4 cm below the ischial
spines”crowning”
=signals the second stage of labor.
 Fetal presentation
-is determined by fetal lie and by the body part of the
fetus that enters the pelvic passage first, the
presenting part
 Fetal presentation may be cephalic (most common),

breech, or shoulder
 Breech and shoulder presentations are referred to as

malpresentations as they are associated with

difficulties during labor
 Of note, some cephalic presentations are considered

malpresentations, i.e. military or face. However, the

overall cephalic category is the PREFERRED
presentation.
 Types of Cephalic presentation

**Vertex or Sinciput brow presentation face presentation

occiput presentation
presentation
Examples of presentations
 Cephalic Presentation
includes all of the following:
 97% of births
 Fetal head presents itself to the passage
 “Subcategories” of cephalic presentation includes:
 Vertex presentation: Occiput is the presenting part – most
common type
 Military presentation: The fetal head is neither flexed nor
extended
 Brow Presentation: The fetal head is partially extended
 Face presentation: The fetal head is hyperextended
 Breech Presentation
 3% of births
 Sacrum is the landmark to be noted
 Frank Breech: the fetal hips are flexed and the knees
are extended. The buttocks of the fetus present to the
maternal pelvis
 Complete Breech: the fetal knees and hips are both
flexed; the thighs are on the abdomen and the calves
are on the posterior aspect of the thighs
 Footling Breech: the fetal hips and legs are extended,
and the feet of the fetus present to the maternal pelvis
(single or double footling)
 Shoulder Presentation
 Also called a transverse lie
 Most frequently, the shoulder is the

presenting part and the acromion

process (A) of the scapula is the
landmark to be noted
 4 method used to determine fetal
position,presentation and lie
1. Combined abdominal inspection and
palpation (Leopold’s maneuvers)
2. Vaginal exam
3. Auacultation of fetal heart tones
4. sonography
 Fetal position
- refers to the relationship of a designated
landmark on the presenting fetal part to the
front, sides, or back of the maternal pelvis

The landmark on the fetal presenting part is

related to 4 imaginary quadrants of the pelvis:
left anterior (LA), right anterior (RA), left
posterior (LP), and right posterior (RP)
 The landmark chosen for vertex presentations
is the occiput (O), and the landmark for face
presentation is the mentum (M)
 In breech presentations, the sacrum (S) is the
designated landmark
 In shoulder presentation, the acromion process
(A) on the scapula is the landmark
 TO COMBINE THE NOTATIONS:
 Three notations are used to describe the fetal position:

Right (R) or left (L) side of the maternal pelvis
 The landmark of the fetal presenting part: occiput (O),
mentum (M), sacrum (S) or acromion process (A)

Anterior (A), posterior (P), or transverse (T), depending on
whether the landmark is in the front, back, or side of the pelvis

Of note, the term dorsal (D) refers to fetal position in
transverse lie, it refers to the fetal back
 Synclitism & Asynclitism:

Asynclitic refers to a fetal head that is not

parallel to the anteroposterior plane of the
pelvis.

 The head is synclitic when the sagittal suture

lies midway between the symphysis pubis
and the sacral promontoryor the
anteroposterior plane of the pelvis
 Engagement
-settling of the fetal head into the pelvis during labor.

*Engagement of the presenting part occurs when the

largest diameter of the presenting part reaches or passes
through the pelvic inlet.
*Engagement can be determined by vaginal, rectal
examination or abdominal palpation
*With abdominal palpation, if hands can pass between the
fetal head and the pelvic inlet (converge), the fetus is not
engaged (ballottment)
*Usually, the point of engagement is station zero
 Engagement confirms the adequacy of the pelvic inlet
 Station
 Station refers to the relationship of the presenting part to an
imaginary line drawn between the ischial spines of the
maternal pelvis.
 The ischial spines as a landmark have been designated as zero
station (the exact point of engagement)
 If the presenting part is higher than the ischial spines, a
negative number is assigned, noting cm above zero station
 Positive numbers are used to indicate that the presenting part
has passed the ischial spines
 Station -5 is the pelvic inlet, and station +4 is the outlet (pelvic
floor)
 Station -4 means the presenting part is floating (ballottment)
 Examinations
 Examinations are done with aseptic
technique (sterile gloves and antiseptic
solution). 
 You insert two fingers into the vagina and feel
the cervix and the top of the baby’s head to
gather information about the dilation and the
presentation of the baby. 
 This may be uncomfortable, especially during
a contraction. 
Vaginal Exam
 Vaginal Exams
 There is no place for routine vaginal examinations
in any labor. 
 Vaginal examination should only be done when there
is doubt about the clinical situation or symptoms, and
the information gathered is necessary or likely to be
of use in making a clinical decision.
 Excessive vaginal examinations carry with it the
risk of increased infection. 
 You should rely on behavior and emotional responses
and physical sensations rather than vaginal exams. 
 Reasons to defer or avoid digital vaginal
examination
 The vaginal examination should be avoided or
deferred in certain circumstances.
 In most of these situations a careful speculum
examination is acceptable:
 (1) Significant vaginal bleeding of unknown etiology
(delay examination until placenta previa has been
ruled out by ultrasonography),
 (2) Presence of placenta previa,
 (3) Ruptured membranes in patients who are not in
labor and for whom immediate induction of labor is
not anticipated,
 (4) Presence of active HIV lesions in a patient with
ruptured membranes.
 Dilatation chart
Cervical dilation: 1 finger represents aprox 1.5 cm.
 Dilatation chart
Cervical dilation: 1 finger represents aprox 1.5 cm.
 Questions to ask yourself as you perform a Vaginal Examination

 Status of amniotic membranes: 

 Are they intact. Bulging through the cervix?
 Status of cervix:
 Is it soft or firm (the cervix must be soft before it can
efface and dilate), anterior or posterior? (the cervix must
be anterior before it can really start to dilate) 
 How much effacement?
 0%/long and thin to 100%/completely thinned out.
 How much dilation? 
 0 (closed) to 10 cm. (dilation complete).
 Questions: continued
 Fetal presentation:
 What is the presenting part? (head, breech, other fetal
part) 
 What is the fetal position? (left/right,
anterior/posterior/transverse)
 Fetal station:
 What is the presenting part in relation to the ischial
spines?
 Engagement:
 Is the presenting part engaged and well applied to the
cervix?  stabilized in the middle of the pelvis below
the level of the ischial spine [zero station].
 How to palpate presenting part:
Palpate the hard skull; palpate for sagital suture;
follow to anterior or posterior fontanel
If what you feel is soft it may be breech or face.
 Assessing Cervical effacement
Cervical effacement: Palpate degree of thickness;
normal cervix about 1 inch thick
 Speculum examination
 A speculum examination will be necessary in cases of
suspected "leaking" or ruptured membranes.
 The presence of "leaking" or ruptured membranes can
be confirmed by performing a nitrazine test,
inspecting the posterior fornix for pooling of fluid
and by obtaining a sample of the fluid with a sterile
applicator and applying the fluid to a glass slide.
 The glass slide is allowed to air dry and is
subsequently inspected for an arborization pattern
("ferning").
 Procedure
 Select speculum - Speculum is made of 2 blades and a
handle
 There is a thumb piece attached to top blade
 The bottom blade is fixed
 The top blade is hinged and thumb piece controls
movement comes in both metal and plastic
 Explain what you will do.
Have client empty bladder.
 Assist client to bend legs, feet resting either flat on table
or in stirrups.
 Place pillow under her head and under her hip.
 Drape client’s legs.
Place a minimum amount of lubricant on speculum.
 Procedure
 Sterile water may be used as lubricant.
 Using dominant hand, place 2 fingers just inside the
introitus and gently press down on base of vagina.
 With other hand, introduce the closed speculum past
your fingers at about 45-degree angle downward.
 Keep a downward pressure on blade to avoid upward
pressure on sensitive bladder and top of vaginal wall.
 After speculum in vagina, remove finger.
 Turn blades into a horizontal plane while keeping
moderate downward pressure.
 Procedure
 Hold blades apart by pressing on thumb piece
and begin withdrawing the speculum until
cervix is released.
 Release pressure on thumb piece and allow
blades to close.
 Rotate the blades to a sideways position; exert
downward pressure.
 Gently and slowly remove.
 Fern testing for ruptured membranes
 Amniotic fluid contains a high amount of salt.
If drops of fluid are spread on glass slide,
allowed to dry and examined through
microscope, a characteristic fern pattern can be
seen.
 2 THE PASSAGEWAY
(Vagina & pelvis)
 REFERS TO THE MATERNAL STRUCTURES-
BONES OF THE PELVIS, SACRUM AND
COCCYX AND THE SOFT STRUCTURES
CERVIX AND VAGINA.
 SIZE OF MATERNAL PELVIS-DIAMETERS OF

THE PELVIC INLET,MIDPELVIS, AND OUTLET

Passage- refers to the route a fetus must travel from the
uterus through the cervix, and vagina to the external
perinium.
Pelvic Types
 4 main types of pelvis
1. Gynecoid
-round, wide, deeper, most suitable for
pregnancy
2.Anthropoid
-oval, ape-like pelvis
-APD wide & TD narrow
Note: this can deliver via NSVD
 4 main types of pelvis
3. Android
-heart shape”male pelvis
-Anterior part: pointed & Posterior: shallow
4. Platypelloid
-flat
-APD: narrow & TD: wide
Pelvic bone
-bony ring formed by 4 united bones
1.) 2 Innominate bone (flaring bone)
- Formes the anterior and lateral portion of

the ring
a.illium
b. ischium
c.pubis
2.) Sacrum
3.)Coccyx
 Pelvic bones
1. Ileum (lateral side of the hips)
*Iliac crest-flaring superior border that forms the
prominence of hips
2. Ischium(inferior portion)
-Ischial tuberosities – area where we sit, basis in
getting external measurement of the pelvis
 Pelvic bones
3. Pubes (anterior portion)
• Symphysis pubis – junction in between two
pubes
4. Sacrum (posterior portion)
-sacral prominence – basis in getting the internal
measurement of the pelvis
5. Coccyx – 5 small bones that compresses
during vaginal delivery.
 THE TYPE OF PELVIS AND ITS
DIAMETERS CAN INFLUENCE THE
DESCENT OF THE FETUS, THE
PROGRESSION OF LABOR AND TYPE OF
DELIVERY.
 -cervix and vagina are contained inside the
pelvis, a fetus must also pass through the bony
pelvic ring.
 2 pelvic measurements are important to
determine the adequacy of the pelvic size
1.Diagonal conjugate
-antero-posterior diameter of the inlet
2. Transverse diameter of the outlet
At pelvic inlet BIPARIETAL-9.5CM
-anteroposteriordiameter(narrowest) BITEMPORAL-8CM
At the outlet OCCIPITOFRONTAL -11.75CM
-transverse diameter (narrowest)
9.5 cm
 Cervical Ripening
 The cervix ripens or softens. As a woman’s
body gets ready to labor it produces
prostaglandin. 
 This causes the cervix to soften from the
consistency of rubber to something that feels
like a marshmallow.
 The cervix moves from a posterior to an anterior
position.
 During most of the pregnancy, the cervix points
toward the back (posterior), but during the last few
weeks of pregnancy or in early labor, it moves
forward (anterior). 
 The uterus may contract for several days
intermittently before true labor begins to accomplish
these first two things, softening the cervix and
bringing the cervix from the back of the vagina to the
front of the vagina.
 3. THE POWER
 INCLUDES PRIMARY AND
SECONDARY FORCES OF LABOR

 PRIMARY FORCES- CONSIST OF THE

INVOLUNTARY CONTRACTIONS OF
THE UTERINE MUSCLES
 CONTRACTIONS-INCREMENT, ACME,
DECREMENT PHASES AND RESTING
PHASES
 The POWERS: Uterine Contractions
 Increment: Beginning, building of pressure
 Acme: Most intense part of the contraction
 Decrement: Diminishing of the contraction
 Rest: Period of time between contractions
 POWER
1.PRIMARY FORCES(uterine contraction)
 CONTRACTIONS-

FREQUENCY,DURATION,INTEN-SITY
 Uterine C. CAUSE EFFACEMENT AND

DILATION OF THE CERVIX

 PRIMIGRAVIDAS WILL EFFACE FIRST

THEN DILATE
 MULTIGRAVIDAS CAN DO BOTH

TOGETHER
 FORCES OF LABOR

Contraction -exhibits a wavelike pattern that begins

slowly climbing (increment) to a peak (acme), and
decreases (decrement)
acme D
t ec
en re
m m
re en
c t
In
Duration
Interval
Frequency

Duration- from beginning of one contraction to the end of the same

contraction
Frequency- from beginning of one contraction to the beginning of
another contraction
Interval - Resting time between contractions for placental perfusion
 Characteristics of Contractions
 Frequency: How often they occur?
 They are timed from the beginning of a contraction
to the beginning of the next contraction.
 Regularity: Is the pattern rhythmic?
 Duration: From beginning to end - How long
does each contraction last?
 Intensity: By palpation mild, moderate, or
strong.

09/18/22 103
 Assessment of Contractions
 Palpation: Use the fingertips to palpate the
fundus of the uterus
 Mild: Uterus can be indented with gentle pressure
at peak of contraction(nose)
 Moderate: Uterus can be indented with firm
pressure at peak of contraction (feels like chin)
 Strong: Uterus feels firm and cannot be indented
during peak of contraction(forehead)

09/18/22 104
The monitor should never be relied on; the mother’s
abdomen should be regularly palpated by hand
 Abdominal exam for contractions
 Uterine contractility can be quantified
subjectively by palpation or objectively by the
use of an external tocodynamometer or an
intrauterine pressure catheter (IUPC).
 The external tocodynamometer can generally
provide reliable information about the
frequency of uterine contractions and their
approximate duration
 2 Changes that occur in the Cervix
1. Effacement
2. Dilatation
 EFFACEMENT
 THE THINNING AND SHORTENING OF
THE CERVIX.
 MEASURED IN PERCENTAGES
 O% TO 100%
 Normally the cannal is approximately 1-2 cm
long with effacement, the canal virtually
disappears.This occurs because of longitudinal
traction from the contracting uterine fundus.
 DILATION
 Refers to the enlargement or widening of the
cervical cannal from an opening a few
milliters wide to one large enough to permit
passage of the fetus
 OPENING OF THE CERVIX
 MEASURED IN CM
 0CM TO 10CM
 10CM =COMPLETE DILATION.
2.SECONDARY POWERS: ( pushing)
CONSIST OF THE VOLUNTARY USE OF
THE ABDOMINAL MUSCLES DURING
THE SECOND STAGE OF LABOR TO
FACLITATE THE DESCENT AND
DELIVERY OF THE FETUS.
PSYCHOLOGICAL
Considerations
 4.PSYCHE
 Refers to the psychological state or feelings
that a woman brings into labor.
 THE PSYCHOLOGICAL COMPONENT OF
CHILDBEARING
 EXCITEMENT
 FEAR/ANXIETY
 PERCIEVED LOSS OF CONTROL
 PSYCHE
 FEAR-TENSION-PAIN CYCLE
 CHANGE VITAL SIGNS-INCREASE B/P,
P,&R.
 LACK OF KNOWLEDGE AND
PREPARATION FOR CHILDBIRTH CAN
NEGATIVELY AFFECT THE PSYCHE.
 5. Position ( mother)
-position by choice
PREMONITORY/PRELIMINARY SIGNS OF LABOR
 PREMONITORY/PRELIMINARY SIGNS OF LABOR

1.LIGHTENING
-Engagement
2. INCREASE LEVEL OF ACIVITY
-Nesting instinct
3. BRAXTON HICKS CONTRACTION
4.RIPENING OF THE CERVIX
 Signs Of True Labor
1.UTERINE CONTRACTION
2.SHOW
3. RUPTURE OF THE MEEMBRANE
 PREMONITORY/PRELIMINARY SIGNS OF
LABOR
1. Lightening(Engagement)

-settling of the presenting part into the pelvic

inlet (true pelvis)
*sign(o)s and symptoms(s)
-shooting pain radiating to legs
*leg cramps during labor due to gravid uterus to
the lumbosacral nerve plexus
-urinary frequency
 PREMONITORY/PRELIMINARY SIGNS OF
LABOR
2.Increase in level of activity/Energy Excess
-related to increase EPINEPHRINE release that
is initiated by a decrease in progesterone
produced by placenta.
-additional epinephrine prepares woman’s body
for labor
-Nursing I: Let the mother save her eenerrgy as
fatigue can affect the type of analgesia needed.
PREMONITORY/PRELIMINARY SIGNS OF
LABOR
3.Braxton-Hicks – Uterine contractions
NOT associated with cervical change.
 Shorter in duration
 Less intense

 Over lower abdomen and groin

 Resolve with ambulation

 PREMONITORY/PRELIMINARY SIGNS OF
LABOR
4.Ripening of the cervix
-internal sign and can seen only through pelvic
examination.
-internal annoucement that labor is very close at
hand
-Goodell’s sign(cervix feels softer than normal-
earlobe)
Term: butter soft
 Different between true labor and false labor

Uterine contraction regular irregular

Interval decrease irregular
Duration increase irregular
Intensity increase irregular
Cervical change progress no change
True labor
-felt first in the lower back and sweep around to
the abdomen in a wave
-continue no matter what the woman’s level of
activity
-achieve cervical dilatation &effacement
False labor
-felt first abdominally & remain confined to the
abdomen & groin.
-often disappear with ambulation & sleep
-do not achieve cervical dilatation
 Signs Of True Labor
1.UTERINE CONTRACTION
-a productive uterine contractions
NI: breathing exercise
 Signs Of True Labor
2.SHOW(pinkish vaginal discharge)
-operculum is expelled due to softening &
repining of the cervix
Operculum-mucus plug that filled the cervical
canal during pregnancy
-the exposed cervical capillaries seep blood as a
result of pressure exerted by fetus
-blood mixed with mucus, takes on a pink tinge
and is referred to BLOODY SHOW
 Signs Of True Labor
3. RUPTURE OF THE MEMBRANE
-labor may begin with rupture of the membrane
-either a sudden gush or a scanty, slow seeping
of clear fluid from the vagina.
-early rupture of the membrane can be
advantages if it causes the fetal head to settle
snugly into the pelvis, this actually shortens
labor
 Signs Of True Labor
3. RUPTURE OF THE MEEMBRANE
Two risks associated with ruptured menbranes
1.Intrauterine infection
2.Prolapse of the umbilical cord(can cut off
oxygen to the fetus)
NI;
-check the FHT
-check temp. every 2 hours (prone to infection)
 Signs Of True Labor
3. RUPTURE OF THE MEEMBRANE
-if labor has not spontaneously occurred by 24
hours after membrane rupture and pregnancy
is term, labor is induced to help reduced the
risks.
 Mechanism of Labor/Cardinal
movements( D FIRE ERE)
D-escent
F-lexion
I-internal
R-otation
E-xtension
E-xternal
R-otation
E - expulsion
 Mechanism of Labor/Cardinal
movements( D FIRE ERE)
DESCENT
-downward movement of the biparietal diameter
of the fetal head (9.25 cm)within the pelvic
inlet(T-13cm & AP-11)
-occurs because of pressure of the fetus by the
uterine fundus.
-pressure of the fetal head on the sacral nerves at
the pelvic floor causes the mother to
experience a pushing sensation
 Mechanism of Labor/Cardinal
movements( D FIRE ERE)
DESCENT
-full decent may be aided by abdominal muscle
contraction as woman pushes(secondary
power)
 Mechanism of Labor/Cardinal
movements( D FIRE ERE)
FLEXION
-the head bends forward onto the chest, making
the smallest anteroposterior
diameter(suboccipitobregmatic diameter – 9.5
cm) is presented to the birth canal
-aided also by abdominal muscle contraction
during pushing.
 Mechanism of Labor/Cardinal
movements( D FIRE ERE)
INTERNAL ROTATION (IR)
- occiput rotates until it is superior, or just below
the spnhysis pubis, bringing the head into the
best relationship to the outlet of the pelvis.
This movement brings the shoulders, coming
next, into the optimal position to enter the
inlet(transverse-bigest diameter) the widest
diameter of the shoulder in line with the
transverse diameter of the inlet)
 Mechanism of Labor/Cardinal
movements( D FIRE ERE)
EXTENSION
-occiput is born , the back of the neck stops
beneath the pubic arc and acts as a pivot for
the rest of the head
-the head extends, and the foremost parts of the
head, the face and chin is born
 Mechanism of Labor/Cardinal
movements( D FIRE ERE)
EXTERNAL ROTATION(Restitution)
-the head rotates from the anteroposterior position
it assumed to enter the outlet back to the
diagonal or transverse position of the early part
of labor.
-this bings the aftercoming shoulders into an
anteroposterior position, which is best for
entering the outlet.
-anterior shoulder is born first assested perhaps by
downward flexion of the infant’s head.
 Mechanism of Labor/Cardinal
movements( D FIRE ERE)
EXPULSION
-the rest of the baby is born easily and smoothly
because of its smaller size.
-the end of the pelvic division of labor.
STAGES OF LABOR
 1st Stage of Labor: dilatation and
effacement
 The first stage of labor is referred to as the
"dilating" stage.
 It is the period from the first true labor
contractions to complete dilatation of the cervix
(10cm)
 The forces involved are uterine contractions.
 The first stage of labor is divided into three
phases:
 (1) Latent
 (2) Active
 (3) Transition
Latent /preparatory Phase
 Latent /preparatory Phase
-begins at the onset of regularly perceived
uterine contractions and ends when rapid
cervical dilatation begins
-contraction are mild and short, lasting 20 to
40 seconds
-cervical effacement occurs and cervix dilates
from 0 to 3 cm.
-this lasts approximately 6 hours in a
nullipara and 4.5 hours in multipara.
 Latent /preparatory Phase
-reasons for prolonged latent phase: CPD or
analgesia if given too early
***woman can still walk
 Latent phase Nursing
Intervention
1.Encourage walking(shorten the first stage of
labor)
2.Encourage to void 2-3 hours( full bladder
inhibits contraction)
3.Chest breathing
Active Phase
 Active Phase
-cervical dilatation occurs more rapidly,
increasing from 4 t0 7 cm
-contractions grow stronger, lasting 40-60
seconds and occur approximately every 3-5
minutes
-this lasts 3 hours in nullipara and 2 hours in
multipara
 Active Phase
-show & spontaneous rupture of the membranes
may occur
-difficult time for woman because contractions
grow so strong, lasts longer and begin to cause
discomfort
-exciting tme(something dramatic is happening)
-frigtening(realizes labor is truly progressing and
her life is about to change foreever.
 Active phase Nursing
Intervention
M –edication(have meds ready)
A-ssessment include v/s, dilatation & effacement
fetal monitor
D- ry lips oral care like oral care ointment
B-reathing (abdominal breathing)
Transition Phase
 Transition Phase
-contraction reach their peak of intensity occuring
every 2—3 minutes with duration of 60 to 90
seconds and causing maximum dilatation of 8 –
10 cm
-woman may expeience intense discomfort, so
strong that is accompanied by nausea and
vomiting
-experience a feeing of loss of control, anxiety,
panic, or irritability(because of intense and
duration of contraction.
 CHARACTERISTICS OF
THE TRANSITION PHASE
 Restlessness  Irritability
 Hyperventilation  Nausea, vomiting
 Bewilderment and  Very warm feeling
anger  Perspiration
 Difficulty following  Increasing rectal
directions pressure
 Focus on self
 2nd Stage: Birth of the Baby:
 Fetal stage
Begins when cervical dilatation
is complete and ends with birth
of the baby.(full dilatation)
 Impending Signs:
 Bulging of the perineum.
 Dilatation of the anal orifice.
 Nausea, Irritability and
uncooperativeness.
 Complaints of severe discomfort.
 Dilatation and effacement –
complete - patient is instructed to
push with each contraction to
bring the presenting part down
into the pelvis
Duration
1 hour in primigravida
 ½ hour in multipara

Note:
-pudendal anesthesia
- Is a local anesthesia produced by blocking the

pudendal nerves near ischial spine of the

ischium
- -administered during the second stage of labor.
 Mgt. of the 2 stage of labor
nd

 Patient to rest between contractions

 Push with contractions
 One person should coach.
 Verbal encouragement and physical contact
help reassure and encourage the patient.
 Monitor the patient's BP and the FHR every 5
minutes and after each contraction.
Second Stage
*episiotomy ( but not encourage in EINC)
*episioraphy
*Ironing the perineum(prevent laceration)
*modified ritgens maneuver(place towel at
perineum)
-prevent laceration
-will facilitate complete flexion & extension
*mechanism of labor(observe)
Indication of episiotomies
1.patient’s preference
2. Size of the baby
3. Fetal distress
4. Maternal exhaustion
Types of Episiotomies
1. Median

-middle portion of the lower vaginal border

directed towards the anus.
-less bleeding, less pain, easy to repair and
heals faster but there is a risk that it may
extend to the rectum creating a urethroanal
fistula
-causes less dyspareunia
Types of Episiotomies
2. Mediolateral
-begun in the midline but directed laterally
away from anus
-more bleeding, more pain, hard to repair, slow
to heal
-indicated if the perineum is very short and if a
lot of room is needed for a large baby.
 Perineal Skin Prep

 Systematic
aseptic perineal
skin prep prior
to delivery
 Ritgen Maneuver

 When the head distends the vulva and

perineum enough to open the vaginal introitus
to a diameter of 5 cm or more, a towel-draped,
gloved hand may be used to exert forward
pressure on the chin of the fetus through the
perineum just in front of the coccyx.
 Concurrently, the other hand exerts pressure
superiorly against the occiput.
 it is customarily designated the Ritgen
maneuver, or the modifiedRitgen maneuver.
 This maneuver allows controlled delivery of
the head.
 It also favors extension, so that the head is
delivered with its smallest diameters passing
through the introitus and over the perineum.

 The McRobert’s Maneuver
 First try the McRobert's maneuver.
 In this maneuver, one nurse stands on each
side of the patient and help her to hyperflex
her legs.
 If possible, the patient must keep her knees
bent back to her abdomen.
 When the patient's legs are hyperflexed, the
birth canal opens to its maximum, facilitating
the delivery of her baby's anterior shoulder.
 Check temperature of the delivery room
 25 - 28 o C
 Free of air drafts

 Notify appropriate staff

 Arrange needed supplies in linear

fashion
 Check resuscitation equipment

 Wash hands with clean water and soap

 Double glove just before delivery

 Implement the 3 cleans
 Clean hands. Wear double gloves
 Clean delivery surface
 Clean cutting and care of cord
 Stay with the woman and encourage her. Make
her comfortable
 Encourage the mother to bear down when the
baby’s head is coming down
 When the birth opening is stretching, support
the perineum and anus with a clean swab to
prevent lacerations
 Ensure controlled delivery of the head
 Keep one hand on the head as it advances
during contractions. Keep the head from
coming out too quickly
 Support perineum with other hand
 Discard pad and replace when soiled to
prevent infection
 During delivery of the head, encourage woman
to stop pushing and breathe rapidly with
mouth open
 Gently feel if the cord is around the
neck
 If it is loosely around the neck, slip it

over the shoulders or head

 If it is tight, place a finger under the

cord, clamp and cut the cord, and

unwind it from around the neck
 Gently wipe the baby’s nose and mouth with a
clean gauze or cloth
 Wait for external rotation (within 1-2
minutes), head will turn sideways, bringing
one shoulder just below the symphysis pubis
and other facing the perineum
 Apply gentle downward pressure to deliver top
shoulder then lift baby up to deliver lower
shoulder. Gently deliver the rest of the baby.
Note the time baby is delivered.
 Call out the time of birth
 Dry the newborn thoroughly for at least 30

seconds
 Wipe the eyes, face, head, front and back, arms
and legs
 Remove the wet cloth
 Do a quick check of breathing while drying
 Notes:

 During the 1st secs:

 Do not ventilate unless the baby is
floppy/limp and not breathing
 Do not suction unless the mouth/nose are

blocked with secretions or other material

 Notes:
 Do not wipe off vernix
 Do not bathe the newborn

 Do not do footprinting

 No slapping

 No hanging upside - down

 No squeezing of chest
 If newborn is breathing or crying:
 Position the newborn prone on the mother’s
abdomen or chest
 Cover the newborn’s back with a dry blanket

 Cover the newborn’s head with a bonnet

 Notes:
 Avoid any manipulation, e.g. routine
suctioning that may cause trauma or infection
 Place identification band on ankle (not wrist)

 Skin to skin contact is doable even for

cesarean section newborns

 Remove the first set of gloves
 After the umbilical pulsations have

stopped, clamp the cord using a sterile

plastic clamp or tie at 2 cm from the
umbilical base
 Clamp again at 5 cm from the base

 Cut the cord close to the plastic clamp

 Notes:
 Do not milk the cord towards the baby
 After the 1st clamp, you may “strip” the cord of

blood before applying the 2nd clamp

 Cut the cord close to the plastic clamp so that

there is no need for a 2nd “trim”

 Do not apply any substance onto the cord
 Exclude second baby by palpating mother’s
abdomen
 Give 10 units oxytocin IM to mother. (Active
management of the 3rd stage of labor) ̽May be
done by a midwife under the supervision of a
doctor.
 Watch for vaginal bleeding
 Leave the newborn in skin-to-skin contact
 Observe for feeding cues, including tonguing,

licking, rooting
 Point these out to the mother and encourage

her to nudge the newborn towards the breast

 Counsel on positioning
 Newborn’s neck is not flexed nor twisted
 Newborn is facing the breast

 Newborn’s body is close to mother’s body

 Newborn’s whole body is supported

 Counsel on attachment and suckling
 Mouth wide open
 Lower lip turned outwards

 Baby’s chin touching breast

 Suckling is slow, deep with some pauses

 Notes:
 Minimize handling by health workers
 Do not give sugar water, formula or other

prelacteals
 Do not give bottles or pacifiers

 Do not throw away colostrum

 Weighing, bathing, eye care, examinations,
injections (hepatitis B, BCG) should be done
after the first full breastfeed is completed

 Postpone washing until at least 6 hours

 Weighing, bathing, eye care,
examinations, injections should be done
after the first full breastfeed is completed

 Postpone washing until at least 6 hours

THIRD STAGE(placental stage)
 Between birth of the baby and delivery of the
placenta
 Deliver the placenta by controlled cord
traction (with counter traction on the uterus
above the symphysis pubis)
 Massage the uterus over the fundus
THIRD STAGE(placental stage)
-two separate phases are involved
1.Placental separation
2.placental expulsion.

Inject oxytocin 10 U IM (if not yet given as part

of the active management)
 Encourage initiation of breastfeeding.
Keep the baby on the mother’s abdomen
for 60-90 mins
 Check that the placenta and membranes
are complete. Put the placenta into a
container for disposal
 Delivery of placenta
Crede’s manuever
-putting gentle pressure on the
fundus of a contacted uterus to
fasten the expulsion of the
placenta.
Delivery of the placenta : Modified Crede’s maneuver
 Controlled cord traction
 Controlled cord traction involves traction on
the umbilical cord, combined with
counterpressure upwards on the uterine body
by a hand placed immediately above the
symphysis pubis.
Controlled cord traction
 Brandt Andrew’s Manuever
Tract the cord slowly, winding it
around the clamp until placenta
spontaneously comes out, rotating it
slowly so that no membranes are left
inside the uterus.
-slowly pull cord and wind the clamp.
Delivery of the placenta :Brandt-Andrew Maneuver
Signs of the placental separation
1. The uterus becomes globular in shape and
firmer, rising to the level of umbilicus
(calkin’s sign)-earliest sign of
placental separation
2. Sudden gush of blood
3. Lengthening of the umbilical cord
- The umbilical cord descends three inches or

more further out of the vagina.

4. Appearance of the placenta at the vaginal
opening.
 Two sides
1) Fetal side- shiny and smooth in appearance,
the amniotic sac is attached to it (Schultz).

2) Maternal side- dark red and rough in

appearance (Duncan).
Fetal Side of placenta Maternal side of placenta
 Nursing Care 3 stage rd

 Following delivery of the placenta:

 Observation of the fundus.
 Retention of the tissues in the uterus can lead to
uterine atony and cause hemorrhage.
 Massaging the fundus gently will ensure that it
remains contracted.
 Allow the mother to bond with the infant. Show
the infant to the mother and allow her to hold the
infant
 Fourth Stage of Labor
(Recovery stage)
- First 1-2 hours after placental delivery
a.Monitor v/s(Bp ,PR sligtly increased due to
excitement and effort of delivery but
normalizes after 1 hour.
b. Do perineal care
c. Flat on bed to prevent dizziness due to
decreased oxygen supply resulting from a
change in intraabdominal pressure
 Fourth Stage of Labor
(Recovery stage)
-provide additional blanket: if patient suddenly
complain of chills due to rapid decrease of pressure,
fatigur or cold temp.
d. Give initial nourishment progressing to regular diet
as ordered
-Clear liquid diet: flavored gelatin, tea, gatorade
-Full liquid diet: milk, icecream soup
-Soft diet
-Regular diet
 Fourth Stage of Labor
(Recovery stage)
-monitoring of v/d q 15 for 1 hour & q 30 in the
second hour
-check placement of the fundus at the level of
umbilicus
-empty bladder to prevent uterine atony
Uterine atony- condition in which woman’s
uterine musles loss the ability to control after
childbirth.
 MATERNAL RESPONSE TO
LABOR
CARDIOVASCULAR
-contraction greatly decreases blood flow to the
uterus because it puts pressure on the uterine
arteries.
-this increases the amount of blood that remains
in the general circulation leading to an increase
pheripheral resistance, which in turn results in
an increase systolic and diastolic blood pressure
 MATERNAL RESPONSE TO
LABOR
CARDIOVASCULAR
-the work of pushing may increase cardiac
output by as much as 40 % to 50% above
prelabor level.
-average blood loss with birth :300 to 500ml
 MATERNAL RESPONSE TO
LABOR
HEMOPOIETIC SYSTEM
- As result of stress and heavy exertion at the end
of labor the WBC count is 25,000 to 30,000
cells/mm3(normal count is 5,000 to 10,000
cells/mm3
 MATERNAL RESPONSE TO
LABOR
RESPIRATORY SYSTEM
-whenever there is an increase in cardiovascular
parameters, the body responds by increasing
the respiratory rate to supply additional
oxygen. This can result to hyperventilation.
-using appropriate breathing patterns during
labor can help avoid severe hyperventilation.
 MATERNAL RESPONSE TO
LABOR
TEMPERATURE REGULATION
-increased muscular activity associated with
labor may result in a slight elevation in temp.
(1F)
-diaphoresis occurs with accompanying
evaporation to cool and limit excessive
warming.
 MATERNAL RESPONSE TO
LABOR
FLUID BALANCE
-insensible water loss increase during labor.
(because of the increase in rrate and dept of
respiration which cuases moisture to be lost
with each breath and disphoresis)
 MATERNAL RESPONSE TO
LABOR
URINARY SYSTEM
-with decrease in fluid intake during labor and
increased insensible water loss, kidneys begin
to concentrate urine to preserve both fluid and
electrolytes.
-specific gravity rise to a high noormal level of
1.020 to 1.030.
 MATERNAL RESPONSE TO
LABOR
MUSCULOSKELETAL SYSTEM
-during pregnancy relaxin (ovarian hormone) has
acted to soften the cartillage between bones.
-in the week before labor, considerable additional
softening causes the symphysis pubis and the
sacral/coccyx joints to become even more
relaxed and movable, allowing them to stretch
apart to increase the size of the pelvic ring by as
much as 2 cm.
 MATERNAL RESPONSE TO
LABOR
-woman may report this increased pubic
flexibility as increased back pain or irritating,
nagging pain at the pubis as she walks or turns
in labor.
 MATERNAL RESPONSE TO
LABOR
GASTROINTESTINAL SYSTEM
-fairly inactive during labor(because of the
shunting of blood to more life-sustaining organs
and also because of pressure on the stomach and
intestines from the contracting uterus.
-Digesting and emptying time of the stomach
becomes prolonged(Reason why eating during
labor is restricted.)
 MATERNAL RESPONSE TO
LABOR
NEUROLOGIC AND SENSORY RESPONSE
-neurologic responses that occur during labor are
responses related to pain.(increase in pulse and
respiratory rate)
-early in labor pain is registered at uterinew and
cervical nerve pelxus(11th and 12 thoracic
nerves.
-moment of birth pain is registred on the
perineum(s2 to s4 nerves)