Nursing Care during

Labor Process
 Case Scenario
Mrs. Sana’a is 30 years of age and is having her first baby.
She has come to the hospital, because she began to get
regular pushing-down pains about 3 hours ago. She says
that the pain start in her back and move forward to the
front of her abdomen, each pain lasts about 40 seconds,
and they occur 2-3 times in every 8 minutes. When you
examine her, you find that her cervix is fully effaced and
the diameter is 4 cm. Mrs. Sanna’a’s mother-in-law has
told her she isn’t in labor because she hasn’t had a ‘show’.
What are the new concepts?

What are the signs suggesting true labour from Mrs

Sana’a’s description and the physical examination?

which stage of labour has she reached and how do you

know this?

What will you say to Mrs Sana’a to help her recognize

that she is really in labour?
Introduction
The journey from conception to birth is one of ongoing
development and adaptation for the woman, the fetus,
and the family.
 Physiological, psychological, and emotional changes
that take place during pregnancy help to prepare the
woman for labor and birth. Near the end of the
pregnancy, the fetus continues to develop
physiological abilities that facilitate successful
adaptation for the transition from in utero life to the
outside environment.
 Intrapartum period extends from the beginning of
contractions that cause cervical dilatation to the first 1 to 4
hours after delivery of the newborn and placenta.
 Preliminary Signs of Labor
Before labor, a woman often experiences subtle signs
that signal labor is imminent.

It is important to review these with women during the

last trimester of pregnancy so they can more easily
recognize beginning signs.
1. Lightening:
It is the descent of the fetal presenting part into the pelvis.
This changes a woman's abdominal contour, because the uterus
becomes lower and more anterior.
Gives a woman relief from the diaphragmatic pressure and
shortness of breath that she has been experiencing and in this way
“lightens” her load.
Lightening probably occurs early in primiparas because of tight
abdominal muscles (10 to 14 days before labor begins).
In multiparas, it usually occurs on the day of labor or even after
labor has begun
2. Increase in Level of Activity:
 A woman may awaken on the morning of labor full of
energy, in contrast to her feelings of chronic fatigue during
the previous month.

 This increase in activity is related to an increase in

epinephrine release that is initiated by a decrease in
progesterone produced by the placenta.

3. Slight Loss of Weight

• As progesterone level falls, body fluid is more easily
excreted from the body.
• This increase in urine production can lead to a weight
loss between 1 and 3 pounds.
30/03/23
4. Braxton Hicks Contractions:
In the last week or days before labor begins, a woman
usually notices extremely strong Braxton Hicks
contractions, which she may interpret as true labor
contractions.
A woman may be admitted to the labor unit of a hospital
or birthing center because false contractions so closely
simulate true labor.

5. Ripening of the Cervix:

It is an internal sign seen only on pelvic examination.
(Butter –Soft)
Ripening is an internal announcement that labor is very
close at hand 30/03/23
True Labor Vs False Labor
 Factors affecting Labor
These critical factors are often referred to as the “P’s”
of labor:
• Powers (physiological forces)
• Passageway (maternal pelvis)
• Passenger (fetus )
• Passageway Passenger and their relationship
(engagement, attitude, position)
• Psychosocial influences (previous experiences,
emotional status)
Power
Physiological forces of labor and birth that include the
uterine contractions and the maternal pushing efforts.

 Frequency, duration and strength of the uterine contractions

cause cervical effacement and dilatation.

A contraction consists of three phases:

- Increment: when the intensity of the contraction increases
- Acme: when the contraction is at its strongest.
- Decrement: when the intensity decreases .
- Between contractions the uterus relaxes.
30/03/23
As labor progresses, the relaxation intervals
decrease from 10 minutes early in labor to only 2
to 3 minutes.

The duration of contractions also changes,

increasing from 20 to 30 seconds to a range of 60
to 90 seconds.
Assessment of Uterine Contractions
Contractions are often described in terms of their
frequency, duration, and intensity.
- The frequency of a contraction: is measured from the
beginning of one contraction to the beginning of the next
contraction.
- The duration of a contraction is measured from the start
of one contraction to the end of the same contraction.
- The intensity of a contraction is most frequently
measured by uterine palpation and is described in terms
of mild, moderate, and strong
Palpation is a noninvasive procedure, and requires the
nurse to place the fingertips of one hand on the fundus of
the uterus where most contractions can be felt.
The nurse applies gentle pressure and keeps the hand in
the same place (moving the hand over the uterus may
stimulate additional contractions, therefore interfering
with the ability to accurately assess labor progress).
Gentle palpation of the uterine fundus can determine the
firmness of the uterus and whether there is an ability to
indent the uterus at the acme (peak) of the contraction.
 Palpating the intensity of contractions is often compared
to palpating one’s nose (mild intensity), chin (moderate
intensity), or forehead (strong intensity).
16 03/30/23
The coordinated efforts of the contractions help to bring
about effacement and dilatation of the cervix.
Effacement: is the process of shortening and thinning of
the cervix, until the cervical canal eventually disappears.
The amount of cervical effacement is usually expressed as
a percentage related to the length of the cervical canal, as
compared to a non-effaced cervix. For example, if a cervix
has thinned to half the normal length of a cervix it is
considered to be 50% effaced.
Dilation: is the opening and enlargement of the cervix that
progressively occurs throughout the first stage of labor,
expressed in centimeters and full dilation is approximately
10 cm.
 Vaginal Examination

19 03/30/23
20 03/30/23
 Maternal Pushing Efforts
After the cervix has become fully dilated,
the laboring woman usually experiences an
involuntary “bearing down” sensation that
assists with the expulsion of the fetus. At
this time, the woman can use her abdominal
muscles to aid in the expulsion.
It is important to remember that the cervix
must be fully dilated before the patient is
encouraged to push.
 PASSAGEWAY
 Route the fetus must travel from the uterus to the external perineum.
consists of the maternal pelvis and the soft tissues.
 The bony pelvis through which the fetus must pass is divided into
three sections: the inlet, midpelvis (pelvic cavity), and outlet. Each
of these pelvic components has a unique shape and dimension
through which the fetus must maneuver to be born vaginally.
 
Type of Pelvis
1. Gynecoid.
2. Android.
3. Anthropoid.
4. Platypelloid
PASSENGER
The passenger is referred to as the fetus and the fetal
membranes.
In the majority (96%) of pregnancies, the fetus
presents in a head-first position.
The fetal skull, usually the largest body structure, is
also the least flexible part of the fetus. However,
because of the sutures and fontanels, there is some
flexibility in the fetal skull. Which give the cranial
bones the capability of movement and overlapping in
response to the powers of labor: (molding)
Fetal Lie: the relationship of the long axis of the
woman to the long axis of the fetus.
Fetal Attitude: The fetal attitude describes the
relationship of the fetus’ body parts to one another
Fetal Presentation: Fetal part that enters the pelvic
inlet first and leads through the birth canal during
labor. The fetal presentation may be cephalic, breech,
or shoulder.
Presenting part: The part of the fetal body first felt by
the examining finger during a vaginal examination,
determined by the fetal lie and attitude
 PASSAGEWAY PASSENGER
The nurse assesses the relationship between the two when
determining the engagement, station, and fetal position.

-Station refers to the level of the presenting part in relation

to the maternal ischial spines.
- Engagement: occurred when the widest diameter of the
fetal presenting part has passed through the pelvic inlet.

- Position: The location of a fixed reference point on the fetal

presenting part in relation to a specific quadrant of the
maternal pelvis
 Nursing care during labor
COLLECTING ADMISSION DATA: The nurse uses
multiple sources and data collection methods to compile a
comprehensive database to plan and deliver individualized care
to the woman in labor.
- The prenatal record provides data (current pregnancy, previous
pregnancies and birth outcomes for the multiparous woman,
measurements, laboratory values , and ultrasound examinations
provide the basis for determining intrapartal risk).
- The admission interview provides the nurse with information
about the woman’s reason for coming to the birthing center, her
understanding and expectations of the labor and birth process,
her subjective experience of the labor, as well as psychosocial
and cultural factors that can impact her birth experience.
-
- The fetal assessment: presentation, fetal heart rate
(FHR), and movement provides essential data
regarding fetal well-being.
- Maternal vital signs, particularly blood pressure and
temperature.
- Assessment of current labor status (uterine contraction
patterns, cervical dilatation, and effacement, fetal
station, rupture of membranes)
Initial Admission Assessments
THE FOCUSED ASSESSMENT
On admission, the nurse initiates a focused assessment to
determine the condition of the mother and fetus and
the progression of the labor. The data collected
answers these critical questions and helps the nurse to
establish priorities for care:
• Is this true labor, and if so, is birth imminent?
• Are there any factors that increase risk to the mother
or fetus?
Nature of nursing care and frequency depends on which
stage of labor the woman in.

Labor divided into four stages:

1. First Stage: begins with true labor contractions and ends
when the cervix is fully dilated.
2. Second stage: period from full dilatation and cervical
effacement to birth of the infant.
3. Third Stage: begins with the birth of the infant and ends
with the delivery of the placenta.
4. Fourth Stage: First two hours after placental delivery
Nursing Interventions

34 03/30/23
 Fetal Monitoring

35 03/30/23
 Auscultation of Fetal Heart Sounds

Locating fetal heart

sounds by
fetal position
36 03/30/23
Partograph
A labor curve assessment tool, often referred to as a
“Friedman curve,” is a graph used to help identify
whether a patient’s labor is progressing in a normal
pattern .
Composite normal labor patterns are graphically
presented for the multiparous and nulliparous patient.
The labor curve assessment tool contains categories that
include the time of day, amount of cervical dilation, and
effacement and hours of labor that have elapsed. The
patient’s own labor progress is plotted on the graph to
allow a comparison between her progress and the norm.
Second Stage
 Care of a Woman During the Second Stage
of Labor

Preparing the Place of Birth

Birthing Room
Positioning for Birth
Promoting Effective Second-Stage Pushing
Perineal Cleaning
Episiotomy

40 03/30/23
41 03/30/23
 Birth
As soon as the head of a fetus is prominent
(approximately 8 cm across) at the vaginal opening,
the physician or nurse-midwife may place a sterile
towel over the rectum and press forward on the fetal
chin while the other hand is pressed downward on the
occiput (a Ritgen maneuver).

This helps a fetus achieve extension, so that the head is

born with the smallest diameter presenting. This also
controls the rate at which the head is born. Pressure
should never be applied to the fundus of the uterus to
effect birth, because uterine rupture may occur.

42 03/30/23
 Ritgen's maneuver.

43 03/30/23
 Episiotomy
An episiotomy is a surgical incision of the
perineum that is made both to prevent tearing of
the perineum and to release pressure on the fetal
head with birth.

An episiotomy incision is made with blunt-tipped

scissors in the midline of the perineum (a midline
episiotomy) or is begun in the midline but directed
laterally away from the rectum (a mediolateral
episiotomy).
44 03/30/23
 Position of episiotomy incision in a woman during second stage of
labor. Baby's head is presenting to vagina outlet (crowning).

45 03/30/23
 Third Stage

Placental stage: begins with the birth of the infant and ends
with the delivery of the placenta.

Two separate phases are involved: placental separation and

placental expulsion.
 Third Stage/ Placental Separation
The following signs indicate that the
placenta has loosened and is ready to deliver:

Lengthening of the umbilical cord

Sudden gush of vaginal blood
Firm contraction of the uterus, & change in the shape of
the uterus
Care of a Woman During the Third and
Fourth Stages of Labor
 Placenta Delivery: If the placenta does not deliver
spontaneously, the physician or nurse-midwife will need to
remove it manually.

 After delivery, the placenta is inspected to be certain that it

is intact and normal in appearance and weight.

 Normally, a placenta is one-sixth the weight of the infant.

If it is unusually large or small, you may be asked to weigh
it.
 Fourth Stage
 This is the beginning of the postpartal period or the fourth stage
of labor.

 Because the uterus may be so exhausted from labor that it cannot

maintain contraction, there is a high risk for hemorrhage.

 In addition, a woman often is so exhausted that she may be

unable to assess her own condition or report any changes.

 Specific assessments done during this time are continued

throughout the postpartal period.
 Care of a Woman During the Third, &
fourth Stage of Labor
 Oxytocin: Once the placenta is delivered, oxytocin is usually
ordered to be administered intramuscularly or intravenously to the
mother.

 Such medication increases uterine contractions and thereby

minimizes uterine bleeding.

 Oxytocin (Pitocin) may be added to an existing intravenous line (20

to 40 U/L in intravenous fluid) or given as 10 U intramuscularly.

 Intravenous administration of oxytocin may be continued for up to

8 hours after birth to ensure uterine contraction. Continue to
monitor blood pressure during this time.
 Care of a Woman During the Third and
Fourth Stages of Labor
 Perineal Repair: After delivery of the placenta, any necessary
perineal stitching is performed. This process can be a long,
tedious one from the mother's perspective.

 Theoretically, if suturing of an episiotomy is done immediately

after the birth of the placenta, a woman who gave birth without
anesthesia will still have so much natural-pressure anesthesia of
the perineum that she will not require an anesthetic.

 In actuality, by the time the placenta is delivered (approximately

5 minutes), enough sensation has returned to the perineum that
the woman will probably need some type of medication for
comfort.
 Immediate Postpartum Assessment and
Nursing Care
Obtain vital signs (i.e., pulse, respirations, and blood
pressure) every 15 minutes for the first hour and then
according to the agency's policy.

Palpate the woman's fundus for size, consistency, and

position and observe the amount and characteristics of
lochia.

 Perform perineal care, and apply a perineal pad.

Immediate Postpartum Assessment and
Nursing Care
Offer a clean gown and a warmed blanket, because a
woman often experiences a chill and shaking sensation
10 to 15 minutes after birth.

This may be due in part to the low temperature of the

birthing room, but may also be a result of the sudden
release of pressure on pelvic nerves or of excess
epinephrine production during labor.