Nursing Care of a

Family During Labor

and Birth
San Sebastian College-Recoletos de Cavite
Bachelor of Science in Nursing - Level II
Presented by: Dr. Archie Guitche
Theories of Why Labor Begins

● Labor normally begins between 37 and 42 weeks of pregnancy,

when a fetus is sufficiently mature to adapt to extrauterine life, yet not
too large to cause mechanical difficulty with birth.

● A number of theories, including a combination of factors originating

from both the woman and fetus, have been proposed to explain why
progesterone withdrawal begins. Some of the theories include:
1. The uterine muscle stretches from the increasing size of the
fetus, which results in release of prostaglandins.
Theories of Why Labor Begins

2. The fetus presses on the cervix, which stimulates the release of

oxytocin from the posterior pituitary.
3. Oxytocin stimulation works together with prostaglandins to initiate
contractions.
4. Changes in the ratio of estrogen to progesterone occurs, increasing
estrogen in relation to progesterone, which is interpreted as
progesterone withdrawal.
Theories of Why Labor Begins

5. The placenta reaches a set age, which triggers contractions.

6. Rising fetal cortisol levels reduce progesterone formation and
increase prostaglandin formation.
7. The fetal membrane begins to produce prostaglandins, which
stimulate contractions
Theories of Why Labor Begins

● The role of prostaglandins answers the often asked question: Does

coitus help induce labor?
● Semen does contain prostaglandins, which can be helpful in
softening, also known as “ripening,” of the cervix; if a cervix is ready
to ripen, semen prostaglandins could possibly stimulate the beginning
of contractions.
● Rhythmical contractions brought on by a woman’s orgasm can
conceivably help as well, although, again, not until a uterus is
prepared and ready for labor.
Components of Labor

A successful labor depends on four integrated concepts, often referred to

as the four Ps:
1. The passage (a woman’s pelvis) is of adequate size and contour.
2. The passenger (the fetus) is of appropriate size and in an
advantageous position and presentation.
3. The powers of labor (uterine factors) are adequate.
4. The psyche, or a woman’s psychological state which may either
encourage or inhibit labor. This can be based on her past life
experiences as well as her present psychological state.
The Passage

● The passage refers to the route a fetus must travel from the uterus
through the cervix and vagina to the external perineum.
● In most instances, if a disproportion between fetus and pelvis occurs,
the pelvis is the structure at fault.
● If the fetus is the cause of the disproportion, it is often not because
the fetal head is too large but because it is presenting to the birth
canal at less than its narrowest diameter.
The Passage

Leopold Maneuvers
● The Leopold maneuvers are used to palpate the gravid uterus
systematically.
● This method of abdominal palpation is of low cost, easy to perform,
and non-invasive.
● It is used to determine the position, presentation, and engagement of
the fetus in utero.
The Passenger

Structure of the Fetal Skull

● The cranium, the uppermost portion of the skull, is composed of eight
bones. The four superior bones—the frontal (actually two fused
bones), the two parietal, and the occipital—are the bones important in
childbirth.
The Passenger

Structure of the Fetal Skull

● Fontanelle spaces compress

during birth to aid in molding of
the fetal head.
● Palpating for fontanelle spaces
during a pelvic examination helps
to establish the position of the
fetal head and whether it is in a
favorable position for birth.
The Passenger

Diameters of the Fetal Skull

The diameters of the fetal skull vary

depending on where the
measurement is taken
• The smallest diameter of the fetal
skull is the biparietal diameter or
the transverse diameter, which
measures about 9.25 cm.
The Passenger

Diameters of the Fetal Skull

• The smallest anteroposterior

diameter is the
suboccipitobregmatic
measurement (approximately
9.5 cm) and is measured from
the inferior aspect of the
occiput to the center of the
anterior fontanelle.
The Passenger

Diameters of the Fetal Skull

• The occipitofrontal diameter,

measured from the occipital
prominence to the bridge of
the nose, is approximately 12
cm.
The Passenger

Diameters of the Fetal Skull

• The occipitomental
diameter, which is the widest
anteroposterior diameter
(approximately 13.5 cm), is
measured from the posterior
fontanelle to the chin.
The Passenger

Diameters of the Fetal Skull

● The anteroposterior diameter of the

pelvis, a space approximately 11
cm wide, is the narrowest diameter
at the pelvic inlet, and so the best
presentation for birth is when the
fetus presents a biparietal diameter
(the narrowest fetal head diameter)
The Passenger

Diameters of the Fetal Skull

● At the outlet, the fetus must rotate to

present this narrowest fetal head
diameter (the biparietal diameter) to
the maternal transverse diameter, a
space, again, approximately 11 cm
wide.
The Passenger

Diameters of the Fetal Skull

● In full flexion, the fetal head

flexes so sharply that the chin
rests on the chest, and the
smallest anteroposterior
diameter, the
suboccipitobregmatic,
presents to the birth canal.
The Passenger

Diameters of the Fetal Skull

• If the head is held in moderate

flexion, the occipitofrontal
diameter presents.
The Passenger

Diameters of the Fetal Skull

• In poor flexion (the head is

hyperextended), the largest
diameter (the occipitomental)
will present.
The Passenger

Diameters of the Fetal Skull

● It follows that full head flexion is an important aspect of labor

because a fetal head presenting a diameter of 9.5 cm will fit through
a pelvis much more readily than if the diameter is 12.0 or 13.5 cm.
The Passenger

Molding

● Molding is overlapping of skull

bones along the suture lines, which
causes a change in the shape of the
fetal skull to one long and narrow, a
shape that facilitates passage
through the rigid pelvis.
The Passenger

Molding

● Parents can be reassured that molding only lasts a day or two and will
not be a permanent condition.
● There is little molding when the brow is the presenting part because
frontal bones are fused.
● No skull molding occurs when a fetus is breech because the buttocks,
not the head, present first.
The Passenger

Fetal Attitude

● Attitude describes the degree of flexion a fetus assumes during

labor or the relation of the fetal parts to each other
The Passenger

Fetal Lie

● Lie is the relationship between the long (cephalocaudal) axis of the

fetal body and the long (cephalocaudal) axis of a woman’s body—in
other words, whether the fetus is lying in a horizontal (transverse) or
a vertical (longitudinal) position.
The Passenger

Fetal Presentation:

Cephalic Presentation
● A cephalic presentation is the most frequent type of presentation,
occurring as often as 96% of the time.
● The fetal head is the body part that first contacts the cervix.
● The four types of cephalic presentation are vertex, brow, face, and
mentum.
The Passenger

Fetal Presentation:

Cephalic Presentation
● A cephalic presentation is the most frequent type of presentation,
occurring as often as 96% of the time.
● The fetal head is the body part that first contacts the cervix.
● The four types of cephalic presentation are vertex, brow, face, and
mentum.
The Passenger

Fetal Presentation:

Cephalic Presentation
● During labor, the area of the fetal skull that contacts the cervix often
becomes edematous from the continued pressure against
it.
● This edema is called a caput succedaneum. In the newborn, what
was the point of presentation can be analyzed from the
location of the caput.
The Passenger

Fetal Presentation:

Breech Presentation
● A breech presentation means either the buttocks or the feet are
the first body parts that will contact the cervix.
• Breech presentation can cause a difficult birth, with the presenting
point influencing the degree of difficulty.
• Three types of breech presentation are complete, frank, and footling
The Passenger

Fetal Position

● Fetal position is the relationship

of the presenting part to a specific
quadrant and side of a woman’s
pelvis.
● The maternal pelvis is divided into
four quadrants according to the
mother’s right and left: (a) right
anterior, (b) left anterior, (c) right
posterior, and (d) left posterior.
The Passenger

Fetal Position

● Four parts of a fetus are typically chosen as landmarks to describe

the relationship of the presenting part to one of the pelvic
quadrants.
• In a vertex presentation, the occiput (O) is the chosen point.
• In a face presentation, it is the chin (mentum [M]).
• In a breech presentation, it is the sacrum (Sa).
• In a shoulder presentation, it is the scapula or the acromion
process (A).
The Passenger

Fetal Position

• Position is indicated 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 (O for occiput, M for
mentum, Sa for sacrum, and A for acromion process).
• The last letter defines whether the landmark points anteriorly (A),
posteriorly (P), or transversely (T).
The Passenger

Fetal Position

● If the occiput of a fetus points to the left anterior quadrant in a

vertex position, for example, this is a left occipitoanterior (LOA)
position.
● LOA is the most common fetal position, and right occipitoanterior
(ROA) is the second most frequent.
The Passenger

Fetal Position

● Typically, a fetus is born fastest from an ROA or LOA position.

● Labor can be considerably extended if the position is posterior
(ROP or LOP) and may be more painful for a woman because the
rotation of the fetal head puts pressure on sacral nerves.
The Passenger

Engagement

● Engagement refers to the settling of the presenting part of a fetus

far enough into the pelvis that it rests at the level of the ischial
spines, the midpoint of the pelvis.

● Descent to this point means the widest part of the fetus has
passed through the pelvis or the pelvic inlet has been proven
adequate for birth.
The Passenger

Engagement

● The degree of engagement is established by a vaginal and cervical

examination.
• A presenting part that is not engaged is said to be “floating.”
• One that is descending but has not yet reached the ischial
spines may be referred to as “dipping.”
The Passenger

Station

● Station refers to
the relationship of
the presenting
part of the fetus
to the level of the
ischial spines
The Passenger

Station

• When the presenting fetal part is at the

level of the ischial spines, it is at a 0
station (synonymous with
engagement).
• If the presenting part is above the
spines, the distance is measured and
described as minus stations, which
range from −1 to −4 cm.
The Passenger

Station

• If the presenting part is

below the ischial spines,
the distance is stated as
plus stations (+1 to +4
cm).
• At a +3 or +4 station, the
presenting part is at the
perineum and can be seen
if the vulva is separated
(i.e., it is crowning).
The Powers of Labor

● This is the force supplied by the fundus of the uterus and implemented
by uterine contractions, which causes cervical dilatation and then
expulsion of the fetus from the uterus.

● After full dilatation of the cervix, the primary power is supplemented by

use of a secondary power source, the abdominal muscles.

● It is important for women to understand that they should not bear down
with their abdominal muscles to push until the cervix is fully dilated.
Doing so impedes the primary force and could cause fetal and cervical
damage.
The Powers of Labor

Uterine Contractions

● The mark of Braxton Hicks contractions is that they are usually irregular
and are painful but do not cause cervical dilation.

● In contrast, effective uterine contractions have rhythmicity, a progressive

increase in length and intensity, and accompany dilatation of the cervix.

● Contractions are assessed according to frequency, duration, and

strength.
The Powers of Labor

Phases of Contractions

● 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
The Powers of Labor

Phases of Contractions

● Between contractions, the uterus relaxes. 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 at the beginning to a range of 60 to 70 seconds by the end
of the first stage
The Powers of Labor

Contour Changes

● As labor contractions progress and become regular and strong, the

uterus gradually differentiates itself into two distinct functioning
areas: an upper portion, which thickens, and a lower segment,
which becomes thin-walled, supple, and passive so the fetus can
be pushed out of the uterus easily.
The Powers of Labor

Contour Changes

● The contour of the overall uterus also changes from a round, ovoid
structure to an elongated one with a vertical diameter markedly
greater than the horizontal diameter.
● This lengthening straightens the body of the fetus, bringing it into
better alignment with the cervix and pelvis.
The Powers of Labor

Cervical Changes:

Effacement
● Effacement is shortening and thinning of the cervical canal. All
during pregnancy, the canal is approximately 1 to 2 cm long.
● During labor, the longitudinal traction from the contracting uterus
shortens the cervix so much that the cervix virtually disappears
The Powers of Labor

Cervical Changes:

Effacement
● In primiparas, effacement is accomplished before dilatation begins.
● In multiparas, dilatation may proceed before effacement is
complete.
The Powers of Labor

Cervical Changes:

Dilatation
● As dilatation begins, there is an increase in the amount of vaginal
secretions (show) because minute capillaries in the cervix rupture
and the last of the mucus plug that has sealed the cervix since early
pregnancy is released.
The Psyche

● It refers to the psychological state or feelings a woman brings into

labor.
● Women who manage best in labor typically are those who have a
strong sense of self-esteem and a meaningful support person with
them.
● Women without adequate support can have a labor experience so
frightening and stressful that they develop symptoms of
posttraumatic stress disorder (PTSD)
Labor and Delivery
Labor: Criteria for Diagnosis

● Uterine contractions (1 in 10 mins; 4 in 20 mins) by direct

observation or by electronic fetal monitor
● Documented progressive changes in cervical dilatation and
effacement
● Cervical effacement of >70-80%
● Cervical dilatation >3cm
Induction of Labor

● Intervention designed to:

○ Artificially initiate uterine contractions leading to
■ Progressively dilate and efface the cervix
■ Effect birth of the baby
Induction of Labor

● Pre-induction assessment:
○ Confirmation of parity
○ Confirmation of gestational age
○ Fetal presentation
○ Bishop’s score
○ Uterine activity
○ Non-stress test (NST)
○ Indication for induction
○ Capability of LR/DR
Induction of Labor

Bishop’s Score
● Quantifiable method used to predict labor induction outcomes is the
score described by Bishop (1964).
● Bishop score of 9: high likelihood for a successful induction.
● Bishop score of ≤4: unfavorable cervix and may be an indication
for cervical ripening.
 Cervical Factor

Dilatation Effacement Station

Score Consistency Position
(cm) (%) (-3 to +2)

0 Closed 0-30 -3 Firm Posterior

1 1-2 40-50 -2 Medium Midposition

2 3-4 60-70 -1 Soft Anterior

3 ≥5 ≥80 +1, +2 -- --
Indications for Induction of Labor

● Gestational hypertension
● Preeclampsia, eclampsia
● Prelabor rupture of membranes (PROM)
● Maternal medical conditions (e.g. DM, renal disease)
● Gestation >41 1/7 weeks
● Intraamniotic infection
● Fetal demise
● Logistic factors for term pregnancy (e.g. history or rapid labor,
proximity from hospital, psychosocial indications)
Contraindications for Induction of Labor

● Malpresentation (e.g. breech)

● Absolute cephalopelvic disproportion
● Placenta previa
● Previous major uterine surgery (e.g. classical CS)
● Invasive carcinoma of cervix
● Cord presentation
● Active genital herpes
● Gynecological, obstetrical, or medical conditions that preclude
vaginal birth
● Physician’s convenience
Methods of Labor Induction

Oxytocin
● Signs of hyperstimulation
○ Five (5) contractions in 10 minutes or more than 10
contractions in 20 mins.
○ Hypertonus - contractions lasting more than 120 seconds
○ Excessive uterine activity with an atypical or abnormal fetal
heart rate
Methods of Labor Induction

Amniotomy
● Artificial rupture of membranes or intentional rupture of the amniotic
sac by an obstetrical provider.
● Early amniotomy (1 to 2 cm); late amniotomy (5cm)
● Uses of amniotomy:
○ Speed up contractions and shorten length of labor
○ Earlier detection of meconium-stained amniotic fluid
Methods of Labor Induction

Amniotomy
● Complications:
○ Chorioamnionitis
○ Umbilical cord prolapse
○ Cord compression
○ Fetal heart rate decelerations
○ Bleeding from fetal or placental vessels
The First Stage of Labor

● Stage of cervical effacement and dilation

● Begins when spaced uterine contractions of sufficient frequency,
intensity, and duration are attained to bring about effacement to full
cervical dilation
● Duration:
○ Nulliparous: 6-12 hrs (ave 10-12 hours)
○ Multiparous: 2-12 hrs (ave 6-8 hrs)
The First Stage of Labor

● Divided into three segments:

○ Latent Phase
○ Active Phase
○ Transition Phase
The First Stage of Labor

Latent Phase

● The latent or early phase begins at the onset of regularly perceived

uterine contractions and ends when rapid cervical dilatation begins.
● Contractions during this phase are mild and short, lasting 20 to 40
seconds.
● Cervical effacement occurs, and the cervix dilates minimally.
The First Stage of Labor

Latent Phase

● A birthing parent who is multiparous usually progresses more

quickly than a nullipara.
● A woman who enters labor with a “nonripe” cervix will probably have
a longer than average latent phase
The First Stage of Labor

Latent Phase

● During this phase, encourage women to continue to walk about and

make preparations for birth, such as doing last- minute packing for
her stay at the hospital or birthing center, preparing older children
for her departure and the upcoming birth, or giving instructions to
the person who will take care of them while she is away.
The First Stage of Labor

Latent Phase

● Ends once dilation of 3-5cm is achieved

● Prolonged latent phase:
○ Nullipara: >20 hrs
○ Multipara: >14 hrs
The First Stage of Labor

Active Phase

● During the active phase of labor, cervical dilatation occurs more

rapidly.
● Contractions grow stronger, lasting 40 to 60 seconds, and occur
approximately every 3 to 5 minutes.
● Show (increased vaginal secretions) and perhaps spontaneous
rupture of the membranes may occur during this time.
The First Stage of Labor

Active Phase

● Corresponds to the dilatational division

● Cervical dilation of 3-6 cm or more in the presence of uterine
contractions
● Rate of cervical dilation:
○ Nullipara: 1.2 cm/hr
○ Multipara: 1.5cm/hr
● Descent commences at 7-8cm for nulliparas
The First Stage of Labor

Transition Phase

● During the transition phase, contractions reach their peak of intensity,

occurring every 2 to 3 minutes with a duration of 60 to 70 seconds,
and a maximum cervical dilatation of 8 to 10 cm occurs.
● If the membranes have not previously ruptured, they will usually rupture
at full dilatation (10 cm).
● By the end of this phase, both full dilatation (10 cm) and complete
cervical effacement (obliteration of the cervix) have occurred.
The Second Stage of Labor

● Stage of fetal expulsion

● The second stage of labor is the time span from full dilatation and
cervical effacement to birth of the infant.
● Mean Duration:
○ 50min for nulliparas
○ 20min for multipara
The Second Stage of Labor

Mechanisms (Cardinal Movements) of Labor

● Effective passage of a fetus through the birth canal involves not only
position and presentation but also a number of different position
changes in order to keep the smallest diameter of the fetal head (in
cephalic presentations) always presenting to the smallest diameter of
the pelvis.
The Second Stage of Labor

Mechanisms (Cardinal Movements) of Labor

● Engagement
● Descent
● Flexion
● Internal Rotation
● Extension
● External Rotation
● Expulsion
The Passenger

Mechanisms (Cardinal Movements)

of Labor

Engagement
● Biparietal diameter (BPD) - the
greatest transverse diameter in an
occiput presentation--passes
through the pelvic inlet
● Fetal head usually enters the pelvic
inlet either transversely or
obliquely
The Passenger
Mechanisms (Cardinal Movements)
of Labor

Descent
● Descent is the downward
movement of the biparietal
diameter of the fetal head within the
pelvic inlet.
● Full descent occurs when the fetal
head protrudes beyond the dilated
cervix and touches the posterior
vaginal floor.
The Passenger

Mechanisms (Cardinal Movements)

of Labor

Flexion
● As descent is completed and the
fetal head touches the pelvic floor,
the head bends forward onto the
chest, causing the smallest
anteroposterior diameter (the
suboccipitobregmatic diameter)
to present to the birth canal.
The Passenger

Mechanisms (Cardinal Movements)

of Labor

Internal Rotation
● As the head flexes at the end of
descent, the occiput rotates so the
head is brought into the best
relationship to the outlet of the
pelvis, or the anteroposterior
diameter is now in the
anteroposterior plane of the pelvis.
The Passenger

Mechanisms (Cardinal Movements)

of Labor

Internal Rotation
● This movement brings the
shoulders, coming next, into the
optimal position to enter the inlet, or
puts the widest diameter of the
shoulders (a transverse one) in line
with the wide transverse diameter
of the inlet.
The Passenger

Mechanisms (Cardinal Movements)

of Labor

Extension
● As the occiput of the fetal head is
born, the back of the neck stops
beneath the pubic arch 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, are born.
The Passenger

Mechanisms (Cardinal Movements)

of Labor

External Rotation
● In external rotation, almost
immediately after the head of the
infant is born, the head rotates a
final time (from the anteroposterior
position it assumed to enter the
outlet) back to the diagonal or
transverse position of the early part
of labor.
The Passenger

Mechanisms (Cardinal Movements)

of Labor

External Rotation
● This brings the after coming
shoulders into an anteroposterior
position, which is best for entering
the outlet.
● The anterior shoulder is born first,
assisted perhaps by downward
flexion of the infant’s head.
The Passenger

Mechanisms (Cardinal Movements)

of Labor

Expulsion
● Once the shoulders are born, the
rest of the baby is born easily and
smoothly because of its smaller
size.
● This movement, called expulsion, is
the end of the pelvic division of
labor.
The Second Stage of Labor

● The fetus begins descent and, as the fetal head touches the internal
perineum to begin internal rotation, her perineum begins to bulge and
appear tense. The anus may become everted, and stool may be
expelled.

● As the fetal head pushes against the vaginal introitus, this opens and
the fetal scalp appears at the opening to the vagina, which termed
crowning.
The Second Stage of Labor

● As the fetal head is pushed out of the birth canal, it extends and then
rotates to bring the shoulders into the best line with the pelvis. The
body of the baby is then born.

● Blood loss at birth is 300–500 ml on average.

Unang Yakap (DOH)

1. Immediate and thorough drying

2. Early skin-to-skin contact
3. Properly timed cord clamping
4. Non-separation for early breastfeeding
○ Eye care
○ Immunization
○ Rooming-in
Episiotomy

● Restricted use is
preferable to
routine use
● Mediolateral
episiotomy may be
preferable to media
episiotomy in
selected cases
Episiotomy

Indications:
o Expedite delivery in the 2nd stage of labor
o When spontaneous laceration is likely
o Maternal or fetal distress
o Breech position
o Assisted forceps
o Large baby
o Maternal exhaustion
Episiotomy

MIDLINE MEDIOLATERAL
Surgical repair • Easy • More difficult
Faulty healing • Rare • More common
Postoperative pain • Minimal • Common
Anatomical results • Excellent • Occasionally faulty
Blood loss • Less • More
Dyspareunia • Rare • Occasional
Extensions • Common • Uncommon
The Third Stage of Labor

● The third stage of labor, the placental stage, begins with the birth of
the infant and ends with the delivery of the placenta.
● Stage of placental separation and placental expulsion.
The Third Stage of Labor

Placental Separation

Signs of placental separation:

● Lengthening of the umbilical cord
● Sudden gush of blood
● Uterus rises in the abdomen
● Uterus becomes firm and globular (Calkin’s sign)
The Third Stage of Labor

Placental Separation

● If the placenta separates first at

its center and lastly at its edges,
it tends to fold on itself like an
umbrella and presents at the
vaginal opening with the fetal
surface evident.
● Appearing shiny and glistening
from the fetal membranes, this is
called a Schultze presentation.
The Third Stage of Labor
Placental Separation

● If, however, the placenta separates

first at its edges, it slides along the
uterine surface and presents at the
vagina with the maternal surface
evident.
● It looks raw, red, and irregular, with
the ridges or cotyledons that
separate blood collection spaces
evident; this is called a Duncan
presentation.
The Third Stage of Labor

Placental Separation

● Duration: up to 30 minutes
● There is a blood loss of about 300 to 500 ml
The Third Stage of Labor

Placental Expulsion

● Once separation has occurred,

the placenta delivers either by the
natural bearing-down effort of the
mother or by gentle pressure on
the contracted uterine fundus by
the primary healthcare provider (a
Credé maneuver).
The Third Stage of Labor

Placental Expulsion

● Pressure should never be applied

to a uterus in a noncontracted
state because doing so could
cause the uterus to evert (turn
inside out), accompanied by
massive hemorrhage
The Third Stage of Labor

Placental Expulsion

● If the placenta does not deliver spontaneously, it can be removed

manually.
● It needs to be inspected after delivery to be certain it is intact and
part of it was not retained (which could prevent the uterus from fully
contracting and lead to postpartal hemorrhage).
The Third Stage of Labor

● Retained placenta - diagnosis is made when the placenta does not

deliver within 30 mins after the infant.
○ Common in preterm deliveries, esp previable deliveries
○ May be a sign of placenta accrete
○ Removed by manual placental extraction: a hand is placed in the
intrauterine cavity and fingers are used to shear the placenta
from the uterine surface
○ Curettage may be performed
The Third Stage of Labor

● Goals of 3rd stage labor:

○ Delivery of an intact placenta
○ Avoidance of uterine invasion
○ Avoidance of post-partum hemorrhage
The Third Stage of Labor

● Active Management of Third Stage of Labor:

○ Palpate abdomen to rule out additional baby
○ Give oxytocin 10 unit/IM
○ Delay cord clamping
○ Gentle cord traction
○ Deliver placenta and examine placenta
○ Check uterus if contracted
○ Inspect for genital tract lacerations
○ Consider additional uterotonics
The Third Stage of Labor

Uterotonic Drugs:

● Oxytocin
○ Effective 1st line prophylactic uterotonic
○ Safe to use in all patients
○ Lesser unpleasant side effects (e.g. nausea, vomiting &
hypertension)
The Third Stage of Labor

Uterotonic Drugs:

● Alternatives
○ Ergot alkaloid (e.g. methylergonovine) - avoided in hypertensive
patients; deteriorate rapidly with exposre to light, heat, and
humidity
○ Prostaglandin E analogue (e.g. Misoprostol) - in the absence of
other uterotonic
Perineal Lacerations

1st Degree Laceration

● Fourchette, perineal
skin, and vaginal
mucous membrane but
not the underlying fascia
and muscle
Perineal Lacerations

2nd Degree Laceration

● Fourchette, perineal
skin, and vaginal
mucous membrane but
not the underlying fascia
and muscle
Perineal Lacerations

3rd Degree Laceration

● Fourchette, perineal
skin, and vaginal
mucous membrane but
not the underlying fascia
and muscle
Perineal Lacerations

4th Degree Laceration

● Extension of laceration
through the rectal
mucosa to expose
lumen of the rectum
The Fourth Stage of Labor

● It begins with the delivery of the placenta and end 1-2 hours later.

● The fourth stage of labor is a crucial time for mother and newborn.
Both are not only recovering from the physical process of birth but
also becoming acquainted with each other and additional family
members.
The Fourth Stage of Labor

● It requires close observation of the patient for uterine blood loss

and vital signs, especially blood pressure and pulse.

● It is during this time that postpartum hemorrhage commonly occur

due to:
○ Uterine atony
○ Retained placental fragments
○ Unrepaired lacerations
Maternal Danger Signs of Labor

High or Low Blood Pressure

● A systolic pressure greater than 140 mmHg and a diastolic pressure

greater than 90 mmHg, or an increase in the systolic pressure of
more than 30 mmHg or in the diastolic pressure of more than 15
mmHg (the basic criteria for gestational hypertension), should be
reported.

● A falling blood pressure because it may be the first sign of

intrauterine hemorrhage
Maternal Danger Signs of Labor

Abnormal Pulse

● A maternal pulse rate greater than 100 beats/min during labor is

unusual and should be reported because it may be another
indication of hemorrhage.
Maternal Danger Signs of Labor

Inadequate or Prolonged Contractions

● Uterine contractions normally become more frequent, intense, and

longer as labor progresses.
● If they become less frequent, less intense, or shorter in duration,
this may indicate uterine exhaustion (inertia).
● Uterine contractions lasting longer than 70 seconds are becoming
long enough to compromise fetal well-being because this interferes
with adequate uterine artery filling.
Maternal Danger Signs of Labor

Abnormal Lower Abdominal Contour

● If a woman has a full bladder during labor, a round bulge appears

on her lower anterior abdomen.
● This is a danger signal for two reasons: First, the bladder may be
injured by the pressure of the fetal head pressing against it; and
second, the pressure of the full bladder may not allow the fetal head
to descend.
● To avoid a full bladder, ask women to try to void about every 2
hours during labor.
Fetal Danger Signs of Labor

High or Low Fetal Heart Rate

● FHR of more than 160 beats/min (fetal tachycardia) or less than

110 beats/min (fetal bradycardia) is a sign of possible fetal distress.

● Frequent monitoring by a fetoscope, Doppler, or a monitor is

necessary to detect these changes as they first occur.
Fetal Danger Signs of Labor

Meconium Staining

● Meconium staining, a green color in the amniotic fluid, reveals the

fetus has had a loss of rectal sphincter control, allowing meconium
to pass into the amniotic fluid.
● It may indicate a fetus has or is experiencing hypoxia, which
stimulates the vagal reflex and leads to increased bowel motility.
Fetal Danger Signs of Labor

Hyperactivity

● Fetal hyperactivity may be a subtle sign that hypoxia is occurring

because frantic motion is a common reaction to the need for
oxygen.
OB Analgesia and Anesthesia

Systemic Pharmacologic Intervention

● First stage of labor: narcotics or sedatives to relax patients and

decrease pain
● Fentanyl, Nubain (nalbuphine), Stadol, IM morphine sulfate
● Sedating medications should not be used close to the time of
expected delivery because they cross the placenta and may result
in a depressed infant.
● Complications: maternal respiratory depression, increased risk of
aspiration
OB Analgesia and Anesthesia

Pudendal Block

● Pudendal nerve travels just posterior to the ischial spine at its

juncture with the sacrospinous ligament
● Injected at that site bilaterally to give perineal anesthesia;
commonly used in the operative vaginal delivery
● May be combined with local infiltration of the perineum
OB Analgesia and Anesthesia

Local Anesthesia

● Used during episiotomy and before repair of lacerations

OB Analgesia and
Anesthesia
Epidural and spinal anesthesia

● Epidural catheter is placed in

the L3-L4 interspace; usually
placed in the active phase
● Spinal anesthesia: difference is
that it is given in a one-time
dose, leading to a more rapid
onset of anesthesia
OB Analgesia and Anesthesia

Epidural and spinal anesthesia

● Complications:
○ Maternal hypotension from ↓ systemic vascular resistance →
↓ placental perfusion & fetal bradycardia
○ Maternal respiratory depression - if anesthesia reaches
diaphragmatic innervation
○ Spinal headache - due to loss of CSF (<1%)
OB Analgesia and Anesthesia

General anesthesia

● Usually in emergency cesarean delivery (e.g. abruptio placenta,

fetal bradycardia, cord prolapse, uterine rupture, hemorrhage from
placenta previa)
● Complications: risk of maternal aspiration and risk of hypoxia to
mother and fetus during induction