3management of All Stages l Labor & Delivery

Process & stages f labor &birth Process & stages f labor &birth

Chapter 22 Chapter 22

Prepared Prepared

By By

Dr/ Hala Thabet ( PhD )Dr/ Hala Thabet ( PhD )

Assistant Prof. In King Abdul-Aziz Assistant Prof. In King Abdul-Aziz University , Faculty of NursingUniversity , Faculty of Nursing

Learning outcomes Learning outcomes

Define labor Define labor Examine the five critical factors that affect the Examine the five critical factors that affect the

labor process labor process Describe the physiology of labor Describe the physiology of labor Discuss premonitory signs of labor Discuss premonitory signs of labor Differentiation between false &true labor Differentiation between false &true labor Describe the characteristics of the four stages of Describe the characteristics of the four stages of

labor and their accompanying process labor and their accompanying process To describe the best practices in caring for the To describe the best practices in caring for the

woman during labor, delivery and immediate woman during labor, delivery and immediate postpartum. postpartum.

Objectives of Care During Objectives of Care During Labor and ChildbirthLabor and Childbirth

Protect the life of the mother and Protect the life of the mother and newborn newborn

Support the normal labor to Support the normal labor to detect and treat complications in detect and treat complications in timely fashion timely fashion

Support and respond to needs of Support and respond to needs of the woman, her partner and the woman, her partner and family during labor and childbirthfamily during labor and childbirth

Normal laborNormal labor

Labor is the series Labor is the series of events by which of events by which the fetus and the the fetus and the placenta are placenta are expelled from the expelled from the woman’s uterus. woman’s uterus. Delivery refers to Delivery refers to the actual delivery the actual delivery of the infant.of the infant.

Characteristics of normal laborCharacteristics of normal labor

The fetus is born at full term ( > The fetus is born at full term ( > completed 37 weeks).completed 37 weeks).

The fetus is living.The fetus is living. The fetal presentation is vertex.The fetal presentation is vertex. The process of labor is completed The process of labor is completed

spontaneously.spontaneously. The process of labor is The process of labor is

completed through the natural completed through the natural passages.passages.

The time of labor does not exceed The time of labor does not exceed 24 hours.24 hours.

Critical factors in labor Critical factors in labor

1. Birth passage 1. Birth passage “ size & types “ size & types of pelvis ,ability of the of pelvis ,ability of the cervix to dilate & effececervix to dilate & effece

2. 2. FetusFetus “ fetal head (size & “ fetal head (size & presence of molding ,fetal presence of molding ,fetal attitude ,lie & presentation) attitude ,lie & presentation)

3. The relationship between the 3. The relationship between the passage & the fetuspassage & the fetus””

-Engagement of the presenting -Engagement of the presenting part part

- Station ‘local of fetal - Station ‘local of fetal presenting part in the maternal presenting part in the maternal pelvis pelvis

-Fetal position -Fetal position

4.4. Physiologic forces of laborPhysiologic forces of labor

- Frequency ,duration - Frequency ,duration &intensity of contraction &intensity of contraction

- Effectiveness of maternal - Effectiveness of maternal pushing effort pushing effort

5. Psychological considerations 5. Psychological considerations

- mental &physical preparation - mental &physical preparation for child birth for child birth

- Sociocultural values and beliefs - Sociocultural values and beliefs

- previous childbirth experience - previous childbirth experience

- support from significant others - support from significant others

- emotional status - emotional status

Factors affecting the progress of Factors affecting the progress of laborlabor

There are five essential factors that affect the process of There are five essential factors that affect the process of laborlabor::

PassengersPassengers: Fetus, placenta, membranes, umbilical : Fetus, placenta, membranes, umbilical cord, blood and amniotic fluid.cord, blood and amniotic fluid.

Passages:Passages: Pelvis, pelvic floor, uterus, cervix, vagina & Pelvis, pelvic floor, uterus, cervix, vagina & vulva vulva

Powers Powers Characteristics of uterine contractionsCharacteristics of uterine contractions::They are quite involuntaryThey are quite involuntary Frequency or interval:Frequency or interval: The period between the start of The period between the start of

one contraction and the start of the next one.one contraction and the start of the next one. Duration:Duration: The period between the start of one The period between the start of one

contraction and its end.contraction and its end. Intensity or amplitudeIntensity or amplitude: The power or strength of the : The power or strength of the

contractioncontraction

Phases of contractionPhases of contraction

♥ ♥ Each contraction has three phases:Each contraction has three phases:

* Increment:* Increment: A period during which A period during which the the

contraction begins contraction begins slowly.slowly.

* Acme:* Acme: A period during which the A period during which the

contraction reaches a peak.contraction reaches a peak.

* Decrement:* Decrement: A period during A period during which the contractions diminisheswhich the contractions diminishes

Position Position :- :- can impact the course can impact the course of laborof labor

PsychologicalPsychological state of the woman & state of the woman & her personality her personality

Possible causes of labor Possible causes of labor onset onset

Progesterone withdrawal hypothesisProgesterone withdrawal hypothesis1. 1. Progesterone produced by the placenta relaxes Progesterone produced by the placenta relaxes

uterine smooth muscle for this reason ,the uterus uterine smooth muscle for this reason ,the uterus is usually without coordinated contractions during is usually without coordinated contractions during pregnancypregnancy

2. Biochemical changes toward the end of gestation 2. Biochemical changes toward the end of gestation result in decreased availability of progesterone to result in decreased availability of progesterone to myometrial cells myometrial cells

Possible causes of labor Possible causes of labor onset onset

Prostaglandin hypothesis Prostaglandin hypothesis 1.1. Although the exact relationship between Although the exact relationship between

prostaglandin and the onset of labor is not prostaglandin and the onset of labor is not yet established yet established

Corticotropin releasing hormone Corticotropin releasing hormone hypothesis hypothesis

1.1. Its possible role in onset of labor is Its possible role in onset of labor is suggested by the fact that CRH suggested by the fact that CRH concentration increases through concentration increases through pregnancy pregnancy

Premonitory signs of labor Premonitory signs of labor

Most primigravidas &many multiparas experience one or more of Most primigravidas &many multiparas experience one or more of the following signs &symptoms of impending labor.the following signs &symptoms of impending labor.

1.1. Lightening Lightening

--The fetus begins to settle into the pelvic inlet (engagement )The fetus begins to settle into the pelvic inlet (engagement )

-With fetal descent ,the uterus moves downward & the funds no -With fetal descent ,the uterus moves downward & the funds no longer pressure on the diaphragm ,which eases breathing longer pressure on the diaphragm ,which eases breathing

The woman due to increase downward pressure of the presenting The woman due to increase downward pressure of the presenting part may notice the following part may notice the following (Cunningham et,al ,2010 )(Cunningham et,al ,2010 )

Leg cramps or pain due to pressure on the nerves Leg cramps or pain due to pressure on the nerves Increase pelvic pressure Increase pelvic pressure Increased venous stasis leading to edema in the lower extremities Increased venous stasis leading to edema in the lower extremities Increase urinary frequency Increase urinary frequency Increased vaginal secretion Increased vaginal secretion


Braxton hicks contractions Braxton hicks contractions

Painless irregular ,intermittent contraction that have been Painless irregular ,intermittent contraction that have been occurring throughout the pregnancyoccurring throughout the pregnancy

When these contractions are strong enough for woman to believe When these contractions are strong enough for woman to believe she is in labor she is in labor

Cervical changes Cervical changes At the beginning of pregnancy the cervix is rigid and firm At the beginning of pregnancy the cervix is rigid and firm It must soften so that it can stretch and dilate to allow fetal It must soften so that it can stretch and dilate to allow fetal

passage passage The softening of the cervix called ripening The softening of the cervix called ripening

Bloody show “ pink tinged secretion “Bloody show “ pink tinged secretion “- During pregnancy ,cervical secretion accumulate in the cervical During pregnancy ,cervical secretion accumulate in the cervical

canal to form barrier called a mucous plug canal to form barrier called a mucous plug - With softening and effacement of the cervix ,the mucous plug is With softening and effacement of the cervix ,the mucous plug is

expelled expelled


Rupture of membranes Rupture of membranes 12% of women ,the amniotic membranes rupture before the 12% of women ,the amniotic membranes rupture before the

onset of labor “ called rupture of membranes “ onset of labor “ called rupture of membranes “ After membranes rupture ,80% of women will experience After membranes rupture ,80% of women will experience

spontaneous labor within 24 hoursspontaneous labor within 24 hours If membranes rupture & labor does not begin spontaneously If membranes rupture & labor does not begin spontaneously

within 12to 24 hours ,labor may be induced to avoid within 12to 24 hours ,labor may be induced to avoid infection infection

At the beginning of labor ,the amniotic membranes bulge At the beginning of labor ,the amniotic membranes bulge through the cervix in the shape of a cone ,when rupture ,the through the cervix in the shape of a cone ,when rupture ,the amniotic fluid may be expelled in large amount amniotic fluid may be expelled in large amount

Sudden burst of energy Sudden burst of energy Approximately 24 to 48 hours before labor ,some women Approximately 24 to 48 hours before labor ,some women

report a sudden burst of energy report a sudden burst of energy


Other premonitory signs include the following Other premonitory signs include the following

1.1. Weight loss of 2.2 to 6.6 kg resulting from fluid loss Weight loss of 2.2 to 6.6 kg resulting from fluid loss

2.2. Increased backache & sacroiliac pressure from the Increased backache & sacroiliac pressure from the influence of relaxine hormone influence of relaxine hormone

3.3. Diarrhea ,indigestion or nausea &vomiting just before the Diarrhea ,indigestion or nausea &vomiting just before the onset of labor onset of labor

Physiology of labor Physiology of labor

1.1. Myometrial activityMyometrial activity- In true labor the uterus divided into two portions . In true labor the uterus divided into two portions .

This division is known the This division is known the physiologic retraction ring physiologic retraction ring

a. The upper portion a. The upper portion

-- contractile segment contractile segment

- Progressively thicker as labor advances- Progressively thicker as labor advances

- With each contraction ,the muscle of upper uterine - With each contraction ,the muscle of upper uterine segment shorten &exert the longitudinal traction on the segment shorten &exert the longitudinal traction on the cervix causing cervix causing effacementeffacement “ “ taking up of cervical os “ taking up of cervical os “

b. The lower portion b. The lower portion - Include the lower uterine segment &cervix Include the lower uterine segment &cervix - Is passive Is passive - Lower uterine segment expend &thin Lower uterine segment expend &thin

Physiology of labor Physiology of labor

2. Musculature changes in the pelvic floor 2. Musculature changes in the pelvic floor

The levator ani muscle &fascia of the pelvic floor The levator ani muscle &fascia of the pelvic floor

- Draw the rectum &vagina upward & forward with - Draw the rectum &vagina upward & forward with each contraction each contraction

-The fetal head descends to the pelvic floor -The fetal head descends to the pelvic floor

- The pressure of the presentation causing the - The pressure of the presentation causing the perineal structure perineal structure

Comparison of true & false laborComparison of true & false labor

False laborFalse labor True laborTrue labor

No showNo show Show (Blood streaked mucousShow (Blood streaked mucous))

DiscomfortDiscomfort is usually in abdomen is usually in abdomen Painful discomfort begins in back Painful discomfort begins in back &radiates around abdomen &radiates around abdomen

Irregular painIrregular pain Regular & interval gradually shortenRegular & interval gradually shorten

Contractions are briefContractions are brief “ rest “ rest &warm tube baths lessen contractions &warm tube baths lessen contractions

Contractions do not decrease with rest or Contractions do not decrease with rest or warm tube bathwarm tube bath

Intensity variesIntensity varies &walking has no &walking has no effect on lessens contraction effect on lessens contraction

Intensity gradually increases with walking Intensity gradually increases with walking

No cervical dilatationNo cervical dilatation Cervix dilatation &effacement are Cervix dilatation &effacement are progressive progressive

Relieved by sedationRelieved by sedation Not affected by sedation Not affected by sedation

Symptoms and signs of the Symptoms and signs of the onset of laboronset of labor

Painful uterine contraction = Painful uterine contraction =

true painstrue pains ShowShow Shorting & dilation of the cervixShorting & dilation of the cervix Formation of the bag of watersFormation of the bag of waters

Stages of Stages of laborlabor

Definition of stageDefinition of stage Duration Duration in primein prime

Duration in Duration in multimulti

1-11-1stst (Dilating (Dilating stage)stage)

begins with the first true begins with the first true uterine contraction and ends uterine contraction and ends with complete dilation of the with complete dilation of the cervixcervix..

12- 16 12- 16 hourshours

6-8 hours6-8 hours

2-22-2ndnd (Expulsiv(Expulsive stage)e stage)

begins with complete dilation of begins with complete dilation of the cervix and ends with the cervix and ends with delivery of the infantdelivery of the infant

1-2 1-2 hourshours

10-30 10-30 minutesminutes

3-33-3rdrd (Placenta(Placental stage)l stage)

begins with delivery of the begins with delivery of the infant and ends with delivery of infant and ends with delivery of the placentathe placenta



4 Fourth 4 Fourth stagestage

the first 2 hours following the first 2 hours following deliverydelivery

Stages of labor Stages of labor &birth &birth

Characteristics of Characteristics of labor labor

First stage Second stage

Latent Active Transition Nullipara 8-6 hr 4-6 hr 3.6 hr UP TO 3 hr

Multipara 5-3hr 2-4 hr Variable 0-30min Cervical dilation

0-3 cm 4-7 cm 8-10cm

Contractions Frequency Every 3-

30min Every 2-5

min Every 11/2 -2

minEvery 11/2 -2

min

Duration 20-40 sec 40-60 sec 60-90sec 60-90sec

Intensity Begin as mild &progress to moderate ,25-40mmHg by intrauterine pressure catheter

Begin as moderate and progress to strong ,50-70mm hg by IUPC

Strong by palpation ,70-

100mmhg by IUPC

Strong by palpation ,70-

90mmhg by IUPC

Physical & psychologic changes Physical & psychologic changes during latent phase during latent phase

The latent or early phase begins with the The latent or early phase begins with the onset of regular contractionsonset of regular contractions

The women feels able to cope with the The women feels able to cope with the discomfort discomfort

She may be anxious She may be anxious She is able to recognize &express those She is able to recognize &express those

feelings of anxiety feelings of anxiety The woman is often talkative and smiling and The woman is often talkative and smiling and

is eager talk about herself &answer questions is eager talk about herself &answer questions Excitement is high Excitement is high

Physical & psychologic changes Physical & psychologic changes during active phase during active phase

Increase anxiety Increase anxiety She begins to fear a loss &may use a She begins to fear a loss &may use a

variety of coping mechanisms variety of coping mechanisms Some women exhibit a decreased ability Some women exhibit a decreased ability

to cope &a sense of helplessness to cope &a sense of helplessness Women who have support persons and Women who have support persons and

family available may experience greater family available may experience greater satisfaction &less anxiety than those satisfaction &less anxiety than those without support without support

Physical & psychologic changes Physical & psychologic changes during transition phase during transition phase

The transition phase is the last part of the first stage The transition phase is the last part of the first stage Anxiety Anxiety She become aware of the increasing force &intensity of the She become aware of the increasing force &intensity of the

contractions contractions Restlessness Restlessness Frequently changing position Frequently changing position Hyperventilation “increases her breathing rate”Hyperventilation “increases her breathing rate” A sense of confusion & anger at the contractions A sense of confusion & anger at the contractions Generalized discomfort including back pain &cramping in the legGeneralized discomfort including back pain &cramping in the leg Increased need for partner's /nurse support Increased need for partner's /nurse support Increased sensitivity to touch Increased sensitivity to touch

Physical & psychologic changes during Physical & psychologic changes during transition phase transition phase

Increased apprehension &irritability Increased apprehension &irritability Requests for medication Requests for medication Hiccupping ,nausea or vomiting Hiccupping ,nausea or vomiting Beads of perspiration on the upper lip Beads of perspiration on the upper lip Increase rectal pressure Increase rectal pressure Loss of control Loss of control Crying Crying

The second stage of laborThe second stage of labor

DefinitionDefinition The second stage of labor The second stage of labor

involves the expulsion of the involves the expulsion of the fetus .It begins with the fetus .It begins with the complete dilation of the complete dilation of the cervix and ends when the cervix and ends when the infant is deliveredinfant is delivered ..

DurationDuration - - The second stage completed The second stage completed

within within 2 hours 2 hours after the becomes after the becomes fully dilated for fully dilated for primigravida primigravida

--Multipara average 15 minutes Multipara average 15 minutes

Uterine contractionsUterine contractions Become stronger, last longer, and are more frequent, together Become stronger, last longer, and are more frequent, together

with full cervical dilatation and effacementwith full cervical dilatation and effacement..

Bearing down or pushingBearing down or pushing The woman starts to push; this will result in contractions of theThe woman starts to push; this will result in contractions of the abdominal abdominal

muscles and diaphragmmuscles and diaphragm

Rupture of bag watersRupture of bag waters The membranes should have ruptured by the end of the first The membranes should have ruptured by the end of the first

stagestage.. Their function is finished, and they are only a hindrance Their function is finished, and they are only a hindrance during the second stageduring the second stage

Crowing : Crowing :

The fetal head is encircled by the The fetal head is encircled by the external opening of the vagina external opening of the vagina

Spontaneous birth “ vertex Spontaneous birth “ vertex presentation “presentation “

-The head distends the vulva -The head distends the vulva with each contractionwith each contraction

-the perineum becomes thin -the perineum becomes thin &the anus stretches &the anus stretches

&protrudes &protrudes ..

Displacement of the pelvic floorDisplacement of the pelvic floor

-The -The bladderbladder is is drawn updrawn up into the abdomen where is less risk of its into the abdomen where is less risk of its being injured by the descending head, and more space is being injured by the descending head, and more space is available in the pelvis for the passage of the fetus .available in the pelvis for the passage of the fetus .

-The -The rectumrectum is pushed is pushed downwarddownward in front of the presenting part. in front of the presenting part. Thus the woman feels pressure on the rectum Thus the woman feels pressure on the rectum accompanied by accompanied by the desire to defecatethe desire to defecate

The anus gaps until the opening is The anus gaps until the opening is 2.5cm in diameter2.5cm in diameter..

Signs of the second stage of Signs of the second stage of laborlabor

Cramps in the legs due to pressure of the descended Cramps in the legs due to pressure of the descended presenting part on the sacral nerves presenting part on the sacral nerves

With each contraction and straining,With each contraction and straining, the head the head advance and then recedes as the uterus relaxes .advance and then recedes as the uterus relaxes .

The perineum bulges, and the introitus becomes an The perineum bulges, and the introitus becomes an anteroposterior slit, then an oval, and finally a circular anteroposterior slit, then an oval, and finally a circular openingopening. .

The amount of bloody show may increase The amount of bloody show may increase

1-Engagement.1-Engagement.

2-Desent.2-Desent.

3-Flexion.3-Flexion.

4-Internal rotation.4-Internal rotation.

5-Extension.5-Extension.

6-Restitution.6-Restitution.

7-External rotation.7-External rotation.

8-Expulsion8-Expulsion

Mechanism of laborMechanism of labor1. Engagement 1. Engagement

Not engagedNot engaged EngagedEngaged

The baby's head has started to move into the pelvis, but more than three- or four-fifths can be felt above the pubic bone.

The baby has dropped into the pelvis in preparation for birth. This causes your belly to change position and shape.

Mechanism of laborMechanism of labor2. DESCENT 2. DESCENT Descent is occur because of Descent is occur because of

four forces four forces

1.1. Pressure of amniotic fluid Pressure of amniotic fluid

2.2. Direct pressure of the funds Direct pressure of the funds of the uterus on the breech of the uterus on the breech of the fetus of the fetus

3.3. Contraction of the Contraction of the abdominal muscles abdominal muscles

4.4. Extension &straightening of Extension &straightening of fetal bodyfetal body

Mechanism of laborMechanism of labor3. Flexion 3. Flexion

Flexion Flexion occurs as fetal occurs as fetal head descends &meet head descends &meet resistance from the soft resistance from the soft tissues of the pelvis , the tissues of the pelvis , the musculature of the pelvic musculature of the pelvic floor & the cervix.floor & the cervix.

As result of the resistance As result of the resistance the the fetal chin flexes fetal chin flexes downward onto the chest downward onto the chest

Mechanism of laborMechanism of labor4. Internal rotation 4. Internal rotation

The fetal head must The fetal head must rotate to fit the rotate to fit the diameter of the pelvic diameter of the pelvic cavity cavity

Is widest in the Is widest in the anteroposterior anteroposterior diameter diameter

The occiput rotates The occiput rotates from left to right from left to right

Mechanism of laborMechanism of labor5. Extension 5. Extension

The resistance of the pelvic The resistance of the pelvic floor and mechanical floor and mechanical movement of the vaginal movement of the vaginal opening anterioly &forward opening anterioly &forward assist with extension of the assist with extension of the fetal head as it passes under fetal head as it passes under the sumphysis pubisthe sumphysis pubis

With this position change the With this position change the occiput the brow occiput the brow &face ,emerge from the &face ,emerge from the vagina vagina

Mechanism of laborMechanism of labor6. Restitution 6. Restitution

The Shoulder of the infant The Shoulder of the infant enter the pelvis obliquely and enter the pelvis obliquely and remain oblique when the remain oblique when the head rotates to the head rotates to the anteroposterior diameter anteroposterior diameter through the internal rotation through the internal rotation

The neck becomes twisted The neck becomes twisted Once the head free of the Once the head free of the

pelvic resistance the neck pelvic resistance the neck untwists untwists

Mechanism of laborMechanism of labor7. External rotation 7. External rotation

The shoulder rotate to the The shoulder rotate to the anteroposterior position in anteroposterior position in the pelvis the pelvis

The head is turned to one The head is turned to one side side

Mechanism of laborMechanism of labor8. Expulsion 8. Expulsion

After the external rotation & After the external rotation & expulsive efforts of the expulsive efforts of the laboring woman laboring woman

1.1. The anterior shoulder meets The anterior shoulder meets the undersurface of the the undersurface of the symphysis pubis under it symphysis pubis under it

2.2. Lateral flexion of the Lateral flexion of the shoulder and head occur shoulder and head occur

3.3. The anterior shoulder is born The anterior shoulder is born before the posterior shoulder before the posterior shoulder

4.4. The body follow quickly The body follow quickly

Mechanism of laborMechanism of labor

The third stage of laborThe third stage of labor

DefinitionDefinition The third stage of The third stage of

labor involves the labor involves the separations and separations and expulsion of the expulsion of the placenta .It begins placenta .It begins with the delivery of with the delivery of the infant and ends the infant and ends with the delivery of with the delivery of the placentathe placenta..

Signs of the placenta separationSigns of the placenta separation

Globular shaped uterus Globular shaped uterus Rise of the fundus in abdomen Rise of the fundus in abdomen Sudden gush of blood Sudden gush of blood Protrusion of the umbilical cord out of vagina Protrusion of the umbilical cord out of vagina Loss of pulsation of the cord when pressure is Loss of pulsation of the cord when pressure is

exerted on the fundusexerted on the fundus

““Usually appear around 5 minutes after birth of infant ,but Usually appear around 5 minutes after birth of infant ,but can take up to 30 minutes to manifest “can take up to 30 minutes to manifest “

ItIt’’s divided into three phases:-s divided into three phases:- 1. Phase of separation1. Phase of separation:: After expulsion of the fetus, the contraction & After expulsion of the fetus, the contraction &

retraction of the uterus causes the placental site retraction of the uterus causes the placental site to diminish in size, while the size of the placenta to diminish in size, while the size of the placenta and placental site can no longer remains in firm and placental site can no longer remains in firm union with each other .union with each other .

2.2. Phase of descentPhase of descent:: With further shrinking of the uterus, the completely With further shrinking of the uterus, the completely

separated placenta slides from the upper segment of the separated placenta slides from the upper segment of the uterus to the lower one .The lower segment becomes uterus to the lower one .The lower segment becomes ballooned the fundus rises to the umbilical levelballooned the fundus rises to the umbilical level

Phase of placenta Phase of placenta separationseparation

3.3. Phase of expulsionPhase of expulsion:: The placenta descend into the The placenta descend into the

vagina and expulsion is vagina and expulsion is brought about by bearing brought about by bearing down while traction by down while traction by descending placenta strips the descending placenta strips the membranes from the deciduasmembranes from the deciduas

Placenta expulsion occurs by Placenta expulsion occurs by one of two mechanismsone of two mechanisms::

Placenta expulsion occurs by one of two mechanismsPlacenta expulsion occurs by one of two mechanisms::

SchultzeSchultzeּיּיs mechanisms mechanism The central portion of the placenta descends into the vagina The central portion of the placenta descends into the vagina

causing the placenta look like an umbrella. As the placenta causing the placenta look like an umbrella. As the placenta is expelled the is expelled the fetal surface fetal surface is emerging from the vagina. The is emerging from the vagina. The maternal surfaces not seen, it’s covered with blood and the maternal surfaces not seen, it’s covered with blood and the enveloping membranesenveloping membranes..

DuncanDuncanּיּיs mechanisms mechanism The placenta slides out sideway through the vagina .The The placenta slides out sideway through the vagina .The

maternal surfaces of the placenta seen first emerging from maternal surfaces of the placenta seen first emerging from the vagina .the vagina .

Normal blood loss is usually 120- 240 c.c. More than 500 c.c. Normal blood loss is usually 120- 240 c.c. More than 500 c.c. Is considered as hemorrhageIs considered as hemorrhage

Fourth stage Fourth stage

The time from 1 to 4 hours after birth in which The time from 1 to 4 hours after birth in which physiologic readjustment of the mother's body beginsphysiologic readjustment of the mother's body begins

Blood loss at birth ranges from 250 to 500ml Blood loss at birth ranges from 250 to 500ml The uterus remains contracted and is in the midline of The uterus remains contracted and is in the midline of

the abdomen the abdomen The fundus is usually midway between the symphysis The fundus is usually midway between the symphysis

pubis &umbilicuspubis &umbilicus The woman may be thirsty and hungryThe woman may be thirsty and hungry The bladder is often hypotonic due to trauma during The bladder is often hypotonic due to trauma during

the second stagethe second stage Hypotonic bladder lead to urinary retention Hypotonic bladder lead to urinary retention

Nursing management of first stage of labor Nursing management of first stage of labor

Admission of the woman :Admission of the woman : The nurse should welcome and great the The nurse should welcome and great the

woman in a kind way .woman in a kind way . The nurse should ask the woman about her The nurse should ask the woman about her

maternal health card , show her the labor maternal health card , show her the labor room ,and help her undress and get into bed room ,and help her undress and get into bed

Admission should be carried out as quickly Admission should be carried out as quickly as possibleas possible

Taking the history of labor:Taking the history of labor: * * Ask the woman why she has come to Ask the woman why she has come to

the hospital and review the history from the hospital and review the history from her Maternal Health Card.her Maternal Health Card.

Determine whether the woman isDetermine whether the woman is in laborin labor or or not not through the presence of the through the presence of the following signs:-following signs:-

a. a. Uterine contractionsUterine contractions:: * * Ask the woman when true Ask the woman when true

contractions began, how often they are contractions began, how often they are coming and how long they last.coming and how long they last.

b. Show:b. Show: Ask the woman if she had a blood Ask the woman if she had a blood

stained mucous discharge and examine stained mucous discharge and examine her underclothes.her underclothes.

c. c. Membranes: Membranes: Ask the woman if she had a gush of Ask the woman if she had a gush of

fluid ? If membranesfluid ? If membranes are ruptured, are ruptured, record the time of rupturerecord the time of rupture..

AssessmentAssessment

d. Sleep, rest and food:d. Sleep, rest and food: Ask the woman if she Ask the woman if she has enough rest and sleep,& if she has had has enough rest and sleep,& if she has had food within 6 hours?food within 6 hours? If yes, it should be If yes, it should be recorded & taken into consideration. recorded & taken into consideration.

e. e. Ask the woman about her previous labor Ask the woman about her previous labor history & her present pregnancy.history & her present pregnancy.

f. Bladder and bowelf. Bladder and bowel:: Ask the woman if Ask the woman if she has passed urine or stool?she has passed urine or stool?

22. Examination of woman in labor. Examination of woman in labor

Explain all the procedures to the woman and Explain all the procedures to the woman and inform her of the results inform her of the results

a. General examination:a. General examination:1.1. The woman's general manner will indicate how The woman's general manner will indicate how

she is coping with labor.she is coping with labor.2.2. Observe the woman's general condition such asObserve the woman's general condition such as

build and stature, limb, deformity and build and stature, limb, deformity and appearance. appearance. Pallor indicates infection and Pallor indicates infection and dehydration.dehydration.

2. Examination of woman in labor2. Examination of woman in labor

3.Temperature, pulse, respiration 3.Temperature, pulse, respiration and blood pressure ,should be and blood pressure ,should be taken between contractions and taken between contractions and recorded. recorded. If temperature is high, If temperature is high, isolate the womanisolate the woman..

4. Inspect any edema. 4. Inspect any edema. 5. Test urine for 5. Test urine for proteinprotein and and sugar sugar

after trimming of hair, and before after trimming of hair, and before enema. enema.

6. A blood sample is drown for 6. A blood sample is drown for syphilis screening ,hemoglobin , syphilis screening ,hemoglobin , hematocrit , hepatitis antibodies hematocrit , hepatitis antibodies and blood typing and blood typing

b. Local examination:b. Local examination: Examination of the abdomenExamination of the abdomen:: 1. Inspect the contour of the 1. Inspect the contour of the

abdomen.abdomen. 2. Palpate the abdomen gently, and 2. Palpate the abdomen gently, and

with warm hands, for the height of with warm hands, for the height of the fundus , the fundus , lie lie , , presentationpresentation, , positionposition, , attitudeattitude and and stationstation, and , and record them.record them.

3. Observe and record the 3. Observe and record the frequency, duration, and intensity frequency, duration, and intensity of contractions.of contractions.

Leopold’s ManeuversLeopold’s Maneuvers

What is in the fundus?What is in the fundus? Where is the back and where Where is the back and where

are the small parts?are the small parts? What is the presenting part?What is the presenting part?

Auscultating Fetal Auscultating Fetal Heart TonesHeart Tones

4. 4. Auscultate and record the Auscultate and record the fetal heart sound for one fetal heart sound for one minute usingminute using Pinard's Pinard's stethoscopestethoscope, or , or SonicaidSonicaid. . A A cardiograph machinecardiograph machine gives gives information about fetal & information about fetal & maternal conditions. The maternal conditions. The normal range of the fetal normal range of the fetal heart rate isheart rate is 120-160 120-160 beats/minute.beats/minute.

LOP ROP

LSA RSA Based on Leopold’s maneuvers, FHR will best be heard in the marked areas for the various positions.

c. c. Examination of the vulva:Examination of the vulva:

* * Inspect for gaping of introitus.Inspect for gaping of introitus.

* * Observe color and odor of liquor Observe color and odor of liquor

& presence of meconium or & presence of meconium or

blood . blood . Offensive odor indicates Offensive odor indicates

infection.infection.

* * Check for edema of the vulva. If Check for edema of the vulva. If

present, it present, it indicates pre-eclampsia.indicates pre-eclampsia.

d. Examination of the vaginad. Examination of the vagina :- :- is made by the midwife or is made by the midwife or

doctor to:doctor to: * * Make a positive diagnosis of labor.Make a positive diagnosis of labor. * * Assess the progress of labor. Assess the progress of labor. * * Determine the extent of effacement & the Determine the extent of effacement & the

degree of dilatation of the cervix.degree of dilatation of the cervix. * Assess the condition of the membranes.* Assess the condition of the membranes. * * Determine position, presentation and Determine position, presentation and

degree of descent of head in pelvis in degree of descent of head in pelvis in relation to ischial spine (station).relation to ischial spine (station).

Nursing management of first Nursing management of first stage of laborstage of labor

* * Observe the presence of umbilical Observe the presence of umbilical cord beside the headcord beside the head.. * Check * Check mouldingmoulding, presence of caput , presence of caput succedaneum and abnormalities.succedaneum and abnormalities. ** Evaluate pelvic capacity and Evaluate pelvic capacity and condition of the vagina.condition of the vagina. e. e. Examination of the rectum Examination of the rectum : : A rectal A rectal

examination is safer than a vaginal examination is safer than a vaginal examination. It reduces the risk of examination. It reduces the risk of infection and gives the same data as a infection and gives the same data as a vaginal examination.vaginal examination.

Nursing management of first stage of laborNursing management of first stage of labor

Observation Observation Close observation is important for both woman Close observation is important for both woman

and fetus . The nurse should observe the and fetus . The nurse should observe the following:- following:-

Reaction of the woman to labor Reaction of the woman to labor Vaginal discharge ,show , amniotic fluid and Vaginal discharge ,show , amniotic fluid and

meconium meconium Progress of labor through descent of head and Progress of labor through descent of head and

cervical dilatation cervical dilatation


Observation Observation Uterine action Uterine action : The frequency ,duration and intensity of : The frequency ,duration and intensity of

uterine contraction should be checked and recorded uterine contraction should be checked and recorded every 30 minutesevery 30 minutes

Interval Interval 30 Minutes 30 Minutes 15-20 minutes 15-20 minutes 2-3 2-3 minutes minutes

Duration Duration <=20 second <=20 second >20-40 second >20-40 second >40-70 >40-70 second second

Intensity Intensity Mild Mild Moderate Moderate Strong Strong


Maternal condition Maternal condition Temperature is checked and record Temperature is checked and record every 4 every 4

hours hours Respiration , pulse ,and blood pressure Respiration , pulse ,and blood pressure

checked and record checked and record every hourevery hour Monitor and record fetal heart rate to Monitor and record fetal heart rate to

recognize fetal distress or abnormalities . It recognize fetal distress or abnormalities . It should heard every should heard every 4 hours4 hours until rupture of until rupture of membranes , then every 30 minutes membranes , then every 30 minutes


Sign of maternal distressSign of maternal distress Increase pulse rate over 100 b/m Increase pulse rate over 100 b/m Elevated temperature more than 37.5 c Elevated temperature more than 37.5 c Decreased blood pressureDecreased blood pressure Sweating and pale face Sweating and pale face Signs of dehydration Signs of dehydration Dark vomitusDark vomitus Ketone bodies in urine Ketone bodies in urine Irritability and restlessness Irritability and restlessness Anxious expressionAnxious expression


Sign of Fetal distressSign of Fetal distress Excessive fetal movementsExcessive fetal movements Excessive moulding of fetal head Excessive moulding of fetal head Excessive formation of caput succedaneumExcessive formation of caput succedaneum A fetal heart rate increase to more than 160 A fetal heart rate increase to more than 160

b/min or decreasing to less than 100 b / m b/min or decreasing to less than 100 b / m or becoming irregular or becoming irregular

Passage of meconium in cephalic Passage of meconium in cephalic presentationpresentation

Nursing management of first Nursing management of first stage of laborstage of labor

The Partograph:The Partograph: The partograph is a single page graphic chart The partograph is a single page graphic chart

designed to record all the important designed to record all the important information about the woman and fetus during information about the woman and fetus during labor.labor.

The midwife or doctor can see the condition of The midwife or doctor can see the condition of the woman and fetus, and the progressthe woman and fetus, and the progress of labor of labor

Partograph and Partograph and Criteria for Active Criteria for Active

LaborLabor

Label with patient Label with patient identifying informationidentifying information

Note fetal heart rate, Note fetal heart rate, color of amniotic fluid, color of amniotic fluid, presence of moulding, presence of moulding, contraction pattern, contraction pattern, medications givenmedications given

Plot cervical dilationPlot cervical dilation Alert line starts at 4 Alert line starts at 4

cm--from here, expect cm--from here, expect to dilate at rate of 1 to dilate at rate of 1 cm/hourcm/hour

Action line: if patient Action line: if patient does not progress as does not progress as above, action is above, action is requiredrequired


Rest and sleep :-Rest and sleep :-

Anxiety and painful uterine contraction produce Anxiety and painful uterine contraction produce sleeplessness , so it is important to be with the woman , sleeplessness , so it is important to be with the woman , reassure her and encourage her to express her discomfort , reassure her and encourage her to express her discomfort , fear and anxiety fear and anxiety

N.BN.B Rest is important in the first stage of labor to :Rest is important in the first stage of labor to :

* Reserve energy * Reserve energy

* Prevent exhaustion and anxiety and maintain * Prevent exhaustion and anxiety and maintain

mental equilibriummental equilibrium . .

* Distracting factors ( divert attention away from * Distracting factors ( divert attention away from

labor painlabor pain) . ) .


The midwife helps the woman to sleep by :-The midwife helps the woman to sleep by :- 1. 1. Evacuate her bladder .Evacuate her bladder . 2. Serving her a warm , nourishing drink.2. Serving her a warm , nourishing drink. 3. Maintaining a quiet room with dim lighting 3. Maintaining a quiet room with dim lighting and a comfortable bed.and a comfortable bed. Ambulation may decrease the need for analgesia ,shorten labor Ambulation may decrease the need for analgesia ,shorten labor

and decrease incidence of fetal heart rate abnormalities and decrease incidence of fetal heart rate abnormalities The woman is allowed to ambulate if there are The woman is allowed to ambulate if there are no no

contraindicationscontraindications like like bleeding ,premature rupture of membranes bleeding ,premature rupture of membranes with high head , pregnancy –induced hypertension , cardiac with high head , pregnancy –induced hypertension , cardiac disease or any other medical problems disease or any other medical problems


NutritionNutrition & Hydration & Hydration During labor , there excessive loss of fluids , During labor , there excessive loss of fluids ,

and increased tendency to exhaustion and and increased tendency to exhaustion and dehydration due to strong muscular exercisedehydration due to strong muscular exercise

The painful contraction of the uterus during The painful contraction of the uterus during labor demand a continuous supply of glucose labor demand a continuous supply of glucose if this not obtained from the diet , the body if this not obtained from the diet , the body will start to metabolize protein and fat stores .will start to metabolize protein and fat stores .

If no food is allowed, an intravenous infusion If no food is allowed, an intravenous infusion may be sited to correct the may be sited to correct the homeostatic homeostatic imbalance imbalance by providing glucose and fluid by providing glucose and fluid


NutritionNutrition & Hydration & Hydration Care must be taken to assess the individual's need Care must be taken to assess the individual's need

and to avoid maternal fluid over load. High and to avoid maternal fluid over load. High concentration of glucose may artificiallyconcentration of glucose may artificially increase increase fetal blood glucosefetal blood glucose levels there by levels there by causing fetal causing fetal hyperinsulinism.hyperinsulinism.

Some times IV fluids are given to provide energy Some times IV fluids are given to provide energy and prevent dehydration in case of and prevent dehydration in case of vomiting & vomiting & possible use of anesthesia possible use of anesthesia

During early labor ,the woman should receive During early labor ,the woman should receive about 75ml of fluid per hour about 75ml of fluid per hour in the form of in the form of juices ,soups or tea with sugar and digestive juices ,soups or tea with sugar and digestive biscuitsbiscuits


NutritionNutrition & Hydration & Hydration Maintain an intake & output chartMaintain an intake & output chart Solid food is usually avoided during active Solid food is usually avoided during active

labor and anticipation of anesthesia may cause labor and anticipation of anesthesia may cause aspiration of vomitus aspiration of vomitus

If solid food is permitted it should rich in If solid food is permitted it should rich in carbohydrates such as jam ,honey .Fat and carbohydrates such as jam ,honey .Fat and portions are not allowed because they are not portions are not allowed because they are not easily digestedeasily digested


Comfort & AssistanceComfort & Assistance Follow the aseptic techniques to prevent infectionFollow the aseptic techniques to prevent infection Provide dry and clean clothes and bed linen for the Provide dry and clean clothes and bed linen for the

woman woman Provide mouth wash and sips of water if her mouth Provide mouth wash and sips of water if her mouth

is dry is dry Massage the back if she complain of backacheMassage the back if she complain of backache Relieve pain by encouraging deep breathing during Relieve pain by encouraging deep breathing during

contractions and use of analgesia contractions and use of analgesia Change the pad frequently if there is excessive Change the pad frequently if there is excessive

vaginal dischargevaginal discharge

Nursing management of first stage of Nursing management of first stage of laborlabor

Preparing for labor to prevent infectionPreparing for labor to prevent infection :- :-* * Trimming of hairTrimming of hair :- :- is permitted to clean and disinfect the is permitted to clean and disinfect the

valve to prevent infection . shaving is not advisable for fear valve to prevent infection . shaving is not advisable for fear of lacerations & infection of lacerations & infection

* * Enema Enema :-:- prepare & administer enema as needed to stimulate prepare & administer enema as needed to stimulate uterine contraction enema should be given early in the first uterine contraction enema should be given early in the first stage of labor & not repeated for 8 hoursstage of labor & not repeated for 8 hours . .

** Bath Bath :- :- A bath or shower is given early following an enema and A bath or shower is given early following an enema and trimming of hair . if the time is limited . wash at least from the trimming of hair . if the time is limited . wash at least from the umbilicus to the knees instruct the woman to wear a clean umbilicus to the knees instruct the woman to wear a clean nightdress or gown and avoid using cosmetic &bed linen should nightdress or gown and avoid using cosmetic &bed linen should be clean & dry be clean & dry


* * Hair and nailsHair and nails :- :- inspect and comp hair and cut and inspect and comp hair and cut and clean nails .clean nails .

* * Perineal swabbingPerineal swabbing :- :- swab the perineum on admission swab the perineum on admission then every 6 hours , before and after vaginal then every 6 hours , before and after vaginal examination , before delivery and before examination , before delivery and before catheterization . cover the valve with sterile padcatheterization . cover the valve with sterile pad

* * P.V :-P.V :- minimize at least 2 time hour and wear gloves , minimize at least 2 time hour and wear gloves , washing hands from case to another case .washing hands from case to another case .

- - N B :-N B :-if membranes is rupture before 12 hours the mother if membranes is rupture before 12 hours the mother must take antibiotic must take antibiotic


Posture of woman in laborPosture of woman in labor The nurse should allow the The nurse should allow the

woman to assume woman to assume any any comfortable positioncomfortable position , , exceptexcept the dorsal recumbent which the dorsal recumbent which may result in supine may result in supine hypotension and lead to fetal hypotension and lead to fetal distress distress

The nurse should encourage The nurse should encourage the woman to walk in the the woman to walk in the room if she is in active labor room if she is in active labor


Position and mobility :-Position and mobility :- Upright positionUpright position during labor will facilitate:-during labor will facilitate:- - Efficient uterine contraction - Efficient uterine contraction - Shorten the latent phase - Shorten the latent phase - Reduce the need for analgesic- Reduce the need for analgesic Lateral positionLateral position side – lying is recommended because :side – lying is recommended because : - Improve uterine contractions .- Improve uterine contractions . - Facilitates kidney function - Facilitates kidney function - Facilitates fetal rotation in posterior position - Facilitates fetal rotation in posterior position - Relives uterine pressure on and compression major - Relives uterine pressure on and compression major maternal blood vessels .maternal blood vessels .


Such position is indicated in the following Such position is indicated in the following conditionsconditions . .

Maternal supine hypotensive syndrome ,Maternal supine hypotensive syndrome , Fetal to correct FHR pattern relive pressure on Fetal to correct FHR pattern relive pressure on

the umbilical cardthe umbilical card Eliminate hypoxia resulting from maternal Eliminate hypoxia resulting from maternal

supine hypotensive syndrome .supine hypotensive syndrome . ROPROP woman should lie on her left sidewoman should lie on her left side . . LOPLOP woman should lie on her right side .woman should lie on her right side .


Woman in labor should not be out of bed in the Woman in labor should not be out of bed in the following cases :-following cases :-

When the membranes have ruptured , because the When the membranes have ruptured , because the risk of card prolapsed risk of card prolapsed

When she is medicated with any drug which might When she is medicated with any drug which might make her dizzy or unsteady on her feetmake her dizzy or unsteady on her feet

Rabidly progressive labor or late first stage in Rabidly progressive labor or late first stage in multipara or second stage of labor in primigravidamultipara or second stage of labor in primigravida . .

Obstetrical complications ante partum Obstetrical complications ante partum hemorrhage sever pre-eclampsia .hemorrhage sever pre-eclampsia .


Bladder & rectum care :-Bladder & rectum care :-

The woman should be encouraged to empty The woman should be encouraged to empty her bladder every 2-3 hours during labor .her bladder every 2-3 hours during labor .

The urine should be tested for the presence The urine should be tested for the presence of glucose ,protein and ketone bodiesof glucose ,protein and ketone bodies

A full bladder causes poor uterine A full bladder causes poor uterine contractions ,postpartum hemorrhage and contractions ,postpartum hemorrhage and injury or vescio- vaginal fistula . It prevents injury or vescio- vaginal fistula . It prevents the descent of the fetal head , increase pain the descent of the fetal head , increase pain and causes unnecessary discomfortand causes unnecessary discomfort


Retention of urine occurs frequently in labor due to :- Retention of urine occurs frequently in labor due to :-

* * Lack of muscle tone of the urinary bladder Lack of muscle tone of the urinary bladder

* * Uncomfortable use of bedpanUncomfortable use of bedpan

* * Pressure on the urethraPressure on the urethra

* * Elongation of the urethra , which Elongation of the urethra , which

inhibits relaxation of the urethral sphincter inhibits relaxation of the urethral sphincter


Early in labor disposable enema or suppository is given if Early in labor disposable enema or suppository is given if neededneeded

** To cleans the rectum To cleans the rectum * * Allows more room for the descent of the fetus .Allows more room for the descent of the fetus . * * Improve the quality of uterine contractions Improve the quality of uterine contractions ** Prevent the soiling of the sterile field during the Prevent the soiling of the sterile field during the birth of baby .birth of baby .Do not give an enema if :-Do not give an enema if :- 11. Membrane have ruptured . Membrane have ruptured 2.2. patient with ant partum hemorrhage . patient with ant partum hemorrhage . 3.3. patient has pre-eclampsia or eclampsia or heart disease patient has pre-eclampsia or eclampsia or heart disease

Nursing management of the second stage of laborNursing management of the second stage of labor

ASSESSMENTASSESSMENT

Assessment should include the Assessment should include the followingfollowing::

Uterine contractions Uterine contractions Maternal physical and emotional Maternal physical and emotional

statusstatus Fetal well being Fetal well being


Sings and symptoms of second stage of laborSings and symptoms of second stage of labor::1. 1. Contractions become strong, and more frequent Contractions become strong, and more frequent 2. Show is increased suddenly and becomes more blood 2. Show is increased suddenly and becomes more blood

tinged tinged 3. Membranes rupture3. Membranes rupture 4. Perineum starts to bulge and the anal orifice to dilate4. Perineum starts to bulge and the anal orifice to dilate 5. Woman starts involuntary bearing down and feels the 5. Woman starts involuntary bearing down and feels the

desire to defecatedesire to defecate 6. She may be eager to sleep6. She may be eager to sleep 7 She is apprehensive, irritable, unwilling to be touched 7 She is apprehensive, irritable, unwilling to be touched

and may cry if disturbedand may cry if disturbed8. She is frustrated, and unable to manage labor alone8. She is frustrated, and unable to manage labor alone

Preparation of the delivery roomPreparation of the delivery room:: Delivery room should always be ready for the conduct of Delivery room should always be ready for the conduct of

labor. Delivery trolley and emergency drug tray should labor. Delivery trolley and emergency drug tray should be readybe ready

The delivery room should be worm enough for the infant The delivery room should be worm enough for the infant All equipment needed for infant care is present and All equipment needed for infant care is present and

resuscitation trolley should be ready for use at all timesresuscitation trolley should be ready for use at all times Safety of woman should be ensured .She should be Safety of woman should be ensured .She should be

transferred between contractions and supported transferred between contractions and supported adequately adequately

Enough privacy should be provided Enough privacy should be provided Strict aseptic technique should be maintainedStrict aseptic technique should be maintained


Transfer to delivery roomTransfer to delivery room Primigravida Primigravida is transferred to the is transferred to the

delivery room when the cervix is delivery room when the cervix is fully dilated and presenting part is fully dilated and presenting part is seen seen

Multipara is transferred when the Multipara is transferred when the cervix is 7-8 cm (3-4 fingers)cervix is 7-8 cm (3-4 fingers)

Preparation of the attendantPreparation of the attendant:: The attended should put on cap and mask, The attended should put on cap and mask,

wash and scrub hands and put on a sterile wash and scrub hands and put on a sterile gown and gloves.gown and gloves.

The attendant starts to scrub up for The attendant starts to scrub up for primigravidaprimigravida when when the head is seen in the vulvathe head is seen in the vulva during contractions and for during contractions and for multiparamultipara towards towards the the end of the first stage.end of the first stage.

Preparation of the womanPreparation of the woman:: Place the woman in the delivery table and put her Place the woman in the delivery table and put her

legs in the leg holderslegs in the leg holders The legs and thighs should be dressed with sterile The legs and thighs should be dressed with sterile

leggings. Sterile should be laid over the abdomen leggings. Sterile should be laid over the abdomen and under buttocks leaving only the vulva and and under buttocks leaving only the vulva and perineum exposed perineum exposed

Empty the bladder. Swab external genitalia and Empty the bladder. Swab external genitalia and apply antiseptic solution apply antiseptic solution


Posture of woman in Posture of woman in laborlabor::

The woman lies on the The woman lies on the delivery table in one of delivery table in one of the following positionsthe following positions: :

Dorsal or lithotomy Dorsal or lithotomy positionposition: :

the woman lies on her the woman lies on her back and puts her legs back and puts her legs up into the stirrups or up into the stirrups or leg holdleg hold

The advantage of this The advantage of this position isposition is

Voluntary effort is betterVoluntary effort is better Change of position is not Change of position is not

needed to check FHS and needed to check FHS and conduct the 3rd stage of conduct the 3rd stage of laborlabor

Draping woman & Draping woman & preserving aseptic preserving aseptic techniques are easytechniques are easy

Left lateral positionLeft lateral position

Woman lies on left side, her thighs are Woman lies on left side, her thighs are partly flexed and her knees are held apart partly flexed and her knees are held apart by another personby another person

The advantage of this position isThe advantage of this position is Decrease liability for perineal Decrease liability for perineal

laceration laceration Easy removal of fecesEasy removal of feces Easy manipulation of shoulders Easy manipulation of shoulders good for fast second stage. good for fast second stage. May be a comfort position for mom. May be a comfort position for mom.

Positions for Second StagePositions for Second Stage

Semi-sitting. With pillows Semi-sitting. With pillows underneath knees, arms, underneath knees, arms, and back. During and back. During contractions, can wrap contractions, can wrap hands around knees and hands around knees and pull knees up toward pull knees up toward shoulders (as in squatting).shoulders (as in squatting).

Most common in hospital Most common in hospital setting setting for mom and babyfor mom and baby:- :-

- - Some help from gravity Some help from gravity moving the babydownmoving the babydown - Mom feels more in control - Mom feels more in control than in lithotomy positionthan in lithotomy position. . Benefits for caregivers:Benefits for caregivers: - Good view of perineum,- Good view of perineum,

- Easy access to perineum- Easy access to perineum..

Infection Prevention PracticesInfection Prevention Practices

Use disposable materials once and decontaminate Use disposable materials once and decontaminate reusable materials throughout labor and childbirthreusable materials throughout labor and childbirth

Wear gloves during vaginal examination, during Wear gloves during vaginal examination, during birth of newborn and when handling placentabirth of newborn and when handling placenta

Wear protective clothing (shoes, apron, glasses)Wear protective clothing (shoes, apron, glasses) Wash handsWash hands Wash woman’s perineum with soap and water and Wash woman’s perineum with soap and water and

keep it cleankeep it clean Ensure that surface on which newborn is delivered is Ensure that surface on which newborn is delivered is

kept cleankept clean High-level disinfect instruments, gauze and ties for High-level disinfect instruments, gauze and ties for

cutting cordcutting cord

Promotion of comfortPromotion of comfort:: Encourage the woman to rest and to let all Encourage the woman to rest and to let all

muscles relax between contractions, e.g. muscles relax between contractions, e.g. breathing exercisesbreathing exercises

Give a few sips of water to provide moisture Give a few sips of water to provide moisture and relieve dryness of the mouth and relieve dryness of the mouth

Sponge the face and hands with cool waterSponge the face and hands with cool water Keep the woman informed of her progressKeep the woman informed of her progress

Bearing downBearing down:: Prop up the woman with additional Prop up the woman with additional

pillows to assume pillows to assume a semi-recumbent a semi-recumbent positionposition

Encourage her to push during Encourage her to push during contractions.contractions.

Teach the woman how to bear down .She Teach the woman how to bear down .She takes a deep breath, holds it, closes her takes a deep breath, holds it, closes her lips and bears downlips and bears down

The woman must not cry out or make The woman must not cry out or make any sound because much of the expulsive any sound because much of the expulsive force will be wastedforce will be wasted

ObservationsObservations:: Close and frequent observation is very important Close and frequent observation is very important

for both the woman and fetusfor both the woman and fetus The fetal heart should be checked after 2-3 The fetal heart should be checked after 2-3

contractions .If fetal distress is suspected, check it contractions .If fetal distress is suspected, check it after each contractionafter each contraction

The maternal pulse should be taken every 10 The maternal pulse should be taken every 10 minutesminutes

The strength and frequency of the contractions and The strength and frequency of the contractions and whether the uterus is relaxed between them must be whether the uterus is relaxed between them must be closely watchedclosely watched


Protection of perineumProtection of perineum:: Obtain the woman’s cooperation .She Obtain the woman’s cooperation .She

should only push when instructed and should only push when instructed and must desist while the head is actually must desist while the head is actually being born being born

Maintain flexion and control too rapid Maintain flexion and control too rapid extension of the head extension of the head

Deliver the head between contractionsDeliver the head between contractions


After delivery of the headAfter delivery of the head:: Wipe any mucus from the Wipe the Wipe any mucus from the Wipe the

eyelids with separate swabs of sterile eyelids with separate swabs of sterile cottoncotton

Mouth and nostrils with gauze swabMouth and nostrils with gauze swab If the umbilical cord is looped round the If the umbilical cord is looped round the

infant’s neck, slip it over the head if it infant’s neck, slip it over the head if it loose or clamp and cut it, if it tightloose or clamp and cut it, if it tight

Give the woman IM syntometrine, Give the woman IM syntometrine, 1ml after delivery of the infant’s 1ml after delivery of the infant’s anterior shoulder, or after anterior shoulder, or after expulsion of placenta, to stimulate expulsion of placenta, to stimulate uterineuterine contractions and prevent contractions and prevent bleedingbleeding

Notes and record the time of birthNotes and record the time of birth

Nursing management of the third stage of laborNursing management of the third stage of labor

AssessmentAssessment Assess uterine contractions Assess uterine contractions Observe maternal vital signsObserve maternal vital signsMidwife role in third stage :- Midwife role in third stage :-

Apply two forceps on umbilical cord, and cut in betweenApply two forceps on umbilical cord, and cut in between Carefully inspect vagina, perineum and labia lacerations Carefully inspect vagina, perineum and labia lacerations

and tearsand tears Inspect vulva for bleeding, edema and hematomaInspect vulva for bleeding, edema and hematoma Make sure that the uterus is well contracted. Flabbiness or Make sure that the uterus is well contracted. Flabbiness or

enlargement of the uterus indicates bleeding enlargement of the uterus indicates bleeding


Palpate the height of the fundus. Feeling the fundus Palpate the height of the fundus. Feeling the fundus above the umbilicus may be due to presence of above the umbilicus may be due to presence of another infant, blood clots, big placenta, or full another infant, blood clots, big placenta, or full bladder.bladder.

Avoid vigorous uterine massage because it may lead Avoid vigorous uterine massage because it may lead to irregular contractions, and causes retained parts to irregular contractions, and causes retained parts or membranesor membranes

Observe signs of placental separationObserve signs of placental separation


Evacuate the bladder by a catheter if the placenta Evacuate the bladder by a catheter if the placenta is not separated within 20 minutesis not separated within 20 minutes

If the placenta delivery , examine the placenta and If the placenta delivery , examine the placenta and membranes for general appearance, completeness, membranes for general appearance, completeness, cord vessels, and weight.cord vessels, and weight.

Look for any abnormality in the insertion of the Look for any abnormality in the insertion of the cord, and check for 2 arteries and 1 vein in the cord, and check for 2 arteries and 1 vein in the cordcord

Estimate the average blood loss (200- less than Estimate the average blood loss (200- less than 500ml) 500ml)

Clean and dry the vulva, buttocks and thighs and Clean and dry the vulva, buttocks and thighs and then apply a sterile pad.then apply a sterile pad.

Immediate care of the newbornImmediate care of the newborn

ABCW principles of deliveryABCW principles of delivery Remember the following ABCW principles Remember the following ABCW principles

of delivery to ensure adequate of delivery to ensure adequate resuscitation of the infantresuscitation of the infant::

AirwayAirway Breathing Breathing CirculationCirculation WarmthWarmth

Objectives of immediate care of the newbornObjectives of immediate care of the newborn::

To establish and maintain respiratory To establish and maintain respiratory function function

To provide warmth and prevent To provide warmth and prevent hypothermiahypothermia

To ensure safety from injury and To ensure safety from injury and infectioninfection

To identify actual and potential problems To identify actual and potential problems that might require immediate actionthat might require immediate action

Assessment of the infantAssessment of the infant’’s conditions condition

Assessment of the infantAssessment of the infant’’s conditions condition

1.Clear the airway, by hold the infant 1.Clear the airway, by hold the infant upside down for seconds and upside down for seconds and perform gentle suction to establish perform gentle suction to establish breathing and improve infant’s colorbreathing and improve infant’s color

2.The APGAR Score it recorded at 1 2.The APGAR Score it recorded at 1 and 5 minutes after birthand 5 minutes after birth

Total score 10Total score 10 Normal =7 –10Normal =7 –10Mild asphyxia = 4-6Mild asphyxia = 4-6 Sever asphyxia =0-3Sever asphyxia =0-3

Sign Score 0 Score 1 Score 2

A Appearance Blue or

pale Body pink limbs blue

All pink

P Pulse or apex beat Absent Below 100/min Above 100/min

G Reflex (Grimace) Non Grimace cry

A Activity, tone Limp Some flexion of limbs

Active movements limbs well flexed

R Respiratory effort Non Slow, irregular Good strong cry

Assessment of the infantAssessment of the infant’’s s conditioncondition

3. 3. Warmth: Warmth: IIt is very important to keep the infant t is very important to keep the infant warm at birth because he will lose heat rapidly warm at birth because he will lose heat rapidly through evaporation .So the labor room should be through evaporation .So the labor room should be worm and the infant should be dried gently and worm and the infant should be dried gently and wrapped in a warm dry towel to avoid exposurewrapped in a warm dry towel to avoid exposure

4. 4. Umbilical cord: Umbilical cord: Double ligation may be used .The Double ligation may be used .The first at 5cm from umbilicus to prevent first at 5cm from umbilicus to prevent strangulation of a congenital umbilical hernia .The strangulation of a congenital umbilical hernia .The second at 2cm further for securitysecond at 2cm further for security


5. Weight and measurements: The normal weight is 5. Weight and measurements: The normal weight is 2.5-3.5 kg. The average length is 50 cm2.5-3.5 kg. The average length is 50 cm

6.Care for eyes, the eyes are washed with sterile 6.Care for eyes, the eyes are washed with sterile warm water and erythromycin ointment is the warm water and erythromycin ointment is the drug of choice nowdrug of choice now

7.Vitamin k should be given to prevent 7.Vitamin k should be given to prevent bleedingbleeding

8.Identification, wrist or ankle band or a foot 8.Identification, wrist or ankle band or a foot print may be used print may be used


9.Position:9.Position: The head of the infant should be placed lower The head of the infant should be placed lower than the body in order to drain mucus and secretions than the body in order to drain mucus and secretions by gravity, stimulate the brain centers, and improve by gravity, stimulate the brain centers, and improve circulation. This is done only to the full term babiescirculation. This is done only to the full term babies

10.Examinations: It is very important to examine the 10.Examinations: It is very important to examine the infantinfant

*General appearance *General appearance ** ColorColor** RespirationRespiration** Muscle toneMuscle tone** TemperatureTemperature 1111. . Assessment of the head and neck to observe Assessment of the head and neck to observe &palpate head for moulding and caput &palpate head for moulding and caput succedaneumsuccedaneum

Documents

3management of All Stages l Labor & Delivery