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TOPIC V.

INTRARTUM/INTRAPARTAL PERIOD
1. The intrapartum period extends from the beginning of contractions that cause cervical
dilation to the first 1 to 4 hours after delivery of the newborn and placenta.
2. A series of physiological and mechanical processes by which all the products of conception
are expelled from the birth canal.
3. Intrapartum care refers to the medical and nursing care given to a pregnant woman and her
family during labor and delivery.
4. Woman in labor is called the PARTURIENT.
GOALS OF INTRAPARTUM CARE
1. To promote physical and emotional well-being in the mother and fetus.
2. To incorporate family-centered care concepts into the labor and delivery experience.
FACTORS AFFECTING THE INTRAPARTUM EXPERIENCE
1. Previous experience with pregnancy
2. Cultural and personal expectations
3. Pre-pregnant health and biophysical preparedness for childbearing
4. Motivation for childbearing
5. Socioeconomic readiness
6. Age of mother
7. Partnered versus unpartnered status
8. Extend of parental care
9. Extend of childbirth education
PHENOMENA AND PROCESS OF LABOR AND DELIVERY
I.

ONSET OF LABOR

Initiation of Labor
1. Labor is the process by which the fetus and products of conception are expelled as the result
of regular, progressive, frequent, strong uterine contractions.
2. The exact mechanism that initiates labor is unknown.
3. Theories include:
A. Uterine stretch theory Uterus becomes stretched and pressure increases, causing
physiologic changes that initiate labor.
B. Oxytocin stimulation The pressure of the fetal head on the cervix in late pregnancywill
stimulate the PPG to secrete oxytoxin.
C. Progesterone deprivation - As pregnancy advances, progesterone (uterine mucle relaxant)
is less effective in controlling rhythmic uterine contractions that normally occur. In
addition, there may also be an actual decrease in the amount of circulating progesterone.
D. Prostaglandin, Estrogenic and Fetal Hormone Theory
a. There is increased production of prostaglandins by fetal membranes
and uterine decidua as pregnancy advances.
b. In later pregnancy, the fetus produces increased levels of cortisol that
inhibit progesterone production from the placenta.
c. Initiation of labor is said to result from the release of arachidonic acid
produced by steriod acstion sonlipid precursors. Arachidonic acid is
said to increase prostaglandin synthesis which causes uterine
contraction.
E. Aging Placenta as the palcenta matures blood supply will be diminished causing uterine
contraction.
II.

SIGNS AND SYMBOLS OF IMPENDING LABOR


(Premonitory signs)
1. Lightening is the descent/dipping/dropping/settling of the fetus and uterus into the pelvic
cavity.
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Criteria
Contractions
Discomfort

2.

3.
4.

5.
6.
7.

True labor
False labor
Regular, progressive
Irregular, non-progressive
Lumbo-sacral radiating to the
Abdominal
front, increasing intensity
Withnot
progressive
cervical
dilation
No cervical dilation and effacement
Cervix
Engagement should
be confused
with ligthening.
and when
effacement
the most
Engagement occurs
presenting
partimportant
passes through the pelvic brim.
For Primis occurs earlier or 2difference
weeks before labor
Generally
intensified
Generally unaffected
Walking
Multis occurs a day before
labor or
on a day of labor.
Enema
Signs of lightening:
Generally intensified
Generally unaffected
Show
Present
and increasing
Absent
a. Relief
of dyspnea
Medication
Notofeasily
disrupted
by
Generally relieved by mild sedation
b. Relief
abdominal
tightness
c. increase in
urinary frequency, varicosities, pedal edema due to
medications
pressure on the bladder and pelvic girdle
d. shooting pains down the legs because of pressure on the sciatic nerve
e. increase amount of vaginal discharge
Braxton hicks contractions occur 3 to 4 weeks before labor are irregular, intermittent
contractions that have occurred throughout the pregnancy; become uncomfortable, produce
a drawing pain in the abdomen and groin and does not dilate the cervix. Relieve by walking
and enema.
Cervical changes include softening ripening and effacement of the cervix that will cause
explosion of the mucus plug (bloody show) and increased vaginal discharge.
Rupture of amniotic membranes may occur before the onset of labor if the woman suspects
that her membranes have ruptured, she should contact her health care provider and go to
the labor suite immediately so that she may be examined for prolapsed cord a lifethreatening condition for the fetus.
Burst of energy or increased tension and fatigue may occur before the onset of labor
because of hormone epinephrin
Weight loss of about 1 to 3 pounds may occur 2 to 3 days before the offset of labor.
Urinary frequency returns.

8. Backache may increase due to fetal pressure


9. Diarrhea may occur.
10. False labor contractions may occur
True and False Labor Contractions

III.
PHYSIOLOGIC ALTERATION IN LABOR
1. Dilatation : progressive opening/widening of the cervical os
a. Expressed in cm
b. Described as opening, widening, enlarging or increase in diameter
c. Specifically refering to external cervical os
d. 10 cm is fully dilated cervix the end of the first stasgse sof labor
2. Effacement: thinning and obliteration of the cervical canal
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a. Expressed in %
b. Described a thinning, shortening or narrowing
c. 100% effacement means the cervix is fully effaced cervical canl is paper-thin or
absent
75% effacement means the cervix has become of its original length
50% effacement means the cervix has become of its original length
25% effacement means the cervix has become of its original length
3. Physiologic retraction ring: Is formed at the boundary of the upper and lower uterine
segments.
In difficult labor when the fetus is larger than the birth canal, the round ligaments of the
uterus become tense during dilatation and expulsion causing abdominal indentation
called BANDLS pathological retraction ring, a danger sign signifying impending
rupture of the uterus if not managed.
IV.

FACTORS AFFECTING LABOR

1. POWER
A. The primary Power: Uterine Contraction
This refers to the frequency duration and strength of uterine contraction to cause
complete cervical effacement and dilation.
Successful labor also depends on uterine contractions occurring at regular intervals
and having adequate intensity.
Uterine contractions are involuntary, rhythmic, and intermittent.
Uterine contractions cause vasoconstriction of the umbilical cord vessels;
considered normal.
Uterine contractions increase in intensity, frequency, and duration as labor
progresses due to stretching of the cervix.

During uterine contractions, the active upper portion of the uterus becomes
thicker and shorter, whereas the lower uterine segment stretches and becomes
thinner and longer (referred to as fundal dominance).

At the completion of a contraction, the upper uterine segment retains its


shortened, thickened cell size and, with each succeeding contraction, becomes
thicker and shorter. As a result, the upper uterine segment never totally relaxes
during labor. Cells of the lower uterine segment become thinner and longer with
each contraction. This mechanism is greatly responsible for the progress of the
fetus through the birth canal.

The differentiation point between the upper and lower uterine segment is known
as the physiologic retraction ring.

Phases of Uterine contractions


Increment (cresendo): the phase of increasing or building up of contraction, the
longest phase
Acme (apex): the height/peak of uterine contraction
Decrement (decresendo): the phase of decreasing contratiuon or letting up the late
phase
Peak
Relaxation
Increment
decrement
A

D
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From A B: Duration. The period from the beginning of increment to the


completion of decrement of the same contraction. Expressed in seconds. The
normal maximin duration is 90 seconds during transition phase and second stage
of labor
From A C: Frequency. The period of the time from the beginning of one
contraction to the beginning of the next contraction. Expreed in
every________minutes.
From B C : Interval: The period from the decrement of the first to the
increment of the second contraction

Intensity refers to the strength of uterine contraction during acme; can be


determined by palpation.
Palpation placing the hand lighlt on the fundus with the fingers spread; described
as mild, moderate, and strong by judging the degree of indentability/depressability
of the uterine wall during acme
a. Strong when the uterine fundus is very frim and cannot be indented with
fingers
b. Moderate - when the fundus is difficult to indent
c. Mild when fundus i s tense but can be indented easily with fingertips
B. The secondary powers
Maternal bearing down
Cervical Dilatation: 10 cm
Fetal station: +1; low enough to stimulate Ferguson reflex: maternal involuntary
urge to push stimulated by strech receptors in the pelvic floor
Correct pushing: take a deep breath as soon as the next contraction begins, and then
with the breath held, exert a downward pressure exactly as though she were
straining at stool
Discourage prolong maternal breath holding of more than 6 seconds, during
pushing. Support involuntary pushing, granting, groaning, exhaling, or breathholding for less than 6 seconds.
Have 4 or more pushes per contraction
Intraabdominal pressure: as the women pushes the intraabdominal pressure increases
2. PASSAGEWAY
This refers to the adequacy of the pelvis and birth canal in allowing fetal descent
Successful labor and delivery depend on adequate pelvic dimensions, adequate fetal
dimensions and presentation, and adequate uterine contractions.
The pelvis is composed of four bones:
Two innominate bones (hip bones) form the sides and front.
- 3 Parts of 2 Innominate Bones
a. Ileum lateral side of hips
Iliac crest flaring superior border forming prominence of hips
b. Ischium inferior portion
Ischial tuberosity where we sit landmark to get external measurement
of pelvis
c. Pubes ant portion symphisis pubis junction between 2 pubis
1 sacrum posterior portion sacral prominence landmark to get internal
measurement of pelvis
1 coccyx 5 small bones compresses during vaginal delivery

These factors include:


a. Type of pelvis (gynecoid, android, anthropoid, or platypelloid)
Gynecoid - round, wide, deeper most suitable (normal female pelvis) for
pregnancy
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Android heart shape male pelvis- anterior part pointed, posterior part shallow,
deep transverse arrest of descent of the fetus and failure of rotation of the fetus are
common
Anthropoid oval, ape like pelvis, oval shape, AP diameter wider transverse
narrow, may allow for easy delivery of an occiput-posterior presentation of the
fetus;
Platypelloid flat AP diameter narrow, transverse wider, arrest of fetal descent
at the pelvic inlet is common
b. Structure of pelvis (true versus false pelvis)
False pelvis lies above an imaginary line called the linea terminalis or pelvic bri.
Function of the false pelvis is to support the enlarged uterus.
True pelvis lies below the pelvic brim or linea terminalis; it is the bony canal
through which the fetus must pass. It is divided into three planes: the inlet, the
midpelvis, and the outlet.
Inlet:
- Upper boundary of the true pelvis bounded by upper margin of symphysis
pubis in front, linea terminalis on sides, and sacral promontory (first sacral
vertebra) in back.
- Largest diameter of inlet is transverse
- Smallest diameter of inlet is anteroposterior. Anteroposterior diameter is
most important diameter of inlet: measured clinically by diagonal
conjugate, distance from lower margin of symphysis to the sacral
promontory (usually 5 inches [14 cm])
- Obstetric (true) conjugate, distance between inner surface of symphysis and
sacral promontory measured by subtracting to inch (1.5 to 2 cm)
(thickness of symphysis) from the diagonal conjugate. Adequate diameter
is usually 11.5 cm. This is the shortest anteroposterior diameter through
which the fetus must pass.
Midpelvis:
- Bounded by inlet above and outlet below true bony cavity. Contains the
narrowest portion of the pelvis.
- Diameters cannot be measured clinically.
- Clinical evaluation of adequacy is made by noting the ischial spines.
Prominent spines that protrude into the cavity indicate a contracted
midpelvic space. The interspinous diameter is 4 inches (10 cm).
Outlet:
- Lowest boundary of the true pelvis.
- Bounded by lower margin of symphysis in front, ischial tuberosities on
sides, tip of sacrum posteriorly.
- Most important diameter clinically is distance between the tuberosities (> 4
inches
Important Measurements at the 3 plane of pelvis for
anteroposterior diameters
1. Diagonal Conjugate measure between sacral promontory and inferior
margin of the symphysis pubis.Measurement: 11.5 cm - 12.5 cm basis in
getting true conjugate. (DC 11.5 cm=true conjugate).estimated on
vaginal examination. Widet anteropoterior diameter at outlet.
2. True conjugate/conjugate vera measure between the anterior surface of
the sacral promontory and superior margin of the symphysis pubis.
Measurement: 11.0 cm
3. Obstetrical conjugate smallest AP diameter. Pelvis at 10 cm or more.
4. Tuberoischi Diameter transverse diameter of the pelvic outlet. Ischial
tuberosity approximated with use of fist 8 cm & above.
Pelvic Dimensions
Adequate pelvic inlet (anteroposterior diameter; normal shape).
Adequate midpelvis (ischial spines do not protrude into bony canal).

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Adequate outlet (adequate distance between tuberosities; mobile coccyx).


Adequacy of pelvic dimensions determined by pelvic examination during
pregnancy and again with the onset of labor.

3. PASSENGER.
This refers to the fetus and its ability to move through the passage way
Important fetal dimensions influenced by fetal size, posture/attitude, lie, and
presentation. Fetal position is also an important factor in successful labor.
i. Fetal head
It is the most important part of the fetus because it is:
a. Largest part of the body
b. Most frequent presenting part
c. Least compessible of all parts
In approximately 95% of all births, the fetal head presents first. The sutures and
fontanelles provide important landmarks for determining fetal position during a
vaginal examination
Bones of the fetal skull:
a. Occipital bone posteriorly
b. Two parietal bones on the sides.
c. Two temporal bones anteriorly.
d. Two frontal bones anteriorly.
Sutures of the fetal skull; membranous spaces between the bones of the fetal skull:
allows the bones to move and overlap, changing the shape of the fetal head in order
to fit the birth canal, a process called molding
a. Frontal suture is between the two frontal bones.
b. Sagittal between the two parietal bones.
c. Coronal between the frontal and parietal bones.
d. Lambdoidal between the back of the parietal bones and the margin of the
occipital bone.
Fontanelles are irregular spaces formed where two or more sutures meet.
a. Anterior fontanelle largest fontanelle; junction of the sagittal, frontal, and
coronal sutures. Closes by age 12 18 months; diamond shaped.
b. Posterior fontanelle located where the sagittal suture meets the
lambdoidal (smaller than anterior). Closes at age 6 to 8 weeks/ 2 3
months; triangle shaped.
ii. Fetal Size
Size of the fetal head and capability of the head to mold the passageway.
With excessive size, fetal skull bones may not be able to override enough to be
accommodated in the bony pelvic cavity.
iii. Fetal presentation
The part of the fetus enters to maternal pelvis first.
Whichever portion of the fetus is deepest in the birth canal and is felt on vaginal
examination is referred to as the presenting part; this determines fetal presentation.
Presentation can be:
A. Vertical
1. Cephalic presentation. Classified according to the relationship between the
head and body of the fetus ordinarily, the head is flexed sharply so that the
chin is in contact with the thorax. 95 % of term deliveries.
a. Vertex or occiput- occipital fontanel is the presenting part,
completely flexed upon the fetal chest
b. Face presentation- fetal neck sharply extended occiput and back
come in contact, hyperexted with the chin presenting.
c. Sinciput- partially flexed with the anterior fontanel or bregma
presenting, moderately flexed.
d. Brow- partially extended,
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Brow and sinciput almost always converted into vertex or face by


flexion and extension, failure leads to dystocia
2. Breech 3% of term births
a. Frank/ Incomplete the hips maybe flexed and the knees extended
b. Complete the fetus knees and hips both maybe flexed, positioning the
thighs on the abdomen and calves on the posterior thighs
c. Footling extension of the knees and hips
Single one leg unflexed and extended; one foot presenting
Double - legs unflexed and extended, feet are presenting
B. Horizontal Transverse Lie
1. Shoulder, or compound (hand/arm presenting same time as vertex [head] or
hand presenting same time as breech.
iv. Fetal position
The relationship of a particular reference points of the presenting part and the
maternal pelvis / Standard landmarks for the fetal presenting part.
Refers to the relationship of the presenting part to the right or left side of maternal
birth canal
A three-letter abbreviation is used to describe the relationship of the presenting part
to the maternal pelvis:
- Identify which side the presenting part is facing in the pelvis: R (right) or L (left).
- Identify the landmark that is presenting:
1. O (occiput, or head) 2/3 of all vertex presentations- LO position
2. S (sacrum) breech
3. Sc (scapula, or shoulders)
In shoulder presentation, the acromion is the portion of the fetus
chosen for orientation with the maternal pelvis
The acromion or back of the fetus may be directed posteriorly or
anteriorly and superiorly and inferiorly
4. M (mentum, or chin) - face
- Identify the direction the presenting part is facing in the pelvis:
A (anterior or front)
P (posterior or back)
T (transverse)
-

DIAGNOSIS OF FETAL PRESENTATION AND POSITION


Methods used to diagnose fetal presentation and position
1. Abdominal palpation (Leopold Maneuvers)
First maneuver - to determine fetal presentation (longitudinal axis) or the
part of the fetus (fetal head or breech) that is in the upper uterine fundus.
While facing the woman, place the hands on top and side of the uterus
(fundus) and palpate. Note the size, shape, and consistency of what is in
the fundus (upper portion of the uterus). The head feels smooth,
hard/firm, and round, freely movable and ballotable. A breech feels
irregular, rounded, softer, and is less mobile.
Second maneuver - to determine the fetal position or identify the
relationship of the fetal back and the small parts to the front, back, or
sides of the maternal pelvis. Still facing the woman, place hands on either
side at the middle of the abdomen. While one hand stabilizes the one side
of the uterus, the other hand pushes the contents of the abdomen toward
the other hand to stabilize the infant for palpation. Next, palpate, applying
gentle but deep pressure, beginning at the midline near the fundus and
continue down the side (posteriorly) toward the woman's back. Continue
down the abdomen to the symphysis pubis. Determine what fetal body
part lies on the side of the abdomen. Reverse the hands and repeat the
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maneuver. If firm, smooth, and a hard continuous structure, it is likely to


be the fetal back; if smaller, knobby, irregular, protruding, and moving, it
is likely to be the small body parts (extremities).
Third maneuver - to determine the portion of the fetus that is presenting.
While facing the woman, grasp the part of the fetus situated in the lower
uterine segment between the thumb and middle finger of one hand. Using
firm, gentle pressure, determine if the head is the presenting part. Pay
close attention to the size, contour, and consistency of the presenting part.
The head will feel firm and globular. If not engaged into the pelvis, the
presenting part is movable. If immobile, engagement has occurred. This
maneuver is also known as Pallach's maneuver or grip.
Fourth maneuver - to determine fetal attitude or the greatest prominence
of the fetal head over the pelvic brim. In this maneuver, the examiner
faces the woman's feet. The examiner places his or her hands on the sides
of the uterus, below the umbilicus and pointing them toward the
symphysis pubis. The examiner then presses deeply with the fingertips
facing in the direction of the pelvic inlet (toward the symphysis pubis)
and begins to feel for the cephalic prominence. If the cephalic
prominence is felt on the same side as the small parts, it is usually the
sinciput (fetus' forehead), and the fetus will be in vertex or flexed
position. If the cephalic prominence is felt on the same side as the back, it
is the occiput (or crown), and the fetus will be vertex or slightly extended
position. If the cephalic prominence is felt equally on both sides, the
fetus' head may be in a military position (common in posterior position).
Then move the hands toward the pelvic brim. If the hands converge
(come together) around the presenting part, it is floating. If the hands
diverge (stay/move apart), the presenting part is either dipping or engaged
in the pelvis.
2. Vaginal examination
Explain the procedure to the woman. Place her in a lithotomy position.
Conduct examination gently, under aseptic conditions.
Evaluate the following:
a. Condition of cervix
Hard or soft (in labor, cervix is soft).
Effaced and thin or thick and long (in labor, cervix is thin and
effaced). Measured in percentages from 0% to 100%.
Easily dilatable or resistant.
Closed (fingertip, < 1 cm) or open (dilated); degree of dilation,
measured in centimeters from 1 to 10 cm (complete dilation).
b. Presentation
Breech, cephalic (head), or shoulder.
Caput succedaneum (edema occurring in and under fetal scalp)
present (small or large).
Station identified: engaged, floating.
c. Positions
Cephalic presentation (identification of the sagittal suture and of
its direction).
Location of posterior fontanelle.
d. Membranes intact or ruptured
Amount and color of fluid.

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Passage of meconium; consistency of meconium (eg, thin, thick,


particulate matter)
Odor.
Bulging.
Rupture usually increases frequency and intensity of uterine
contractions.
ROM may be contraindicated in presence of vaginal bleeding,
premature labor, or abnormal fetal presentation or position.
e. Perineum
Assess for ulcerations or vesicles that might indicate sexually
transmitted disease, such as syphilis or genital herpes.
Note: If these are present, stop the examination and notify the
primary care provider.
f. Auscultation
3. Imaging studies (UTZ)
Uses in the first trimester of pregnancy include:
a. Early confirmation of pregnancy and determination of the estimated
date of confinement.
b. Diagnosis of an ectopic pregnancy.
c. Detection of an intrauterine device.
d. Evaluation of placental location.
e. Diagnosis of a multiple gestation.
f. Guidance for chorionic villus sampling (CVS).
Uses in the second and third trimester include:
a. Evaluation of fetal growth, weight, and gestational age.
b. Evaluation of the placenta for placenta previa or separation associated
with vaginal bleeding.
c. Evaluation of fetal presentation and position.
d. Evaluation of fetal abnormalities.
e. Evaluation of fetal viability.
f. Determination of the Biophysical Profile (BPP) Score.
g. Evaluation of amniotic fluid volume.
h. Guidance for amniocentesis or fetal blood sampling.
v. Fetal posture/attitude
Relationship of the fetal parts to trunk or to one another
In later months of pregnancy the fetus assumes a characteristic posture described
as attitude or habitus to accommodate to the uterine cavity.
a. Flexion
b. Extenion
The fetus forms an ovoid mass that corresponds roughly to the shape of the
uterus
- the fetus becomes folded upon itself that the back becomes markedly convex
- head flexed so that chin is in contact with the chest
- thighs are flexed over the abdomen
- legs are bent at the knees
- arches of feet rest upon the anterior surfaces of the legs
Flexed head allows smallest diameter of fetal head (occiput) to present and pass
through the birth canal
vi. Fetal lie
Fetal lie is the relation of the long axis of the fetus to that of the mother
1. Longitudinal 99% of labors at term: has two alsternatives
The fetal head will present (cephalic presentation)
or the buttocks or feet will present (breech presentation
2. Transverse the shoulder presents
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Predisposing factors for transverse lies:


1. multiparity
2. Placenta previa
3. Hydramnios
4. uterine anomalies
3. Oblique lie the fetal and the maternal axes may cross at a 45 degree angle,
unstable the fetus is in an angle off the transverse lie
4.

vii. Fetal station


Relationship of the ischial spines, the single most important landmark of the pelvis
Measures how far the presenting part has devcended into the pelvis --- measures the
degree of descent
- Floating : unengaged presenting part
- Station 0: presenting part at the level of ischial spines
- Minus station: if the presenting part is above the level of the ischial spines, the
station is expressed s negative number.
- Plus station : if the presenting part is below the ischial spines (outlet , the station
is expressed as positive number
- Station +3 or +4 : synonimous to crowning ( encircling of the largest diameter of
the fetal head by the vulvar ring)
4. Psyche/Person psychological state when the mother is fighting the labor experience
Cultural Interpretation
Preparation considers as a valuable tranquilizer during the birth process
Support System the presence of the husband in the labor and delivery room can
provide emotional support less anxiety less emotional tension less pain
perception
Past Experience
V.

STAGES OF LABOR
Normal Length of Labor
Stages of Labor
First
Second
Third
Total

Primipara
12 hours
80 minutes
10 minutes
14 hours

Multipara
7 hours, 20 minutes
30 minutes
10 minutes
8 hours

1. First Stage of Labor (Stage of Cervical Dilation)


Begins with the first true labor contractions and ends with complete effacement and
dilation of the cervix (10 cm dilation).
Power/forces: Involuntary uterine contractions
It is composed of a latent, an active, and a transition phase.
i. Latent phase (early):
Dilates from 0 to 3 cm.
Dilatation is minimal because effacement is occuring
Contractions are usually every 5 to 20 minutes, lasting 20 to 40 seconds, and of
mild intensity.
The contractions progress to about every 5 minutes and establish a regular pattern.
Best time to seek admission to the hospital
Mother is excited with some degree of apprehension but still with ability to
communicat
Nursing Care:
o Encourage walking - shorten 1st stage of labor
o Encourage to void q 2 3 hrs full bladder inhibit contractions
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o Breathing chest breathing


o Hospital admission:
a. Personal data
b. OB Hx
o General physical examination
a. Effacement and dilatation
b. Station
c. Presentation
d. Position
ii. Active phase:
Dilates from 4 to 7 cm.
Rapid increase in duration, frequency and intensity of contractions
Contractions are usually every 2 to 5 minutes; lasting 30 to 50 seconds and of mild
to moderate intensity.
After reaching the active phase, dilation averages 1.2 cm/hour in the nullipara and
1.5 cm/hour in the multipara.
Mother fears losing control of herself, less talkative, more anxious,restless
Nursing Care:
o Monitoring and evaluating important aspects
a. Uterine contractions
b. Blood pressure
should not be taken during contraction
should be taken at least every half hour
should be taken immediately when woman complainv of headache
same, just let mother rest; increase, refer immediately to the doctor
c. Fetal Heart Rate (FHR)
Fetal heart tone sounds like a clock ticking distinctly
Should not be mistaken with uterine souffle (synchronizes with maternal
pulse rate)
Should not be taken during uterine contraction
Auscultate the FHR every 30 minutes during the first stage latent; every
15 minutes during first stage active and stage transition; every 5 to 15
seconds.
Possible Fetal heart tone location on the abdominal wall and the Point of
Maximim Impulse(PMI)
a. Cephalic (Vertex, Brow, and Chin): the PMI is usually below the
umbilicus and along the side of the fetal back.
Left occipitoanterior (LOA) and Left occipitoposterior (LOP).
PMI is on the LLQ
Right occipitoanterior (ROA) and Right occipitoposterior (ROP).
PMIis on the RLQ
b. Cephalic( Face): the PMI is below the umbilicus and along the side of
the fetal feet
c. Breech: the PMI is usually above the ambilicus and along the side of
the sacrum , which is line with the fetal back
Left sacroanterior (LSA) and left sacroposterior (LSP). PMI --LUQ
Right sacroanterior (RSA) and Right sacroposterior (RSP). PMI
---RUQ
Assess changes in FHR to identify the following.

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Early deceleration slowing of the FHR early on the contraction. It


is considered benign, minor the contraction and has a characteristics
V or U pattern.
Late deceleration an indication of fetal hypoxia due to
uteroplacental insufficiency. It usually begins at the peak of the
contraction and ends after the contraction ends.
Variable deceleration a transient decrease in FHR before, during or
after the contraction. It indicates cord compression and has a
characteristics V or U pattern.
Bradycardia an FHR less than 100 beats per minutes or a drop of
20 beats per minutes below baseline. In indicates cord compression
or placental separations
Tachycardia an FHR greater than 160 beats per minute. It indicates
fetal distress if it persists for more than 1 hour is accompanied by
late deceleration.
Loss of beat-to-beat variability indicates fetal reaction to maternal
drugs, fetal sleep, or fetal demise.
Signs of fetal distress
1.) FHR <120 & >160
2.) Mecomium stain amnion fluid
3.) Fetal thrushing hyperactive fetus due to lack O2
Provide emotional support
Bathing is advisable to make mother feel comfortable if contraction is tolerable
NPO
Encourage to void q 2 3 hours
Perform enema if necessary
Do perineal prep ue the no. 7 method, front to back
Perineal shave not a routine procedure;move along the direction of hair
Encourage sims position
a. It favors rotation of the fetal head
b. Promotes relaxation between contractions
c. Prevents vena cava symdrome
Not allowed to push unnecessarily during contractions of the first stage
a. It leads to unnecessary exhaustion
b. Repeated pounding of the fetus against the pelvic floor will lead to cervical
edema ---interfere with the dilatation and prolonging length of labor.
Advise abdominal breathing to reduce tension and hyperventilation
Administer analgesia as ordered
Transport mother to delivery room once there is bulging of the perineum or
when cervix is fully dilated for primis. Multis are transported once cervical
dilatation is 7-8 cm.

o
o
o
o
o
o
o
o

o
o
o

iii. Transitional phase:


Dilates from 8 to 10 cm.
Contractions are every 2 to 3 minutes, lasting 50 to 60 seconds and of moderate to
strong intensity. Some contractions may last up to (but not exceed) 90 seconds.
Maternal behavior: with increased perspiration, nausea and vomiting, restlessness,
panic, irritability, have lost control of labor, tends to push during contractions, with
circumoral pallor
Time to perform Lamaze technique; pant-blow pattern of chest breathing
Should push can cause caput succedaneum a serous effusion or edema overlying
the scalp periosteum on an infants head.
Characteri stics

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o Sudden gush of amniotic fluid(if membranes are intact) as fetus is pushed into
the birth canal
o Amniotomy is done (if BOW is not ruptured) to prevent fetus from aspirating
the fluid as it makes its different fetal position changes. Done only if station is
still minus to prevent cord compression.
o Show becomes prominent
o Nausea and vomiting decrease gastric motility and aborption
o In primis, baby I delivered within 20 contractions (40 minutes); in multis, after
10 contractions (20 minutes)
Nursing Actions: Primarily comfort measures
o Sacral pressure; relieves discomfort from contractions
o Proper bearing down technique; push with contractions
o Controlled chest breathing during contractions
o Emotional support
2.

SECOND STAGE (Stage of Expulsion)


The second stage begins with complete dilation of the cervix and ends with delivery of
the newborn.
Durations may differ among primiparas (longer) and multiparas (shorter), but this stage
should be completed within 1 hour after complete dilation.
Contractions are severe at 2 to 3 minute intervals, with duration of 50 to 90 seconds.
Powers/Forces: invouluntary uterine contractions and contraction of the diaphragmatic
and abdominal muscles.
The newborns exists the birth canal with help from the following cardinal movements or
MECHANISMS OF LABOR:
If the woman's pelvis is adequate, size and position of the fetus are adequate, and
uterine contractions are regular and of adequate intensity, the fetus will move
through the birth canal.
The position and rotational changes of the fetus as it moves down the birth canal will
be affected by resistance offered by the woman's bony pelvis, cervix, and
surrounding tissues.
The events of engagement, descent, flexion, internal rotation, extension,
external rotation, and expulsion (ED FIRE ERE) overlap in time.
1. Engagement
Engagement- mechanism by which the biparietal diameter (BPD), the greatest
transverse diameter of the fetal head in occiput presentation, passes through
the pelvic inlet
occurs during the last few weeks of pregnancy or until after the
commencement of labor
Usually, the fetal head is in the transverse diameter or in one of the
oblique diameters
in the "floating" phenomenon, the head is not yet engaged and is freely
movable above the pelvic inlet
Primigravidas occurs up to 2 weeks before onset of labor.
Multigravidas usually occurs with onset of labor.
Cardinal movements are the remaining movements which are the passive
adjustments of position the fetus makes as it descends through the pelvis
during labor.
ASYNCLITISM- the lateral deflection of the fetal head to a more anterior or
posterior position in the pelvis
Anterior Asynclitism (naegele's Obliquity)- the sagittal suture approaches
the sacral promontory; the anterior parietal bones presents itself to the
examining fingers
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2.

3.

4.

5.

Posterior Asynclitism (Litzmann's Obliquity or Ear presentation)- the


sagittal suture lies close to the symphysis and more of the posterior
parietal bone will present
Note: Severe asynclitism may lead to CPD
Descent
Descent- the first requisite for the birth of the infant
in nulliparas-engagement may take place before onset of labor; descent may
not follow until the 2nd stage of labor
multiparous- descent begins with engagement
Occurs throughout labor and is the downward movement of the fetus; occurs
simultaneously with engagement.
Accomplished by force of uterine contractions on fetal portion in fundus and
pressure of the amniotic fluid; during second stage of labor, bearing down
increases intra-abdominal pressure, thus augmenting effects of uterine
contractions. In addition, the extension and straightening of the fetal body
assists with its descent.
Station is the relationship of the level of the presenting part to the ischial
spines. The degree of descent is described as:
Floating - fetal presenting part is not engaged in pelvic inlet
Fixed - fetal presenting part has entered pelvis.
Engagement - fetal presenting part (usually BPD of fetal head) has passed
through pelvic inlet.
Stations -1, -2, -3, or -4 occur when the presenting part is 1, 2, 3, or 4 cm
above the level of the ischial spine
Station 0 occurs when the presenting part is at the level of the ischial
spines.
Flexion
Resistance to descent causes head to flex so the chin is close to the chest; this
causes the smallest fetal head diameter, the suboccipitobregmatic, to present
through the canal.
This puts the posterior fontanelle at almost the center of the cervix, making it
easily palpable on vaginal examination.
Flexion begins at the pelvic inlet and continues until the fetal head (or
presenting part) reaches the pelvic floor.
Internal rotation
In accommodating the birth canal, the fetal occiput rotates 45 or 90 degrees
from its original position toward the symphysis.
The rotation is usually anteriorly, but if the pelvis cannot accommodate the
occiput anteriorly due to a narrow forepelvis, it will rotate posteriorly,
resulting in an occipitoposterior (OP) position of the fetus.
This movement results from the shape of the fetal head, space available in the
midpelvis, and contour of the perineal muscles.
it is accomplished when the head is already engaged
The ischial spines project into the midpelvis, causing the fetal head to rotate
anteriorly to accommodate to the available space.
Deviations from the normal internal rotation:
1. If rotation is incomplete, transverse arrest results
2. if the occiput rotates to the direct occiput position, persistent occiput
posterior results
Extension
Extension- it is the movement that brings the base of the occiput into direct
contact with the inferior margin of the symphysis
> if extension does not occur, the fetal head will impinge upon the posterior
portion of the perineum and would eventually tear the perineum upon delivery
of the head
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6.

7.

The two forces bringing about extension


1. Force exerted by uterus which acts more posteriorly
2. Force supplied by the resistant pelvic floor and the symphysis which acts
more anteriorly
As the fetal head descends further, it meets resistance from the perineal
muscles and is forced to extend. The fetal head becomes visible at the
vulvovaginal ring; its largest diameter is encircled (crowning), and the head
then emerges from the vagina.
External rotation
External rotation-it is the mechanism in which the delivered head undergoes
restitution such that the head returns to the original oblique posistion
Initial phase is called restitution. It is simply the fetal head returning to its
normal relationship with the shoulders.
After restitution, the second phase of external rotation occurs as the body
rotates so that the shoulders are in the anteroposterior diameter of the pelvis.
Expulsion
Expulsion-the anterior shoulder appears under the symphysis and is delivered
first, followed by the delivery of the posterior shoulder. The rest of the body is
quickly extruded
After delivery of the infant's head and internal rotation of the shoulders, the
anterior shoulder rests beneath the symphysis pubis. The posterior shoulder is
born, followed by the anterior shoulder and the rest of the bod
CHANGES IN THE SHAPE OF THE FETAL HEAD
CAPUT SUCCEDANEUM-it is the swelling of the fetal scalp over the cervical
os due to edema resulting from prolonged labor before dilatation of the cervix
It occurs more commonly when the head is in the lower portion of the
birth canal and after the resistance of a rigid vaginal outlet is
encountered
MOLDING- It refers to the certain degree of overlapping of the parietal bones
( with the anterior parietal usually overlapping the posterior), leading to a
diminution in the biparietal and suboccipitobregmatic diameters of 0.5 to 1.0cm
or even more in prolonged labors

Nursing Care:
o Continue to offer psychological support
Praise
Reassurance
Encouragement
Inform mother of the progress
Support system
Touch
o Placed mother in lithotomy position put legs same time up.
o During crowning instruct mother to pant--- if hyperventilation occurs --- let
patient breathe into a paper bag or cupped hands over the mouth to recover lost
CO2.
o Assist in the Episiotomy (surgical incision in perineum) may be done to facilitate
delivery and avoid laceration of the perineum, reduced duration of second stage
and enlarge outlet.
Types of episiotomy:
a. median from middle portion of lower vaginal border directed
towards the anus;less bleeding, less pain easy to repair, fast to heal,
possible to reach rectum ( urethroanal fistula)
b. Mediolateral begun in the midline but directled laterally away from
the anus, often done because it prevents 4th degree laceration. More
bleeding & pain, hard to repair, slow to heal
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Use local or pudendal anesthesia


o Apply the Modified Ritgen Manuever: place towel at perineum
a. To prevent laceration
b. Will facilitate complete flexion & extension. (Support head & remove
secretion, check cord if coiled. Pull shoulder down & up.
c. Check time, identification of baby.
o IMMEDIATE CARE OF THE NEONATE
A. Promoting Airway Clearance and Transitioning of the Neonate

Transitioning/close observation of the neonate is essential for at least 6 to 12


hours after birth.

Wipe mucus from the face and mouth and nose.

Clamp the umbilical cord approximately 1 inch (2.5 cm) from the abdominal
wall with a cord clamp.
o Count the number of vessels in the cord; fewer than three vessels have
been associated with renal and cardiac anomalies or normal outcome.

Evaluate the neonate's condition by the Apgar scoring system at 1 and 5


minutes after birth.
SIGN
Heart rate
Respiratory effort
Muscle tone
Reflex irritability
Color

Apgar Scoring Chart


0
1
Absent
Slow (<100)
Absent
Slow, irregular
Flaccid
Some flexion of extremities
No response cry
Blue, pale
Body pink, extremities blue

2
> 100
Good, crying
Active motion
Vigorous cry
Completely pink

o Neonates scoring 7 to 10 are free from immediate stress.


o Neonates scoring 4 to 6 are moderately depressed.
o Neonates scoring 0 to 3 are severely depressed.
o Apgar scores < 7 at 5 minutes are to be repeated every 5 minutes until 20
minutes have passed, the infant is intubated, or two successive scores of >
7 occur.
B. Promoting Thermoregulation
Dry the neonate immediately after delivery.Drying the infant cuts this heat
loss in half.

Cover the neonate's head with a cotton stocking cap to prevent heat loss.

Wrap the neonate in warm blankets.

Place the neonate under a radiant heat warmer, or place the neonate on the
mother's abdomen with skin-to-skin contact.

Provide a warm, draft-free environment for the neonate.


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Take the neonate's axillary temperature; a normal temperature is between


97.5F and 99 F (36.4 and 37.2 C).

C. Preventing Injury and Infection


Administer prophylactic treatment against ophthalmia neonatorum
(gonorrheal or chlamydial).
Administer a single parental prophylactic injection of vitamin K within 1 hour
of birth.
While in the delivery room (DR), place identical identification bracelets on
the mother and the neonate. The nurse in the DR should be responsible for
preparing and securely fastening the bands on the neonate.
>Complete all identification procedures before the infant is taken from the
delivery room.
Weigh and measure the infant shortly after birth.
>Normal neonate weight is 6 to 9 lb (2,700 to 4,000 g).
>Normal neonate length is 19 to 21 inches (48 to 53 cm).
No later than 2 hours after birth, nursery/mother-baby personnel should
evaluate the neonate's status and assess risks.
Administer hepatitis B vaccine according to institution policy.
Administer BCG vaccine according to institution policy
B. THIRD STAGE (placental stage)
This stage begins with delivery of the newborn and ends with delivery of the placenta. It
occurs in two phases placental separation and placental expulsion.
Powers: strong uterine contractions cause placental separation from the uterine wall;
when placenta is fully detached, maternal pushing can affect final delivery of the
placenta.
Contraction of the uterus controls uterine bleeding and aids placental separation and
explanation.
Generally, oxytocic drugs are administered to help the uterus contract.
Signs of placental separation include:
Calkins sign the uterus changes its shape (from discoid to globular) and consistency
(soft to firm)
Sudden gushing of blood
Lengthening of the cord most definitive sign
Types of placental delivery
Shultz mechanism
shiny begins to separate from center to edges causing
inverted umbrella shape, presenting the fetal side shiny,clean bluish side. Most
common, present in 80% of cases. Less bleeding.
Duncans mechanism dirty begin to separate form edges to center, umbrellashaped delivered sideways, presenting natural side rough, beefy red or dirty
Nursing care:
o Obeserve principle of placental delivery stage: watchful waiting
o Slowly pull cord and wind to clamp BRANDT ANDREWS MANEUVER.
Hurrying of placental delivery will lead to inversion of uterus.
o Note the time of delivery of the placenta it should be delivered within 20 minutes
after the delivery of the baby.
o Inspect for completeness:
a. Complete cotyledons
b. Complete coed vessels
c. Complete membranes

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o Feel the fundus for contraction or firmness. If boggy, soft, non-palpable, noncontracted means uterine atony --- massage fundus gently and properly until firm.
Ice cap maybe applied will further contract the uterus.
o Inject oxytoxin (Methergin=0.2mg/ml or Syntocinon= 10U/ml, IM) after placental
delivery, to maitain uterine contractions
o Assess VS, Monitor BP for HPN (or give oxytocin IV)
o Check perineum for lacerations
a. First degree involves the vaginal mucous membranes and perineal skin
b. Second degree involves not only the vaginal mucous membranes and perineal
skin but also the muscles
c. Third degree involves not only the vaginal mucous membranes and perineal
skin and muscles including the external sphincter of the rectum
d. Fourth degree - involves not only the vaginal mucous membranes and perineal
skin and muscles and the external sphincter of the rectum but also the mucous
membranes of the rectum
o Assist MD for episiorapy (repair of episiotomy); vaginal pack should be removed
after 24-48 hours.
o Position mother flat on bed to prevent dizziness
o May complain of Chills-due dehydration or decreased BP, fatigue or cold
temperature in DR. Provide blanket; give clear liquid-tea, ginger ale, clear gelatin.
Allow to sleep to regain energy.
C. FOURTH STAGE (Recovery and Bonding Stage)
This stage lasts form 1 to 4 hours after birth.
The mother and newborn recover from the physical process of birth.
The maternal organs undergo initial readjustment to the nonpregnant state.
The newborn body systems begin in the midline of the abdomen with the fundus midway
between the umbilicus and symphysis pubis.
Monitor v/s q 15 for 1 hr. 2nd hr q 30 minutes.
Check placement of fundus at level of umbilicus.
If fundus above umbilicus, deviation of fundus
Empty bladder to prevent uterine atony
Check lochia a vaginal discharge that consists of fatty epithelial cells, shreds of
membrane, decidua, and blood

Parameter

Rubra

Color

Red

Amount

Moderate

Time Present

1 3 days

Serosa
Brownish

Alba

Scanty

White
Slight

4 10 days lower
limit 7 days)

10 -14 days(upper
limit 21 days)

Check the Perineum for


R edness
E dema
E cchymosis
D ischarges
A pproximation of blood loss. Count pad & saturation
Fully soaked pad : 30 40 cc weigh pad. 1 gram=1cc
95

Check for bladder distention displaces uterus to the side a factor for uterine atony.
Bonding interaction between mother and newborn rooming in types
1.) Straight rooming in baby: 24hrs with mom.
2.) Partial rooming in: baby in morning , at night nursery

96