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Labor and Delivery - Lecture notes 1
Nursing Care Management (Colegio San Agustin – Bacolod)
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NCM 107: Maternal & Child Nursing
INTRAPARTAL

Theory of the Aging Placenta
Learning Objectives:

Progesterone Deprivation Theory
1. Explain thoroughly the theories of labor
onset.

Prostaglandin Theory

Rising fetal cortisol level
2. Discuss the role of the passenger, passage
and powers in labor.
3.
PRELIMINARY SIGNS OF LABOR
Assess the woman’s needs and readiness
4. Formulate simple nursing diagnosis related
to the physiological and behavioral aspects
of labor and delivery.
1. Lightening – descent of the fetal presenting
part into the pelvis – 10-14 days before
labor (primipara), on the day of labor
(multipara)
5. Establish a nursing care plan to meet the
needs of the woman and family throughout
labor and delivery.
Results in:
6. Plan nursing interventions to promote
optimal outcomes for the woman and her
family during labor and birth  7. Implement
planned nursing interventions  8. Evaluate
expected outcomes for achievement and
effectiveness of care
7. Implement planned nursing interventions
8. Evaluate
expected
outcomes
achievement and effectiveness of care.
for
o
Relief of dyspnea
o
Increase frequency of urination
o
Leg cramps
o
Increase vaginal discharge
o
Decrease fundal height
PRELIMINARY SIGNS OF LABOR

Increase in level of activity
LABOR & DELIVERY

Braxton Hicks contractions
LABOR is the series of events by which uterine
contraction and abdominal pressure expel the
fetus and placenta from the woman’s body

Ripening of the cervix – internal

Weight Loss
DELIVERY Actual event of birth
SIGNS OF TRUE LABOR
THEORIES OF LABOR ONSET
Uterine contractions – effective, productive and
involuntary

Uterine Stretch Theory

Oxytocin Stimulation Theory
2. Show- cervical mucus with blood tinge
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NCM 107: Maternal & Child Nursing
3. Rupture of the membranes (BOW)
False Contractions
possible effects :

Do not increase in duration, frequency or
intensity.

Do not achieve cervical dilation

Intrauterine infection

prolapse of the cord
True Contraction

Increases in duration frequency & intensity

Achieve cervical dilation
COMPONENTS OF LABOR
1. PASSAGEWAY
a. Pelvis
DIFFERENCE BETWEEN FALSE & TRUE LABOR
False Pelvis – ilia, support the uterus &
directs the fetus to true pelvis
False Labor

Begin & remain irregular

Felt inabdominally & remain confined in the
abdomen & groin

Often disappear with ambulation & sleep
True Pelvis – forms the passageway of the
fetus during labor
True Labor
PELVIC SHAPES

Begin irregularly but become regular &
predictable

Felt initially in the lower back & sweep
around to the abdomen in a wave
1. GYNECOID
2. ANTHROPOID- elongated

Continue no matter what the woman’s level
of activity
3. ANDROID- male pelvis
4. PLATYPELLOID- kind of flat (not ideal pelvis)
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NCM 107: Maternal & Child Nursing
Pelvic Measurements
A. Cervix before effacement begins
a) Diagonal
conjugate
(anteroposterior
diameter of the inlet) 12.5 cm
B. Effacement in its early phase
C. Effacement with some dilation
b) Transverse Diameter of the Outlet 13.5 cm
D. Complete effacement and dilation
c) R & L Oblique Diameter 12.75 cm
2. Passenger
Cervix
Fetus


Effacement - shortening & thinning of the
cervical canal. (%)

head of the fetus is the most impt part of
the body because:
Dilation - increase in cervical diameter. (cm)
a. It is the largest part of the fetal body

In primis: effacement first, ff by dilatation 
In multis: dilatation and effacement takes
place at the same time.
b. It is often the presenting part
c. It is the least compressible part
Cranial bones
o
o
o
o
o
o
Effacement
1 frontal
2 parietal
2 temporal
1 occipital
1 sphenoid
1 ethmoid
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NCM 107: Maternal & Child Nursing
Suture lines – allow the skull bones to overlap
to reduce size of fetal head.
o
o
o
o
sagittal suture
frontal suture
coronal suture
lambdoidal suture
STATION -relationship of the presenting part of
the fetus to the level of the ischial spines
-relationship of the presenting part of the fetus
to the level of the ischial spines
Fetal Descent Stations (Birth Presentation)
Fontanels - membrane covered spaces found in
between the intersections of suture lines. They
help determine the position and presentation of
the fetus.
o
o
Anterior fontanel/Bregma
Posterior fontanel/Lambda
o
o
o
At -4 station, head is “floating”
At 0 station – head is “engaged”
At +4 station – head is “at outlet”
Molding - overlapping of the skull bones
Attitude
Fetal Lie- relationship of the long axis of the
fetus to the long axis of the mother
the degree of flexion the fetus assumes
a) Complete flexion – fetus is in good attitude
b) Moderate flexion – military position
c) Partial extension – browis the presenting
part
d) Poor flexion – back is arched, neck
extended. Face presentation
Fetal Presentations
Vertex
Face/brow
Shoulder/ transverse
Frank breech
Complete breech
Incomplete/ footling breech
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NCM 107: Maternal & Child Nursing
Components of Labor
Fetal Position
o
relationship of the presenting part to the
specific quadrant of the woman’s pelvis
Four quadrants of the mother’s pelvis
1)
2)
3)
4)
right anterior
right posterior
left anterior
left posterior
Four parts of the fetus as landmarks
1)
2)
3)
4)
vertex presentation- occiput (O)
face presentation – chin/mentum (M)
breech presentation – sacrum (Sa)
shoulder presentation – acromion process
(A)
3. Power
A. Uterine Contractions
1. Phase
Increment/crescendo
Acme/apex
Decrement/ decrescendo
Characteristics of uterine contractions
 Involuntary
 Intermittent
 Involves discomfort (labor pains)
o
a. Mild – slightly tense fundus and easy to
indent with fingertips
Position is marked by an abbreviation of 3
letters
b. Moderate – firm fundus, difficult to
indent with finger
middle letter – denotes fetal landmarks- O for
occiput, M for mentum, Sa for sacrum and A for
acromion process –
first letter – whether the landmark is pointing
to the mother’s right (R) or left (L)
last letter – whether the landmark points
anteriorly (A), posteriorly (P) or transverse (T)
What is the position if:
1) Vertex presentation at the left side of the
mother anteriorly
2) Shoulder presentation located at the right
side of the mother posteriorly.
Intensity – strength of uterine contraction
c. Strong – rigid, boardlike fundus that is
almost impossible to indent with finger
Frequency – Measured from the beginning
of a contraction to the beginning of the next
contraction
o Duration - Measured from the beginning of
a contraction to the end of the same
contraction
o Interval - Measured from the end of one
contraction to the beginning of the next
contraction
Components of Labor
4. Psyche
Maternal attitudes and behaviors during
labor depends on the ff. Factors:
o Perception and meaning of childbirth
o Readiness and preparation for childbirth
o Past experiences
o Coping skills
o
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NCM 107: Maternal & Child Nursing
o
o
Cultural and social background
Presence of significant others and
support system
Length of Normal labor
Primis
1st stage
2nd stage
3rd stage
Total 14 hrs
Prolonged laborMore than 18 hours
Multis
1st stage- 7hrs 20 mins
2nd stage- 30 mins
3rd stage- 10 mins
Total 8 hrs
Prolonged laborIf more than 12 hrs
o
o
o
o
o
o
SECOND STAGE ( Stage of Expulsion) –
full cervical dilation to delivery of the infant
o
STAGES OF LABOR
o
o
FIRST STAGE (Dilatation Stage) – begins with
true labor contractions and ends with full
cervical dilatation
o
o
o
A. Latent phase - mild & short contraction, 20
– 40 sec; every 5-10 mins;
o 3 cm cervical dilation; 6 hrs in nullipara;
mother still excited, able to communicate
o Station – primi 0, multi 0 to -2
o FHR heard at the level of umbilicus
B. Active phase
o 4 – 7 cm dilation; 40 – 60 sec contractions,
stronger every 3-5 mins
o 3 hrs in nullipara
o show & rupture of BOW
o station +1 to +2 - FHR heard slightly below
umbilicus or lower abdomen
C. Transiti
on
Phase
cervical dilatation – 8-10cm
UC strong , 2-3 mins apart, last for 45-90 sec
copious bloody show
station +2 to +3
FHR clearest at the symphysis pubis
duration of this phase 1-2 hrs
cervical
dilatation
10cm,
cervical
effacement 100%
UC strong 2-3 mins apart, 60-90 sec
fetal descent continues at a rate of 1cm/hr
in primi & 2cm/hr in multi
urge to push begins
perineum flattens, bulges
crowning, fetus is born
Mechanism of Labor






Descent
Flexion
Internal Rotation
Extension
External Rotation
Expulsion
THIRD STAGE (Placental Stage)
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NCM 107: Maternal & Child Nursing
Signs of placental separation
Baseline rate 120-160 BPM
a) Calkin’s sign- uterus becomes firm and
round in shape
b) Sudden gush of blood from the vagina c.
Lengthening of the cord * Delivered within
5-10 mins but not to exceed 20 mins
Early Deceleration – FHB decreases at the onset of UC but returns to normal before the
end of UC – head compression
Acceleration – as fetus moves FHB also
increases 15 bpm for 15 sec is normal
MATERNAL & FETAL ADAPTATION TO LABOR
A.






Maternal Adaptation
moderate increase in cardiac output
increase HR & RR
15 mmHg increase in BP
labor prolongs normal gastric-emptying
time leads to n/v
increase WBC as high as 30,000/mm3
urine specific gravity is high
Abnormal FHB pattern

Tachycardia –161-180 bpm
(mild fetal hypoxia, maternal fever)

Bradycardia – 100-119 bpm
Fetal Adaptation
(Congenital heart dis)




decrease in FHR by 5 bpm during a
contraction
increased intracranial pressure caused
by uterine pressure on the fetal head petechiae or ecchymotic areas
caput succedanum
pressure applied to the chest helps to
clear the lungs of fluids.

Late Deceleration – FHB decreases during
UC and do not return to normal after the
end of the same contraction
(uteroplacental insufficiency)
Maternal Danger Signs:
1)
2)
3)
4)
5)
6)
Rising or falling BP
Abnormal pulse
Inadequate or prolonged contractions
Pathologic retraction ring
Increasing apprehension
Blood loss of more than 500 cc

Variable Deceleration – deceleration
occurring at unpredictable times during
UC –(cord compression)
Nursing Care
Tachycardia
o
Normal FHR Pattern:
monitor maternal vital signs
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NCM 107: Maternal & Child Nursing
o
change maternal position
o
close monitoring
contractions - instruct pt. to pant with
contractions
2) Fetal Status - FHB, fetal lie, presentations,
Bradycardia
attitude, station & position
o
change maternal position
o
administer oxygen to the mother
3) Risk Assessment - ruptured membranes
(nitrazine test) - vaginal bleeding
o
prepare for immediate delivery
4) Maternal Status - vital signs
Late Deceleration
Correct cause:

Supine Hypotension – change maternal
position Anesthesia – elevate legs, increase
hydration w/ IV fluids

Uterine hyperactivity - discontinue oxytocin

Left lateral position

Admin. Oxygen to the mother
Maternal Care:
Variable Deceleration

NURSING CARE DURING 1ST STAGE OF LABOR
a) Bath
b) Encourage ambulation to shorten 1st stage
change maternal position - if lasting 2 mins
help
mother
into
knee-chest
or
trendelenburg position
c) Solid and liquid foods are avoided
d)
Enema
e) Perineal prep and perineal shaving

prepare for immediate delivery if patterns
does not improve
f)

admin oxygen to the mother
g) Advise abdominal breathing, shld not bear
down or push unnecessarily
NURSE’S ROLE DURING ADMISSION
1) Birth Imminence - signs: sitting on one
buttocks, bearing down or grunting w/
Encourage emptying of the bladder every 23 hrs
h) . Encourage Sim’s position
i)
Emotional support
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NCM 107: Maternal & Child Nursing
j)
Remain attuned to the maternal psyche

provide ongoing assessment

promote positive coping

provide supportive care

Heavy or bright red bleeding

Maternal reports of unrelenting pain, right
upper quadrant pain or visual changes
NURSING CARE DURING 2ND STAGE OF LABOR
a) Position legs at the stirrups together
Fetal Care:
b) Instruct mother to push not pant
A. Assess FHR
c) Assist in episiotomy
o
q 1 hr during latent phase; q 30 mins
during active phase; q 15 mins during
the 2 nd stage
o
after rupture of membranes
o
before & after
medications
o
before & after invasive procedures
administration
Primary reason: to prevent laceration
Secondary reasons: prevent stretching of
rectal and bladder muscles, reduce duration
of 2nd stage, enlarge outlet
of
Types of episiotomy
median & mediolateral
DANGER SIGNS DURING LABOR

Elevated maternal BP
a) Apply Ritgen’s maneuver

Low or suddenly decreased maternal BP

Elevated maternal temperature

Amniotic fluid is green, cloudy or foul
smelling

Non reassuring FHR patterns
b) Newborn should be held below the
mother‘s vulva to allow blood from the
placenta to enter the baby’s body
c) Cutting of umbilical cord is postponed until
pulsation has stopped, then clamp twice an
inch apart then cut in between
DANGER SIGNS DURING LABOR

Prolonged uterine contractions

Failure of the uterus to relax between
contractions
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NCM 107: Maternal & Child Nursing
b. Positions for pushing
o
Lithotomy
o
modified dorsal recumbent
o
Side-lying
o
Squatting
o
Hands-to-knees
c. Preparing for Delivery of the Newborn
NURSING CARE DURING 3RD STAGE OF LABOR
1) Do not hurry the expulsion of the placenta
2) Tract the cord slowly, winding it around the
clamp until placenta comes out (BrandtAndrew’s method). Note time
3) Check for completeness of cotyledons
4) Palpate uterus to determine degree of
contraction
5) Inject oxytocin (Methergin 0.2 mg/ml). Shld
not be given before placental delivery to
NURSE’S ROLE DURING THE 2ND STAGE OF
LABOR
prevent placental entrapment
6) Inspect perineum for lacerations
1. Promoting effective pushing despite fatigue
7) Perform perineal care h. Position flat on bed
to prevent dizziness
2. Reduce risk for trauma
8) Give initial nourishment
a. Effective pushing technique
o
open-glottis pushing
o
urge-to-push method
PAIN MANAGEMENT TECHNIQUES
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NCM 107: Maternal & Child Nursing
I. Nonpharmacologic Interventions
A. Comfort measures- Relaxation techniques
1) Patterned breathing
2) Attention focusing/imagery
b. Prostaglandins ( Cytotec, Cervidil)
3) Movement & positioning
o
used to stimulate UC
4) Touch & massage – effleurage
o
used in pregnant women to ripen or soften
the cervix
o
used to control uterine atony
o
may be given orally, rectally or vaginally
5) Water therapy
6) Hypnosis
7) Acupressure & acupuncture
PHARMACOLOGIC INTERVENTIONS
Major adverse side effects : Maternal
o
Hypertonic uterus/uterine rupture
o
N/V, diarrhea
a. Oxytocics (Pitocin, Syntocinon)
Nursing Care:
o
used to stimulate UC
o
used to induce labor
o
exert vasopressor and antidiuretic effect
o
used to control uterine atony
o
Monitor UC
o
Have oxygen and resuscitative equip. ready
Maternal Analgesia and Anesthesia
Nursing Care
Opoids Analgesics
o
Monitor client continuously
o
Use infusion-control device for IV admin
Monitor UC
o
IV, IM, Epidural, intrathecal
o
Assess BP and PR every 15 mins.
o
Given during active labor
o
Maintain fetal monitoring
o
o
Have oxygen and emergency resuscitation
equip. available
Administration timed to allow
metabolism and excretion before
birth to avoid resp depression on
the newborn
a. Meperidine HCL (Demerol)
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NCM 107: Maternal & Child Nursing
Naloxone (Narcan) – used to counteract
resp. depression
o
If hypotension occur, position mother on
left side, increase iv infusion, admin oxygen
o
Assess FHR
Additional Notes:
b. Butorphanol (Stadol)
o
IM, 30-40 times more potent than
Demerol
o
does not interfere with labor
o
less neonatal depression
c. Nalbuphine (Nubain)
o
IV, IM d. Fentanyl (Sublimaze) - IV,
IM, epidural, intrathecal
o
100 x more potent than Demerol
o
min. resp depression
Regional Analgesia & Anesthesia

Epidural: maybe used during labor, cs

Spinal: maybe used during labor or
anesthesia during cs
-

inj. Into subarachnoid space, single dose
Local Infiltration: used during episiorrhaphy
Nursing Care
o
Observe mother & newborn for resp.
depression
o
Monitor BP for maternal hypotension
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