NCM 107: Care of Mother, Child, Adolescent (Well-Client)
DEFINITION OF TERMS
1. Labor
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A series of events by which uterine contraction
and abdominal pressure expel a fetus and
placenta from the uterus
Begins within 37–42 weeks
➔ Considered the term age of pregnancy
Primipara: 14–16 hours
Multipara: 6–8 hours
However, this could be longer. Recently, research
suggests that this could be longer.
2. Episiotomy
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A surgical incision made at the opening of the
vagina during childbirth to aid a difficult delivery
and prevent rupture of tissues
2 kinds of Episiotomy:
A. Midline – lesser chance of bleeding, less
painful
B. Mediolateral – less risk of greater
laceration
Allows the accommodation of the fetal head
In the perineum, as the mother is delivering her
child, if the doctor sees that the fetal head
needs some assistance in being delivered, the
doctor or obstetrician may opt to make a small
cut at the perineal area
In order to facilitate the delivery of the fetus
and at the same time prevent further injury
One of the duties of a student nurse is to
support the perineum using the hands and a
towel so that as the mother delivers the child,
the perineal incision or the episiotomy won’t
tear all the way down.
➔ Support the perineal area in order to
prevent that from further lacerating
Each kind of episiotomy have their pros and
cons but in the end, it will be the obstetrician
who will decide which one is the more
appropriate incision for the mother.
MODULE 3F: INTRA-NATAL CARE
3. Duration
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Length of a uterine contraction
How long a contraction lasts
4. Intensity
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Strength of a uterine contraction
5. Frequency
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Measured from the beginning of one
contraction to the beginning of the next
As labor increases, the frequency also increases
6. Increment
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Building-up phase of the contraction
7. Acrement
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Peak of the contraction
8. Decrement
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Letting down phase of the contraction
Interval
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Space between two contractions
The Augmentation of Labor and Induction of Labor
procedures help initiate or at least strengthen labor.
9. Augmentation of Labor
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Assisting labor that has spontaneously started
but is not effective or strong enough
As the mother approaches true labor, there
may be times wherein her labor contractions
are not strong enough or not effective enough
and that could cause her to be prolonged in a
certain stage
In order to enhance that labor, the obstetrician
can administer oxytocin through IV fluids
Other way to augment the labor is through
amniotomy
➔ Artificial rupture of membranes during
labor
➔ The mother would experience bursting of
the bag of waters. Sometimes, it doesn’t
happen spontaneously during labor so the
YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
doctor can actually induce that using
forceps in order to rupture the bag of
waters so that labor can be triggered
➔ In that case if that is the reason why she
requires CS, there is a chance that in her
following delivery, she would still need to
undergo CS
➔ But there are also some mothers whose
reason may not be the shape of the pelvis
but other reasons and maybe this mother
would want to try vaginal birth instead. So,
instead of going to vaginal birth directly, the
mother would still have to undergo through
trial of labor wherein the obstetrician will
observe and assess if the mother is ready
for a normal spontaneous vaginal delivery.
10. Induction of Labor
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Applicable when the mother is already of term
age. Around 37-40 weeks of gestation but has
not yet initiated labor yet. The mother has not
felt any contractions.
Labor started artificially
It can be inducted through oxytocin or
amniotomy as well. But amniotomy is the most
common.
Labor that is started by the obstetrician rather
than the mother’s body itself
11. Dysfunctional Labor
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Prolonged labor due to the sluggishness of
contractions
Indication of augmentation of labor
THEORIES OF LABOR
Progesterone levels will decrease slightly during the
later weeks of pregnancy especially as the mother
approaches labor and delivery.
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12. Eutocia
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Normal labor
13. Dystocia
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Difficult labor
How Does Labor Start?
LABOR
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14. Amniotomy
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Artificial rupture of membranes during labor
15. Trial of Labor
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Full acronym is TOLAC (Trial of Labor after
Cesarean Delivery)
An attempt labor to determine whether labor
will progress normally especially for women
who have experienced cesarean section
For women post-cesarean section
Ideally, if the mother has experienced cesarean
section in her previous delivery, she would
ideally still be in cesarean section in the
following delivery
The mother would need to undergo cesarean
delivery due to various reasons and one of that
is the shape of her pelvis is not wide enough or
not conducive enough for labor and delivery
MODULE 3F: INTRA-NATAL CARE
This is actually due to various factors and one of
the theorized factors is actually due to the
increase of estrogen and also the increase in
prostaglandins.
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Series of events by which uterine contractions
and abdominal pressure expel a fetus and
placenta from uterus
Normally begins between 37 and 42 weeks of
pregnancy
Many factors known to be responsible for the initiation
of spontaneous labor:
1. Uterine muscle stretching resulting in release of
prostaglandins
• As the fetus continues to grow, it also
continues to expand the uterus
• One of the theories in labor that is the
uterus expands to a certain size, the body
recognizes it as the fetus being ready to be
delivered therefore resulting in the release
of prostaglandins in the uterine area
YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
2. Cervical pressure
• Fetus pressing on the cervix stimulates the
release of oxytocin from the posterior
pituitary gland
• As the fetus becomes bigger, the fetal head
presses into the cervix so the fetus pressing
the cervix can stimulate the release of
oxytocin from the posterior pituitary gland
• Oxytocin is also known as labor hormone
Oxytocin stimulation + Prostaglandins
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Oxytocin stimulation works together with
prostaglandins to initiate contractions
- Together, they are very much observed during
the initiation of true labor or labor itself
3. Estrogen – Progesterone Ratio
• Progesterone withdrawal: Increasing
estrogen in relation to progesterone can
trigger or initiate labor
• Throughout pregnancy, we have there a
stable ratio or sustained level of estrogen
and progesterone, particularly
progesterone. It’s actually the high levels of
progesterone that prevents the initiation of
uterine contractions.
• Near the end of the pregnancy, what
happens is progesterone, the pregnancy
hormone, decreases. In this case, there is an
increasing level of estrogen and that these
two have an inverse relationship.
• As the estrogen increases, especially due to
the secretion of prostaglandins,
progesterone will reduce or decrease. Or
rather the prostaglandins will overpower
the effects of progesterone, therefore
leading to labor and delivery.
4. Placental Degeneration
• Placenta is thought to have a set age
• So, if the placenta reaches around 37 to 40
weeks of age, the placenta starts to
degenerate because it has reached the peak
of maturity and therefore could lead to
labor and delivery
MODULE 3F: INTRA-NATAL CARE
5. Rising Fetal Cortisol Levels
• Reduction of progesterone and increase in
prostaglandins
• In the fetal area or the fetal side of the
pregnancy, the fetus will experience
secretion of rising fetal cortisol levels
• The fetal cortisol levels can stimulate the
increase of prostaglandins in the mother
which will also inhibit or reduce
progesterone
6. Fetal Membrane prostaglandin production
• The fetal membrane also continues to
secrete prostaglandins leading to labor and
delivery
PREPARATION FOR LABOR
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Where we observe the signs and symptoms of a
mother who is about to go through labor and
delivery
Preliminary Signs of Labor
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Subtle signs or symptoms
Days or hours before labor begins.
NOTE: These signs don’t occur on the same day
during delivery. They could occur as early as
days away from the labor
It is important that you, especially when you are
conducting your health teaching, it’s important
to inform the mother of these signs, especially
the first-time mother so that they will not panic
and instead, they will have a better experience
in preparing themselves for the upcoming labor
and delivery
1. Lightening
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Sinking of fetal head into the true pelvis
Changes in abdominal contours (“Decreasing”
fundal height)
Causes relief from diaphragmatic pressure
➔ Encourage deep breathing exercises for the
mother in preparation for the labor and
delivery
There’s a chance if you take your Leopold’s
maneuver again, you might notice a decrease in
the fundal height. So, do not panic if you
observe that.
YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
➔ That just means that the baby is sinking into
3. Excess energy
the true pelvis or descended
- Burst of adrenaline to provide energy for labor
➔ Because of this, there is lesser pressure in
- The mother’s body actually recognizes that the
the lungs and also in the abdominal area
mother’s about to go and give birth. So, the
- At the same time, the relief from the
body also prepares by supplementing the
diaphragmatic pressure and also from the
mother with a burst of adrenaline especially
abdomen, this may cause feelings of nausea. So,
during delivery to provide energy for labor
be mindful of that. At least you could explain it
to the mother
4. Backache
Primiparas: Approximately 10-14 days before labor
Multiparas: On the day of labor/after the beginning
of true labor
2. Slight weight loss
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1-3 lbs.
➔ Due to the decreasing levels of
progesterone which leads to increased fluid
excretion, one of the effects of decreasing
progesterone, which then leads to
increased urine production
Not the loss of fat but rather the loss of fluid
Progesterone level decreases
Increased fluid excretion
Increased urine production
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5. Cervical Ripening
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MODULE 3F: INTRA-NATAL CARE
One of the most common complaints of
mothers who are experiencing labor and
delivery
Onset of true labor contractions
Intermittent, stronger than usual backache
Labor contractions begin in the back
Why backache?
➔ There’s the pressure because of the weight
distribution and also more significantly is
the location of your uterus
➔ In anatomy and physiology, the location of
your uterus is retroperitoneal. So, the pain
is actually strongest at the back and then it
sweeps throughout the abdomen.
When a nurse or a student nurse is assigned to
perform labor watch, what you can do is to
provide back rubs.
➔ Not too deep pressure just back rubs in
order to relieve the pressure and also
provide for relief from pain
Cervix feels very soft upon palpation during
internal examination
➔ In internal examination, what happens is
the obstetrician will be inserting 2 of her
fingers into the birth canal to both assess
the cervical dilation and also the
effacement
➔ The mother will be placed in a lithotomy
position
“Butter soft” (usual assessment finding)
Goodell’s sign – earlobe consistency of cervix
throughout pregnancy
Marks the beginning of true labor
Refers to the steady thinning of the cervix
YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
waters has already been ruptured, amniotic
fluid still continues to be produced until
delivery.
➔ At least there’s still some fluid that is
buffering the baby and also ensuring that
the baby will be delivered properly
6. Rupture of Membranes
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Sudden gush or scanty, slow seeping of clear
fluid from the vagina
Early rupture of membranes helps fetal head
descent and engagement (engaged into the true
pelvis)
➔ Therefore, the rupture of the bag of waters
could lead to enhanced cervical dilation and
labor progression
Amniotic fluid continues to be produced until
delivery of the membranes after the birth of the
child
Risks to need to watch out for
➔ Intrauterine Infection – labor does not
before spontaneously by 24h
◼ You need to observe for maternal or
intrauterine infection
➔ Umbilical Cord prolapse
◼ What happens is the umbilical cord of
the baby may be pushed downwards
and instead of the presenting head, that
is really directly presenting into the
cervix, you might find there an umbilical
cord.
◼ This is very dangerous for the baby.
◼ You need to watch out for this as well.
Amniotic fluid is colloquially known as bag of
water.
In movies, the pregnant mothers would say,
“my water broke”
➔ This is actually the rupture of the bag of
water
Maybe, you may encounter some mothers who
may be concerned especially if they early
rupture of membranes. They may be concerned
if the delivery is “dry”.
➔ One health teaching to give them is that it’s
not possible because even if the bag of
MODULE 3F: INTRA-NATAL CARE
7. Show
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Internal cervical mucus plug has been released
“Bloody Show” – blood from cervical capillaries
mixed with mucus plug
As the mother approaches true labor, her cervix
will get rid of the mucus plug.
The picture is what she may find in her pads.
Sometimes it may be bloody
Assure the mother that this is a normal finding
because as the cervical mucus plug detaches
from the cervix, some of the capillaries of the
cervix will also rupture and will induce a slight
bleeding. The blood from these capillaries may
be mixed with the mucus plug. Therefore,
leading to a bloody show.
8. Uterine Contractions
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Braxton Hicks
YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
➔ Known as the trial contractions
➔ Can start Last week or days before labor
begins
➔ May be extremely strong for the mother
(but the frequency varies or there is no
change in strength)
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➔ Localized mostly in the abdomen
◼ It does not radiate from the back or
towards the legs
➔ Triggered due to decreasing progesterone
levels
➔ Primigravid mothers may not be able to
distinguish between Braxton Hicks and true
contractions
◼ Assure them and also give them
adequate health teaching
➔ You know that this is not yet true labor
because the contractions is relieved by rest,
activity, or repositioning
True Labor
➔ Begin at the back and sweeps forward
across abdomen and possibly legs
➔ Gradually increases in frequency and
intensity
➔ Painful, wavelike, building and receding
➔ Not relieved by rest
◼ It constantly increases
➔ Uterus becomes hard on palpation,
indentation with fingers is not possible
◼ When you try to palpate the fundus, it
is hard and indentation cannot be done
3 Main Signs:
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➔ Because knowing this will help us create the
nursing care plan of a mother who is
undergoing labor and delivery
➔ It is really important not to just focus on the
physiologic aspects but also focus on the
psyche of the mother, assist her as she
experiences her uterine contractions, etc…
➔ All of these components has to be good in
order to ensure both the survival of the
mother and the baby
PASSAGE
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PASSENGER
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Rupture of membranes
Show or the bloody show
Uterine contractions
COMPONENTS OF THE BIRTHING PROCESS
Successful labor depends on the 4 concepts or
components: passage, passenger, powers, and psyche
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A problem in one of these can significantly
impact the progression of labor
Why do we need to review this again and again?
MODULE 3F: INTRA-NATAL CARE
Mother’s pelvis
Route a fetus must travel from the uterus
through the cervix
Fetopelvic disproportion – commonly caused
by the insufficient pelvic structure
➔ One problem involving this factor
➔ In some examinations, the fetal head may
be a bit too big for the pelvis
➔ If that’s the case, it is really not the fetal
head that is too big but rather the uterus is
not really conducive for labor and delivery
Shape of Pelvis
• Gynecoid (maternal pelvis)
• Android
• Anthropoid
• Platypelloid
Refers to the fetus and its ability to move
through the passage
Affected by the following fetal features
• Fetal skull
• Fetal Presentation (Cephalic)
• Fetal Lie (Longitudinal)
• Fetal Attitude
• Fetal Position
• Fetal Station
POWER or POWERS
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Uterine contractions
Phases
• Increment – building up phase (longest)
• Acrement or Acme – peak of contraction
YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
• Decrement – letting down phase
- Characteristics
• Duration
◼ Beginning of increment to end of
decrement
◼ Early labor: 30 seconds
◼ Late labor: 60-90 seconds
• Frequency
◼ Beginning of one contraction to the
beginning of the next
◼ Early labor: 5-30 mins apart
◼ Late labor: 2-3 mins apart or even lesser
• Intensity
◼ Measured through palpation itself or
through insertion of intrauterine
catheter
•
•
•
◼ Can also contribute to the knowledge of
the mother
Past experiences
Accomplishment of pregnancy tasks
Feeling of control over situation
STAGES OF LABOR
FIRST STAGE OF LABOR
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From onset of true labor contractions until full
cervical dilation
Average – 12 hours
• Primipara: 6-18 hours
• Multipara: 2-10 hours
Recent research suggests that normal labor can
take longer
Three Phases:
1. Latent Phase
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PSYCHE
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Maternal psychological state
Feelings that the mother brings to the labor
Apprehension, fear, wonder, excitement
Factors affecting psychological readiness
• Presences of support system
◼ Very crucial according to studies.
◼ The mother is able to undergo effective
delivery with the presence of her
partner or support system
◼ In the local setting, our institutions
don’t allow the partner to be physically
there for the mother. So, in lieu of the
partner, we, nurses, get to be their
support system
◼ We need to keep the family and the
partner updated
• Degree of preparation from the mother’s
side
• Childbirth education classes
MODULE 3F: INTRA-NATAL CARE
Begins at onset of regularly perceived uterine
contractions
- Ends when rapid cervical dilatation begins
- Cervical dilation: 0-3 cm
- Mild and short contractions
• 20-40 seconds
• May be irregular Longer for women with
“nonripe” cervix
- Primipara: around 6 hours
- Multipara: 4 ½ hours
Nursing Care:
Pain Management
❖ Analgesia may be given but if given too early, it
may prolong the stage
❖ Assist mother to prepare psychologically
❖ Teach controlled and deep breathing exercises
❖ Encourage activity, ambulation, and other non –
pharmacotherapeutic measures
❖ Offer clear liquids or ice chips Involve partner,
family, or support person
❖ Provide calm environment
Psychological Maternal Responses
- Anticipation
- Excitement
- Apprehension
YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
2. Active Phase
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More rapid cervical dilatation (4-7 cm)
Uncomfortable phase for the mother
Stronger contractions (40-60 seconds every 3-5
minutes)
- Bloody show and spontaneous rupture of
membranes may occur
- Primipara: around 3 hours
- Multipara: around 2 hours
Nursing Care
❖ Frequent perineal care
❖ Encourage mothers to keep active and assume
most comfortable position except flat on back
❖ Pain management
❖ Anticipate mood swings and difficulty in coping
(offer support)
❖ Continue to involve family and partner
❖ Positioning
• Upright
• Left side lying
3. Transition Phase
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Cervical Dilatation (8-10 cm)
Contractions reach peak of intensity
Longer contractions (60-70 seconds every 2-3
minutes)
- Full cervical dilatation and effacement
- ROM may occur at full cervical dilation
- Strong urge to push
Nursing Care:
❖ Mothers may experience intense discomfort,
nausea and vomiting, feeling of loss of control,
anxiety, panic, or irritability
❖ Help direct maternal focus to birthing of baby
❖ Provide support
❖ Stay with the mother at all times
SECOND STAGE OF LABOR
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Exhaustion
Nursing Care:
❖
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Assist with second stage pushing
Prepare birthing area
Assist mother in birthing position
Be ready to assist in episiotomy
Prepare for and assist with delivery
Mother may feel:
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Uncontrollable urge to push
Nausea and vomiting (due to decrease in
abdominal pressure)
Cardinal Movements of Labor
1. Fetal Engagement, Descent, and Flexions
2. Internal Rotation
- Of the fetal head at the internal perineum
- Aligns fetal head in the most optimum position
for descent (widest part at widest inlet area)
- Perineum may appear bulging and tense
- Anus may be everted; stool may be expelled
- Crowning – fetal scalp visible at the opening of
the vagina
3. Extension
- Delivery of the head
- Compression of presenting parts
4. External Rotation
- Head rotates to being the anterior shoulders
into the best line with the pelvis
- Slight upward flexion needed to deliver
posterior shoulder
- Watch for: Shoulder dystocia in macrosomic
babies
5. Expulsion of the baby
- The baby is considered born once the entire
body is already delivered and exposed to the
extrauterine life
Complete cervical dilatation to delivery of the
neonate
Lasts 2-60 minutes Primipara: 40 mins average
Multipara: 20 mins average
Fetus moved along the birth canal by the
mechanisms of labor
Psychological Maternal Responses:
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Focus from discomfort to active pushing
MODULE 3F: INTRA-NATAL CARE
YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
THIRD STAGE OF LABOR
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Fourth Degree
Begins with the birth of the infant and ends
with the delivery of the placenta (1-30 mins)
Entire perineum, rectal sphincter,
and some of the mucous
membrane of the rectum
Two Phases:
Signs:
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➢
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➢
1. Placental Separation
Placenta detaches from the uterine wall
Lengthening of the umbilical cord
Sudden gush of vaginal blood
Placenta is visible at the vaginal opening
Uterus contracts and feels firm
Presentations: Schultze and Duncan
2. Placental Expulsion
Placenta is delivered through natural bearing
down or gentle pressure on the contracted
uterine fundus (Crede’s Maneuver)
- No pressure on noncontracted uterus – can
cause uterine eversion and massive hemorrhage
- Excessive hemorrhage with poor contraction –
administer Hemabate or Methergine (Check BP
before administration)
- Note time of placental delivery
- Inspect intactness of placenta
- Inspect for placental remains (leads to
uncontracted uterus and bleeding)
Psychological Maternal Responses:
- Concern for neonate’s condition
- Discomfort from uterine contractions before
placental expulsion
Nursing Care:
❖ Assist with the delivery of the placenta
❖ Assist with episiorrhaphy
❖ Administer oxytocin as ordered (IV)
❖ Introduce neonate to the parents and allow
breastfeeding
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Classification of Perineal Lacerations
Classification
Description of Involvement
First Degree
Vaginal mucous membrane and skin
of the perineum to the fourchette
Second Degree
Vagina, perineal skin, fascia, levator
ani muscle, and perineal body
Third Degree
Entire perineum, extending to reach
the external sphincter of the
rectum
MODULE 3F: INTRA-NATAL CARE
FOURTH STAGE OF LABOR
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Time immediately after placental delivery
First hour after delivery (recovery period)
Beginning of the postpartum period
Postpartum period: 6 weeks
High risk for hemorrhage
Psychological Maternal Responses:
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Attention towards neonate
Adjusting to maternal role
Nursing Care:
❖ Primary activity is stabilizing the status of the
neonate and helping neonate get acclimated to
extrauterine life
❖ Focus on maternal-neonatal bonding
❖ Obtain vital signs every 15 mins for the first
hour
❖ Assess lochia, consistency and position of the
fundus, episiotomy site
❖ Be prepared to initiate emergency procedures if
mother’s or child’s condition do not stabilize
YUSON, DREA