LABOR & DELIVERY maternal support (compared to usual

care).
During labor the nurse assesses the following:
vital signs, physical exam, contraction pattern  Measure duration of latent phase. For
(frequency, interval, duration, and intensity), nulliparas, it should not be more than
intactness of membranes through vaginal 6 hours. On the other hand, for
exam, and fetal well-being through fetal heart multiparas, it should be within 4.5
rate, characteristic of amniotic fluid, and hours. Determine if patient received
contractions, and performs Leopold’s anesthesia because it can prolong
maneuver to determine fetal presenting part, latent phase. One of the most
point of maximum impulse, fetal descent and common causes of prolonged latent
engagement. phase is cephalopelvic disproportion
(CPD) and it requires cesarean birth.
When a patient arrives at the labor floor,
pertinent information about the pregnant  Allow patient to be continually active.
woman’s health history is taken during Upright maternal positions are
admission. recommended for women on the first
stage of labor. Patients without
These include personal data pregnancy complications can still walk
 blood type around and make necessary birth
preparations.
 allergies
 previous illness
 pregnancy complications
 preferences for labor and delivery
 childbirth preparations.

 Conduct interviews and filling in of

forms (e.g. birth certificate) at this
phase while the patient experiences
minimal discomfort and has control
1ST STAGE over contraction pains.
Latent (Preparatory) Phase starts from the  Conduct health teaching on
onset of true labor contractions to 3 cm breastfeeding, newborn care, and
cervical dilatation. Here are nursing effective bearing down because
responsibilities during this phase: during this time, patient’s anxiety is
controlled and she is able to focus on
 Assess patient’s psychological
nurse’s instructions.
readiness. Provide continuous
 Educate patient on different  Determine when patient last voided
relaxation techniques. As early as this because a full bladder can hinder fast
phase, encourage patient to begin labor progress.
alternative therapy of pain relief.
 Institute non-pharmacological pain
 Ensure that the total number of measures (e.g. breathing exercises,
internal examinations the woman distraction method, imagery, music
receives in the entire course of labor therapy, etc.)
is limited to 5 only.
 1ST STAGE
 Ensure that birthing companion of
choice is present all throughout the  Transition Phase starts from 8 cm
course of labor cervical dilatation to 10 cm (full)
cervical dilatation and full cervical
 Active Phase starts from 4 cm cervical effacement. During this time, patient
dilatation to 7 cm cervical dilatation. may be exhausted and withdrawn or
During this phase, contraction aggressive and restless. Patient’s urge
intensity is stronger, interval shortens, to push is noticeable. Here are nursing
and duration lengthens. This is where responsibilities in this phase:
true discomfort is first felt by the
patient so she is dependent and her  Inform patient on progress of her
focus is on herself. Here are nursing labor.
responsibilities in this phase:  Assist patient with pant-blow
 Inform patient on the progress of her breathing.
labor to lessen her anxiety and obtain  Monitor maternal vital signs and fetal
her trust and cooperation. heart rate every 30 minutes -1 hour,
 Start monitoring progress of labor or depending on the doctor’s order.
with the use of WHO partograph, 2- Contraction monitoring is also
hour action line. continued.

 Encourage patient to be continually  When perineal bulging is noticeable,

active to maximize the effect of prepare for delivery. Check room
uterine contractions. Upright temperature (25-280C and free of air
maternal positions are recommended drafts).
if tolerated.  The nurse should also notify staff and
 Assist patient in assuming her position prepare necessary supplies and
of comfort. For those who can’t stay equipment, including resuscitation
upright, left-side lying is machine.
recommended to avoid disruption in  Lastly, perform handwashing and
fetal oxygenation. double gloving.
 Monitor maternal vital signs and fetal  WHO do not recommend the
heart rate every 2 hours, or following nursing interventions during
depending on the doctor’s order. labor because they have low quality
 Anticipate patient needs (e.g. of evidence:
sponging face with cool cloth, keeping  Routine perineal shaving
bed clean and dry, providing ice chips
or lip balm) to promote comfort.  Routine use of enema
 Admission cardiotocography (CTG) for
low-risk women
 Vaginal douching  Use of fundal pressure
 Routine amniotomy for patients in  THIRD STAGE
spontaneous labor
 Third Stage of Labor or the placental
 Massage and reflexology stage starts from birth of infant to
delivery of placenta. It is divided into
 SECOND STAGE two separate phases: placental
 Second Stage of Labor starts when separation and placental expulsion.
cervical dilatation reaches 10 cm and Five minutes after delivery of baby,
ends when the baby is delivered. At the uterus begins to contract again,
this stage, the patient feels an and placenta starts to separate from
uncontrollable urge to push. The the contracting wall. Blood loss of
patient may also experience 300-500 mL occurs as a normal
temporary nausea together with consequence of placental separation.
increased restlessness and shaking of Placenta sinks to the lower uterine
extremities. The nurse at this stage segment or upper vagina. The
must coach quality pushing and placenta is then expelled using gentle
support delivery. traction on the cord.

 Here are some nursing care for this  Here are the signs of placental
stage: separation:

 Instruct patient on quality pushing.  Lengthening of umbilical cord

The abdominal muscles must aid the  Sudden gush of vaginal blood
involuntary uterine contractions to
deliver the baby out.  Change in the shape of uterus
(globular in shape)
 Provide a quiet environment for the
patient to concentrate on bearing  Firm uterine contractions
down.
 Appearance of placenta in vaginal
 Provide positive feedback as the opening
patient pushes.
 At this stage, here are the nursing
 Repeat doctor’s instructions. At this care:
phase, the patient barely hears the
conversation around the room  Coach in relaxation for delivery of
because all her energy and thoughts placenta.
are being directed toward giving birth.  Congratulate on delivery of baby.
 Take note of the time of delivery and  Encourage skin-to-skin contact to
proceed to initiate essential newborn facilitate bonding and early
care. Delayed cord clamping is breastfeeding.
recommended.
 Ask patient whether placenta is
 Assist in restrictive episiotomy for important to them before it is
patients who had vaginal births. destroyed. For those who want to
 WHO do not recommend the take it home, ensure that they
following interventions during understand and follow standard
delivery because they provide low infection precautions and hospital
quality of evidence: policy.

 Perineal massage  Administer prophylactic oxytocin as

ordered.
  Utilize controlled cord traction frequency, and strength of uterine
technique for placental expulsion. contractions.
 Utilize absorbable synthetic suture A tocodynamometer is a device for
materials (over chromic catgut) for monitoring and recording uterine contractions
primary repair of episiotomy or before and during labor. It consists of a
perineal lacerations. pressure transducer that is placed over the
fundus area of the uterus using a belt, and
 For immediate postpartum, the nurse then records the duration of contractions and
checks the vital signs and monitors for the intervals between them on a monitor or
excessive bleeding. The first four on graph paper
hours after birth is sometimes
referred to as the fourth stage of
labor because this is the most critical
period for the mother. The nurse is
set to perform nursing interventions
that would prevent the patient from
infection and hemorrhage. Also, they
are being reminded of the importance
of breastfeeding, ambulation, and
newborn care.
 Here are WHO recommendations for
immediate postpartum:
 Early (<6 hours) resumption of
feeding for patients who have vaginal
birth
 Prophylactic antibiotics for women
who sustained third to fourth degree
of perineal tear during delivery
 In healthy women who delivered
vaginally to term infants, early Tocodynamometer reading-Varies between 5-
postpartum discharge is 25 mmHg. Active labor contractions. Intensity
recommended. of a contraction is between 40-60 mmHg.
 Here are interventions not Second phase of labor. Intensity of
recommended during immediate contractions increases to 50-80 mmHg.
postpartum: Cardiotocography (CTG) is a technical means
 Routine use of ice packs of recording (-graphy) the fetal heartbeat
(cardio-) and the uterine contractions (-toco-)
 Oral during pregnancy, typically in the third
methylergometrine/METHERGINE for trimester. The machine used to perform the
patients who delivered vaginally monitoring is called a cardiotocograph, more
commonly known as an electronic fetal
LABOR CONTRACTIONS
monitor. CTG can be used to identify signs of
During labor, uterine contractions are usually fetal distress.
monitored along with the fetal heart rate. A
METHOD
pressure-sensitive device called a
tocodynamometer is placed on the mother's Simultaneous recordings are performed by
abdomen over the area of strongest two separate transducers, one for the
contractions to measure the length, measurement of the fetal heart rate and a
second one for the uterine contractions. watch the CTG traces of multiple patients
Transducers may be either external or simultaneously, via a computer station.
internal.
This procedure should not be any more
External measurement means strapping the uncomfortable than a normal vaginal
two transducers to the abdominal wall examination.
The pressure-sensitive contraction transducer, The internal electrode monitors the baby’s
called a tocodynamometer (toco), measures heart rate more accurately than an external
the tension of the maternal abdominal wall – Doppler.
an indirect measure of the intrauterine
pressure Internal measurement requires a certain
degree of cervical dilatation and the waters
The fetal heart rate transducer overlays the need to be broken to attach an FSE to the
fetal heart, measures the fetal heart rate baby’s head. If they are not already broken,
this will need to be done to allow the
Internal monitoring differs from external electrode to be attached.
monitoring.
Women who carry the Herpes, Hepatitis B or
The pressure-sensitive contraction transducer, C or HIV viruses are recommended not to
called a tocodynamometer (toco), measures have internal monitoring, because it can
the tension of the maternal abdominal wall – increase the baby’s chances of becoming
an indirect measure of the intrauterine infected with these viruses.
pressure
INTERPRETATION
The fetal heart rate transducer is replaced by
a smaller lead that is placed inside the Cardiotocography is used to monitor several
woman’s vagina and attached to the head of different measures:
the baby. The internal lead is called a ‘fetal
scalp electrode’ (or FSE). It is ONLY used to (1) Uterine contractions
monitor the baby’s heart rate during labour, Four fetal heart rate features
usually if external monitoring is not being
reliable. Baseline heart rate

A fetal scalp electrode is a small, circular, Variability

corkscrew-shaped needle attached to a Accelerations
coated wire. The clip is covered with a long,
protective, flexible, plastic covering and Decelerations
guided up through the mother’s vagina by the
Uterine contractions – They are quantified as
caregiver doing an internal examination. The
the number of contractions present in a 10
needle is gently rotated into the SKIN on the
min period and averaged over 30 min.
baby’s scalp. Once the clip is attached, the
plastic cover is removed, leaving just the wire. Normal: ≤ 5 contractions in 10 min.
The fetal scalp clip has 2 colored wires High: ≥ 5 contractions in 10 min represent
attached. The wires are connected to the lead uterine tachysystole
with a small conducting device (about the size
of a match-box), strapped to the woman’s Baseline heart rate – average baseline fetal
thigh. The lead is then plugged into the heart rate
monitor and a typical CTG reading is printed Reassuring feature: 110 – 160 beat per minute
on paper and/or stored on a computer for (bpm)
later reference. Use of CTG and a computer
network allows continual remote surveillance: Non-reassuring feature: 100 – 109 bpm OR
a single nurse, midwife, or physician can 161 – 180 bpm
Abnormal feature: < 100 bpm OR > 180 bpm 1. Early deceleration
Variability – Fluctuations in the fetal heart  Begin at start of uterine contraction
rate and end with conclusion of
contraction (mirror image)
This causes the tracing to appear as a jagged,
rather than a smooth, line. Variability is  Due to increased vagal tone due to
indicative of a mature fetal neurologic system fetal head compression
and is seen as a measure of fetal reserve
2. Variable deceleration
Reassuring feature: ≥ 5 bpm
 Occur at any time irrespective of
Non reassuring feature: < 5 bpm for ≥ 40 uterine contractions
minutes but < 90 minutes
 Due to umbilical cord compression
Abnormal feature: < 5 bpm for > 90 minutes
3. Late deceleration
Decreased variability may occur in the
following situations:  Begin at or after the peak of a
contraction and ends long after it,
Hypoxia and Acidosis. The lack of oxygen and hence the “late” when compared to
the build-up of acid in the fetal body depress early decelerations
the fetal heart and nervous system
 Due to fetal hypoxia (uteroplacental
Narcotics and anesthetic agents, depress the insufficiency) – the most worrisome
fetal nervous system. Usually, variability deceleration
increases as the drug is eliminated from the
baby.  Reassuring feature: No deceleration

Prematurity. The fetal nervous system in a  Non reassuring feature: Early

premature baby cannot effectively control the deceleration, variable deceleration or
heart rate. single prolonged deceleration up to 3
minutes
Fetal sleep (as noted above).
 Abnormal feature: Atypical variable
ACCELERATIONS decelerations, late deceleration or
single prolonged deceleration greater
Increases in fetal heart rate from the baseline than 3 minutes
by at least 15 beats per minute, lasting for at
least 15 seconds and should be 2  Normal trace: Tracings with all four
accelerations every 20 minutes lasting no features:
longer than 2 minutes.
1. Baseline rate 110-160 bpm,
Reassuring feature: Present
2. Normal variability,
In labor, the absence of accelerations with an
otherwise normal CTG is of uncertain 3. Absence of decelerations,
significance 4. Accelerations (may or may not be
DECELERATIONS present)

Decreases in fetal heart rate from the baseline  Suspicious trace:

by at least 15 beats per minute, lasting for at 1. Tracing with ONE non reassuring
least 15 seconds feature and the other three are
There are three types of decelerations, reassuring.
depending on their relationship with uterine 2. This is not predictive of abnormal
contraction: fetal acid-base status, but evaluation
 and continued surveillance and listening intermittently (usually after a
reevaluations is indicated contraction during labor)
 Pathological trace:  If the waters break and there is
meconium staining of the amniotic
1. Tracing with TWO or more non fluid.
reassuring features or ONE or more
abnormal feature 6. If the labor is being induced or
augmented with an oxytocin drip or
2. It predicts abnormal fetal acid-base prostaglandins.
status; this requires prompt
evaluation and management  These medications have the potential
to overstimulate the uterus and
Reasons to monitor the baby’s heart rate can distress the baby.
include:
7. If the woman is having an epidural
1. If there are health concerns for the for pain relief in labor.
mother during late pregnancy
 The baby’s heart rate can lower in
 Bleeding response to a fall in the woman’s
 High blood pressure blood pressure, a possible side effect
of an epidural.
 Premature labor
MECHANISMS OF LABOR
 Diabetes
The fetus undertakes a series of movements
 Cholestasis to adapt the smallest possible diameter of the
2. If there are health concerns for the presenting part to the anatomy of the
baby maternal pelvis. The commonest situation is
fetus in longitudinal lie, cephalic position and
 Small for dates well-flexed attitude.
 Abnormality of the baby For description, head is only the index, the
trunk also participates in and probably also
 Pregnancy is overdue
initiates some movements. These movements
3. As a routine procedure during labor are:

 Some delivery suites have a policy to  Engagement

perform a routine 20 minute
 Descent
recording of the baby’s heart rate
when the woman arrives in labor  Flexion
4. If the waters break and the labor has  Internal rotation
not started
 Restitution
 If the woman is waiting for her labor
to start with ruptured membranes,  External rotation
the caregiver may perform a 20  Engagement
minute trace to check her baby’s well
being.  Engagement is the mechanism by
which the greatest transverse
5. If the baby is showing signs of diameter of the fetal head: the
distress biparietal diameter (BPD) (9.4 cm) is
 If the baby’s heart rate is noticed to at or has passed the pelvic inlet
be lower, when the caregiver is (brim). In nulliparous women
engagement occurs weeks prior to
 onset of labor, whereas in the head to come back in line with the
multiparous women it may occur in shoulders. The occiput points to the
labor. maternal thigh of the corresponding
side to which it originally lies.
 Descent is a continuous process
throughout the first and second stage  External rotation – the movement of
of labor. the head due to the internal rotation
of the shoulder as it comes in the
 Flexion – the head is already flexed to antero–posterior diameter of the
an extent at the time of engagement pelvic outlet. This is visible externally
and further flexion occurs during the in a direction opposite to internal
first stage of labor due to soft tissue rotation. It occurs in the same
resistance of the pelvis. The flexion direction as restitution. Now the
facilitates the shortest anterior– shoulders are in antero–posterior
posterior diameter suboccipito– diameter (A-P) axis. The anterior
bregmatic (9.5 cm) to be presented at shoulder escapes under the pubic
the pelvic outlet. arch, while the posterior shoulder
 Internal rotation is defined as turning sweeps over the perineum. After the
of the head in such a manner that the delivery of the shoulders, the rest of
occiput gradually moves anteriorly body is delivered spontaneously by
towards the symphysis pubis. This lateral flexion.
carries the long diameter of the head
into the antero–posterior diameter
(A-P), i.e. the longest diameter of the
pelvic outlet from the previous
occipito lateral positions. Internal
rotation brings the occiput forwards
under the pubic arch. The fetal
shoulder enters the pelvis in the
transverse diameter. This results in
degree of rotation at the fetal neck.
 Extension – the force of uterine
contraction and active maternal effort
along with the pelvic floor muscles
facilitates the birth of head by
extension. The chin slides over the
edge of the perineum and becomes
separated from the chest wall, i.e. the
head becomes extended. The vaginal
outlet is stretched and crowning
occurs. With progressive distension of PERINEAL PREPARATIONS PRIOR TO
the perineum the occiput, forehead, DELIVERY
mouth and chin are delivered
PURPOSES
successively.
• To remove normal perineal secretions and
 Restitution – the visible external
odors
movement of the fetal head that
corrects the torsion of neck sustained • To promote client comfort
during internal rotation. The direction
of movement is opposite to that of EQUIPMENT
the internal rotation (45°). This allows
Perineal-genital care provided in conjunction  Position the female in a back-lying
with the bed bath: position with the knees flexed and
spread well apart.
• Bath towel
 Cover her body and legs with the bath
• Bath blanket blanket positioned so a corner is at
• Clean gloves her head, the opposite corner at her
feet, and the other two on the sides.
• Bath basin with warm water at 43°C to 46°C Drape the legs by tucking the bottom
(110°F to 115°F) corners of the bath blanket under the
• Soap inner sides of the legs. Rationale:
Minimum exposure lessens
• Washcloth embarrassment and helps to provide
warmth. Bring the middle portion of
IMPLEMENTATION
the base of the blanket up and then
PREPARATION over the pubic area.

• Determine whether the client is  Apply gloves. Wash and dry the upper
experiencing any discomfort in the perineal- inner thighs.
genital area.
6. Inspect the perineal area.
• Obtain and prepare the necessary
 Note particular areas of inflammation,
equipment and supplies
excoriation, or swelling, especially
PROCEDURE: between the labia

1. Prior to performing the procedure,  Also note excessive discharge or

introduce self and verify the client’s identity secretions from the orifices and the
using agency protocol. Explain to the client presence of odors.
what you are going to do, why it is necessary,
7. Wash and dry the perineal-genital area.
and how he or she can participate, being
particularly sensitive to any embarrassment
displayed by the client.
2. Perform hand hygiene and observe other
appropriate infection prevention procedures.
3. Provide for client privacy by drawing the
curtains around the bed or closing the door to
the room. Some agencies provide signs
indicating the need for privacy. Rationale:
Hygiene is a personal matter.
4. Prepare the client:
 Fold the top bed linen to the foot of
the bed and fold the gown up to
expose the genital area
 Place a bath towel under the client’s
hips. Rationale: The bath towel
prevents the bed from becoming
soiled.
5. Position and drape the client and clean the
upper inner thighs;