Unit 4

UNIT 4 NORMAL LABOUR AND NURSING MANAGEMENT
INTRODUCTION
You have seen in Unit 3 that pregnancy is unique to each individual. For a woman to go
through the labour process without complications to herself and her baby, it is important to
receive good antenatal care. Women will undergo many physical and physiological
changes during this period. They will also experience excitement as well as anxiety.
Midwives must be sensitive in order to meet the woman’s individual needs and the needs of
her family.
In this unit, you will learn about normal labour, mechanism of labour and the management
of first, second, third and fourth stage of labour.
NORMAL LABOUR
You have already learnt about pregnancy and nursing management. Pregnancy culminates
into a process called labour. You will now learn on labour.
Normal labour, also called ‘eutocia’, is a process by which the foetus, placenta and
membranes are expelled through the birth canal. There are four stages of labour. These are
:
i) The First Stage (Dilatation of the cervix)
This is from the onset of true labour to complete dilatation of the cervix. It comprises
a latent phase and an active phase. The latent phase is from the onset of true labour to
3 cm dilatation of cervix, and the active phase is from 3 cm dilatation to complete
dilatation of cervix.
ii) The Second Stage (Expulsion of foetus)

It begins when the cervix is fully dilated and ends when the baby is born.
iii) The Third Stage (Separation and expulsion of the placenta and membranes)
It begins at the birth of the baby and ends at the expulsion of the placenta and
membranes.
iv) The Fourth Stage

This begins from the birth of the placenta, till one hour after delivery.
Normal labour occurs when:
• the foetus is born at term

• the foetus presents by vertex
• the process is completed spontaneously
• the duration does not exceed 18 hours
• no complications arise to the mother and baby
Causes of Onset of Labour

As you learnt about stages of labour now we will aquaint you with the causes of onset of
labour.
The onset of labour is said to be multifactorial in origin, i.e. hormonal, mechanical and
neuronal factors. You will be learning about each of these now.
a) Hormonal Factors
The hormones responsible for the onset of labour are oxytocin, progesterone and
prostaglandins.The foetal hypothalamus is triggered to produce the releasing factors. These
releasing factors stimulate the anterior pituitary gland to produce adrenocorticotrophic
hormones (ACTH). ACTH stimulates the foetal adrenal glands to secrete cortisol. Cortisol 77
causes changes in relative levels of placental hormones, i.e. the oestrogen levels rise and
the progesterone levels fall (See Fig. 4.1).
Maternal Health and Nursing Foetal hypothalamus
Intervention (triggered)
Releasing factors are produced
Stimulation of anterior pituitary gland
Production of adrenocorticotrophic hormone
Stimulation of foetal adrenal gland
Secretion of cortisol
Fig. 4.1: Hormonal factors in onset of labour

Increase in oestrogen level Decrease in progesterone level
Now you will see the role of each of these hormones in the onset of labour.
i) Progesterone: It has a relaxant effect on the uterus. It is first produced by the corpus
luteium and then by placenta. It inhibits uterine contractility. When the oestrogen
level increases (as seen in Fig. 4.1), the progesterone levels decrease. This decreases
at the end of pregnancy. (The increased production of foetal dehydroepiandrosterone
sulphate (DHEAS) inhibits the production of foetal pregnalone to progesterone).
ii) Oxytocin: This hormone is released by the posterior pituitary gland of the mother. It
has a stimulating action on the pregnant uterus. Towards the end of pregnancy, there
is an increase in the oxytocin receptors in the decidue vera. The oxytocin released
acts directly on the myometrium and causes the uterus to contract. Further, it acts on
the endometrial tissue and causes the release of prostaglandin.
iii) Prostaglandin: The major sites of synthesis of prostaglandins are placenta, foetal
membrane, decidual cells and myometrium. It is thought that the decidua at term
releases prostaglandins from the uterus in response to the release of oestrogen. They
act on the uterine muscles and causes it to contract.
b) Mechanical Factors
This is due to mechanical stimulation of the uterus and cervix:
i) Uterus: As pregnancy advances, its contractility increases and it becomes more
susceptible to stimulation.
ii) Cervix: The presence of the presenting part on the nerve ending of the cervix causes
onset of labour.
c) Neuronal Factors
α and § adrenergic receptors are present in the myometrium. When progesterone gets
withdrawn, onset of labour takes place.
Signs and Symptoms of True and False Labour
It is important to know the signs and symptoms of true and false labour and as a midwife
you need to differentiate between them. They are given in Table 4.1.
Table 4.1: Difference Between True Labour and False Labour
True labour False labour

Uterine • Always present • Not always present
contractions • Are accompanied by • Are not always painful
abdominal tightening,
discomfort or pain
• Duration exceeds 60 seconds • Duration for three to four minutes
• Often backache is present • Back ache is not present
Cervix • Is shortened • Not shortened
• Progressive dilatation of the os • The os is not dilating
Membranes Feel tense during a contraction Do not become tense
Show Is usually present Not present
Premonitory Signs of Labour
During the three weeks prior to the onset of labour, some changes take place. These are
useful to determine the approach of labour.
• Lightening or sinking of the uterus: Takes place 2-3 weeks before the onset of
labour. This is because the symphysis pubis widens and softens; the pelvic floor
descends into the true pelvis.
• Frequency of micturation: Due to pressure of the foetal head on the bladder.
• Presence of false pain: These are erratic and irregular, causing the uterus to contract
and relax.
• Taking up of the cervix: It gradually merges into the lower uterine segment.
Mechanism of Labour
You have already learnt premonitory signs of mechanism of labour. Now we will tell you
about steps of mechanism of labour.
The mechanism of labour is a series of passive movements of the foetus in its passage
through the birth canal. It is as a result of the expulsive action of the uterus, abdominal
muscles, diaphragm, and the resistance offered by the pelvis, cervix and the pelvic floor.
The position of the foetus is left-occipito anterior position (LOA). To understand the
mechanism, you need to review the terms; lie, attitude, presentation , denominator, position
and presenting part. In LOA, the lie is longitudinal, attitude is flexion, presentation is
vertex, denominator is occiput and presenting part is anterior part of right parital bone.
The movements that take place are described below.
Descent
In primigravida, it takes place two weeks before the onset of labour. When engagement of
the head occurs, further descent takes place during the first stage and is more rapid in the
second stage.
Flexion of the Head
Usually the head is flexed at the beginning of labour. The sub occipito frontal diameter, 10
cm lies at the pelvic brim. With increasing flexion, the sub-occipito bregmatic diameter 9.5
cm engages. The occiput then becomes the leading part.
Internal Rotation
This is the forward turning of the part of foetus that reaches the anterior, lateral half of the
gutter-shaped pelvic floor first. In LOA, the occiput rotates forward, one eighth of a circle,
from the left ileo-pectineal eminence to the symphysis pubis, where it can escape under the
pubic arch and allow the sub-occipital region to pivot on the lower border of the symphysis
pubis. Internal rotation takes place because of the passive recoil of the lateral half of the
pelvic floor and the gutter-shape of the pelvic floor tends to direct the leading part towards
the front, where it passes through the areas of the pelvic floor, that is weak and under the
pubic area.
Crowning of the Head
Here, the occipital prominence escapes under the symphysis pubis and the head no longer
recedes between uterine contractions. The sub-occipital bregmatic diameter 9.5 cm
distends the vulval orifice.
Mechanism of Labour in left occiput anterior (LOA) presentation
Extension of the Head

It is a movement by which flexion of the head is undone. This takes place because the
uterine and abdominal muscles exert downward pressure and there is resistance from the
pelvic floor and the perineum. This tends to push the head forward and upwards through
the vaginal orifice. Thus the nape of the neck pivots on the lower border of the symphysis
pubis, while the sinciput, face and chin pass over the thinned perineum. The sub occipito-
Posterior fontanele
Posterior fontanele
(d) Extension
(a) Onset
Posterior fontanele Posterior fontanele
(b) Flexion (e) Restitution
Posterior fontanele
Posterior fontanele
(f) External rotation

(c) Internal rotation to OA
frontal diameter, 10 cm sweeps the perineum, and the head is born.
Restitution
This is the turning of the head to undo the twist in the neck that took place during internal
rotation of the head. In L.O.A., the occiput restitutes one eighth of a circle to the left, back
to where it was before internal rotation took place. Through this movement one will know
whether she is delivering an L.O.A. or an R.O.A. Thus she is likely to manage the birth of
the shoulders without causing a pereneal laceration.
Internal Rotation of the Shoulders
When the uterine contraction takes place after the head is born, internal rotation of
shoulders, a movement similar to the internal rotation, of the head takes place. The anterior
shoulder reaches the right side of the pelvic floor and rotates forward bringing the
shoulders into the antero-posterior diameter of the outlet.
External Rotation of the Head
This accompanies the internal rotation of the shoulders. The occiput turns a further one-
eighth of the circle, always in the same direction as in restitution When this takes place, it
indicates that the shoulders are in the antero-posterior diameter of the pelvic outlet and is
ready for expulsion.
(a) Increased flexion (b) Descent and engagement
(c) Internal rotation

(d) Internal rotation and beginning of extension
(f) Summary of steps in normal mechanism of

(e) Extension (external rotation not shown) labour with foetus presenting as LOA
Fig. 4.3: Steps in normal mechanism of labour (head passing through birth canal)
R.O.P. 3/8
L.O.P. 3/8
R.O.L. 2/8
L.O.I. 2/8
R.O.A. 1/8
L.O.A. 1/8
Diagrammatic representation of internal rotation in anterior, lateral and posterior

positions of the vertex presentation
Lateral Flexion of the Body
This is a sideways bending of the spine, which takes place while the body is being expelled.
The anterior shoulder escapes under the symphysis pubis, the posterior shoulder passes
under the perineum and the baby is born.
MANAGEMENT OF FIRST STAGE OF LABOUR

We have already learnt under section 4.2 that the first stage of labour is from the onset of
true labour pains to complete dilatation of the cervix. You will now learn the physiological
changes that take place in this stage.
Physiological Changes
It is important for you to make observation and determine deviation from normal while caring
for women in labour. This knowledge about physiology is needed for effective management.
The physiological changes of the first stage of labour is described as follows :
i) Contraction and retraction of the uterine muscle
Uterine contractions are involuntary, regular and rhythmic. The intensity increases
progressively. The intervals between them gradually diminish from around 15 minutes at the
beginning of the first stage to two or three minutes at the end of the second stage.
ii) Retraction
It is the quality of the uterine muscle whereby the contraction does not pass off entirely.
Instead of becoming completely relaxed after the contraction, the muscle fibers retain some
of the contraction. Thus the upper segment of the uterus becomes shorter and thicker and
its cavity diminishes, helping in the progressive expulsion of the foetus (see Fig. 4.5).
Fig. 4.5: Progressive contraction and retraction of myometrium

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The other characteristics of uterine contractions are fundal dominance and polarity. Normal Labour and Nursing
Management
iii) Fundal dominance
Each contraction starts in the fundal region and spreads downward being stronger and
persisting longer in the upper region. This makes the fundus and midzone remain hard
throughout the period of contraction, while the wave of contraction weakens in the lower
uterine segment.
iv) Polarity
This is the neuromuscular harmony between the two poles or segments of the uterus
throughout labour. The upper pole contracts strongly and retracts to expel the foetus, while
the lower pole contracts slightly and dilates to allow expulsion of the foetus.
v) Formation of the upper and lower uterine segment
Functionally, the uterus is divided into two segments, by the end of pregnancy i.e. the upper
uterine segment and the lower uterine segment. The upper uterine segment is the thick
muscular contractile part. The lower uterine segment develops from the isthmus of the
uterus and extends to the cervix. It is thin and distensible and measures 7.5 to 10 cm in
length. When labour begins the lower uterine segment stretches because there is a pull on
it by the retracted longitudinal fibers in the upper segment.
vi) Development of the retraction ring
The retraction ring is a ridge that forms at the lower border of the thick segment where it
meets the lower segment. It is normal if it is not visible over the symphysis pubis. If it is
visible as a depressed ridge running transversely or slightly obliquely across the abdomen
above the symphysis pubis, it is called Bandl’s ring. It appears in obstructed labour
because the lower uterine segment stretches. Thus the greater the distension of the lower
segment, the higher will be the retraction ring rise, causing danger of rupture of uterus. (See
Fig. 4.6).
(R) (R)
Retraction Ring
Fig. 4.6: Retraction ring between upper and lower uterine segment
vii) Taking up of the cervix

The muscle fibers surrounding the internal os are drawn upwards by the retracted upper
segment causing the cervix to shorten. It then merges into and becomes part of the lower
uterine segment. Gradually cervical effacement also takes place.
viii) Show
It is the operculum that is formed during pregnancy and expelled in the form of
bloodstained mucoid discharge, a few hours before within or after labour has started. The
blood is from the ruptured capillaries where the chorion is detached and from the dilating
cervix.
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Maternal Health and Nursing
Intervention ix) Formation of the bag membrane
With the dilatation of the lower uterine segment, the chorion gets detached from it. This
loosened part of the fluid, bulge downward into the dilating internal os. The amniotic fluid
in front of the head that fits into the cervix is called fore waters. The fluid behind the head
is the hind water. Thus with contraction, the pressure is not exerted on the forewaters.
There is a general fluid pressure, i.e. the pressure of the uterine contractions is exerted on
the fluid when the membranes are intact. Thus the pressure is equalised throughout the
uterus (see Fig. 4.7).
Placenta
Uterus
Foetus
Amniotic Fliod
Fig. 4.7: General fluid pressure
x) Rupture of the membranes
When extensive cervical dilation has taken place towards the end of the first stage, the bag
of membranes receives very little support. Along with this, there is increased force of the
strong uterine contractions. This causes the membranes to rupture.
Nursing Management of First Stage of Labour

In the previous sub-section you have learnt about causes of onset of labour and its signs and
symptoms and mechanism of labour. Now you will learn about nursing management of 1st
stage of labour.
The basic principles in the management of women in the first stage of labour includes
understanding and meeting the woman’s need and providing efficient care, i.e. giving
comfort, relieving pain, and conserving woman’s strength. One also needs to maintain
asepsis throughout labour and exercise vigilant observation of both maternal and foetal
status and coping with emergencies that may arise.
Recognition of First Stage of Labour by Nursing Personnel
The following signs will enable the nurse to know that the woman is in first stage of
labour.
On Abdominal Examination
• The uterine contractions will recur with rhythmic regularly and will not exceed 60
minutes
• Presence of abdominal tightening, discomforts or pain
• Presence of backache with contraction
On Vaginal Examination
• The cervix is shortened

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• The membranes feel tense during a contraction Normal Labour and Nursing
Management
• The os dilates progressively
• Show is present
Admission and Initial Assessment of a Woman in Labour
When the woman is admitted, the nurse has two priorities:
Establishing a Therapeutic Relationship
This is done by making the woman and family feels comfortable, thus strengthening the
confidence in the woman’s ability to give birth and by using communication skills. The
woman in labour needs to be reassured that she is accepted and will be taken care of. From
time to time the family members must be informed about the progress/condition of the
woman.
Assessing the Condition of the Mother and the Foetus
This includes an initial interview and nursing history, a physical examination, psychosocial
assessment and review of laboratory tests. The prenatal records need to be reviewed by the
admitting nurse to assist in the assessment of the woman.
Nursing History
This includes:
• Identification data: Name, age, occupation etc.
• Chief complaints: Reason for seeking care
• History of labour: Uterine contractions: onset, duration, frequency, intensity,
discomfort and pain.
• Show and/or bleeding: Presence of show (blood and mucus), bleeding; time and
quantity
• Amniotic membrane: Ruptured or intact; gush or trickling of fluid, time of
occurrence.
• Sleep, rest and food
• Any deprivation of sleep and rest.
• Time when food and fluids was taken and amount
i) Obstetric History
Booked or unbooked case
• Gravida, parity, abortions
• Last menstrual period and expected date of confinement
• Past obstetrical history
• Any complications present during previous and present pregnancy
ii) Medical History
Presence of any medical problems that can influence labour and birth.
• Allergies of food and medication
iii) Psychosocial History
• Prenatal education received
• Response to labour
• Support system
iv) Physical examination
This includes abdominal examination, vulval examination, vaginal examination and general
examination.
85
Intervention v) Abdominal Examination
• Uterine contraction: characteristics – palpation to assess frequency, duration and

intensity
• Assessment of fundal height (in weeks and cm)
• Abdominal inspection: shape, size and obvious foetal movement, any surgery scar,
strial gravida, rum etc.
• Abdominal palpation (Leopold manoeuver) i.e. position, presentation, attitude and
degree of engagement.
• Auscultation of foetal heart rate before, during and after contraction for rate and
rhythm.
vi) Vulval examination
• For gaping of vaginal orifice or anus and bulging of perineum (suggestive signs of
second stage of labour)
• Presence of bleeding; colour and odour of amniotic fluid.
• Oedema of labia.
vii) Vaginal Examination
This is done to assess:

• Cervical dilatation, firmness and effacement.
• Amniotic membrane status: intact or ruptured.
• Presentation
• Position
• Station of the presenting part
• Any abnormalities: cord prolapse, anencephaly, hydrocephaly or compound
presentation
viii) General Examination
• General appearance: Build and stature, conveys impression about health, nutrition
and psychological condition.
• Temperature, pulse and respiration: Any elevation needs to be reported immediately.
• Blood pressure: If over 140/90 mm of Hg and needs physician’s attention.
• Head to toe examination: Observe for pallor, respiratory difficulty. Oedema -–
presence and location, signs of infections.
ix) Laboratory Tests
• Complete blood count
• Blood group and Rh type
• Blood glucose and VDRL.
• Urine analysis: Protein, glucose and ketones
Preparation for Delivery
Now you will learn how to prepare for a delivery. Details of these will be presented in the
practical section.
The preparation for delivery includes
• Physical and psychological preparation of the woman
• Preparation of the environment i.e. the delivery room
a) Physical Preparation
Evacuation of the Lower Bowel

86
A soap and water enema is administered to prevent the presence of stool in the rectum,
which might impede the descent of the presenting part, and to ensure that no stool is Normal Labour and Nursing
expelled during delivery. It is contraindicated in conditions like unengaged vertex, vaginal Management
bleeding, abruptio placentae, placenta praevia and advanced labour.
b) Vulvar and Perineal Preparation
• Shaving or clipping of the perineal hair is done. In some institutions, this practice is
discontinued because research does not show that there is decrease in rates of
infection, by performing this procedure.
• Cleansing of the vulvar area is done with soap and water and then with a non-
irritating detergent preparation like 10% Dettol solution or Hibitane (Chlorhexidine) 1
in 2000.
General Care
• The woman needs to have a bath and wear clean clothes if delivery is imminent, The
area from umbilicus to knees can be washed.
• The hair is to be combed.
• Finger and toe nails are to be trimmed.
• Nail polish and lipstick are to be removed
c) Psychological Preparation
Emotions of the woman in labour profoundly influences her reaction to discomfort and
pain. The woman should be explained the birth process. Emotional support should be
given by the nurse.
Emotional support consists of helping the mother to feel in control of her self and to feel
accepted.
The nurse can give practical advice to the woman, as to what is expected of her and how
she can help during labour. If a companion will be present, the nurse can give advice to
her/him about the role in labour.
d) Preparation of Environment i.e. the Delivery Area/Room
High standards of cleanliness need to be maintained at all time. The midwife needs to:
• Prepare the delivery room: warm, well-lit, sterile delivery kit and keep oxytocin/
syntometrine
• Set-up for the delivery (See practical)
• Provide a warm environment for the new born
• Ensure that the new born resuscitation equipment is present and functioning.
• Ensure that adult emergency equipment is available.
Observation of Woman During First Stage of Labour: Use of Partograph
During the first stage, the midwife needs to constantly observe the woman to safeguard her
and the foetus and notify the progress of labour.
a) Observation of the Mother
• Reaction to labour: observation of psychological attitude during labour.
• Vital signs:
— Pulse rate: Steady pulse rate indicates that the woman is in good condition. A
pulse rate more than 100 beats per minute is indicative of infection, ketosis or
hemorrhage. Record it every one-hour or 2 hours during early labour and every
15-30 minutes when labour progresses.
— Temperature: should be recorded every 4 hours. It should remain within normal
range. Pyrexia indicates Ketosis or infection.
— Blood pressure: should be recorded every 4 hours. If it is abnormal, it is to be
recorded more frequently.
87
Intervention — Urinalysis : urine must be tested for glucose, ketones and proteins.
— Fluid balance : a record must be kept of all fluid intake and urine output.
b) Progress of Labour
The woman usually recognises the first stage of labour by the following signs:
Show: A jelly-like pink, red or brown discharge is experienced by the woman. This is the
bloodstained mucus.
Contractions: This exhibits a pettern of rhythm and regularity, usually increasing in length,
strength and frequency as the time goes on. She will experience backache. If she places her
hand on the abdomen, she will feel simultaneous hardening of the uterus.
Rupture of the membranes: She will experience a sudden gush of fluid as rupture of
membranes or there may be dribble of amniotic fluid.
Abdominal examination
Contractions
The frequency, duration and intensity of the contractions should be assessed. The
frequency of contractions is timed from the beginning of one contraction to the beginning
of the next.
The duration of contractions is timed from the moment the uterus first begins to tighten
until it relaxes again.
The intensity of a contractions may be mild, moderate or strong at its acme.
This is assessed by palpating the fundus of the uterus.
Acme
Beginning of
Beginning of
Contraction
Relaxation
Relaxation
Interval of contraction Interval of contraction
Fig. 4.8: Characteristics of a

contraction
Descent of the Presenting Part
If there is no undue bony or soft tissue obstruction with passage descent is a continuous
process. It is slow or insignificant in first stage of labour but is pronounced during second
stage of labour and descent is completed with the birth of the baby. In primingravida, with
prior engagement of the head, practically no descent takes place in first stage of labour,
while in multiparae, descent starts with engagement. Head is expected to reach the pelvic
floor by the time the cervix is fully dilated. Descent is measured by abdominal palpation.
Factors that facilitate descent are:
i) Uterine contractions and retraction.

ii) Bearing down efforts of the woman
iii) Straightening of the fetal avoid, specially after the rupture of membranes.
c) Vaginal Examination
88 Effacement and dilatation of the cervix, descent, flexion and rotation of the foetal head
need to be assessed.
• Effacement and dilatation of the cervix. Normal Labour and Nursing
Management
Effacement
Effacement of cervix in primigravida takes place before dilation. In multigravida they

occur simultaneously. When effacement is complete only a thin edge of the cervix can be
palpated. The degree of effacement is expressed in percentage from 0% to 100 %.
Dilatation
The rate of cervical dilation changes from the latent to the active phase of labour.
The latent phase is from 0-2 cm with a gradual shortening of the cervix.
The active phase is from 3 cm to 10 cm (full dilatation)
Descent
The head descends progressively during normal labour. The level or station of the
presenting part is estimated in relation to the ischial spines.
Flexion
In vertex presentation, vertex depends on increased flexion. Flexion is assessed by the

position of the sutures and fontanells. In complete flexion of the head, the posterior
fontanelle becomes almost central; if the head is deflexed, both anterior and posterior
fontanelles are palpable.
Rotation
It is assessed by noting changes in the position of the foetus between one examination and
the next. The sutures and fontanellaes are palpated in order to determine the position (see
Fig. 4.9).
Pelvic bom
High head Flexion and descent Engaged Deeply engaged Oppelvic floor and rotatingRotation into A.P.
Membrances intact Sagittal suture Cervix dilating Head descending Occiput rotating forwards
Rim of cervix felt
in transverse diameter
Fig. 4.9: Diagrammatic representation of head descending through the pelvic brim and findings
per vaginum
d) Observation of Foetal Condition
The foetal condition during labour can be assessed by assessing the foetal heart rate, and
pattern, status of membranes and liquor and the pH of the foetal blood.
89
Intervention The Foetal Heart Rate
This may be assessed intermittently or continuously.
Intermittent recording: It is auscultated at intervals using a foctoscope/foetal stethoscope

or Doppler ultrasound apparatus. The best time to listen to the foetal heart is just after the
contraction has passed its strongest phase. It should be listened for 1 minute with the
woman lying in left lateral position. The normal limits are 120 to 160 per minute.
A rate of >160 beats/minute (tachycardia) and <120 beats/minute (bradycardia) may

indicate foetal distress.
Pattern
In case a cardiotocography is done, observations are made for baseline foetal heart rate,
baseline variability and response of the foetal heart to uterine contractions.
Membranes and Liquor
The state of liquor can assist in assessing the foetal condition. This is done at each vaginal
examination. When the membranes have ruptured, the amniotic fluid escapes from the
uterus. Normally the fluid is clear. Thick meconium shows that there is foetal distress.
Bleeding which is sudden in onset at the time or rupture of membrane may be due to vasa
previa.
pH of Foetal Blood
Normal pH of foetal blood is 7.35 or above. This is assessed through foetal blood
sampling. In case of acidosis in first stage, it will fall below 7.25.
e) Observation of Signs of Distress
Foetal Maternal
• Foetal tachycardia (> 160 b/m) • Ketoacidosis
• Foetal bradycardia ( < 120 b/m) or • Ketonuria and dehydration
foetal decelerations related to uterine • A rising pulse > 100
contraction
• Temperature > 37.2 C
• Passage of meconium stained
amniotic fluid • Late signs:
Anxious expressions; Circumoral
pallor.
Beeds of perspiration on the Upper lip
and signs of dehydration.
Marked restlessness; does not relax between
contractions and vomiting.
f) Use of Partograph
This is a graphic method of recording the salient features of labour. This is a tool for managing
labour only.
The observations charted on the partograph are :
Progress of Labour
• Latent and active phases of labour

• Cervical dilation
• Descent of foetal head
• Uterine contractions
The Foetal Condition
• Foetal heart rate

• Membranes, liquor
• Molding of the foetal skull bones
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The Maternal Condition Normal Labour and Nursing
Management
• Pulse, blood pressure and temperature
• Urine: volume, protein and acetone
• Drugs and IV fluids
• Oxytocin regime.
The method of using the partograph will be discussed in practical.
General Care of Woman during First Stage of Labour
Providing general care to a woman in labour is an essential function of the nurse. The care
to be given is presented in Table 4.2, giving the needs, nursing actions and rationale.
Table 4.2: General Care of Woman During First Stage of Labour

Need Nursing Actions Rationale
General Hygiene • Encourage to bathe. If • Provides feeling of

unable to get up, personal freshness and
sponging of face and comfort.
neck with cold water. • Reduces multiplication of
• Wash hands after organism
handling used sanitary • Helps the woman feel
pads refreshed.
• Encourage cleaning
the teeth and have a
mouth wash
Fluid Oral • Provide only small sips of • Provides hydration; absorbs

clear liquids during the quickly; is less likely to be
active phase of labour; vomited and prevents
small amounts of ice potential sequel of tracheal
chips thereafter irritation and aspiration of
• If epidural anesthesia is fluids into the lungs.
given, nothing by • Minimizes aspiration of
mouth. gastric contents into the lungs
that may compromise
the oxygen perfusion.
• Provides positive
emotional experience
• Maintains hydration.
• Maintains hydration
• Establish and maintain • Avoid excess glucose in the

Intravenous I.V. line if the woman blood stream. Excessive
does not tolerate oral maternal glucose results in
fluids. foetal hyperglycemia, foetal
hyperinsulinism and neonatal
• Administer electrolyte
solution without hypoglycemia
glucose.
• Small amount of I.V. • This assists in fatty acid
fluids with dextrose metabolism thereby
may be given if the preventing Ketonuria.
woman is in labour for
a number of hours
without calories.
• Inform family and
woman if Nil Per
Orally and give
rationale
Nutrition • Provide light and • This provides energy
easily digested food
rich in carbohydrate.
• Avoid very sweet drinks • May cause nausea
91
Intervention Need Nursing Action Rationale
Elimination Voiding • Encourage voiding at l A distended bladder may
least every two hours impede descent of the
especially if the bladder presenting part; may cause
is palpable or visibly bladder injury and decreased
distended bladder tone or
atony after birth.
• Catherization, if bladder is
incompletely empty
Position and mobility Position as per maternal Provides comfort

preference and comfort like
leaning forward, supporting
her weight on a table, walk
up and down.
If she wants to rest in lying Avoids compression of the inferior

down, encourage a left vena cava and consequent
lateral position hypertension.
Pain relief Discuss various methods that

are used for pain relief
Encourage woman to choose

the method of pain relief
from the following
Massage:
• Perform circular massage Provides comfort; is soothing and

over the lumbo-sacral relieves pain.
area, reducing friction
with the use of talcum
powder
• Massage the abdomen
with light strokes using
both hands and passing
the finger tips up from the
symphysis pubis, across
the fundus of the uterus
end down either side of
the abdomen.
• Administer sedatives,
analgesics, and narcotics
as per prescription of the
obstetrician. Examples
of Narcotics are:
— Pethidine
— Morphine
— Maptazinol
• Administer Inhalation
Analgesia if prescribed
• Assist/teach women to
use other measures of Stimulates release of endogenous
pain relief: pictes; causes interruption of the
— Hypnosis transmission of pain stimuli.
— Acupuncture
— Music therapy
Psychological care Explain regarding the This will allay anxiety and help
observation that are made, and her to cooperate in the care.
the actions they will take.
92
Check Your Progress 2 Normal Labour and Nursing
Management
1) Give meaning of the following terms:
a) Fundal dominance ....................................................................................................

..................................................................................................................................
b) Polarity .......................................................................................................................
..................................................................................................................................
c) Bandl’s ring ...................................................................................................................

..................................................................................................................................
d) Show ........................................................................................................................
..................................................................................................................................
2) What signs will indicate to you as a nurse that the woman is in the first stage of
labour?
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..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
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3) On admission of a woman in the first stage of labour, you will perform an abdominal
examination. What observation will you make?
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
4) What are the components of a partograph?

..........................................................................................................................................
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..........................................................................................................................................
5) Enumerate the signs of foetal distress?

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Immediate Care of the Newborn

Care immediately after birth focuses on assessing and stabilising the newborn. You must
be vigilant. If there are any signs of distress, appropriate interventions need to be
implemented.
A brief physical examination of the newborn is performed immediately after birth.
The care to be provided is presented here in the table.

93
Intervention Table 4.3: Immediate Care of the Newborn
Intervention Rationale
a) Clear the air passage
• As soon as the head is born, suction the • Expedites drainage and prevents
oral pharynx with a small bulb syringe. If aspiration of amniotic fluid, mucus and
a mucus extractor is used, direct it over maternal blood which could cause
the dorsum of the tongue into the pharynx atelectasis or pneumonia.
not more than 5 cm of tubing being inside
• This prevents inspiration of the amniotic
• Suction fluid mucus and maternal blood before
clearing of the mouth.
• Avoid deep suctioning with catheter
• Prevents bradycardia or/and
• Hold baby with head lowered (10 to 15
larygospasm
degree)
• Gravity helps in drainage of fluids from
• Avoid holding baby by ankles upside
the trachea
down
• Prevents hyper-extension of baby and
sudden increase in blood supply to the
brain.
b) Clamping and cutting of cord

Prevents drainage of blood from foetus to
• Immediately after birth, place the neonate placenta.
at the same level as uterus till the cord
has stopped pulsating or the cord is Avoid “stripping’ or ‘milking’ the cord, because
clamped red blood cell destruction is increased which
may lead to hyperbilirubinaemia; polycythemia
• If neonate appears normal and mature,
increases blood viscosity leading to cardio -
clamp cord close to the umbilicus,
pulmonary problems.
approximately 30 seconds after birth
without’ stripping’ or ‘milking it’. Ligature acts as a haemostat to the
umbilical blood vessels.
• l Ligate cord, 2.5 cm from the umbilicus and
place the second ligature 5 cm on the outer Permits access to umbilical vessels.
side; if there is a need for exchange
Absence of one artery indicates presence of
transfusion, place ligature not closer than 4
congenital abnormalities and need for further
cm from umbilicus.
assessment
• Examine the cord, for two arteries and
one vein.
c) Apgar score Enables assessment of physiological state :

Appraise neonate at one minute and
The score at 5 minutes gives an accurate
again at five minutes using Apgar
prediction regarding survival.
scoring method. (See Table 4.4)
d) Care of the eyes
It is a precaution against ophthalmic
Prophylactic agents are to be instilled in the
neonatorum.
eyes as per institutional policy.
This meets the legal requirements.
e) Attachment and warmth (Bonding)

Facilitates attachment between mother and
If immediate intervention is not required, baby.
dry the infant and place on mother’s
abdomen, covering both. The body may
be covered in warm blanket first or in
some cases, the baby is placed on the
mother’s abdomen, soon after birth,
having skin-to-skin contact
– do –
Allow mother to caress and cuddle the
baby and talk in a soothing tone of voice.
Caution parents to keep the newborn’s
head covered. Prevents hypothermia.
Encourage mother to feed the baby as

soon as possible Facilitates uterine contractions and expulsion
of placenta.
94
Apgar Scoring Normal Labour and Nursing
Management
This is a means of standardising the method of evaluating and recording the conditions of
the baby, in numerical terms at one minute after birth and if necessary at 5 minutes. Five
vital signs are each given a score of 0, 1 or 2 points, i.e. colour, respiratory effort, heart
beat, muscle tone, reflex response. Heart beat is the most important observation. ‘High
risk’ pregnancy and labour potentiates the incidence of a low Apgar score.
Table 4.4: Apgar Scoring
Signs Score
0 1 2
Colour Blue pale Body pink, Limbs blue Completely Pink
Respiratory effort Absent Slow, irregular Weak cry Strong cry
Heart beat Absent Slow, less than 100 Over 100
Muscle bone Limp Some flexion of limbs Active movement
Response to flicking foot Absent Facial grimace Crying
ONE MINUTE SCORE

Severe 0-2 Moderate 3-4 Mild 5-7 No asphyxia 8-10
Check Your Progress 3
1) Enumerate the physiological changes that take place in the second stage of labour.
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
2) Define the following terms related to the second stage of labour
a) Latent phase .............................................................................................................
b) Active phase ...................................................................................................................
3) What signs will indicate to you as a nurse that the woman is in the second stage of
labour?
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
4) Which is appropriate time for performing an episiotomy?
..........................................................................................................................................
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5) What are the advantages of performing an episiotomy?
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6) What signs will show that the perenium is liable to tear?
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
7) List five nursing interventions you will perform while giving immediate care to the
new born.
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95
Intervention MANAGEMENT OF SECOND STAGE OF LABOUR
The basic principles in the management of the woman in the second stage of labour is to
prevent injury to the mother and the foetus. The duration of second stage varies. In
multigravida it may last as little as 5 minutes. In privigravida, it may take two hours. This
stage has two phases, that is the latent phase and the latent phase is from the onset of
labour until the cervix reaches 3 cm dilatation, and the active phase is from 3cm dilatation
to complete dilatation of the cervix, i.e., 10 cm.
A knowledge about physiological processes will help the midwife in managing women in
second stage of labour. You will now see what are the changes.
i) Stronger and More Frequent Contractions
The contractile power of the uterus is intensified because the foetus is closely applied to the
uterus, as some of the fluid has escaped. The upper uterine segment becomes short and
thick because of the retraction of uterine muscle fibres. During each contraction, its force is
transmitted through the long axis of the foetus, directing it through the birth canal. This is
known as the foetal axis pressure (see Fig. 4.10).
Placenta
Uterus
Foetus
Fig. 4.10: Foetal axis pressure
ii) Expulsive Action of the Abdominal Muscles and Diaphragm
The abdominal muscles and diaphragm contracts, known as ‘bearing down’ or ‘pushing’.
Initially it is reflex, but can be aided by voluntary effort. With the distension of the pelvic
floor by the presenting part, the expulsive action becomes involuntary.
iii) Displacement of the Pelvic Floor
The bladder is drawn up into the abdomen, the vagina is dilated by the advancing head, the
posterior segment of the pelvic floor is pushed downwards in front of the presenting part
and the reaction is compressed by the advancing head. Further changes that takes place is
pouting and gaping of the anus, thinning out of the perineum and lengthening of the
posterior wall of the birth canal.
iv) Expulsion of the Foetus
The head is visible at the vulva. With each contraction it advances and recedes till crowing
takes place. The head is born by extension, after which the shoulders and body is born,
with the remaining amniotic fluid.
96
Nursing Management of Women in Second Stage of Labour Normal Labour and Nursing
Management
Recognition of the Commencement of the Second Stage of Labour by the Nursing
Personnel
It is very important for the nursing personnel to recognise the commencement of the second
stage. You will be able to do it if you look for the following signs that shows that the
second stage is approaching. There are many probable signs that indicate the transition
from first to second stage. There is only one positive sign. You will be able to understand
this if you read the following.
i) Positive Signs
• On vaginal examination
• No cervix is felt
ii) Probable signs
• Expulsive uterine contractions: The woman has a strong inclination to bear down.
• Trickling of blood: It is due to mild laceration of the cervix that takes place when it is
stretched and laceration of the vaginal mucous when the head descends down.
• Rupture of the membranes may take place.
• Pouting and gaping of the anus: This occurs when the head has reached the pelvic
floor. When the anus gapes and faeces are expelled, the cervix is usually dilated.
• Tenseness between anus and coccyx: This can be assessed by applying pressure with
the middle finger between the anus and the coccyx. This tenseness is because of the
pressure exerted by the descending head on the rectum and pelvic floor.
• Congestion and gaping of the vulva.
• Presenting part appears. This is considered as the probable sign because in some
cases like footling breech presentation, the foot may appear, although the cervix is not
dilated completely or if excessive moulding of head is present.
• A caput may appear.
Observation: Maternal and Foetal Condition
The factors that determine the safety of the second stage and must be carefully observed
are:
Uterine Contractions
The strength, length and frequency of contractions should be assessed continuously. In

comparison to the first stage, it is stronger, the duration is longer (1 minute), with a longer
resting phase.
The Descent
The progress is observed by noting the descent. It accelerates during the active phase. If
there is delay, a vaginal examination should be performed to note whether internal rotation
of the head has taken place to note the station of the presenting part and for presence of
caput succedaneum.
Foetal Condition
Observation of colour of liquor amnii (for meconeum staining)
Changes in foetal heart pattern
Maternal Condition
Physical ability
Coping ability
Pulse rate every 15 minutes
Blood pressure half hourly 97
Intervention General Care of Woman
Women in the second stage of labour will feel exhausted, and may not have the ability to
care for self. You as a nurse will have to give best possible care to the woman and help her
to cope with this stage of labour. The care includes:
• Maternal comfort and hygiene
• Sponge the face and neck of the mother with a wet towel.
• Provide ice-chips or sips of water
• Apply moisturizing cream to lips to prevent dryness and cracking
Bladder Care
Encourage to pass urine at the beginning of the second stage if she hasn’t done it during
the late first stage.
Pain Relief
Apply measures like massaging, encourage deep breathing, distraction, etc., to relieve
pain.
Psychological Care
Reassure the woman. Encourage her to bear down only when instructed to.
Pre-birth Considerations: Maternal Position and Bearing Down Effort
Maternal Position
You will have to give the woman an appropriate position, to enable the birth process to be
completed smoothly. There are several factors that will affect the decision for adopting a
specific position, i.e., the maternal and foetal condition, the need for frequent monitoring,
the woman’s personal choice, the environment; is it safe? Is privacy provided? and the
midwive’s confidence in her skills to assist in the delivery process. Some of the positions
that can be adopted are:
Semi-recumbent or supported sitting
This increases the efficiency of the uterine contractions and prevents hypotension and
reduced placental perfusion.
Squatting, kneeling or standing
The squatting position increases the transverse diameter by 1 cm and the anteroposterior
diameter by 2 cm, thereby resulting in easy delivery. The kneeling and standing position
also contributes to easy delivery.
Left lateral position
The midwife can view the perineum clearly. This position is useful for women who cannot
abduct their hips.
Bearing Down Effort
The woman should be helped to avoid ‘active pushing’ before the vertex is visible at the
vulva. This will allow the mother to conserve her effort and will permit the vaginal tissues
to stretch passively. Once the head becomes visible, the mother should be encouraged to
follow her own inclinations in relation to expulsive efforts.
Conducting the Delivery (For more details, refer practical)
To avoid complications in the mother as well as the newborn, one must conduct the
delivery very skillfully. You will now learn about the conduct of delivery in a vertex
presentation.
The two phases of delivery of the foetus in a vertex presentation are:
i) delivery of the head, and
ii) delivery of the shoulders and body.
The principles to be kept in mind while conducting the delivery is to minimise maternal
and foetal trauma and ensure a safe delivery for the baby. Principle of asepsis must be
98 maintained.
Delivery of the head (For more details, refer practical) Normal Labour and Nursing
Management
The perineum is swabbed and the woman is draped with sterile towels. A pad is used to
cover the anus. With each contraction the head descends and the superficial muscles of the
pelvic floor especially the transverse perineal muscles are visible. During the resting
phase, the head recedes, thereby the muscle thins gradually. The midwife places her
fingers on the advancing head to monitor descent and prevent expulsive crowning. Once
crowned, and episiotomy is given, the head is born by extension. The baby’s neck is
checked for cord around it. If it is loose, it is passed through the head, if tight, it is cut.
(See Fig. 4.11)
b) Stretching of the perineum when

a) Crowning the head is emerging at the outlet.
c) Extension of the head d) External rotation
Fig. 4.11: Delivery of the head
Delivery of the shoulders and the body
When external rotation of the head occurs, it shows that the shoulders are rotating
internally into the antero posterior diameter of the pelvic outlet. While waiting for this to
occur, mucus from the baby’s mouth and nostrils may be wiped with a gauze swab. Placing
the hand on each side of the baby’s head, over the ears, and applying downward traction,
the anterior shoulder is born. The anterior shoulder slips below the symphysis pubis. The
head is then guided in an upward direction towards the mother’s abdomen so that the
posterior shoulder can escape over the perineum. As soon as the baby is born, the cord is
cut, eyes are cleaned, airway is cleared and the Apgar score is noted.
Episiotomy
It is an incision made into the thinned out perineal body to enlarge the vaginal orifice
during delivery (see Fig. 4.12).
(a)
(b)
99
Fig. 4.12: Steps of mediolateral episiotomy – (a) Perineal infiltration, (b) Cutting the perineum
Intervention Types of Episiotomy
Median
The incision begins in the centre of the fourchette and is directed posteriorly for
approximately 2.5 cms in the midline of the perineum.
Medio lateral
The incision begins in the centre of the fourchette and is directed posteriorly, i.e. made
diagonally in a straight line, 2.5 cm away from the anus, i.e. at 7 o’clock position, if the
anus is considered to be at 6 o’clock position.
J-shaped
The incision is made in the centre of the fourchette and directed posteriorly in the midline
for about 2 cm and then directed towards 7 o’clock position.
Lateral
The incision is begun one or more cm distant from the centre of the fourchette.
Indications
Maternal : Rigid perineum disproportion between foetus and vaginal orifice.
Foetus: Cord prolapse in second stage, preterm baby.
Others: For vaginal or intrauterine manipulation, e.g. forceps and breech delivery.
Advantages
• Reduction of foetal hypoxia and acidosis.
• Reduction in overstretching of the perineum
• Bruising of urethra is avoided
• Reduction in bearing down effort in conditions like preeclampsia and cardiac
diseases.
• Prevention of third degree tear, in case of presence of scar tissue, which does not
stretch, well.
Perineal Lacerations
Perineal lacerations usually occur as the head is being born. The perineum elongates and
thins out and is liable to tear. The extent of the laceration is defined on the basis of the
depth.
First degree: Laceration extends through the skin and structures superficial to muscles ; the
fourchette only is torn.
Second degree: Laceration extends through muscles of perineal body; it is beyond the
fourchette, but does not involve rectum or anus.
Third degree: Laceration continues the anal sphincter muscle.
Fourth degree: Laceration also involves the anterior rectal wall.
Signs that the perineum is liable to tear:
• Perineum does not stretch; resists the pressure of the descending head.
• A long perineum ; appears edematous
• Trickling of blood from the vagina (due to laceration of the vaginal mucous on the
inner surface) when the head is on the perineum.
• Bluish appearance in the midline of the perineum, which later becomes white, shiny
and transparent.
Prevention of Perineal Tears
How can you prevent perineal tears?
• Principle of management of the second stage of labour should be that the smallest
100 possible diameter of the head and shoulders should be permitted to emerge and
distend the vulva.
• Encourage woman to take deliberate breaths through her mouth without accentuating Normal Labour and Nursing
expiration. This inhibits the desire to push when the head is distending the perineum. Management
• Midwife to have control of the advancing head, by placing finger tips on or near the
head to restrain it.
• Maintain flexion and controlling too rapid extension of the head in vertex
presentation.
• Prevent/active extension before crowing; prevent sinciput from gliding over the
perineum until the occipital prominence and if possible the parietal eminencies have
been born.
• Keep hands off the perineum: Pressure of the fingers on the perineum further thins
the perineum and causes bruising which favours tearing.
• Deliver the head at the end of or between contractions.
• Allow the woman to ‘breathe the head out’.
• While delivering the shoulders ensure that they have rotated internally, if not they will
rotate while passing through the vulva, causing strain on the perineum.
MANAGEMENT OF THIRD STAGE OF LABOUR

The third stage of labour is that of separation and expulsion of the placenta and membrane.
It lasts from the birth of the baby until the placenta is expelled. You will now learn about
the physiological changes that take place in this stage of labour.
The physiological changes that take place during this stage, comprises two phases, i.e.
i) the phase of placental separation and ii) the mechanism of placental expulsion. The
control of bleeding also takes place during this period. It will be discussed here.
Mechanism of Placental Separation
During this phase, the placenta separates from the uterine wall and descends. There are
some signs which enables one to know that it has taken place.
The uterine wall contracts and retracts. The upper uterine segment thickens and its
capacity reduces. The area of the placental site is diminished; the cotyledons of the
placenta becomes compact. Separation begins in the centre or the lower edge of the
placenta, at the level of the deep spongy level of the decidua. The process is like the
detachment of postage stamps at the perforation between them.
The blood sinuses are torn; a retroplacental clot is formed; the placenta gets detached from
the uterus; descends from the lower upper uterine segment into the uterine segment. With
the traction, the membranes are peeled off the decidua (see Fig. 4.13).
Placenta
Contraction Retroplacental
and clot
retraction
Placenta
Placenta completely
partial separated
separated
a) Partial retraction of b) Further contraction and c) Complete separation of the
uterine wall contraction retroction of the uterine wall: placenta : fromation of
reduction in the placental site retroplacental clot
Fig. 4.13: Mechanism of placental separation

101
Intervention Signs of Placental Separation
• The uterus becomes globular and contracts firmly
• The uterus rises upward in the abdomen. Changes from discoid to a globular ovoid
shape
• The umbilical cord descends 3 inches or more further out of the vagina
• A sudden gush of dark blood from the introitus.
Control of Bleeding
The uterine fibres contracts and retracts as the contraction and retraction of the uterus takes
place. They are arranged in three layers, i.e. the outer longitudinal, inner circular and the
intermediate, which is the thickest and strongest layer arranged in criss-cross fashion
through which the blood vessels run. When the uterus contracts, the blood vessels running
through the fibres are occluded, thus controlling haemorrhage. They are also called ‘living
ligatures’ (see Fig. 4.14).
Muscle fibres
Blood vessel
(a) Blood vessels running through the

(b) Occlusion due to contracted
interlocking muscle fibres
retracted muscle fibre
Fig. 4.14: Living ligatures

.
Nature’s Method of Expulsion of Placenta
Nature has two methods of expelling the placenta, described as Schultze and Mathews
Duncan.
The Schultze Method

• Is common; occurs in 80% of cases
• Placenta slips into the vagina through the hole in the amniotic sac, like and inverted
umbrella.
• Foetal surface appears at the vulva.
• Placental surface is not seen.
• Blood clot is inside the inverted sac.
The Mathews Duncan Method
Occurs in about 20% of deliveries
• Placenta slides down sideways and comes through the vulva with the lateral border
first. This is like button slipping through a button -hole. The maternal surface is seen
and blood escapes (see Fig. 4.15).
102
Normal Labour and Nursing
Management
(b) Mathews Duncan method of

(a) Schultze Method placental separation
Fig. 4.15: A. Schultze Method, B. Mathews Duncan method of placental separation
Nursing Management of Third Stage of Labour

Position of the Woman
This will vary according to the mother’s personal choice, normality of progress and
experience of the midwife and the need for monitoring the uterine contractions and blood
loss. The positions are described below:
Dorsal position: It enables the mother to cuddle her baby and allow easy palpation of the
uterus fundus. The disadvantage is that blood will pool in the vagina.
Upright/kneeling/squatting position: These positions may be used when the third stage is
to be managed passively, but contraindicated following an epidural block.
It is of advantage because it will hasten expulsion of the placenta due to gravity and
increased intra-abdominal pressure; aids in observation of blood loss. However, the mother
will need support to cuddle her baby.
Observation
You will now learn about the observations to be made in the mother during this stage of
labour.
The maternal status needs to be observed. The following observations need to be made by
the nurse.
B.P. and Pulse
Blood pressure should be checked periodically. The systolic should be over 110 mm Hg.
The pulse is the best guide to the loss of blood. A pulse rate over 90/mt and rising with
pallor indicate haemorrhage.
Consistency of the Uterus
The uterus must have the consistency of a firm tennis ball and its shape must be broader
laterally than antero-posteriorly. It will feel like a cricket ball when a contraction occurs
and between contraction its firm distinct outline should be clearly defined.
Size of the Uterus
After the birth of the baby, the fundus is 2.5 cm above the umbilicus. If it is more than this
one should suspect that there is another baby, the placenta is unduly large, blood clots are
present in the uterus, or the bladder is full.
Amount of the Blood L oss
The vulva is to be observed for loss of blood. Average amount of blood loss is 120 ml to 103
Intervention 240 ml. At times blood loss may not be visible, because clots may form. An increasing
pulse rate is indicative of blood loss.
• Level of consciousness
• Respiration: Rate and rhythm
Delivery of Placenta and Membranes (Refer Practical Manual also)
This is done either by active management or by passive physiological management. You

will now learn about this management.
Active Management by Controlled Cord Traction
Delivering the placenta by controlled cord traction following the administration of

syntometrine 1 ml, at the appearance of the anterior shoulder or after the birth of the head
shortens the third stage of labour and reduces blood loss.
Timing of Controlled Cord Traction
After the birth of the baby, usually the placenta should be delivered with the first uterine
contraction within 4-5 minutes.
Method of Controlled Cord Traction
Wait for a strong uterine contraction when it is palpably contracting. Place palm of the left
hand on the lower abdomen, at the symphysis pubis.
• With the palmer surface, apply counter traction, i.e. brace back the upper uterine
segment, the fingers stretching the lower uterine segment, upwards towards the
umbilicus to prevent inversion of the uterus.
• With the right hand, grasp the cord.
• Apply traction on the cord in a downward and backward direction, following the line
of the birth canal.
• Avoid jerky movements and force.
• Some resistance is felt, but it is important to apply steady tension by pulling the
cord firmly and maintaining the pressure.
• If the uterus relaxes, stop traction temporarily. First release the downward traction on
the uterus and then the counter traction.
• Then start the same procedure again.
• Once the placenta is visible, cup it in the hand to ease pressure on the membranes.
• Apply gentle upward and downward movement, or twist the placenta. This helps in
delivering the membranes intact.
Passive Physiological Management
Before making an attempt to expel the placenta, you ensure that the placenta has separated
and is lying in the lower uterine segment.
There are two ways of passively delivering the placenta and membranes. They are :
• fundal pressure
• bearing down by the woman
Fundal Pressure
The firmly contracted fundus of the uterus is used as a piston to push out the placenta.
Method
• Ask the woman to open her mouth and breathe through it slowly and quietly.
This helps in relaxation of the muscles.
104
• Stand on the right side of the woman. Normal Labour and Nursing
Management
• During a contraction, grasp the fundus with the left hand, positioning the hand in
such a way that the fingers are behind the uterus and the thumb is on the anterior
surface of the uterus.
• Apply pressure with the palm of the hand in the axis of the pelvic inlet, then
in a downward and backward direction.
• With the right hand hold the placenta at the vulva.
• Hold it with both the hands when it is almost completely expelled.
• If the membranes are adherent, turn the placenta round, apply a pair of artery forceps
to the membrane and apply gentle traction in an up and down, sideways and
circular manner.
Bearing Down
When the placenta has separated and descended and the uterus is contracted, ask the
woman to hold her breath and bear down.
Examination of Placenta and Membranes
You need to examine the placenta and the membranes to make sure that no part of it has
been retained.
Method
The placenta is to be held by the cord allowing the membranes to hang. The hole through
which the baby was delivered can be seen. Place a hand and inspect the membrane.
Inspection of Membranes
The amnion has to be peeled from the chorion, till the umbilical cord to see if the chorion is
complete. If not complete, assess the amount of membrane that is missing.
The blood vessels in the membrane should be inspected from its destination. If it runs to a
hole in the membrane, it is evident of a retained succenturiate lobe.
Inspection of Maternal and Foetal Surface
Look for :
• The colour of the placenta – dark bluish red

• The consistency – firm. If it is unhealthy it is soft and mushy ; if hydrops fetalis
is present, it is large, pale, edematous with water oozing from it.
• Cotyledons – all should be present
• Retro – placental clots
• Infarcts i.e. whitish areas
• Position of the insertion of the cord
• Length of the cord
• Blood vessels – Presence of two arteries and one vein is normal.
Care of Mother and Baby
Maternal Comfort and Safety
Some women feel cold and shiver, which is transient. Warmth may be provided by
covering with clean dry linen, a blanket and a warm drink.
Care of the Baby
• The baby should be dried, and kept warm with pre-warmed linen or placing an
electrically warmed cot mattress.
• The baby can be cuddled by the mother.
105
Intervention • Initiate breast feeding as early as possible.
• Observe general skin colour, respiration and temperature.
MANAGEMENT OF FOURTH STAGE OF LABOUR

The fourth stage of labour, the stage of recovery, is a critical period for the mother and the
newborn, because they are recovering from the physical process of birth and are initiating
new relationships, careful management of this stage is essential to promote the best
possible outcome for the mother and baby. The management includes observation and care
of the mother and the baby as given in table.
Observation and Care
106
Table 4.5: Observation of Women in Fourth Stage of Labour
Assessment Rationale/Elaboration Normal Findings Abdominal Findings
Observation
A) Vital signs Provide a data base for As per pre – Hypertension

Blood pressure diagnosis of potential pregnant state – suggests
complication haemorrhage
Assessment of rate, Prelabour levels, by – Hypertension

amplitude (indicating first hour suggests re-
volume) rhythm, symmetry hypertensive
and regularity. disorder of
pregnancy or
Pulse Readings provide a data drug reaction to
base for diagnosis of ergot
complications preparation.
(haemorrhage) – Tachycardia (over
100/mt ) suggests
haemorrhage,
infection, pain or
anxiety
Temperature Stabilizes within normal No temperature Over 100.4° F (oral)

range during the first hour. elevation or slight Sign of infection.
Slight elevation may be due elevation
to fatigue or dehydration
B) Uterus Woman is positioned with Uterus is firm and Atonic.

head slightly elevated and contracted in Action :
Uterine tone knees flexed to relieve midline – Massage uterus
tension on the abdomen. gently until it is
Fundal position and Palpation is beginning just firm
height below the umbilicus, by – expel clots
cupping the hand and
pressing firmly into the
abdomen.
C) Bladder Bladder distension is Non palpable Suprapubic rounded

assessed by noting the bladder; And firm bulge; dull to
location and firmness of the uterine fundus in percussion’
uterine fundus and by the midline fluctuates. Uterus
observation and palpation of may be boggy; above
the bladder umbilicus ; dextro-
Distension displaces fundus rotated.
upward and to the right and
may lead to uterine atony and
hemorrhage; stasis of urine
predisposes to infection.
D) Lochia Amount and character are Lochia Rubra: Bleeding per

assessed by observation of: Moderate in amount, vagina :
– perineal pads may contain some Bright red blood is
small continuous trickling
Normal Labour and Nursing
Assessment Rationale/Elaboration Normal findings Abdominal Management
Observation findings
– woman’s perineum clots; Fleshy odour; or in spurts.

– linen under woman’s does not come out Large number of clots.
buttocks from the vagina in
– number and size of continuous trickle or
clots are noted in spurts
– findings give database to
differentiate between After vaginal birth:
lochia rubra and mild oedema or
hemorrhage labial swelling or
slight bruising may
Perineum The woman turns to on to be present. Painful perineum with
her side, flexing her thigh swelling and bruising;
against her hip. The nurse Episiotomy: Indicative of a
gently lifts her upper buttock haematomas.
to assess the perineum. No redness,
edema,
If episiotomy is present ecchymosis discharge.

assessment is made for
REEDA i.e. redness,
edema ecchymosis, Wound is well
discharge and approximated
approximation of wound
Degree of discomfort is
noted.
A painful perineum bruising

and swelling may indicate a
haematoma in that area
General Instructions for Care

A brief physical assessment of the neonate will include:
– External Inspection for skin colour; staining creases on soles palm and feet,
nasal potency meconium staining of cord, skin, finger nails.
– Chest Auscultation for rate and quality of heart beat, murmurs; for rales or
ronchi.
– Abdomen Inspection for anomalies and umbilical cord condition.
– Neurological Checks muscles tone, reflex action; moros reflex; palpation

fontanelle; notes, presence and size of sutures and fontannellae.
– Others Weight, length, head circumference and gestational age. Gross

structural malformations.
While caring for the mother you need to follow the following principles
Prevention of Haemorrhage
Palpate uterus at frequent intervals, check pads, observe for haemotoma under the vaginal
mucose.
Careful monitoring of the perineum and blood loss, maintenance of intravenous fluids, if
prescribed, monitoring vital signs are important. You have already learnt this from Table
4.5.
Prevention of Bladder Distension
Palpate to determine bladder distension. Encourage the woman to void naturally ; use
nursing measures : placing a bed pan, pour warm water over the perineum, help to walk to
the bathroom.
107
Intervention Maintenance of Safety
Ambulate woman only after considering baseline BP, amount of blood loss, type and
amount of analgesic or anesthetic medications, administered during labour, amount of pain
and desire of women to ambulate.
• Assist in ambulation; observe for orthostatic hypotension.

Maintenance of Comfort
The woman may have uterine contractions, which may result in discomfort known as ‘after
pain’. This can be taken care of by helping the woman to keep her urinary bladder empty,
placing a warm blanket on the woman’s abdomen, administering analgesics that are
ordered, encouraging relaxation and breathing exercises.
Maintenance of Cleanliness
The perineum is cleaned, the buttocks are dried and a clean perineal pad is placed. She is
instructed to wash hands and then cleanse the vulval area.
Maintenance of Fluid Balance and Nutrition
The woman is encouraged to take small amounts of fluid, as large amounts can lead to
nausea and possibly vomiting. If the woman has severe bleeding, nothing is given by
mouth and intravenous fluids containing dextrose is given.
If the woman tolerates oral fluids, the type, amount and tolerance is noted.
Psychosocial Needs
The nurse reassures the mother that her behaviour during the delivery was normal. Some
women may want to rest, because of the exhaustion during labour. The nurse assists in the
bonding process by:
• encouraging the parents to hold the newborn enface

• encouraging skin contact
• assisting the woman to breast feed the baby.
1) List the signs of placental separation.

.........................................................................................................................................
.
.........................................................................................................................................
.
.........................................................................................................................................
.
2) What observations in the mother will indicate that there is no complication in the
third stage ?
.........................................................................................................................................
.
.........................................................................................................................................
.
.........................................................................................................................................
.
RECORDS AND REPORTS

A complete and accurate documentation of all observations is the responsibility of the midwife.
The records should include:
• progress of labour
108
• duration of labour Normal Labour and Nursing
Management
• drug administration
• reason for episiotomy ; type of episiotomy
• perineal repair
• date and time of delivery
• type of delivery
• sex, weight, condition and apgar of the baby
• findings of exam of placenta ; weight and fundus, amount of blood loss
• condition of mother
• presence of any complications in mother and baby
Birth notification should be made as per the policy of the institution.
LET US SUM UP
In this unit on normal labour and its management, we have discussed on causes of onset of
labour, signs and mechanism of labour and the management in various stages of labour.
It is important for you to know the premonitory signs of labour and differentiate between
true and false labour. Nursing management of women in labour involves the ability of the
nurse to recognise the various stages of labour, perform a thorough assessment of women
in labour, especially the initial assessment on admission and throughout the four stages of
labour.
Observation and general care of the woman and the foetus/newborn baby is the
responsibility of the nurse. Skill in conduct of the deliveries is important, in order to
prevent complications in both mother and the baby. Appropriate records are essential in
midwifery practice.
KEY WORDS
Apgar Score : Numeric expression of the condition of a new born
obtained by rapid assessment at 1,5 and 15 minutes of
age; developed by Dr. Virginia Apgar.
Caput succedaneum : Swelling of the tissue over the presenting part of the
foetal head caused by pressure during labour.
Cervical os : ‘mouth’ or opening to the cervix.
Delivery : Expulsion of the foetus with placenta and membranes

by the mother or their extraction by the obstetric
practitioner.
Dilatation of cervix : Stretching of the external os from an opening a few

millimeters in size to an opening large enough to allow
the passage of the infant.
Episiotomy : A surgical incision of the perineum at the end of the

second stage of labour to facilitate birth and to avoid
laceration of the perineum.
False labour : Uterine contractions that do not result in cervical

dilation; are irregular, do not become stronger and does
not result in backache.
Foetal presentation : The part of the foetus that presents at the cervical os.
Fundus : Upper part of the uterus which is dome-shaped, in

between the points of insertion of the fallopian tubes.
109
Intervention Meconium : First stools of infant. It is greenish black in colour and
contains bile pigments and salts, mucous, intestinal
epithelial cells and usually liquor amnii.
Perineum : Area between the vagina and rectum in the female and
between the scrotum and rectum in the male.
Placenta : The after-birth : a disc-shaped organ for maternal foetal

gas and nutrient exchange; is developed from the
trophoblastic layers with a lining of mesoderm in which
the blood vessels develop. It is formed by the 12th
week of pregnancy.
Premonitory : Serving as an early symptom or warning
ANSWERS TO CHECK YOUR PROGRESS

1) Normal labour or entocia is a process by which the foetus placenta cord and
membranes are expelled through the birth canal.
2) a) Oxytocin stimulates the pregnant uterus by acting directly on the myometrium

and causing it to contract.
b) Oxytocin acts on the endometrial tissue and causes the release of prostaglandin,
which makes the uterus contract.
3) a) Lightening of the uterus

b) Frequency of micturition
c) Presence of false pain
d) Taking up of the cervix
4) a) Descent
b) Flexion of the head
c) Internal rotation
d) Crowing of the head
e) Extension of the head
f) Restitution
g) Internal rotation of the shoulders
h) External rotation of the head
i) Lateral flexion of the body
1) a) Uterine contractions start in the fundus making it hard throughout the period of
contraction and spreads downwards to the lower segment where it weakens.
b) It is the neuromuscular harmony between the upper and lower pole of the uterus.
The upper pole contracts strongly and retracts to expel the foetus, while the
lower pole contracts mildly and dilates to allow the expulsion of the foetus.
c) It is the visible depressed ridge running transversely or slightly obliquely across
the abdomen above the symphysis pubis. It is present when labour is obstructed.
d) It is the blood-stained mucoid discharge, which is expelled per vagina. It is a
sign of true labour.
2) a) Rhythmic, regular uterine contractions not exceeding 60 seconds of duration.

b) Presence of abdominal tightening, discomfort or pain
110 c) Presence of backache
d) Shortening of the cervix Normal Labour and Nursing
Management
e) Progressive dilatation of the os
f) Presence of show
3) a) Frequency, duration and intensity of uterine contraction

b) Fundal height
c) Shape and size of uterus
d) Presence of foetal movements
e) Position, presentation, attitude and degree of engagement
f) Foetal heart rate and rhythm before, during and after contraction
4) a) The foetal condition

b) The progress of labour and
c) The maternal condition
5) a) Foetal tachycardia ( > 160 b/m )

b) Foetal bradycardia ( < 120 b/m )or
c) Foetal deceleration related to uterine contraction
d) Presence of meconium-stained liquor amnii
1) a) Uterine contractions become stronger and more frequent.

b) Expulsive action of the abdominal muscles and diaphragm
c) Displacement of the pelvic floor
d) Expulsion of the foetus
2) a) Latent phase: Is from the onset of the labour until the cervix reaches 3 cm
dilatation.
b) Active phase: Is from 3 cm dilatation to complete dilatation (10 cm ) of the

cervix.
3) Probable signs : • Expulsive uterine contractions

• Trickling of blood
• Rupture of the membranes
• Pouting and gaping of the anus
• Tenseness between anus and coccyx
• Congestion and gaping of the vulva
• Presenting part appears
Positive sign: No cervix is felt on vaginal examination
4) When the presenting part distends the perineum, the buldging thinned out perineum is
visualised, during a uterine contraction; one deliberate cut is given
5) Reduction of foetal hypoxia and acidosis; reduction of over stretching of the perineum
and prevention of third degree tears; reduction in bearing down efforts in preeclampsia
and cardiac diseases.
6) a) Perineum does not stretch; is oedamatous.

b) When the head is on the perineum, blood trickles down the vagina.
c) Bluish appearance in the midline of the perineum; it becomes white, shiny and
transparent. 111
Intervention 7) a) Clear the air passage
b) Clamp the cord and cut
c) Observe apgar score
d) Provide care to the eyes
e) Encourage bonding
1) – Uterus is globular and contracts firmly

– Uterus rises upward in the abdomen
– Umbilicus cord descends 3 inches or more in the vagina
– A sudden gush of dark blood from the vagina
2) – Blood pressure : systolic >110 mm Hg

– Pulse rate : 90/mt
– Respiration : 10-16; not dysnoec or laboured
– Uterus– consistency : Firm tennis ball
– shape : Broader laterally than antero-posteriorly
– size : Fundus is 2.5 cm above umbilicus
– Average blood loss : 120-240 ml
– Level of consciousness : Not altered
3) Apply traction only during a strong palpable contraction
– Apply counter traction

– Follow the line of birth canal while applying traction
– Avoid jerky movements ; avoid force
– Stop traction if the uterus relaxes
– Apply gentle upward and downward movement or twist the placenta
FURTHER READINGS
Bennett, V.R. and Brown, L.K. (1993), Myle’s Textbook for Midwives, 12th edn.,
Edinburgh, Churchill Livingstone.
Bobak, I.M. and Jensen M.D. (1993), Maternity and Gynaecologic Care. 5th edn.,
St. Louis, Mosby.
Dutta, D.C. (1992), Textbook of Obstetrics including Perinatology and Contraception.
3rd edn., Calcutta, New Central book Agency.
112

Unit 4

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Unit 4

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UNIT 4 NORMAL LABOUR AND NURSING MANAGEMENT

i) The First Stage (Dilatation of the cervix)

ii) The Second Stage (Expulsion of foetus)

iv) The Fourth Stage

Normal labour occurs when:

• the foetus is born at term

Causes of Onset of Labour

Releasing factors are produced

Stimulation of anterior pituitary gland

Production of adrenocorticotrophic hormone

Stimulation of foetal adrenal gland

Fig. 4.1: Hormonal factors in onset of labour

True labour False labour

• Frequency of micturation: Due to pressure of the foetal head on the bladder.

The movements that take place are described below.

Flexion of the Head

Crowning of the Head

Extension of the Head

Posterior fontanele Posterior fontanele

(b) Flexion (e) Restitution

(f) External rotation

frontal diameter, 10 cm sweeps the perineum, and the head is born.

(a) Increased flexion (b) Descent and engagement

(c) Internal rotation

(f) Summary of steps in normal mechanism of

Diagrammatic representation of internal rotation in anterior, lateral and posterior

MANAGEMENT OF FIRST STAGE OF LABOUR

Fig. 4.5: Progressive contraction and retraction of myometrium

vii) Taking up of the cervix

Fig. 4.7: General fluid pressure

x) Rupture of the membranes

Nursing Management of First Stage of Labour

Recognition of First Stage of Labour by Nursing Personnel

• The cervix is shortened

• Uterine contraction: characteristics – palpation to assess frequency, duration and

vi) Vulval examination

vii) Vaginal Examination

This is done to assess:

viii) General Examination

Preparation for Delivery

Evacuation of the Lower Bowel

Interval of contraction Interval of contraction

Fig. 4.8: Characteristics of a

Descent of the Presenting Part

i) Uterine contractions and retraction.

Effacement of cervix in primigravida takes place before dilation. In multigravida they

The active phase is from 3 cm to 10 cm (full dilatation)

In vertex presentation, vertex depends on increased flexion. Flexion is assessed by the

d) Observation of Foetal Condition

This may be assessed intermittently or continuously.

Intermittent recording: It is auscultated at intervals using a foctoscope/foetal stethoscope

A rate of >160 beats/minute (tachycardia) and <120 beats/minute (bradycardia) may

Membranes and Liquor

e) Observation of Signs of Distress

The observations charted on the partograph are :

• Latent and active phases of labour

The Foetal Condition

• Foetal heart rate

The method of using the partograph will be discussed in practical.

General Care of Woman during First Stage of Labour

Table 4.2: General Care of Woman During First Stage of Labour

General Hygiene • Encourage to bathe. If • Provides feeling of

Fluid Oral • Provide only small sips of • Provides hydration; absorbs

• Establish and maintain • Avoid excess glucose in the

Position and mobility Position as per maternal Provides comfort

If she wants to rest in lying Avoids compression of the inferior

Pain relief Discuss various methods that

Encourage woman to choose

• Perform circular massage Provides comfort; is soothing and

a) Fundal dominance ....................................................................................................

c) Bandl’s ring ...................................................................................................................

4) What are the components of a partograph?

5) Enumerate the signs of foetal distress?

Immediate Care of the Newborn

A brief physical examination of the newborn is performed immediately after birth.

The care to be provided is presented here in the table.