Nursing Management During

Labor and Delivery

 Child birth preparation
• Method of Grantly Dick-Read
– prenatal courses and training reduce fear,
overcome ignorance, and build a woman's self-
confidence
– woman is given empathic understanding and
support during labor by her partner, the nurse,
and the health care provider
 Psychoprophylactic or Lamaze Method

• replace responses of restlessness, fear, and the

loss of control with more useful activity
• Breathing techniques to help the process of
labor
• breathing normally while silently mouthing the
words to a song and simultaneously tapping
the rhythm with the fingers
 Bradley Method of Delivery
• husband-coached childbirth
• Doula
• Involves the concepts of leading, guiding,
supporting, caring, and fostering specific skills
and confidence
• Medications are not encouraged for pain relief
• Relaxation is the core component
 Components of Labor
• Passage
• Passenger (fetus)
• Powers of labor (uterine factors)
• Psyche
 PASSAGE
• from the uterus through the cervix & vagina to the
external perineum
• pelvic inlet
– AP diameter is the narrowest diameter
• Pelvic outlet
– transverse diameter is the narrowest.
• Pelvic inlet & outlet
 The Fetal Skull
• The most important part of the fetus
because:
– Largest part of the body
– Most frequent presenting part
– Least compressible of all parts
 Cranial bones
• The first 3 are not important because they
lie at the base of the cranium and therefore
are never the presenting parts
– Sphenoid - occipital
– Ethmoid - parietal
– Temporal
– frontal
 Membrane spaces
• allow the bones to move and overlap
• change the shape of the fetal head in order
to fit through the birth canal
• MOLDING
 Membrane spaces
• SAGITTAL SUTURE
– Membranous interspace which joins the parietal
bones
• CORONAL SUTURE
– joins the frontal bones and parietal bones
• LAMBDOID SUTURE
– joins the occiput and the parietals
 Fontanels
• Membrane covered spaces at the junction of
the main suture lines
• Anterior fontanel
– larger
– diamond shaped
– Closes by 12-18 months
• Posterior fontanel
– smaller
– triangular shaped fontanel
– Closes by 2-3 months
 Measurements
• The shape of the fetal skull causes it to be
wider in its anteroposterior diameter (AP)
than its transverse diameter
• Transverse diameter
– Biparietal 9.25 cm
– Bitemporal 8 cm
– Bimastoid 7 cm
 Measurements
• Anteroposterior diameter
– Suboccipitobregmatic
• From below the occiput to the anterior fontanel
• 9.5cm
• Narrowest AP diameter
– Occipitofrontal
• From the occiput to the mid-frontal bone
• 12 cm
– Occipitomental
• From the occiput to the chin
• 13.5 cm
• Widest AP diameter
 Estimating the pelvic size

• Diagonal conjugate
– distance between the anterior surface of the sacral
prominence and the anterior surface of the inferior
margin of the symphysis pubis
– lithotomy position
– > 12.5cm
• adequate for vaginal delivery
 Estimating the pelvic size

• True conjugate or conjugate vera

– measurement between the anterior surface of
the sacral prominence and the posterior surface
of the inferior margin of the symphysis pubis
– diagonal conjugate – 1.5 or 2 cm
• true conjugate
– 10.5-11cm
 Estimating the pelvic size
• Ischial tuberosity diameter
– distance between the ischial tuberosities or the
transverse diameter of the outlet
– medial and lowermost aspect of the ischial
tuberosities at the level of the anus
– pelvimeter or ruler
– 11cm
• Pelvic inlet & outlet
 Theories of labor
• Uterine stretch theory
– uterus becomes stretched and pressure
increases, causing physiologic changes that
initiate labor.
– Any hollow body organ when stretched to
capacity will necessarily contract and empty
 Theories of labor
• Oxytocin theory
– Labor stimulates the hypophysis to produce
oxytocin from the posterior pituitary gland
– Oxytocin causes contraction of the smooth
muscles of the body
 Theories of labor
• Progesterone deprivation theory
– Progesterone inhibit uterine motility
– If its amount decreases labor pain occurs
– In later pregnancy
• fetus produces increased levels of cortisol
• inhibit progesterone production from the placenta
 Theories of labor
• Prostaglandin theory
– increased production of prostaglandins by fetal
membranes and uterine decidua as pregnancy
advances
 Theories of labor
• Theory of aging placenta
– Because of the decrease in blood supply, the
uterus contracts
 Events Preliminary to Labor
• Lightening
– the settling of the fetus in the lower uterine
segment
– occurs 2 to 3 weeks before term in the
primigravida
– multigravida- on or before labor onset
 Events Preliminary to Labor
• Lightening
– Results in:
• Increased urinary frequency
• Relief of abdominal tightness and diaphragmatic
pressure
• Shooting pains down the legs
– pressure on the sciatic nerve
• Increase in the amount of vaginal discharges
 Events Preliminary to Labor
• Increased activity level
• Due to increased epinephrine secreted to prepare the body
for the coming “work” ahead.
• Advise the woman not to use this increased energy for
doing household chores
• Loss of weight
• About 2-3 lbs 1 to 2 days before labor onset
• Due to decrease in progesterone production leading to
decrease in fluid retention
 Events Preliminary to Labor
• Braxton-Hicks contractions
• Ripening of the cervix
• Rupture of membranes
• Labor is inevitable
• Will occur within 24 hours
• The integrity of the uterus have been destroyed
• Infection can easily set in
 Events Preliminary to Labor
• Rupture of membranes
• Labor inevitable ( within 24 hrs)
• Aseptic technique should be observed in all
procedures
• Less frequent internal examination
• Enema is no longer ordered
• Temperature should be taken regularly so that fever
can be detected
• Cord compression and cord prolapse can occur
 Events Preliminary to Labor
• Rupture of membranes
• If not yet admitted
• Put to bed immediately
• Check temperature
• In the labor room
• Take the fetal heart tones
• For cord prolapse
• trendelenburg position to reduce pressure on the cord
• 5 mins of compression can lead to irreversible brain
damage or death
• Apply os on the prolapsed cord to prevent drying
 Events Preliminary to Labor
• Show
• A pinkish vaginal discharge
• Operculum
• rupture of minute capillaries in the mucus
membranes of the cervix
 Signs of True Labor
• Uterine Contractions
– Surest sign that labor has begun
– Is the initiation of effective, productive uterine
contractions
 Signs of True Labor
• Uterine Contractions
– Pain in uterine contractions results from
• Contraction of uterine muscles when in an ischemic state
• Pressure on nerve ganglia in the cervix and lower uterine
segment
• Stretching of ligaments adjacent to the uterus and in the
pelvic joints
• Stretching and displacement of the tissues of the vulva and
perineum
 Signs of True Labor
• Uterine Contractions
– Phases of uterine contractions
• Increment
– first phase during which the intensity of contraction increases
– Crescendo
• Acme
– the height of the uterine contraction
– Apex
• Decrement
– last phase during which intensity of contraction decreases
– Decrescendo
 Signs of True Labor
FALSE LABOR PAINS TRUE LABOR PAINS
-Remain irregular -May be slightly irregular at first but become
irregular and predictable in a matter of hours

-Generally confined to the abdomen -First felt in the lower back and sweep around
to the abdomen in a girdle-like fashion

-No increase in duration, frequency, and -Increase in duration, frequency and intensity
intensity

-Often disappears if the woman -Continue no matter what the woman’s level
ambulates of activity is

-Absent cervical changes -Accompanied by cervical effacement and

dilatation (the most important difference)
 Effacement
• Shortening and thinning of the cervical canal as
distinct from the uterus
• Expressed in percentage

DILATION
• Enlargement of the external cervical os
• 10cm
• a result of uterine contractions
• a result of pressure of the presenting part and the
BOW
 Uterine changes
• The uterus is gradually differentiated into two
distinct portions
– Upper uterine segment- thick and active to expel out
fetus
– Lower uterine segment- thin walled, supple and
passive so that the fetus can be pushed out easily
 Uterine changes
• Physiological retraction ring
– is formed at the boundary of the upper and lower
uterine segments
• Bandl’s ring
– the round ligaments of the uterus becomes tense
during dilatation and expulsion causing an abdominal
indentation
– Danger sign
– uterine rupture
– Pathologic retraction ring
 Length of normal labor
STAGE OF LABOR PRIMIS MULTIS
FIRST STAGE 12 ½ hours 7 hours 20 minutes
SECOND STAGE 80 minutes 30 minutes
THIRD STAGE 10 minutes 10 minutes
TOTAL 14 hours 8 hours
 STAGES OF LABOR
• First stage of labor
– True labor pains and ends with complete dilatation
of the cervix
– Power/Forces: involuntary uterine contractions
– Phases:
• Latent
• Active/ accelerated
• Transitional
 Phases of Labor
• Latent
– Early time in labor
– Cervical dilatation is minimal because effacement
is occuring
– Cervix dilates only 3-4 cm
– Contractions are of short duration and occur
regularly 5-10 minutes apart
– Mother is excited but has some degree of
apprehension and still has the ability to
communication
 Phases of Labor
• Active/Accelerated
– Cervical dilatation reaches 4-8 cm
– Rapid increase in duration, frequency and
intensity of contractions
– Mother fears losing control of herself
– dilation averages 1.2 cm/hour in the nullipara
– 1.5 cm/hour in the multipara
Nursing Care during the 1 phase st

of Labor
• Hospital admission- provide privacy and
reassurance from the very start
• Personal data- name, age address,civil status
• Obstetrical data
– EDC, OB score, amount and character of show,
membranes ruptured or not
Nursing Care during the 1 phase st

of Labor
• P.E., IE and Leopold’s done to determine the
following
– Effacement and dilatation
– Station
– Fetal presentation/Lie
 Presentation
• Relationship of long axis of the mother with
the long axis of the fetus
• Lie
• Presenting part
– Fetal part which enters the pelvis first and
covers the cervical os
1. Vertical
a. Cephalic or Vertex
- Head sharply flexed
- FHT best heard at the fetal back
- For face- fetal chest
- In poor flexion
- Face
- Brow
- Chin
a. Breech
- Buttocks are the presenting part
- Complete – thighs and legs are flexed
- Frank- thighs flexed, legs extended
b. Footling
- Single- one leg unflexed and extended, one foot presenting
- Double- both legs extended
 Presentation
2. Horizontal
a. Transverse
b. Shoulder
 Presentation
3. Important Considerations
- Hazards of breech delivery
- Cord compression
- Abruptio placenta
- Horizantal lie
- Very rare (1%)
- May be due to a relaxed abdominal wall
- Multiparity
- Pelvic contraction
- Placenta previa
 Position
• Relationship of the fetal presenting part to a
specific quadrant in the mother’s pelvis
• The sutures and fontanelles
– provide important landmarks for determining fetal
position during a vaginal examination
• Pelvis divided in 4 quadrants
– RA
– LA
– RP
– LP
• Posterior position results in more backaches
– Pressure on the maternal sacrum
• MC fetal position : LOA
• 2nd MC ROA
 FETAL POSITION
• Landmarks on the fetal presenting part :
– Occiput (O)
• vertex
– Buttocks (sacrum-S)
• breech
– Shoulder (scapula or acromion – A)
• horizontal
– chin or mentum (M)
• face
 Fetal Presentation & Position
• ENGAGEMENT
– settling of the presenting part of a fetus far enough
into the pelvis to be at the level of the ischial spines,
midpoint of the pelvis

• ATTITUDE
– degree of flexion a fetus assumes during labor or the
relation of the fetal parts to each other
– Aka Flexion
 Fetal Attitude
• Fetal head is flexed, back is bent, extremities are
flexed
• Good flexion
– chin rests on the thorax
– suboccipitobregmatic or vertex presentation
• MODERATE flexion
– occipitofrontal diameter or brow
• POOR flexion
– head is hyperextended (largest diameter),
occipitomental (face)
 Station
• relationship of the fetal presenting part to the
level of the ischial spines
– 0- level of the ischial spines; Engagement
– -1- presenting part above the ischial spines
– +1- presenting part below the ischial spines
– +4- Crowning > encircling of the largest diameter of
the fetal head by the vulvar ring
 Transition period
• Mood of the woman suddenly changes and the
nature of the contractions intensify
• Membranes still intact
• Sudden gush of AF
• If spontaneous rupture did not occur,
amniotomy is done except if station is still
“minus”
– Can lead to cord compression
• Show becomes prominent
 Transition period
• Uncontrollable urge to push
• Profuse perspiration and distention of neck
veins are seen
• Nausea and vomiting
– Due to decreased gastric motility and absorption
• Primis- delivered within 20 contractions
(40mins)
• Multis- delivered within 10 contractions (20
mins)
 Transition period
• Nursing actions to provide comfort measures
– Sacral pressure
• Applying pressure with the heel of the hand on the
sacrum
• Relieves discomfort
– Proper bearing down techniques
– Controlled chest (costal) breathing during
contractions
– Emotional support
 Monitoring and evaluating
important aspects
• Assess uterine contractions, fingers should
be spread lightly over the fundus
– Duration
• From the beginning of one contraction to the end of
the same contraction
• Early labor- 20-30 secs
• Late- 60-70 secs (should never be longer!)
 Monitoring and evaluating
important aspects
Interval
- From end of one contraction to the beginning of
the next contraction
- Early- 40-45 mins
- Late- 2-3 mins
Frequency
- Beginning of one contraction to the beginning of
the next contraction; observe 3-4 contractions
 Monitoring and evaluating
important aspects
Intensity
- The strength of a contraction
- May be mild, moderate, or strong
- Measured by the consistency of the fundus at the
acme of contraction
- To estimate intensity, check the fundus at the end
of the contraction to determine whether it relaxes
 Monitoring and evaluating
important aspects
Blood pressure
- Not to be taken during contraction as it tends to
increase
- Should be taken at least every half hour during
active labor
- Headache- take the BP
- If normal, stress related
- If increased, refer immediately to MD (sign of
toxemia)
 Monitoring and evaluating
important aspects
Fetal Heart Rate
-120-160 bpm
- not to be taken because it tends to decrease
during contractions
- compression of fetal head when the uterus contracts
stimulates vagal reflex which in turn causes bradycardia
- Latent phase- every hour
- Active phase- every half hour
- Transition- every 15 mins
 Monitoring and evaluating
important aspects
Fetal Heart Rate
-any abnormality in FHR initial nursing
intervention is to change maternal position
- Signs of fetal distress
- bradycardia- <100/min or tachycardia >180 bpm
- meconium staining in non breech presentation
- fetal thrashing
- hyperactivity of fetus as it struggles for more O2
 Monitoring and evaluating
important aspects
Emotional support is provided for the
woman in labor by keeping her constantly
informed of the progress of labor
 Health Teachings
• Bath
– Advisable if contractions are tolerable or not too close
to one another
– Will make the mother feel more comfortable
• Ambulation
– it helps shorten the first stage of labor if done during
the latent phase
– Not indicated for ruptured membranes
 Health Teachings
• Solid or liquid foods
– To be avoided because:
• Digestion is delayed during labor
• A full stomach interferes with proper bearing down
• May vomit and cause aspiration
 Health Teachings
• Enema
– Not a routine procedure
– A full bowel hinders the progress of labor
• Effectiveness of enema in labor can be determined
by evaluating change in uterine tone and the
amount of show
– Expulsion of feces during the 2nd of labor
predisposes mother and baby to infection
 Health Teachings
Enema
• Procedures
– May either be soap suds or fleet enema (C/I in patients with
toxemia due to its sodium content)
– Optimum temperature of the solution- 105 °F to 115 °F
(40.5- 46.1 °C)
– Side lying position
– Clamp rectal tube during contraction
– Check FHR afte enema to determine fetal distress
 Health Teachings
Enema
• Contraindications to enema in labor
– Vaginal bleeding
– Premature labor
– Abnormal fetal presentation or position
– Ruptured membranes
– Crowning
Perineal prep
• Done aseptically
• Use figure of 7, from front to back
 Health Teachings
• Encourage the mother to void every 2-3 hours by
offering the bedpan because
– A full bladder retards fetal descent
– Urinary stasis can lead to UTI
– A full bladder can be traumatized during delivery
• Perineal shave
– Not a routine procedure maybe done to provide a clean
area for delivery
– Muscles at the symphisis pubis should be kept taut and
razor moved along the direction of hair growth
 Health Teachings
• Encourage Sim’s position because it
– Favors anterior rotation of the fetal head
– Promotes relaxation between contractions
– Prevents continual pressure of the gravid uterus on the
IVC
– Pressure results in supine hypotensive syndrome (aka
as vena cava syndrome)
– It is due to reduced venous return resulting in
decreased cardiac output and subsequent fall in BP
 Health Teachings
• Do not push during the first stage
– Leads to unnecessary exhaustion
– Repeated strong pounding of the fetus against the
pelvic floor will lead to cervical edema thus
interfering with dilatation and prolonging length to
labor
• Abdominal breathing
– Advised for contractions during the 1st stage
– To reduce tension and prevent hyperventilation
 Health Teachings
• Administer analgesics as ordered
– Narcotics most commonly used
– Demerol
– Analgesic, sedative and anti-spasmodic
– Not given in early labor- can retard the progress of labor
because of its anti-spasmodic effect
– Not given if cervical dilatation is 6-8cm
• Causes respiratory depression in fetus
– Take effect in 20 mins
– Patient experiences euphoria and a sense of well being
– Antidote: Narcan
 Health Teachings
• Assist in administration of regional anesthesia
– Does not enter maternal circulation
– Does not affect the fetus
– Patient is completely awake and aware of what is
happening
– Does not depress uterine tone, optimal uterine
contraction
– Xylocaine is the anesthetic of choice
– NPO with IVF to prevent dehydration, exhaustion and
aspiration
 Types of anesthesia
• Paracervical
– Transvaginal injection into either side of the cervix
– Lithotomy
– Painless childbirth
• Pudendal
– Through the sacrospinous ligament into the areolar
tissue
– Lithotomy
– Side effect
• Ecchymosis (blood in SQ); apply ice bag on the first day to
reduce swelling
 Types of anesthesia
• Low spinal
– Epidural
• Lumbar level outside the dura matter
– Saddle block
• 5th lumbar; anesthesia at the perineum, upper thighs, lower
pelvis
– Blocks pain of first stage of labor
– Side lying position or sitting position with back flexed
– Forceps delivery
 Types of anesthesia
• Low spinal
– Post spinal HA
• Leakage of anesthetic into the CSF
• Injection of air at time of needle insertion
• Flat on bed for 12 hours
• Increase fluid intake
– Side effects
• Hypotension- xylocaine is a vasodilator
– Prompt elevation of legs
– administration of vasopressor
• Fetal bradycardia
• Decreased maternal respirations
 Second stage of labor
• Complete cervical dilatation of the cervix and
ends with the delivery of the baby
• Involuntary uterine contractions and
contractions of the diaphragmatic and abdominal
muscles
• Mechanisms of labor
– Descent, flexion, internal rotation, extension,
external rotation, expulsion
 Second stage of labor
• Descent – may be preceded by engagement
• Flexion- as descent occurs, pressure from the
pelvic floor causes the chin to bend forward
onto the chest
• Internal Rotation- from AP to transverse, then
AP to AP
• Extension- as the head comes out, the back of the
neck stops beneath the pubic arch.
– Head extends and forehead, nose, mouth and chin
 Second stage of labor
• External rotation
– Restitution
– Anterior shoulder rotates externally to the AP
position
• Expulsion
– Delivery of the rest of the body
• Positioning
– upright position is the preferred position with
the head of the bed 45 degrees
• Pushing Techniques
– Delayed pushing
• Ferguson's reflex
• a physiologic response that is activated when the
presenting part of the fetus is at least at a +1 station and
• usually accompanied by spontaneous bearing-down
efforts
• can be used with epidural anesthesia/analgesia as
women cannot feel the urge to push
• Pushing Techniques
– Nondirected pushing
• Open glottis
• pushing for 4 to 6 seconds followed by slight
exhaling (essentially pushing while
exhaling/grunting)
• repeating this pattern for 5 or 6 pushes/uterine
contraction
 Third Stage of Labor (Placental
Stage)
• Begins with delivery of the baby and ends
with delivery of the placenta.
• The third stage may last from a few minutes
to 30 minutes
 Third Stage of Labor (Placental
Stage)
• Ask the woman to bear down gently.
• Fundal pressure is never applied to facilitate
delivery of the fetus or the placenta.
• Observe for the signs of placental separation
– The uterus rises upward in the abdomen.
– The umbilical cord lengthens.
– Trickle or spurt of blood appears.
– The uterus becomes globular in shape.
 Third Stage of Labor (Placental
Stage)
• Evaluate the placenta for size, shape, and cord site
implantation.
• Evaluate placenta for Duncan or Schultze presentation.
– Schultze –central region of the placenta separates first with the
shiny surface of the placenta (fetal side) appearing first.
• Commonly referred to as shiny Schultze.
– Duncan - periphery of the placenta separates first with the
dull, irregular surface of the placenta (maternal side)
appearing first.
• Commonly referred to as dirty Duncan
 Third Stage of Labor (Placental
Stage)
• administer oxytocin (Pitocin 10 to 40 units/L at 100
mU/min) either I.V. piggyback or I.M. as directed by
facility policy and provider.
• Pitocin should never be administered I.V. push as it
can cause cardiac dysrhythmia and death.
• massage uterine fundus until firm
 Third Stage of Labor (Placental
Stage)
• Check to see that the placenta and membranes are
complete.
• Evaluate and massage the uterine fundus until firm.
• Evaluate vaginal bleeding.
 Fourth Stage
• Lasts from delivery of the placenta until the
postpartum condition of the woman has
become stabilized (usually 1 hour after
delivery).
 Fourth Stage
• Monitor BP, RR, PR every 15 minutes for 1 hour
• every ½ hour for 1 hour
• Every hour until stable
• Take temperature every 4 hours unless elevated, then
every 1 to 2 hours.
• Uterine fundal tone, height, and position.
– The uterus should be firm around the level of the umbilicus, at
the midline.
– If deviated to the side (usually the right side), it is indicative of
a full bladder
– have the mother empty her bladder and the uterus should return
to midline.
 Fourth Stage
– Amount of vaginal bleeding.
• Scant
– blood only on tissue when wiped
– or less than 1-inch (2.5-cm) stain on perineal pad within 1 hour.
• Small/light
– less than 4-inch (10-cm) stain on perineal pad within 1 hour.
• Moderate
– less than 6-inch (15.2-cm) stain on perineal pad within 1 hour.
• Heavy
– saturated perineal pad within 1 hour
 Fourth Stage
• Perineum for edema, discoloration, bleeding, or
hematoma formation.
• Episiotomy for intactness and bleeding.
• Apply a covered ice pack to the perineum during the
first 24 hours for an episiotomy, perineal laceration, or
edema.
• Administer analgesics as indicated
• Allow for privacy and rest periods between postpartum
checks.
• Provide warm blankets, and reassure the woman that
tremors are common during this period
 Fourth Stage
• Show the neonate to the mother and father or support
person immediately after birth when possible.
• Encourage the mother and father to hold the infant as
soon as possible.
• Teach the mother or parents to hold the neonate close to
their faces, about 8 to 12 inches (20.5 to 30.5 cm), when
talking to the baby.
• Have the mother or parents look at and inspect the
infant's body to familiarize themselves with their child.
 Fourth Stage
• Assist the mother with breast-feeding during the first 30
minutes, then 2 hours, after birth.
– This is typically a period of quiet alert time for the neonate,
and he or she will usually take to the breast.
• Provide quiet alone time in a low-lighted room for the
family to become acquainted.
• Observe and record the reaction of the mother or
parents to the neonate