MATERNAL & CHILD HEALTH NURSING (LEC) transcribed by: Shiane Viloria

1st Sem: MIDTERM | A.Y 2024-2025 ​ ​ ​ ​ Prof: Chresence Anne Garcia, PhD
WEEK 7 : becomes still softer (described as “butter
INTRAPARTAL CARE soft”) and it tips forward.
ASSESSMENT OF THE LABORING MOTHER -​ Cervical ripening is an internal
Subtle signs of labor are important to review with announcement that labor is very close at
women during the last trimester of pregnancy so hand.
they can more easily recognize beginning signs.
SIGNS OF TRUE LABOR
PRELIMINARY SIGNS OF LABOR
Signs of true labor involve uterine and cervical
★​ Lightening– descent of the fetal presenting part changes.
into the pelvis. ★​ Uterine Contraction
-​ Occurs approximately 10-14 days before -​ The uterus begins to contract and relax
labor begins– primipara periodically as it it is rehearsing for labor
-​ Fetal descent changes a woman’s -​ The surest sign that labor has begun is
abdominal contour because it positions the productive uterine contractions.
uterus lower and more anterior in the -​ Because contractions are involuntary and
abdomen. come without warning, their intensity can
-​ Gives a woman relief from the be frightening in early labor.
diaphragmatic pressure and shortness of -​ Helping a woman appreciate that she can
breath that she has been experiencing and predict when her next one will occur and
“lightens” her load. therefore can control the degree of
★​ Increase in Level of Activity discomfort she feels by using breathing
-​ Related to an increase in epinephrine release exercises offers her a sense of well-being.
initiated by a decrease in progesterone ★​ Show
produced by the placenta. This additional -​ Mucus plug (operculum) fills the cervical
epinephrine prepares a woman’s body for canal during pregnancy as the cervix softens
the work of labor ahead. and ripens
★​ Slight Loss of Weight -​ The exposed cervical capillaries seep blood
-​ As progesterone level falls, body fluid is as a result of pressure exerted by the fetus.
more easily excreted from the body. -​ This blood, mixed with mucus, takes on a
-​ This increase in urine production can lead to pink tinge and is referred to as “show” or
a weight loss between 1 and 3 pounds. “bloody show.” Women need to be aware of
★​ Braxton Hicks Contraction this event so that they do not think they are
-​ Prodromal or false labor pains bleeding abnormally.
-​ Contractions of the uterus that typically not ★​ Rupture of Membranes
felt until the second or third trimester of -​ Labor begins experienced as a sudden gush
pregnancy or as scanty, slow seeping of clear fluid from
-​ Random and unpredictable the vagina. Early rupture of the membranes
-​ Usually mild but can be so strong that a can be advantageous as it can cause the
woman mistakes them for true labor. fetal head to settle snugly into the pelvis,
★​ Ripening of the Cervix shortens labor.
-​ At term (37 weeks above), the cervix
Amniotic Fluid VS. Urine TWO PELVIC MEASUREMENTS
pH level of amniotic fluid is more alkaline while -​ Important to determine the adequacy of the
urine is more acidic. pelvic size.
Artificial Rupture- also known as amniotomy, is a a.​ Diagonal conjugate - the anteroposterior
procedure where the amniotic sac (the fluid-filled diameter of the inlet; the narrowest diameter at
sac that surrounds the baby during pregnancy) is the pelvic inlet.
deliberately ruptured to induce or accelerate labor.
This is typically done using a sterile tool, such as an
amnihook, to puncture the amniotic sac, allowing
the amniotic fluid to flow out.
Amniotic sac and umbilical cord- lack of nerve
supply

Two risks associated with rupture of the

membranes: Intrauterine infection and prolapse of
the umbilical cord, which could cut off the oxygen b.​ Transverse diameter of the outlet- the
supply to the fetus (Lewis et al., 2007). narrowest at the outlet.
-​ If labor has not spontaneously occurred by
24 hours after membrane rupture and the
pregnancy is at term, labor will be induced
to help reduce these risks.

COMPONENTS OF LABOR

A successful labor depends on four integrated

concepts, often referred to as the four Ps:
1.​ The passage (a woman’s pelvis) is of adequate
size and contour.
2.​ The passenger (the fetus) is of appropriate size
and in an advantageous position and
presentation.
3.​ The powers of labor (uterine factors) are
adequate. (The powers of labor are strongly
influenced by the woman’s position during
labor.)
4.​ The psyche, or a woman’s psychological outlook
II.​ PASSENGER (fetus)
is preserved, so that afterward labor can be
-​ The body part of the fetus that has the
viewed as a positive experience.
widest diameter is the head, so this is the
I.​ PASSAGE part least likely to be able to pass through
-​ The route a fetus must travel from the the pelvic ring. Whether a fetal skull can
uterus through the cervix and vagina to the pass depends on both its structure (bones,
external perineum. fontanelles, and suture lines) and its
alignment with the pelvis.
a.​ MOLDING is a change in the shape of the d.​ FETAL ATTITUDE
fetal skull produced by the force of uterine -​ Describes the degree of flexion a fetus assumes
contractions pressing the vertex of the head during labor or the relation of the fetal parts to
against the not-yet-dilated cervix. each other.
●​ Max contraction → 10 cm -​ A fetus in good attitude is in complete/ full
●​ Only last a day or two and will not be a flexion:
permanent condition 1.​ Spinal column is bowed forward
●​ Little molding → brow is the presenting 2.​ Head is flexed forward so much that the
part because frontal bones are fused chin touches the sternum
●​ No skull-molding → fetus is breech 3.​ The arms are flexed and folded on the chest
because the buttocks, not the head, present 4.​ The thighs are flexed onto the abdomen
first. 5.​ Calves are pressed against the posterior
●​ No molding → babies born by cesarean aspect of the thighs.
birth when there is no pre procedure labor
e.​ DESCENT- downward movement of the
Note: Cervix is part of the uterus
biparietal diameter of the fetal head within the
b.​ ENGAGEMENT- settling of the presenting pelvic inlet.
part is far enough into the pelvis to be at the ●​ Full descent- fetal head protrudes beyond
level of the ischial spines, a midpoint of the the dilated cervix and touches the posterior
pelvis. vaginal floor occurs because of the pressure
●​ The degree of engagement is established by on the fetus by the uterine fundus.
a vaginal and cervical examination. ●​ As the pressure of the fetal head presses on
●​ Floating → presenting part is not engaged the sacral nerves at the pelvic floor, mother
●​ Dipping → one trait is descending but has will experience a “pushing sensation.”
not yet reached the ischial spines.
f.​ FETAL LIE- relationship between the long
c.​ STATION refers to the relationship of the (cephalocaudal) axis of the fetal body and the
presenting part of a fetus to the level of ischial long (cephalocaudal) axis of the woman’s body.
spines. ●​ Transverse lie- fetus is lying in a horizontal
●​ 0 station (synonymous with engagement) – position.
presenting part is at the level of the ischial ●​ Longitudinal- fetus is lying in a vertical
spines. position. 96% of fetuses with their long axis
●​ - 1 to - 4 station – the presenting part is lie parallel to the long axis of the woman.
above the spines (floating), the distance is
measured and described as minus stations.
●​ + 1 to + 4 station – presenting part is below
the ischial spines, the distance is stated as
plus stations.
●​ +3 or +4 station or crowning – presenting
part is at the perineum and can be seen if the
vulva is separated.
 g.​ TYPES OF FETAL PRESENTATION ●​ Breech Presentation- either buttocks or the
-​ Fetal presentation denotes the body part feet are the first body parts that will contact
that will first contact the cervix or be the cervix. Occur in approximately 3% of
born first. This is determined by a births.
combination of fetal lie and degree of fetal GOOD attitude brings the fetal knees up against the
flexion (attitude). fetal abdomen; POOR attitude knees are extended.
●​ Cephalic Presentation- the fetal head is the can be difficult births, with the presenting point
body part that will first contact the cervix. It influencing the degree of difficulty.
is the most frequent type, occurring 95% of THREE types: (complete, frank, footling)
the time. Type Lie Attitude Description
FOUR types: (vertex, brow, face, and mentum)
Complete Longitudinal Good (full The fetus has the thighs
flexion) tightly flexed on the
abdomen; both the
buttocks and the tightly
flexed feet present to the
cervix.

Frank Longitudinal Moderate Attitude is moderate

because the hips are
flexed, but the knees are
extended to rest on the
chest. The buttocks alone
present to the cervix.
Type Lie Attitude Description
Footling Longitudinal Poor Neither the thighs nor
Vertex Longitudinal Good The head is sharply flexed, lower legs are flexed. If
(Full making the parietal bones or one foot presents, it is a
flexion) the space between the single-footling breech; if
fontanelles (the vertex) the both present, it is a
presenting part. This is the double-footling breech.
most common presentation
& allows the suboccipito-
bregmatic diameter to
present to the cervix.

Brow Longitudinal Moderate Because the head is only

(military) moderately flexed, the brow
or sinciput becomes the
presenting part

Face Longitudinal Poor The fetus has extended the

head to make the face the ●​ Shoulder presentation- the presenting part
presenting part. From this is usually one of the shoulder’s (acromion
position, extreme edema &
distortion of the face may process), an iliac crest, a hand, or an elbow,
occur. In a transverse lie, a fetus lies horizontally
Mentum Longitudinal Very poor The fetus has completely
in the pelvis so that the longest fetal axis is
hyperextended the head to perpendicular to that of the mother.
present the chin, causing the
presenting diameter (the
occipitomental) to be so
wide that vaginal birth may
not be possible.
Fewer than 1% of fetuses lie transversely. Position
CAUSES: The first letter defines whether the landmark is
1.​ Pelvic contractions, in which the horizontal pointing to the mother’s pelvis.
space is greater than the vertical space Right or Left
2.​ Presence of a placenta previa (the placenta is
located low in the uterus, obscuring some of the The middle letter denotes the fetal landmark
vertical space). O for occiput,
3.​ Relaxed abdominal walls from grand M for mentum,
multiparity, which allow the unsupported uterus Sa for sacrum, and
to fall forward. A for acromion process​

h. FETAL POSITION- relationship of the The last letter defines whether the landmark points
presenting part to a specific quadrant of a woman’s A- anteriorly (front toward symphysis pubis)
pelvis. For convenience, the maternal pelvis is P- posteriorly (back toward the sacrum)
divided into four quadrants according to the T- transversely (midway between symphysis and
mother’s right and left. sacrum)
●​ Right anterior
●​ Left anterior All are vertex presentations:
●​ Right posterior Anterior, Left, Occiput, Posterior, Right, Transverse
●​ Left posterior
Four parts of a fetus chosen as landmarks to
describe the relationship of the presenting part to
one of the pelvic quadrants
1.​ Vertex presentation, the occiput (O) is the
chosen point.
2.​ Face presentation, it is the chin (mentum [M]).
3.​ Breech presentation, it is the sacrum (Sa).
4.​ Shoulder presentation, it is the scapula or the
acromion process (A).

Position is important because it can influence both

the process and efficiency of labor
Typically, a fetus is born fastest from an ROA or
LOA position
Labor can be considerably extended if the position
is posterior (ROP or LOP) and may be more painful
because the rotation of the fetal head puts pressure
on sacral nerves.
Possible fetal position i. MECHANISMS OF LABOR
Vertex Breech Face Shoulder (CARDINAL MOVEMENTS)
(occiput) (sacrum) (Mentum) (acromion GOAL
process) -​ Passage of a fetus through the birth canal
involves several different position changes
●​ LOA, ●​ LSaA, ●​ LMA, ●​ LAA, to keep the smallest diameter of the fetal
left occipito left sacro- left mento- left
head (in cephalic presentation) always
anterior anterior anterior scapulo-
●​ LOP, left ●​ LSaP, ●​ LMP, anterior presenting to the smallest diameter of the
occipito- left sacro- left mento- ●​ LAP, pelvis.
posterior posterior posterior left ●​ Descent- downward movement of biparietal
●​ LOT, ●​ LSaT, ●​ LMT, scapulo- diameter of the fetal head within the pelvic
Left left sacro- left mento- posterior inlet
occipito- transverse transverse -​ Full descent may be aided by
transverse
abdominal muscle contraction as the
●​ ROA, ●​ RSaA, ●​ RMA,
right right sacro- right woman pushes
occipito- anterior mento- ●​ RAA, ●​ Flexion- as descent occurs
anterior anterior right 1.​ Fetal head reaches the pelvic floor
●​ ROP, ●​ RSaP, ●​ RMP, scapulo- 2.​ Head bends forward onto the chest,
right right sacro- right anterior making the smallest anteroposterior diameter
occipito- posterior mento- ●​ RAP,
present to the birth canal.
posterior posterior right
●​ ROT, ●​ RSaT, scapulo- -​ Aided by abdominal muscle
right right sacro- ●​ RMT, posterior contraction during pushing
occipito- transverse right
transverse mento-
transverse

●​ Internal Rotation- during the descent, the

head enters the pelvis with the fetal
anteroposterior head diameter in a diagonal
or transverse position.
-​ The head flexes as it touches the
pelvic floor, and the occiput rotates
to bring the head into the best
relationship to the outlet of the
pelvis.
-​ This movement brings the
shoulders, coming next, into the
optimal position to enter the inlet,
putting the widest diameter of the
shoulders (transverse) in line with
the wide transverse diameter of the
inlet.
 III.​ POWERS OF LABOR
-​ This is the force supplied by the fundus of
the uterus, implemented by uterine
contractions, a natural process that causes
cervical dilatation and then expulsion of the
fetus from the uterus.
-​ After full dilatation of the cervix, the
●​ Extension - as the occiput is born, the back primary power is supplemented by use of
of the neck stops beneath the pubic arch the abdominal muscles.
and acts as a pivot for the rest of the head. -​ It is important for women to understand
-​ The head extends, and the foremost they should NOT bear down with their
parts of the head, the face and chin, abdominal muscles until the cervix is fully
are born. dilated. Doing so impedes the primary
source and could cause fetal and cervical
damage.
★​ Differentiating between True and False Labor
Contractions
False Contractions True Contractions
Begin and remain Begin irregularly but
irregular becomes regular and
predictable
●​ External Rotation - immediately after the Felt first abdominally and Felt first in lower back
head of the infant is born, the head rotates remain confined to the and sweep around to the
abdomen and groin abdomen in a wave
back to the diagonal or transverse
position of the early part of labor. Often disappear with Continue no matter what
-​ The anterior shoulder is born first, assisted ambulation or sleep the woman’s level of
activity
by downward flexion of the infant’s head.
Do not increase in Increase in duration,
duration, frequency, or frequency, and intensity
intensity
Do not achieve cervical Achieve cervical
dilatation dilatation

★​ Contraction Phases
1.​ Increment, when the intensity of the
●​ Expulsion- end of the pelvic division labor
contraction increases;
-​ Once the shoulders are born, the rest
2.​ Acme, the contraction is at its strongest;
of the baby is born easily and
3.​ Decrement, when the intensity decreases.
smoothly because of its smaller size.
Between contractions, the uterus relaxes.
As labor progresses, the relaxation intervals the last of the mucus plug that has sealed the
decrease from 10 minutes early in labor to only 2 to cervix since early pregnancy is released.
3 minutes. The duration of contraction also changes, 1 finger = 1.5 cm, ​ 2 fingers = 3 to 3.5 cm
increasing from 20 to 30 seconds at the beginning to
a range of 60 to 70 seconds by the end of the first Stages of Cervical Dilation
stage. 1 cm – blueberry​ 6 cm – lemon
2 cm – cherry​ ​ 7 cm – apple
Duration- from beginning of one contraction to the 3 cm – strawberry​ 8 cm – orange
end of the same contraction 4 cm – lime​ ​ 9 cm – grapefruit
Frequency- from beginning of one contraction to 5 cm – kiwi​ ​ 10 cm – melon
the beginning of another contraction
Interval- resting time between contractions for IV.​ THE PSYCHE
placental perfusion. -​ A woman’s psychological outlook refers to
the psychological state or feelings a woman
CERVICAL CHANGES brings into labor. For many women, this is a
★​ Effacement - shortening and thinning of the feeling of apprehension or fright. For almost
cervical canal. All during pregnancy, the canal everyone, it includes a sense of excitement
is approximately 1 to 2 cm long. During labor, or awe.
the longitudinal traction from the contracting -​ Women who manage best in labor typically
uterus shortens the cervix so much that the are those who have a strong sense of
cervix virtually disappears. self-esteem and a meaningful support person
with them (husband, parent, loved ones)
(A)​Beginning of labor -​ These factors allow women to feel in control
(B)​Effacement is of sensations and circumstances they have
beginning, dilatation is never experienced before and which may not
not apparent yet be what they pictures
(C)​Effacement is -​ Women without adequate support can have a
almost complete labor experience so frightening and stressful
(D)​After complete that they develop symptoms of
effacement, dilatation post-traumatic stress disorder (PTSD).
proceeds rapidly. -​ Encourage women to ask questions at
prenatal visits and to attend preparation for
childbanoxirth classes so they are as well
prepared for labor as possible
★​ Dilatation - enlargement or widening of the -​ Encourage them after birth to talk about and
cervical canal from an opening a few share their experience because a
millimeters wide to one large enough (approx. “‘debriefing time” can be an important way
10 cm) to permit passage of a fetus. to help them appreciate everything that
-​ Dilatation occurs first because uterine happened and integrate the experience into
contractions gradually decrease the diameter of their total life.
the cervical canal lumen by pulling the cervix up
over the presenting part of the fetus.
-​ As dilatation begins, there is an increase in the
amount of vaginal secretions (show) because
minute capillaries in the cervix rupture and
 WEEK 8 : b.​ Active Phase
STAGES OF LABOR AND DELIVERY -​ Cervical dilatation occurs more rapidly,
(DANGER SIGNS OF LABOR) increasing from 4 to 7 cm.
-​ Contractions grow stronger, lasting 40 to 60
STAGES OF LABOR seconds, and occur approximately every 3 to
★​ First Stage of Dilatation - which begins with 5 minutes.
the initiation of true labor contractions and ends -​ Show and spontaneous rupture of the
when the cervix is fully dilated; membranes may occur during this time.
★​ Second Stage - extending from the time of full -​ 3 hours – nullipara, 2 hours – multipara
dilatation until the infant is born -​ The active stage of labor in a FRIEDMAN
★​ Third or placental stage - lasting from the time GRAPH can be subdivided into ff. periods:
the infant is born until after the delivery of the Acceleration (4 to 5 cm)
placenta Maximum slope (5 to 9 cm)
★​ Fourth Stage - first 1 to 4 hours after birth of -​ During maximum slope, cervical dilatation
the placenta to emphasize the importance of the proceeds at its most rapid pace. 3.5 cm per
close maternal observation needed at this time. hour in nulliparas, and 5 to 9 cm per hour in
multiparas.
I.​ FIRST STAGE -​ Encourage women to remain active
a.​ Latent Phase (preparatory phase) participants in labor by assuming what
-​ Onset of regularly perceived uterine position is most comfortable for them during
contractions and ends when rapid cervical this time.
dilatation begins. c.​ Transition Phase
-​ Contractions are mild and short, lasting 20 -​ Contractions reach their peak of intensity
to 40 seconds -​ Interval: every 2 to 3 minutes
-​ Cervical effacement occurs, and the cervix -​ Duration: 60 to 90 seconds
dilates from 0 to 3 cm. -​ Cervical dilatation: 8 to 10 cm
-​ The phase lasts approximately: 6 hours - -​ Rupture of membranes and show occurs as
nullipara, and 4.5 hours - multipara. the last of the mucus plug from the cervix is
-​ A woman who enters labor with a released.
“nonripe” cervix will have a longer than -​ By the end, both full dilatation (10 cm) and
usual latent phase complete cervical effacement have occurred.
-​ Women should not be denied analgesia at -​ A woman may experience intense
this point but given too early may prolong discomfort, so strong that it is accompanied
this phase. by nausea and vomiting
-​ Reason for prolonged latent phase is -​ Because of the intensity and duration of the
cephalopelvic disproportion (a contractions, they may also experience a
disproportion between the fetal head and feeling of loss control, anxiety, panic, or
pelvis) that could require a cesarean birth. irritability.
-​ A woman can (and should) continue to walk -​ The peak: slight slowing in the rate of
about and make preparations for birth cervical dilatation when 9 cm is reached
-​ Encourage to continue or begin alternative (deceleration on a labor graph) As a woman
methods of pain relief such as aromatherapy reaches the end of this stage at 10 cm of
or distraction dilatation, a new sensation (i.e., an
irresistible urge to push) occurs.
 II.​ SECOND STAGE a.​ Placental Separation
-​ The period from full dilatation and cervical -​ Folding and separation of the placenta occur
effacement to birth of the infant; with as the uterus contracts down
uncomplicated birth, this stage takes ~ 1 hr -​ Active bleeding on the maternal surface of
-​ Contractions change from the characteristic the placenta begins with separation; this
crescendo-decrescendo pattern to an bleeding helps to se
overwhelming, uncontrollable urge to push -​ parate the placenta still farther by pushing it
or bear down. away from its attachment site
-​ Patient feels momentary nausea or vomiting -​ As separation is completed, the placenta
because pressure is no longer exerted on her sinks to the lower uterine segment or the
stomach as the fetus descends into the pelvis upper vagina.
-​ She pushes with such force that she
perspires and the blood vessels in neck The following signs indicate that the placenta has
(jugular vein) may become distended loosened and is ready to deliver:
-​ As the fetal head touches the internal side of ●​ Lengthening of the umbilical cord
the perineum, the perineum begins to ●​ Sudden gush of vaginal blood
bulge and appears tense. ●​ Change in the shape of the uterus
-​ Anus may become everted, and stool may ●​ Firm contraction of the uterus
be expelled. ●​ Appearance of the placenta at the vaginal
-​ As fetal head pushes against the perineum, opening
vaginal introitus (hole at the vaginal
Schultze Presentation Duncan Presentation
opening) opens and the fetal scalp appears at
the opening to the vagina (slit-like→ oval→ Placenta separates first It looks raw, red, and
circular) at its center and last at irregular, with the
-​ Circle enlarges, from the size of a dime→ its edges ridges or cotyledons
(20) that separate blood
quarter→ half a dollar (crowning)
collection spaces
-​ As she pushes, using her abdominal muscles showing
to aid the involuntary uterine contractions,
the fetus is pushed out of the birth canal. Fold onto itself like an
III.​ THIRD STAGE (Placental stage) umbrella and presents at
-​ Begins with the birth of the infant and the vaginal opening with
the fetal surface evident
ends with the delivery of the placenta
-​ After the birth of an infant, a uterus can be Appearing shiny and
palpated as a firm, round mass just glistening from the fetal
inferior to the level of the umbilicus. membranes
-​ After a few minutes of rest, uterine
“Shiny” with Schultze “Dirty” with Duncan
contractions begin again, and the organ (the fetal membrane (the irregular maternal
assumes a discoid shape. surface) surface)

Bleeding occurs as part of the normal consequence

of placental separation, before the uterus contracts
sufficiently to seal maternal sinuses. The normal
blood loss is 300 to 500 mL.
 b.​ Placental Expulsion Blood Pressure - systolic blood pressure rises an
-​ After separation, the placenta is delivered average of 15mmHg with each contraction.
either by the natural bearing-down effort of -​ When a woman lies in a supine position and
the mother or by gentle pressure on the pushes during the second stage of labor,
contracted uterine fundus by a physician pressure of the uterus on the vena cava
or nurse midwife (Crede’s Maneuver) causes her blood pressure to drop
-​ Pressure must never be applied to a uterus in precipitously, leading to hypotension.
a non contracted state, because doing so may -​ An upright or side-lying position during the
cause the uterus to evert and hemorrhage. second stage of labor not only makes
-​ This is a grave complication of birth pushing more effective but also can help
because the maternal blood sinuses are open avoid such problems.
and gross hemorrhage could occur. If the
placenta does not deliver spontaneously, it b.​ Hemopoietic System- development of
can be removed manually. (as the last resort) leukocytosis, or a sharp increase in the number
of circulating white blood cells, possibly as a
Crede’s Maneuver result of stress and heavy exertion.
-​ Place your palms flat on the patient’s -​ At the end of labor, the average woman has
abdomen just below the navel. Then apply a white blood cell count of 25, 000 to 30,000
gentle firm pressure and move downwards 3
cells/𝑚𝑚 , compared with a normal count
toward the symphysis pubis 3
of 5,000 to 10,000 cells/𝑚𝑚 .
MATERNAL RESPONSES TO LABOR
c.​ Respiratory System- total oxygen consumption
increases by about 100% during the second
★​ Physiologic Effects of Labor on a Woman
stage of labor. It can result in hyperventilation
a.​ Cardiovascular System
(there is more oxygen introduced inside the
Cardiac Output - each contraction greatly decreases
body and there’s no balance with the carbon
blood flow to the uterus because the contracting
dioxide) Using appropriate breathing patterns
uterine wall puts pressure on the uterine arteries
during labor can help avoid severe
-​ This increases the amount of blood that
hyperventilation.
remains in a woman’s general circulation,
results in an increase in systolic and d.​ Temperature Regulation- the increased
diastolic blood pressure muscular activity associated with labor can
-​ The work of pushing during labor may result in a slight elevation (1° F) in temperature.
increase cardiac output (combination of Diaphoresis (excessive sweating) occurs with
heart rate and stroke volume– blood volume accompanying evaporation to cool and limit
that is being ejected by the heart during excessive warming.
every beat) by as much as 40-50% above the
pre labor level. Cardiac output then e.​ Fluid Balance- Because of the increase in rate
gradually decreases from this high level, and depth of respirations (which causes
within the first hour after birth, by about moisture to be lost with each breath) and
50% diaphoresis, insensible water loss increases
-​ CO = SV x HR during labor. It is further affected if a woman
eats nothing (she can sip fluid or eat ice cubes or
hard candy)
f.​ Urinary System- with a decrease in fluid intake b.​ Fear- women appreciate a review of the labor
during labor and the increased insensible water process early in labor as a reminder that
loss, the kidneys begin to concentrate urine to childbirth is not a strange, bewildering event but
preserve both fluid and electrolytes. Specific a predictable and well-documented one.
gravity may rise to a high normal level of -​ Explain that contractions last a certain
1.020 to 1.030. It is not unusual for protein length and reach a certain firmness but
(trace to 1) to be evident in urine because of the always have a pain-free rest period in
breakdown of protein caused by the increased between.
muscle activity.
c.​ Cultural Influences - in the past, women were
g.​ Musculoskeletal System- All during accustomed to following hospital procedures
pregnancy, relaxin, an ovarian-released and medical model of care. Today, women are
hormone, has acted to soften the cartilage educated to help plan their care. They respond
between bones. In the week before labor, to cultural cues in some way. This makes her
considerable additional softening causes the response to pain, her choice of nourishment,
symphysis pubis and the sacral/coccyx joints to preferred birthing position, the proximity and
become even more relaxed and movable, involvement of a support person, and customs
allowing them to stretch apart to increase the related to the immediate postpartal period
size of the pelvic ring by as much as 2 cm. individualized.

h.​ Gastrointestinal System- becomes fairly FETAL RESPONSES TO LABOR

inactive during labor. Digestive and emptying
time of the stomach becomes prolonged. Some ★​ Physiologic Effects of Labor to a Fetus
women experience a loose bowel movement as a.​ Neurologic System- uterine contractions exert
contractions grow strong, similar to what they pressure on the fetal head, so increased
may experience with menstrual cramps. intracranial pressure occurs. The fetal heart
rate (FHR) decreases by as much as 5 bpm
i.​ Neurologic and Sensory Responses- responses
during a contraction. This decrease appears on a
related to pain (increased pulse and respiratory
fetal heart monitor as a normal or early
rate). Early in labor, the contraction of the
deceleration pattern.
uterus and dilatation of the cervix cause the
discomfort. At the moment of birth, the pain is b.​ Cardiovascular System- during a contraction,
centered on the perineum as it stretches to allow the arteries of the uterus are sharply constricted
the fetus to move past it. and the filling of cotyledons almost completely
halts. The amount of nutrients, including oxygen
★​ Psychological Responses of a Woman to
exchanged during this time is reduced, causing a
Labor
slight but inconsequential fetal hypoxia.
a.​ Fatigue- by the time a date of birth approaches,
a woman is generally tired from the burden of c.​ Integumentary System- The pressure involved
carrying so much extra weight. Most of them do in the birth process is often reflected in minimal
not sleep well during the last month of petechiae (pinpoint rashes) or ecchymotic areas
pregnancy. It can make the process of labor on a fetus (particularly the presenting part).
loom as an overwhelming, unendurable There may also be edema of the presenting part
experience unless they have competent support (caput succedaneum).
people with them.
d.​ Musculoskeletal System- the force of uterine uterine rupture. For this reason, it is important to
contractions tends to push a fetus into a position observe the contours of a woman's abdomen
of full flexion, the most advantageous position periodically during labor. Fetal heartbeat
for birth. auscultation automatically provides a regular
opportunity to assess a woman’s abdomen.
e.​ Respiratory System- the process of labor
appears to aid in the maturation of surfactant
production by alveoli in the fetal lung. The
pressure applied to the chest from contractions
and passage through the birth canal helps to
clear it of the lung fluid.

MATERNAL DANGER SIGNS

❖​ High or Low Blood Pressure - normally, a ❖​ Abnormal Lower Abdominal Contour- indicates
woman’s bp rises slightly in the second (pelvic) a FULL BLADDER- a round bulge on her
stage of labor because of her pushing effort. lower anterior abdomen may appear.
-​ Pregnancy-induced hypertension DANGERS:
Systolic pressure > 140 mmHg and a 1.​ The bladder may be injured by the pressure
Diastolic pressure > 90 mmHg of a fetal head
-​ An increase in the systolic pressure > 30 2.​ The pressure of the full bladder may not
mmHg or in diastolic pressure of > 15 allow the fetal head to descend
mmHg should be reported. -​ To avoid a full bladder, women need to try
-​ Just as important to report is a falling blood to void about every 2 hours during labor.
pressure, because it may be the first sign of
intrauterine hemorrhage. ❖​ Increasing Apprehension- despite clear
explanations of unfolding events may only be
❖​ Abnormal Pulse- most pregnant women have a approaching the second stage of labor. It also
pulse rate of 70 to 80 bpm. A maternal pulse needs to be investigated for physical reasons,
rate greater than 100 bpm during the normal because it can be a sign of oxygen deprivation
course of labor is unusual and should be or internal hemorrhage.
reported. It may be another indication of
hemorrhage. FETAL DANGER SIGNS
❖​ High or Low Fetal Heart Rate
❖​ Inadequate or prolonged contractions- if they
FETAL DISTRESS
become less frequent, less intense, or shorter in
FHR > 160 bpm (fetal tachycardia) or < 110 bpm
duration, this may indicate uterine exhaustion
(fetal bradycardia) is a sign of possible fetal
(inertia). A cesarean birth may be necessary if
distress.
not corrected. As a rule, uterine contractions
-​ An equally important sign is a late or
lasting longer than 70 seconds should be
variable deceleration pattern on a fetal
reported.
monitor.
❖​ Pathologic retraction ring- an indentation across -​ The FHR may return to a normal range in
a woman’s abdomen, where the upper and lower between these irregular patterns, giving a
segments of the uterus join, may be a sign of false sense of security if FHR is assessed
extreme uterine stress and possible impending only between contractions.
❖​ Meconium Staining- fetus has had loss of rectal A woman needs to feel that she has some control
sphincter control, allowing meconium to pass over her situation during labor to face this big event
into the amniotic fluid. Fetus has or is in her life. Help her express her feelings in her own
experiencing hypoxia which stimulates the way, one that works the best for her.
vagal reflex and leads to increased bowel 1.​ Respect Contraction Time- do not interrupt a
motility. Although meconium staining may be woman who is in the middle of breathing
normal in a breech presentation, because exercises during labor because once her
pressure on the buttocks causes meconium loss, concentration is disrupted, she will feel the
it should always be reported immediately so extent of the contraction
that its cause can be investigated. 2.​ Promote change of positions- In early labor, a
woman may be out of bed walking or sitting up
❖​ Hyperactivity- ordinarily, a fetus is quiet and in bed or in a chair, in whatever position she
barely moves during labor. Fetal hyperactivity prefers.
may be a sign that hypoxia is occurring, because -​ A woman whose membranes have ruptured
frantic motion is a common reaction to the need should lie on her side until a fetal monitor
for oxygen. shows good baseline variability and no variable
❖​ Oxygen Saturation- if a fetus is assessed for decelerations because unless the head of the
oxygen saturation by a catheter inserted next to fetus is well engaged, the umbilical cord may
the cheek, a low oxygen saturation level (under prolapse into the vagina if she walks
40%) or if fetal blood was obtained by scalp -​ If medication such as narcotics is given, educate
puncture, the finding of acidosis (blood pH 7.2) women to remain in bed for approximately 15
suggests that fetal well-being is becoming minutes afterward to avoid a fall (dizziness
compromised. Oxygen saturation in a fetus is side effect). While the woman is in bed,
normally 40-70%. encourage her to lie on her side, preferably the
left side. This position causes the heavy uterus
Care of a woman during the First Stage of Labor to tip forward, away from the vena cava,
allowing free blood return from the lower
Six major concepts to make labor and birth as extremities and adequate placental filling and
natural as possible are: circulation.
1.​ Labor should begin on its own, not be -​ Some women have learned to do breathing
artificially induced exercises in a supine position and may need
2.​ Women should be able to move about freely additional coaching to do them in a side-lying
throughout labor, not be confined to bed. position. If a woman must turn to her back
3.​ Women should receive continuous support during a contraction to make her breathing
during labor exercises effective, help her to remember to
4.​ No interventions such as intravenous fluids return to her side between contractions.
should be used routinely 3.​ Offers Support- Simple touches like a gentle
5.​ Women should be allowed to assume a pat on her arm, fixing her hair, or cooling her
non-supine (e.g.., upright, side-lying) position forehead with a cloth can be comforting.
for birth 4.​ Respect and promote the support person- Let
6.​ Mother and baby should be together after the her chosen support person stay with her and
birth, with unlimited opportunity for help. Show them where things are kept, like
breastfeeding. washcloths or ice chips, so they can assist when
needed.
5.​ Help with Pain Management​ 3.​ Promoting effective second-stage pushing
Many women plan to use natural methods like Encourage the woman to push only when she feels
breathing or aromatherapy to handle pain. the urge, even if she is fully dilated. Pushing during
Support her choice, and if she feels unsure, contractions is ideal, and positions like squatting or
reassure her that her breathing techniques or semi-sitting help gravity make the pushing more
other methods are helping. This confidence can effective. Remind her to exhale as she pushes to
often give her the boost she needs to continue avoid straining her heart and circulation.
her exercises effectively. 4.​ Perineal Cleaning
Clean the area around the vagina with a warm
Care of a woman during Second Stage of Labor antiseptic to keep the area sanitary. Clean from the
vagina outward with fresh compresses to avoid
Even women who have taken childbirth education
pushing bacteria toward the birth canal.
classes are surprised at the intensity of the
5.​ Introducing the Infant
contractions in this phase of labor.
Once the baby is born and the cord is cut, hand the
Because the feeling to push is so strong, some
baby to the parents to hold and bond. Wrap the
women react to this change in contractions by
newborn in a blanket because they’re often slippery.
growing increasingly argumentative and angry or by
This special first contact helps build a strong
crying and screaming.
parent-child connection.
Other women react by tensing their abdominal
muscles and trying to resist, making the sensation Care of a woman during third & fourth stage
even more painful and frightening.
1.​ Preparing the Place of birth 1.​ Placenta delivery
Multipara- convert a birthing room into a birth After the baby is born, the placenta will come out.
room by opening the sterile packs of supplies on The doctor or midwife will gently help remove it,
waiting tables when the cervix has dilated to 9 to 10 making sure everything is out to prevent
cm. complications.
Primipara- this can be delayed until the head has 2.​ Oxytocin Administration
crowned to the size of a quarter or half-dollar (full Oxytocin may be given to the mother after birth to
dilatation and descent). help her uterus contract and reduce bleeding.
A table set with equipment can be left covered for 3.​ Perineal repair
up to 8 hours. If there were any tears or cuts (like an episiotomy)
Be certain that drapes and materials used for birth during birth, the doctor or midwife will stitch them
are sterile so that no microorganisms can be up to help them heal properly.
accidentally introduced into the uterus. 4.​ Immediate Postpartum assessment and
2.​ Positioning for Birth nursing care
Women can choose a comfortable position for ●​ Check the mother’s pulse, breathing, and blood
pushing and delivery, like squatting, side-lying, pressure every 15 minutes for the first hour.
semi-sitting, dorsal recumbent, and lateral or sim’s Expect her pulse and breathing to be faster than
position. Traditionally, the lithotomy position (lying normal (80-90 bpm, 20-24 rpm), and her blood
on the back with legs in stirrups) was used, but it pressure slightly elevated due to the excitement
can reduce blood flow and increase blood loss if and the effects of oxytocin.
used for a long time. Reserve this position for the ●​ Check the mother’s abdomen to see if her uterus
final moments of birth, if preferred or necessary. is firm and positioned correctly. Look at her
bleeding (lochia) to ensure it’s normal.
●​ Help her clean up, provide a fresh pad, and give
her a warm blanket and gown. It’s common for
her to feel chills and shivers shortly after birth.
5.​ Aftercare
This is the start of the postpartum period. The uterus
may be tired from labor and might struggle to stay
contracted, so there’s a risk of hemorrhage. The
mother may also be very exhausted and might need
help to notice any changes or report concerns.