CARE OF MOTHER AND CHILD

MODULE 3

CARE OF THE MOTHER DURING THE INTRAPARTAL PERIOD

3.1 THEORIES OF LABOR ONSET

A. THE UTERINE STRETCH THEORY
 As the fetus inside the mother’s womb increases its size, the uterine muscle
stretches resulting to prostaglandins release. Prostaglandins are compounds
in the body made of fats that have hormone-like effects. Some known effects
include uterine cramping and increase sensitivity to pain.
 Unlike other hormones, prostaglandins aren’t released from a specific gland;
instead the body has a number of tissues that produces prostaglandins.
 A woman starts to have a larger amount of certain types of prostaglandins in
her uterine tissue during late pregnancy (Healthline2020) specifically at the
onset of labor.

B. FETAL OXYTOCIN THEORY

 Oxytocin is a patent uterotoxin (uterine muscle contractant) Secretion of
oxytocin increases just before 37-42 weeks of gestation. Oxytocin stimulates
contractions thus facilitating sealing of ruptured capillaries which then stops
bleeding. Due to its contractile activity on the myometrium labor is initiated.
Then the fetus head presses on the cervix, which stimulates the release of
oxytocin from the posterior pituitary. Oxytocin stimulation works together with
prostaglandins to initiate contractions.

C. PROGESTERONE DEPRIVATION THEORY

 Progesterone produced by the placenta relaxes uterine smooth muscle by
interfering with conduction of the impulses form one cell to the next.
 Changes in the ratio of estrogen to progesterone occur, increasing estrogen
in relation to progesterone, which is interpreted as progesterone withdrawal.
 Decreased amount of progesterone inhibits the relaxation effect on the
uterus initiating labor onset.

D. PLACENTAL AGING THEORY

 The aging placenta cannot supply enough nutrients to the growing fetus
because it reaches a set age which triggers uterine contraction

E. FETAL CORTISOL SECRETION THEORY

 Rising fetal cortisol levels reduce progesterone formation and increase
prostaglandin formation which stimulates uterine contraction.

F. RISING PROSTAGLANDIN THEORY

 The fetal membrane (amnion and decidua) begins to produce prostaglandins,
which stimulate contractions.

G. FETAL CORTISOL SECRETION THEORY

 The placental-fetal adrenal endocrine cascade.
 In late gestation, placental corticortropin releasing hormone(CRH)
 Stimulates fetal adrenal production of dehydroepiandrosterone
Sulfate(DHEA-S) and cortisol. The latter stimulates production of placental
CRH, which leads to feed-forward cascade that enhances adrenal steroid
hormone production. (ACTH-Adrenocorticotropic hormone)
 FACTORS AFFECTING LABOR AND DELIVERY PROCESS
 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.
4. The psyche, or a woman’s psychological state which may either encourage
or inhibit labor.
 This can be based on her past life experiences as well as her present
psychological state.

A. THE PASSAGEWAY: PELVIS

 The passageway refers to the route a fetus must travel from the uterus
through the cervix and vagina to the external perineum. In most cases,
disproportion occurs between the fetus and pelvis due to the faulty structure
of the pelvis. If the disproportion is caused by the fetus, the fetal head is
presenting to the birth canal at less than its narrowest diameter, therefore
Normal Spontaneous Vaginal delivery is not feasible. The passage (a
woman’s pelvis) should be of adequate size and contour to accommodate
the passenger (fetus) to travel out of the vaginal canal.
 THE NORMAL PELVIS The ideal normal female is the GYNECOID PELVIS:
 Characteristic of a Normal Female Pelvis
1. BRIM - slightly oval transversely.
2. SACRAL PROMONTORY - not prominent.
3. TRANSVERSE DIAMETER - slightly longer than the anteroposterior.
4. SIDEWALLS - parallel and straight.
5. ISCHIAL SPINES - not prominent.
6. SACROSCIATIC NOTCHES - wide.
7. SACRUM - good curve.
8. PUBIC ARCH ANGLE - wide, more than 90
9. INTER TUBEROUS DIAMETER - wide
 Factors considered for the passage of the fetus to the pelvis:
1. Obstetric conjugate of the inlet
2. Distance between ischial spines
3. Subpubic angle & transverse diameters
4. Posterior & sagittal diameters of the 3 planes
5. Curve & length of the sacrum
 Three Anteroposterior Diameters of the Pelvic Inlet:
1. 12.5 cm by PELVIMETRY
2. OBSTETRIC CONJUGATE - CONJUGATA VERA (11 cm) upper
margin subtract 1.5-2cm from. Diagonal conjugate slightly longer than
the anteroposterior.
3. TRUE CONJUGATE - CONJUGATA VERA (11.5 cm) upper margin-
sacral promontory

B. THE PASSENGER (FETUS)

 The head is the body part of the fetus that has the widest diameter that
passes through the pelvic ring depending on the structure (bones,
fontanelles, and suture lines) and alignment with the pelvis. Fetal head’s
diameter is the ability of fetus to fit thru the maternal pelvis.
 Factors which determine the way it moves thru the birth canal:
1. Fetal Head’s Size
 Fetal head/skull:
 Sutures
  Fontanels
2. Fetopelvic Relationships
 Fetal attitude
 Fetal Lie
3. Fetal presentation
4. Fetal position
 Importance of sutures and fontanels:
1. Skull’s Flexibility
2. Moulding of the fetal head in cephalic positions
3. Diameter of the fetal skull
 MOLDING OF THE FETAL SKULL
‒ Molding is the overlapping of skull bones along the suture lines, which
causes a change in the shape of the fetal skull to one long and narrow, a
shape that facilitates passage through the rigid pelvis. It is caused by
the force of uterine contractions as the vertex of the head is pressed
against the not yet dilated cervix.
 Other factors that play a part in whether a fetus is properly aligned in the
pelvis and is in the best position to be born are fetal attitude, fetal lie, fetal
presentation, and fetal position.
 PASSENGER: FETOPELVIC RELATIONSHIPS
1. FETAL ATTITUDE is the degree of flexion a fetus assumes during labor
or the relation of the fetal parts to each other.
‒ Normal attitude – flexion of neck, arms and legs
‒ Hyperextension - abnormal attitude
‒ Fetal attitude changes cause larger diameter of fetal head to present
to pelvis.

2. FETAL LIE is the relationship between the long axis of the fetal body
and the long axis of a woman’s body—regardless whether the fetus is
lying in a horizontal (transverse) or a vertical (longitudinal) position.

3. FETAL PRESENTATION indicates the body part as the first to contact

the cervix or be delivered first and is determined by the combination of
fetal lie and the degree of fetal flexion (attitude).
Type of Fetal Presentations: Classification of Fetal
presentation
a. Cephalic presentation vertex, military, brow or face
b. Breech presentations complete, frank or footling
c. Shoulder presentation: shoulder, arm, back, abdomen or
occurs rarely; side

4. FETAL POSITION is the relationship of the presenting part to a specific

quadrant and side of a woman’s pelvis. To determine the position of the
fetus, the maternal pelvis is divided into four quadrants according to the
mother’s right and left: (a) right anterior, (b) left anterior, (c) right
posterior, and (d) left posterior.
FETAL LANDMARKS MATERNAL PELVIS
O = Occiput (vertex) R = Right side
M = Mentum (face) L = Left side
S = Sacrum (breech) A = Anterior
A = Acromion process(shoulder) P = Posterior
T = Transverse
  In a vertex presentation, the occiput (O) is the chosen point.
 In a face presentation, it is the chin (mentum [M]).
 In a breech presentation, it is the sacrum (Sa).
 In a 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 a
RIGHT OCCIPUT ANTERIOR or LEFT OCCIPUT ANTERIOR
position.

5. FETAL STATION - refers to the relationship of the presenting part of the

fetus to the level of the ischial spines. Refer to the illustration below.
 ENGAGEMENT refers to the settling of the presenting part of a fetus
far enough into the pelvis that it rests at the level of the ischial
spines, the midpoint of the pelvis. A vaginal and cervical
examination is done to determine the degree of engagement.
 A presenting part that is not engaged is said to be “FLOATING”
 One that is descending but has not yet reached the ischial spines
may be referred to as “DIPPING”

MECHANISMS (CARDINAL MOVEMENTS) OF LABOR

‒ Effective passage of a fetus through the birth canal involves not only position
and presentation but also a number of different position changes in order to keep
the smallest diameter of the fetal head (in cephalic presentations) always
presenting to the smallest diameter of the pelvis. These position changes are
termed the cardinal movements of labor: descent, flexion, internal rotation,
extension, external rotation, and expulsion.

C. POWER = CONTRACTIONS + MATERNAL PUSHING

 The most important factor that facilitates labor and delivery is successful
powers of labor. It is a force applied by the fundus of the uterus initiated by
uterine contractions that causes efficient cervical dilatation and effacement
and eventually expulsion of the fetus from the uterus.
 Once full cervical dilatation occurs, the primary powers enhance by the
involuntary uterine muscle fibers, stimulated by the pacemaker (ureterotubal
junction) in the upper uterine segment supplemented by the secondary
forces the voluntary abdominal muscle which facilitates descent and delivery
of the fetus. Therefore, it is very important to instruct the mother to bear
down with their abdominal muscles when the cervix is fully dilated to avoid
fetal and cervical damage.
POSITION: Position of Woman in Labor:
The different positions of a woman in labor which promote good circulation provide
comfort and relieve fatigue. Furthermore, it could facilitate descent, improve blood
flow, relieves back ache, straightens axis of birth canal and increases pelvic outlet.
To mention the following positions, they are- squatting, kneeling, sitting, walking.

PSYCHE: refers to the psychological state or feelings a woman brings into labor. It is
a feeling of apprehension or anxiety that includes a sense of excitement or fear.
Those who could manage great during labor are woman with a strong sense of self-
worth and with significant person supporting them.
 Concerns of a Woman During Labor and Birth.
 Preparation for childbirth
 Socio-cultural heritage
 Previous childbirth experience
 Support from significant others
 Emotional status
 Environmental influence

3.3 COMMON SIGNS OF LABOR

PRELIMINARY SIGNS OF LABOR:
1. LIGHTENING – 10-14 days before labor in primigravida and 1 day before labor
in a multipara
‒ Lightening is heralded by the following signs:
‒ Relief of dyspnea
‒ Relief of abdominal tightness
‒ ENGAGEMENT refers to the settling of the presenting part of a fetus far
enough into the pelvis that it rests at the level of the ischial spines, the
midpoint of the pelvis.
2. INCREASE IN THE LEVEL OF ACTIVITY – this is due to the increase in
epinephrine release initiated by a decrease in progesterone level produced by
the placenta. It prepares the woman’s body for labor.
3. SLIGHT LOSS OF WEIGHT – Loss of weight is about 2-3 lbs. one to two days
before the onset of labor (progesterone & loss of appetite)
4. BACKACHE – due to pressure or cramping in the pelvic and rectal areas.
5. BRAXTON HICKS CONTRACTION or FALSE LABOR CONTRACTIONS – are
extremely strong contractions which may be interpreted as true labor
contractions that can be noticed in the last week or days before labor begins.
6. RIPENING OF THE CERVIX (Goodell’s sign) – the cervix become softer or
“butter-soft” and can only be seen during pelvic examination. It is a sign that
labor is near.

SIGNS OF TRUE LABOR:

1. UTERINE CONTRACTIONS – this is a definite sign that labor begins because
contractions are involuntary and increases in intensity. In order to know the
difference between true labor from false labor

TRUE LABOR
a. Uterine contractions – Regular
b. Progressive frequency & intensity
c. Pain/Discomfort from lower back to abdomen
d. Increases in Activity/Ambulation
e. Progressive effacement and dilation of cervix
f. Not relieved by Sedation
g. Presence of bloody show
FALSE LABOR
a. Irregular contractions frequency & intensity
b. Discomfort in lower abdomen and groin
c. Activity change
d. UCs stop when sleeping
e. No appreciable cervical change
f. Sedation decreases UCs
g. Bloody show usually not present

2. SHOW – “OPERCULUM” are pink-tinged blood mixed with mucus that plugs the
cervical canal during pregnancy. As the cervix ripens, it becomes soft and the
exposed cervical capillaries leaks due to the pressure applied by the fetus.
3. RUPTURE OF MEMBRANES – due to the pressure exerted by the fetus, the
amniotic sac (membrane that protects the fetus from intrauterine infection)
breaks, a woman in labor may experience a sudden gush or scanty slow clear
fluid coming out of the vagina.

Important nursing considerations:

 INITIAL NURSING ACTION
‒ Early rupture of membranes
‒ Put her immediately in bed and monitor fetal heart rate. Instruct the client
not to ambulate to prevent fetal cord compression.
 CORD PROLAPSE
‒ Trndelenburg position to reduce pressure on the umbilical cord
‒ Remember: only 5 minutes of umbilical cord compression causes CNS
damage & even death.
‒ Warm saline saturated OS on the cord – to prevent injury and drying of the
cord

3.4 STAGES OF LABOR AND DELIVERY

1. THE FIRST STAGE OF LABOR
‒ The Latent Phase
‒ The Active Phase
‒ The Transition Phase
2. THE SECOND STAGE OF LABOR
3. THE THIRD STAGE OF LABOR
‒ Placental Expulsion
‒ Placental Separation

LABOR is the process of delivering a baby and the placenta, membranes, and
umbilical cord from the uterus to the vagina to the outside world. Usually, it is divided
into four stages. The different stages of labor need to be monitored and recorded in
order to ensure the safety of the mother and the baby as well. Furthermore, it could
also help determine expected outcomes and nursing intervention in a woman
experiencing labor and birth.

A. FIRST STAGE OF LABOR: EFFACEMENT and DILATATION STAGE

 Starts with the beginning of true labor contractions and ends in a fully dilated
cervix. The first stage of labor is divided into three phases.
1. The LATENT PHASE or the PREPARATORY PHASE – onset of
regularly perceived uterine contractions and ends when rapid cervical
dilatation begins.
‒ Characteristic of contraction – mild and short
‒ Duration of contraction – 20-40 seconds
‒ Cervical dilatation – 0 to 3cm
 ‒ Lasts for approximately 6 hours in a nullipara and 4.5 hours in a
multipara.
‒ Reasons for prolonged latent phase:
a. “Non-ripe cervix”
b. Cephalopelvic disproportion – a disproportion between the fetal
head and the pelvis)
2. The ACTIVE PHASE – cervical dilatation occurs more rapidly, true
discomfort is experienced by a woman because contractions grow so
much stronger and last so much longer.
‒ Characteristic of contractions – stronger and longer
‒ Cervical dilatation – 4 to 7cm
‒ Duration of contraction – 40-60 seconds
‒ Interval of contraction - every 3 t0 5 minutes
‒ Lasts for approximately 3 hours in a nullipara and 2 hours to a
multipara
3. The TRANSITION PHASE – contractions reach its peak of intensity. It
is during this stage wherein a woman in labor may experience nausea
and vomiting, a feeling of loss of control, anxiety, irritability and may
panic as well due to an intense contraction.
‒ Chaacteristic of contraction – intense,
‒ Duration of contraction – 60 to 70 seconds
‒ Cervical dilatation – 8 to
‒ Interval of contraction – 2-3 minutes

B. SECOND STAGE OF LABOR: DILATATION STAGE

 Starts from the period of full cervical dilatation and effacement to delivery of
the baby. This stage takes about an hour if complications will not arise.
Contractions change its characteristic pattern from increasing to decreasing
intensity to an uncontrollable urge to push or bear down with each
contraction as if there is an urge to defecate.

CROWNING is the appearance of the fetal scalp at the opening of the vagina as the
fetal head pushes against the vaginal introitus.
Management of the Second Stage of labor:
1. Fetal heart rate monitoring at least every 5 minutes and after each contraction if
the woman is in complete cervical dilatation.
2. Empty the bladder to facilitate descent of the fetal head.
3. Avoid lying down in supine position or semi- supine, rather adopt a comfortable
position.
4. Light diet or if possible keep client on NPO to prevent vomiting.
5. Instruct the woman in labor not to push if the cervix is not fully dilated (Vaginal
examination) to prevent damage of the perineal tissue.
6. Support the perineum to increase flexion of the fetal head and relieve pressure
on the perineum. (Ritgen Maneuver)
7. Check that the umbilical cord does not coil around the infant’s neck.
8. Deliver the shoulder and body in gentle continuous posterior traction on the head
and lateral flexion, to deliver the anterior shoulder then left the posterior shoulder
over the perineum.

PARTOGRAM - is a graphical information about the progress of labour in which the

salient information about the fetal well-being, maternal well-being and the progress of
labour are recorded into a chart.
COMPONENTS OF A PARTOGRAPH:
 Mother information (Name, age, parity, gestational age, date & time of admitted,
time membrane ruptured, short antenatal history)
 Fetal well-being (Fetal Heart Rate, Character of fluid, Molding)
 Labor Progress (Cervical Dilatation, Descent, Uterine contraction)
 Medications (Oxytocin, Pain reliever Medication)
 Maternal well-being (B/P, Pulse, Temp, Urine-(albumin, glucose, acetone) Urine
output

C. THIRD STAGE OF LABOR: PLACENTAL STAGE – begins with birth of the

baby and end with the delivery of the placenta. It involves two different phases:
PLACENTAL SEPARATION and PLACENTAL EXPULSION. Actual placental
expulsion, determining completeness of cotyledons and if the placenta and
placental fragments are totally expelled.

MECHANISM OF PLACENTAL EXPULSION

 Active Management of the third stage of labor:
1. Prophylactic uterutonic after delivery of the baby. (Oxytocin 10 IU
intramuscularly)
2. Cord clamping, cutting and controlled cord traction of the umbilical cord.
3. Uterine massage to prevent uterine atony and minimizes bleeding.
 Excites powerful uterine contraction, aids in early placental separation,
minimizes blood loss and duration of the third stage of labor.(5 minutes)

D. FOURTH STAGE OF LABOR: The hour or two after delivery when the tone of
the uterus is reestablished as the uterus contracts again, expelling any
remaining contents (placenta and placental fragments). These contractions are
hastened by breastfeeding, which stimulates production of the hormone oxytocin.
 The mother may experience:
1. Tremors and chills
2. After-pains
3. Episiotomy or tears
4. Hemorrhoids
5. Postural hypotension ( dizziness, fainting)
 Nursing Management during the fourth stage of labor:
1. Monitor vital signs and the general condition of the mother.
‒ Take BP, P, and R every 15 minutes for an hour, then every 30
minutes for an hour, and then every hour as long as the patient
is stable. Take the patient’s temperature every hour.
‒ Keep the cliennt warm with blanket if ever chills is experienced.
‒ Observe for uterine atony or hemorrhage.
‒ Encourage the patient to drink fluids.
2. Ensure the fundus remains firm.
‒ Massage the fundus every 15 minutes during the first hour, every 30
minutes during the next hour, and then, every hour until the patient
is ready for transfer.
‒ NOTE: A boggy uterus many indicate uterine atony or retained
placental fragments. Boggy refers to being inadequately contracted
and having a spongy rather than firm feeling.
3. Monitor lochia flow.
‒ Lochia is the maternal discharge of blood, mucus, and tissue from
the uterus.
‒ Identify lochia amounts as small, moderate, or heavy (large)
4. Observe patient’s urinary bladder for distention.
Characteristics of a full bladder:
 ‒ Bulging of the lower abdomen
‒ Spongy feeling mass between the fundus and the pubis.
‒ Displaced uterus from the midline, usually to the right.
‒ Increased lochia flow.

3.5 MATERNAL RESPONSES TO LABOR

 Labor is an intense localized process affecting the abdomen and the
reproductive organs with a complete physiologic effect to both the mother and
the fetus. Because of its powerful strength, almost all body systems are involved.
 Pregnancy has effects on many systems of the birthing parent. During labor,
there are yet further effects which may require the nurse to deliver specific care
to their patient. Knowing and recognizing what is normal and what is not normal
can help to ensure safe provision of care.

A. PHYSIOLOGICAL EFFECTS OF LABOR

1. The CARDIOVASCULAR SYSTEM
 Cardiac output increases from pre-labor levels by 40%-50%
 Approximately 300-500 ml of blood is lost during birth.
 Due to pain during contractions B/P rises up to 15mmHG
systole/contraction
 Nursing action:
1. Monitor closely for hemorrhage
2. Monitor for pathologic signs (hypertensive episodes)
3. Ensure hydration of the client prior to epidural administration. (IV
fluid bolus)
2. The HEMATOPOIETIC SYSTEM
 WBCs increase to a level of 25,000– 30,000 cells/mm3 during labor.
 Nursing action:
1. Monitor signs of infection continuously.
3. The RESPIRATORY SYSTEM
 Due to increase cardiovascular factor, RR increases as a response.
 During the second stage of labor oxygen demand increases to 100%
 Nursing Care:
1. Monitor for any signs of hyperventilation. (re-breathing into a paper
bag can help)
2. In order to regulate respiratory rate instruct the client to use
appropriately patterned breathing.
4. TEMPERATURE REGULATION
 Diaphoresis may occur
 Temperature may increase to 1ºF
 Nursing care:
1. Monitor for any signs of infection.
2. Offer cool washcloth on client’s forehead for comfort if needed.
5. FLUID BALANCE
 Due to diaphoresis insensible water loss increases during labor.
 Nursing Care:
1. Encourage sips of fluid during labor to keep hydrated.
2. If nauseated, offer ice chips or hard candy to give some extra fluid.
6. The URINARY SYSTEM
 Due to the pressure of the fetal head as it descends in the birth canal
against the anterior bladder reduces bladder tone or the ability of the
bladder to sense its fullness.
 Nursing care:
 1. Encourage the mother to void every 2 hours during labor to avoid
fullness of the bladder that decreases postpartal bladder tone
causing postpartum bleeding.
7. The MUSCULOSKELETAL SYSTEM
 Relaxin is secreted from the ovaries causing the cartilage between joints
to be more flexible during pregnancy allowing the joints of the pelvis to be
able to open as much as 2 cm in labor to allow for fetal passage.
 Nursing care:
1. Monitor mobility of the mother to reduce the risk of fall.
8. The GASTROINTESTINAL SYSTEM
 Blood shunts to life-sustaining organs causing the GI system to become
fairly inactive during labor, thus causing digestion and emptying time of
the stomach longer.
 Nursing care:
1. NPO is advised during active labor to prevent vomitting
9. NEUROLOGIC and SENSORY RESPONSES
 Pain and respiratory rate increases.
 Nursing Care:
1. When the mother does not desire medication, discuss the non
pharmacologic pain techniques.
2. Epidural anesthesia is administered to mother with low tolerance to
pain and those who desires to have it, but make sure to discuss the
effects.

B. THE PSYCHOLOGICAL RESPONSES

1. The RESPONSE TO PAIN
 Women are encouraged to help plan their care that makes her response
to pain, her choice of nourishment, her preferred birthing position, the
proximity and involvement of a support person, and customs a positive
experience during labor and birth.
2. The RESPONSE TO FATIGUE
 A woman is generally tired from the normal discomforts of pregnancy and
has not slept well for the past month due to backache when in side –lying
position, fetus kicking that waken her up when in supine position. Sleep
hunger from this type of discomfort can make it difficult for a woman to
perceive situations clearly or to adjust rapidly to new situations.
3. The RESPONSE TO FEAR
 Labor moving faster or slower, contractions harder and longer can lead a
woman to feel out of control and increase the level of pain she
experiences. This sense of lack of control combined with pain may
cause her to begin to worry for her infant and may make her afraid she
will not meet her own behavioral expectations.

3.6 FETAL RESPONSES TO LABOR

 The physiologic changes experienced by the mother during labor could also
affect the fetus as well.
1. THE NEUROLOGIC SYSTEM
 FHR decreases by as much as 5 beats/min during a contraction and
could be interpreted as a normal response or early deceleration pattern.
2. The CARDIOVASCULAR SYSTEM
 A full term fetus is unaffected by the continual variations of heart rate
that occur with labor contractions.
3. The INTEGUMENTARY SYSTEM
  Minimal petechiae or ecchymotic areas and edema of the presenting
part (caput succedaneum) as well from the pressure involved in the birth
process.
4. The MUSCULOSKELETAL SYSTEM
 Due to the force of uterine contractions which pushes the fetus out of the
introitus a position of full flexion or with the head bent forward is
assumed, which is the most advantageous position for birth.
5. The RESPIRATORY SYSTEM
 The process of labor appears to aid in the maturation of surfactant
production by alveoli in the fetal lung. Both the pressure applied to the
chest from contractions and passage through the birth canal help to
clear the respiratory tract of lung fluid.

DANGER SIGNS DURING LABOR AND DELIVERY

 Danger signs during labor and delivery:
1. High or Low Blood Pressure
2. Abnormal Pulse
3. Inadequate or Prolonged Contractions
4. Abnormal Lower Contour
5. Increasing Apprehension
 Appropriate nursing diagnosis:
1. Pain related to labor contractions
2. Anxiety related to process of labor and birth
3. Health-seeking behaviors related to management of discomfort of labor
4. Situational low self-esteem related to inability to use planned childbirth
method

MATERNAL AND FETAL ASSESSMENT DURING LABOR

 Response to labor and pattern of labor contractions varies among parturient but
when something goes wrong during labor and birth, it is very important for a
woman to get the care she needs to save her life.
 The health care practitioner must know how to assess a parturient in labor with
abnormal signs and symptoms of complications during labor and birth so that
immediate interventions will be implemented.

HOW TO ASSESS A PARTURIENT FOR DANGER SIGNS OF LABOR:

1. Vital Signs: B/P, Temp.,PR, RR
2. Uterine Contractions
3. Increasing Apprehension
4. Abnormal lower contour

A. HIGH or LOW BLOOD PRESSURE – an increase in the systolic pressure of

more than 30 mmHg or in the diastolic pressure of more than 15 mmHg should
be reported because it is the basic criteria for gestational hypertension, as well
as a falling blood pressure because it may be the first sign of intrauterine
hemorrhage, although a falling blood pressure from hemorrhage is often
associated with other clinical signs of hypovolemic shock, such as apprehension,
increased pulse rate, and pallor.
B. ABNORMAL PULSE RATE – a maternal pulse rate greater than100 beats/ min
during labor is unusual and should be reported because it may be another
indication of hemorrhage.
C. INADEQUATE or PROLONGED CONTRACTIONS – as labor progresses
uterine contraction become more frequent, intense and longer normally but If
they become less frequent, less intense, or shorter in duration, this may indicate
uterine exhaustion (inertia). As a rule, uterine contractions lasting longer than 70
 seconds are becoming long enough to compromise fetal well-being because this
interferes with adequate uterine artery filling.
D. ABNORMAL LOWER ABDOMINAL CONTOUR – a round bulge that appears
on the lower anterior abdomen of the mother indicates a full bladder. This could
cause the bladder to be injured due to the pressure of the fetal head pressing
against it; and the pressure of the full bladder may not allow the fetal head to
descend.
E. INCREASING APPREHENSION – maternal well-being of the mother must be
assessed during labor for signs of psychological danger.

FETAL DANGER SIGNS OF LABOR:

 During labor, you’re not only monitoring the condition of the mother but the
condition of the baby as well, to prevent further complications. The health care
provider must monitor the following fetal danger signs:
1. HIGH or LOW FETAL HEART RATE – the normal fetal heart rate ranges
from 120 beats per minute to 160 beats per minute. If the fetal heart rate
falls below 110 beats per minute (fetal bradycardia) and is above 160 beats
per minute (fetal tachycardia), it is a sign of fetal distress. Therefore, as a
health care provider you need to monitor and record the fetal heart rate
frequently during labor to prevent such complication.
2. MECONIUM STAINING – a green color in the amniotic fluid, reveals that
the fetus has had a loss of rectal sphincter control, allowing meconium to
pass into the amniotic fluid. This is an indication of fetal hypoxia, wherein an
immediate intervention is needed.
3. HYPERACTIVITY – Normally, during labor the fetus is quite and seldom
moves inside the womb. If ever fetal hyperactivity occurs during labor, it
indicates that the fetus is in active motion because of the need for oxygen
due to hypoxia.
4. LOW OXYGEN SATURATION – Normally the oxygen saturation of a fetus
is 40% to 70% inside the womb. If fetal oxygen saturation falls below 40%
and the blood pH level is below 7.2, the fetal well-being is compromised.

APPROPRIATE NURSING DIAGNOSIS OF A WOMAN DURING LABOR AND

DELIVERY:
1. Pain related to labor contractions
2. Anxiety related to process of labor and birth
3. Health-seeking behaviors related to management of discomfort of labor
4. Situational low self-esteem related to inability to use planned childbirth method

MONITORING THE PROGRESS OF LABOR:

1. MATERNAL ASSESSMENTS DURING LABOR
 To know how the parturient manage physically and emotionally the intense
effect of labor and delivery, nursing assessment is very important.
A. IMMEDIATE ASSESSMENT of a parturient during the first stage of labor.
1. The Initial Interview and Physical Examination
‒ Obtain the prenatal record of the mother
‒ Let the mother describe the characteristic of labor
‒ The general physical condition of the mother and her
preparedness and plans for labor and birth.
‒ Asks for her baby’s EDB (expected date of birth)
‒ When her contractions began
‒ Amount and character of any show
‒ Whether rupture of membranes has occurred
‒ Any known drug allergies
‒ If she uses any recreational or prescription drugs
 ‒ History of past and present pregnancy if prenatal record is not
available
2. Assess for the following
‒ Vital signs (assess between contraction for comfort and
accuracy) Temperature, Pulse rate, Blood pressure,
Respirations
‒ Nature of contractions (frequency, duration, intensity)
‒ Pain scale rating (1-10)
‒ Urine specimen for protein and glucose
‒ Position and presentation of her fetus (Leopold’s Maneuver)
‒ Learning of birthing exercises if any
B. COMPREHENSIVE ASSESSMENT during the first stage of labor
1. History taking
‒ Current history of pregnancy
‒ Past history of pregnancy
‒ Past health history
‒ Family Medical history
2. Physical Examination (head to toe assessment)
‒ Pelvic examination to consider the fetus presentation and
position and the stage of cervical dilatation
‒ Abdominal assessment
a. FUNDIC HEIGHT MEASUREMENT – nto determine the
size of the fetus
b. LEOPOLDS MANEUVER – to determine the position and
presentation of the fetus.
‒ Assessing rupture of membranes – sudden gush of amniotic
fluid from the vagina.
‒ VAGINAL EXAMINATION – to determine the extent of cervical
effacement and dilatation, and to confirm the fetal presentation,
position and degree of descent.
‒ Assessment of pelvic adequacy
a. SONOGRAPHY – to determine the internal conjugate and
ischial tuberosity diameters.
‒ Vital signs monitoring at the beginning of labor and during labor.
‒ Laboratory analysis
a. CBC (hemoglobin and hematocrit), VDRL test, Hepatitis B
screening, Blood typing and RH factor.
b. URINALYSIS – clean-catched urine to test for protein and
glucose
‒ Assessment of uterine contractions- frequency, intensity,
duration

2. FETAL ASSESSMENT DURING LABOR

 It is very important to assess the fetal heart rate of the fetus during labor to
determine that the FHR remains within normal limit despite extreme pressure
by uterine contractions and passage to the birth canal.
A. AUSCULTATION OF FETAL HEART SOUNDS
‒ Fetal heart beat is best heard at the convex part of the fetus
because it is the part that lies near the uterine wall.
B. ELECTRONIC FETAL MONITORING
‒ External Monitoring
EXTERNAL FETAL MONITORING is useful for monitoring both uterine contractions
and fetal heart rate continuously or intermittently. Contractions are monitored by
means of a pressure transducer or a tocodynamometer. The transducer is placed
over the uterine fundus and secure it with a strap.
‒ The fetal heart rate is monitored with the use of an ultrasonic sensor or monitor
strapped over the woman’s abdomen

INTERNAL FETAL MONITORING is the most precise method for assessing fetal
heart rate and uterine contractions.
‒ It is done by inserting a pressure - sensing catheter via the vagina into the
uterine cavity along the side of the fetus once the membranes ruptured and the
cervical dilatation is at least 3 cm.
‒ This test is performed to evaluate fetal heart rate and variability between beats,
especially in relation to the uterine contractions of labor.
‒ Below are pictures of internal fetal monitoring with placement of catheter and
electrodes.

ELECTRONIC MONITORING STRIP showing the baseline FHR and uterine

contractions