SIGNS OF LABOR (WRISLIR) 2ND STAGE

30 MINS – 2 HOURS
Ave: 50 mins
Weight Loss – 2-3 pounds
20 – 90 MINS
(progesterone) Ave: 20 mins
Ripening of the Cervix – “soft” 3RD STAGE
Increased Braxton Hicks – “irregular, 5 – 20 MINS
5 – 20 MINS
painless” 4TH STAGE
Show – “ruptured capillaries + 2 – 4 HOURS
operculum = pinkish color” 2 – 4 HOURS
Lightening – “the baby dropped” ESSENTIAL FACTORS OF LABOR (5Ps)
1. Passages
 2 weeks (primi) and before or during 2. Power
(multi) 3. Passenger
Relief of respiratory discomfort 4. Person
5. Position
Increased frequency of urination
Leg pains PASSAGES
Muscle spasms FUNCTIONS (Sit Sit)
Increased vaginal discharge Serves as birthcanal
It proves attachment to muscles, fascia and
Decreased fundal height ligaments
Increased Level of Activity – large Supports uterus during pregnancy
amount of epinephrine (AG) It provides protection to the organs found
Rupture of Membranes – gush or within the pelvic cavity
TYPES (GAPA)
steady trickle of clear fluid Gynecoid – normal female type of pelvis
 most ideal for childbirth
FALSE LABOR  round shape, found in 50% of women
(CANDAC) Android – male pelvis
 presents the most difficulty during childbirth
Contraction disappear with  found in 20% of women
ambulation Platypelloid – flat pelvis, rarest, occurs to 5% of
Absence of cervical dilation women
Anthropoid – apelike pelvis, deepest type of
No ↑ DIF (duration, intensity, pelvis found in 25% of women
frequency) DIVISION OF PELVIS
Discomfort @ abdomen 1. False Pelvis – “provide and direct”
Absence of show 2. True Pelvis – “the tunnel” IPO
 Inlet or Pelvic Brim – entrance to true pelvis
Contraction stops when sedated ANTEROPOSTERIOR DIAMETER DOT
1. Diagonal Conjugate – midpoint of sacral promontory
TRUE LABOR to the lower margin of symphysis pubis (12.5 cm)
(CUPPAD) 2. Obstetric Conjugate – midpoint of sacral promontory
to the midline of symphysis pubis (11 cm)
Contraction persists when sedated 3. True Conjugate – midpoint of sacral promontory to
Uterine contraction ↑ DIF (duration, the upper margin of symphysis pubis (11.5 cm)
intensity, frequency) Pelvic Canal -situated between inlet and outlet designed
to control the speed of descent of the fetal head
Progressive cervical dilation
Outlet - most important diameter of the outlet
Presence of show
Ambulation increase contractions POWERS 3I’s
Discomfort radiates to lumbosacral ⦿ Involuntary – not within the control of the parturient
⦿ Intermittent – alternating contraction and relaxation
area ⦿ Involves discomfort (compression, stretching and
hypoxia)
LENGTH OF LABOR
(STAGE OF LABOR) ⦿ PHASES OF UTERINE CONTRACTIONS
 PRIMI (VIRGIN) 1. Increment/Crescendo – “ready, get set”
 MULTI (DIS-VIRGIN) 2. Acme/Apex – “go”
1ST STAGE 3. Decrement/Decrescendo – “stop”
10 – 12 HOURS
6 – 8 HOURS ⦿ INTENSITY - strength of uterine contraction
 Mild – slightly tensed fundus - measured from the chin to the posterior fontanel
Moderate – firm fundus - average size is 13.5 cm
Strong – rigid, board like fundus
⦿ FETAL LIE – relationship of the long axis of the
⦿ FREQUENCY – rate of uterine contraction fetus to the long axis of the mother
- measured from the beginning of a contraction to the Longitudinal Lie – “parallel”
beginning of the next contraction Transverse Lie – “right angle/lying
crosswise”
⦿ DURATION – length of uterine contraction Oblique Lie – “slanting”
- measured from the beginning of a contraction to the
end of the same contraction ⦿ Attitude or Habitus – degree of flexion or
relationship of the fetal parts to each other
⦿ INTERVAL – measured from the end of contraction to
the beginning of the next contraction PRESENTATION AND PRESENTING PART
LIE
PASSENGER PRESENTATION ATTITUDE
A. Longitudinal Lie
⦿ HEAD (BOTu) 1. Cephalic (head)
Biggest part of the fetal body 2. Breech (butt)
Always the presenting part
Turn to present smallest diameter B. Transverse Lie
Causes:
⦿ CRANIAL BONES 1 FOSE, 2 PaTe 1. relaxed abdominal wall
1 frontal bone2 parietal bone 2. placenta previa
1 occipital bone2 temporal bone
1 sphenoid bone Vertex – most ideal
1 ethmoid bone  suboccipitobregmatic is presented (9.5 cm)
 Brow – occipitomental is presented (13.5
⦿ SUTURE LINES – allow skull bones to overlap cm)
(molding) and for further brain development (SFC La)  Sinciput – occipitofrontal is presented (12.5
Sagittal Suture – between 2 parietal bones cm)
Frontal Suture – between 2 frontal bones  Face presentation
Coronal Suture – between frontal and parietal  Chin presentation
Lamdiodal Suture – between parietal and
occipital Complete breech - feet & legs flexed on the
thighs and the thighs are flexed on the
⦿ FONTANELS – intersection of suture lines abdomen
Anterior Fontanel or Bregma – intersection of
SFC. diamond shaped, closes b/n 12 – 18 Frank breech - hips flexed and legs extended
months 3 x 4 cm (MOST COMMON)
Posterior Fontanel or Lambda – intersection of
Sla. triangular shaped, closes b/n 2 – 3 months Footling Breech – one or both feet are the
presenting parts
⦿ DIAMETERS OF THE FETAL HEAD
AP > T (fetal head) Shoulder Presentation – fetus is lying
1.Tranverse Diameters BBB perpendicular to the long axis of the mother
Biparietal – most important TD  vaginal delivery is NOT POSSIBLE
 greatest diameter presented to the pelvic
inlet’s AP and at the outlet’s TD Compound Presentation – when there is
 average measurement is 9.5 cm prolapsed of the fetal hand alongside the
Bitemporal – average measurement is 8 cm vertex, breech or shoulder.
Bimastoid – average measurement is 7 cm  Complete flexion
 Moderate flexion
Anteroposterior Diameters SOO  Partial flexion (military position)
Suboccipitobregmatic – smallest APD  Extension
- fully flexed (presenting part)  Hyperextended
- measured from the inferior aspect of occiput to  Good flexion
the anterior fontanel  Moderate flexion
- average measurement is 9.5 cm  Very poor flexion
Occipitofrontal – head partially extended  Flexion
and presenting part is the anterior fontanel
- average size is 12. 5 cm
Occipitomental – head is extended and the
presenting part is the face POSITION
⦿ LOA (Left Occipitoanterior) – most favorable & 4. Show – slightly blood-tinged mucus discharge
common fetal position 5. Internal Examination – to assess status of amniotic
fetus in vertex presentation (occiput) fluid, consistency of cervix, effacement/dilatation,
fetus usually accommodates itself on the left presentation, station and pelvic measurement.
because the placement of the bladder is at the  do it during relaxation
right  less IE done once membrane have ruptured
⦿ LOP/ROP – mother will suffer more back pains  start with middle finger then index finger
⦿ FHT Breech: Upper R or L Quadrant (above 6. Status of Amniotic Fluid (if ruptured)
Umbilicus) ● Danger of cord prolapse if fetal head is not yet
⦿ FHT Vertex: Lower R or L Quadrant (below Umbilicus) engaged.
⦿ STATION - relationship of the presenting part of the ● Danger of serious intrauterine infection if delivery
fetus to the ischial spine of the mother does not occur in 24 hours
Minus (-) station – presenting part is above the NITRAZINE PAPER TEST
ischial spine used to assess whether membrane ruptured or
Zero (0) station – presenting part is at the level not.
of the ischial spine ● Procedure: “Insert and Touch”
Positive (+) station – presenting part is below Yellow – intact BOW
the level of the ischial spine Blue – ruptured
FLOATING – head is movable above the pelvic ● Normal Color of AF – clear, colorless to straw colored
inlet ● Green tinged – meconium stain (fetal distress in non –
+1 station – fetus is engaged breech presentation)
+2 station – fetus is in midpelvis ● Yellow/Gold – hemolytic disease
+4 station – perineum is bulging ● Gray/Cloudy – infection
● Pinkish/Red stained – bleeding
⦿ THE PERSON ● Brownish/Tea Colored/Coffee Colored – fetal death
FACTORS affecting labor PRC PCP
Perception & meaning of childbirth OTHER TEST TO DETERMINE STATUS OF AMNIOTIC
Readiness & preparation for childbirth FLUID
Coping skills
Past experiences ⦿ Ferning pattern of cervical mucus
Cultural & social background (“swab – dry – view”)
Presence of significant others and support
system ⦿ Nile blue sulfate staining of fetal squamous cells
STAGES OF LABOR
STAGE 1 – DILATATION STAGE FETAL ASSESSMENT DURING LABOR FHT
Starts from first true uterine contraction until Monitoring Latent Phase – every hour
the cervix is completely effaced and dilated. Active Phase – every 30 minutes
 Dilatation – widening of cervical os to 10 cm Second Stage of Labor – every 15 minutes
 Effacement – thinning to 1- 2 cm FHT is taken more frequently in high – risk cases
CAUSES:
1. Pergusion Reflex ⦿ Normal FHT Pattern
2. Fetal head and intact BOW serves as a wedge to Baseline rate: 120 – 160 bpm
dilate the cervix Early Deceleration – FHT @ contraction, Normal
Maternal Assessment During Labor @ end of contraction (head compression)
1. PIPIT PEPA HF Acceleration - FHT when fetus moves
2. Check V/S q 4hrs during the first stage
 temp q hour if membranes are already ruptured ⦿ Abnormal FHT Pattern
(risk of infection) Bradycardia – 100 – 119 bpm – moderate
 BP b/n contractions, in left lateral pos, q 15 – 20 below 100 bpm – marked
mins after giving anesthesia
 a rapid pulse indicates hemorrhage & CAUSES:
dehydration 1. Fetal hypoxia (analgesia & anesthesia)
3. Uterine contraction 2. Maternal hypotension
 Manual: fingers over fundus, you feel it about 5 3. Prolonged cord compression
secs before the client feels it MGT:
Techniques: 1. place mother on left side
1. assess contraction (DIIF) 2. assess for cord prolapse
2. check contraction q 15 – 30 mins during the first 3. administer oxygen
stage Tachycardia – 161 – 180 bpm – moderate
3. Refer immediately if: above 180 bpm – marked
 duration more than 90 secs CAUSES:
 interval less than 30 secs 1. maternal fever, dehydration
 uterus not relaxing completely after each 2. drugs (atrophine, terbutaline, ritodrine, etc.
contraction MGT:
 1. D/C oxytocin, position on LLP 3. Encourage fast-blow breathing to remove the
2. give 02 at 8 – 10 lpm urge to bear down
3. prepare for birth if no improvement
⦿ CARE OF THE BLADDER – encourage the woman to
Variable Pattern – deceleration at unpredictable void q 2 hrs to: DIPC
times of uterine contraction Delay fetal descent
CAUSE: sign of cord compression Increases the discomfort of labor
MGT: release pressure on the cord Predispose to UTI
Sinusoidal Pattern – no variability in FHT Can be traumatized during labor
CAUSE: hypoxia, fetal anemia & prematurity ⦿ FOODS & FLUIDS – NPO on active phase
Clear fluids on latent phase
CARE OF THE PARTURIENT ⦿ POSITIONING – LLP - best position bcoz J RIPES
1. LATENT PHASE Relieves pressure – IVC
○ Cervical Dilation: 0 – 4 cm Improves urinary function
○ Nature of Contraction: Duration: < 30 secs Prevent hypotensive syndrome
Interval: 3 – 5 mins Encourage anterior rotation of the fetal head
○ Length of Latent Phase:Primis – 6 hours Squatting is ideal position – directs presenting
Multis – 4 – 5 hours part towards the cervix promoting dilatation
○ Attitude of mother: feel comfortable, walking and ⦿ AMBULATION – during the latent phase to shorten
sitting at this time the first stage, to decrease the need for analgesia, FHT
○ Nsg Responsibilties:TGC abnormalities & to promote comfort
1. Teach breathing techniques NO WALKING IF BOW IS RUPTURED
2. Give instructions ⦿ IV FLUIDS – reasons: PLUA
3. Conversation is possible (cooperative & focus Prevent dehydration/fluid & electrolyte
mother) imbalances
Life – line for emergencies
2. ACTIVE PHASE Usually required before administration of A/A
 Cervical Dilation: 4 – 7 cm Administration of oxytocin after delivery to
 Nature of contractions: Duration: 30 – 50 secs prevent atony
Intensity: moderate to strong ⦿ PERINEAL PREP
 Length of Active Phase:Primis – 3 hours Clean & disinfect the external genitalia
 Multis – 2 hours Provide better visualization of the perineum
 Attitude of mother:prefer to stay in bed, ⦿ ENEMA – emptying the colon of fecal matters to:
withdraws from her environment and self – Prevent infection
focused Facilitate descent of fetus
Nsg Responsibilities: CPIC Stimulate uterine contractions
CONTRAINDICATIONS: NIRVAA
1. Coach woman on breathing and relaxation  Not given during active phase
techniques  If premature labor bcoz of danger of cord
2. Prescribed analgesics given during active phase prolapse
3. Instruct woman to remain in bed, minimize  Rupture of BOW
noise, raise side rails, NPO  Vaginal bleeding
4. Check BP 30 mins after giving analgesics  Abnormal fetal presentation & position
(hypotension)  Abnormal fetal heart rate pattern
SECOND STAGE – EXPULSIVE STAGE
3. TRANSITION PHASE  MECHANISM OF LABOR: EDFIRE ERE
 Cervical Dilatation: 8 – 10 cm Engagement
 Nature of Contractions:Duration: 50 – 60 secs Descent – entrance of the greatest biparietal
Interval: 2 -3 mins diameter of the fetal head to the pelvic inlet
Intensity: moderate to strong Flexion – the chin of the fetus touches his chest
 Length of Transition Phase: enabling the smallest diameter
 Primis – 1 hour (baby delivered within 10 (suboccipitobregmatic) to be presented to the
contractions or 20 mins) pelvis for delivery
 Multis – 30 mins (baby delivered within 10 Internal Rotation – when the head reach the
contractions or 20 mins) level of the ischial spine, it rotates from
 Attitude of mother: feel discouraged, ask transverse diameter to AP diameter so that its
midwife/nurse repeatedly when labor will end, largest diameter is presented to the largest
not in control of her emotions and sensations, diameter of the outlet. This movement allows
irritated, may not want to be touched the head to pass through the outlet.
Nsg Responsibilities: RRE Extension – the head of the fetus extend
1. Reassure woman that labor is nearing end & towards the vaginal opening. As the head
baby will be born soon extend, the chin is lifted up and then it is born.
2. Reinforce breathing and relaxation techniques External Rotation – when the head comes out,
the shoulder which enters the pelvis in
 transverse position turns to anteroposterior  20% of placental separation
position for it become in line with the
anteroposterior diameter of the outlet & pass MANAGEMENT:
through the pelvis. 1. Watchful waiting.
Expulsion – when the head is born, the  Do not hurry placental delivery.
shoulder & the rest of the body follows without  Rest a hand over the fundus to make sure the
much difficulties. uterus remains firm
Duration of Second Stage: Primis – 50 mins  Wait for signs of placental delivery
 Multis – 20 mins Calkin’s sign – uterus is firm, globular & rising to
Assessment: monitor FHT q 15 mins in normal case and the level of umbilicus
every 5 mins in high risk cases if not yet delivered Sudden gush of blood from vagina
Transfer to the DR: Primis – cervix fully dilated Lengthening of the cord
 Multis – cervix is 8 cm dilated 2. Manage the uterus to keep it contracted.
3. Administer methergin as prescribed.
Delivery Position 4. Never leave the client unattended.
1. Lithotomy – used when forcep delivery & episiotomy 5. Oxygen & emergency equipment made available.
are to be performed.
2. Dorsal Recumbent – head of the bed is 35 – 45˚ THE FOURTH STAGE – PUERPERIUM
elevated, knees are flexed & feet flat on bed. This MANAGEMENT:
position facilitates the pushing effort of the mother. 1. Repair of lacerations.
3. Left Lateral Position – indicated for woman with heart CLASSIFICATION OF PERINEAL LACERATIONS
disease. First Degree – fourchette, vaginal mucous
membrane, perineal skin
⦿ ASSISTING THE MOTHER IN THE DR Second Degree – fourchette, vaginal mucous
1. Coach the mother to push effectively membrane, perineal skin, muscles of perineal
2. Instruct the woman to pant body
3. Dorsiflex the affected foot and straigthen the Third Degree – fourchette, vaginal mucous
leg until the cramps disappear membrane, perineal skin, muscles of perineal
4. Perform ironing on vaginal orifice if the body & anal sphincter
presenting part moves towards the outlet
5. When the head is crowning, instruct the Fourth Degree - fourchette, vaginal mucous
mother to pant. membrane, perineal skin, muscles of perineal
6. Perform Ritgen’s Maneuver while delivering body, anal sphincter & mucous membrane of
the fetal head to: rectum
 Slows down delivery of the head 2. After repair of lacerations & episiotomy, perineum is
 Lets the smallest diameter of the head cleansed, the legs are lowered from stirrups at the same
to be born time.
 Facilitates extension of the head 3. Check V/S of the mother every 15 mins for the first
7. Just after delivery, immediately wipe the nose hour & every 30 mins for the next 2 hours until stable.
& mouth of secretions then suction. 4. Check uterus & bladder q 15 mins.
8. Take note of the exact time of baby’s birth HYPEREMESIS GRAVIDARUM
9. After the delivery of the baby, place the Causes:(UTEP)
newborn in dependent position to facilitate 1. Unknown
drainage of secretions. 2. Thyroid dysfunction
10. Place the infant over the mother’s abdomen to 3. Elevated HCG
help contract the uterus. 4. Psychological stress
11. Clamping the cord:
 After the pulsation stops
 Clamp the cord twice and cut in
between 8 – 10 inches from umbilicus
 After cutting the cord, look for 2
arteries & 1 vein
12. Wrap the infant & bring to the nursery

THIRD STAGE – PLACENTAL DELIVERY

1. Schultz Mechanism – separation of the placenta