NORMAL LABOUR: MANAGEMENT

USING NURSING PROCESS

NHS 223: Midwifery II (Labour and
Delivery)
ASSESSMENT OF THE WOMAN IN
LABOR
 HISTORY AND CHART REVIEW : COMPONENTS OF THE HISTORY TO
CONSIDER
 Verify LMP, estimated date of Birth(EDB) and estimated gestational
age(EGA)
 Initial data may be gathered by phone or in person:
 Onset of labor
 Frequency length and duration of contractions
 Pain level
 Coping skills
 Status of membranes
 Amount color and consistency of fluid
 Presence of meconium
 Presence of bloody show
HISTORY AND CHART REVIEW : COMPONENTS OF
THE HISTORY TO CONSIDER

 Recent nutritional intake

 Hydration status
 Rest and energy level
 Timing of labor onset
 Recent sleep history
 Maternal affect and feelings about labor
 Perform labor risk assessment
 Current pregnancy course
 Prenatal laboratory review
 Group B Streptococcus (GBS) status
 Other risk factors that can contribute to adverse outcomes
HISTORY AND CHART REVIEW : COMPONENTS
OF THE HISTORY TO CONSIDER

 Review previous pregnancy and birth history

 Length of labors
 Size of infants
 Use of analgesia or anesthesia in labor
 Problems during pregnancy, labor and birth
 Review past medical and surgical history
 Allergies
 Medication and herb use
 Reaction to anesthesia
 Surgical procedures
 Chronic and acute illness
 Injuries
HISTORY AND CHART REVIEW : COMPONENTS
OF THE HISTORY TO CONSIDER

 Social history
 Partner and family support
 History or current substance use
 Maternal well-being
 Coping mechanisms for labor
 Emotional status
 Developmental status
 Woman’s preference for her labor and birth
 Cultural practices
 Support for labor
 Birth plan
 Fetal well-being : Fetal activity patterns
HISTORY AND CHART REVIEW : COMPONENTS
OF THE HISTORY TO CONSIDER

 Review of systems (subjective)

 Genitourinary system
 Respiratory system
 Circulatory system
 Gastrointestinal system
 Nervous system
 Musculoskeletal system
Physical Examination: Components
Of The Physical Exam To Consider
 Maternal vital signs: T,P, R, and BP
 Abdominal examination
 Contraction pattern: frequency, duration and strength
 Fetal evaluation
 Fetal lie, presentation, position and variety
 Fetal heart rate (FHR) pattern
 Auscultation or EFM
 Baseline rate, variability
 Presence of accelerations
 Presence of decelerations, note type
 Early, variable or late
 Determine FHR category
Physical Examination: Components
Of The Physical Exam To Consider
 Estimated fetal weight (EFW): all methods are equally flawed
 Provider palpation
 Ultrasound
 Maternal perception
 Pelvic examination
 Inspect external genitalia, perineum and pelvic floor
 Presence of any lesions’
 Presence of female genital cutting
 Presence of fluid, bleeding or show
 Note landmarks and configuration to guide potential repair
Physical Examination: Components
Of The Physical Exam To Consider
 Digital vaginal examination
 Determine presenting part and position
 Dilatation effacement and station
 Verify status of membranes
 Reassess clinical pelvimetry
 Defer digital exam with
 Vaginal bleeding beyond bloody show
 Verified spobntaneous rupture of membranes (SROM)
 With possible SROM until IBOW(intact bag of waters) has been verified
Physical Examination: Components
Of The Physical Exam To Consider
 Speculum exam if rupture of membranes (ROM) is suspected
 Poooling
 Obtain specimen for testing
 Meconium staining
 Extremities
 Reflexes
 Edema
 Preanesthesia considerations
 dentition
 Airway
 Cardiopulmonary status
 Spine
Physical Examination: Components
Of The Physical Exam To Consider
 Evaluate additional body systems as indicated by the following
factors:
 History and woman’s general presentation
 Physical examination findings
 Diagnostic test results
Clinical impression: differential
diagnoses to consider
 Prelabor or early labor
 Active labor; specify satge and status of mambranes
Screening and diagnosis: tests and
procedures to consider
 Testing is performed as indicated by the following factors:
 History
 Active risk factors or clinical findings
 Birth environment or practice standards
 Urinalysis
 Dip for protein and glucose
 Microscopic evaluation as needed
 Fluid from vaginal vault
 Test with Nitrazine, ferning or Amnisure
 Complete blood count (CBC)
 Type and screen/cross-match
 Other screening as indicated by history and physical exam
Providing treatment: therapeutic
measures to consider
 Expectant management
 Watchful waiting
 Oral hydration and nutrition
 Ambulation and position changes
 Support people present
 Reassess for labor progression in several hours for decision making
 For admission to birth facility
 For presence of birth care team at home birth
 As indicated by the mother’s history, or by the facility’s protocol, if admitted
 Saline lock for venous access
 Intravenous (IV) fluids for hydration or venous access
 Pain relief measures per maternal preference and indication
Providing treatment : integrative
therapies to consider
 Send home from facility if in early labor
 Recognize increased anxiety of woman and her family
 Provide strategies for self-care
 Self-care
 Rest , nourishment, hydration
 Ambulation and position changes’
 Distraction techniques
 Massage
 Application of heat or cold
 Hydrotherapy
 Doula services
Providing support : education and
support measures to consider
 Provide information
 Role of birth professionals
 Labor evaluation process
 Expected care during labor and birth
 Hydration and nourishment options
 Activity options
 Pain relief or comfort options
 Nonpharmaceutical
 Pharmaceutical
 Positions for labor and birth
 Indications for the following measures:
 Artificial ROM (AROM)
 Internal examinations
 Medications
 Provide progress updates
 Provide encouragement and support
 Provide information for shared decision making/informed consent
 If sent home from health facility, provide the following:
 Contact information
 Review of when to call or return for care
Follow-up care : follow up measures
to consider
 Document and discuss
 Admission history and physical exam findings
 Reevalaute for presence of progress
 As indicated by maternal and fetal status
 Limit digital exams
 Use multiple parameters to assess maternal/ fetal well being and labor progress
 Digital exams at intervals of 4 hours recommended for routine assessment of active labor (WHO,2014)
 Document interval evaluation in progress notes
 Anticipated progression
 Anticipatory thinking
 Consultations/referrals
 Assess the woman’s responses
 To support people
 To unfamiliar care providers
 To labor progress and information
LABOR AND BIRTH
PROCESS
Premonitory Signs of Labor

 1. Cervical Changes
 Cervical softening and possible cervical dilatation with descent of the
presenting part
 Can occur 1 month to 1 hour before actual labor begins
 Shortening and thinning of the cervix
 Effect of prostaglandins and pressure from Braxton Hicks contractions

OBSTETRICS, Lydia Ondiba 20/02/2025

Premonitory Signs cont..

2. Lightening
 Occurs when the fetal presenting part begins to descend into the
maternal pelvis
 It causes increased pelvic pressure, cramping and low back pain
 Can occur 2 or more weeks before labor begins or until labor starts

OBSTETRICS, Lydia Ondiba 20/02/2025

Premonitory signs..

 3. Increasing Energy Level

 Some women report a sudden increase in energy before labor
 Increase in epinephrine release caused by a decrease in progesterone

OBSTETRICS, Lydia Ondiba 20/02/2025

Braxton Hicks Contractions

 Experienced throughout pregnancy but they become stronger and

more frequent
 Felt as tightening or pulling sensation of the top of the uterus
 They last between 30 seconds to 2 minutes

OBSTETRICS, Lydia Ondiba 20/02/2025

Spontaneous Rupture of Membranes

 Can occur before the onset of labor

 Sudden gush or steady leakage of amniotic fluid
 After rupture, the barrier to infection is gone
 Danger for cord prolapse if engagement has not occurred

OBSTETRICS, Lydia Ondiba 20/02/2025

True versus False Labor

 False labor: irregular uterine contractions but the cervix is not

affected
 True labor: regular contractions, that increase in frequency, duration
and intensity
 True labor contractions bring about progressive cervical dilatation and
effacement

OBSTETRICS, Lydia Ondiba 20/02/2025

Differences Between True & False
Labor

True labor False labor

 Contraction timing  Contraction timing
- regular, becoming closer -irregular, not occurring close
together, usually 4-6min apart together
lasting 30-60sec  Contraction strength
 Contraction strength
-weak, not getting stronger with
-stronger with time, vaginal time
pressure is felt
 Contraction discomfort
 Contraction discomfort
-usually felt in the front of the
-starts in the back and radiates abdomen
around toward the abdomen
OBSTETRICS, Lydia Ondiba 20/02/2025
Differences Between True & False
Labor

True labor False labor

 Contractions continue no  Contractions may slow down
matter what position change is wit walking or making a
made position change
 Stay home until contractions  Drink fluids and walk around to
are 5 min apart, last 45-60 sec see if there is any change in
and are strong enough- go to the intensity of the
the hospital or birthing center contractions. Stay home if the
intensity diminishes

OBSTETRICS, Lydia Ondiba 20/02/2025

Factors Affecting the Labor Process

 Outlined as five P’s”

 Passageway (birth canal)
 Powers (contractions)
 Position (maternal)
 Passenger ( fetus and placenta)
 Psychological response

OBSTETRICS, Lydia Ondiba 20/02/2025

Passageway

 Maternal pelvis and soft tissues

The bony pelvis
 Made up of the true and false pelvis
 The false pelvis is made up of the upper flared parts of the iliac
bones, concavities and the wings of the base of the sacrum

OBSTETRICS, Lydia Ondiba 20/02/2025

Passageway

 The true pelvis is the bony passageway through which the fetus must
travel
 It is made up of three planes
The inlet
The mid-pelvis (cavity)
The outlet

OBSTETRICS, Lydia Ondiba 20/02/2025

Passageway

 To ensure adequacy of the pelvic outlet for vaginal birth, the following
pelvic measurements are assessed:
 Diagonal conjugate of the inlet
 Transverse or ischial tuberosity
:clenched fist measurement at the lowest aspect of the ischial tuberosity
 True or obstetric conjugate: estimated by the measurement of the diagonal
conjugate by subtracting 1.5cm

OBSTETRICS, Lydia Ondiba 20/02/2025

Pelvic Shape

 The gynecoid pelvis is

considered the true female pelvis, occurs in 50% women
 Vaginal birth is most favorable with this type
 The inlet is round and the outlet is roomy
 It offers the optimal diameters in all three planes of the pelvis

OBSTETRICS, Lydia Ondiba 20/02/2025

Pelvic Shape

 The anthropoid pelvis is common in men and occurs 25% of women

 The pelvic inlet is oval and the sacrum is long
 Wider front to back( anterior to posterior) than side to
side(transverse)
 Vaginal birth is more favorable compared to android or platypelloid
shape

OBSTETRICS, Lydia Ondiba 20/02/2025

Soft Tissues

 Stretchy lower uterine segment

 Cervix: effacement
 Pelvic floor muscles: helps the fetus to rotate anteriorly as it passes
through the birth canal
 Vagina: expand to accommodate the fetus during birth
 The introitus

OBSTETRICS, Lydia Ondiba 20/02/2025

Powers

 Primary powers- involuntary uterine contractions that signal the

beginning of labor
 Once the cervix has dilated , voluntary bearing down efforts by the
woman called secondary powers begin
 The secondary powers augment the force of the involuntary
contractions

OBSTETRICS, Lydia Ondiba 20/02/2025

Primary Powers

 Frequency – the time from the beginning of one contractions to the

beginning of the next
 Duration- length of the contraction
 Intensity- strength of the contraction at its peak
 Responsible for effacement and dilatation of the cervix and descent
of the fetus

OBSTETRICS, Lydia Ondiba 20/02/2025

Primary Powers

 Effacement means the shortening and thinning of the cervix in the

first stage of labor
 The cervix normally is 2 to 3cm long and about 1 cm thick
 It is taken up by a shortening of the uterine muscle bundles as the
lower uterine segment thins in advancing labor
 Dilatation

OBSTETRICS, Lydia Ondiba 20/02/2025

Secondary Powers

 As the presenting part reaches the pelvic floor the contractions

change in character and become more expulsive
 Involuntary urge to push/bear down to expel the uterus
 Increased intra-abdominal pressure that compresses the uterus on all
sides and adds to the power

OBSTETRICS, Lydia Ondiba 20/02/2025

Position of the Laboring Woman

 Frequent changes in position relieve fatigue, increase comfort and

improve circulation
 A laboring woman should be encouraged to find positions that are
most comfortable to her
 Position is determined by the woman, HCP ,environment

OBSTETRICS, Lydia Ondiba 20/02/2025

Passenger

 The way the passenger or the fetus passes through the birth canal is
determined by the following:
 The size of the fetal head
 Fetal presentation
 Fetal lie
 Fetal attitude
 Fetal position

OBSTETRICS, Lydia Ondiba 20/02/2025

Passenger:
Size of the Fetal Head
 Fetal skull is composed of two parietal bones, two temporal bones,
the frontal bone and the occipital bone
 The bones are united by membranous sutures:
 Sagittal
 Lambdoidal
 Coronal
 Frontal
 Fontanels are located where the sutures intersect

OBSTETRICS, Lydia Ondiba 20/02/2025

Passenger cont..

 The most important fontanels are the anterior and posterior

 The anterior fontanel is diamond shaped about 3 cm by 2cm and
closes by 18mos
 The posterior fontanel is triangular about 1cm by 2cm and closes 6-8
weeks after birth
 Sutures and fontanels make the skull flexible to accommodate the
infant brain which continues to grow after birth

OBSTETRICS, Lydia Ondiba 20/02/2025

Passenger cont..

 During labor slight overlapping or molding occurs, because the bones

are not firmly united
 The capacity of the bones to slide over one another permits
adaptations to various diameters of the maternal pelvis
 Molding can be extensive but the heads of most newborns assume
their normal shape 3 days after birth

OBSTETRICS, Lydia Ondiba 20/02/2025

Fetal Presentation

 Presentation refers to the part of the fetus that enters the pelvic inlet
first and leads through the birth canal during labor
 The 3 main presentations are;
 Cephalic presentation/ head
 Breech presentation( buttocks, feet, or both first)
 Shoulder presentation
 The presenting part is the part of the fetus that lies closest to the
internal os of the cervix

OBSTETRICS, Lydia Ondiba 20/02/2025

Fetal presentation cont..

 Presenting part is the part of the fetal body first felt by the examining
finger during a VE
 In cephalic presentation the presenting part is the occiput
 In breech presentation the sacrum
 In shoulder presentation the scapula
 When the presenting part is the occiput, the presentation is noted as
vertex

OBSTETRICS, Lydia Ondiba 20/02/2025

Examples of fetal vertex presentation in
relation to front, back or side of the maternal
pelvis
 ROP- right occiput posterior
 LOP
 ROT- right occiput transverse
 LOT
 ROA-right occiput anterior
 LOA

OBSTETRICS, Lydia Ondiba 20/02/2025

Lie :
Presentation:
Attitude:

OBSTETRICS, Lydia Ondiba 20/02/2025

Factors that Determine the
Presenting Part
 Fetal lie
 Fetal attitude
 Extension or flexion of the fetal head

OBSTETRICS, Lydia Ondiba 20/02/2025

Fetal Lie

 Lie is the relation of the long axis (spine) of the fetus to the long axis
(spine)of the mother
 The two primary lies are;
 longitudinal or vertical, the long axis of the fetus is parallel to the long
axis of the mother
 Transverse, horizontal diagonal to the long axis of the mother
 an oblique lie is the one which the long axis of the fetus is lying at an
angle to the long axis of the mother- less common. Converts to
transverse/longitudinal during labor

OBSTETRICS, Lydia Ondiba 20/02/2025

Fetal Attitude

 Fetal attitude (degree of flexion)is the relation of fetal body parts to

one another
 The back of the fetus is rounded so that the chin is flexed on the
chest touching the sternum, the thighs are flexed on the abdomen
and the legs are flexed at the knees
 The arms are crossed over the thorax
 The umbilical cord lies between the arms and legs
 This attitude is termed general / complete flexion

OBSTETRICS, Lydia Ondiba 20/02/2025

Fetal Attitude cont..

 Moderate flexion- the top of the head/sinciput is the presenting part

 The head of the fetus is slightly flexed, but held straighter than in
complete flexion
 The chin doesn’t touch the chest
 Converts to complete flexion as labor progresses
 Partial extension-the head of the fetus is extended, the brow
becomes the first part to pass through the pelvis during birth.
 In partial extension vaginal delivery is unlikely
 The brow/forehead is the presenting part

OBSTETRICS, Lydia Ondiba 20/02/2025

Fetal Attitude cont..

 Full extension: in complete extension the head and neck of the fetus
are hyperextended and the occiput touches the fetus’s upper back
 The back is usually arched, which increases the degree of
hyperextension
 Commonly, this skull diameter is too large to pass through the pelvis
 The mentum (chin) is the presenting part

OBSTETRICS, Lydia Ondiba 20/02/2025

Fetal Attitude

 Deviations from the normal attitude may cause difficulties in

childbirth
 Diameters of the fetal head are measured
 Bi-parietal diameter 9.25cm at term is the largest transverse
diameter, an important indicator of fetal head size
 In a well flexed cephalic presentation, the bi-parietal diameter is the
widest part of the head entering the pelvic inlet

OBSTETRICS, Lydia Ondiba 20/02/2025

Diameters of the Fetal Head

OBSTETRICS, Lydia Ondiba 20/02/2025

Fetal Position

 Fetal position is the relationship of the presenting part of the fetus to

a specific quadrant of the mother’s pelvis
 It influences the progression of labor and whether surgical
intervention is needed
 Fetal position is defined using 3 letters.
 The first letter designates whether the presenting part is facing the
woman’s right (R) or left (L) side

OBSTETRICS, Lydia Ondiba 20/02/2025

Fetal Position cont..

 The second letter or letters refer to the presenting part of the fetus :
occiput (O), mentum (M), sacrum (Sa), or scapula or acromion
process (A)
 The third letter designates whether the presenting is pointing to the
anterior(A), posterior (P), or transverse (T) section of the mother’s
pelvis
 The most common fetal positions are left occiput anterior (LOA) and
right occiput anterior (ROA)

OBSTETRICS, Lydia Ondiba 20/02/2025

Fetal Position cont..

Station; is the relationship of the presenting part of the fetus to the mother’s
ischial spines

 If the fetus station is at 0, the fetus is considered to be at the level of the

ischial spines
 The fetus is considered engaged when it reaches station 0
 Fetal station is measured in cm
 The measurement is minus, when it is above the level of the ischial spines
and plus when it’s below
 Station measurements range from -1 to -3 cm(minus station) and +1 to +4
cm (Plus station)
 At +4cm –perineum- crowning
OBSTETRICS, Lydia Ondiba 20/02/2025
OBSTETRICS, Lydia Ondiba 20/02/2025
Engagement

 Indicates that the largest transverse diameter (bi-parietal) of the

presenting part has passed through the maternal pelvic brim or inlet
into the true pelvis and corresponds to station 0
 Can be determined by abdominal or vaginal examination

OBSTETRICS, Lydia Ondiba 20/02/2025

Process of Labor

 Labor refers to the process of the moving fetus, placenta and

membranes out of the uterus and thru’ the birth canal
 Various changes take place days and weeks before labor begins

OBSTETRICS, Lydia Ondiba 20/02/2025

Signs Preceding Labor

 Lightening
 Return of urinary frequency
 Backache
 Stronger Braxton Hick’s contractions
 Weight loss of 0.5 to 1.5kg
 Surge of energy
 Increased vaginal discharge; bloody show
 Cervical ripening
 Possible rupture of membranes

OBSTETRICS, Lydia Ondiba 20/02/2025

Signs preceding labor cont..

 Descending of the fetus’s presenting part into the true pelvis

 It usually occurs gradually about 2 weeks before term
 the woman feels less pressure below the rib cage and breathe more
easily
 Causes bladder pressure
 A return of urinary frequency occurs due to the descent

OBSTETRICS, Lydia Ondiba 20/02/2025

Preceding signs of Labor

 Relaxation of the pelvic joints cause the backache

 The vaginal mucus becomes more profuse in response to the extreme
congestion of the vaginal mucous membranes
 Brownish or blood-tinged cervical mucus(bloody show) may be
passed
 Loss of weight due to water loss by electrolyte shifts produced by
changes I estrogen and progesterone levels

OBSTETRICS, Lydia Ondiba 20/02/2025

Onset of Labor

 Increased concentrations of estrogen and prostaglandins and

decreasing progesterone levels
Stages of labor: 1. the first stage of labor
2. Second stage of labor
3. Third stage of labor
4. Fourth stage of labor

OBSTETRICS, Lydia Ondiba 20/02/2025

Stages of Labor

First stage of labor; begins with the onset of regular uterine

contractions that result in progressive cervical change and ends with
complete dilatation of the cervix @10cm(fully dilated)
It is divided into 3 phases:
-Latent
-Active
-Transition

OBSTETRICS, Lydia Ondiba 20/02/2025

Stages of Labor-1st stage

 Latent phase
 Begins with the onset of regular contractions
 Mild contractions lasting 20 to 40 seconds and recur every 5 to 30 minutes
 Lasts about 6 to 8 hours in the primipara and 5 to 6 hours in the multipara
 Cervical dilatation of 0 to 3cm
 Fully effacement of the cervix
 Minimal fetal descent

OBSTETRICS, Lydia Ondiba 20/02/2025

Stages of labor-1st stage

 Monitor the woman’s vital signs

 Monitor fetal heart rate
 Time the frequency and length of the contractions and assessing their
intensity
 Gently rest a hand on the woman’s abdomen at the fundus of the
uterus to assess the frequency
 Count from the beginning of one contraction to the beginning of the
next,
 Tense to end the timing when the uterus has fully relaxed

OBSTETRICS, Lydia Ondiba 20/02/2025

Stages cont..

 The intensity can be determined by palpating the uterus , from soft to

firm to extremely hard as the contractions become stronger

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Stages of Labor-1st stage

Active phase
 Release of show
 Membranes may rupture spontaneously
 Contractions are stronger and last 40 to 60seconds, every 3 to 5
minutes
 Increasing strength of contractions causes pain
 Rapid cervical dilatation 4 to 7cm
 Descent of the fetus

OBSTETRICS, Lydia Ondiba 20/02/2025

Stages of Labor- 1st stage

 Active phase
 Lasts 6 to 12 hours
 Cervix undergoes more rapid dilatation. Begins when the cervix is 4 cmdilated
 Analgesics at this time wont slow labor, poor fetal position and a full bladder may
prolong this phase
 Encourage the woman to use proper breathing techniques
 Place the woman in an upright or side lying position for comfort
 Monitor IVF if ordered for fluid balance
 Monitor I& O
 Monitor VS
 Auscultate / assess the FHR q 30m for a low-risk and q15 min for high risk patient
 Perform perineal care to reduce chances of infection esp. after voiding and bowel
mov’t
OBSTETRICS, Lydia Ondiba 20/02/2025
Stages of labor-1st stage

 Transition phase
 Contractions reach maximum intensity
 They last 60 to 90 seconds each’
 Occur q 2-3 minutes
 Cervix dilates from 8cm to 10 fully dilatation and effacement
 If the membranes are not ruptured they do at 10cm
 The remainder of the mucus plug is expelled from the cervix
 It peaks when cervical dilatation slows slightly at 9cm
 This slowdown denotes the end of the 1st stage of labor. 3-4 hours for
primis but birth may be imminent for multipara
OBSTETRICS, Lydia Ondiba 20/02/2025
PHYSIOLOGY OF THE FIRST STAGE
OF LABOUR
 Duration
 Varies depending on:
 Parity
 Birth interval
 Psychological state
 Presentation of the fetus
 Position of the fetus
 Maternal pelvic shape and size
 Character of uterine contractions
 The greatest part of labor is taken up by the first stage and its
common to expect the active phase to be completed within 6-12h
PHYSIOLOGY OF THE FIRST STAGE
OF LABOUR
 Cervical effacement
 It refers to the inclusion(taking up)of the cervical canal into the lower uterine
segment
 The process takes place from above downwards, the muscle fibers
surrounding the internal os are drawn upwards by the retracted upper
segment and the cervix merges into the lower uterine segment
 Cervical dilatation
 It’s the process of enlargement of the os uteri from a tightly closed aperture
to an opening large enough to permit passage of the fetus
 Dilatation is assessed in cm and full dilatation at term equates to about 10
cm
 Ferguson reflex: refers to the pressure applied evenly to the cervix
causing the uterine fundus to respond by contraction and retraction
PHYSIOLOGY OF THE FIRST STAGE
OF LABOUR
 UTERINE ACTION
 Fundal dominance
 Each uterine contraction commences in the fundus near one of the cornua
and spreads across and downwards
 The contraction lasts longest in the fundus where it is also most intense,
but the peak is reached simultaneously over the whole uterus and
contraction fades from all parts all together
 This pattern permits the cervix to dilate
Uterine action

 Polarity
 This is the neuromuscular harmony that prevails between two poles or
segments of the uterus throughout labor
 They act harmoniously
 The upper pole contracts strongly and retracts to expel the fetus, the lower
pole contracts slightly and dilates to allow expulsion to take place
 Contraction and retraction
 Muscle fibers retain some of the shortening of contraction- retraction
 Intensity and resting tone
 Rhythmic regularity and intervals between them where the muscles relax
 At the end of the first stage, contractions may occur at 2-3min intervals, last
for 50-60 seconds and are very powerful
Uterine action

 Formation of upper and lower uterine segments

 Divides at the end of pregnancy
 The upper uterine segment formed from the body of the fundus, is mainly for
contraction and retraction, and is thick and muscular
 The lower uterine segment is formed of the isthmus and the cervix and is about 8-
10cm in length

 The retraction ring

 A ridge between the upper and lower uterine segment
 The physiological retraction ring gradually rises as the upper uterine segment
contracts and retracts and the lower uterine segment thins out to accommodate
the descending fetus
 Mechanically obstructed labor-the physiological retraction ring becomes visible
above the symphysis pubis and it’s described as a Bandl’s ring
 Can cause fetal compromise
Mechanical factors

 Formation of the forewaters and hindwaters

 The chorion detaches from the lower uterine segment and the intrauterine
pressure causes the sac of fluid to bulge downwards to the internal os
 The well-flexed fetal head fits snugly into the cervix and cuts off the
amniotic fluid in front of the head from that which surrounds the body,
forming two separate pools of fluid
 Separation prevents the pressure that is applied to the hindwaters during
the uterine contractions from being applied to the forewaters and this
keeps the membranes intact in the first stage of labor. Benefit?
 General fluid pressure
 While the membranes remain intact, the pressure of the uterine
contractions is exerted on the amniotic fluid, the pressure is equalized
throughout the uterus and over the fetal body
 When the membranes rupture, the fetal head, the placenta and umbilical
cord are compressed between the uterine wall and the fetus during
contractions with a consequential reduction in the oxygen supply to the
fetus
 Fetal and intrauterine infection – intact or ruptured ?
 Intact membranes- Oxygen supply to the fetus?
 Rupture of the membranes
 The optimum physiological time for the membranes to rupture
spontaneously is at the end of the first stage of labor, after the cervix
becomes fully dilated and no longer supports the bag of forewaters
 The uterine contractions are also applying increasing expulsive force
at this time

 Fetal axis pressure

 During each contraction the uterus rises forward and the force of the
fundal contraction is transmitted to the upper pole of the fetus, down the
long axis of the fetus and applied by the presenting part to the cervix
 More significant after rupture of membranes and during the second stage
of labor
Stages of Labor-2nd stage

Second Stage of labor

 Starts with full dilatation and effacement of the cervix and ends with
the delivery of the neonate
 It lasts up-to 3 hours for primipara and 0 -30minutes for multipara
 Contraction frequency slows every 3 to 4 minutes
 Last 60-90 seconds
 Uncontrollable urge to push or bear down

OBSTETRICS, Lydia Ondiba 20/02/2025

Stages of labor-2nd Stage

 Auscultate FHR q15 minutes for a high-risk patient

 This stage involves moving the fetus through the birth canal
 The fetus pushes on the internal side of the perineum causing the
perineum to bulge and become tense
 The fetal scalp becomes visible at the opening to the vagina
(crowning)

OBSTETRICS, Lydia Ondiba 20/02/2025

Mechanism of Labor

 The turns and other mechanisms necessary in the human birth

process are termed the mechanism of labor
 The seven cardinal movements of the mechanism of labor that occur
in vertex presentation are:
 Engagement, descent, flexion, internal rotation, extension, external
rotation(restitution) and birth by expulsion

OBSTETRICS, Lydia Ondiba 20/02/2025

OBSTETRICS, Lydia Ondiba 20/02/2025
OBSTETRICS, Lydia Ondiba 20/02/2025
Descent

 Downward movement of the fetus

 Bi-parietal diameter of the head passes the ischial spines an moves
into the pelvic inlet
 Occurs because of several forces:
 Direct pressure on the fetus by the contacting uterine fundus
 Pressure of the amniotic fluid
 Contraction of maternal diaphragm & abdominal muscles
 Extension and straightening of the fetal body

OBSTETRICS, Lydia Ondiba 20/02/2025

Flexion

 Occurs during descent

 Caused by resistance of the fetal head against the pelvic floor
 The combined pressure from this resistance and uterine and
abdominal muscle contractions forces the head of the fetus to
bend forward so that the chin is pressed to the chest
 This allows the smallest diameter of the fetal head to descend
through the pelvis
 It permits the smaller suboccipitobregmatic diameter (9.5cm)
rather than the larger diameter to present to the outlet

OBSTETRICS, Lydia Ondiba 20/02/2025

Internal Rotation

 The fetal head typically enters the pelvis with its anteroposterior
diameter in a transverse (right or left)position
 The diameter at the pelvic inlet is widest from left to right,
transverse(shoulders) will not go through the pelvic inlet
 To allow the shoulders to pass through the pelvic inlet, the fetal head
rotates about 45 degrees as it meets the resistance of the pelvic floor

OBSTETRICS, Lydia Ondiba 20/02/2025

Internal Rotation

 With the head rotated, the anteroposterior diameter of the head is in

the anteroposterior plane of the pelvis (front to back)
 This places the widest part of the shoulders in line with the widest
part of the pelvic inlet and outlet

OBSTETRICS, Lydia Ondiba 20/02/2025

Extension

 Occurs after the internal rotation is complete

 As the head passes through the pelvis, the occiput emerges from the
vagina and the back of the neck stops under the symphysis pubis
(pubic arch)
 Anterior deflection of the fetal head at the perineum
 The occiput passes under the lower border of the symphysis pubis
first and then the head emerges by extension: first the occiput, face
and finally the chin

OBSTETRICS, Lydia Ondiba 20/02/2025

Restitution & External Rotation

 External rotation is necessary because the shoulders must turn again

to fit thru the pelvic outlet and under the pubic arch
 After the head is born, it rotates about 45 degrees, back to the
transverse diameter position during descent
 The anterior shoulder is delivered first with downward flexion on the
head

OBSTETRICS, Lydia Ondiba 20/02/2025

External Rotation

 Slight upward flexion to deliver the posterior shoulder

 A neonate who weighs more than 4.5kg has a likelihood of
experiencing shoulder dystocia than one who weighs less
 Shoulder dystocia occurs when lack of room for passage causes the
shoulders to stop at the pelvic outlet

OBSTETRICS, Lydia Ondiba 20/02/2025

Expulsion

 After the delivery of the shoulders, the remainder of the body is

delivered quickly and easily
 This step signifies the end of second stage of labor

OBSTETRICS, Lydia Ondiba 20/02/2025

Stages of Labor- 3rd Stage

 Also called the placental stage occurs after delivery of the neonate
and ends with the delivery of the placenta
 Has two phases:

placental separation
Placental expulsion

OBSTETRICS, Lydia Ondiba 20/02/2025

3rs Stage :Signs that the placenta
has separated
 Absence of cord pulse
 Lengthening of the umbilical cord
 Sudden gush of vaginal blood
 Change in the shape of the uterus

OBSTETRICS, Lydia Ondiba 20/02/2025

3rd Stage: Placental Expulsion

 Should be expelled within 30 minutes

 Examine the placenta to make sure is intact and normal in
appearance and weight
 Usually one sixth of the weight of the infant
 An outer area of decidua (lining of the uterus) is expelled at the same
time as the placenta
 The superficial layer is shed in lochia during the postpartum period
 The basal layer remains in the uterus to regenerate new endothelium

OBSTETRICS, Lydia Ondiba 20/02/2025

3rd Stage

 Blood loss is 300 to 500ml

 > 500ml indicate cervical tear or a problem at the episiotomy site,
retained placenta, full bladder and uterus isn’t contracting properly
 After delivery of the placenta, administer IM oxytocin- increase
uterine contractions and minimize bleeding

OBSTETRICS, Lydia Ondiba 20/02/2025

Fourth Stage

 Occurs immediately after delivery of the placenta

 Last 1-4 hours, It initiates the postpartum period
 Inspect and repair any tears
 Provide perineal care, provide a clean perineal pad
 Encourage full ambulation
 Monitor vital signs, palpate for uterine involution, encourage woman
to void, observe amount , color and consistency of lochia.
 Monitor for:
 HEMMORRHAGE
 BLADDER DISTENSION
 VENOUS THROMBOSIS
OBSTETRICS, Lydia Ondiba 20/02/2025
Physiological Adaptations to Labor

 Fetal adaptation
 Fetal heart rate ( average 110-160beats per minute
 Fetal circulation: affected by maternal position, uterine contractions, BP and
umbilical blood flow
 Fetal respiration: decreases during labor, fetal lung fluid is cleared from the air
passages as the infant passes thru the birth canal during labor, fetal oxygen
pressure, arterial PH and bicarbonate levels decreases.

OBSTETRICS, Lydia Ondiba 20/02/2025

Physiological Adaptations to Labor

 Maternal adaptation
 Cardiac output increases 10 -15% in the first stage and 30% to 50 % in the
second stage
 Heart rate increases slightly in 1 st and 2nd stages
 Bp increases during contractions and back to baseline levels between
contractions
 WBC count increases
 Respiratory rate increases
 Proteinuria may occur
 Temp may be slightly elevated
 Blood glucose level decreases
 Gastric motility and absorption of solid food are decreased: nausea and vomiting
may occur during transition to 2 nd stage of labor
OBSTETRICS, Lydia Ondiba 20/02/2025
Nursing Care During Labor
and Birth
First stage of Labor

 Starts with the onset of regular uterine contractions and ends with full
cervical dilatation and effacement
 Has 3 phases earlier discussed

OBSTETRICS, Lydia Ondiba 20/02/2025

Nursing assessments in first stage
of labor
 Latent phase – every 30 -60 minutes
 Specific assessments
 Maternal blood pressure, pulse and respirations
 Fetal heart rate and pattern
 Uterine activity
 Presence of vaginal show

OBSTETRICS, Lydia Ondiba 20/02/2025

 Every 30 minutes
 Changes in maternal appearance, mood, affect, energy level and condition
of partner
 Every 2-4 hours
 Temperature every 4 hours until membranes rupture then 2 hourly
 As needed
 Vaginal examination to identify progress of labor

OBSTETRICS, Lydia Ondiba 20/02/2025

Active phase of Labor

 Every 30 minutes
 Maternal BP, P and respiration
 Every 15-30 minutes
 FHR and pattern, uterine activity, presence of vaginal show
 Every 15 minutes
 Changes in maternal appearance, mood
 Every 2-4hours
 Temperature
 As needed
 VE
OBSTETRICS, Lydia Ondiba 20/02/2025
Transition labor Phase

 Every 15-30 minutes

 FHR and pattern
 Maternal BP, pulse and respirations
 Every 10-15minutes
 Uterine activity
 Presence of vaginal show
 Every 5 minutes
 Changes in maternal appearance, mood affect, energy level
 Every 2-4 hours
 Temperature
 As needed/ q4 hours
 VE
OBSTETRICS, Lydia Ondiba 20/02/2025
Procedure: Vaginal Examination of
the Laboring Woman
 Use a sterile glove and antiseptic solution or soluble gel for
lubrication
 Position the woman to prevent supine hypotension. Drape to ensure
privacy
 Cleanse the perineum and vulva, if needed
 After obtaining permission to touch her, gently insert the middle and
index fingers into the woman’s vagina

OBSTETRICS, Lydia Ondiba 20/02/2025

Procedure: VE

 Determine:
 Cervical dilatation, effacement and position (anterior, posterior, mid)
 Presenting part, position and station: molding of the head with
development of caput succedaneum( may affect accuracy of
determination of the station)
 Status of membranes (intact, bulging, ruptured)
 Characteristics of amniotic fluid( color, clarity, and odor) if membranes
ruptured

OBSTETRICS, Lydia Ondiba 20/02/2025

Procedure : VE

 Explain the findings of the examination to the woman

 Document your findings and report them to the nurse midwife or
physician

OBSTETRICS, Lydia Ondiba 20/02/2025

Nursing Interventions

 General hygiene
 Showers or bed baths , perineum, oral hygiene, hair, hand washing, face,
gowns and linens
 Nutrient and fluid intake
 Oral for hydration, emotional experience and maternal control
 Intravenous intake: establish and maintain IV
 Hydration and venous access for medication
 Elimination; voiding q2hrs-catheterization and bowel elimination-
reduces risk of infection

OBSTETRICS, Lydia Ondiba 20/02/2025

Nursing Interventions

 Ambulation and positioning

 Upright positions and mobility
 Improved uterine contractions intensity
 Shortens labor
 Less need for pain medications
 Reduced rate of operative birth
 Increased maternal autonomy and control

OBSTETRICS, Lydia Ondiba 20/02/2025

Second Stage of Labor

 Infant is born, begins with full cervical dilatation and complete

effacement and ends with the baby’s birth
 Assessment- signs that suggest the onset of 2nd stage
 Urge to push or feeling need to have a bowel movement
 Sudden appearance of sweat on the upper lip
 An episode of vomiting
 Increased bloody show
 Shaking of extremities
 Increased restlessness: verbalization
 Involuntary bearing down efforts

OBSTETRICS, Lydia Ondiba 20/02/2025

Physical Assessment

 Assess every 5 to 30 minutes: maternal BP, pulse and respirations

 Assess every 5 to 15 minutes, depending on risk status: fetal heart
rate and pattern
 Assess every 10 to 15 minutes: vaginal show, signs of fetal descent,
changes in maternal appearance, mood, affect, energy level and
condition of partner
 Assess every contraction and bearing-down effort

OBSTETRICS, Lydia Ondiba 20/02/2025

Interventions

 Latent (“Laboring Down”) Phase

 Help to rest in a position of comfort ; encourage relaxation to
conserve energy
 Promote progress of fetal descent and onset of urge to bear down by
encouraging position changes, pelvic rock, ambulation showering

OBSTETRICS, Lydia Ondiba 20/02/2025

Interventions

 Active Pushing (Descent) Phase

 Help to change position and encourage spontaneous bearing-down
efforts
 Help to relax and conserve energy between contractions
 Provide comfort and pain relief measures as needed
 Cleanse perineum promptly if fecal material is expelled

OBSTETRICS, Lydia Ondiba 20/02/2025

Interventions

 Coach to pant during contractions and to gently push between

contractions when head is emerging
 Provide emotional support, encouragement and positive
reinforcement of efforts
 Keep woman informed regarding progress
 Create a calm and quiet environment
 Offer mirror to watch birth

OBSTETRICS, Lydia Ondiba 20/02/2025

Immediate assessment and care of
the newborn
 Dry and place on the mothers abdomen immediately after birth
 Cover with a warm dry blanket
 Clamp the cord
 Cut the cord 1inch (2.5cm) above the clamp
 Assess and stabilize the newborn
 Two nurses be present for each birth, one takes care of the baby the
other assists in delivery of the placenta and care of the mother

OBSTETRICS, Lydia Ondiba 20/02/2025

Immediate assessment and care of
the newborn
 Watch the infant for any signs of distress and initiate appropriate
interventions
 Perform a brief assessment of the newborn immediately while the
mother is holding the infant
 Apgar score at 1 and 5 minutes after birth
 Maintaining a patent airway
 Supporting respiratory effort
 Preventing cold stress by drying and cover with a warm blanket while on
the mothers abdomen skin to skin or place under a radiant warmer

OBSTETRICS, Lydia Ondiba 20/02/2025

Immediate assessment cont..

 Further examination of the newborn can be done in the fourth stage

 Identification procedures
 Care of the newborn
 Education to the mother on the care

OBSTETRICS, Lydia Ondiba 20/02/2025

Perineal Lacerations

 Perineal lacerations usually occur as the fetal head is being born

 The extent of laceration is defined in terms of its depth

 1st degree: laceration that extends thru the skin and vaginal mucous
membrane but the underlying fascia and muscle
 2nd degree: laceration that extends thru the fascia and muscles of the
perineal body; but not the anal sphincter
 3rd degree: laceration that involves the external anal sphincter
 4th degree: lacerations that extends completely through the rectal
mucosa, disrupting both the external and internal anal sphincters

OBSTETRICS, Lydia Ondiba 20/02/2025

Episiotomy

 An episiotomy is an incision in the perineum used to enlarge the

vaginal outlet
 Its use has declined due to lack of sound and rigorous research to
support its benefits
 Side lying position places less tension on the perineum, making
possible a gradual stretching of the perineum with fewer indications
for an episiotomy
 Giving birth on an intact perineum provides the best outcomes( less
blood loss, less risk of infection, less postpartum pain)

OBSTETRICS, Lydia Ondiba 20/02/2025

Episiotomy

 Different types of episiotomies may be performed, classified by site

and direction of the incision
 The site and direction that provides the best outcome is unknown
 Midline (median) episiotomy
 It is effective
 Easily repaired
 Generally the least painful

OBSTETRICS, Lydia Ondiba 20/02/2025

Episiotomy

 Midline episiotomies are associated with higher incidence of third

and fourth-degree lacerations
 Sphincter tone is usually restored after primary healing and a
good repair
 Medio-lateral episiotomy is used in operative births when the need
for posterior extension is likely
 It is defined as one that is performed between 40 and 60 degrees
from the midline
 A third degree laceration may occur
 Blood loss is greater and repair more difficult and painful tan midline
episiotomies
 More painful in postpartum and the pain last longer
OBSTETRICS,
Episiotomy Lydia Ondiba
should 20/02/2025
be avoided whenever possible!
Technique of perineal repair- second
degree tears
 Suturing the vagina
 Use 2/0 absorbable polyglactin 910 material (Vicryl rapide)
 The first stitch is inserted above the apex of the vaginal skin laceration to
secure any bleeding points
 The vaginal laceration is closed using a loose, continuous, non-locking
technique ensuring that each stitch is inserted not more than 1 cm apart
to avoid vaginal narrowing
 Suture down to the hymenal remnants and insert the needle at the
fourchette to emerge in the centre of the perineal wound
 Read on obstetric anal sphincter injuries , repair and postop care
Technique of perineal repair

 Suturing the muscle layer

 Approximate muscle layers with the depth of the trauma
 Perineal muscles are approximated with continuous non-locking stitches
 Suturing the perineal skin
 The needle is brought out at the inferior end of the wound, just under the skin
surface
 The skin sutures are placed below the surface in the subcutaneous tissue, thus
avoiding the profusion of nerve endings
 A loop or Aberdeen knot is placed in the vagina behind the hymenal remnants
 A VE is done to ensure that the vagina is not narrowed
 A rectal exam to ensure that sutures have not been placed through the
anorectal epithelium
Nursing Care in Third Stage of Labor

 Assessment- Signs that suggest the onset of Third Stage

 A firmly contracting fundus
 A change in the uterus from a discoid to a globular ovoid shape as the
placenta moves into the lower uterine segment
 A sudden gush of dark blood from the introitus
 Apparent lengthening of the umbilical cord as the placenta descends to the
introitus
 the finding of vaginal fullness(the placenta) on vaginal or rectal
examination or of fetal membranes at the introitus

OBSTETRICS, Lydia Ondiba 20/02/2025

Nursing care in 3rd Stage of
Labor ;Physical Assessment
 Assess every 15 minutes: maternal blood pressure, pulse and
respirations
 Assess for signs of placental separation and amount of bleeding
 Assist with determination of Apgar score at 1 and 5 minutes after
birth
 Assess maternal and paternal response to completion of childbirth
process and their reaction to the newborn

OBSTETRICS, Lydia Ondiba 20/02/2025

APGAR

OBSTETRICS, Lydia Ondiba 20/02/2025

Interventions

 Assist to bear down to facilitate fetal expulsion of the separated

placenta
 Administer an oxytocic medication as ordered to ensure adequate
contraction of the uterus, thereby preventing hemorrhage
 Provide non-pharm and pharm comfort and pain relief measures
 Keep mother informed of progress of placental separation and
expulsion and perineal repair if appropriate

OBSTETRICS, Lydia Ondiba 20/02/2025

Interventions cont..

 Explain purpose of medications administered

 Introduce parents to their baby and facilitate attachment process by
delaying eye prophylaxis
 Wrap mother and baby together for skin to skin contact
 Provide private time for parents to bond with new baby
 Encourage breastfeeding if desired

OBSTETRICS, Lydia Ondiba 20/02/2025

Fourth stage of Labor

 The first 1 to 2 hours after birth, is crucial for the mother and baby
 Recovery and acquainting to each other
 The maternal organs undergo their initial readjustment to the non
pregnant state and functions of the body systems begin to stabilize

OBSTETRICS, Lydia Ondiba 20/02/2025

Assessment during the fourth stage
of Labor
 Blood pressure and pulse every 15 minutes for the 1st 2 hours
 Temperature : at the beginning of the recovery period
 Every 4 hours for the first 8 hours after birth and then at least every 8
hours

OBSTETRICS, Lydia Ondiba 20/02/2025

Assessment 4th stage of Labor

 Fundus
 Position woman with knees flexed
 Just below the umbilicus, cup hand and press firmly into abdomen, at the
same time stabilize the uterus at the symphysis pubis
 If fundus is firm( and bladder empty), with uterus midline, measure its
position relative to woman’s umbilicus
 Lay fingers flat on the abdomen under umbilicus; measure how many
fingerbreadths or cm fit between umbilicus and top of fundus

OBSTETRICS, Lydia Ondiba 20/02/2025

Assessment 4th stage of Labor

 Fundus
 If fundus is not firm, massage it gently to contract and expel any clots
before measuring the distance from umbilicus
 Place hands appropriately: massage gently only until firm
 Expel clots and observe amount and size of expelled clots at the perineum

OBSTETRICS, Lydia Ondiba 20/02/2025

Assessment 4th stage of Labor

 Bladder
 Assess distension- boggy uterus, well above the umbilicus and displaced to
the right side
 Assist woman to void spontaneously
 Catheterize as necessary
 Reassess after voiding / catheterization to ensure the bladder is not
palpable and the fundus is firm and in the midline


OBSTETRICS, Lydia Ondiba 20/02/2025

Assessment 4th stage of Labor

 Lochia
 Observe lochia on perineal pads and on linen under the mother’s buttocks
 Determine the amount and color, note size and number of clots; note odor
 Observe perineum for source of bleeding( episiotomy, lacerations)

OBSTETRICS, Lydia Ondiba 20/02/2025

Assessment 4th stage of Labor

 Perineum
 Ask or assist the woman to turn on her side and flex upper leg on hip
 Lift upper buttock
 Observe perineum in good lighting
 Assess episiotomy or laceration repair for redness , edema,
ecchymosis( bruising), drainage and approximation (REEDA)
 Assess for presence of hemorrhoids

OBSTETRICS, Lydia Ondiba 20/02/2025

 POSTPARTUM CARE &
PHYSIOLOGIC CHANGES
Introduction

 The first 6 weeks after the birth of an infant are known as the
postpartum period, or puerperium.
 During this time, mothers experience numerous changes
 Physiological changes
 Psychosocial changes
 Many of the physiologic changes are retrogressive in nature: changes
that occurred in body systems during pregnancy are reversed as the
body returns to the nonpregnant state. Progressive changes such as
the initiation of lactation also occur.

OBSTETRICS, Lydia Ondiba 20/02/2025

Physiologic Changes

 Retrogressive
 Progressive
 Retrogressive changes involve returning the body to its nonpregnant state
 Reproductive retrogressive changes include:
 Shrinkage and descent of the uterus into its prepregnancy position in the pelvis
 Sloughing of the uterine lining and development of lochia
 Contraction of the cervix and vagina
 Recovery of vaginal and pelvic floor muscle tone

OBSTETRICS, Lydia Ondiba 20/02/2025

Uterine Involution

 Involution – the gradual decrease in size of the uterus and descends

into its pre-pregnancy position in the uterus
 Uterine involution involves three processes: (1) contraction
of muscle fibers, (2) catabolism (the process of converting cells into
simpler compounds), and (3) regeneration of the uterine
epithelium.

OBSTETRICS, Lydia Ondiba 20/02/2025

Uterine involution cont..

 Begins immediately after delivery

 The firmly contracted uterus lies midway between the umbilicus and
symphysis pubis
 Descends into the pelvis at a rate of 1cm/day(I fingerbreadth/day)
 By 10th to 14th postpartum day , the uterus lies deep in the pelvis- at
or below the symphysis pubis, cannot be palpated
 This process is normally slower when the uterus was distended during
pregnancy with more than one fetus, a large fetus, or hydramnios
(excessive amniotic fluid).
 When the process of involution does not occur properly,
subinvolution occurs. Subinvolution can cause postpartum
hemorrhage
OBSTETRICS, Lydia Ondiba 20/02/2025
Uterine involution cont…

Catabolism
 The total number of cells remains unchanged, the enlarged uterine
muscle cells undergo catabolic changes in protein cytoplasm that
cause a reduction in individual cell size.
 The products of this catabolic process are absorbed by the
bloodstream and excreted in the urine as nitrogenous waste.

OBSTETRICS, Lydia Ondiba 20/02/2025

Uterine involution cont…

 Regeneration of the uterine epithelial lining begins soon after

childbirth.
 The outer portion of the endometrial layer is expelled with the
placenta
 Within 2 to 3 days, the remaining decidua (the endometrium during
pregnancy) separates into two layers.
 The first layer is superficial and is shed in the lochia.
 The basal layer containing the residual endometrial glands remains to
provide the source of new endometrium.
 Regeneration of the endometrium, except at the site of placental
attachment, occurs by 2 to 3 weeks after birth

OBSTETRICS, Lydia Ondiba 20/02/2025

Uterine involution cont…

 Healing at the placental site occurs approximately 6 weeks

 The site, which is about 9 cm in diameter immediately postpartum,
heals by a process of exfoliation (scaling off of dead tissue)
 New endometrium is generated at the site from the sides and from
glands and tissue that remain in the lower layer of the decidua after
separation of the placenta
 This process leaves the endometrial layer smooth and spongy, as it
was before pregnancy, and the uterine lining is free of scar tissue
unless the birth was cesarean.
 Scarring of the uterine lining may interfere with implantation of future
pregnancies.

OBSTETRICS, Lydia Ondiba 20/02/2025

Retrogressive changes cont..

 Reduction in pregnancy hormones such as hCG, HPL,progestin,

estrogen and estradiol
 Extensive diuresis, which rids the body of excess fluid and reduces
the added blood volume
 Gradual rise of hematocrit
 Reactivation of digestion and absorption
 Eventual fading of striae gravidarum, chloasma and linea nigra
 Gradual return of tone to abdominal muscles, wall and ligaments
 Drop in estrogen and progesterone and FSH rises

OBSTETRICS, Lydia Ondiba 20/02/2025

Retrogressive changes cont…

 Weight loss
 Approximately 4.5 to 5.8 kg (10 to 13 lb) are lost during childbirth.
 This includes the weight of the fetus, placenta, and amniotic fluid and
blood lost during the birth. An additional 2.3 to 3.6 kg (5 to 8 lb) are
lost as a result of diuresis and 0.9 kg to 1.4 kg (2 to 3 lb) from
involution and lochia by the end of the first week (Blackburn, 2013).
 Weight loss continues with the greatest loss during the first 3 months.

OBSTETRICS, Lydia Ondiba 20/02/2025

Progressive changes

 Building of new tissues

 Lactation
 Menstrual flow

OBSTETRICS, Lydia Ondiba 20/02/2025

Postpartum assessment

 Patient history
 Physical examination
 General appearance
 Vital signs
 Skin color
 Energy level/ fatigue
 Pain
 GI elimination, flatus and hemorrhoids
 Fluid intake
 Urinary elimination
 Peripheral circulation; lower extremities for varicose, thrombophlebitis
 Breasts
 Uterus / location and firmness of the fundus
 Lochia
 Vagina
 Perineum(edema, episiotomy, lacerations, hematoma)
OBSTETRICS, Lydia Ondiba 20/02/2025
Physical Examination

General Appearance.
 A woman’s general appearance in the
postpartal period reveals a great deal about her energy level,
her self-esteem, and whether she is moving into the taking hold
phase of recovery.
 Before beginning assessment, ask a woman to void so that she has
an empty bladder. Observe how much energy she uses when reaching
for her robe or walking to the bathroom—does she struggle or move
listlessly, or does she accomplish this task quickly?
 Observe for a cringing expression or hand pressure against her
abdomen that suggests pain on movement.
OBSTETRICS, Lydia Ondiba 20/02/2025
Breasts

 Inspect and palpate

 3rd postpartum they feel firm and warm
 Inspect nipples for cracks, fissures or configuration
 Cracks can provide an entry for organisms and lead to infection
 Breastfeeding success
 Nipples may be inverted or flat

OBSTETRICS, Lydia Ondiba 20/02/2025

Breasts cont..

 Engorgement may result from venous and lymphatic stasis and

alveolar milk accumulation
 The breast may appear reddened and feel warm, firm and tender
 Difficult latching for the neonate
 Encourage woman to perform frequent and regular breast feedings to help
prevent this problem

OBSTETRICS, Lydia Ondiba 20/02/2025

Breasts cont..

 If warmth, tenderness and redness are localized to only one portion of

the breast and the patient has a fever or flulike symptoms, suspect
mastitis
 Mastitis- inflammation of the glands or milk ducts
 Results from pathogen that passes from infant nose or pharynyx into
breast tissue thru a cracked nipple
 Teach the mother about mastitis

OBSTETRICS, Lydia Ondiba 20/02/2025

Uterus

 Position the woman supine so that the height of the uterus is not
influenced by an elevated position.
 Observe her abdomen for contour, to detect distention, and for the
appearance of striae or a diastasis
 If a diastasis is present (a slightly indented, possibly bluish-tinged
groove in the midline of the abdomen), measure the width and length
by fingerbreadths.

OBSTETRICS, Lydia Ondiba 20/02/2025

Uterus

 Palpate the fundus of the uterus by placing one hand on the base of
the uterus, just above the symphysis pubis, and the other at the
umbilicus
 Press in and downward with the hand at the umbilicus until you
“bump” against a firm globular mass in the abdomen: the uterine
fundus

OBSTETRICS, Lydia Ondiba 20/02/2025

Uterus

 Assess consistency (firm, soft, or boggy), location (midline), and

height
 For the first hour after birth, the height of the fundus is at the
umbilicus or even slightly above it.
 It decreases one fingerbreadth in size daily

OBSTETRICS, Lydia Ondiba 20/02/2025

Assessing the Uterine Fundus

 Purpose: To determine the location and firmness of the uterus

1. Explain the procedure and rationale before beginning the procedure.
 Explanations reduce anxiety and elicit cooperation.
2. Ask the mother to empty her bladder if she has not voided recently.
 A distended bladder lifts and displaces the uterus.
3. Place the mother in the supine position with her knees flexed.
 This relaxes the abdominal muscles and permits accurate location of
the fundus.

OBSTETRICS, Lydia Ondiba 20/02/2025

Assessing the Uterine Fundus

4. Put on clean gloves and lower the perineal pads to observe lochia as the
fundus is palpated.
 Gloves are recommended whenever contact with body
fluids may occur.

5. Place your nondominant hand above the woman’s symphysis pubis.

 This supports and anchors the lower uterine segment.

6. Use the flat part of your fingers (not the fingertips) for palpation. Palpation
may be painful, particularly for the mother who had a cesarean birth.
 The larger surface of the fingers provides more comfort.
OBSTETRICS, Lydia Ondiba 20/02/2025
Assessing the Uterine Fundus

7. Begin palpation at the umbilicus, and palpate gently until the fundus
is located.
 It should be firm, in the midline, and approximately at the level of
the umbilicus.
 Locating the fundus is more difficult if the woman is obese or if the
abdomen is distended.
 Palpation helps determine the firmness and
location of the fundus.

OBSTETRICS, Lydia Ondiba 20/02/2025

Assessing the Uterine Fundus

 8. If the fundus is difficult to locate or is “boggy,” (soft) keep the

nondominant hand above the woman’s symphysis pubis and massage
the fundus with the dominant hand until the fundus is firm. The
nondominant hand anchors the lower segment of the uterus and
prevents inversion while the uterus is massaged.
 The uterus contracts in response to tactile stimulation, and this helps
control excessive bleeding.

OBSTETRICS, Lydia Ondiba 20/02/2025

Assessing the Uterine Fundus

9. After massaging a boggy fundus until it is firm, press firmly to expel

clots.
Do not attempt to expel clots before the fundus is firm.
Keep one hand pressed just above the symphysis (over the lower
uterine segment)throughout.
 Removing clots allows the uterus to contract properly.
 Attempting to expel clots on a boggy uterus might result in uterine
inversion.
 A firm fundus and pressure over the lower uterine segment help
prevent uterine inversion.

OBSTETRICS, Lydia Ondiba 20/02/2025

Assessing the Uterine Fundus

10. If the fundus is above or below the umbilicus, use your fingers to
determine the number of fingerbreadths between the fundus and the
umbilicus.
 Using the fingers to measure allows an approximation of the number
of
centimeters.

11. Document the consistency and location of the fundus.

Record consistency as “fundus firm,” “firm with massage,” or “boggy.”
 Record fundal height in fingerbreadths or centimeters above or below
the umbilicus. For example, “fundus firm, midline, ↓1” (one
fingerbreadth or 1 cm below the umbilicus); “fundus firm with light
massage, U + 2 (two fingerbreadths or 2 cm above the umbilicus),
displaced to right.”
 This promotes accurate communication

and identifies deviations from expected so that potential problems can

be OBSTETRICS, Lydia Ondiba 20/02/2025

identified early.
Lochia

 After birth, the outermost layer of the uterus becomes necrotic and is
expelled
 This vaginal discharge called lochia is similar to menstrual flow and
consists:
 Blood
 Fragments of the decidua
 White blood cells
 Mucus

OBSTETRICS, Lydia Ondiba 20/02/2025

Assess lochia flow

 3 types of Lochia
 Lochia rubra- red vaginal discharge that occurs approximately day 1 to
day 3 postpartum
 Lochia serosa- pinkish or brownish discharge that occurs from approx.
day 4 to day 10 postpartum
 Lochia alba- creamy white or colorless vaginal discharge that occurs
approximately day 10 to 14 postpartum may continue till 6 weeks

OBSTETRICS, Lydia Ondiba 20/02/2025

Characteristics of Lochia
Time and Type Normal Discharge Abnormal Discharge

Days 1-3: lochia rubra Bloody; small clots; Large clots; saturated
fleshy, earthy odor; perineal pads; foul odor
dark red
or red-brown

Days 3-10: lochia Decreased amount; Excessive amount; foul

serosa serosanguinous; pink smell; continued or
or recurrent
brown-tinged reddish color

Days 10-14 (or up to White, cream, or light Persistent lochia

3rd to 6th week): lochia yellow color; serosa; return to lochia
alba decreasing rubra; foul
amounts odor; discharge
OBSTETRICS, Lydia Ondiba 20/02/2025
continuing
Estimating Lochia Amount

 One method for recording the amount of lochia in 1 hour uses the
following labels:
 • Scant—less than a 2.5-cm (1-inch) stain on the peripad
 • Light—less than 10-cm (4-inch) stain
 • Moderate—less than 15-cm (6-inch) stain
 • Heavy—saturated peripad in 1 hour
 • Excessive—saturated peripad in 15 minutes

OBSTETRICS, Lydia Ondiba 20/02/2025

 Lochia changes from rubra (first three days), to serosa (10 days), to
Alba (two weeks).
This may go temporarily back to rubra with increased activity.

OBSTETRICS, Lydia Ondiba 20/02/2025

Vagina

 The vagina and vaginal introitus are greatly stretched during birth to
allow passage of the fetus.
 Soon after childbirth, the vaginal walls appear edematous, and
multiple small lacerations may be present.
 Very few vaginal rugae (folds) are present.
 The vagina regains tone and decreases in size although it does not
completely return to the prepregnancy state (Blackburn, 2013).
 Dyspareunia due to decreased estrogen production=vaginal dryness

OBSTETRICS, Lydia Ondiba 20/02/2025

Perineum and rectum

 Edema
 Tenderness
 Ecchymotic areas due to rupture of surface capillaries
 Sutures from episiotomy or laceration – healing begins at 2 to 3
weeks
 Hemorrhoids are commonly seen
 Foul odor
 Infection

OBSTETRICS, Lydia Ondiba 20/02/2025

Assessing the perineum

 Purpose: To assess perineal trauma and the state of healing.

1. Provide privacy, and explain the purpose of the procedure.
 This elicits cooperation and reduces anxiety.
2. Put on clean gloves.
 Implements standard precautions to provide protection from possible
contact with body fluids.

OBSTETRICS, Lydia Ondiba 20/02/2025

3. Ask the mother to assume the Sims (side-lying) position and flex her
upperleg. Lower the perineal pads, and lift her superior buttock. If
necessary,
use a flashlight to inspect the perineal area.
 Position provides an unobstructed view of the perineum and allows
assessment of lochia that may be under the mother; light allows
better visualization.
4. Note the extent and location of edema or bruising.
 Extensive bruising or asymmetric edema may indicate formation of a
hematoma

OBSTETRICS, Lydia Ondiba 20/02/2025

5. Examine the episiotomy or laceration for redness, ecchymosis,
edema,
discharge, and approximation (“REEDA”).
 Redness, edema, or discharge may indicate infection of the wound;
extensive bruising may delay healing; wound edges must be in direct
contact for uncomplicated healing to occur.
6. Note the number and size of hemorrhoids.
 Swollen, painful hemorrhoids interfere with activity and bowel
elimination

OBSTETRICS, Lydia Ondiba 20/02/2025

Perineal care

 Water jet system

 Rinsing the perineum with antiseptic or medicated solution for 2 minutes
from front to back
 Peri bottle
 Rinsing as well with use of a bottle
Topical anesthetics
Taking ordered analgesics

Note pain, tenderness – apply ice packs or cold packs to reduce pain and
edema for the first 24 hours after birth
Cold therapy is not effective after 24 hours..use heat packs/sitz baths
OBSTETRICS, Lydia Ondiba 20/02/2025
Lactation

 Lactation is the production of breast milk

Physiology of lactation
 Prolactin
 Progesterone and estrogen suppress breast milk secretion
 Estrogen helps breasts to grow by increasing their fat content
 Progesterone causes lobule growth and develops the accinar/alveolar
cells secretory capacity
 Oxytocin is necessary for milk ejection or “let-down.”
 This hormone, causes milk to be expressed from the alveoli into the
lactiferous ducts during suckling

OBSTETRICS, Lydia Ondiba 20/02/2025

Breast milk composition

 Colostrum- thick, sticky, golden yellow fluid it contains;

 Proteins(helps bind bilirubin and also has a laxative effect which helps
passage of meconium
 Sugar
 Fat
 Water
 Minerals
 Vitamins
 Maternal antibodies

OBSTETRICS, Lydia Ondiba 20/02/2025

Breast milk

 2nd to 3rd day postpartum , mature breast milk

 Composition of the milk changes with each feeding
 Bluish white foremilk primarily provides:
 Protein
 Lactose
 Water-soluble vitamins
 Hind milk or cream is produced within the first 10 to 20 minutes of
breast feeding and contains denser calories from fat(gain wt, build
brain tissue and satiety
 This transitional breast milk is replaced by true or mature breast milk
by around day 10 after delivery
OBSTETRICS, Lydia Ondiba 20/02/2025
Benefits of breastfeeding

 Passive immunity
 Immunoglobulin A (IgA)
 WBCs
 Fewer allergies and intolerances
 Supplies smaller amounts of IgM and IgG
 Easily digestible
 Brain booster- high in linoleic acid and cholesterol needed for brain
development
 Low protein content
 Convenient and inexpensive

OBSTETRICS, Lydia Ondiba 20/02/2025

Muscle strengthening exercises

Exercise Description
Abdominal Lying flat on her back or sitting, a woman should
breathing breathe slowly and deeply in and
1st day out 5 times, using her abdominal muscles. Check
by watching her abdominal wall rise that
she is actually using these muscles.
Chin-to-chest Lying on her back with no pillow,
2nd day a woman raises her head and bends her chin
forward on her chest without moving any other
part of her body while exhaling. She should start
this gradually, repeating it no more than 5
times the first time and then increasing it to 10–15
times in succession. The exercise can be done 3 or
4 times a day. She will feel her abdominal muscles
pull and tighten if she is doing
OBSTETRICS, LydiaitOndiba
correctly 20/02/2025
Muscle Strengthening exercises
Exercise Description
Perineal contraction (3rd day) She should tighten and relax her
perineal muscles
10–25 times in succession as if
she were trying to stop voiding
(Kegel exercises). She will feel her
perineal muscles working if she is
doing it correctly
Arm raising( 4th day) Arm raising helps both the
breasts and the abdomen return
to good tone
Lying on her back, arms at her
sides, a woman moves her arms
out from her sides until they are
perpendicular to her body. She
then raises them
over her body until her hands
OBSTETRICS, Lydia Ondiba 20/02/2025
touch and lowers them slowly to
her sides. She should rest a
Muscle Strengthening exercises

Abdominal crunches Lying flat on her back with knees bent, a

( 10th to 12th day) woman folds her arms across her chest and
raises herself to a sitting position. This exercise
expends a great deal of effort and tires a
postpartal woman easily. Caution her to begin
very gradually and work up slowly to doing it
10 times in a row.

OBSTETRICS, Lydia Ondiba 20/02/2025

Summary

 A. Physical Changes—Reproductive System

 1. Uterus
a. Involution—returns to pre-pregnant state. Fundus
descends by one finger-breadth each day
after delivery. By six weeks, it is close to pre-pregnant size.
 b. Lochia—uterine discharge of blood and waste from decidua. May persist
for three or more
weeks
 c. Placental site—blood vessels become compressed/thrombosed

OBSTETRICS, Lydia Ondiba 20/02/2025

2. Cervix
a. Internal os closes by two weeks
b. External os remains more open—looks like a slit
3. Vagina
a. Rugae reappear in two weeks
b. Remains slightly larger—close to pre-pregnant size six to
eight weeks after delivery
c. Normal mucus production returns with ovulation

OBSTETRICS, Lydia Ondiba 20/02/2025

SUMMARY CONT…

 4. Perineum
a. Episiotomy initial healing by two to three weeks; may take
four to six months to heal
completely.
 b. Hemorrhoids are common.
 c. Muscle tone restored by Kegel exercises.

OBSTETRICS, Lydia Ondiba 20/02/2025

SUMMARY CONT..

 5. Menstruation
 a. Time of return is variable.
 b. Lactating women resume menses within 12 weeks to 18 months.
 c. Non-lactating women begin to menstruate from six weeks to six months

OBSTETRICS, Lydia Ondiba 20/02/2025

SUMMARY CONT…

 6. Breasts
 a. Vascularity and size increased approximately day 3—milk ―comes in
 b. If not breastfeeding, engorgement subsides in 24–36 hours
 c. Secrete colostrum first two to three days, becomes transitional and then
―true milk after
this
 d. Oxytocin releases milk, prolactin produces more milk. Both are secreted
in response to
suckling.

OBSTETRICS, Lydia Ondiba 20/02/2025

SUMMARY CONT..
Physiological changes- other systems

 1. Cardiovascular
 a. Cardiac output returns to normal in two to four weeks.
 b. Cardiac load increases

OBSTETRICS, Lydia Ondiba 20/02/2025

Summary cont…
 2. Hematologic
 a. Average blood loss at delivery less than 500 ml—more is considered
hemorrhage
 b. Blood volume returns to pre-pregnant within three to four weeks
 c. Hematocrit increases immediately after delivery, returns to pre-pregnant
level in four to five
weeks
 d. White blood cell count may increase during first ten days
 e. Clotting factors, which were elevated, return to normal in four to five
weeks. There is an
increased risk of thrombophlebitis and thromboembolism after delivery.
 f. White blood cells 20–30,000/mm

OBSTETRICS, Lydia Ondiba 20/02/2025

 3. Renal
 a. Urinary retention may occur after birth
 b. Increased renal blood flow returns to normal within first six weeks
postpartum
 c. Diuresis 8–12 hours postpartum
4. Gastrointestinal
 a. Decreased motility after delivery
 b. Normal bowel elimination returns after two to three days

OBSTETRICS, Lydia Ondiba 20/02/2025

 5. Integumentary System
 a. Abdominal skin and muscle is flabby—tone regained gradually after
several months
 b. Skin discolorations fade gradually, although some mild changes may
persist
 c. Stretch marks gradually fade and turn silvery color

OBSTETRICS, Lydia Ondiba 20/02/2025

Summary cont…

 6. Weight Loss
 a. Initial 10–12 pound (in kgs?) loss due to infant, amniotic fluid, and
placenta
 b. Diuresis leads to an additional 5-pound(2.27kgs) weight loss
 c. By six to eight weeks, if there was a 25–35 pound(11.3-15.9kgs) weight
gain, return to pre-pregnant weight

OBSTETRICS, Lydia Ondiba 20/02/2025

Nursing Care of the Postpartum Mother
1. Assessment

 a. Vital signs
 b. Breasts (engorgement), nipples (soreness, cracks)
 c. Uterine fundus—height and firmness
 d. Bladder—assess for distention, especially first 24–48 hours
 e. Perineum—check episiotomy, approximated, swelling, hematoma;
comfort measures—ice,
sitz bath. Hemorrhoids—comfort measures, hydrocortisone cream.
 f. Lochia—record color, odor, amount.
 g. Lower extremities—assess for Homan’s sign
 h. Abdomen and perineum—initiate exercises: Kegel and pelvic tilt

OBSTETRICS, Lydia Ondiba 20/02/2025

2. Comfort Measures

 a. Analgesics for uterine after pains

 b. Episiotomy—ice, sitz baths
 c. Perineal care—peri bottles for cleansing
 d. Hemorrhoids—sitz baths, anesthetic ointment, stool
softeners,rectal
suppositories, hydrocortisone cream
 e. Breast engorgement—warm compresses before a feeding, cold
compresses after,
Acetaminophen, and a well-fitting bra

OBSTETRICS, Lydia Ondiba 20/02/2025

3. Promoting Attachment

 a. Encourage parents to care for infant

 b. Encourage kangaroo care or skin to skin contact
 c. Point out unique features in the infant (i.e. dimples, long lashes,
etc.)
 d. Use infant’s name when discussing baby
 e. Help parents accept and adjust to older sibling’s behavior

OBSTETRICS, Lydia Ondiba 20/02/2025

4. Infant Care and Feeding

 a. Non-lactating mother
 1) Teach how to bottle feed and burp.
 2) Discuss types of formulas, emphasize importance of following mixing
instructions exactly
 3) Teach typical feeding schedules, amounts of formula usually taken

OBSTETRICS, Lydia Ondiba 20/02/2025

4. Infant care and feeding

 b. Lactating mother
 1) Teach proper latch on and positioning
 2) Discuss nipple soreness and measures for relief
 3) Teach mother ways to assess adequacy of feedings—after milk has
come in, six to eight wet
diapers plus two or more stools
 4) Feed baby on demand, 8–12 times per day 5) Discuss need for mother
to avoid recreational drugs, excessive alcohol or caffeine; inform MD she is
breastfeeding when receiving medication for illness.

OBSTETRICS, Lydia Ondiba 20/02/2025

4. Infant care and feeding

c. Diapering
 1) Diaper changes frequently to avoid diaper rash
 2) Petroleum jelly or diaper ointment to protect skin
d. Bathing
 1) Sponge bathe until cord falls off
 2) Every other day is often enough
 3) Mild soap, lotion if desired, no talc powder
e. Cord care
1) Alcohol to cord three to four times a day
2) 2) Report redness, discharge, foul odor to provider

OBSTETRICS, Lydia Ondiba 20/02/2025

4. Infant care and feeding

 f. Sleep
 1) Position on back or side (protective against Sudden Infant Death
Syndrome SIDS).
 2) Sleep when the baby sleeps
 g. Illness
 1) Teach parent how to take infant’s temperature.
 2) Inform parent to call provider if infant has fever, is lethargic, or
unusually irritable. Other
signs to report include projectile vomiting, poor appetite, and yellow skin
tone indicating
jaundice.

OBSTETRICS, Lydia Ondiba 20/02/2025

4. Infant care and feeding

 h. Health measures
 1) Need for car seat- need to have car seat placed in the back seat and
should be rear –facing
until the infant is 9kgs
 2) Importance of follow-up well baby care and immunizations

OBSTETRICS, Lydia Ondiba 20/02/2025

OBSTETRICS, Lydia Ondiba 20/02/2025