LABOR AND DELIVERY

Prof. Raquel Estabillo-Ponelas, RN, MAN, MS Psych

Estabillo-Ponelas Learning, Training and Review Center

LABOR AND DELIVERY
OVERVIEW

Five Factors of Labor (5 Ps)
1. Passenger
The size, presentation and position of the fetus
A. Fetal head
Usually the largest part of the baby; it has
profound effect on the birthing process
Bones of the skull are joined by membranous
sutures, which allow for overlapping or molding
of cranial bones during birth process.
Anterior and posterior fontanels are the points
of intersection for the sutures and are important
landmarks
4. Fontanels are used as landmarks for internal
examinations during labor to determine position of
fetus

B. Fetal shoulders: may be manipulated during delivery to
allow passage of one shoulder at a time


LABOR AND DELIVERY
1. Passenger continue

C. Presentation: that part of the fetus which enter the
pelvis in the birth process
Types of Presentation are:
Cephalic: head is presenting part; usually vertex
(occiput), which is the most favorable for birth.
Head is flexed with chin on chest.
Breech: buttocks or lower extremities present first.
Types are:
a. Frank: thighs flexed, legs extended on
anterior body surface, buttocks presenting
b. Full or complete: thighs and legs flexed,
buttocks and feet (baby is squatting position)
c. Footling: one or both feet are presenting
Shoulder: presenting part is the scapula and baby
is in horizontal or transverse position. Cesarean
birth indicated.

LABOR AND DELIVERY
1. Passenger continue

VERTEX PRESENTATION
When the head is well flexed, the
subocciptobregmatic diameter and the biparietal
diameter present. When the head is not flexed but
erect, the presenting diameters are occipitofrontal, and
the biparietal. (95%)

BROW PRESENTATION
When the head is partially extended, the mento
vertical diameter, 13.5 cm, and the bitemporal
diameter, 8.2 cm. If this presentation persist, vaginal
delivery is extremely unlikely.

FACE PRESENTATION
When the head is completely extended, will distend
the vaginal orifice the presenting diameters are the
SOB 9.5 cm, BT 8.2 cm, the SMV diameter 11.5
cm,

LABOR AND DELIVERY
1. Passenger continue

D. Position: relationship of reference point on fetal
presenting part to maternal bony pelvis

I. Maternal bony pelvis divided into four quadrants (right
and left anterior; right and left posterior). Most
common positions are:
LOA (left occiput anterior): fetal occiput is on
maternal left side and toward front, face is down.
This is a favorable delivery position
ROA (right occiput anterior): fetal occiput on
maternal right side toward front, face is down. This
is a favorable delivery position
LOP (left occiput posterior): fetal occiput is on
the maternal side and toward back, face is up.
Mother experiences much back discomfort
during labor; labor may be slowed; rotation
usually occurs before labor to anterior position or
health care provider may rotate at the time of
delivery.
LABOR AND DELIVERY
1. Passenger continue
4. ROP (right occiput posterior): fetal occiput is on
maternal side and toward back, face is up. Presents
problem similar to LOP

II. Assessment of fetal position can be made by:
Leopolds maneuvers: external palpitation (4
steps) of maternal abdomen to determine fetal
contours or outlines. Maternal obesity; excess
amniotic fluid, or uterine tumors may make
palpitation less accurate.
Vaginal examination: location of sutures and
fontanels and determination of relationship to
maternal bony pelvis
Rectal examination: now virtually completely
replaced by vaginal examination
Auscultation of fetal heart tones and
determination of quadrant of maternal abdomen
where best heard. (Correlate with Leopold
maneuvers)

LABOR AND DELIVERY
1. Passenger continue

LEOPOLDS MANEUVER done to
a. estimate fetal size,
b. locate parts, and
c. determine - presentation,
- position,
- engagement and
- attitude.

Presentation of client:
place in dorsal recumbent position to relax the
abdominal muscle
palpate with warm hands because cold hands
cause muscle contraction
use palm not finger (will tickle the ptx.)
LABOR AND DELIVERY
1. Passenger continue

LEOPOLDS MANEUVER
1st Maneuver: Facing the head part, palpate for fetal
part found in the fundus ( a hard, smooth balotable in the
fundus means breech)

2nd Maneuver: Palpate sides of the uterus to determine
location of fetal back

3rd Maneuver: Grasp lower portion of the abd. just
above symphysis pubis to determine the degree of
engagement.

4th Maneuver: Facing the feet part. Cross fingers
downward on both sides of the uterus above the inguinal
ligaments above the inguinal ligaments to determine
attitude.

LABOR AND DELIVERY
2. Passageway
- Shape and measurement of maternal pelvis and
distensibility of birth canal
A. Engagement: fetal presenting part enters true pelvis
(inlet). May occur two weeks before labor in Primipara;
usually occurs at beginning of labor for Multipara.

B. Station: measurement of how far he presenting part has
descended into the pelvis. Referrant is ischial spines,
palpated through lateral vaginal walls. When presenting
part is :
at ischial spines, station is 0

above ischial spines, station is negative number

below ischial spines, station is positive number

High or floating terms used to denote
unengaged presenting part.

LABOR AND DELIVERY
2. Passageway continue
C. Soft tissue (cervix, vagina): stretches and dilates
under the force of contractions to accommodate the
passage of the fetus.

3. Powers
Forces o labor, acting in concert, to expel fetus and
placenta. Major forces are:
A. Uterine Contractions (involuntary)
Frequency: timed from the beginning of one
contraction to the beginning of the next
Regularity: discernable pattern; better established
as pregnancy progresses
Intensity: strength of contraction; May be
determined by the depressability of the uterus
during a contraction. Describe as mild, moderate
or strong.
Duration: length of contraction. Contraction lasting
more than 90 seconds without a subsequent
period of uterine relaxation may have severe
implications for the fetus and should be reported.

LABOR AND DELIVERY
3. Powers continue

B. Voluntary bearing down efforts
After full dilatation of the cervix, the mother can use
her abdominal muscles to help expel fetus
These efforts are similar to those for defecation, but
the mother is pushing out the fetus from the birth
canal
Contraction of levator ani muscles

4. Placenta
As the placenta usually forms in the fundus of the
uterus, it seldom interferes with the progress of
labor.
A low-lying, marginal, partial or complete
placenta previa may require medical intervention
to complete the birth process
LABOR AND DELIVERY

5. Psychologic response

A woman who is relax, aware and participating in the
birth process usually has a shorter, less intense labor.

A woman who is fearful has high levels of adrenaline which
slows uterine contractions.
LABOR AND DELIVERY
The Labor Process

Causes
Actual cause unknown. Factors involved include:
Progressive uterine distension

Increasing intrauterine pressure

Aging of the placenta

Changes in the levels of estrogen, progesterone,
and prostaglandins

Increasing myometrial irritability
LABOR AND DELIVERY
The Labor Process
THEORIES OF LABOR (Onset of Labor)
Prostaglandin Theory initiation of labor is said to
result from the release of arachidonic acids produces
by steroid action on lipid precursors. Arachidonic acid is
said a increase prostaglandin synthesis which is turn
causes uterine contractions.

Oxytocin Theory release of oxytocin from the
posterior pituitary glands causes contraction of the
smooth muscles. Eg. Uterine muscles will necessarily
contract and empty.

Uterine Stretch Theory releases of oxytocin from
the posterior pituitary.

Placental Degeneration Theory because of
decreased blood supply and functional capacity, the
uterus starts to contract.
Progesterone deprivation theory decreased
amount of progesterone initiates uterine motility.

Maternal Assessment

Premonitory Assessment

Physiologic changes preceding labor:
Lightening (engagement):
occurs up to two weeks before labor in Primipara;
at beginning of labor for Multipara

Braxton Hicks contractions: may become more
noticeable; may play a part in ripening of cervix

Easier respirations from decreased pressure on
diaphragm

Frequent urination, from increased pressure on
bladder

Restlessness/ poor sleeping patterns, nesting
behaviors


Maternal Assessment

True vs. False Labor



LABOR AND DELIVERY
Stages of Labor

I. Definitions
Stage 1: from onset of labor until full dilatation of
cervix
Latent phase: 0-3 cm
Active phase: 4-7 cm
Transition phase: 8-10 cm.

Stage 2: from full dilatation of cervix to birth of
baby

Stage 3: from birth of baby to expulsion of placenta

Stage 4: time after birth (usually 1-2 hours) of
immediate recovery
LABOR AND DELIVERY
Stages of Labor

II. Cervical changes in first stage labor
A. Effacement:
Shortening and thinning of cervix
In Primipara, effacement is usually well advanced
before dilatation begins;
in a Multipara, effacement and dilatation
progress together

B. Dilatation:
Enlargement or widening of the cervical os and
canal
Full dilatation is considered 10 cm.

LABOR AND DELIVERY
Duration of Labor

A. Depends on
Regular, progressive uterine contraction
Progressive effacement and dilatation of cervix
Progressive descent of presenting part

B. Average length
Length of Normal Labor:
PRIMI MULTI
First Stage 12 hours 8 hours
Second Stage 80 minutes 30 minutes
Third Stage 10 minutes 10 minutes
TOTAL 14 hours 8 hours

LABOR AND DELIVERY
STAGES OF LABOR:

FIRST STAGE (Stage of Dilatation)
begins with true labor contractions and ends with
complete dilatation of the cervix.
Power of forces at work: involuntary uterine contractions
Phases:
a. Latent early time in labor
Cervical dilatation is minimal because effacement is
occurring.

Cervix dilates 0-3 cm.

Contractions are of shorts duration and are
occurring regularly 5-10 mins apart hence
admission can be done.

The woman in this stage is excited with some
degree of apprehension but still with the ability to
communicate.

LABOR AND DELIVERY
STAGES OF LABOR:
FIRST STAGE (Stage of Dilatation)
Phases continue
b. Active or accelerated cervical dilatation reaches
4-7 cm. rapid increase in duration, frequency
and intensity of contraction, woman fears losing of
herself.

c. Transition Period 8-10 cm cervical dilatation
occurs
the mood of the woman suddenly changes and the
nature of contractions intensify.

-If cervix is intact, this period is marked by a sudden
gush of amniotic fluid as the fetus is pushed into the
birth canal. Show becomes prominent.

-There is an uncontrollable urge to push with
contractions (a sign that the second stage of
labor is very near).

-Duration of contraction 60 to 70 seconds;
-Interval 30 to 90 seconds
LABOR AND DELIVERY
Palpitation
Assess intensity of contraction by manual palpitation of
uterine fundus

Mild: tense fundus but can be indented with finger
tips

Moderate: firm fundus, difficult to indent with
fingertips

Strong: very firm fundus, cannot indent with finger
tips




Maternal Assessment

FIRST STAGE OF LABOR
PRIMI MULTI
First Stage 12 hours 8 hours

Latent Phase (0-4 cm)
Assessment
Contractions: frequency, intensity, duration
Membranes: intact or ruptured, color of fluid
Bloody show
Time of onset
Cervical changes
Time of last ingestion of food
FHR every 15 minutes; immediately after rupture
of membranes
Maternal vital signs
Temperature every 2 hours if membranes ruptured,
every 4 hours if intact
Pulse and respirations every hour or prn as
indicated
Progress of descent
Clients
Maternal Assessment

FIRST STAGE OF LABOR

Latent Phase (0-3 cm)

Analysis
Nursing diagnoses for the latent phase of first stage of
labor may include
Anxiety
Ineffective breathing pattern
Pain
Knowledge deficit

Planning and Implementation
A. Goals
Complete all admission procedures
Labor will progress normally
Mother/fetus will tolerate latent phase successfully

Maternal Assessment

FIRST STAGE OF LABOR
Latent Phase (0-3 cm)

B. Interventions
Administer perineal prep/enema if
ordered/appropriate
Assess V.S., B.P., FHR, contractions, bloody show,
cervical changes, descent of fetus as scheduled
Maintained bed rest if indicated or required
Reinforced/teach breathing technique as needed
Support laboring woman/couple based on their needs
Have client attempt to void every 1-2 hrs
Apply external fetal monitoring if indicated or ordered

Evaluation
Admission procedure complete
B. Progress through latent stage normal, cervix dilated
C. Labor progressing through latent phase well, mother
as comfortable as possible, vital sign normal.
FHR maintained in response to contraction

Maternal Assessment

FIRST STAGE OF LABOR
Active Phase (4-7 cm)

Assessment
Cervical changes
B. Bloody show
C. Membranes
D. Progress of Descent
E. Maternal / fetal vital sign
F. Clients affect

Analysis
Nursing diagnoses for the active phase of first stage of
labor
may include:
A. Ineffective individual coping
B. Alteration in oral mucous membranes
C. Knowledge deficit
D. Pain
E. Altered tissue perfusion
F. High risk for injury
Maternal Assessment

FIRST STAGE OF LABOR
Active Phase (4-7 cm)

Planning and Implementation
Goals
Progress will be normal through the active phase
Mother/ fetus will successfully complete active phase
B. Interventions
Continue to observe labor progress
Reinforce/teach breathing techniques as needed
Position client for maximum comfort
Support client/ couple as mother becomes more
involved in labor
Administer analgesia if ordered or indicated
Assist with anesthesia if given and monitor
maternal/fetal vital signs
Provide ice chips or clear fluids for mother to drink if
allowed or desired
Keep client/couple informed as labor progresses
With posterior position, apply sacral counter-pressure
or have father do so.
Maternal Assessment

FIRST STAGE OF LABOR
Active Phase (4-7 cm)

Evaluation
Labor progressing through active phase, dilatation
progressing
Mother/fetus tolerating labor appropriately
No complications observed

Transition Phase (8-10 cm)
Assessment
Progress of Labor
Cervical changes
Maternal mood changes: if irritable or aggressive may
be tiring or unable to cope
Signs of nausea, vomiting, trembling, crying,
irritability
Maternal/fetal vital signs
Breathing patterns, may be hyperventilating
Urge to bear down with contractions

Maternal Assessment

FIRST STAGE OF LABOR

Transition Phase (8-10 cm)

Analysis
Nursing Diagnoses for transition phase if first stage of
labor may include:
Ineffective breathing pattern
Powerlessness
Ineffective individual coping

Planning and Implementation
A. Goals
Labor will continue to progress through transition
Mother/fetus will tolerate process well
Complications will be avoided
Maternal Assessment

FIRST STAGE OF LABOR

Transition Phase (8-10 cm)
B. Interventions
Continue observation of labor progress, maternal/
fetal vital signs
Give mother positive support if tired or discouraged
Accept behavioral changes of mother
Promote appropriate breathing patterns to prevent
hyperventilation
If hyperventilation present, have mother re-breath
the expelled carbon dioxide to reverse respiratory
alkalosis
Discourage pushing efforts until cervix is completely
dilated, then assist with pushing
Observe for signs of delivery

Evaluation
Mother/fetus progressed through transition
No complications observed
Mother/ fetus ready for second stage labor
LABOR AND DELIVERY
STAGES OF LABOR:
SECOND STAGE OF LABOR (STAGE OF EXPULSION)
begins with the complete dilatation and ends with
the delivery of the infant.
Primi- 80 minutes Multi- 30 minutes

Power/forces at work :Involuntary uterine
contractions of the diaphragmatic and abdominal
muscles.

Mechanisms of Labor/Fetal position.
Changes: (ED FIRE ERE)
1.Engagement -The head is fixed in the pelvis
2.Descent fetus goes down in the birth canal
3.Flexion fetal chin bends toward the chest.
4.Internal Rotation from AP to transverse then
AP to AP.
5.Extension the head extends, the forehead, nose
mouth and chin appears.
6.External Rotation (restitution) anterior
shoulder rotates externally to AP position.
7.Expulsion delivery of the rest of the body.



Maternal Assessment

SECOND STAGE OF LABOR

Assessment
Signs of imminent delivery
Progress of descent
Maternal/fetal vital signs
Maternal pushing efforts
Vaginal distension
Bulging of perineum
Crowning
Birth of baby

Analysis
Nursing diagnoses for the second stage of labor may
include
High risk for injury
Noncompliance related to exhaustion
Knowledge deficit

Maternal Assessment

SECOND STAGE OF LABOR

Planning and Implementation
A. Goals
Safe delivery of living, uninjured fetus
Mother will be comfortable after tolerating delivery

B. Interventions
If necessary, transfer mother carefully to delivery
table or birthing chair; support legs equally to
prevent/ minimize strain on ligaments
Carefully position mother on delivery table, in delivery
chair or birthing bed to prevent Popliteal vein pressure
Help mother use handles or legs to pull on as she
bears down with contractions
Clean vulva and perineum to prepare for delivery
Continue observation of maternal/fetal vital signs
Encourage mother in sustained (5-7 seconds)
pushes with each contraction
Maternal Assessment

SECOND STAGE OF LABOR

Planning and Implementation
7. Support fathers participation if in delivery area

8. Catheterize mothers bladder if indicated

9. Keep mother informed of delivery progress

10. Note time of delivery of baby.

Evaluation
Delivery of healthy viable fetus

Mother comfortable after procedure

No complications during procedure
LABOR AND DELIVERY
STAGES OF LABOR:
THIRD STAGE (PLACENTA STAGE)
Begins with the delivery of the baby and ends with the
delivery of the placenta.
Primi- 10 minutes Multi- 10 minutes

Signs of placental separation:
1. Calkins sign the uterus becomes round and firm,
rising up to the level of the umbilicus. Earliest
Sign.
2. Sudden gush of the blood from the vagina
3. Lengthening of the cord.

Types of placenta delivery:
Schultz the placenta separates first at the center
and presents the shiny fetal surface. Most common
(80%)
Duncan placenta separates first at the margin
presents the maternal side.(20%)

LABOR AND DELIVERY
STAGES OF LABOR:
THIRD STAGE (PLACENTA STAGE)
Primi- 10 minutes Multi- 10 minutes
Avoid tugging at the cord as it can cause uterine
inversion. Just watch for the sings of placental
separation.
Perform Brandt Andrew Maneuver
Take note of the time of placental delivery; it
should be delivered within 20 minutes after the
baby. Otherwise, refer stat to the M.D.
Inspect for completeness of cotyledons; retained
placental fragments cause severe bleeding and
possible death.
Palpate the uterus to determine degree of
contraction. Massage gently, ice cap is also allowed.

Medical management: Methergin is injected IM post-
placental delivery to maintain uterine contraction.

LABOR AND DELIVERY
STAGES OF LABOR:
THIRD STAGE (PLACENTA STAGE)

Inspect the perineum for lacerations.
Categories: 1
st
degree : involves the vaginal mucus
membrane and perineal skin.
2nd degree : plus the muscles
3rd degree : plus the external sphincter of
the rectum
4th degree : plus the mucus membrane of
the rectum

Episiorrhaphy
repair of the episiotomy or lacerations.
Vaginal pack is sometimes inserted to prevent
bleeding. Removed pack 24-48 hours.
- Make the pt. comfortable by doing perineal care and
applying clean sanitary napkins. Place flat on bed.


Maternal Assessment

THIRD STAGE OF LABOR

Assessment
A. Signs of placental separation
Gush of blood
Lengthening of cord
Change in shape of uterine (discoid to globular)
B. Completeness of placenta
C. Status of mother/ baby contact for first critical 1-2
hrs
Babys Apgar scores
Blood pressure, pulse, respirations, lochia, fundal
status of mother

Analysis
Nursing diagnoses for the third stage of labor may
include:
Pain
Potential fluid volume deficit



Babys Apgar scores (1 min & 5 mins.)
Interpretation:

7-10 the baby is in the best possible health
4-6 the babys condition is guarded the needs more
extensive clearing of airway.
0-3 the baby is in serious danger and needs immediate
resuscitation.


Maternal Assessment

THIRD STAGE OF LABOR
Planning and Implementation
A. Goals
Placenta will be delivered without complications.
Maternal blood loss will be minimized
Mother will tolerate procedures well.
B. Interventions
Palpate fundus immediately after delivery of placenta;
massage gently if not firm
Palpate fundus at least every 15 minutes for first
1-2 hours
Observe lochia for color and amount
Inspect perineum
Assist with maternal hygiene as needed.
a. Clean gown
b. Warm blanket
c. Clean perineal pads.
Offer fluids as indicated
Promote beginning relationship with baby and parents
through touch and privacy
Administer medications as ordered/needed (pitocin
added to IV if present)

Maternal Assessment

THIRD STAGE OF LABOR

Evaluation
Placenta delivered without complications

Minimal maternal blood loss

Mother tolerated procedure well

LABOR AND DELIVERY
STAGES OF LABOR:
FOURTH STAGE (RECOVERY STAGE)
- first 2 hours post partum is the most crucial stage of
the mother due to unstable vital signs.

Assessment:
Fundus should be checked q 15 mins for 1 hour
and q 30 mins for the next 4 hours.
Lochia should be moderate in amount.
Bladder full bladder is evidenced by the shifting of
the uterus to the right.
Perineum normally tender, discolored and
edematous. It should be cleaned with intact sutures.
BP & HR should be monitored closely: 15 mins
during the 1 hr, q 30 mins for the next 2 hours.
Rooming in concept the mother and the baby
stays in the same room in the hospital to promote the
bonding at the same time encourages breastfeeding.

Maternal Assessment

FOURTH STAGE OF LABOR
Assessment
Fundal firmness, position
Lochia; color, amount
The endometrial surface is sloughed off as lochia, in
three stages:
Lochia rubra: dark red color, days 1-3 after
delivery; consists of blood and cellular debris from
decidua.
Lochia serosa: pinkish brown, days 4-10; mostly
serum, some blood, tissue debris
Lochia alba: yellowish white, days 11-21; mostly
leukocytes, with decidua, epithelial cells, mucus.
3. Perineum
4. Vital signs
5. IV if running
6. Infants heart rate, airway, color, muscle tone,
reflexes, warmth, activity state
7. Bonding/ family integration

Maternal Assessment

FOURTH STAGE OF LABOR

Analysis
Nursing diagnoses for the fourth stage of labor may
include
Pain
High risk for fluid volume deficit
High risk for altered family processes

Planning and Implementation
A. Goal: critical first hour after delivery will pass without
complications for mother/baby.
Maternal Assessment

FOURTH STAGE OF LABOR

B. Interventions
Palpate fundus every 15 minutes for first 1-2
hours; massage gently if not firm
Check mothers blood pressure, pulse, resp. every 15
min. for first 1-2 hrs. or until stable
Check lochia for color and amt. Every 15 min. for
the first 1-2 hrs.
Inspect perineum every 15 min. for first 1-2 hrs.
Apply ice to perineum if swollen or if episiotomy
Encourage mother to void, particularly if fundus not
firm or displaced

Evaluation
Mothers vital signs stable, fundus and lochia within
normal limits
Evidence of bonding: parents cuddle, touch, talk to
baby
No complications observed for mother or baby during
crucial time
LABOR AND DELIVERY
ASSESSMENT DURING LABOR
Fetal Assessment
Auscultation
Auscultate FHR at least every 15-30 minutes during
first stage and every 5-15 minutes during second
stage (depends on the risk status of the client)
Normal range 120-160 beats/minute
Best recorded during the 30 seconds immediately
following a contraction
Palpation
Assess intensity of contraction by manual palpation of
uterine fundus
Mild: tense fundus but can be indented with finger
tips
Moderate: firm fundus, difficult to indent with
fingertips
Strong: very firm fundus, cannot indent with finger
tips