1. THE LABOR PROCESS
The woman in labor

2. Theories of Labor Onset
• Uterine Stretch Theory – any hollow body
organ when stretched to capacity will
necessarily contract and empty
• Oxytocin Theory – Labor being considered a
stressful event, stimulates the hypophysis to
produce oxytocin from the posterior pituitary
gland. It causes the contraction of the
smooth muscles of the body

3. • Progesterone Deprivation Theory –
proesterone being the hormone designed to
promote pregnancy is believed to inhibit
uterine motility.
• Prostaglandin Theory – Initiation of labor is
said to result from the release of arachidonic
acid produced by steroid action on lipid
precursors. Arachidonic acid is said to
increase prostaglandin synthesis which in
turn causes uterine contractions.

4. • Theory of Aging Placenta –
because of the decrease in blood
supply the uterus contracts.

5. Labor is influenced by a
combination of Factors from the
mother and Fetus:
• Uterine muscle stretching which results
in prostaglandin release
• Pressure on the cervix, which stimulates
the release of oxytocin from the
posterior pituitary
• Oxytocin stimulation, which works
together with prostaglandin to initiate
contractions

6. • Change in the ratio of estrogen and
progesterone
• Placental age which triggers contraction
at a set point
• Rising fetal cortisol levels, which reduce
progesterone formation and increase
prostaglandin formation
• Fetal membrane production of
prostaglandin, which stimulates
contraction

7. PRELIMINARY SIGNS OF LABOR
• LIGHTENING – the settling of the fetal
head into the pelvic brim. In PRIMIs, it
occurs 2 weeks before EDC; in MULTIS
it occurs on or before labor onset.
• It should not be confused with
engagement, engagement occurs when
the presenting part has descended into
the pelvic inlet.

8. Lightening results in:
• Increase in urinary frequency
• Relief of abdominal tightness and
diaphragmatic pressure
• Shooting pain down the legs because of
pressure on the sciatic nerve
• Increase in the amount of vaginal
discharges

9. • Increased Activity Level – due to increased
epinephrine secreted to prepare the body for
the coming “work” ahead. Advise the
pregnant woman not to use this increased
energy for doing household chores
• Loss of weight – about 2-3 lbs, 1 to 2 days
before labor onset; due to decrease in
progesterone production leading to decrease
in fluid retention

10. • BRAXTON HICKS CONTRACTIONS – pain
less irregular practice contractions
• RIPENING OF THE CERVIX - an internal
sign seen only on pelvic examination. At
term, the cervix becomes still softer and can
be described as buttersoft, and it tips
forward.
• SHOW – as the cervix softens and ripens the
mucus plug that filled the cervical canal
during pregnancy is expelled. The blood,
mixed with mucus, takes on a pinked tinge.

11. RUPTURE OF THE MEMBRANES
• It is important to remember that once
membranes have ruptured:
1. Labor is inevitable. It will occur within 4
hours
2. The integrity of the uterus has been
destroyed. Infection can easily set in. That
is why once membrane have ruptured:
1. Aseptic techniques should be observed in all
procedures

12. 2. Less obstetric manipulation (e.g.
IE)
3. Enema is no longer ordered
4. Temperature should be taken
regularly so that fever a sing of
infection can be detected

13. UMBILICAL CORD COMPRESSION/
CORD PROLAPSE CAN OCCUR
• A woman in labor seeking admission to the
hospital and saying that her BOW has
ruptured should be put to bed immediately
and the fetal heart tones taken consequently
• If a woman in the labor Room says that her
membranes have ruptured, the initial nursing
action is to take the fetal heart tones

14. • If a woman in labor says that she feels a loop
of the cord coming out of the vagina (cord
prolapse), the first nursing action is to put her
on Trendelenburg position in order to reduce
pressure on the cord ( REMEMBER: ONLY 5
MINUTES OF CORD COMPRESSION CAN
ALREADY LEAD TO IRREVERSIBLE
BRAIN DAMAGE OR EVEN DEATH)
• Apply a warm saline-saturated OS on the
prolapsed cord to prevent drying

15. TRUE AND FALSE LABOR
CONTRACTIONS
• FALSE CONTRACTIONS
– BEGIN AND REMAIN IRREGULAR
– REMAIN CONFINED TO ABDOMEN AND
GROIN
– DISAPPEARS WITH AMBULATION AND
SLEEP
– NO INCREASE IN DURATION FERQUENCY
OR INTENSITY
– DO NOT ACHIEVE CERVICAL DILATION

16. TRUE LABOR PAINS
• MAY BEGIN IRREGULAR BUT BECOME
REGULAR AND PREDICTABLE
• FELT FIRST IN THE LOWER BACK AND
SWEEP AROUND TO THE ABDOMEN IN A
GIRDLE-LIKE FASHION
• INCREASE IN DURATION, FREQUENCY
AND INTENSITY
• CONTINUE NO MATTER WHAT THE
WOMAN’S LEVEL OF ACTIVITY
• ACHIEVE CERVICAL DILATION

17. SIGNS OF TRUE LABOR
• UTERINE contractions – the surest sign that
labor has begun is the initiation of effective,
productive uterine contractions
• Pain in uterine contractions results from:
• Contraction of uterine muscles when in an
ischemic state
• Pressure on nerve ganglia in the cervix and
lower uterine segments

18. • Stretching of ligaments adjacent to
the uterus and in the pelvic joints
• Stretching and displacement of the
tissues of the vulva and perineum

19. PHASES OF UTERINE
CONTRACTIONS
• INCREMENT – FIRST PHASE DURING
WHICH THE INTENSITY OF
CONTRACTION INCREASES; ALSO
KNOWN AS CRESENDO
• ACME – THE HEIGHT OF UTERINE
CONTRACTION ALSO KNOWN AS APEX
• DECREMENT – LAST PHASE DURING
WHICH INTENSITY OF CONTRACTION
DECREASES; ALSO KNOW AS

20. • EFFACEMENT – shortening and thinning of
the cervical canal as distinct from the uterus.
It is expressed in percentage
• DILATION – enlargement of the external
cervical os up to 10 cm primarily as a result
of uterine contractions and secondarily as a
result of pressure of the presenting part and
the BOW

21. UTERINE CHANGES
• The uterus is gradually differentiated into two
distinct portions
• UPPER UTERINE SEGMENT – becomes
thick and active to expel out fetus
• LOWER UTERINE SEGMENT – becomes
thin walled, supple and passive so that fetus
can be pushed out easily

22. PHYSIOLOICAL RETRACTION
RING
• Formed at the boundary of the upper and
lower uterine segments.
• In difficult labor when the fetus is larger than
the birth canal, the round ligaments of the
uterus become tense during dilation and
expulsion, causing an abdominal indentation
called BANDL’S pathological retraction
ring, adanger sign of labor signifying
impending rupture of the uterus.

23. COMPONENTS OF LABOR
• The womans pelvis (PASSAGE) is of
adequate size and contour
• The PASSENGER (fetus) is of appropriate
size and in an advantageous position and
presentation
• The POWERS of labor (uterine factors) are
adequate
• The woman’s PSYCHE

24. PASSAGE
• The route the fetus must travel from the
uterus through the cervix and vagina to the
external perineum.
• For the fetus to pass through the pelvis, the
pelvis must be of adequate size.
• DIAGONAL CONJUGATE = the anterior-
posterior diameter of the inlet
• TRANSVERSE DIAMETER of the outlet

25. PASSENGER
• The passenger is the fetus
• The body part of the fetus that has the widest
diameter is the head
• STRUCTURE OF THE FETAL SKULL:
• CRANIUM – upper most portion of the skull,
comprises of 8 bones
• Important bones in childbirth: Frontal, 2
parietal and the occipital bone

26. • Frontal bone is referred to as the sinciput
• Occipital bone is referred to as the occiput
• The bone of the skull meet at suture lines
• Sagittal suture, Coronal suture, Lambdoid
suture
• The suture lines are important in birth
because they allow the cranial bones to
move and overlap = MOLDING

27. • Significant membrane-covered spaces called
the fontanelles are found at the junction of
the main suture line
• Anterior Fontanelle (Bregma) lies at the
junction of coronal and sagittal sutures.
Diamond in shape. AP diameter is 3 – 4 cm.
Transverse Diameter 2 – 3 cm.
• Posterior Fontanelle lies at the junction of
Lambdoidal and sagittal sutures
• VERTEX the space between the two
fontanelles

28. Diameters of the Fetal Skull
• Wider in its anterior posterior diameter than
in its transverse diameter
• To fit through the birth canal, the fetus must
present the smaller diameter to the smaller
diameter of the maternal pelvis
• SUBOCCIPITOBREGMATIC DIAMETER –
the narrowest diameter (9.5 cm), measured
from the inferior aspect of the occiput to the
center of anterior fontanelle

29. • OCCIPITOFRONTAL DIAMETER –
measured from the bridge of the nose to
the occipital prominence (12cm)
• OCCIPITOMENTAL DIAMETER – widest
anteroposterior diameter, measured from
the chin to the posterior fontanelle.(13.5
cm)
• BIPARIETAL DIAMETER (9.25 cm) – the
narrowest diameter

30. • In full flexion, the head flexes so sharply that
the chin rest on the thorax, the smallest
anteroposterior diameter will be presented to
the birth canal. (suboccipitobhregmatic)
• Moderate flexion, Occipitofrontal diameter
will be presented
• Poor Flexion, head is hyperextended, the
largest diameter (occipitomental) will be
presented

31. • The anteroposterior diameter of the fetal
head must fit through the transverse
diameter of the pelvic inlet, (12.4 to 13.5 cm)
and at the outlet through the anteroposterior
diameter of the pelvis (9.5 to 11.5 cm)
• MOLDING – the change in shape of the fetal
skull produced by the force of uterine
contractions pressing the vertex against the
not yet dilated cervix.

32. Fetal Presentation and Position
• ATTITUDE – the degree of flexion the fetus
assumes during labor or the relation of the
fetal parts to each other.
• A fetus in good attitude is in complete
flexion: spinal column is bowed forward,
head is flexed forward so much that the chin
touches the sternum, the arms are flexed
and folded on the chest, the thighs are flexed
onto the abdomen the calves are pressed
aginst the posterior aspect of the thighs

33. • A fetus is in moderate flexion if the chin is
not touching the chest but is in an alert or
military position. Occipital diameter present
to the birth canal
• Partial extension presents the brow of the
head to the birth canal.
• If a fetus is in poor flexion, the back is
arched, the neck is extended and the fetus is
in complete extension, presenting the
occipitomental diameter of the head to the
birth canal.

34. • ENGAGEMENT – refers to the settling of the
presenting part of the fetus far enough into
the pelvis to be at the level of the ischial
spines, a midpoint of the pelvis.
• A presenting part that is not engaged is said
to be floating
• One that is descending but has not yet
reached the iliac spines can be said to be
dipping
• The degree of engagement is assessed by
vaginal and cervical examination.

35. Station
• Refers to the relationship of the presenting
part of the fetus to the level of the ischial
spines
• Presenting part is at the level of ischial
spines, it is at a 0 station.
• Above the spines, the distance is measured
and described as minus station (-1cm to – 4
cm)
• Below the spines = plus stations (+1cm to
+4cm)

36. FETAL LIE
• Lie is the relationship between the long axis
of the fetal body and the long axis of the
woman's body
• Longitudinal lie ( with their long axis parallel
with the long axis of the woman)
• Horizontal or transverse lie

37. Types of fetal Presentation
• Denotes the body part that will first contact
the cervix or deliver first
• CEPHALIC PRESENTATION – the head is
the body part that first contacts the cervix
• Four types of cephalic presentation (vertex,
brow, face and mentum)
• BREECH PRESENTATION – means that
either the buttocks or feet are the first body
parts to contact the cervix (complete, Frank,
and footling)

38. SHOULDER PRESENTATION
• Fetus is lying horizontally in the pelvis so that
its long axis is perpendicular to that of the
mother.
• Presenting part may be the acromion of
shoulder, iliac crest, a hand, or elbow.
• Caused by grand multiparity, placenta
previa, pelvic contractions

39. Types of Fetal Position
• POSITION is the relationship of the
presenting part to a specific quadrant of the
woman’s pelvis
• 4 quadrant of the pelvis: Right anterior, Left
anterior, Right posterior, Left posterior
• Landmarks: Vertex: occiput, Face: Chin or
Mentum, Breech: Sacrum, Shoulder:
Scapula or acromion

40. • Position is marked by abbreviation of 3
letters. The middle letters denotes the fetal
landmark( O for occiput, M for Mentum, Sa
for sacrum, A for acromion process)
• The 1st
letter defines whether the landmark is
pointing to the mothers right or left.
• The last letter defines whether the landmark
is pointing Anteriorly, posteriorly or
transveresely.
• LOA most common fetal position; ROA 2nd
most frequent position

41. FOUR METHODS ARE USED TO
DETERMINE FETAL POSITION
PRESENTATION AND LIE
• Combined abdominal inspection and
palpation
• Vaginal examination
• Auscultation of FHT
• Sonography

42. CARDINAL MOVEMENTS OF
LABOR
• DESCENT – downward movement of the
biparietal diameter of the fetal head to within
the pelvic inlet
• Occurs when the fetal head extrudes beyond
the dilated cervix and touches the posterior
vaginal wall
• Occurs because of pressure on the fetus by
the uterine fundus aided by abdominal
muscle contractions.

43. • FLEXION
• Pressure from the pelvic floor causes the
fetal head to bend forward onto the chest
• The smallest anteroposterior diameter is the
one presented to the birth canal in this flexed
position
• Flexion is aided by abdominal muscle
contraction during pushing

44. INTERNAL ROTATION
• The occiput rotates until it is superior, or just
below the symphysis pubis, bringing the
head into the best diameter for the outlet of
the pelvis.
• This movement brings the shoulders, into the
optimal position to enter the inlet or puts the
widest diameter of the shoulders in line with
the wide transverse diameter of the inlet.

45. EXTENSION
• As the occiput is born, the back of the
neck stops beneath the pubic arch and
acts as a pivot for the rest of the head.
The head thus extends, and the
foremost parts of the head, the face and
the chin are born.

46. EXTERNAL ROTATION
• Almost immediately after the head of the
infant is born, the head rotates back to the
diagonal position or transverse position of
the early part of labor.

47. Expulsion
• Once the shoulders are born, the rest of the
baby is born easily and smoothly because of
its smaller size.
• This is the end of pelvic division of labor

48. Powers of Labor
• Supplied by the fundus of the uterus, a process that
causes cervical dilatation and then expulsion of the
fetus from the uterus.
• Uterine contractions, labor contractions begin at a
pacemaker point located in the myometrium near
one of the uterotubal junctions.
• Each contraction begins at that point and then
sweeps down over the uterus as a wave.

49. • In some women, contractions appear to
originate in the lower uterine segment rather
than in the fundus.
• Reverse, ineffective contractions, cause
tightening rather than dilation of the cervix.

50. Phases of Contraction
• INCREMENT – when the intensity of
contractions increases
• ACME – when the contraction is at its
strongest
• DECREMENT – when the intensity
decreases

51. • Between contractions the uterus relaxes
• Relaxation intervals decreases from 10
minutes early in labor to - 3 minutes.
• The duration of contractions also changes,
increasing from 20 – 30 seconds to a range
of 60 to 90 seconds.

52. PHYSIOLOGIC RETRACTION
RINGS
• As labor contractions progress and become
regular and strong, the uterus gradually
differentiates itself into two distinct
functioning areas.
• The upper portion becomes thicker and
active.
• Lower segments become thin walled, supple,
and passive, so the fetus can be pushed out
of the uterus easily.

53. PATHOLOGIC RETRACTION RING
OR
BANDL’S RING
• It is a danger sign that signifies impending
rupture of the lower uterine segment if the
obstruction to labor is not relieved.

54. CERVICAL CHANGES
• EFFACEMENT – shortening and thinning of
the cervical canal.
• In primiparas, effacement is accomplished
before dilation begins
• In multiparas, dilation may proceed before
effacement is complete

55. DILATATION
• ENLARGEMENT OF THE CERVICAL
CANAL FROM AN OPENING A FEW
MILLIMETERS WIDE TO ONE LARGE
ENOUGH TO PERMIT PASSAGE OF THE
FETUS.
• As dilation begins, there is an increase in the
amount of vaginal secretions (SHOW),
because it is dislodge.
• Minute capillaries in the cervix ruptures.

56. PSYCHE
• Psychological state or feelings that women
bring into labor with them.
• A feeling of apprehension or fright.
• For many it includes a sense of excitement
or awe
• Women who manage best in labor typically
are those who have a strong sense of self
estem and a meaningful support person.

57. STAGES OF LABOR

58. FIRST STAGE
• Divided into three phases: LATENT,
ACTIVE, AND TRANSITION PHASE
• Latent Phase – or preparatory phase begins
at the onset of regularly perceived uterine
contractions and ends when rapid cervical
dilation begins.
• Contractions are mild and short, lasting 0 –
40 seconds.

59. LATENT PHASE
• CERVIX DILATES FROM 0 TO 3 CM
• LAST FOR 6 HOURS IN A NULLIPARA
• 4.5 HOURS IN A MULTIPARA
• MOTHER IS EXCITED WITH SOME
DEGREE OF APPREHENSION BUT STILL
WITH ABILITY TO COMMUNICATE

60. NURSING CARE
• ENCOURAGE WALKING
• ENCOURAGE TO VOID EVERY 2 – 3
HOURS
• BREATHING EXERCISES

61. ACTIVE PHASE
• Cervical dilation reaches 4-8cm
• Rapid increase in duration, frequency and
intensity or contractions
• Mother fears losing control of himself
• Contractions are stronger lasting 40-60
seconds and occuring every 3-5minutes.
• Last for 3 hours in NULLIPARA and 2 hours
in a multipara

62. NURSING CARE
• MONITORING AND EVALUATING
IMPORTANT ASPECT
• Uterine contractions
– DURATION – from the beginning of one
contraction to the end of the same contraction.
– INTERVAL – from the end of one contraction to
the beginning of the next contraction (early in
labor 40 – 45 minutes, late in labor 2 – 3
minutes)

63. • INTENSITY – The strength of a contraction,
maybe mild moderate or strong
• FREQUENCY – from the beginning of one
contraction to the beginning of the next
contraction

64. BLOOD PRESSURE
• Should not be taken during a contraction as
it tend to increase
• BP reading should be taken at least every
half hour during active labor
• When a woman in labor complains of a
headache, the first nursing action is to take
the BP.

65. FETAL HEART RATE
• Should not be mistaken with uterine souuffle
• Normally 120 – 160 per minute
• Should not be taken during a uterine contraction
because it tends to decrease. Compression of the
fetal head when the uterus contracts stimulates the
vagal reflex which, in turn, causes bradycardia.
• Should be taken every hour during the latent phase
of labor, every half of an hour during active phase.

66. • Every 15 minutes during the transition
phase
• For any abnormality in FHR, the initial
nursing action is to change the mothers
position

67. SIGNS OF FETAL DISTRESS
• BRADYCARDIA (FHR less than 100/minute
or tachycardia (FHR more than 180/minute)
• Meconium-stained amniotic fluid in non-
breech presentation
• Fetal – thrashing – hyperactivity of the fetus
as it struggles for more oxygen

68. • Emotional support is provided for the woman
in labor by keeping her constantly informed
of the progress of labor
• Health Teachings:
• Bath – is advisable if contractions are
tolerable or not too close to one another. Will
make the mother more comfortable
• AMBULATION – helps shorten the first stage
of labor

69. • Solid or liquid foods are to be avoided
because:
• Digestion is delayed during labor
• A full stomach interferes with proper
bearing down
• May vomit and cause aspiration

70. • Enema
– Purpose: A full bowel hinders the progress of
labor
– Expulsion of feces during second stage of labor
predisposes the mother and baby to infection
– Full bowel predisposes to postpartum discomfort

71. • Contraindications to enema in labor
– Vaginal bleeding
– Premature labor
– Abnormal fetal presentation or position
– Ruptured membranes
– crowning

72. • Encourage the mother to void every
-3 hours by offering the bedpan
because
–A full bladder retards fetal descent
–Urinary stasis can lead to urinary
tract infection
–A full bladder can be traumatized
during delivery

73. • Perineal prep – done aseptically. Use no. 7
method, always from front to back
• Perineal shave – not a routine procedure;
maybe done to provide a clean area for
delivery. Muscles at the symphysis pubis
should be kept taut and razor moved along
the direction of hair growth

74. SIMS POSITION
• Favors anterior rotation of the fetal head
• Promotes relaxation between contractions
• Prevents continual pressure of the gravid
uterus on the inferior venacava
• Women in labor should not be allowed to
push or bear down unecessarily during
contractions of the first stage because it
leads to unnecessary exhaustion

75. • ABDOMINAL BREATHING – advised for
contractions during the first stage in order to
reduce tension and prevent hyperventilation

76. TRANSITION PERIOD
• When the mood of the woman suddenly
changes and the nature of the contractions
intensify
• Characteristics
– If membranes are still intact, this period is
marked by a sudden gush of amniotic fluid as
fetus is pushed into the birth canal
– Show becomes more prominent

77. • There is an uncontrollable urge to push with
contractions, a sign of impending second
stage of labor. Profuse perspirations and
distention of the neck veins are seen.
• Nausea and vomiting is a reflexreaction due
to decreased gastric motility and absorption
• In primis, baby is delivered within 20
contractions (40 minutes); in multis, after 10
contractions (20 minutes)

78. Comfort measures
• Sacral pressure
• Proper bearing down techniques: push with
contractions
• Controlled chest breathing during
contractions
• Emotional support

79. SECOND STAGE
• Stage of expulsion
• Begins with complete dilatation of the cervix
and ends with the delivery of the baby
• Overwhelming, uncontrollable urge to push
or bear down with contractions as if she had
to move her bowels

80. NURSING CARE
• When positioning legs on lithotomy, put them
up at the same time to prevent injury to the
uterine segments
• As soon as the fetal head crowns instruct the
mother not to push, but to pant. If panting is
deep and rapid, called hyperventilation,
patient will experience lightheadedness and
tingling sensation of the fingers leading to
carpopedal spasms because of respiratory
alkalosis.

81. • Assist in episiotomy – incision made in the
perineum primarily to prevent lacerations
• Prevent prolonged and severe stretching of
muscles supporting the bladder or rectum
• Enlarge outlet
• Reduce duration of second stage

82. Types of Episiotomy
• MEDIAN – from middle portion of the lower
vaginal border directed toward the anus
• MEDIOLATERAL – Begun in the midline but
directed laterally away from the anus
• Natural anesthesia is used in episiotomy
because pressure of fetal presenting part
against the perineum is so intense that nerve
endings for pain are momentarily deadened.

83. MODIFIED RITGEN’S MANEUVER
• Cover the anus with sterile towel and exert
upward and forward pressure on the fetal
chin, while exerting gentle pressure with two
fingers on the head to control emerging
head.
• This will not only support the perineum, thus
preventing lacerations, but will also favor
flexion so that the smallest diameter of the
fetal head is presented.

84. • Immediately after delivery, the newborb
should be held below the level of the
mothers vulva for a few minutes to
encourage flow of blood from the placenta to
the baby
• The infant is held with his head in a
dependent position to allow for drainage of
secretions. Never stimulate the baby to cry
unless you have drained the secretions

85. • Wrap the baby in a sterile towel to keep him warm.
Chilling increases the body’s need for oxygen
• Put the baby on the mothers abdomen. The weight
of the baby will help contract the uterus
• Cutting of the cord is postponed until the pulsations
have stopped because it is believed tha 50 – 100
ml of blood is flowing from the palcenta to the baby
at this time

86. THIRD STAGE/ PLACENTAL
STAGE
• SIGN OF PLACENTAL SEPARATION
• Uterus becoming round and firm again, rising
high to the level of the umbilicus (calkin’s
sign) – earliest sign of placental separation
• Sudden gush of blood from the vagina
• Lengthening of the cord

87. TYPES OF PLACENTAL DELIVERY
• SCHULTZ – If placenta separates first at its
center and last at its edges, it tends to fold
back on itsefl like an umbrella and presents
the fetal surface which is shiny (shiny for
schultz) 80 % of placenta separate inthis
manner

88. • DUNCAN – if placenta separates first at its
edges, it slides along the uterine surface and
presents with the maternal surface which is
raw, red, beefy, irregular and dirty (dirty for
duncan). Only about 20 % of placenta
separates this way.

89. NURSING CARE
• Do not hurry the expulsion of the placenta by
forcefully pulling out the cord or doing
vigorous fundal push as this can cause
uterine eversion, just watch for the sign of
placental separation
• Tract the cord slowly, winding it around the
clamp until the placenta spontaneously
comes out, slowly rotating it so that no
membranes are left inside the uterus =
BRANDT ANDREWS MANEUVER

90. • Take note of the time of placental delivery. It
should be delivered within 20 minutes after
the delivery of the baby.
• Inspect for the completeness of cotyledons;
any placental fragments retained can cause
severe bleeding in the mother
• Palpate the uterus to determine degree of
contraction. If relaxed boggy or non-
contracted, first nursing action is to massage
gently and properly. An ice cap over the
abdomen will also help contract the uterus.

91. • Inject OXYTOCIN (Methergin = 0.2 mg/ml or
syntocinon = 10 U/ml) IM to maintain uterine
contractions, thus prevent hemorrhage.
NOTE: oxytocin are not given before
placental delivery
• inspect the perineum for laceration=bright
red vaginal bleeding

92. Categories of lacerations
• First Degree – involves the vaginal mucous
membranes and perineal skin
• Second Degree – involves not only the muscles,
vaginal mucous membranes and skin, but also the
muscles
• Third degree – involves not only the vaginal
mucous membranes and skin, but also the external
sphincter of the rectum
• Fourth Degree – involves not only the external
sphincter of the rectum, the muscles, vaginal
mucous membranes and skin, but also the mucous
membrane of the rectum.

93. • Assist the doctor in doing episiorrhapy
(repair of the episiotomy or laceration). In
vaginal episiorrhapy, packing is done to
maintain pressure on the suture line, thus
prevent further bleeding. Vaginal packs have
to be removed after 24 – 48 hours
• Make mother comfortable by perineal care
and applying clean sanitary napkin snugly to
prevent the moving forward from the anus to
the vaginal opening. Soiled napkin should be
removed from front to back

94. • Position the newly delivered mother flat on
bed without pillows to prevent dizziness due
to decrease in intraabdominal pressure
• The newly delivered mother may suddenly
complains of chills due to decreased blood
pressure, fatigue or cold temperature in the
delivery room.
• Give initial nourishment: milk, tea
• Allow patient to sleep in order to regain lost
energy

95. Fourth stage
• First 1 – 2 hours after delivery which is said
to be the most critical stage for the mother
because of unstable VS
• Assessment:
• FUNDUS – should be checked every 15
minutes for 1 hour then every 30 minutes for
the next 4 hours. Fundus should be firm in
the midline and during the first 12 hours
postpartum, is a little above the umbilicus

96. LOCHIA
• Should be moderate in amount. Immediately
after delivery, a perineal pad can be
completely saturated after 30 minutes. If
saturated in 15 minutes or earlier, amy mean
hemorrhage
• Uterine discharges consisting of blood,
decidua,WBC, mucus and some bacteria

97. PATTERN
• RUBRA – first 3 days postpartum, red and
moderate in amount
• SEROSA – next 4 – 9 days; pink or brownish
and decreased in amount
• ALBA – from 10th
day up to 3 – 6 weeks
postpartum; colorless and minimal in amount

98. CHARACTERISTICS OF LOCHIA
• Pattern should not reverse
• Should not have any offensive odor; foul
smelling, may mean either poor hygiene or
infection
• It should not contain large clots
• It should never be absent, regrdless of
method of delivery
• Increases with activity and decreases with
breastfeeding

99. BLADDER
• A full bladder is evidenced by a fundus
which is to the right of the midline and dark
red bleeding with some clots. Will prevent
adequate uterine contraction

100. PERINEUM
• Is normally tender, discolored and
edematous. It should be clean with intact
sutures
• Blood pressure and pulse rate may be
slightly increased from excitement and effort
of delivery, but normalize within one hour

101. Puerperium
• Postpartum – refers to the six weeks period
after delivery of the baby of the baby
• Involution – return of the reproductive organs
to their pre pregnant state.
• Principles of postpartum care:
– Promote healing and return to normal of different
parts of the body

102. Vascular Changes
• The 30 – 50 % increase in total cardiac
volume during pregnancy will be reabsorbed
into the general circulation within 5 – 10
minutes after placental delivery.
• Implications: the first 5 – 10 minutes after
placental delivery is crucial to
gravidocardiacs because the weak heart
may not be able to handle such workload

103. • WBC count increases to 20,000 – 30,000
• Implication: The WBC count therefore,
cannot be used as an indication or sign of
postpartum infection
• There is an extensive activation of the
clotting factors, which encourage
thromboembolization.

104. This is the reason why:
• Ambulation is done early – 4 – 8 hours after
normal vaginal delivery
• Recommended exercises:
– Kegels and abdominal breathing on postpartum
day 1
– Chin to chest on PPD2 to tighten and firm up
abdominal muscles
– Knee to abdomen when perineum has healed, to
strenghten the abdominal muscles and gluteal
muscles.

105. • All blood values are back to prenatal levels
by the 3rd
or 4th
week postpartum
• Genital changes – uterine involution is
assessed by measuring the fundus or
fingerbreadth.
• On PPD 1 fundus is 1 fingerbreadth below
the umbilicus
• On PPD2 fundus is 2 fingerbreadths below
and until PPD10.

106. • To encourage the return of the uterus to its
usual anteflexed position, prone and knee
chest position are advised
• Afterpains/ afterbirth pains – normal and
rarely last for more than 3 days
• Management:
– Never apply heat on the abdomen
– Give analgesics as ordered

107. Pain in the Perineal region may
be relieved by:
• Sim’s Position – minimizes strain on the
suture line
• Perineal heat lamp or warm Sitz baths twice
a day
• Application of topical analgesics or
administration of mild oral analgesics as
ordered

108. Sexual Activity
• Maybe resumed by the third or 4th
week
postpartum if bleeding has stopped and
episiorrhapy has healed.
• Decreased physiologic reactions to sexual
stimulation are expected for the first 3
months postpartum because of hormonal
changes and emotional factors

109. MENSTRUATION
• If not breast feeding return of menstrual flow
is expected within 8 weeks after delivery.
• If breastfeeding, menstrual return is
expected in 3 – 4 months
• In some women no menstruation occurs
during the entire lactation period

110. • Postpartum check – up – should be done
after the 6th
week postpartum to assess
involution
• Gastrointestinal Changes – delayed bowel
evacuation postpartally may be due to:
– Decrease muscle tone
– Lack of food or enema during labor
– Dehydration
– Fear of pain from perineal tenderness

111. URINARY CHANGES
• MARKED DIURESIS within 12 hours
postpartum to eliminate excess tissue fluid
accumulation during pregnancy

112. Vital Signs
• Temperature may increase because of the
dehydrating effects of labor
• Implications: any increase in body
temperature during the first 24 hours
postpartum is not necessarily a sign of
postpartum infection
• Bradycardia is common for 6 – 8 days
postpartum
• No change in the respiratory rate

113. WEIGHT
• There is an immediate weight loss of 10 – 12
pounds
• Further weight loss will occur during the next
days due to diaphoresis

114. Psychological phases during
postpartum period are:
• Taking-in-phase – first 1 – 2 days
postpartum when mother is passive and
relies on others to care for her and her
newborn
• She keep on verbalizing her feelings
regarding the recent delivery for her to be
able to integrate the experience into herself

115. Taking-hold phase
• Begins to initiate action and make decision
• Postpartum blues (an overwhelming feeling
of sadness that cannot be accounted for)
• Could be due to hormonal changes, fatgue
or feelings of inadequacy in taking care of a
new baby.
• Management: explain that it is normal; crying
is therapeutic

116. • 7 days and above, interdependent phase
• Redifine roles and set new goals as parent
• Extends until the child grows
Letting Go phase

117. • Prevent Postpartum complications
– HEMORRHAGE
– INFECTION

118. RISK CONDITION
• INFECTIONS
• Syphilis
– causes: Treponema Pallidum- a spirochete
which enters the body during coitus or through
cuts and breaks in the skin or mucous
membrane
– Treatment: 2.4 – 4.8 million units of Penicillin will
usually prevent congenital syphilis in the
newborn because it readily crosses the placenta

119. • If untreated syphilis can cause midtrimester
abortion, CNS lesions in the newborn or
even death
• The Newborn with congenital syphilis
– jaundice at 2 weeks of life – first sign of the
disease
– Anemia and Hepatosplenomegaly
– Snuffles (persistent rhinorrhea), coppery rashes
on palms and soles; mucous patches;
pseudoparalysis d/t bone inflammation

120. RUBELLA/GERMAN MEASLES
• Incidence:
– Mother: the earlier the mother contracted the
disease, the greater the likehood that the baby
will be affected. Rubella virus slows down
division of infected cells dring organogenesis,
thus causing congenital defects
– Newborn: can carry and transmit the virus for as
long as 12 – 24 months after birth

121. SIGNS AND SYMPTOMS
• Low birth weight; jaundice;
petechiae;anemia;thrombocytopenia;hepatos
plenomegaly
• Classic sequelae:
– Eyes:cataract, glaucoma
– Heart: PDA, Stenosis, Coarctations
– Ear: Nerve deafness
– Dental and facial clefts

122. POSTPARTUM INFECTIONS
• SOURCES:
– Endogenous (primary) source – bacteria in the
normalflora become virulent when tissues are
traumatized and general resistance is lowered
– Exogenous Sources – pathogens introduced
from external sources (streptococci)

123. Common exogenous sources
• Hospital personnel
• Excessive obstetric manipulation
• Break in aseptic technique – faulty
handwashing, unsterile equipments and
supply
• Coitus in late prenancy
• Premature rupture in the membrane

124. General symptoms:
• Malaise
• Anorexia
• Fever
• Chills
• Headache

125. General Management
• Complete bed rest
• Proper nutrition
• Increased fluid intake
• Analgesics
• Antipyretics and antibiotics as ordered

126. • If untreated can progress to deformed bones,
teeth, nose joints and CNS syphilis
• Management: Penicillin IM for 10 days or
one long acting penicillin

127. Types of Infection
• Infection of the Perineum
• Specific symptoms:
• Pain, heat and feeling of pressure in the
perineum
• Inflammation of the suture line with 1 or 2
stitches sloughed off
• With or without elevated temperature

128. • Specific Management
– Doctor remove sutures to drain area and
resutures
– Hot sitz bath or warm compress

129. ENDOMETRITIS
• Inflammation or infection of the lining of the
uterus
• Specific symptoms:
• Abdominal Tenderness
• Uterus not contracted and painful to touch
• Dark brown foul smelling lochia

130. • Specific Management
• Oxytocin administration
• Fowlers position to drain out lochia and
prevent pooling infected discharges

131. THROMBOPHLEBITIS
• Infection of the lining of a blood vessel
formation of clots; usually an extension of
endometritis
• Specific symptoms:
• Pain, stiffness and redness in the affected
part of the leg
• Legs begins to swell below the lesion
because venous circulation has been
blocked

132. • Skin is stretched to a point of shiny
whiteness, called milk leg or phlegmasia alba
dolens
• Positive Homan’s sign – pain in the calf
when the foot is dorsiflexed

133. Management
• Bed rest with affected legs elevated
• Anticoagulants to prevent furthe
clotformation or extension of a thrombus
• MASTITIS – inflammation of breast tissues

134. BLEEDING HEMORRHAGE
• Bleeding in Pregnancy
• First Trimester Bleeding:
• ABORTION
– Spontaneous( Threatened/Imminent) = Complete
& incomplete
– Induced
– Missed

135. ECTOPIC PREGNANCY
• Tubal
• Cervical
• Ovarian
II. SECOND TRIMESTER BLEEDING
a. Hydatidiform Mole
b. Incompetent Cervical Os
III. THIRD TRIMESTER BLEEDING
a. Placenta Previa
b. Abruptio Placenta