1.  Evaluate volume of vaginal bleeding as stable or unstable per
the patient’s vital signs and uterine response .
 Stable : vital signs within 20% of patient’s average readings and
uterus remains firm between assessment or quickly firms after
fundal massage
 Unstable : vital signs vary greater than 20% from the patient’s
average readings or repetitive blood pressure readings below
90/60 mm Hg , pulse more than 110/min , respiration 24 to 26 /
min accompanied by continuous bleeding and a boggy uterine
tone
 INCREASE PULSE RATE IS THE FIRST SIGN OF THE
HYPOVOLUMIA AND VHYPOTENSION IS LATE .
 If bleeding continues and uterus is firm , notify health care
provider for evaluation of laceration or retained placental
fragments .
 AUTOTRANSFUSION
1

2. SEMINAR
WHAT IS MEANT BY “ THE SEMINAR ” ?
A SMALL GROUP OF ADVANCED STUDENTS IN A
COLLEGE OR GRADUATE SCHOOL ENGAGED IN
ORGINAL RESEARCH OR INTENSIVE STUDY UNDER THE
GUIDANCE OF PROFESOR WHO MEET REGULARLY WITH
THEM TO DISCUSS THEIR REPORTS AND FINDINGS .
2

3. MANAGEMENT OF
PHASES OF LABOUR
BHUSHAN RHISHIKESH JOSHI
( IIIRD B.BSC. NSG )
3

4. CONTENTS
 OBJECTIVES
 INTRODUCTION TO TOPIC
 PHASES OF LABOUR
 MANAGEMENT OF FIRST STAGE
 MANAGEMENT OF SECOND STAGE
 CARE OF NEW BORN
 MANAGEMENT OF THIRD STAGE
1. EXPECTANT
2. ACTIVE ( PREFERRED)
 MANAGEMENT OF FOURTH STAGE
 SUMMARY
4

5. OBJECTIVES
 DEFINE LABOR .
 DESCRIBE EVENTS OCCURING IN STAGES OF LABOR .
 HIGHLIGHT PRINCIPLES AND OBJECTIIVES OF MANAGEMENT OF
LABOR .
 DISCUSS MANAGEMENT OF FIRST STAGE OF LABOUR
 ELLABORATE MANAGEMENT OF SECOND STAGE OF LABOR .
 EXPLAIN IMMEDIATE CARE OF NEW BORN .
 DESCRIBE MANAGEMENT OF THIRD STAGE OF LABOR .
 DISCUSS MANAGEMENT OF FOURTH STAGE OF LABOR
 SUMMERIZATION OF TOPIC .
5

6. THE CHALLENGE IS, CAN YOU PROVIDE
VIGILANCE WITHOUT INTERVENTION….
You are the
only one ,
who can
help you in
best way .
6

7. DEFINING LABOR
 SERIES OF EVENTS THAT TAKES PLACE IN THE GENITAL ORGANS IN AN
EFFORT TO EXPEL THE VIABLE PRODUCT OF CONCEPTION OUT OF THE
WOMB THROUGH VAGINA INTO THE OUTER WORLD IS CALLED AS
LABOR .
 NORMAL LABOR (EUTOCIA)
LABOR IS CALLED AS NORMAL IF IT FULFILS FOLLOWING CRITERIA
1. SPONTANEOUS IN ONSET AND AT TERM
2. WITH VERTEX PRESENTATION
3. WITHOUT UNDUE PROLONG
4. NATURAL TERMINATION WITH MINIMAL AIDS
5. WITHOUT HAVING ANY COMPLICATIONS AFFECTING THE HEALTH OF
THE MOTHER AND/OR THE BABY .
 ABNORMAL LABOR (DYSTOCIA)
ANY DEVIATION FROM THE DEFINATION OF NORMAL LABOR IS CALLED
ABNORMAL LABOR
7

8.  FACTORS INITIATING LABOR
THEORETICAL
 MATERNAL FACTORS
 PROGESTERONE
 ESTROGEN
 OXYTOCIN
 PROSTAGLANDIN
 PSYCHE
 FETAL FACTORS
 FETAL CORTISOL
ARTIFICIAL
 CERVICAL EXAM
 STRIPPING OF MEMBRANES
 PROSTAGLANDINS
 ARTIFICIAL RUPTURE OF
MEMBRANES
 SEX
 NIPPLE STIMULATION
8
EVENTS OCCURRING IN STAGES OF
LABOR

9. EVENTS IN FIRST STAGE OF LABOR
CHIEFLY CONCERNED WITH PREPARATION OF BIRTH CANAL SO AS TO
FACILITATE EXPULSION OF FETUS IN SECOND STAGE .MAIN EVENTS THAT
OCCURS IN THIS STAGE ARE :
DILATION AND TAKING UP OF CERVIX
THERE ARE DIFFERENT FEACTORS WHICH PREDISPOSE SMOOTH
DILATION OF CERVIX :
a) UTERINE CONTRACTION AND RETRACTION – CRVIX BECOMES
SHORTENED AND RETRACTED IN BUCKET HOLDING FASHION .
b) BAG OF MEMBRANE –
EFFACEMENT OR TAKING UP OF THE CERVIX : IS A PROCESS OF THINNING
OUT . NOTE THE FOLLOWING :
 DILATION : HOW FAR THE CEVIX HAS BEEN OPENED ( IN CM )
 EFFACEMENT : HOW THIN IS THE CERVIX ( IN CM OR % )
FULL FORMATION OF LOWER UTERINE SEGMENT
9
IN NULLIPARA THE FIRST STAGE MAY BE PROLONG UP TO 12 HOURS
WHILE IN MULTIPARA IT GET COMPLETED IN 4 – 6 HOURS .

10. CERVICAL DILATION AND EFFACEMENT

11. EVEN TS IN SECOND STAGE OF
LABOR
THIS STAGE IS CONCERNED WITH THE DESCENT AND DELIVERY OF THE
FETUS THROUGH THE BIRTH CANAL , CERVICAL DILATION CONTINUES ,
WITH FULL DILATION OF CERVIX , THE MEMBRANES USUALLY RUPTURE AND
THERE IS ESCAPE OF GOOD AMOUNT OF LIQUOR AMNII .
UTERINE CONTRACTION AND RETRACTION BECOMES MORE STRONGER
EXPULSIVE FORCE OF UTERINE CONTRACTION IS ADDED BY
CONTRACTION OF THE ABDOMINAL MUSCLES CALLED “ BEARING DOWN
” EFFORTS .
THE SECOND STAGE MAY LAST FROM 1 TO 4 HOURS IN NULLIPARA AND
LESS THAN 1 HOUR IN MULTIPARA .
11

12. EVENTS IN THIRD STAGE OF LABOR
 THE THIRD STAGE OF LABOR COMPRISES THE PHASE OF PLACENTAL
SEPARATION ITS DECENT TO LOWEAR SEGMENT AND FINALY ITS
EXPULSION WITH MEMBRANES .
 PLACENTAL SEPARATION : AFTER THE BIRTH SHAPE OF UTERUS
BECOMES DISCOID AND CAVITY IS MUCH REDUCED(20CMX10CM) .
 AS THE PLACENTA IS INELASTIC IT CAN NOT KEEP PACE WITH SUCH
EXTENT OF RETRACTION AND RESULTS IN BUCKLING .
 SEPARATION MAY BE MARGINAL MAY BE CENTRAL .
 SEPARATION OF THE MEMBRANES
 AFTER THE SEPARATION OF PLACENTA IT GET EXPELLED OUT .
 THE THIRD STAGE MAY LAST FROM A FEW MINUTES TO 30 MINUTES .
12

13. PRINCIPLES AND OBJECTIIVES OF
MANAGEMENT OF LABOR .
 NON INTERFERENCE WITH WATCHFUL EXPECTANCY FOR NATURAL BIRTH .
 MONITOR CAREFULLY SO AS TO DETECT ANY INTRAPARTUM
COMPLICATION .
 ASSIST IN THE NATURAL EXPULSION OF THE FETUS SLOWLY AND STEADILY .
 TO PREVENT PERINEAL INJURIES .
 IMMEDIATE CARE OF NEWBORN .
 ENSURE STRICT VIGILANCE .
 TO FOLLOW THE MANAGEMENT GUIDELINES STRICTLY IN PRACTICE
13

14. MANAGEMENT OF FIRST STAGE OF
LABOR
PRELIMINARIES
BASIC EVALUATION OF CURRENT CLINICAL CONDITIONS.
OBSTETRICAL AND GENERAL EXAMINATION INCLUDING
VAGINAL EXAMINATION TO EXCLUDE ANY ABNORMALITIES.
RECORDS OF ANTE NATAL VISITS , INVESTIGATION REPORTS AND ANY
SPECIFIC TREATMENT GIVEN ARE TO BE REVIEWED .

15. ACTUAL MANAGEMENT
General
 ANTISEPTIC DRESSING
 ENCOURAGEMENT , EMOTIONAL SUPPORT AND ASSURANCE
 CONSTANT SUPERVISION
REST AND AMBULATION
BOWEL :ENEMA WITH SOAP AND WATER OR GLYCERINE SUPPOSITORY
DIET: FOOD IS WITH HELD DURING ACTIVE LABOUR.
BECAUSE DELAYED EMPTYING OF THE STOMACH AND LOW PH OF
GASTRIC CONTAIN IS REAL DANGER IF ASPIRATED FOLLOWING
GENERAL ANESTHESIA WHEN NEEDED UNEXPECTEDLY .
BLADDER CARE : ENCOURAGED TO PASS URINE BY HERSELF . IF PATIENT
FAILS TO PASS URINE SPECIALLY IN LATE FIRST STAGE , CATHETERIZATION
SHOULD BE DONE WITH STRICT ASEPTIC PRECAUTIONS .
15

16. MANAGEMENT OF LABOR PAIN
PAIN IS SUBJECTIVE , COMPLEX INTERACTION OF INFLUENCES :
a. PHYSIOLOGIC
b. PSYCHOSOCIAL
c. CULTURAL
d. ENVIRONMENTAL
NATURE OF LABOR PAIN –
1ST STAGE
VISCERAL PAIN
DIFFUSE ABDOMINAL CRAMPING
UTERINE CONTRACTIONS

17. NONPHARMACOLOGICAL PAIN RELIEF
1. CONTINUOUS LABOR SUPPORT
INCREASINGLY AVAILABLE AT HOSPITALS & BIRTH CENTERS
RECENT SURVEY (2002 - WHO)
6% OF WOMEN USED WARM WATER BATHS
49% FOUND THEM VERY HELPFUL
2. WARM WATER BATHS
LABOR MAY SLOW IF USED IN EARLY LABOR LESS THAN 5CM DILATION
3. STERILE-WATER INJECTIONS
INTRADERMAL INJECTIONS OF STERILE WATER IN THE SACRAL AREA
CAUSES A BURNING SENSATION
COUNTERIRRITATION
DECREASES BACK PAIN FOR 45-90 MINS.
4 .POSITIONS, TOUCH, & MASSAGE

18. 18
 NON-MEDICAL CARE BY A TRAINED PERSON
 DIFFERENT DEFINITIONS/CRITERIA DEPENDING ON STUDIES:
a) “MINIMUM OF 80%” PRESENCE
b) PRESENCE “WITHOUT INTERRUPTION, EXCEPT FOR TOILETING”
 VARIOUS TERMS: DOULA, LABOR ASSISTANT, BIRTH
COMPANION, MONITRICE
 MAY REFER TO HUSBAND OR UNTRAINED FEMALE COMPANION
CONTINUOUS LABOR SUPPORT

19. EFFECTS OF PSYCHOLOGICAL
SUPPORT DURING LABOUR
Continuous Labor Support: Mechanism of Action from Hodnett (2007)
Negative
experiences
may impede
labor
Negative
experiences may
impede adjustment
to motherhood
Mitigates
potentially
harsh
environment
Positive impact
of
companionship
on mom
woman
uses
gravity &
position changes
fetopelvic
relationship
is enhanced
Mobility
encouraged by
support
person
fewer
abnormal
FHR
patterns
preserves
uterine
contractility
stress hormones
(epinephrine)
may be
reduced
Support
person
decreases
anxiety of mom
Physiologic
impact of
continuous
labor support
19

20. WHY ARE WE LOOKING TO DECREASE THE USE OF MEDICATION?
THE THEORY “NATURAL BIRTH” : BODY PRODUCES ENDORPHINS TO COPE WITH
PAIN . BABY‟S ENDORPHINS RAISE WHEN MOM‟S ENDORPHINS RAISE .
MEDICATIONS DECREASE NATURAL ENDORPHINS FOR BOTH .IT ALSO
STIMULATES THE BABY‟S ADRENAL GLANDS . “FIGHT OR FLIGHT” – HELPS TO
ADAPT TO LIFE OUTSIDE OF THE UTERUS . IT INCREASES BLOOD FLOW TO BABY .
STIMULATES IMMUNE SYSTEM (INCREASED WBC‟S) . MAKING BABY MORE ALERT
– FACILITATES BONDING . OXYTOCIN PEAKS JUST AFTER AN UNMEDICATED
BIRTH AND STIMULATES MATERNAL BEHAVIORS .
OPIODS AND NARCOTICS
CONTINUOUS LUMBAR EPIDURAL
PARACERVICAL BLOCK
50 / 50 NITROUS / OXYGEN
PSYCHOPROPHYLAXIS
HYPNOSIS
PHARMACOLOGICAL PAIN RELIEF

21. PARENTERAL OPIOIDS : MOTHER
 LESS PAIN RELIEF AND SATISFACTION WITH PAIN RELIEF (ALL STAGES)
 LOWER RATE OF OXYTOCIN AUGMENTATION
 SHORTER STAGES OF LABOR
 FEWER CASES OF MALPOSITION
 FEWER INSTRUMENT-ASSISTED DELIVERIES
PARENTERAL OPIOIDS - INFANT
NEONATAL RESPIRATORY DEPRESSION
DECREASED ALERTNESS
INHIBITION OF SUCKING
LOWER NEUROBEHARIORAL SCORES
DELAY IN EFFECTIVE FEEDING
LONG-TERM EFFECTS CANNOT BE EXCLUDED

22. EPIDURAL ANALGESIA
 BALANCE BETWEEN PAIN RELIEF AND OTHER GOALS…
1. WALKING (1ST STAGE)
2. PUSHING EFFECTIVELY (2ND STAGE)
3. MINIMIZING SIDE EFFECTS MATERNAL AND NEONATAL
“WALKING EPIDURAL”
INTRATHECAL OPIOID INJECTION BEFORE CONTINUOUS EPIDURAL INFUSION
 *OFTEN ARE UNABLE TO WALK…
1. SUBSTANTIAL MOTOR BLOCKADE
2. NEED CONTINUOUS FETAL MONITORING
 ADVANTAGES:
1. RAPID ONSET OF PAIN RELIEF
2. POTENTIAL FOR THE INTRATHECAL MEDICATION TO SUFFICE
3. LIKELY TO DELIVER IN 2-3 HOURS

23. EPIDURAL ANALGESIA - EFFECTS
 SLOWS LABOR (1ST AND 2ND STAGES)
 INCREASES USE OF PITOCIN
 OXYTOCIN AUGMENTATION
 INCREASED PERINEAL TEARS
 INCREASED INSTRUMENT-ASSISTED DELIVERY
 FORCEPS/VACUUM EXTRACTION
 INCREASED CESAREAN (?)
 ESPECIALLY WHEN ADMINISTERED EARLY
 MATERNAL FEVER
EPIDURAL – SIDE EFFECTS
COMMON:
 HYPOTENSION
 IMPAIRED MOTOR FUNCTION (INABILITY TO WALK)
 NEED FOR CATHETERIZATION
UNCOMMON (<10%):
 PRURITIS
 NAUSEA & VOMITING
 SEDATION

24. NITROUS OXIDE
 WIDELY USED IN MOST DEVELOPING COUNTRIES
a) >60% FINLAND AND UNITED KINGDOM
b) 50/50 BLEND NITROUS OXIDE AND OXYGEN
FULL EFFECT 50 SECONDS AFTER INHALATION
USUALLY SELF-ADMINISTERED AS NEEDED
NITROUS OXIDE – SIDE EFFECTS
 NAUSEA ,VOMITING ,POOR RECALL OF LABOR
1. NITRAZINE PAPER TURNS BLUE IN THE
PRESENCE OF ALKALINE AMNIOTIC
FLUID .
2. VAGINAL SECERITIONS ARE
NITRAZINE NEGATIVE AS THEY ARE
ACIDIC .
3. POOLING OF THE AMNIOTIC FLUID
IN THE VAGINAL VAULT IS A RELIABLE
SIGN .
STATUS OF MEMBRANES

25. MONITORING FOR FETAL WELL-BEING: THE
EVIDENCE
25
EARLY LABOR, FOR LOW RISK
PATIENTS, NOTE THE FETAL HEART
RATE EVERY 1-2 HOURS.
DURING ACTIVE LABOR, EVALUATE
THE FETAL HEART EVERY 30 MINUTES
NORMAL FHR IS 120-160 BPM
PERSISTENT TACHYCARDIA (>160)
OR BRADYCARDIA (<120,
PARTICULARLY <100) IS OF
CONCERN

26.  TO NOTE THE PROGRESS OF LABOR :
ABDOMINAL FINDINGS
1. UTERINE CONTRACTIONS- INTENSITY , FREQUENCY AND DURATION SHOULD
ASSESSED . PROGRESSIVE INCREASE IN INTENSITY SIGNIFIES GOOD
PROGRESS OF LABOR .
2. PELVIC GRIP – GRADUAL DISAPPEARANCE OF POLES OF HEAD .
3. SHIFTING OF MAXIMUM IMPULSE OF FETAL HEART BEAT DOWNWARDS AND
MEDIALLY .
VAGINAL EXAMINATIONS
1. DILATION OF CERVIX
2. POSITION OF HEAD AND DEGREE OF FLEXION
FREQUENT VAGINAL EXAMINATIONS ARE STRICTLY CONDEMNED DUE TO
MATERNAL UNCOMFORT AND RISK OF INFECTIONS .
26

27. NURSING DIAGNOSIS
 DEFICIT FLUID VOLUME RELATED TO DECREASE ORAL INTAKE , DIETARY
RESTRICTIONS AND ENERGY REQUIREMENT OF LABOR .
 ACUTE PAIN RELATED TO UTERINE CONTRACTIONS OR POSITION OF
THE FETUS AND NAUSEA AND VOMITING .
 ANXIETY RELATED TO CONCERN FOR SELF AND THE FETUS .
 IMPAIRED URINARY ELIMINATION RELATED TO EPIDURAL ANESTHESIA
OR FROM PRESSURE OF THE FETUS .
 INEFFECTIVE COPING RELATED DISCOMFORT .
 RISK FOR INFECTION RELATED TO RUPTURE OF MEMBRANES .
 IMPAIRED PHYSICAL MOBILITY RELATED TO MEDICAL INTERVENTIONS
AND DISCOMFORTS .
 INEFFECTIVE BREATHING PATTERN RELATED TO PAIN AND FATIGUE .
27

28. NURSING INTERVENTIONS
MAINTAINING NUTRITION AND HYDRATION
a) PROVIDING CLEAR LIQUID IN SMALL SIPS .
b) EVALUATE URINE FOR KETONE AND GLUCOSE .
c) ADMISTER I.V. FLUID AS INDICATED AND ORDERED
RELIEVING ANXIETY
a) PSYCHOLOGICAL SUPPORT .
b) INFORM ABOUT THE MATERNAL STATUS FETAL STATUS AND LABOR
PROGRESS PERIODICALY .
c) ANSWER THE QUESTIONS AND OFFER THE SUPPORT .
d) EXPLAIN THE PROCEDURE AND EQUIPMENTS USED DURING LABOR .
28

29. CONTROLLING PAIN
1. ENCOURAGE AMBULATION AS TOLERATED
2. ENCOURAGE DIVERSIONAL ACTIVITIES SREADING , TALKING
, WATCHING T.V. PLAYING CARDS …
3. TEACH PROPER BREATHING TECHNIQUE
SLOW CHEST BREATHING AVERAGE 10 TO 12 BREATHS PER MINUTE
MODIFIED PACED BREATHING AS LABOR PROGRESS SLOW CHEST
BREATHING IS NO LONGER EFFECTIVE THEN REGULAR SHALLOW
BREATHS WHILE CONTRACTION SHOULD USED
4 PROVIDING COMFORT MEASURES . GIVE BACK AND FOOT RUB .
ASSIST WOMAN IN CHANGING OF POSITION .
5 WARM SHOWER CAN BE ENCOURAGED SUCH LABORING WOMAN
SITTING ON CHAIR AND WATER RUNNING OVER HER LOWER BACK .
29

30. ENCOURAGE BLADDER EMPTYING :
1. ENCOURAGE TO VOID EVERY 2 HOURS AT LEAST 100 ML IF POSSIBLE
2. PALPATE THE LOWER ABDOMEN AND EVALUATE FOR BLADDER
DISTENTION .
3. PROVIDE PRIVACY TO PATIENT TO COMPLETE THE TASK .
4. CATHETERIZE THE PATIENT IF UNABLE TO VOID VOLUNTARILY .
5. MONITOR INTAKE OUTPUT AS PER THE FACILITY POLICY .
PREVENTING INTRA- UTERINE INFECTIONS :
1. TAKE VITALS EVERY 2 HOURS
2. PERIODICALLY CHANGE PAD AND LINEN WHEN WET OR SOILED.
3. PROVIDE PERINEAL CARE AFTER VOIDING AND WHEN NEEDED .
4. MINIMIZE VAGINAL EXAMINATIONS .
5. OBSERVE FOR FETAL TACHYCARDIA AND WARMTH OF MATERNAL SKIN
6. ASSES THE COMPLETE BLOOD COUNT AS INDICATED AND AVAILABLE
30

31. SECOND STAGE OF LABOR
TRANSITION FROM THE FIRST STAGE
TO SECOND STAGE IS EVIDENCE BY
FOLLOWING :
1. RUPTURE OF THE BAG OF MEMBRANES
WITH ESCAPE OF LIQUOR AMNII
2. INCREASING INTENSITY OF UTERINE
CONTRACTION
3. APPEARANCE OF BEARING DOWN
EFFORTS .
4. COMPLETE DILATION OF CEVIX
BIRTH
1. PERINEAL MANAGEMENT
2. ASK MOTHER TO FEEL THE BABY‟S HEAD
3. STAY FOCUSED ON WOMAN, NOT
TASKS
31

32. PRELIMINARIES
 ALL OBSERVATIONS SHOULD BE DOCUMENTED ON THE PARTOGRAM.
 OBSERVATIONS BY A MIDWIFE OF A WOMAN IN THE SECOND STAGE
OF LABOR INCLUDE:
• HOURLY BLOOD PRESSURE AND PULSE
• CONTINUED 4-HOURLY TEMPERATURE
• VAGINAL EXAMINATION OFFERED HOURLY IN THE ACTIVE SECOND
STAGE OR IN RESPONSE TO THE WOMAN‟S WISHES (AFTER ABDOMINAL
PALPATION AND ASSESSMENT OF VAGINAL LOSS)
• HALF-HOURLY DOCUMENTATION OF THE FREQUENCY OF
CONTRACTIONS
• FREQUENCY OF EMPTYING THE BLADDER
• ONGOING CONSIDERATION OF THE WOMAN‟S EMOTIONAL AND
PSYCHOLOGICAL NEEDS.
32

33. POSITIONING
 IT IS MOST BENEFICIAL FOR THE PRACTITIONERS WHO OFFERS LABOR
SUPPORT TO ENCOURAGE THE PATIENT TO UTILIZE POSITIONS IN ORDER
TO FACILITATE FETAL DESCENT . RESEARCH SUPPORTS THAT THE MOST
SUCCESSFUL POSITIONS IS THE SQUAT , ALTHOUGH OTHER POSITIONS
EXISTS . ADVANCED IMAGING TECHNIQUE HAVE VERIFIED THAT
DURING THE SQUAT POSITION THE PELVIC OUTLET INCREASES
APPROXIMATELY BY 1-2 CM .
 ADDITIONAL POSITIONING ARE AVAILABLE TO ENCOURAGE FETAL
DESCENT : SIDE LYING , KNEE-CHEST , HANDS- AND- KNEE , AND
FORWARD LEAN ACCOMPANIED BY PELVIC TILT OR PELVIC ROCKING .
 SUPINE POSITION IS INAPPROPRIATE DURING LABOR – AT ALL STAGES –
AS IT PROMOTES MATERNAL VENA CAVA COMPRESSION AND
SUBSEQUENT DEOXYGENATION OF THE MOTHER AND FETUS .
33

34. PUSHING TECHNIQUE
 FOR OPTIMAL SUCCESS THE PUSHING TECHNIQUES SHOULD BE INITIATED
ONCE THE CERVIX IS FULLY DILATED , FETAL PRESENTING PART ON THE
PELVIC FLOOR , AND PATIENT HAS SENSE TO PUSH / BEAR DOWN (
FERGUSON'S REFLEX )
 TWO METHODS OF PUSHING EXIST : PASSIVE PUSHING AND ACTIVE PUSHING
A . PASSIVE PUSHING : ( LABORING DOWN / REST AND
DESCENT )
TECHNIQUE OFFERS NO ACTIVE PARTICIPATION FROM THE PATIENT TO
FACILITATE DESCENT . THE NEED FOR THIS METHOD :
1. DUE TO EPIDURAL ANESTHESIA / ANALGESIA , THE WOMAN DOES NOT FEEL
THE URGE TO PUSH .
2. MATERNAL CLINICAL CONDITION , SUCH AS CARDIAC DISEASE , TRAUMA .
3. FETAL CLINICAL CONDITIONS , SUCH AS NON REASSURING FHR .
4. LACK OF NURSING PERSONNEL TO PROVIDE 1:1 SUPPORT .
5. MATERNAL EXHAUSTION .
34

35. B. ACTIVE PUSHING
 ACTIVE PARTICIPATION OF THE PATIENT AND THE PRACTITIONER TO
ASSIST DESCENT OUT THE FETUS . IF PROLONGED THE TECHNIQUE MAY
NEGATIVELY IMPACT ON THE FETAL WELL BEING . STRATEGIES THAT
PROMOTE OXYGEN EXCHANGE IN THE MOTHER INCLUDE :
 OPEN GLOTTIS PUSHING - THE TECHNIQUE ALLOW WOMAN TO
MAINTAIN HER AIRWAY PATENT FOR GAS EXCHANGE WHILE
ENHANCING BEARING DOWN EFFORTS WITH SEVERAL SHORTS , QUICK
BREATHS FOR CONTRACTIONS (60-90SEC) . SHORT BREATHS 4 – 6 SEC
FOLLOWED BY SLOW EXHALING WITH BEARING DOWN EFFORTS .
 BIRTHING AIDS – BIRTHING BALLS , SQUAT BARS , BIRTHING STOOLS
, AND CUSHION MAY BE UTILIZED TO SUPPORT THE WOMAN .
35

36. NURSING DIAGNOSIS
A. FEAR OR ANXIETY RELATED TO IMPENDING DELIVERY .
B. ACUTE PAIN RELATED TO DESCENT OF FETUS .
C. RISK FOR INFECTION RELATED TO EPISIOTOMY AND TISSUE TRAUMA
36
NURSING INTERVENTION
MINIMIZING FEAR AND ANXIETY
1. MONITOR MATERNAL VITAL SIGNS AS PER FACILITY POLICY .
2. MONITOR FHR AND UTERINE CONTRACTIONS EVERY 15 MINUTE IN LOW –
RISK WOMAN AND EVERY 5 MINUTE IN HIGH – RISK WOMAN .
3. EXPLAIN PROCEDURE , BREATHING , AND EQUIPMENTS DURING THE
DELIVERY PROCESS .
4. PERIODICALLY INFORM ABOUT THE PROGRESS OF LABOR TO WOMAN OR
COUPLE .
5. PROVID FREQUEN POSITIVE ENCOURAGEMENT .

37. PROMOTING COMFORT
1. CHANGE POSITION FREQUENTLY TO INCREASE AND PROMOTE FETAL
DESCENT .
2. EVALUATE BLADDER FULLNESS AND ENCOURAGE VOIDING OR
CATHETERIZE AS NEEDED .
3. EVALUATE EFFECTIVENESS OF THE ANESTHESIA AS INDICATED : NOTIFY IF
THE ALTERATION IN DOSING IS NEEDED .
PREVENTING INFECTION AND PROMOTING SAFETY
1. PREPARE BIRTHING ROOM WITH STERILE TECHNIQUES , ALLOWING AMPLE
TIME BEFORE THE DELIVERY .
2. PREPARE FETUS RESUSCITATION AREA : NOTIFY THE PEDIATRIC PERSONNEL
, IF APPROPRIATE , PER FACILITY POLICY .
3. PLACE ALL SIDES RAIL UP BEFORE MOVING AND INSTRUCT THE WOMAN
KEEP HER HANDS OFF THE RAILS MOVE BETWEEN CONTRACTIONS .
4. CLEAN THE VULVA AND PERINEAL AREA WHILE THE WOMAN IS
POSITIONING FOR THE DELIVERY .
5. PRACTICE STANDARD PRECAUTIONS DURING THE DELIVERY .
37

38.  DELIVERY OF THE HEAD
-”CROWNING: : ENCIRCLEMENT OF THE LARGEST HEAD DIAMETER BY THE
VULVAR RING .
-UNLESS EPISIOTOMY ; SPONTANEOUS LACERATION .
-IT IS NOW CLEAR THAT AN EPISIOTOMY WILL INCREASE THE RISK OF A TEAR
INTO THE EXTERNAL ANAL SPHINCTER AND THE RECTUM .
-UNLESS EPISIOTOMY. ANTERIOR TEARS INVOLVING THE URETHRA AND LABIA
ARE MUSH MORE COMMON .
RITGEN MANEUVER
- BY THE TIME THE HEAD DISTENDS THE VULVA AND PERINEUM ENOUGH TO
OPEN THE VAGINAL INTROITUS TO A DIAMATER OF 5 CM OR MORE
- ONE HAND: A TOWEL-DRAPED, GLOVED HAND MAY BE EXERT FORWARD
PRESSURE ON THE CHIN OF THE FETUS THROUGH THE PERINEUM JUST IN
FRONT OF THE COCCYX
THE OTHER HAND: EXERTS PRESSURE SUPERIORLY AGAINST THE OCCIPUT
CONDUCTION OF DELIVERY

39.  DELIVERY OF SHOULDER
THE OCCIPUT : TURNS TOWARD ONE OF THE MATERNAL THIGH
FETAL HEAD: TRANSVERSE POSITION
EXTERNAL ROTATION: BISACROMIAL DIAMETER HAD ROTATED INTO THE
ANTERIO-POSTERIOR DIMETER OF THE PELVIS .
SUCKING THE NASOPHARINX OR CHECKING FOR A CORD
DOWNWARD TRACTION : ANT. SHOULDER UNDER THE PUBIS
UPWARD MOVEMENT: POST. SHOULDER IS DELIVERED
 DELIVERY OF THE TRUNK
THE REST OF THE BODY ALMOST ALWAYS FOLLOWS THE SHOULDER WITHOUT
DIFFICULTY
PROLONGED DELAY : MORE TRACTON PRESSURE ON THE FUNDUS
TRACTION SHOULD BE EXERTED ONLY IN THE DIRECTION OF THE LONG AXIS
OF THE INFANT .

40. IMMEDIATE CARE OF THE NEWBORN
 SOON AFTER THE DELIVERY OF THE BABY PLACE IT ON THE TRAY
COVERED WITH DRY LINEN WITH THE HEAD SLIGHTLY DOWNWARDS
(15DEGREE) .
 IT FACILITATE DRAINAGE OF THE MUCUS ACCUMULATED IN THE
TRACHEO - BRONCHIAL TREE BY GRAVITY .
 AIR PASSAGE SHOULD BE CLEARED IMMEDIATELY OF MUCUS AND
LIQUOR BY GENTLE SUCTION
 A P G A R RATING : 1 MIN AND 5 MIN
40

41. PROVISION OF INTIAL CARE
 MAINTAIN RESPIRATION AND INITIATE LUNG EXPANSION
a) POSITION- MODIFIED TRENDELENBERG
b) SUCTION PM
 SUPPORTING THERMO REGULATION
a) WRAP INFANT BLANKET OR PLACE IN RADIANT WARMER
b) SKIN TO SKIN CONTACT WITH MOTHER TO PROMOTE BONDING
 PROPHYLAXIS WITH NEOMYCIN AND VIT. „K‟
 CORD CUTTING AND DRESSING AND IDENTIFYING THE INFANT
 TAKING ANTHROPOMETRIC MEASUREMENTS AND PRINTING
 GIVING THE FIRST BATH
41

42. IMMEDIATE NEWBORN ASSESSMENT AND
CARE (DELIVERY ROOM)
 NURSING ASSESSMENT
 MATERNAL HISTORY/LABOR DATA INDICATING
POTENTIAL PROBLEMS WITH NEWBORN
 APGAR SCORES
 FINDINGS OF BRIEF PHYSICAL EXAMINATION
PERFORMED IN THE DELIVERY ROOM
42
NURSING DIAGNOSES
 INEFFECTIVE AIRWAY CLEARANCE RELATED TO NASAL AND ORAL
SECRETIONS FROM DELIVERY
 INEFFECTIVE THERMOREGULATION RELATED TO ENVIRONMENT AND
IMMATURE ABILITY FOR ADAPTATION
 RISK FOR INJURY RELATED TO IMMATURE DEFENSES OF THE NEWBORN

43. Plans and Interventions
 WHEN THE HEAD IS DELIVERED BIRTH
ATTENDANT IMMEDIATELY SUCTION
SECRETIONS
 WIPE MUCUS FROM FACE AND MOUTH
AND NOSE
 ASPIRATE/SUCTION MOUTH AND NOSE
BULB SYRINGE
 KEEP HEAD SLIGHTLY LOWER THAN THE
BODY
43
1. SUCTIONING IMMEDIATELY
CLEAN MUCOUS FROM THE FACE , MOUTH AND NOSE . ASPIRATION WITH
BULB SYRINGE AS PER NECESSARY .
NEONATAL RESUSCITATOR PROTOCOLS NO LONGER REQUIRE SUCTIONING
ON THE PERINEUM IF MECONIUM IS PRESENT IN THE AMNIOTIC FLUID .
 IF MECONIUM IS PRESENT AND BABY IS NOT VIGOROUS SUCTION THE
TRACHEA BEFORE PROCEEDING WITH OTHER STEPS .

44. 2. ASSESSING RESPIRATORY STATUS
A. ASSESS FOR 5 SYMPTOMS OF RESPIRATORY DISTRESS
1. RETRACTIONS
2. TACHYPNEA (RATE: >60 CPM)
3. DUSKY COLOR/CIRCUMORAL CYANOSIS
4. EXPIRATORY GRUNT
5. FLARING NARESB.
B. DO NOT HYPEREXTEND NECK AT ANYTIME (MAY CLOSE GLOTTIS)
1. PLACE INFANT IN “SNIFF” POSITION
2. NECK SLIGHTLY EXTENDED AS IF SNIFFING AIR OPENS AIRWAY
44
3.PREVENT HEAT LOSS
 IMMEDIATELY DRY INFANT UNDER A RADIANT
WARMER OR SKIN TO SKIN CONTACT WITH THE
MOTHER
 KEEP NEONATES HEAD COVERED
 INFANT TEMPERATURE SHOULD BE ABOVE
36.4°C.
 INFANTS LOSE HEAT THROUGH EVAPORATION,
RADIATION, CONDUCTION AND CONVECTION.

45. 4.APGAR SCORE
OBTAIN APGAR SCORING AT 1 MIN AND 5 MIN
 APGAR TEST IS A SCORING SYSTEM DESIGNED BY DR. VIRGINIA APGAR,
AN ANESTHESIOLOGIST,
 A SYSTEMATIC AND MEASURABLE METHOD TO ACCESS THE NEWBORN
IN THE CRUCIAL MINUTES AFTER BIRTH.
 PURPOSES:
1. IDENTIFY NEONATES EVALUATE THE CONDITIONS OF THE BABY AT BIRTH.
2. DETERMINE THE NEED FOR RESUSCITATION.
3. EVALUATE THE EFFECTIVENESS OF RESUSCITATIVE EFFORTS.
4. IDENTIFY NEONATE AT RISK FOR MORBIDITY AND MORTALITY.
45

46. TEST 0 POINTS 1 POINT 2 POINTS
ACTIVITY (MUSCLE
TONE)
ABSENT ARMS & LEGS
EXTENDED
ACTIVE MOVEMENT
WITH FLEXED ARMS
& LEGS
PULSE (HEART RATE) ABSENT BELOW 100
BPM
ABOVE 100 BPM
GRIMACE (RESPONSE
STIMULATION OR REFLEX
IRRITABILITY)
NO
RESPONSE
FACIAL
GRIMACE
SNEEZE, COUGH,
PULLS AWAY
APPEARANCE (SKIN
COLOR)
BLUE-GRAY,
PALE ALL
OVER
PINK BODY
AND BLUE
EXTREMITIES
NORMAL OVER
ENTIRE BODY –
COMPLETELY PINK
RESPIRATION
(BREATHING)
ABSENT SLOW,
IRREGULAR
GOOD, CRYING
46
APGAR SCORE

47. APGAR SCORE
IF THERE ARE PROBLEMS WITH THE INFANT
• AN ADDITIONAL SCORE MAY BE REPEATED AT A 10-MINUTE
INTERVAL.
• FOR A CESAREAN SECTION:
• THE BABY IS ADDITIONALLY ASSESSED AT 15 MINUTES AFTER
DELIVERY.
SCORING
• 7-9 = FREE FROM IMMEDIATE DISTRESS; NORMAL
• 4-6 = MODERATELY DEPRESSED; MAY REQUIRE ADDITIONAL
RESUSCITATIVE MEASURES
• 0-3 = SEVERELY DEPRESSED; NECESSITATES IMMEDIATE MEDICAL
ATTENTION
NOTE: APGAR SCORE
IS STRICTLY USED TO DETERMINE THE NEWBORN‟S IMMEDIATE
CONDITION AT BIRTH AND DOES NOT NECESSARILY REFLECT THE
FUTURE HEALTH OF YOUR BABY. 47

48. 48
CLAMPING AND LIGATURE OF THE
CORD
THE NEAR ONE IS PLACED 5 CM AWAY FROM THE UMBILICUS AND IS CUT IN
BETWEEN .
TWO SEPARATE CORD LIGATURE IS APPLIED WITH STERILE COTTON TREADS 1
CM APART USING REEF KNOT , THE PROXIMAL BEING PLACED 2.5 CM AWAY
FROM THE NAVAL . SQUEEZING THE CORD WITH FINGERS PRIOR TO APPLYING
LIGATURE . LEAVING BEHIND A LENGTH OF CORD ATTACHED TO THE NAVAL
NOT ONLY PREVENTS INCLUSION OF THE EMBRYONIC STRUCTURES , IF
PRESENT , BUT ALSO FACILITATE CONTROL OF PRIMARY HAEMORRHAGE DUE
TO SLIPPED LIGATURE .THE CORD IS DIVIDED WITH SCISSOR 1 CM BEYOND THE
LIGATURE TAKING ASEPTIC PRECAUTIONS SO AS TO PREVENT CORD SEPSIS .

49.  CLAMP THE CORD WITH TWO KOCHER‟S FORCEPS . THE CUT END IS THEN
COVERED WITH STERILE GUAZE PIECE AFTER MAKING SURE THAT THERE IS
NO BLEEDING.
PURPOSE OF CLAMPING OF CORD ON MATERNAL END IS TO PREVENTING
SOILING OF BED WITH BLOOD AND TO PREVENT FETAL BLOOD LOSS OF
SECOND BABY IN UNDIAGNOSED MONOZYGOTIC TWIN .
 DELAY IN CLAMPING FOR 2-3 MIN OR TILL CESSATION OF THE CORD
PULSATION FACILITATES TRANSFER OF 80-100 ML BLOOD FROM
COMPRESSED PLACENTA TO BABY WHEN PLACED BELOW THE LEVEL OF
UTERUS .
 QUICK CHECK IS MADE TO DETECT ANY ABNORMALITY AND THE BABY IS
WRAPPED WITH DRY WARM TOWEL . THE IDENTIFICATION TAG IS TIED TO
BOTH MOTHER AND BABY ON THE WRIST .
 BABY WHEN PLACED BELOW LEVEL OF THE UTERUS . ITS BENEFICIAL FOR
MATURE BABY BUT CAN BE DELETERIOUS TO A PRE-TERM BABY DUE TO
HYPERVOLAEMIA .
49

50.  THE UMBILICAL STUMP NEEDS PARTICULAR ATTENTION AS THERE ARE
RISKS OF BLEEDING AND INFECTION.
 GOOD CORD CARE INCLUDES:
 CUTTING CORD WITH STERILE EQUIPMENT OR A NEW RAZOR BLADE
DEPENDING ON THE SETTING
 LIGATION WITH A STERILE PLASTIC CLAMP OR CLEAN THREAD
 KEEPING CORD STUMP EXPOSED, CLEAN (WITH 70% ALCOHOL, 4%
CHLORHEXIDINE OR SIMPLE SOAP AND WATER) AND DRY
50
CORD CARE
EXAMINE CORD FOR PRESENCE OF 3 VESSELS AND DOCUMENT 2
ARTERIES AND 1 VEIN.

51. CORD BLOOD COLLECTION
MAKE SURE CORD BLOOD IS COLLECTED FOR ANALYSIS AND SENT TO
LABORATORY FOR CHECKING :
◦ RH
◦ BLOOD TYPE
◦ HEMATOCRIT
◦ POSSIBLE CORD BLOOD GASES
51
FOOT PRINTING
FOOTPRINTS ARE OFTEN TAKEN AND RECORDED IN THE MEDICAL RECORD.

52. NEWBORN VITAL SIGNS
52

53. VITAMIN K
ADMINISTER A PROPHYLACTIC VITAMIN K
◦ PREVENT NEONATAL HEMORRHAGE DURING FIRST FEW DAYS OF LIFE
BEFORE INFANT IS ABLE TO PRODUCE VIT. K
◦ RECOMMENDED ROUTE OF ADMINISTRATION: INTRAMUSCULAR
◦ DOSE:
 1MG (OF KONAKION MM®, 2MG/0.2ML) BEING GIVEN AT BIRTH.
 PRETERM INFANTS MAY RECEIVE 0.5MG.
◦ ALTERNATIVE ROUTE: ORAL
◦ DOSE:
 2MG ORALLY AT BIRTH;
 REPEAT DOSE (2MG) AT 3-5 DAYS AND AT 4-6 WEEKS OF AGE.
 REPEAT DOSE IF THE INFANT VOMITS OR REGURGITATES WITHIN 1
HOUR
53

54. ANTHROPOMETRIC MEASUREMENTS
MEASURE WEIGHT, LENGTH, AND HEAD CIRCUMFERENCE
 HELPS DETERMINE IF A BABY'S WEIGHT AND MEASUREMENTS ARE
NORMAL FOR THE NUMBER OF WEEKS OF PREGNANCY.
 SMALL OR UNDERWEIGHT BABIES, AS WELL AS VERY LARGE BABIES,
MAY NEED SPECIAL ATTENTION AND CARE.
54

55. LENGTH (FROM TOP OF HEAD TO THE HEEL WITH
THE LEG FULLY EXTENDED
55
AVERAGE RANGE:
18-22 INCHES (46-56 CM)
MEASURED FROM CROWN TO RUMP AND RUMP TO HEEL OR FROM CROWN
TO HEEL AT BIRTH
HEAD CIRCUMFERENCE (REPEAT AFTER
MOLDING AND CAPUT SUCCEDANEUM ARE
RESOLVED)
AVERAGE RANGE:
33 TO 35 CM (13-14 INCHES)
NORMALLY, 2 CM LARGER THAN CHEST CIRCUMFERENCE
PLACE TAPE MEASURE ABOVE EYEBROWS AND STRETCH AROUND FULLEST
PART OF OCCIPUT AT POSTERIOR FONTANELE

56. WEIGHT MEASUREMENT
56
CHEST CIRCUMFERENCE
(AT THE NIPPLE LINE)
AVERAGE RANGE:
30-33 CM (12-13 INCHES)
NORMALLY, 2 CM SMALLER THAN HEAD CIRCUMFERENCE
STRETCH TAPE MEASURE AROUND SCAPULAE AND OVER NIPPLE LINE

57. NEWBORN IDENTIFICATION
 BEFORE A BABY LEAVES THE
DELIVERY AREA, IDENTIFICATION
BRACELETS WITH IDENTICAL
NUMBERS ARE PLACED ON THE
BABY AND MOTHER.
 BABIES OFTEN HAVE TWO, ON
THE WRIST AND ANKLE.
57
EXERCIESE :SAY TRUE OR FALSE
a. NURSING A NEWBORN WITH THE MOTHER RATHER THAN IN THE NURSERY
PREDISPOSES THE CHILD TO INFECTIONS
b. HAND WASHING WITH SOAP AND WATER BEFORE HANDLING A
NEWBORN SIGNIFICANTLY REDUCES THE RISK OF INFECTION IN THE BABY
c. FORTIFIED INFANT FORMULA IS SUPERIOR TO MOTHER‟S BREAST MILK IN A
SICK TERM NEWBORN .
d. NEWBORN BABIES CANNOT BE KEPT WARM WITHOUT THE USE OF
INCUBATORS

58. MANAGEMENT OF THIRD STAGE OF
LABOR
58
 ENSURE SRTICT VIGILANCE AND
TO FOLLOW THE MANAGEMENT
GUIDELINES SRICTLY IN PRACTICE
IN ORDER TO PREVENT POST
PARTUM COMPLICATIONS , THE
IMPORTANT ONE BEING
HEMORRHAGE .
TWO METHODS OF MANAGEMENT
ARE CURRENTLY IN PRACTICE :
1. WATCHFUL EXPECTANCY
(15-20MIN)
2. ACTIVE MANAGEMENT
(PREFERRED)

59. TWO METHODS OF THIRD STAGE
MANAGEMENT
PHYSIOLOGIC (“EXPECTANT”) MANAGEMENT
OXYTOCICS ARE NOT USED
PLACENTA IS DELIVERED BY GRAVITY AND MATERNAL EFFORTS
SPONTANEOUSLY .
CONSTANT WATCH IS MANDATORY AND PATIENT SHOULD NOT BE LEFT ALONE
CATHETERIZE ONE MORE TIME IF THE BLADDER BECOMES FULL .
A HAND PLACED OVER FUNDUS :
a) TO RECOGNIZE THE SIGNS OF SEPARATION OF PLACENTA
b) TO NOTE THE UTERINE ACTIVITY – CONTRACTION AND RELAXATION
c) TO DETECT CUPPING OF FUNDUS , THOUGH RARE ,WHICH IS AN EARLY
EVIDENCE OF INVERSION OF UTERUS .
DESIRE TO FIDDLE WITH THE FUNDUS OR MASSAGE THE UTERUS IS ONLY TO
MET DISASTER AND IS STRONGLY CONDEMNED . CORD IS CLAMPED
AFTER DELIVERY OF THE PLACENTA . A WATCHFUL EXPECTANCY CAN
BE EXTENDED UP TO 15-20 MIN .
59

60. ASSISTED EXPULSION
◦ FUNDAL PRESSURE FUNDUS IS PUSH DOWNWARD AND BACKWARD AFTER
PLACING FOUR FINGERS BEHIND THE FUNDUS AND THE THUMB IN FRONT OF
USING UTERUS AS SORT OF PISTON . THE PRESSURE MUST BE GIVEN ONLY WHEN
UTERUS BECOMES HARD .IF IT IS NOT THEN MAKE IT BY GENTLY RUBBING .IF BABY
IS MACERATED OR PREMATURE THIS METHOD IS PREFERABLE FOR CORD
CONTRACTIONS TENSILE STRENGTH OF CORD IS MUCH REDUCED IN BOTH THE
INSTANCES .
◦ PLACENTA DELIVERED BY CONTROLLED CORD TRACTION (CCT) ALSO CALLED
MODIFIED BRANDT – ANDREWS METHOD WITH COUNTER-TRACTION ON THE
FUNDUS THE PALMER SURFACE OF THE FINGERS OF THE LEFT HAND IS PLACED
ABOVE APPROXIMATELY AT THE JUNCTION OF UPPER AND LOWER UTERINE
SEGMENT . THE BODY OF UTERUS PUSHED UPWARD AND BACKWARD , TOWARDS
THE UMBILICUS WHILE BY THE RIGHT HAND STEADY TENSION IS GIVEN IN
DOWNWARD AND BACKWARD DIRECTION HOLDING THE CLAMP UNTIL THE
PLACENTA COMES OUTSIDE THE INTROITS .
60

61. PLACENTAL SEPARATION
61
1. INCREASED BLEEDING
2. LENGTHENING OF CORD
3. UTERUS RISES , BECOMES GLOBULAR
INSTEAD OF DISCOID
4. UTERUS ENLARGES , APPROACHING
UMBILICUS
 NORMALY SEPARATES WITHIN A FEW
MINUTES AFTER DELIVERY OF FETUS .
SIGNS OF SEPARATION
FUNDAL MASSAGE AFTER DELIVERY OF PLACENTA WHICH FACILITATES THE
EXPULSION OF RETAINED CLOTS IF ANY .
NOTE THE FOLLOWING
MAKE SURE IT IS COMPLETE
LOOK FOR MISSING PIECES
LOOK FOR MALFORMATION
LOOK FOR AREA OF ADHERENT BLOOD CLOT

62. ACTIVE MANAGEMENT OF THIRD STAGE
THE UNDERLYING PRINCIPLES
 EXCITE POWERFUL UTERINE CONTRACTION WITHIN ONE MINUTE OF DELIVERY
OF THE BABY BY GIVING PARENTERAL OXYTOCIC .
 IT PRODUCE EARLY PLACENTAL SEPARATION AND ALSO PRODUCE EFFECTIVE
UTERINE CONTRACTION .
ADVANTAGES
 MINIMIZE BLOOD LOSS UP TO 1/ 5 TH
 SHORTEN DURATION OF THIRD STAGE TO HALF
 ONLY DISADVANTAGE IS SLIGHTLY INCREASE INCIDENCE OF RETAINED
PLACENTA AND CONSEQUENT INREASED INCIDENCE OF MANNUAL
REMOVAL
62

63. OXYTOCIC(UTEROTONIC)
DRUGS
 COMBINED ERGOMETRINE AND OXYTOCIN
 1ML AMPOULE CONTAINS 5 INTERNATIONAL UNITS OF OXYTOCIN AND 0.5 MG
(500 MCG) OF ERGOMETRINE
 INTRAMUSCULAR ADMINISTRATION OF 1ML AT DELIVERY OF ANTERIOR
SHOULDER
 NO MORE THAN 2 DOSES OF 0.5MG ERGOMETRINE SHOULD BE GIVEN .
 OXYTOCIN COMPONENT ACTS ON OUTER REGION WITHIN 2-3 MINUTES AND
PRODUCES STRONG „PHYSIOLOGICAL‟ CONTRACTIONS
 ERGOMETRINE ACTS ON INNER REGION WITHIN 6-7 MINUTES AND PRODUCES A
CONTINUOUS (TONIC) CONTRACTION LASTING UP TO 2 HOURS
 COMBINED ACTION RESULTS IN A RAPID CONTRACTION ENHANCED BY A
STRONGER, SUSTAINED CONTRACTION
 DELIVERY OF PLACENTA TIMED TO TAKE PLACE WITH THE CONTRACTION
CAUSED BY THE OXYTOCIN AND BEFORE ERGOMETRINE COMPONENT ACTS
OTHERWISE IT MAY BE RETAINED

64. PREVENTING HEMORRHAGE
1. ENSURE ACCURATE MEASUREMENT OF INTAKE AND OUTPUT MAINTAINED
THROUGH OUT THE LABOR AND DELIVERY .
2. IMMEDIATELY AFTER DELIVERY OF PLACENTA , ADMINISTER OXYTOCIN
(PITOCINE) AS DIRECTED BY FACILITY POLICY AND PROVIDER . INFUSE AS
BOLUS INITIALY , THEN TITRATE AS PER UTERINE RESPONSE ( I.E.. IF UTERUS IS
FIRM , DECREASE THE INFUSION AND IF BOGGY , INCREASE INFUSION ) .
OXYTOCINE SHOULD NEVER ADMINISTERED I.V. PUSH AS IT CAN CAUSE
CARDIAC DYSRHYTHMIA AND DEATH .
3. IMMEDIATELY AFTER INITIATING OXYTOCINE , GENTLY MASSAGE UTERINE
FUNDUS PERIODICALLY TO PROMOTE FIRMNESS .
4. EVALUATE THE UNDERSIDE OF PLACENTA . INTACT COTYLEDON , CLOT
, MEMBRANE MAY ALSO STIMULATE THE BLEEDING . IF CLOT ARE NOT
EXPELLED DURING PERIODIC EVALUATION DURING FIRST HOUR
FOLLOWING DELIVERY , RISK OF HEMORRHAGE INCREASES .
64

65. 5. EVALUATE VOLUME OF VAGINAL BLEEDING AS STABLE OR UNSTABLE AS PER
THE PATIENT‟S VITAL SIGNS AND UTERINE RESPONSE .
STABLE : VITAL SIGNS WITHIN 20% OF PATIENT‟S AVERAGE READINGS AND
UTERUS REMAINS FIRM BETWEEN ASSESSMENT OR QUICKLY FIRMS AFTER
FUNDAL MASSAGE
UNSTABLE : VITAL SIGNS VARY GREATER THAN 20% FROM THE PATIENT‟S
AVERAGE READINGS OR REPETITIVE BLOOD PRESSURE READINGS BELOW
90/60 MM HG , PULSE MORE THAN 110/MIN , RESPIRATION 24 TO 26 / MIN
ACCOMPANIED BY CONTINUOUS BLEEDING AND A BOGGY UTERINE TONE .
 INCREASE PULSE RATE IS THE FIRST SIGN OF THE HYPOVOLUMIA AND
VHYPOTENSION IS LATE .
6. IF BLEEDING CONTINUES AND UTERUS IS FIRM , NOTIFY HEALTH CARE
PROVIDER FOR EVALUATION OF LACERATION OR RETAINED PLACENTAL
FRAGMENTS .
7. AUTOTRANSFUSION

66. NURSING DIAGNOSIS
 RISK FOR INJURY RELATED TO UTERINE ATONY AND HEMORRHAGE
 DEFICIENT FLUID VOLUME RELATED TO DECREASE ORAL INTAKE , BLEEDING
AND DIAPHORESIS .
 ACUTE PAIN RELATED TO TISSUE TRAUMA AND BIRTH PROCEESS ,
INTENSIFIED BY FATIGUE .
 IMPAIRED URINARY ELIMINATION RELATED TO EPIDURAL AND SPINAL
ANESTHESIA AND TISSUE TRAUMA .
 RISK OF IMPAIRED PARENTING RELATED TO INEXPERIENCE .
66
MANAGEMENT OF FORTH STAGE OF LABOR
EVENTS IN FORTH STAGE OF LABOR
LASTS FROM DELIVERY OF PLACENTA UNTIL POSTPARTUM CONDITION OF
WOMAN HAS BECOME STABILIZED
( TYPICALLY 1TO 2 HOURS AFTER DELIVERY )

67. 67
NURSING INTERVENTIONS
PROMOTING UTERINNE CONTRACTION AND CONTROLING BLEEDING
1. MONITOR VITAL SIGNS
2. SPECIALY TEMPERATURE SHOULD BE MONITOR EVERY 4 HOUR UNLESS
ELEVATED .
3. EVALUATE UTERINE FUNDAL TONE , HEIGHT , AND POSITION . THE UTERUS
SHOULD BE FIRM AROUND THE LEVEL OF THE UMBILICUS , AT THE MIDLINE
4 . AMOUNT OF VAGINAL BLEEDING (LOCHIA ) AT EACH INTERVAL OF
ASSESSMENT :
I. SCANT - BLOOD ONLY ON TISSUE WHEN WIPED OR LESS THAN 1 – INCH
STAINED ON PERINEAL PAD .
II. SMALL / LIGHT - LESS THAN 4 – INCH STAIN ON PAD .
III. MODERATE - LESS THAN 6 – INCH STAINED ON PERINEAL PAD
IV. HEAVY - SATURED PERINEAL PAD

68. 68
PERINEUM FOR EDEMA , DISCOLORATION , BLEEDING , ODOR OR HEMATOMA
FORMATION .
MAINTAINING FLUID VOLUME
I. MAINTAINING I.V. FLUIDS AS INDICATED .
II. PROVIDE ORAL FLUIDS AND SNACK OR MEAL AS TOLERATED IF VITALS
ARE STABLE AND BLEEDING IS CONTROLLED .
RELIEVING DISCOMFORT AND FATIGUE
I. APPLY THE COVERED ICE PACK TO THE PERINEUM PERIODICALLY DURING
FIRST 24 HOURS FOR EPISIOTOMY , PERINEAL LACERATION , OR EDEMA .
II. ADMINISTER ANALGESIC AS PER INDICATED .
III. ASSURE THAT EPIDURAL CATHETER HAS BEEN REMOVED .
IV. ASSIST WOMAN IN FINDING COMFORTABLE POSITIONS .

69. ENCOURAGING BLADDER EMPTYING
I. EVALUATE THE BLADDER FOR DISTENTION .
II. ENCOURAGE THE WOMAN TO VOID .
III. PROVIDE PRIVACY AND TIME.
IV. THE RUNNING TAP WATER MAY STIMULATE VOIDING .
V. CATHETER THE WOMAN IF THE BLADDER IS FULL AND SHE IS UNABLE TO
VOID .
PROMOTING PARENTING
I. SHOW THE NEONATE TO MOTHER AND FATHER OR SUPPORT PERSON
IMMEDIATELY AFTER THE BIRTH WHEN POSSIBLE .
II. TEACH THE MOTHER AND FATHER TO HOLD THE INFANT AS SOON AS
POSSIBLE .
III. ASSIST THE MOTHER WITH BREAST – FEEDING DURING THE FIRST 30
MINUTE THEN 2 HOURS AFTER THE BIRTH .
69

70. 70
Partograph (Progress of labor )

71. REFERENCES
 TEXT BOOK OF OBSTETRICS – D. C. DUTTA – FIF TH EDITION
 LIPPINCOTT MANUAL OF NURSING PRACTICE – SECTION THREE –
MATERNAL AND NEONATAL NURSING – NINTH EDITION
 ESSENTIALS OF PEDIATRICS – O P GHAIS – SIXTH EDITION
 INTERNET – www.nursingcrib.com
ENCYCLOPEDIA- GOOGLE SEARCH
 MYLES TEXTBOOK OF MIDWIFERY – FIFTINTH EDITION
71