LABOR

Theories of Labor
● Oxytocin Stimulation Theory – PPG releases oxytocin which stimulates uterine
contraction
● Uterine Stretch Theory – “any hollow muscular organ when stretched to capacity
will contract and empty”
● Progesterone Deprivation Theory – decrease progesterone production by
placenta
● Prostaglandin Theory – fetal membrane produce arachidonic acid converted by
deciduas into the prostaglandin
● Theory of Aging Placenta – “aged” placenta is less efficient

● Fetal Adrenal Response Theory – increase cortisol, decrease progesterone and

increase prostaglandin

Signs of Labor (Prodromal/Preliminary Sign)

● Lightening – descent of fetal presenting part into the pelvis
- 2 weeks before labor in primi’s
- During labor in multiparas
- Results in shooting leg pains, due to increase pressure on the sciatic
nerve, increase leucorrhea, increase urinary frequency
● Increase Level of Activity - increase energy due to decrease progesterone by
placenta
- increase epinephrine prepares woman’s body for labor
● Braxton Hicks Contraction – strong uterine contractions enough to cause
discomfort
● Ripening of the Cervix – internal sign seen only in pelvic exam
- ripe cervix is “butter-soft”
● Weight Loss – 2 weeks before labor, 2-4 weight loss

● Uterine Contraction – productive uterine contractions (surest sign labor has

begun)
● Show – mucus plug in the cervix (operculum) is mixed with blood from ruptured
cervical capillaries (pink or red)
 ● Rupture of Membranes (BOW) Ruptures – sudden gush or as scanty, slow,
seeping of clear fluid from the vagina
- 2 risks: intrauterine infection and prolapse cord

Signs of True Labor

True labor False Labor

- begin irregularly but become regular and predictable - irregular and remain no dilatation
- felt in lower back then in the abdomen - confined in the abdomen
- continue with activity, cervix dilates -disappears with ambulation/sleep
- increase duration, frequency, intensity - no increase duration, intensity

Components of Labor: (5 P’s)

A. Passage – Pelvis
B. Passenger
C. Power
D. Psyche
E. Person

Passage: (Pelvis)

Types of Passage
Soft – lower uterine segment, cervix, vagina, pelvic floor, perineum
Hard – bony pelvis
Functions:
● Protect organs in the pelvic cavity

● Provides attachments to muscles, fascia and ligaments

● Support the uterus during pregnancy

● Birth canal

THE PELVIS
Structure
a. 2 os coxae or innominate bone (ilium, ischium, pubes)
b. Sacrum (wedge-shaped bone)
c. Coccyx (lowest part of the spine)
Divisions
1. False Pelvis- superior half of the pelvis formed by the ilia
2. True pelvis- inferior half formed by the pubis in front, ilia and ischia on the sides
and sacrum and coccyx behind.

THREE PARTS
 1. Inlet- entranceway to the true pelvis
2. Cavity- space between the inlet and outlet.
3. Outlet- inferior portion of the pelvis bounded by the coccyx at the back, ischial
tuberosities at the sides and inferior symphysis pubis and pubic arch in front.

Types/Variations
a. Gynecoid- normal female pelvis most ideal for childbirth.
b. Anthropoid
c. Platypelloid
d. Android

Measurements

A. External – suggestive only of the pelvic size

1. Intercristal- distance between the middle points of the iliac crests. Average is 28
cm
2. Interspinous- distance between the antero-superior iliac spines. Average is 25
cm.
3. Intertrochanteric- distance between the trochanters of the femur. Average is 31
cm.
4. External conjugate/ Baudeloque’s- distance between the anterior aspect of the
symphysis pubis and depression below the lumbar 5 average is 18-20 cm.

B. Internal- gives the actual diameter of the inlet and outlet

1. Diagonal Conjugate- distance between the sacral promontory and inferior margin
of the symphysis pubis average is 12.5 cm.
2. True Conjugate or Conjugata Vera- distance between the anterior surface of the
sacral promontory and superior margin of the symphysis pubis. Average
diameter is 10.5 –11 cm.
3. Bi- ischial diameter/Tuberischii- transverse diameter of the pelvic outlet. Average
is 11 cm.

Types:
● Gynecoid – normal female pelvis, most ideal for child birth (50%)

● Android – male pelvis, most difficult (20%)

● Anthropoid – ape-like, deepest type, wide AP diameter (25%)

● Platypelloid – flat pelvis, wide transverse diameter, shallow AP diameter

Parts:
1. Innominate bones – ilium, ischium, pubis (all paired)
● Ilium – flared portion, forms the hip of the bone
 ● Ischium – ischial tuberosities (body sits on it), ischial spines (fetal
station)
● Pubis – front bones
2. Sacrum – triangular shape bone, fused sacral vertebra, 1 st vertebra –
sacral promontory (conjugate measurement)
3. Coccyx – tail bone

Division: Linea Terminalis (separates true and false pelvis) at the level of
sacral promontory and symphysis pubis

Labor refers to the process of childbirth, during which a pregnant woman

experiences rhythmic uterine contractions that lead to the progressive opening of
the cervix and the eventual delivery of the baby. It is a natural and dynamic
process that signifies the end of pregnancy and the beginning of motherhood.

Establishing Therapeutic Relationship

To gain the patient and family’s cooperation and trust, it is important that the
nurse should be able to establish a therapeutic relationship with them. The nurse
should introduce himself and make them feel welcome. At this point, they are all
anxious and it is best for the nurse to convey his message gently and confidently.
Expectations of the family about birth should be determined and it is also the best
time to ascertain cultural values.

Admission Assessment
When a patient arrives at the labor floor, pertinent information about the pregnant
woman’s health history is taken during admission. These include personal data
(e.g. blood type, allergies, etc.), previous illness, pregnancy complications,
preferences for labor and delivery, and childbirth preparations. Standard
obstetric, medical, and social history taking is also done.

In addition, the nurse assesses the following: vital signs, physical exam,
contraction pattern (frequency, interval, duration, and intensity), intactness of
membranes through a vaginal exam, and fetal well-being through fetal heart rate,
characteristic of amniotic fluid, and contractions. The nurse performs Leopold’s
maneuver to determine the fetal presenting part, point of maximum impulse, fetal
descent, and engagement.
Admission into the labor room is only done when the patient is in active labor.

Stages of Labor
The progress of cervical effacement, cervical dilatation, and descent of the fetal
presenting part dictate stages of labor. Here are the stages of labor and
significant events that mark their beginning and end:

Stages Start End Duration

of Labor

Nullipara Multipara

First True labor contractions Full 10-12 hr but 6-8 hrs but
Stage cervical 6-20 hrs is 2-12 hrs is
dilatation the normal the normal
limit limit

Latent Onset of regularly 3 cm 6 hrs 4.5 hrs

phase perceived uterine cervical
contractions (mild dilatation
contractions lasting
20-40 sec)

Active Stronger uterine 7 cm 3 hrs 2 hrs

phase contractions lasting cervical
40-60secs dilatation
 Transitio Uterine contractions 10 cm 3 hrs 1.5-2 hrs
nal phase reaching their peak, cervical
occurring every 2-3 dilatation
minutes for 60-90 s

Second Full cervical dilatation Infant <2 hrs 0.5-1 hrs

Stage birth

3 hrs with 2 hrs with

epidurals epidurals

Third Infant birth Placental Maximum of 30 min.

Stage delivery

First Stage of Labor

As mentioned above, the first stage of labor is divided into three sub-phases,
namely: latent, active, and transitional phases.

Latent Phase

Latent (Preparatory) Phase starts from the onset of true labor contractions to 3
cm cervical dilatation. Here are nursing responsibilities during this phase:

1. Assess patient’s psychological readiness. Provide continuous

maternal support (compared to usual care).
2. Measure duration of latent phase. For nulliparas, it should not be
more than 6 hours. On the other hand, for multiparas, it should be
within 4.5 hours. Determine if patient received anesthesia because it
can prolong latent phase. One of the most common cause of
prolonged latent phase is cephalopelvic disproportion (CPD) and it
requires cesarean birth.
 3. Allow patient to be continually active. Upright maternal positions are
recommended for women on the first stage of labor. Patients without
pregnancy complications can still walk around and make necessary
birth preparations.
4. Conduct interviews and filling in of forms (e.g. birth certificate) at this
phase while the patient experiences minimal discomfort and has
control over contraction pains.
5. Conduct health teaching on breastfeeding, newborn care, and
effective bearing down because during this time, patient’s anxiety is
controlled and she is able to focus on nurse’s instructions.
6. Educate patient on different relaxation techniques. As early as this
phase, encourage patient to begin alternative therapy of pain relief.
7. Ensure that the total number of internal examinations the woman
receives in the entire course of labor is limited to 5 only.
8. Ensure that birthing companion of choice is present all throughout
the course of labor.

Active Phase

Active Phase starts from 4 cm cervical dilatation to 7 cm cervical dilatation.

During this phase, contraction intensity is stronger, interval shortens, and
duration lengthens. This is where true discomfort is first felt by the patient so she
is dependent and her focus is on herself. Here are nursing responsibilities in this
phase:

1. Inform patient on the progress of her labor to lessen her anxiety

and obtain her trust and cooperation.
2. Start monitoring progress of labor with the use of WHO partograph,
2-hour action line.
3. Encourage patient to be continually active to maximize the effect
of uterine contractions. Upright maternal positions are recommended
if tolerated.
4. Assist patient in assuming her position of comfort. For those
who can’t stay upright, left-side lying is recommended to avoid
disruption in fetal oxygenation.
5. Monitor maternal vital signs and fetal heart rate every 2 hours,
or depending on the doctor’s order.
6. Anticipate patient needs (e.g. sponging face with cool cloth, keeping
bed clean and dry, providing ice chips or lip balm) to promote
comfort.
7. Determine when patient last voided because a full bladder can hinder
fast labor progress.
 8. Institute non-pharmacological pain measures (e.g. breathing
exercises, distraction method, imagery, music therapy, etc.)

Transition Phase

Transition Phase starts from 8 cm cervical dilatation to 10 cm (full) cervical

dilatation and full cervical effacement. During this time, patient may be exhausted
and withdrawn or aggressive and restless. Patient’s urge to push is noticeable.
Here are nursing responsibilities in this phase:

1. Inform patient on progress of her labor.

2. Assist patient with pant-blow breathing.
3. Monitor maternal vital signs and fetal heart rate every 30 minutes -1
hour, or depending on the doctor’s order. Contraction monitoring is
also continued.
4. When perineal bulging is noticeable, prepare for delivery. Check
room temperature (25-280C and free of air drafts). The nurse should
also notify staff and prepare necessary supplies and equipment,
including resuscitation machine. Lastly, perform handwashing and
double gloving.

WHO do not recommend the following nursing interventions during labor

because they have low quality of evidence:

1. Routine perineal shaving

2. Routine use of enema
3. Admission cardiotocography (CTG) for low-risk women
4. Vaginal douching
5. Routine amniotomy for patients in spontaneous labor
6. Massage and reflexology

Second Stage of Labor

Second Stage of Labor starts when cervical dilatation reaches 10 cm and ends
when the baby is delivered. At this stage, the patient feels an uncontrollable urge
to push. The patient may also experience temporary nausea together with
increased restlessness and shaking of extremities. The nurse at this stage must
coach quality pushing and support delivery.

Here are nursing care tips for this stage:

 1. Instruct patient on quality pushing. The abdominal muscles must aid
the involuntary uterine contractions to deliver the baby out.
2. Provide a quiet environment for the patient to concentrate on bearing
down.
3. Provide positive feedback as the patient pushes.
4. Repeat the doctor’s instructions. At this phase, the patient barely
hears the conversation around the room because all her energy and
thoughts are being directed toward giving birth.
5. Take note of the time of delivery and proceed to initiate essential
newborn care. Delayed cord clamping is recommended.
6. Assist in restrictive episiotomy for patients who had vaginal births.

WHO do not recommend the following interventions during delivery because

they provide low quality evidence:

1. Perineal massage
2. Use of fundal pressure

Third Stage of Labor

Third Stage of Labor or the placental stage starts from birth of infant to
delivery of placenta. It is divided into two separate phases: placental separation
and placental expulsion. Five minutes after delivery of baby, the uterus begins to
contract again, and placenta starts to separate from the contracting wall. Blood
loss of 300-500 mL occurs as a normal consequence of placental separation.
Placenta sinks to the lower uterine segment or upper vagina. The placenta is
then expelled using gentle traction on the cord.

Here are the signs of placental separation:

1. Lengthening of umbilical cord

2. Sudden gush of vaginal blood
3. Change in the shape of uterus (globular in shape)
4. Firm uterine contractions
5. Appearance of placenta in vaginal opening

At this stage, here are the nursing care tips:

1. Coach in relaxation for delivery of placenta.

2. Congratulate on delivery of baby.
 3. Encourage skin-to-skin contact to facilitate bonding and early
breastfeeding.
4. Ask patient whether placenta is important to them before it is
destroyed. For those who want to take it home, ensure that they
understand and follow standard infection precautions and hospital
policy.
5. Administer prophylactic oxytocin as ordered.
6. Utilize controlled cord traction technique for placental expulsion.
7. Utilize absorbable synthetic suture materials (over chromic catgut) for
primary repair of episiotomy or perineal lacerations.

For immediate postpartum, the nurse checks the vital signs and monitors for
excessive bleeding. The first four hours after birth is sometimes referred to as
the fourth stage of labor because this is the most critical period for the
mother. The nurse is set to perform nursing interventions that would prevent the
patient from infection and hemorrhage. Also, they are being reminded of the
importance of breastfeeding, ambulation, and newborn care.

Here are WHO recommendations for immediate postpartum:

1. Early (<6 hours) resumption of feeding for patients who have vaginal
birth
2. Prophylactic antibiotics for women who sustained third to fourth
degree of perineal tear during delivery
3. In healthy women who delivered vaginally to term infants, early
postpartum discharge is recommended.

On the other hand, here are interventions not recommended during

immediate postpartum:

1. Routine use of ice packs

2. Oral methylergometrine for patients who delivered vaginally

Assessment
The key to a successful individualized care plan is the precise assessment and
accurate obtaining of data. The woman would be placed under observation
during labor to monitor her progress and ensure a safe delivery for her and the
child.
 ● Assess for the signs of true labor. The signs of true labor are
contractions that begin irregularly but progresses regularly and
predictably, the pain is felt first at the lower back and circles towards
the abdomen, continues to progress no matter what the woman’s
activity level is, increases in duration, frequency, and intensity and
cervical dilation is already present.
● Assess for the appearance of show, which is blood mixed with
mucus and would be present once the operculum or mucus plug is
expelled.
● Assess for the rupture of membranes. This is the scanty or
sudden gush of clear fluid from the vagina.
● Assess for the engagement of the fetal head. Engagement refers
to the settling of the presenting part into the pelvis at the level of the
ischial spines.
● Assess for the station. Station is the relationship of the presenting
part to the level of the ischial spines.
● Assess for the effacement and dilatation of the cervix.
Effacement is the shortening and thinning of the cervical canal. In
cervical dilatation, the enlargement or widening of the cervical canal
is assessed.

Planning
With all the data gathered during assessment and through an accurate diagnosis,
a care plan for the woman in labor would be made to aid her through her
progress.

Care of a woman in the first stage of labor

● Labor should be allowed to start naturally, not artificially induced.

● The woman must also be allowed to move freely throughout the
labor. Artificial interventions should also be prohibited.
● Allow the woman to assume a non-supine position for delivery.
● Upon delivery of the newborn, mother and child should be given
unlimited opportunity for breastfeeding and bonding.

Care of a woman in the second stage of labor

● During the second stage of labor, the place of delivery of the woman
must be prepared.
● The position of birth wherein the woman is most comfortable must
also be determined at this stage.
 ● Another important part is the promotion of second stage effective
pushing.
● Perineal cleaning is also an integral part of the second stage.

Care of the woman in the third stage of labor

● Placental delivery should be given focus at this stage. Once the

placenta is delivered, oxytocin should be administered
intramuscularly to promote uterine contractions.
● If there is episiotomy performed, perineal repair should be integrated
into the care plan.

Implementation
Some interventions are implemented to give comfort and safety for the mother
during and after the labor period. These are essential in promoting the strength
that the mother would need during delivery.

● Encourage the client to void every 2 hours.

● Observe and review the client’s breathing techniques.
● Inform the client if c interventions are necessary.
● Create a birth plan with the client so she could integrate her
preferences in the care plan.
● Provide ice chips, hard candies, or fluids to relieve dry mouth.
● Provide a comfortable environment to aid in the effective coping
management of the client.
● Allow the client to walk and move around freely during labor.
● Do not intervene with the client during a contraction to avoid
disturbing her focus on her technique.

Evaluation
After the labor has passed, delivery would commence immediately. And when
the labor period for the woman has gone smoothly, a great chance for a safe and
healthy delivery is within reach.

● Client should exhibit no signs of bladder distention and have the

ability to void every 2 hours.
● Client has a good to tolerable level of pain.
● Client can express her preferences during labor.
● Client has the ability to understand the usual process of labor.
 ● Client reports that her environment is comfortable and secure.
● Client would be able to verbalize her feelings about her experiences
during her labor period.

Cervical Ripening

● Cervical ripening must be complete during early labor.

● If there is no cervical ripening, there would be no dilatation and
coordination of uterine contractions.
● To determine whether the cervix is ripe, Bishop established criteria
for scoring the cervix.
● If the woman’s score is 8 or greater, the cervix is already ready or
birth and would respond to induction.
● One of the ways to ripen the cervix is known as “stripping the
membranes”, or separating the membranes from the lower uterine
segment manually using a gloved finger in the cervix.
● Complications that may arise from this procedure include bleeding
due to undetected low-lying placenta, inadvertent rupture of
membranes, and infection when the membranes rupture.
● Another method that is also considered is the use of hygroscopic
suppositories or suppositories of seaweed that swell upon contact
with cervical secretions.
● These suppositories gradually and gently urge dilatation.
● They are held in place by gauze sponges saturated with povidone
iodine or an antifungal cream.
● The number of sponges and dilators should be documented
accordingly to avoid leaving behind one of them inside the cervix.
● A more common method of speeding cervical ripening is the
application of a prostaglandin gel to the interior surface of the cervix
by a catheter or suppository, or to the external surface by applying it
to a diaphragm and then replacing it against the cervix.
● Additional doses may be applied every six hours, but two or three
doses are usually enough to achieve ripening.
● Instruct the woman to remain in a side lying position to avoid leakage
of the medication.
● Continuously monitor the FHR at least every 30 minutes after each
complication.
● Side effects of this method include diarrhea, fever, hypertension, and
vomiting.
● Oxytocin administration may also be started, but that would be 6 to
12 hours after the last prostaglandin dose.
 ● Use prostaglandin with caution in women with asthma, renal or
cardiovascular disease, or glaucoma.
● Women who underwent cesarean birth in the past are
contraindicated with prostaglandin method.

The labor process is the gateway towards a safe delivery. Once the woman has
undergone labor, it is imminent that delivery would follow suit. It is important for
the woman to have a smooth labor process for this is where she would be
gathering her strength to deliver her precious bundle of joy.

Comfort and Pain Management

Etiology and Physiology of Pain

● Pain is a basic protective mechanism that alerts a person that

something threatening is happening somewhere in the body.
● Involuntary muscles do not normally cause pain when contracting,
which is why uterine contractions are unique.
● Blood vessels constrict during contractions, reducing the blood
supply to uterine and cervical cells resulting to anoxia of the muscle
fibers.
● The anoxia causes the pain just like what happens in a heart attack.
● Ischemia to the cells increases as labor progresses, and anoxia also
increases leading to intense pain.
● Another explanation for the pain is the stretching of the cervix and
perineum.
● The moment that the stretching of the cervix is complete, the woman
would feel the strong urge to push, and the pain disappears as the
woman pushes.
● The pressure of the fetal presenting parts to the tissues also
contributes to the discomfort that the woman is feeling.
● Cultural differences also determine the way a woman may perceive
the pain.
● Pain sensations start in nociceptors which are stimulated by
mechanical, chemical, or thermal stimuli.
● As they are stimulated, chemical mediators help transmit the pain
impulse along myelinated and unmyelinated fibers to the spinal cord.
● Neurotransmitters assist the pain impulse across the synapse
between the peripheral and the spinal nerve.
● The pain impulse ascends the spinal cord to the brain cortex where it
would be interpreted as pain.
 ● The Melzack-Wall gate control theory of pain proposes that pain can
be halted at three points: the peripheral end terminals, the synapse
points, or at the point where the impulse is interpreted as pain.
● The major action of pain medications is to block the spinal cord
neurotransmitters to halt the pain impulse from crossing towards the
spinal nerve.

Comfort Measures

Relaxation

● Relaxation is mostly taught in preparing for childbirth classes.

● Relaxing keeps the abdominal wall from becoming tense and allows
the uterus to rise during contractions without pressing against the
abdominal wall.
● As the woman focuses on relaxing, it will also serve as a distraction
technique because it distracts her from the pain she is feeling.
● Advise the woman to find her position of comfort during labor as it will
greatly help her to relax.
● Another way for the woman to relax is to listen to her favorite music
or do aromatherapy while inside her birthing room.

Focusing and Imagery

● Focusing is concentrating intently on an object that will serve as the

distraction.
● It also keeps the sensory input from reaching the cortex of the brain,
thus avoiding pain.
● A photograph would be used by the woman and she concentrates on
it during contractions.
● Avoid disturbing the woman by asking questions while she is
focusing because it would break her concentration.

Prayer

● There are women who find prayers comforting whenever they are
in a stressful situation.
● Worship objects such as Bibles, rosaries, and crosses could give
comfort to a woman during labor.
● Be careful in changing the sheets because the worship objects might
be thrown away; these are sacred to the woman.
Breathing Techniques

● Most preparing for childbirth classes also teach breathing techniques

or patterns.
● Breathing techniques help relax the woman’s abdomen during
contractions.
● It can be considered as a distraction technique because the woman
concentrates on slow-paced breathing instead of minding the pain.
● Breathing techniques are best taught to the woman before labor, but
if she is not familiar with it, she can still be coached even while she is
in labor.

Herbal Preparations

● There may be little evidence that shows the effectiveness of herbal

medicines against pain during labor, but it is still widely used by
some women.
● Raspberry leaves, life root, and fennel are some of the examples of
these herbs.

Heat or Cold Application

● Women who are experiencing back pain during labor will find heat
application to their lower backs soothing.
● After labor, a cool cloth to the forehead could also soothe the woman
from too much exertion.
● Ice chips also help relieve the dryness of the woman’s mouth during
labor.

Therapeutic Touch and Massage

● Therapeutic touch is the use of touch to comfort and relieve pain.

● According to its philosophy, the body contains energy fields.
● If the energy fields are plentiful, it results to good health.
● If the energy fields are few, it results to ill health.
● Therapeutic touch redirects the energy fields that lead to pain
through the laying of hands.
● The release of endorphins is increased as touch or massage is
applied, leading to decrease in pain.
● Effleurage is a form of therapeutic touch taught at Lamaze classes
and is especially helpful during the first and second stages of labor.
Pharmacologic Measures

Narcotic Analgesics

● Narcotics have potent analgesic effects but are used cautiously

because they can cause fetal CNS depression.
● Women in preterm labor should not have any narcotics as
pharmacologic measure because of the lung immaturity of the fetus.
● Meperidine is an advantageous drug during labor because of its
sedative and antispasmodic effects which relieve pain and helps
relax the cervix.
● Meperidine is given 3 hours before birth to allow the peak action of
the drug in the fetus to pass by the time of birth.

Regional Anesthesia

● Regional anesthesia involves the injection of a local anesthetic to

block specific nerve pathways.
● Research has proven that some effects of the anesthesia to the fetus
result to fetal heart rate decelerations and symptoms of flaccidity,
bradycardia, and hypotension in the newborn.
● Regional anesthesia allows the woman to stay awake and aware of
the happenings during birth.
● It also helps prevent postpartum hemorrhage as it does not depress
the uterine tone, so the uterus remains capable of contraction after
birth.

Local Anesthesia

● Local anesthesia reduces the ability of local nerve fibers to conduct

pain.
● Local infiltration uses the injection of a local anesthetic into the
superficial nerves of the perineum.
● The effect lasts for 1 hour, which allows for a pain-free birth and
suturing of episiotomy.
● The pudendal nerve block is the injection of an anesthetic near the
right and left pudendal nerve at the level of the ischial spine.
● This anesthetic provides pain relief after 2 to 10 minutes for 1 hour.
● FHR and the maternal blood pressure should be checked
immediately after injection to detect maternal hypotension.
The types of pain relief during labor and birth vary widely, and it is up to the
woman if she would want to employ these measures during the right time. Proper
education and information from the healthcare providers is a must so that the
couple could make the right decision when it comes to the procedures and
measures that they would want during labor and birth.

Fetal Position, Presentation, Size, & Passage

A pregnant woman would always want the best for the fetus growing inside of
her. However, when problems arise regarding the welfare of the growing fetus,
she may feel fear and anxiety. This is where healthcare providers enter the
scene, to educate and assist the woman in caring for her fetus and also herself.

Occipitoposterior Position

● The usual fetal position is posterior rather than anterior.

● Assuming that the presentation is vertex, the occiput is directed
diagonally and posteriorly, either to the left or to the right.
● During internal rotation in these positions, the fetal head must rotate
through an arc of approximately 135 degrees.
● Rotations from a posterior position can be aided by having the
woman assume a hands-and-knee position, squatting or lying on her
side; however, this is tiring for women in labor.
● Posterior positions usually occur in women with android, anthropoid,
and contracted pelvis.
● Posterior positions happen in dysfunctional labor patterns such as
prolonged active phase, arrested descent, or fetal heart sounds
heard best at the lateral sides of the abdomen.
● A head in the posterior position does not fit the cervix like a head in
the anterior position does.
● This can be confirmed through vaginal examination or through
ultrasound because it might cause umbilical cord prolapse.
● Labor is prolonged because the arc of rotation is greater.
● Pressure and pain would be experienced by the woman in her lower
back owing to sacral nerve compression when the fetal head rotates
against the sacrum.
● To relieve a portion of the pain, applying counterpressure on the
sacrum by a back rub may be done, and heat or cold application can
also help.
● To help the fetus rotate, the woman may lie on the side opposite the
fetal back or assume a hands-and-knees position.
 ● The woman should void every 2 hours to keep her bladder empty
and avoid impeding the descent of the fetus.
● The woman may also need an oral sports drink or IV glucose solution
to replace glucose stores used for energy.
● Maternal exhaustion can cause uterine dysfunction, so a rotation of
135 degrees may not be possible if the contractions are ineffective or
if the fetus is larger than average.
● The fetal head might arrest in the transverse position or there might
be no rotation at all, so cesarean birth would be necessary.
● Provide reassurances to the woman that even though her labor is not
“by the book” it is still within safe and controlled limits.

Oversized Fetus

● Macrosomia or an oversized fetus weighs more than 4000 to 4500g,

and this size may become a problem.
● Macrosomic babies are usually born to women with diabetes or
develop gestational diabetes, and multiparas.
● Uterine dysfunction might result from an oversized fetus because of
the overstretching of the fibers of the myometrium.
● The wide shoulders pose a problem at birth because it can cause
fetal-pelvic disproportion or uterine rupture from obstruction.
● Cesarean birth is necessary if the fetus is so oversized to be born
vaginally.
● To compare the size of the fetus with the woman’s pelvic capacity,
pelvimetry or ultrasound can be performed.
● If a macrosomic baby is born vaginally, there are high risks for
cervical nerve palsy, diaphragmatic injury, or fractured clavicle due to
shoulder dystocia.
● The woman is at risk for over because of the overdistended uterus
and uterine atony.

Shoulder Dystocia

● Shoulder dystocia occurs during the second stage of labor when the
fetal head is born but the shoulders are too broad to enter and be
born through the pelvic outlet.
● The woman is at risk for vaginal and cervical tears, while the fetus is
at risk for cord compression between the fetal body and the bony
pelvis.
● If birth is forced through the vaginal opening, the fetus would sustain
a fractured clavicle or a brachial plexus injury.
 ● Shoulder dystocia usually occurs in women who have diabetes, in
multiparas, and in post-date pregnancies.
● Shoulder dystocia is discovered often during the birth of the head
and the shoulders lock beneath the symphysis pubis.
● Other conditions that may suggest shoulder dystocia are prolonged
second stage of labor, arrest of descent, or when the head starts to
crown, it retracts instead of protruding with each contraction.
● Instruct the woman to flex her thighs sharply on her abdomen
(McRobert’s maneuver) to widen the pelvic outlet and allow the
anterior shoulder to be born.
● Applying suprapubic pressure can also help the shoulder out from
beneath the symphysis pubis.

Breech Presentation

● Most fetuses are in a breech presentation early in pregnancy;

however, by week 38, it turns into a cephalic presentation.
● The fetal head may be the widest single diameter but the fetus’
buttocks and legs take up more space.
● The fetus turns into a cephalic position mostly because the fundus is
the largest part of the uterus, so the buttocks and the lower
extremities are in the fundus.
● Types of breech presentation include complete, frank, and footling.
● Breech presentation increases the fetal risk for anoxia, traumatic
injury to the head, fracture of the spine or arm, dysfunctional labor,
and early rupture of membranes.
● Meconium present in the amniotic fluid is a sign of buttock pressure,
and this can lead to meconium aspiration once the infant inhales
amniotic fluid.
● Fetal heart sounds are heard high in the abdomen in breech
presentation.
● Leopold’s maneuver and vaginal examination can determine breech
presentation.
● Be certain to monitor the FHR and uterine contractions continuously
to detect fetal distress early and provide prompt intervention.
● In a breech birth, the birth of the head is the most dangerous part
because a loop of the umbilical cord that has passed down alongside
the head may be compressed.
● Intracranial hemorrhage is another danger of breech birth because of
the pressure changes that have occurred spontaneously.
 ● An infant born from a frank breech position usually extends his or her
legs continuously during the first 2 or 3 days of life, so be sure to
point out to the parents that this is normal.

Face Presentation

● Face and brow presentations are called asynclitism or a fetal head

presenting at a different angle than expected.
● In face presentation, the head diameter the fetus presents to the
pelvis is often too large for birth to proceed.
● The back would be difficult to outline because it is concave.
● Face presentation can be determined through vaginal examination
when the nose, mouth, or chin is felt as the presenting part or
through ultrasound.
● Face presentation usually occurs in women with contracted pelvis, or
placenta previa, in a relaxed uterus of a multipara, with prematurity,
hydramnios, or fetal malformation.
● If the chin is anterior and the pelvic diameters are within normal
limits, the infant can be born vaginally.
● If the chin is posterior, cesarean birth is the birth method of choice.
● Facial edema and ecchymosis are present in a baby born after a face
presentation.
● Assess the patency of the infant’s airway closely.
● Reassure the parents that the edema is transient and will disappear
after a few days.

Brow Presentation

● The rarest among the presentations is the brow presentation.

● This presentation usually occurs in multipara women or in a woman
with relaxed abdominal muscles.
● Obstructed labor occurs because the head becomes jammed in the
brim of the pelvis as the occipitomental diameter presents.
● Cesarean birth would be necessary unless the presentation
spontaneously corrects itself.
● Extreme ecchymosis on the face is also present in infants born after
a brow presentation.
● Reassure the parents that the bruising over the same area as the
anterior fontanelle is normal.

Inlet Contraction
 ● Inlet contraction is the narrowing of the anteroposterior diameter to
less than 11 cm or the transverse diameter to 12 cm or less.
● The usual cause is rickets in early life or an inherited small pelvis.
● If the fetal head engages during the 36th to 38th week of pregnancy,
then the pelvic inlet is adequate.
● If there is no engagement in primigravidas, then either a fetal
abnormality or a pelvic abnormality should be suspected.
● Every primigravida should have pelvic measurements taken and
recorded before week 24 of pregnancy so that a birth decision can be
made.
● In CPD, the fetus remains in a floating position which could further
complicate the already difficult situation.
● If the membranes rupture, then the risk of cord prolapse increases
greatly.

Outlet Contraction

● Outlet contraction is the narrowing of the transverse diameter at the

outlet to less than 11 cm.
● This is the distance between the ischial tuberosities, a measurement
that is easy to make during a prenatal visit, so the narrow diameter
can be anticipated before labor starts.
● This can also be assessed easily during labor.

Trial Labor

● Trial labor refers to the determination of the progress of labor in a

woman who has borderline inlet measurement with a good fetal lie
and position.
● Trial labor may continue as long as the descent of the presenting part
and dilatation of the cervix continue to occur.
● Monitor fetal heart sounds and uterine contractions continuously.
● Instruct the woman to void every 2 hours to aid in fetal descent.
● After the rupture of membranes, assess the FHR closely; if the fetal
head is still high, there is an increased danger of prolapsed cord and
anoxia in the fetus.
● Cesarean birth would be necessary if there is no progress in labor
after 6 to 12 hours.
● If trial labor fails and cesarean birth is scheduled, provide an
explanation about why cesarean birth is the best birth method.
 ● Women undergoing trial labor need to be reassured, as well as her
support person, that cesarean birth is only an alternative, not an
inferior, method of birth because the labor is not progressing.

External Cephalic Version

● External cephalic version is the turning of a fetus from a breech to a

cephalic position before birth.
● As early as 34 to 35 weeks external cephalic version can be done but
the usual time is 37 to 38 weeks of pregnancy.
● Record FHR and ultrasound continuously during the procedure.
● The uterus should relax, so the administration of a tocolytic agent is
done.
● The breech and vertex of the fetus are located and grasped
transabdominally by the examiner’s hands on the woman’s abdomen.
● External cephalic versions can decrease the number of cesarean
births necessary from breech presentations.
● Contraindications to the procedure include multiple gestations,
severe oligohydramnios, vaginal birth, cord coil, and unexplained
third-trimester bleeding which could be placenta previa.
● The feeling of pressure may be uncomfortable for the woman.
● Women who are Rh-negative should receive Rh immunoglobulin
after the procedure in case bleeding occurs.

Nursing Process During Labor and Delivery

Assessment

Assessment for delivery starts at the second stage of labor, which is the full
cervical dilatation until the birth of the baby. This would be a crucial time since
the mother would need to deliver her baby at this stage without any troubles and
with her strength intact so she could push for a normal vaginal delivery.

● Assess the responses of the mother towards the intensity and

duration of the contractions.
● Assess the comfortability of the mother with her birthing position.
● Assess her breathing techniques if they are effective or could add to
the difficulty that the mother might be experiencing.
● Assess the ability of the support person to assist the mother during
labor and birth.
● Assess the fetal heart sounds to make sure that there is no occlusion
in the cord that could hinder fetal circulation.
 ● Assess if the environment is comfortable for both the mother and the
baby.

Diagnosis

The difficulties that the mother may encounter during delivery are endless. Not all
deliveries have gone smoothly, so every caregiver must be capable of whipping
up a diagnosis and care plan immediately to assist the mother towards a safe
and meaningful delivery.

● Pain related to intensity of uterine contractions

Planning

● The place of birth must be prepared prior to delivery.

● For multigravidas, preparation of the room could start when the
cervix has dilated to 9 to 10 cm.
● For primiparas, preparation of the birth place should start when the
head has crowned to the size of a quarter.
● The newborn care area must also be prepared within the same room
and include supplies for eye care, suction and resuscitation
equipment, radiant heat warmer, sterile towels, and identification of
the newborn.
● The mother should choose a position that will be most comfortable
for her during birth.
● Alternative birthing positions today are the dorsal recumbent position,
the lateral Sim’s position, squatting, and semi-sitting.
● A health care provider must be situated at the foot of the birthing
table already so that the infant would not fall off if birth happened
precipitously.

Implementation

Now that the care plan is already established, time to take some action and
implement those interventions listed on your cheat sheet.

● If the client has a birth plan, make sure all health care providers are
aware of her individual preferences.
● Encourage the mother to void before delivery to reduce the
discomfort.
● Allow client to take ice chips or hard candies for relief of dry mouth.
 ● Provide a comfortable environment for both the mother and the baby.
● Allow the client to assume a birthing position of her choice as long as
it is not contraindicated.
● Assist the client in venting out any emotions with regards to her
delivery experience.

Evaluation

A care plan would not be complete if no evaluation was done to test the
effectiveness of your plan.

● Client will be able to manage her discomfort using nonpharmacologic

methods.
● Client will be able to identify other pain relief measures.
● Client has no signs of bladder distention and can void every 2 hours.
● Client states that she has reduced or no mouth discomfort.
● Client states that the environment is comfortable enough.
● Client reports that the delivery is a tolerable and highly meaningful
part of her life.