Labor and Delivery

repared By/ Dr. Nagwa Ibrahim

Labor and Delivery

Labor is a physiologic process during which the

products of conception (ie, the fetus, membranes,

umbilical cord, and placenta) are expelled outside
of the uterus

Labor is a clinical diagnosis. The onset of labor is

defined as regular, painful uterine contractions

resulting in progressive cervical effacement and
dilatation.

Cervical dilatation in the absence of

uterine contraction suggests cervical

insufficiency,

whereas

uterine

contraction without cervical change

does not meet the definition of labor.

The delivery process is

described in some terms :
1- Fetal position
Refers to the orientation of the fetus
within the birth canal , It can be :

Occiput Anterior(OA)
Occiput anterior is usually the easiest
position for the fetal head to traverse
the maternal pelvis.

Left Occiput Anterior(LOA)

The fetal occiput is directed towards
the mother's left, anterior side.

Right Occiput Anterior (ROA)

The fetal occiput is directed towards
the mother's right, anterior side
6

Occiput Posterior (OP)

Right Occiput Posterior (ROP)

Left Occiput Posterior (LOP)

7

Left Occiput Transverse (LOT)

Right Occiput Transverse (ROT)

Fetal lie :
Relationship of long axis of fetus [spine] to
long axis of mother
If the two are parallel, then the fetus is said
to be in a longitudinal lie. If the two are at
90-degree angles to each other, the fetus
is said to be in a transverse lie. Nearly all
(99.5%) fetuses are in a longitudinal lie.
9

Transverse lie.

Longitudinal lie.
10

Fetal attitude:
This is the degree of flexion of the fetus body
parts (body, head, and extremities) to each other
Types of Fetal attitude
(a) Complete flexion. This is normal attitude in cephalic
presentation. there is complete flexion at the head
when the fetus "chin is on his chest." This allows the
smallest cephalic diameter to enter the pelvis, which
gives the fewest mechanical problems with delivery .
11

b) Moderate flexion. In cephalic presentation, the

fetus head is only partially flexed or not flexed. A
larger diameter of the head would be coming
through the passageway
(c) Poor flexion. the fetus head is extended or bent
backwards.. It is difficult to deliver because the
widest diameter of the head enters the pelvis
first. This type of cephalic presentation may
require a C/Section if the attitude cannot be
changed.

12

(d) Hyperextended. the fetus head is

extended all the way back. This allows
a face or chin to present first in the
pelvis.

13

Complete flexion

Poor flexion

Moderate flexion

Hyperextended

14

Fetal station:
This

is

the

relationship

between

the

presenting part of the baby (the head,

shoulder, buttocks, or feet ) and two parts of
the mother's pelvis called the ischial spines.
Normally the ischial spines are the narrowest
part of the pelvis. They are a natural
measuring point for the delivery progress.
15

If the presenting part lies above the ischial

spines, the station is reported as a negative

number from -1 to -5 (each number is a
centimeter). If the presenting part lies below
the ischial spines, the station is reported as
a positive number from +1 to +5. The baby
is said to be "engaged" in the pelvis when it
is even with the ischial spines at 0 station.
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17

Fetal presentation
The part of the fetus that is "presenting"
at the cervix
A ) Cephalic (head) presentation:
Cephalic presentation is considered
normal and occurs in about 97% of
deliveries. There are different types of
cephalic presentation

18

2- vertex presentation

1- Face presentation

3- Brow presentation
19

B ) Breech presentation:
Breech presentation is considered abnormal.
A complete breech presentation occurs when
the buttocks present first, and both the hips
and knees are flexed. A frank breech occurs
when the hips are flexed so the legs are
straight. Other breech positions occur when
either the feet or knees come out first.
20

Frank
Breech
21

c) Shoulder presentation:
The

shoulder,

present

first

arm,
if

the

or

trunk

fetus

is

may
in

transverse lie. This type of presentation

occurs less than 1% of the time.
Transverse lie is more common with
premature

delivery

or

multiple

pregnancies
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Stages of Labor

he labor divided into four stages :

First Stage of Labor
The first stage begins with regular uterine
contractions and ends with complete
cervical dilatation at 10 cm
Divided into :
Early

labor

Active

labor

Transition

labor

1- Early labor :
Defined by cervical dilation of 0 to 3

cm
Contractions occurring every 5 to 20

minutes and lasting 30 to 45 seconds

In this stage, mother typically notices

backache and mild discomfort

Contractions progress over time, becoming

longer, stronger, and closer together

Between

contractions,

mother

feels

relatively normal and pain free

For first-time mothers, may last 8 to 20

hours
With

subsequent births, stage lasts 6 to 8

hours or less

2- Active labor :
Defined by cervical dilation of 4 to 8

cm, and contractions 4 to 5 minutes

apart, lasting about 60 seconds
Marks
beginning
of
intense
contractions
Between contractions, mother may
experience
trembling,
nausea,
vomiting
Relaxation
and slowed breathing
between
contractions
often
is
comforting to mother

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3- Transition Labor :
Defined by cervical dilation of 8 to 10 cm
Contractions are about 2 to 3 minutes

apart and last for about 60 to 90 seconds

Contractions are intense and may occur

with little rest for mother in between

May be accompanied by rectal pressure

if baby's head is positioned low

In many pregnancies, amniotic sac

ruptures (rupture of membranes) toward

end of first stage
Period of transition lasts only 15 to 30

minutes on average

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Management of First stage of labor

Admission assessment
Obtain a verbal history and perform an
assessment of the woman including:
Relevant medical/obstetric history
Frequency and duration of contractions
Pain intensity of the contractions
Assessing if the membranes are ruptured
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The fetus' movements

The presence or absence of vaginal bleeding.
Baby lightening : the fetus' head is descent

into the pelvis. The mother may feel that her

baby has become light , Her breathing may
be

relieved

because

tension

on

the

diaphragm is reduced, whereas urination may

become more frequent due to the added
pressure on the urinary bladder.
33

Maternal observations

Monitor the maternal vital signs

Assess the fetus' presentation

Assess the frequency, duration, and
intensity of uterine contractions

Women with ruptured membranes should

have the amniotic fluid loss checked for
colour, consistency and odor
34

Monitor the progress of labor by:

Assessing the contractions

Abdominal palpation
Vaginal examination
Fetal well-being assessment :

Auscultate the fetal heart rate (FHR)

Notify any deviations from normal

labor as soon as possible

35

Allow the mother to:

Ambulate as they desire
Diet as desired( low fat, low roughage diet )and

encourage oral hydration In the latent phase

Select comfortable positions ( left side position).

Advise the woman to avoid the supine position

Empty her bladder prior to abdominal or vaginal

assessment and void 2 hourly in the active phase

of labor
36

Second Stage of Labor

The second stage begins with

complete cervical dilatation and ends

with the delivery of the fetus.
Fetal head enters birth canal
Contractions become more intense

and frequent (usually 2 to 3 minutes

apart)
Often mother becomes diaphoretic

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38

Experiences an urge to bear down with each

contraction
May express need to have bowel movement
Normal

sensation caused by pressure of

fetal head against mothers rectum

Mucous plug (sometimes mixed with blood,

thus name bloody show) is expelled from

dilating cervix and discharged from vagina

Presenting part of fetus (usually head)

emerges from vaginal opening

Known as crowning, indicates delivery is

imminent
Usually lasts 1 to 2 hours in nullipara

mother
Usually lasts 30 minutes or less in

multipara mother

Signs and Symptoms of False

Labor
Lightening
Irregular intermittent contractions
Cervical changes: cervix dilates

slightly
Baby's head in pelvis pushes against

cervix causing relaxation

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Signs and Symptoms of Imminent Delivery

Regular contractions lasting 45 to 60 seconds at 1- to 2-

minute intervals
Intervals

are measured from beginning of one

contraction to beginning of next

Mother has urge to bear down or has sensation of bowel

movement
Large amount of bloody show and Rupture of Membranes
Crowning occurs

Mechanism of Labor
Passage of fetus through birth canal
involves position changes called:
Cardinal Movements of Labor
The cardinal movements are described
as seven movements

43

1.Engagement: presenting part enters

midpoint of pelvis at ischial spines, the
presenting part is at 0 station

2. Descent :
The downward passage of the presenting
part

through

the

pelvis.

This

occurs

intermittently with contractions.

44

3. Flexion : pressure from pelvic floor

causes head to flex towards chest and
chin touches chest.
4. Internal rotation :
As the head descends, the presenting
part, usually in the transverse position,
is rotated about 45 to anteroposterior
(AP) position under the symphysis
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5. Extension :
Upward resistance from the pelvic
floor and the downward forces from
the uterine contractions cause the
occiput to extend and rotate around
the symphysis. This is followed by the
delivery of the head
46

6. Restitution and external

rotation :
When the fetus' head is free of
resistance, it untwists about 45 left
or right, returning to its original
anatomic position in relation to the
body.
47

7. Expulsion :
After the fetus' head is delivered, further
descent brings the anterior shoulder to
the level of the pubic symphysis. The
anterior shoulder is then rotated under
the symphysis and delivered , followed
by delivery the posterior shoulder and
the rest of the fetus.
48

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49

Management of second stage of labor

Preparation for Delivery :
When preparing for delivery, try to
provide area of privacy
Mother should be positioned on a bed,

stretcher, or table
Surface should be long enough to

project beyond mothers vagina

Delivery area should be as clean as possible

Should

be covered with absorbent material to

guard against staining and contamination by

blood and fecal material
Mother should be placed in dorsal lithotomy

position
Knees should be flexed and widely

separated
Vaginal area should be draped

Dorsal lithotomy position

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Evaluate mothers vital signs for baseline

measurements
Monitor fetal heart for signs of fetal

distress at least every 5 minutes and after

each contractions
Advise mother should be bear down and

push during contractions and to rest

between contractions to conserve strength

If mother finds it difficult to refrain

from pushing, should be encouraged

to breathe deeply or through her
mouth between contractions
Deep breathing help decrease force of

bearing down and promote rest

Aid in delivery of infant :

Ritgen maneuver
Modified Ritgen maneuver can be performed to
deliver the head , By the time the head distends :
*

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
occiput ,Thus, the head is delivered

55

Ritgen maneuver

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Suction infants mouth and nose with bulb

syringe to clear airway but before next

contraction

Check the fetus' neck for a wrapped umbilical

cord
If the cord is wrapped too tightly to be removed,

the cord can be double clamped and cut

Deliver the anterior shoulder
57

Guide infants head

downward to deliver
anterior shoulder

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Next, the fetus' anterior shoulder is

delivered with gentle downward traction

on its head and chin. And upward pressure
in the opposite direction facilitates
delivery of the posterior shoulder
The rest of the fetus should now be easily

delivered with gentle traction away from

the mother
59

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Clamping and cutting the cord

After delivery, the infant is placed at the

level
of vagina for 3 min, the fetoplacental
circulation
is not occluded :80 ml of blood shift to
the fetus -> then clamps the cord
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62

Take following steps to manage

umbilical cord :
Clamp cord about 4 to 6 inches away

from infant in two places

Cut between two clamps with sterile

scissors
Examine cut ends of cord to ensure

there is no bleeding

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64

Evaluation of the Infant

After delivery, infant should be positioned on

side or with padding under back if needed

Clear airway and provide tactile stimulation

to initiate respirations
If no need for resuscitation, assign an Apgar

score at 1 minute and 5 minutes to evaluate

in infant

cesarean section
Definition :
Is a surgical procedure to deliver
the baby through incisions in the
abdominal and uterine wall.

66

Indications of cesarean section

Cephalopelvic disproportion: the

head of the foetus is too large to come

through the pelvis.
Small pelvis
Uterine Inertia : Inefficient uterine

contraction.
Placenta pravia : Implantation of
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Small pelvis
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Malposition and malpresentation

Pre-eclamsia
Diabetes ( causes over size of the

fetus. )
Cardiac diseases.
Vaginal scaring.
multiple births
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Cervical dystoctia (failure of the

cervix to dilate in spite of strong

contraction of the uterus).
Prolapse of the umbilical cord.
Fetal distress.
Previous Cesarean Sections
Maternal hypertension

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Types of cesarean section

A midline
longitudinal incision

The lower uterine

segment section
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Complications of cesarean section

Respiratory complications: due to effects of pain,

immobilization in post operative period and

anaesthesia.
So
Encourage deep breathing exercises.
Teach the patient to cough (the abdomen must

be supported by the patients hands and/or towel)

73

Excessive abdominal pain due to:

o Wound infection.
o Haematoma.
o Excessive localized edema.
Intestinal complications.
Haemorrhage
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Third Stage of Labor

Begins with delivery of infant and ends
when placenta is expelled and uterus
has contracted
Length of this stage varies from 5 to

30 minutes

Delivery of the Placenta

During this period, uterine contraction

decreases
whichresults

basal

blood

flow,

in

thickening

and

reduction in the surface area of the

myometrium underlying the placenta
with subsequent detachment of the
placenta

Signs of placental separation from the uterus:

1. uterus become globular and firmer

2. Sudden gush of blood
3. Uterus rises in the abdomen because the
placenta passes down
4. The umbilical cord protruded out of the
vagina. indicating that the placenta has
descended
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78

79

Management of third stage of labo

Allowing the placenta to deliver spontaneously
Excessive traction should not be applied to the

cord to avoid inverting the uterus, which can

cause severe postpartum hemorrhage
Oxytocin can be administered throughout the

third stage to facilitate placental separation by

inducing uterine contractions and to decrease
bleeding.

The placenta can also be manually

separated by passing a hand between

the placenta and uterine wall. After the
placenta is delivered, inspect it for
completeness and for the presence of 1
umbilical vein and 2 umbilical arteries
When placenta is expelled, should be

placed in plastic bag or other container

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Pieces of placenta retained in uterus

can cause persistent hemorrhage and
infection

After the placenta is delivered, Palpate

the

patient's

abdomen

to

confirm

reduction in the size of the uterus and

its firmness. Ongoing blood loss and a
boggy uterus suggest uterine atony

Initiate fundal massage to promote uterine

contraction
Monitor mother for signs of hemorrhage or

shock
Examination of the birth canal, including

the cervix and the vagina, the perineum,

and the distal rectum, is warranted, and
repair of episiotomy or perineal /vaginal
lacerations should be carried out.

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EPISIOTOMY AND REPAIR

Episiotomy is an incision on perineum
to

enlarge vaginal outlet

Purposes of episiotomy
- Easier to repair

- Postoperative pain is less

- Healing improved
84

Timing of episiotomy
when the head is visible
during a contraction to a
diameter of 3 to 4 cm
Timing of the repair of
episiotomy
After the placenta has been
delivered
Suture material
3-0 chromic catgut
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Fourth Stage of Labor

The fourth stage of labor is the period from the

delivery of the placenta until the uterus remains firm

on its own.
In this stabilization phase, the uterus makes its

initial readjustment to the non pregnant state. The

primary goal is to prevent hemorrhage from the
uterine atony and the cervical or vaginal lacerations.
NOTE :Atony is the lack of normal muscle tone.

Uterine atony is failure of the uterus to contract.

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NURSING CARE DURING THE FOURTH

STAGE OF LABOR
Transfer the patient from the delivery

table. Remove the drapes and soiled linen.

Remove both legs from the stirrups at the
same time and then lower both legs down
at the same time to prevent cramping.
Assist the patient to move from the table to
the bed.
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Provide care of the perineum. An ice

pack may be applied to the perineum

to reduce swelling from episiotomy
especially if a fourth degree tear has
occurred and to reduce swelling from
manual manipulation of the perineum
during labor from all the exams. Apply
a clean perineal pad between the legs.
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Transfer the patient to the recovery

room. This will be done after you place

a clean gown on the patient, obtained
a complete set of vital signs, evaluated
the fundal height and firmness, and
evaluated the lochia.

89

Ensure

emergency equipment is available in the

recovery room for possible complications.

(1) Suction and oxygen in case patient becomes eclamptic.
(2) Pitocinis available in the event of hemorrhage.
(3) IV remains patent for possible use if complications develop.

Check the fundus.

(1) Ensure the fundus remains firm.
(2) Massage the fundus until it is firm if the uterus should relax

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(3)

Massage the fundus every 15 minutes

during the first hour, every 30 minutes

during the next hour, and then, every
hour until the patient is ready for
transfer.
(4) Inform the physician if the fundus
remains boggy after being massaged.
91

Massagi
ng the
fundus
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92

NOTE: A boggy uterus many indicate uterine

atony or retained placental fragments. Boggy
refers to being inadequately contracted and
having a spongy rather than firm feeling..
Monitor lochia flow. Lochia is the maternal

discharge of blood, mucus, and tissue from

the uterus. This may last for several weeks
after birth.
93

(1) Keep a pad count. Record the number of

pads soaked with lochia during recovery.
(2) Identify presence of bright red bleeding or
blood clots.
(3) Document thick, foul-smelling lochia.
(4) Observe for constant trickle of bright red
lochia. This may indicate lacerations.
(5) Identify lochia amounts as small, moderate,
or heavy (large)

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95

Observe the mother for chills. The

cause

of

the

mother

being

chilled

following birth is unknown. However, it

refers

primarily

to

the

result

of

circulatory changes after delivery. The

best means of relief is to cover the
mother with a warm blanket.
96

Monitor the patient's vital signs and general condition.

Observe patient's urinary bladder for distention. Be

able to recognize the difference between a full bladder

and a fundus

Characteristics of a full bladder.

(a) Bulging of the lower abdomen
(b) Spongy feeling mass between the fundus and the pubis.
(c) Displaced uterus from the midline, usually to the right.
(d) Increased lochia flow.

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Bulging of the lower abdomen

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Evaluate the perineal area for signs of

edema and/or hematoma

Observe for signs of hemorrhage.
(1) Uterine atony.
(2) Vaginal or cervical lacerations.
(3) Retained placental fragments.
(4) Bladder distention.
(5) Severe hematoma in vagina or
surrounding perineum.
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Delivery Complications
1 ) Premature Rupture of the
Membranes /PROM
Premature rupture of membranes (PROM) is a
rupture (breaking open) of the membranes
(amniotic sac) before labor begins
In most cases, the cause of PROM is unknown.
Some causes or risk factors may be:
Infections of the uterus, cervix, or vagina
Poor eating or drinking

100

Too much stretching of the amniotic sac

(this may happen if there is too much

fluid, or more than one baby putting
pressure on the membranes)
Smoking
Previous history of PROM
Natural weakening of the membranes or

from the force of contractions

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What are the symptoms of PROM?

leaking or a gush of watery fluid from

the vagina
Constant wetness in panties

Treatment and Nursing Care:

Bed rest, no intercourse
Assess time membranes ruptures
and if labor started
Check temperature frequently
102

Describe character of amniotic

fluid
Check WBC
Provide psychological support
Monitoring for signs of infection
such as fever, pain, increased fetal
heart rate, and/or laboratory tests
103

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2) Prolapsed Umbilical Cord

The umbilical cord drops (prolapses) through

the open cervix into the vagina ahead of the

baby.
Causes of umbilical cord prolapse :
Premature rupture of the membranes
Premature delivery of the baby
Delivering more than one baby per

pregnancy (twins, triplets, etc.)

105

Excessive amniotic fluid

Breech delivery (the baby comes through the

birth canal feet first)

An umbilical cord that is longer than usual
Umbilical cord prolapse presents a great

danger to the fetus , the fetus can put stress

on the cord. This can result in a loss of
oxygen to the fetus, and may even result in
a stillbirth.
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How is an umbilical cord prolapse

detected?
Use a fetal heart monitor to measure

the babys heart rate. If the umbilical

cord has prolapsed, the baby may have
bradycardia
Conduct a pelvic examination and may

see the prolapsed cord, or palpate the

107

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108

Management of Prolapsed umbilical cords

1. Immediate delivery is the best solution
2. Palpate FHTs, NEVER ATTEMPT TO REPLACE
CORD!
3. Give O2 per mask to the mother
4. Cover exposed cord with sterile wet gauze Will
minimize temperature changes that may cause
umbilical artery spasm
5. Instruct mother to pant with each contraction to
prevent bearing down
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5.

6.

7.

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3 ) Abnormal Presentation
Most infants are born head first

(cephalic or vertex presentation)

Sometimes presentation is

abnormal :

Breech presentation

Shoulder presentation

Breech Delivery
Most babies will move into delivery

position a few weeks prior to birth with

the head moving closer to the birth
canal. When this fails to happen, the
babys buttocks and/or feet will be
positioned to be delivered first. This is
referred to as "breech presentation

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Categories of breech presentation :

Frank breech
Fetal hips are flexed and legs extend in front of
fetus
Buttocks are presenting part
Complete breech
Fetus has both knees and hips flexed
Buttocks are presenting part
Incomplete breech
Fetus has one or both hips incompletely flexed
Results in presentation of one or both lower
extremities (often foot)

Causes A Breech Presentation:

Most common causes are:
Abnormal shape of the pelvis, uterus
Anatomical malformation of the fetus
Excessive amniotic fluid

(polyhydramnios).
In pregnancies of multiples
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Management
Infant in breech presentation is best

delivered
emergency

in

hospital

cesarean

where

section

is

alternative to vaginal delivery

116

Shoulder Dystocia
Occurs when fetal shoulders are

wedged against maternal symphysis

pubis
In this presentation, head delivers

normally but then pulls back tightly

against maternal perineum

Common condition in pregnancy

Complications :
Brachial

plexus damage

Fractured
Fetal

clavicle

anoxia from cord

compression

Management
Position mother on her left side in

dorsal-knee-chest position

This increases diameter of pelvis

Try to guide infants head downward

to allow anterior shoulder to slip

under symphysis pubis

Avoid excessive force or

Dorsal-knee-chest position
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Gently rotate fetal shoulder girdle at

angle to wider pelvic opening

Posterior shoulder usually delivers

without resistance

Anterior shoulder usually follows

After delivery, continue with
resuscitative measures as needed

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Shoulder Presentation
Results when long axis of fetus lies
perpendicular to that of mother
Position usually results in fetal

shoulder lying over pelvic opening

Fetal arm or hand may be

presenting part

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124

Management
Normal delivery of a presentation is

not possible
Provide mother with adequate

oxygen, ventilatory and circulatory

support, and rapid transport
Cesarean delivery is required

whether fetus is viable or not

Ruptured Uterus
Spontaneous or traumatic rupture of the
uterus
Etiology:
Rupture of a previous C-birth scar
Prolonged labor
Injudicious use of Pitocin -- overstimulation
Excessive manual pressure applied to the
fundus during delivery

126

Signs and Symptoms:

Sudden sharp abdominal pain,

abdominal tenderness
Cessation of contractions
Absence of fetal heart tones
Shock

Therapeutic Interventions:
Deliver the baby ! / Cesarean Delivery
127

Thank you
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128