M3 107lec

University of San Agustin
General Luna St., Iloilo City 5000, Philippines

www.usa.edu.ph
COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING
NCM 107: CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Module 3:
Care of The Mother During The Intrapartal Period
Module Overview:
To all Level II nursing students. Welcome to Module 3!

This module will introduce you to the different concepts, theories, principles of science and
humanities in the formulation and application of appropriate nursing care during labor and birth;
provide safe and quality, appropriate and holistic care to individuals and families and population
groups utilizing the nursing process during labor and birth; and enable you to work effectively in
collaboration with inter-, intra, and multi-disciplinary and multi-cultural teams in maternal and child
care, specifically in the delivery room.
Module Outcomes:
This module will enable the Level II nursing students to:
1. Discuss the interrelationships of the different critical factors in normal labor and birth.
2. Explain the theories of labor onset and the common signs of labor.
3. Discuss the stages of labor, the common discomforts and the danger signs which are
experienced by the parturient during labor and delivery.
4. Assess accurately by monitoring the progress of labor and perform interventions
promptly and safely for psychological and physical comfort.
Module Content:
Unit 1. Theories of Labor
i. Uterine Stretch Theory
ii. Fetal Oxytocin Theory
iii. Progesterone Deprivation Theory
iv. Placental Aging Theory
v. Fetal Cortisol Secretion Theory
vi. Rising Prostaglandin Theory
A Legacy of Excellent Education in Virtus et Scientia

Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403
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Schedule of Activity:
ACTIVITY DESCRIPTION TIME FRAME

Meet and Greet (eportfolio) 10 minutes
1. Audio-visual presentation on the theories of labor 45 minutes
please check the link:
https://www.youtube.com/watch?v=KSan1saN1SE
Interactive discussion (Google Classroom/Meet)
Pose questions regarding the video clips and predicts the
answer, then verify during the discussion.
2. Journal Entry, Learning Insights
3. Assessment Tasks: 20 minutes
a. Summative assessment
Graded Quiz, Rubrics
Course Content:
Let’s Meet and Greet!

ePortfolio (10-15 minutes) Introduce yourself and identify your strengths, weaknesses, and
experiences (negative or positive).
Instructions:
1. Answer the following questions below to determine your strengths, weaknesses
and experiences:
 What was your favorite subject and why? Explain in 3 - 4 sentences.
 Do you have any positive or negative experience in that subject? 2-3 sentences
 What is your expectation in the subject NCM 107? (2-3 sentences)
2. Post your reply in our blog or discussion board. This is ungraded, but you need to comply so
that we could work together to achieve the objective of this module. Submit in 20minutes.
Discussion Board:

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Discussion Board
UNIT 1. Theories of Labor Onset
DISCUSSION:
The Uterine Stretch Theory
As the fetus inside the mother’s womb increases its size, the uterine muscle stretches
resulting to prostaglandins release. Prostaglandins are compounds in the body made of fats
that have hormone-like effects. Some known effects include uterine cramping and increase
sensitivity to pain.
Unlike other hormones, prostaglandins aren’t released from a specific gland; instead the
body has a number of tissues that produces prostaglandins.
A woman starts to have a larger amount of certain types of prostaglandins in her uterine
tissue during late pregnancy (Healthline2020) specifically at the onset of labor.
Fetal Oxytocin Theory
Oxytocin is a patent uterotoxin (uterine muscle contractant)
Secretion of oxytocin increases just before 37-42 weeks of gestation.
Oxytocin stimulates contractions thus facilitating sealing of ruptured capillaries which then
stops bleeding. Due to its contractile activity on the myometrium labor is initiated. Then the
fetus head presses on the cervix, which stimulates the release of oxytocin from the posterior
pituitary. Oxytocin stimulation works together with prostaglandins to initiate contractions.
Progesterone Deprivation Theory
Progesterone produced by the placenta relaxes uterine smooth muscle by interfering with
conduction of the impulses form one cell to the next.
Changes in the ratio of estrogen to progesterone occur, increasing estrogen in relation to
progesterone, which is interpreted as progesterone withdrawal.
Decreased amount of progesterone inhibits the relaxation effect on the uterus initiating
labor onset.

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Placental Aging Theory

The aging placenta cannot supply enough nutrients to the growing fetus because it
reaches a set age which triggers uterine contraction
Fetal Cortisol Secretion Theory
Rising fetal cortisol levels reduce progesterone formation and increase prostaglandin
formation which stimulates uterine contraction.
Rising Prostaglandin Theory
The fetal membrane (amnion and decidua) begins to produce prostaglandins, which
stimulate contractions (Bienstock, Fox, & Wallach, 2015).
Illustrations/Diagram on the Theories of labor Onset:
Fetal Oxytocin Theory
Fetal Cortisol Secretion Theory
The placental-fetal adrenal endocrine cascade.

In late gestation, placental corticortropin releasing hormone(CRH)
Stimulates fetal adrenal production of dehydroepiandrosterone
Sulfate(DHEA-S) and cortisol. The latter stimulates production of
placental CRH, which leads to feed-forward cascade that enhances
adrenal steroid hormone production. (ACTH-Adrenocorticotropic
hormone)

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Activity 1
Audio-visual presentation on the theories of labor please check the link:
https://www.youtube.com/watch?v=KSan1saN1SE
Interactive discussion (Google Classroom/Meet) Pose questions regarding the video clips and
predicts the answer, then verify during the discussion. Post your questions and answers on the
discussion board below.
DISCUSSION BOARD
Pose at least 2 questions regarding the video clip presentation on the theories of labor onset. Post
your answer as well. Submit in 15 minutes. Verification of answers will be done during the
discussion in Google Meet.

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Activity 2. b. Journal Entry

In 150 words record your learning gained regarding the topic theories of labor onset. Post your
answer on the space provided so that your teacher could review your entry to check what you’ve
gained from the topic or concept that was taught. Submit your entry in 10 minutes. You will be
evaluated through rubrics.
Journal Entry Board

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Activity 3 Graded Quiz
Multiple Choice Select the letter of the best answer.

1. The following hypothesis cause pain in labor EXCEPT: (1 point)
A. Hypoxia due to circulatory stasis in the myometrium
B. Cervical stretching during dilatation
C. Emotional tension caused by fear & anxiety
D. A breech presentation
2. The following hypotheses/theories are true EXCEPT: (1 point)

A. Uterine stretch theory C. Increase in cortisol level
B. Increase in estrogen level D. Increase in prostaglandin level
3. Which of the following phenomenon of the uterine stretch theory does NOT (1 point)
occur in the uterus?
A. Differentiation of the upper and lower uterine segment
B. Retraction of the upper segment
C. Thickening of the lower segment
D. Thinning of the upper segment
4. Semen does contain prostaglandins which can help the cervix to soften (1 point)
during labor. Does coitus help induce labor?
A. Yes C. Not sure
B. No D. No idea
Thank you for your time and effort. We’re done with Lesson 1.
“Keep going”
“The secret of getting ahead is getting started”- Mark Twain
References:
1. Maternal-and-Child-Health-Nursing_-Care-of-JoAnne-Silbert-Flagg; 2018; pp960-966.
2. www.nucleusinc.com
3. Lee health: Health matters
4. pinterest.co.uk
5. https://www.youtube.com/watch?v=rpzBPqKgvGk
6. https://www.youtube.com/watch?v=YIW6fN-9wbw
NOTE: Posted online resources depends upon your connectivity.

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Discussion board post will be graded according to the rubrics below:
Criteria 10 7 3 0
Quality of Suitable comments, Suitable comments and Responds but with No post at
Post reflective, thoughtful responds respectfully to hesitation or not sure all
and respectful of other’s comments. of the answer posted.
other’s posting
Relevance of Topics posted are Posts topics related to the Topics posted are No post at
Post relevant to the subject content with minimal irrelevant and with all
matter; inserting new remarks or suggestions. few remarks or
ideas related to topics. suggestions.
Involvement Attempts to motivate Attempts to lead the Does not make effort No
to the the discussion process, discussion process to take part in the feedback
Learning presenting innovative presenting relevant learning community provided to
Community techniques involving viewpoints to be as it develops. fellow
the community’s considered by the group student
awareness. with minimal community
involvement.

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REFLECTIVE JOURNAL RUBRICS
CATEGORIES 3 2 1 TOTAL
CLARITY Coverage is Lacks focus and Lacks focus with
contextualize With context some inaccuracies.
focus and accuracy
THEME Covers most key Some relevant Unrelated/irrelevant
themes & relevant ideas or themes information
ideas. Holistic with some areas Little/no attempt to
understanding & lacking link/connect ideas
ideas coherently linked development
REFLECTION High level critical Makes attempt to Lacks critical
reflection critique but inconsistent reflection
in treatment of issues.
ORGANIZATION Ideas/themes linked Some undeveloped Repetition of main
AND cohesively and ideas and themes. points and themes, and
MANAGEMENT effectively sequenced ideas are unclear
Reasoned personal Weak positioning Little/no analysis
ANALYSIS AND standpoint & of personal/ and lacks personal
SYNTHESIS presents new creative standpoint.
knowledge/ideas synthesis
Within word limit, Within word limit Ignores word limit
COMMUNICATION appropriate writing but writing style and writing style
& APPLICATION style, < similarity with inconsistent, lesser inappropriate, with
ETHICALLY proper referencing similarity may be with more similarity
where required some inconsistency in and many sources
Few errors in referencing sources. not cited or cited
grammar, spelling incorrectly.
& punctuation.
TOTAL

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GROUP DISCUSSION RUBRICS

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UNIT 2. Factors Affecting Labor and Delivery Process
FACTORS THAT INFLUENCE PROGRESS OF LABOR

The 5 P’s
Passenger (Fetus)
Passageway
Powers
Pelvis
Uterine
Contraction
Psyche
Position Woman
psychological
outlook
A successful labor depends on four integrated concepts, often referred to as the four Ps:
1. The passage (a woman’s pelvis) is of adequate size and contour.
2. The passenger (the fetus) is of appropriate size and in an advantageous position and
presentation.
3. The powers of labor (uterine factors) are adequate.
4. The psyche, or a woman’s psychological state which may either encourage or inhibit labor.
This can be based on her past life experiences as well as her present psychological state.
(Maternal-and-Child-Health-Nursing_-Care-of-JoAnne-Silbert-Flagg; Adelle Pillitteri).

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ACTIVITY DESCRIPTION TIME
FRAME
1. Presentation of the factors affecting labor and delivery process through 10-15
video on the link to be provided. (You tube) minutes
www.nucleusinc.com,
https://www.youtube.com/watch?v=ybWQCkElMiI
https://www.youtube.com/watch?v=rpzBPqKgvGk
https://www.youtube.com/watch?v=zT-E0kbMZYI (intrapartum care)
2. Interactive discussion through Google classroom on the factors 45
affecting labor and delivery process. minutes
3. Please give your learning insights on the different factors affecting labor 15
and delivery process. Write your learning insights on the discussion minutes
board (at least 75 words)
4. Summative evaluation: Graded quiz (1-5 items) 15
Learning Insights rubrics minutes
Welcome back.
Ready-Get set!
Let’s Start! Discussion:
B.1.The Passageway (Pelvis)
Parts of the Pelvis

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The passageway refers to the route a fetus must travel from the uterus through the cervix and
vagina to the external perineum. In most cases, disproportion occurs between the fetus and pelvis
due to the faulty structure of the pelvis. If the disproportion is caused by the fetus, the fetal head is
presenting to the birth canal at less than its narrowest diameter, therefore Normal Spontaneous
Vaginal delivery is not feasible. The passage (a woman’s pelvis) should be of adequate size and
contour to accommodate the passenger (fetus) to travel out of the vaginal canal.
THE NORMAL PELVIS
The ideal normal female is the gynecoid pelvis:
The important diameters of the female pelvis.
Characteristic of a Normal Female Pelvis

1. BRIM - slightly oval transversely.
2. SACRAL PROMONTORY - not prominent.
3. TRANSVERSE DIAMETER - slightly longer than the anteroposterior.
4. SIDEWALLS - parallel and straight.
5. ISCHIAL SPINES - not prominent.
6. SACROSCIATIC NOTCHES - wide.
7. SACRUM - good curve.
8. PUBIC ARCH ANGLE - wide, more than 90
9. INTER TUBEROUS DIAMETER -wide

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Factors considered for the passage of the fetus to the pelvis:

1. Obstetric conjugate of the inlet
2. Distance between ischial spines
3. Subpubic angle & transverse diameters
4. Posterior & sagittal diameters of the 3 planes
5. Curve & length of the sacrum
Three Anteroposterior Diameters of the Pelvic Inlet:
12.5 cm by
(Pelvimetry
)
Obstetric Conjugate-Conjugata Vera
(11 cm) upper margin subtract 1.5-
2cm from. Diagonal conjugate
slightly longer than

True Conjugate - Conjugata the anteroposterior.
Vera (11.5 cm) upper margin-
sacral promontory

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Discussion
B.2. The Passenger (Fetus)
The head is the body part of the fetus that has the widest diameter that passes through the
pelvic ring depending on the structure (bones, fontanelles, and suture lines) and alignment with the
pelvis. Fetal head’s diameter is the ability of fetus to fit thru the maternal pelvis.
Factors which determine the way it moves thru the birth canal:
1. Fetal Head’s Size 2.Fetopelvic Relationships
o Fetal head/skull: o Fetal attitude
Sutures o Fetal Lie
Fontanels
3. Fetal presentation 4. Fetal position
Importance of sutures and fontanels:

1. Skull’s Flexibility
2. Moulding of the fetal head in cephalic positions
3. Diameter of the fetal skull
Skull’s Flexibility Sutures of the fetal skull
Molding of the Fetal skull

Molding is the overlapping of skull bones along the suture
lines, which causes a change in the shape of the fetal skull
to one long and narrow, a shape that facilitates passage
through the rigid pelvis. It is caused by the force of uterine
contractions as the vertex of the head is pressed against the not yet dilated cervix.

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Other factors that play a part in whether a fetus is properly aligned in the pelvis and is in the best
position to be born are fetal attitude, fetal lie, fetal presentation, and fetal position.
Passenger: Fetopelvic relationships

1. Fetal Attitude is the degree of flexion a fetus assumes during labor or the relation of
the fetal parts to each other.
o Normal attitude – flexion

of neck, arms and legs
o Hyperextension -
abnormal attitude
o Fetal attitude changes
cause larger diameter of

fetal head to present to
pelvis.
2. Fetal Lie is the relationship between the long axis of the fetal body and the
long axis of a woman’s body—regardless whether the fetus is lying in a
horizontal (transverse) or a vertical (longitudinal) position.

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3. Fetal presentation indicates the body part as the first to contact the cervix or be delivered
first and is determined by the combination of fetal lie and the degree of fetal flexion
(attitude).
Type of Fetal Presentations: Classification of Fetal presentation
a. Cephalic presentation vertex, military, brow or face
b. Breech presentations complete, frank or footling
c. Shoulder presentation: occurs rarely; shoulder, arm, back, abdomen or side
TYPES OF CEPHALIC PRESENTATION
TYPES OF BREECH PRESENTATION

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4. Fetal Position is the relationship of the presenting part to a specific quadrant and side of a
woman’s pelvis. To determine the position of the fetus, the maternal pelvis is divided
into four quadrants according to the mother’s right and left:
(a) right anterior, (b) left anterior, (c) right posterior, and (d) left posterior.
Fetal Landmarks Maternal Pelvis
O = Occiput (vertex) R = Right side
M = Mentum (face) L = Left side
S = Sacrum (breech) A = Anterior
A = Acromion process(shoulder) P = Posterior
T = Transverse
In a vertex presentation, the occiput (O) is the chosen point.
In a face presentation, it is the chin (mentum [M]).
In a breech presentation, it is the sacrum (Sa).
In a shoulder presentation, it is the scapula or the acromion process (A).
Position is important because it can influence both the process and efficiency of labor. Typically,
a fetus is born fastest from a Right Occiput Anterior or Left Occiput Anterior position.

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5. Fetal Station - refers to the relationship of the presenting part of the fetus to the level of the
ischial spines. Refer to the illustration below.
Engagement refers to the settling of the presenting part of a fetus far enough into the pelvis
that it rests at the level of the ischial spines, the midpoint of the pelvis.
A vaginal and cervical examination is done to determine the degree of
engagement.
A presenting part that is not engaged is said to be “floating.”
One that is descending but has not yet reached the ischial spines may be referred to as
“dipping.”
Mechanisms (Cardinal Movements) of Labor

Effective passage of a fetus through the birth canal involves not only position and
presentation but also a number of different position changes in order to keep the smallest
diameter of the fetal head (in cephalic presentations) always presenting to the smallest
diameter of the pelvis. These position changes are termed the cardinal movements of labor:
descent, flexion, internal rotation, extension, external rotation, and expulsion.
Mechanisms of Labor will be discussed further on the next unit.

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B.3.POWER ► Contractions + Maternal pushing
Initiate by pacemakers ~ uterotubal junction Additional force

Contraction waves meet at the fundus
Contraction waves progress downward “maternal
pushing”
Shortening of muscle fibres ⁭

Retractions Intra abdominal
⁭Intra uterine pressure pressure
EXPULSION OF THE FETUS
The most important factor that facilitates labor and delivery is successful powers of
labor. It is a force applied by the fundus of the uterus initiated by uterine contractions that
causes efficient cervical dilatation and effacement and eventually expulsion of the fetus from the
uterus.
Once full cervical dilatation occurs, the primary powers enhance by the involuntary
uterine muscle fibers, stimulated by the pacemaker (ureterotubal junction) in the upper uterine
segment supplemented by the secondary forces the voluntary abdominal muscle which
facilitates descent and delivery of the fetus. Therefore, it is very important to instruct the mother
to bear down with their abdominal muscles when the cervix is fully dilated to avoid fetal and
cervical damage.

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B.4. POSITION: Position of Woman in Labor:

The different positions of a woman in labor which promote good circulation provide
comfort and relieve fatigue. Furthermore, it could facilitate descent, improve blood flow, relieves
back ache, straightens axis of birth canal and increases pelvic outlet. To mention the following
positions, they are- squatting, kneeling, sitting, walking.
Below are pictures of the different positions of woman in labor.
B.5. PSYCHE: refers to the psychological state or feelings a woman brings into labor.
PSYCHE is a feeling of apprehension or anxiety that includes a sense of
excitement or fear. Those who could manage great during labor are woman with
a strong sense of self-worth and with significant person supporting them.
Concerns of a Woman During Labor and Birth.
o Preparation for childbirth
o Socio-cultural heritage
o Previous childbirth experience
o Support from significant others
o Emotional status
o Environmental influence
Start reading the module so that you could have an idea of the topics to be discussed via
Google classroom. See you online for our interactive discussion about the topic. Let’s proceed
to our activities.

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Activity 1.
Audio-visual presentation of the factors affecting labor and delivery process.

Please open the links below and start watching:
www.nucleusinc.com,
https://www.youtube.com/watch?v=rpzBPqKgvGk
At the end of the presentation, you have to post your reactions, learning insights,
to the discussion board. Posts will be graded according to the rubrics below. This is applicable
to all students in this class. Comments and suggestions among others are very well appreciated.
Discussion Board
You will be graded according to the rubrics on the next page. Submit your answer after 20
minutes same lecture day.

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Discussion board post will be graded according to the rubrics below:

Criteria 10 7 3 0
Quality of Post Suitable Suitable Responds but with No post at

comments, comments and hesitation or not all
reflective, responds sure of the answer
thoughtful and respectfully to posted.
respectful of other’s
other’s posting comments.
Relevance of Topics posted are Posts topics Topics posted are No post at
Post relevant to the related to the irrelevant and all
subject matter; content with with few remarks
inserting new minimal remarks or suggestions.
ideas related to or suggestions.
topics.
Involvemen Attempts to Attempts to lead Does not make No feedback

t to the motivate the the discussion effort to take part provided to
Learning discussion process in the learning fellow
Community process, presenting community as it student
presenting relevant develops.
innovative viewpoints to be
techniques considered by the
involving the group with
community’s minimal
awareness. community
involvement.
Total Score

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Activity 2. Interactive discussion via Google classroom on the factors affecting labor
and delivery process. (20-25 minutes), then processing of ideas about the
topic via Google Meet.
Illustrations of the different types of pelvis.

1. Which of the following is considered as the female pelvis? Why? (3 points)
2. What is the role of the pelvis to the delivery process? (5-6 sentences) (3 points)
3. Draw a female pelvis. (4 points)

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Identify the different fontanels of the skull: (1 point/number) Post your answer on the
discussion board below.
#1
#2 #4
#3
Pictures after delivery: Take note of the shape of the head and compare.
Determine how this happen. In three sentences, write your discussion below. Submit after 20
minutes (date to be inserted)
Discussion Board:

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Activity 3. Please give your learning insights on the different factors affecting
labor and delivery process. Please watch the link below and post
your reflections/learning insights on the space
provided below.
2. https://www.youtube.com/watch?v=dTieUflVyio&pbjreload=101
Answer the following questions based on the video presented:

1. What do you think is the best position for birth? Why?
2. The best position during labor that could reduce labor pain. Why?
Discussion board:

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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSION-NURSING
focus and accuracy
& punctuation.
TOTAL

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Activity 4:
Summative evaluation: Graded quiz (1-5 items)
Learning Insights rubrics
GRADED QUIZ: (1 point each number)
1. An x-ray pelvimetry was done for a woman due to prolonged 2nd stage of labor.
Which type of pelvis resembles the male pelvis which is a heart-shaped & often
complicates labor?
A. Gynecoid B. Anthropoid C. Android D. Platypelloid
2. The membranous-filled spaces of strong band of connective tissues with cranial bones:
A. Sutures B. Fontanels C. Fetal skull D. Caul
3. All of the following factors will influence the length of a woman’s labor EXCEPT:
A. Size of the placenta C. Fetal attitude
B. Bearing down effort D. Parturient’s mental attitude
4. The primary power involved in labor and delivery is:

A. Bearing down ability of mother C. Uterine contraction
B. Cervical effacement and dilatation D. Valsalva technique
5. When the fetal head is at the level of the ischial spine, it is said that the station of the
fetal presenting part is:
A. Station – 1 B. Station 0 C. Station +1 D. Station +2
“Do what you can, with what you have, where you are” Theodore Roosevelt
Congratulations! You did it!
Let’s Proceed
References:
1. Maternal-and-Child-Health-Nursing_-Care-of-JoAnne-Silbert-Flagg; 2018; pp960-966.
3. https://www.youtube.com/watch?v=dTieUflVyio&pbjreload=101
4. www.nucleusinc.com,
5. https://www.youtube.com/watch?v=ybWQCkElMiI
NOTE: Online resources can be viewed depending on your connectivity.

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Unit 3
Common Signs of Labor
Overview:
Before labor actually begins, many pregnant women experience common signs indicating
that labor start. Some experienced symptoms like abdominal cramping weeks before actual labor.
Therefore, health teaching regarding the different common signs of labor is a must, so that the
parturient could understand and recognize that labor begins.
Learning Outcomes:
At the end of the lesson, students will be able to;
1. Discuss the stages of labor, the common discomforts and the danger signs which are
experienced by the parturient during labor and delivery.
Content
A. Preliminary Signs of labor
A.1. Lightening
A.2. Increase in energy
A.3. Slight loss of weight
A.4. Backache
A.5. Braxton Hicks Contraction
A.6. Ripening of the cervix
B. Signs of true labor
B.1. Uterine contraction
B.2. Show
B.3. Rupture of membranes

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ACTIVITY DESCRIPTION TIME FRAME

1. Video presentation on the common signs of labor. Please follow the link 10-20
provided. After the video clip presentation, please post your learning minutes
insights on the discussion board provided.
https://www.youtube.com/watch?v=nSPsew1mTEo
https://www.youtube.com/watch?v=5lBA7d1RR8U
2. Interactive discussion through Google classroom 45
Differentiate true labor from false labor. Watch the video below and minutes
post your learning, comments, clarifications in the discussion board.
https://www.youtube.com/watch?v=HVS2tFHP6Z4
https://www.youtube.com/watch?v=uey4eOb35yY
3. Summative evaluation: 30
Graded quiz (1-5 items), minutes
Formulate a Nursing Care Plan on a parturient in
labor. Identify problems according to priority. Case to be
posted.
Let’s get started!
Discussion:
Preliminary signs of labor:
1. Lightening - 10-14 days before labor in primigravida and 1 day before labor in a multipara
 Lightening is heralded by the following signs:
Relief of dyspnea Relief of abdominal tightness
 Engagement refers to the settling of the presenting part of a fetus far enough into the
pelvis that it rests at the level of the ischial spines, the midpoint of the pelvis.
2. Increase in the level of activity –this is due to the increase in epinephrine release
initiated by a decrease in progesterone level produced by the placenta. It prepares the
woman’s body for labor.
3. Slight loss of weight - Loss of weight is about 2-3 lbs. one to two days before the onset of
labor (progesterone & loss of appetite)
4. Backache – due to pressure or cramping in the pelvic and rectal areas.

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5. Braxton Hicks Contraction or false labor contractions are extremely strong contractions
which may be interpreted as true labor contractions that can be noticed in the last week
or days before labor begins.
6. Ripening of the cervix (Goodell’s sign) - the cervix become softer or “butter-soft” and can
only be seen during pelvic examination. It is a sign that labor is near.
B. Signs of true labor:

1. Uterine Contractions – this is a definite sign that labor begins because contractions are
involuntary and increases in intensity. Inorder to know the difference between true labor
from false labor please refer to the box below
TRUE LABOR FALSE LABOR
1. Uterine contractions – Regular 1. Irregular contractions
2. Progressive frequency & intensity frequency & intensity
3. Pain/Discomfort from lower back to 2. Discomfort in lower abdomen and groin
abdomen 3. Activity change
4. Increases in Activity/Ambulation 4. UCs stop when sleeping
5 Progressive effacement and dilation of 5. No appreciable cervical change
cervix 6. Sedation decreases UCs
6. Not relieved by Sedation 7. Show usually not present
7. Show usually present
2. Show – “Operculum” are pink-tinged blood mixed with mucus that plugs the cervical
canal during pregnancy. As the cervix ripens, it becomes soft and the exposed cervical
capillaries leaks due to the pressure applied by the fetus.
Illustration is taken from:
(ConceiveEasy.com)
“Mucus plug or bloody show”

3. Rupture of membranes – due to the pressure exerted by the fetus, the amniotic sac
(membrane that protects the fetus from intrauterine infection) breaks, a woman in labor
may experience a sudden gush or scanty slow clear fluid coming out of the vagina.

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Important nursing considerations:

Initial Nursing Action
A. Early rupture of membranes
Put her immediately in bed and monitor fetal heart rate. Instruct
the client not to ambulate to prevent fetal cord compression.
B. Cord Prolapse
Trendelenburg position to reduce pressure on the umbilical cord
Remember: only 5 minutes of umbilical cord compression causes
CNS damage & even death.
Warm saline saturated OS on the cord – to prevent injury and drying of the cord
STAGES OF LABOR and DELIVERY
A. The First Stage of Labor

A.1. The Latent Phase
A.2. The Active Phase
A.3. The Transition Phase
B. The Second Stage of Labor
C. The Third Stage of Labor
C.1. Placental Expulsion
C. 2. Placental Separation
Let’s have an eye view of the definition of
Labor as well as the causes of labor onset
before going on to the stages of labor.
Labor is the process of delivering a baby and

the placenta, membranes, and umbilical cord
from the uterus to the vagina to the outside
world. Usually, it is divided into four stages.
The different stages of labor need to be
monitored and recorded in order to ensure
the safety of the mother and the baby as well.
Furthermore, it could also help determine expected outcomes and nursing intervention in a
woman experiencing labor and birth.

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Our discussion in this unit ends; let’s carry on to our activity!
A. First stage of labor: (Effacement and dilatation stage)

Starts with the beginning of true labor contractions and ends in a fully dilated cervix. The first
stage of labor is divided into three phases.
1. The Latent phase or the preparatory phase – onset of regularly perceived uterine contractions
and ends when rapid cervical dilatation begins.
 Characteristic of contraction – mild and short
 Duration of contraction – 20-40 seconds
 Cervical dilatation – 0 to 3cm
 Lasts for approximately 6 hours in a nullipara and 4.5 hours in a multipara.
Reasons for prolonged latent phase:
1. “Non-ripe cervix”
2. Cephalopelvic disproportion – a disproportion between the fetal head and the pelvis)
2. The active phase – cervical dilatation occurs more rapidly, true discomfort is
experienced by a woman because contractions grow so much stronger and last so
much longer.
 Characteristic of contractions – stronger and longer
 Cervical dilatation – 4 to 7cm
 Duration of contraction – 40-60 seconds
 Interval of contraction - every 3 t0 5 minutes
 Lasts for approximately 3 hours in a nullipara and 2 hours to a multipara
3. The transition phase – contractions reach its peak of intensity. It is during this stage
wherein a woman in labor may experience nausea and vomiting, a feeling of loss of
control, anxiety, irritability and may panic as well due to an intense contraction.

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Transition phase:
 Characteristic of contraction – intense,
 Duration of contraction – 60 to 70 seconds
 Cervical dilatation – 8 to
 Interval of contraction – 2-3 minutes
Contraction Cycle
Characteristics:
*Frequency
*Duration
*Intensity
Phases:
*Increment
*Acme
*Decrement
B. Second Stage of Labor – (Dilatation Stage)

 Starts from the period of full cervical dilatation and effacement to delivery of the baby.
This stage takes about an hour if complications will not arise. Contractions change its
characteristic pattern from increasing to decreasing intensity to an uncontrollable urge
to push or bear down with each contraction as if there is an urge to defecate.

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Crowning is the appearance of the fetal scalp at the opening of the vagina as the fetal head pushes
against the vaginal introitus.
Management of the Second Stage of labor:
1. Fetal heart rate monitoring at least every 5 minutes and after each contraction if the
woman is in complete cervical dilatation.
2. Empty the bladder to facilitate descent of the fetal head.
3. Avoid lying down in supine position or semi- supine, rather adopt a comfortable position.
4. Light diet or if possible keep client on NPO to prevent vomiting.
5. Instruct the woman in labor not to push if the cervix is not fully dilated (Vaginal examination)
to prevent damage of the perineal tissue.
6. Support the perineum to increase flexion of the fetal head and relieve pressure on the
perineum. https://www.youtube.com/watch?v=7qBlhpjIzwc (Ritgen Maneuver)
7. Check that the umbilical cord does not coil around the infant’s neck.
8. Deliver the shoulder and body in gentle continuous posterior traction on the head and
lateral flexion, to deliver the anterior shoulder then left the posterior shoulder over the
perineum.
.
Comparison of cervical dilatation to the
different fruits for a clearer picture
CARDINAL MOVEMENTS OF LABOR


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PARTOGRAPH
Partogram - is a graphical information about the progress of labour in which

the salient information about the fetal well-being, maternal well-being and
the progress of labour are recorded into a chart.
Components of a Partograph:
Mother information (Name, age, parity, gestational age, date & time of admitted,
time membrane ruptured, short antenatal history)
Fetal well-being (Fetal Heart Rate, Character of fluid, Molding)
Labor Progress (Cervical Dilatation, Descent, Uterine contraction)
Medications (Oxytocin, Pain reliever Medication)
Maternal well-being (B/P, Pulse, Temp, Urine-(albumin, glucose, acetone) Urine output

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C. Third Stage of Labor (Placental Stage) – begins with birth of the baby and end with the delivery
of the placenta. It involves two different phases: placental separation and placental expulsion
Actual placental expulsion, determining completeness of cotyledons and if the placenta and
placental fragments are totally expelled.

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MECHANISM OF PLACENTAL EXPULSION
 Active Management of the third stage of labor:

1. Prophylactic uterutonic after delivery of the baby. (Oxytocin 10 IU intramuscularly)
2. Cord clamping, cutting and controlled cord traction of the umbilical cord.
3. Uterine massage to prevent uterine atony and minimizes bleeding.
 Excites powerful uterine contraction, aids in early placental separation, minimizes blood
loss and duration of the third stage of labor.(5 minutes)
Uterine massage
to minimize
bleeding
D. Fourth stage of labor: The hour or two after delivery when the tone of the uterus is
reestablished as the uterus contracts again, expelling any remaining contents (placenta and
placental fragments). These contractions are hastened by breastfeeding, which stimulates
production of the hormone oxytocin. (www.healthyfamiliesbc.ca)
The mother may experience:
1. Tremors and chills
2. After-pains
3. Episiotomy or tears
4. Hemorrhoids
5. Postural hypotension ( dizziness, fainting)

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Nursing Management during the fourth stage of labor:

1. Monitor vital signs and the general condition of the mother.
 Take BP, P, and R every 15 minutes for an hour, then every 30 minutes for an
hour, and then every hour as long as the patient is stable. Take the patient’s
temperature every hour.
 Keep the cliennt warm with blanket if ever chills is experienced.
 Observe for uterine atony or hemorrhage.
 Encourage the patient to drink fluids.
2. Ensure the fundus remains firm.
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.
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.
3. Monitor lochia flow.
Lochia is the maternal discharge of blood, mucus, and tissue from the uterus.
Identify lochia amounts as small, moderate, or heavy (large)
4. Observe patient’s urinary bladder for distention.

Characteristics of a full bladder:
1. Bulging of the lower abdomen
2. Spongy feeling mass between the
fundus and the pubis.
3. Displaced uterus from the midline,
usually to the right.
4. Increased lochia flow.
We’re done with our discussion on the different stages of labor and delivery.
Questions and clarifications will be entertained in our interactive discussion via Google classroom.
Please send questions and clarifications via text messages if you have poor connectivity.
Let’s proceed to our activity!

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Activity 1. (COMMON SIGNS OF LABOR)

Video clip presentation on the Common signs of labor. Please follow the link
provided. After the video clip presentation, please post your learning insights
on the discussion board provided.
https://www.youtube.com/watch?v=nSPsew1mTEo
https://www.youtube.com/watch?v=5lBA7d1RR8U
Answer the following questions:
1. What are the common signs of labor (preliminary signs and signs of true labor)
Discussion Board:
2. How will you determine if a parturient is in true labor?
Discussion board:

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Activity 2 Interactive discussion via Google Classroom:

1. How to differentiate true labor from false labor.
Discussion board:
2. What is the importance of such to a parturient in labor?

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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSION-NURSING_____
Activity 3
1. Graded Quiz)
1. Which of the following statements is correct regarding true labor pain: (1point)
A. In true labor, the discomfort felt by the parturient occurs at the abdomen radiating to the lumbosacral area
B. In true labor, the discomfort felt by the parturient occurs at the lumbosacral area radiating to the abdomen
C. In true labor, the discomfort felt by the parturient occurs at the lumbosacral area radiating to the left upper arm
D. In true labor, the discomfort felt by the parturient occurs at the lumbosacral area
2. A client identifies the correct signs of true labor if she experiences the following EXCEPT: (1 point)
A. She stops ambulating when there is a strong uterine contraction
B. She observes moderate amount of bloody show
C. The uterine contractions monitored at home is more frequent and increasing in strength
D. She experiences pain over her abdomen radiating towards her back
3. The following are correct statements about false labor EXCEPT (1 point)
A. The pain is regular in intensity and frequency C. There is no vaginal bloody discharge
B. The duration of contraction progressively lengthens over time D. The cervix is still closed
4. A client of 40 5/7 wks AOG came to the clinic with the following labor complaints but one is NOT an
indication of her premonitory/impending labor: (1 point)
A. Lightening B. Bloody show C. Desire to bear down D. Rupture of membranes
2. Case Study:

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3. Formulate a Nursing Care Plan according to priority nursing problem identified on the case
presented in page 42. Your answer will be graded according to the rubrics on the next page.

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4. NCP Rubrics:
Content 4 3 2 1 Weight
Nursing Identifies CORRECT Identifies CORRECT Identifies CORRECT Problems identified is __x 1+
nursing problems basing nursing problems basing nursing problems basing not found in the
Diagnosis NANDA or No problems
on NANDA; Follows the on NANDA; Follows the on NANDA; does not
PES format for the PES format for the follows the PES format for identified at all;
diagnostic label; lists diagnostic label; some the diagnostic label; some
appropriate cues to cues are not significant cues are not significant or
support the problem; uses medical did not supply significant
uses nursing terminology for the supporting details at all;
terminology; both etiology; both elements uses medical terminology
elements does not say does not say the same in any elements; both
the same thing; cause thing; cause and effect elements does not say OR
and effect correctly clearly stated. say the same thing.
stated
Objectives Student demonstrates Some objective is not Most objective is not All objective is NOT __x .5=
full knowledge; all specific, measurable specific, measurable (uses specific, measurable
Objective is specific, (uses verbs found in the verbs found in the (uses verbs found in the
measurable (uses verbs taxonomy of objectives), taxonomy of objectives), taxonomy of
found in the taxonomy of attainable, realistic, and attainable, realistic, and objectives), attainable,
objectives), attainable, time-bound; some not time-bound; most related realistic, and time-
realistic, and time-
related to the concept to the concept bound; all not related
bound; all are related to
to the concept
the concept.
Intervention All Interventions are Most interventions are Some interventions are No interventions are __x 2 =
addressed to eliminate addressed to eliminate addressed to eliminate or addressed to eliminate
or alleviate the etiology or alleviate the etiology alleviate the etiology of or alleviate the etiology
of the nursing problem of the nursing problem the nursing problem and is of the nursing problem;
and is in congruence and is in congruent with in congruent with the OR student has no
with the Goal/objective; the Goal/objective; most Goal/objective; some are nursing
all are appropriate to the are appropriate to the appropriate to the client’s interventions/strategies
client’s understanding client’s understanding understanding, and planned at all.
and resources; specific and resources; specific resources; not specific and
and laid out in detail; and laid out in detail; not laid out in detail; some
realistic realistic are realistic
Evaluation Able to evaluate Able to evaluate Able to evaluate in Failed to evaluate. __X .5=
correctly in accordance correctly in accordance accordance with only some
with the outcome criteria with the outcome criteria of the outcome criteria /
/ objective and able to / objective and but is objective and is unable to
give correct justification unable to give correct give justification
to the evaluation by justification to the
listing appropriate evaluation by listing
significant cues appropriate significant
cues
Total= 20pts

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Schedule of Activity: STAGES OF LABOR
Activity Description Time

Frame
1 Video presentation of the stages of labor and the cardinal movements of labor. 15
Please open the link below. minutes
https://www.youtube.com/watch?v=9NUF6mebhhk&t=44s Labor
https://www.youtube.com/watch?v=w0iDfcAYZWc stages of labor
https://www.youtube.com/watch?v=ybWQCkElMiI cardinal movements of labor
2 Google classroom INTERACTIVE discussion on the following topics: 30
 Assessment of client in labor. minutes
 Identify the stages of labor and discuss. Post your discussions on the
discussion board before each picture.
 Use of partograph in the recording of the progress of labor.
 Answer the questions posted below the graph.
3. Assessment Tasks: 10
 Physical Assessment rubrics minutes
 Quiz Graded
 Labor and delivery Puzzle
 Stages of Labor worksheet.
 Partograph worksheet, Cardinal movements of labor worksheet

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Activity 1.
Video clips of the stages of labor, partograph, and the cardinal movements
of labor. Please open the link below.
https://www.youtube.com/watch?v=9NUF6mebhhk&t=44s Labor
https://www.youtube.com/watch?v=w0iDfcAYZWc stages of labor
https://www.youtube.com/watch?v=ybWQCkElMiI Cardinal Movements
https://www.youtube.com/watch?v=UNPJK0aLW0U Cardinal movements
https://www.youtube.com/watch?v=8hn7Mdlz_X4 Partograph
Answer the question below:

1. How will you determine if a parturient is in true labor in 150 words and post your
answer on the space provided below.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

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Activity 2 Google classroom INTERACTIVE discussion on the following topics:

 Assessment of client in labor.
 Identify the stages of labor
 Use of partograph in the recording of the progress of labor.
 Cardinal Movements of Labor
 Nursing care management during labor and birth.
Answer the following questions below:

1. How are you going to asses a client in labor?
2. What are the parameters that you are going to use?
3. Identify the stages of labor and discuss.
4. What is a partogram and discuss how it is use during labor.
5. Identify the cardinal movements of labor and discuss.
6. How are you going to manage a parturient during labor and birth?
DISCUSSION BOARD:

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DISCUSSION BOARD:


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Activity 3 Assessment Tasks:

1. Physical assessment rubrics 4. Partograph Worksheet
2. Graded Quiz 5. Cardinal Movements of Labor
3. Labor and Delivery Puzzle Worksheet Worksheet
WORKSHEET # 1 PARTOGRAPH
https://www.youtube.com/watch?v=8hn7Mdlz_X4 –components of the partograph.

https://www.youtube.com/watch?v=VpG3OTCLvOE- how to plot WHO partograph
After watching the video, write on the box provided the components of a partograph.


www.usa.edu.ph
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WORKSHEET #2
Labor and Delivery Puzzle
₁
₂
₃
₄ ₅ ₆
₇ ₈
₉
₁₀
₁₁
₁₂
₁₃
₁₄
₁₆ ₁₇
₁₈
₁₉
This is a puzzle about labor and delivery. Since we are done with our discussion and
video clip presentation regarding the topics on labor and delivery, it’s time to determine how you
comprehend the topic. You will be given one (1) point in every correct answer. Submit your
worksheet as soon as you’re done, so that we could proceed to the next worksheet. Thank you.
Follow the arrow for your question

which is located on the next page

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SELECT YOUR ANSWER HERE:

FOR THE LABOR AND DELIVERY PUZZLE
Across:
2. The fetus is in a longitudinal lie with the buttocks or feet closest to the cervix.
6. secretion of milk from the breast
9. The fluid surrounding the fetus
11. the normal from the uterus after childbirth
12. The lower part of the uterus that dilatesas labor progresses
16. Used to determine the position of the fetus inside the woman's uterus
18. A synthetic form of oxytocin, used to induce labor.
19. Shortening of the uterine muscles occuring at intervals before and during childbirth
Down
1. Cervical thinning
3. A surgical cut made at the opening of the vagina during childbirth.
4. A procedure wherein the amniotic sac is artificially ruptured.
5. A decrease in the fetal heart rate below the fetal baseline
7. The sensation that a pregnant woman feels when the baby drops.
8. The fluid sac that protects the fetus in the womb.
10. The act of giving birth.
13. The opening of the cervix as it pulled upward and the fetus is pushed downwards.
14.
17. The location of the presenting part of the fetus is in the birth canal.

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Worksheet #3
Identify the pictures below, determine the cardinal movements of labor accordingly.
You will be given one (1) point/answer.

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Physical Assessment Rubrics:

EXCELLENT GOOD FAIR POOR
CRITERIA SCORE
(4 PTS.) (3 PTS.) (2 PTS.) (1 PT.)
All information Information generally Errors in format; Errors in
organized in logical organized in logical information format;
Organization
sequence; follows sequence; follows intermittently information
acceptable format acceptable format organized disorganized
Provides adequate
physical examination
Provides adequate
documentation that
covers all systems Provides minimal
documentation that
using inspection, physical examination
covers majority of
palpation, documentation with
systems with minimal
Thoroughness auscultation as numerous Provides no
grammatical, spelling
of Physical appropriate with no grammatical, spelling physical
or word usage errors.
Exam grammatical, spelling or word usage errors. examination
Evidence of
or word usage errors. No evidence of documentation.
appropriate
Evidence of further assessment
assessment of
appropriate of negative findings.
negative findings
assessment of
documented.
negative findings
documented.
Consistently
Consistently
Consistently Demonstrates demonstrates
demonstrates below
demonstrates average level of below average
average of
knowledge and knowledge and of knowledge
knowledge and
responsibility in responsibility in and
responsibility in
Assessment completing a full completing a full responsibility in
completing a full
Skill body assessment. body assessment. completing a
body assessment.
Demonstrates above Requires a moderate full body
Requires a maximum
average level of level of instructor assessment.
level of instructor
competence in involvement in the Does not have
involvement in the
assessment skills assessment process. basic
assessment process.
knowledge
Score equivalent to Percentage:
3 = 80 4 = 82 5 = 84 6 = 87 7 = 89 8 = 93 10 = 96 11 = 98 12= 100 (Roobrix converter)

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GRADED QUIZ:
Multiple Choice: Select the letter of the best answer. You will be given one (1) point in each
correct answer.
1. Which of the following factors does NOT influence effacement and dilatation during the
1st stage of labor?
A. Obliteration
B. Pressure exerted by the amniotic fluid
C. Force applied by the presenting part
D. Sudden gush of blood
2. As labor progresses, the nurse expects to monitor the uterine contractions becoming:
A. More intense, less frequent and of longer duration
B. More intense, more frequent and of longer duration
C. Constant in intensity, more frequent and of shorter duration
D. Constant in intensity & frequency but of shorter duration
3. A change of the fetal skull’s shape produced by the force of uterine contractions pressing
the vertex against the not yet dilated cervix:
A. Caput Succedaneum B. Moulding C. Brow D. position
4. The following are characteristics of the passageways in labor and delivery EXCEPT:
A. Distensibility of the lower uterine segment
B. Cervical dilatation and effacement
C. Distensibility of vaginal canal and introitus
D. Flexibility of the pelvis
5. A client identifies the exact signs of true labor if she experiences the following EXCEPT:
A. She stops ambulating when there is a strong uterine contraction
B. She observes moderate amount of bloody show
C. The uterine contractions monitored at home is more frequent and increasing in strength
D. She experiences pain over her abdomen radiating towards her back
“You may be disappointed if you fail, but you’ll be doomed if you don’t try”- Beverly Sills
We’re about to proceed to the next unit. Are you ready?
Then, fasten your seat belt. Let’s take it away!

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UNIT 4
MATERNAL and FETAL RESPONSES TO LABOR
Overview:
Labor is an intense localized process affecting the abdomen and the reproductive organs
with a complete physiologic effect to both the mother and the fetus. Because of its powerful
strength, almost all body systems are involved.
Pregnancy has effects on many systems of the birthing parent. During labor, there are yet
further effects which may require the nurse to deliver specific care to their patient. Knowing and
recognizing what is normal and what is not normal can help to ensure safe provision of care.
(Textbook_-Maternal-and-Child-Health-Nursing_-Care-of-JoAnne-Silbert-Flagg & Pellitirre)
Learning Outcomes:
1. Assess accurately the progress of labor and perform interventions promptly and
safely for psychological and physical comfort.
Content:
1. Maternal Responses to Labor
A. Physiologic Effects of Labor
A.1. The Cardiovascular System
A.2. The Hematopoietic System
A.3. The Respiratory System
A.4. Temperature Regulation
A.5. Fluid Balance
A.6. The Urinary System
A.7. The Musculoskeletal System
A.8. The Gastrointestinal System
A.9. Neurologic and Sensory Responses
B. The Psychological Responses
B.1. Responses to pain
B.2. The Response to Fatigue
B.3. The Response to Fear
2. Fetal Response to Labor
A. The Neurologic System
B. The Cardiovascular System
C. The Integumentary System
D. The Musculoskeletal System
E. The Respiratory System

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Activity Description Time

Frame
1. Video clip presentation of the maternal and fetal responses to labor and birth. 10-15
Links provided before the start of our activity. minutes
2. Interactive Discussion via Google classroom on the following topics:
1. The physiologic and psychological effects of labor and delivery to a parturient. 30-45
2. The physiologic effect of labor and delivery to the fetus. minutes
3. Implementation of nursing interventions efficiently and safely for psychological
and physical comfort of a parturient during labor and birth.
3. Assessment Tasks:
 Learning insight rubrics/Reflective journal rubrics 45
 Q-R Grid – At the start of the lesson, please pose questions and predict minutes
the answer. Verify your answers during the discussion. Post your
questions and answer in the discussion board provide
 Graded Quiz via Google met
To start, let’s proceed to the discussion room.
MATERNAL RESPONSES TO LABOR

A. PHYSIOLOGICAL EFFECTS OF LABOR
A. 1. The Cardiovascular System
 Cardiac output increases from pre-labor levels by 40%-50%
 Approximately 300-500 ml of blood is lost during birth.
 Due to pain during contractions B/P rises up to 15mmHG
systole/contraction
 Nursing action:
1. Monitor closely for hemorrhage
2. Monitor for pathologic signs (hypertensive episodes)
3. Ensure hydration of the client prior to epidural administration.
(IV fluid bolus)
A.2. The Hematopoietic System

 WBCs increase to a level of 25,000– 30,000 cells/mm3 during labor.
 Nursing action:
1. Monitor signs of infection continuously.

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A.3. The Respiratory System

 Due to increase cardiovascular factor, RR increases as a response.
 During the second stage of labor oxygen demand increases to 100%
 Nursing Care:
1. Monitor for any signs of hyperventilation.
(re-breathing into a paper bag can help)
2. In order to regulate respiratory rate instruct the client to use
appropriately patterned breathing.
A.4. Temperature Regulation

 Diaphoresis may occur
 Temperature may increase to 1ºF
 Nursing care:
1. Monitor for any signs of infection.
2. Offer cool washcloth on client’s forehead for comfort if needed.
A.5. Fluid Balance

 Due to diaphoresis insensible water loss increases during labor.
 Nursing Care:
1. Encourage sips of fluid during labor to keep hydrated.
2. If nauseated, offer ice chips or hard candy to give some
extra fluid.
A.6. The Urinary System

 Due to the pressure of the fetal head as it descends in the birth canal
against the anterior bladder reduces bladder tone or the ability of the
bladder to sense its fullness.
 Nursing care:
1. Encourage the mother to void every 2 hours during labor to avoid
fullness of the bladder that decreases postpartal bladder
tone causing postpartum bleeding.
A.7. The Musculoskeletal System

 Relaxin is secreted from the ovaries causing the cartilage between joints
to be more flexible during pregnancy allowing the joints of the pelvis to
be able to open as much as 2 cm in labor to allow for fetal passage.
 Nursing care:
1. Monitor mobility of the mother to reduce the risk of fall.

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A.8. The Gastrointestinal System

 Blood shunts to life-sustaining organs causing the GI system to become
fairly inactive during labor, thus causing digestion and emptying time of
the stomach longer.
 Nursing care:
1. NPO is advised during active labor to prevent vomitting
A.9.Neurologic and Sensory Responses

 Pain and respiratory rate increases.
 Nursing Care:
1. When the mother does not desire medication, discuss the non
pharmacologic pain techniques.
2. Epidural anesthesia is administered to mother with low tolerance
to pain and those who desires to have it, but make sure to discuss
the effects.
B. THE PSYCHOLOGICAL RESPONSES

A. The response to pain
 Women are encouraged to help plan their care that makes her
response to pain, her choice of nourishment, her preferred birthing
position, the proximity and involvement of a support person, and
customs a positive experience during labor and birth.
B. The Response to Fatigue
 A woman is generally tired from the normal discomforts of pregnancy
and has not slept well for the past month due to backache when in
side –lying position, fetus kicking that waken her up when in supine
position. Sleep hunger from this type of discomfort can make it difficult
for a woman to perceive situations clearly or to adjust rapidly to new
situations.
C. The Response to Fear
 Labor moving faster or slower, contractions harder and longer
can lead a woman to feel out of control and increase the level of
pain she experiences. This sense of lack of control combined with
pain may cause her to begin to worry for her infant and may
make her afraid she will not meet her own behavioral expectations.

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FETAL RESPONSES TO LABOR

The physiologic changes experienced by the mother during labor could also affect
the fetus as well. (Textbook_-Maternal-and-Child-Health-Nursing_-Care-of-JoAnne-
Silbert-Flagg &Pillitteri, Adele)
A. The Neurologic System

 FHR decreases by as much as 5 beats/min during a contraction and could
be interpreted as a normal response or early deceleration pattern.
B. The Cardiovascular System

 A full term fetus is unaffected by the continual variations of
heart rate that occur with labor contractions.
C. The Integumentary System

 Minimal petechiae or ecchymotic areas and edema of the presenting part
(caput succedaneum) as well from the pressure involved in the birth process.
D. The Musculoskeletal System

 Due to the force of uterine contractions which pushes the fetus out of the
introitus a position of full flexion or with the head bent forward is assumed,
which is the most advantageous position for birth.
E. The Respiratory System

 The process of labor appears to aid in the maturation of surfactant
production by alveoli in the fetal lung. Both the pressure applied to the chest
from contractions and passage through the birth canal help to clear the
respiratory tract of lung fluid.
Let’s proceed to our activity but before we proceed, try to watch the video clip on the link
provided below.
Activity 1
https://slideplayer.com/slide/7036784/

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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSI
Activity # 2 Interactive discussion via Google Classroom on the

following topics:
Before the start of our discussion, please pose a question and predict the answer. Write your
questions and answer in the discussion board below. Verify your answers during our discussion
to check whether your answer is correct. You will be evaluated through REFLECTIVE JOURNAL
rubrics posted in the previous unit.

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focus and accuracy
& punctuation.
TOTAL

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ACTIVITY 3………..
Write your learning insights of at least 150 words on the

discussion board below. You will be evaluated through
rubrics used during our previous topics. Submit on our next
meeting. (Date to be inserted)

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Discussion Board Rubrics
Criteria 10 7 3 0
Quality of Suitable comments, Suitable comments and Responds but with No post at
Post reflective, thoughtful responds respectfully to hesitation or not sure all
and respectful of other’s comments. of the answer posted.
other’s posting
Relevance of Topics posted are Posts topics related to the Topics posted are No post at
Post relevant to the subject content with minimal irrelevant and with all
matter; inserting new remarks or suggestions. few remarks or
ideas related to topics. suggestions.
Involvement Attempts to motivate Attempts to lead the Does not make effort No
to the the discussion process, discussion process to take part in the feedback
Learning presenting innovative presenting relevant learning community provided to
Community techniques involving viewpoints to be as it develops. fellow
the community’s considered by the group student
awareness. with minimal community
involvement.
Matching type Quiz 1:

Match column A with column B. Write the letter of the best answer
before each number.
Column A Column B
____1. Relaxin A. Swelling or edema of the infant’s scalp with
subcutaneous fluid collection that occurs shortly
after delivery..
____2. Caput Succedanum B. A fluid secreted by the cells of the alveoli (the tiny air sacs
in the lungs) that serves to reduce the surface tension of
pulmonary fluids.
_____3. Cardiac output C. Secreted from the ovaries causing the cartilage
between joints to be more flexible during pregnancy
allowing the joints of the pelvis to be able to open as
much as 2 cm in labor to allow for fetal passage
_____4. White blood cells D. Increases from pre-labor levels by 40%-50%.
_____5. Surfactant E. increase to a level of 25,000– 30,000 cells/mm3 during labor

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Multiple Choice Quiz 2: Select The Letter Of The Best Answer!

You will be given 1 point each correct answer.
1. The nurse should offer support to a parturient during her labor contraction. Which of
the following would be best for her to do?
A. Leave her alone most of the time to provide privacy
B. Offer her a back rub to ease her pain & discomfort
C. Offer her sips of water to quench her thirst
D. Provide her with warm blankets to prevent colds
2. The following are cardiovascular change that takes place after delivery EXCEPT:
A. Hypovolemia during pregnancy allows the postpartum client to withstand blood
loss during labor and Birth
B. Cardiac output remains elevated for 48 hours post delivery
C. Decrease in melanocyte-stimulating hormone
D. Decrease cardiac output, pulse & BP begins to resolve shortly after delivery
3. The following statement is true of the physiologic adaptations in the bladder and
bowel functions during involution EXCEPT:
A. An increase in the urinary output resulting from normal diuresis
B. An increase in bladder capacity
C. Diminished urge to urinate
D. Lacerations or episiotomy suture line gradually heals
4. When planning comfort measures to help the woman in active labor cope with her
pain, you must consider which of the following?
A. Early labor contractions are usually regular, coordinated, and very painful
B. Proper preparation for labor typically results in the need for less
medication to manage pain
C. Pain medication given during the latent phase of labor is not likely to impair
contractions
D. The transition phase of labor represents a time of minimum pain and discomfort
“Learning is not just about the answers we get, but the questions we ask”- Adapted quote
We’re done with Unit 5! Let’s proceed to the next unit!

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Unit 5. Danger Signs during Labor and Delivery

Maternal and Fetal Assessment during Labor
Response to labor and pattern of labor contractions varies among parturient but
when something goes wrong during labor and birth, it is very important for a
woman to get the care she needs to save her life.
The health care practitioner must know how to assess a parturient in labor with
abnormal signs and symptoms of complications during labor and birth so that immediate
interventions will be implemented.
Learning Outcome:
At the end of the unit the student will be able to:
1. Discuss the danger signs experienced by the parturient during labor and delivery.
2. Assess accurately a parturient during labor and delivery.
Content:
Danger signs during labor and delivery
A. High or Low Blood Pressure
B. Abnormal Pulse
C. Inadequate or Prolonged Contractions
D. Abnormal Lower Contour
E. Increasing Apprehension
Appropriate nursing diagnosis
A. Pain related to labor contractions
B. Anxiety related to process of labor and birth
C. Health-seeking behaviors related to management of discomfort of labor
D. Situational low self-esteem related to inability to use planned childbirth method
Activity 1 – Interactive discussion via Google classroom – 45 minutes

a. Danger signs during labor and delivery
b. Assessment and history taking of a parturient during
labor and delivery
c. Appropriate nursing diagnosis during labor and birth
Activity 2 – Assessment Tasks - 45 minutes
It’s time to check the 1. Physical assessment and history taking rubrics
schedule of activity for 2. NCP formulation (Case study) NCP rubrics
this unit! Let talk about 3. Journal updates with reflections
the danger signs during
labor and delivery.

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Discussion:
How to assess a parturient for danger signs of labor:
Maternal danger signs:

What to assess during
labor and delivery?
1. Vital Signs-
B/P, Temp.,PR, RR
2. Uterine Contractions
3. Increasing
Apprehension
4. Abnormal lower
contour
1. High or Low Blood Pressure - an increase in the systolic

pressure of more than 30 mmHg or in the diastolic pressure of
more than 15 mmHg should be reported because it is the basic
criteria for gestational hypertension, as well as a falling blood
pressure because it may be the first sign of intrauterine
hemorrhage, although a falling blood pressure from hemorrhage
2. Abnormal pulse rate –a is often associated with other clinical signs of hypovolemic shock,
maternal pulse rate greater
such as apprehension, increased pulse rate, and pallor.
than100 beats/ min during
labor isunusual and should
be reported because it may 3. Inadequate or Prolonged Contractions – as labor progresses
be another indication of uterine contraction become more frequent, intense and longer
hemorrhage.
normally but If they become less frequent, less intense, or
shorter in duration, this may indicate uterine exhaustion
(inertia). As a rule, uterine contractions lasting longer than 70
seconds are becoming long enough to compromise fetal well-
being because this interferes with adequate uterine artery filling.
Next page please

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4. Abnormal Lower Abdominal Contour - a

round bulge that appears on the lower 5. Increasing Apprehension –
anterior abdomen of the mother indicates a maternal well-being of the
full bladder. This could cause the bladder to mother must be assessed during
be injured due to the pressure of the fetal labor for signs of psychological
head pressing against it; and the pressure of danger.
the full bladder may not allow the fetal head
to descend.
FETAL DANGER SIGNS OF LABOR:

During labor, you’re not only monitoring the condition of the mother but the
condition of the baby as well, to prevent further complications. The health care provider must
monitor the following fetal danger signs:
1. High or Low Fetal Heart Rate – the normal fetal heart rate ranges from 120 beats per
minute to 160 beats per minute. If the fetal heart rate falls below 110 beats per minute
(fetal bradycardia) and is above 160 beats per minute (fetal tachycardia), it is a sign of
fetal distress. Therefore, as a health care provider you need to monitor and record the
fetal heart rate frequently during labor to prevent such complication.
2. Meconium Staining - a green color in the amniotic fluid, reveals that the fetus has had
a loss of rectal sphincter control, allowing meconium to pass into the amniotic fluid.
This is an indication of fetal hypoxia, wherein an immediate intervention is needed.
3. Hyperactivity –Normally, during labor the fetus is quite and seldom moves inside the
womb. If ever fetal hyperactivity occurs during labor, it indicates that the fetus is in
active motion because of the need for oxygen due to hypoxia.
4. Low Oxygen Saturation - Normally the oxygen saturation of a fetus is 40% to 70%
inside the womb. If fetal oxygen saturation falls below 40% and the blood pH level is
below 7.2, the fetal well-being is compromised.
Appropriate Nursing Diagnosis of a woman during labor and delivery:

1. Pain related to labor contractions
2. Anxiety related to process of labor and birth
3. Health-seeking behaviors related to management of discomfort of labor
4. Situational low self-esteem related to inability to use planned childbirth method
Monitoring the Progress of Labor:

1. Maternal Assessments During Labor
To know how the parturient manage physically and emotionally the intense effect of
labor and delivery, nursing assessment is very important.

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A. Immediate assessment of a parturient during the first stage of labor.

a.1. The Initial Interview and Physical Examination
 Obtain the prenatal record of the mother
 Let the mother describe the characteristic of labor
 The general physical condition of the mother and her preparedness and
plans for labor and birth.
 Asks for her baby’s EDB (expected date of birth)
 When her contractions began
 Amount and character of any show
 Whether rupture of membranes has occurred
 Any known drug allergies
 If she uses any recreational or prescription drugs
 History of past and present pregnancy if prenatal record is not available
a.2. Assess for the following
 Vital signs (assess between contraction for comfort and accuracy)
Temperature, Pulse rate, Blood pressure, Respirations
 Nature of contractions (frequency, duration, intensity)
 Pain scale rating (1-10)
 Urine specimen for protein and glucose
 Position and presentation of her fetus (Leopold’s Maneuver)
 Learning of birthing exercises if any
B. Comprehensive assessment during the first stage of labor
 History taking
a. Current history of pregnancy
b. Past history of pregnancy
c. Past health history
d. Family Medical history
 Physical Examination (head to toe assessment)
a. Pelvic examination to consider the fetus presentation and position
and the stage of cervical dilatation
 Abdominal assessment
a. Fundic height Measurement- to determine the size of the fetus
b. Leopolds maneuver – to determine the position and
presentation of the fetus.
 Assessing rupture of membranes – sudden gush of amniotic fluid from
the vagina.
 Vaginal Examination – to determine the extent of cervical effacement
and dilatation, and to confirm the fetal presentation, position and
degree of descent.

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 Assessment of pelvic adequacy

a. Sonography – to determine the internal conjugate and ischial
tuberosity diameters.
 Vital signs monitoring at the beginning of labor and during labor.
 Laboratory analysis
a. CBC (hemoglobin and hematocrit), VDRL test,
Hepatitis B screening, Blood typing and RH factor.
b. Urinalysis – clean-catched urine to test for protein and glucose
 Assessment of uterine contractions- frequency, intensity, duration
2. Fetal Assessment during labor

It is very important to assess the fetal heart rate of the fetus during labor to
determine that the FHR remains within normal limit despite extreme pressure by
uterine contractions and passage to the birth canal.
A. Auscultation of Fetal Heart Sounds
 Fetal heart beat is best heard at the convex part of the fetus because
it is the part that lies near the uterine wall.
B. Electronic Fetal Monitoring
 External Monitoring
External fetal monitoring is
useful for monitoring both uterine
contractions and fetal heart rate
continuously or intermittently.
Contractions are monitored by means of
A pressure transducer or a tocodynamometer
The transducer is placed over the uterine fundus
And secure it with a strap.
Electronic Fetal Monitoring
The fetal heart rate is monitored with the use

of an ultrasonic sensor or monitor strapped
over the woman’s abdomen

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 Internal fetal monitoring is the most precise method for assessing

fetal heart rate and uterine contractions.
 It is done by inserting a pressure - sensing catheter via the vagina
into the uterine cavity along the side of the fetus once the
membranes ruptured and the cervical dilatation is at least 3 cm.
 This test is performed to evaluate fetal heart rate and variability
between beats, especially in relation to the uterine contractions of
labor.
 Below are pictures of internal fetal monitoring with placement of
catheter and electrodes.
Electronic monitoring strip showing the baseline FHR and uterine contractions
LET’S PROCEED TO OUR ACTIVITY!

QUESTIONS AND CLARFICATIONS WILL BE ENTERTAINED DURING OUR INTERACTIVE DISCUSSION

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Activity 1. Interactive discussion via NeoLMS/Google meet

The maternal dangers signs during labor and birth.
 Based on our discussion forum, identify the danger signs of labor and delivery.
 What is your role as a student nurse during labor and delivery?
 How are you going to assess a parturient in labor?
 What do you think is the priority nursing problem of a parturient in labor?
 Please post your answer in the discussion board below.
Discussion Board:

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Activity 2: Assessment Tasks:

Physical Assessment Rubric
EXCELLENT GOOD FAIR POOR
CRITERIA SCORE
(4 PTS.) (3 PTS.) (2 PTS.) (1 PT.)
All information Information generally Errors in format;
Errors in format;
organized in logical organized in logical information
Organization information
sequence; follows sequence; follows intermittently
disorganized
acceptable format acceptable format organized
Provides adequate
Provides adequate Provides minimal
documentation that
physical examination physical
covers all systems
documentation that examination
using inspection,
covers majority of documentation
palpation,
systems with minimal with numerous
Thoroughness auscultation as Provides no
grammatical, spelling grammatical,
of Physical appropriate with no physical
or word usage errors. spelling or word
Exam grammatical, spelling examination
Evidence of usage errors.
or word usage errors. documentation.
appropriate No evidence of
Evidence of
assessment of further
appropriate
negative findings assessment of
assessment of
documented. negative findings.
negative findings
documented.
Consistently
demonstrates
Consistently
Demonstrates average below average of Consistently
demonstrates
level of knowledge knowledge and demonstrates
knowledge and
and responsibility in responsibility in below average of
responsibility in
completing a full body completing a full knowledge and
Assessment completing a full body
assessment. Requires body assessment. responsibility in
Skill assessment.
a moderate level of Requires a completing a full
Demonstrates above
instructor involvement maximum level of body assessment.
average level of
in the assessment instructor Does not have
competence in
process. involvement in basic knowledge
assessment skills
the assessment
process.
Score equivalent to Percentage:

3 = 80 4 = 82 5 = 84 6 = 87 7 = 89 8 = 93 10 = 96 11 = 98 12= 100 (Roobrix converter)

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Case Study:

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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS

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Journal Updates
Submit a journal update about labor and delivery. Post your answer in the discussion box below.
You will be evaluated according to the rubrics on the next page of the module.
Questions and clarifications will be entertained later in our Interactive discussion

Those with poor connectivity could send questions and clarifications through text messages
“Trust yourself that you can do it and get it.”-Baz Luhrmann

CONGRATULATIONS!
YOU DID IT AGAIN
BE READY WITH OUR NEXT LESSON

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focus and accuracy
& punctuation.
TOTAL

Page | 76

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University of San Agustin

General Luna St., Iloilo City 5000, Philippines

NCM 107: CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)

To all Level II nursing students. Welcome to Module 3!

A Legacy of Excellent Education in Virtus et Scientia

ACTIVITY DESCRIPTION TIME FRAME

Let’s Meet and Greet!

A Legacy of Excellent Education in Virtus et Scientia

UNIT 1. Theories of Labor Onset

A Legacy of Excellent Education in Virtus et Scientia

Placental Aging Theory

Illustrations/Diagram on the Theories of labor Onset:

Fetal Oxytocin Theory

Fetal Cortisol Secretion Theory

The placental-fetal adrenal endocrine cascade.

A Legacy of Excellent Education in Virtus et Scientia

A Legacy of Excellent Education in Virtus et Scientia

Activity 2. b. Journal Entry

A Legacy of Excellent Education in Virtus et Scientia

Activity 3 Graded Quiz

Multiple Choice Select the letter of the best answer.

2. The following hypotheses/theories are true EXCEPT: (1 point)

A Legacy of Excellent Education in Virtus et Scientia

Discussion board post will be graded according to the rubrics below:

A Legacy of Excellent Education in Virtus et Scientia

REFLECTIVE JOURNAL RUBRICS

A Legacy of Excellent Education in Virtus et Scientia

GROUP DISCUSSION RUBRICS

A Legacy of Excellent Education in Virtus et Scientia

UNIT 2. Factors Affecting Labor and Delivery Process

FACTORS THAT INFLUENCE PROGRESS OF LABOR

A Legacy of Excellent Education in Virtus et Scientia

B.1.The Passageway (Pelvis)

Parts of the Pelvis

A Legacy of Excellent Education in Virtus et Scientia

Characteristic of a Normal Female Pelvis

A Legacy of Excellent Education in Virtus et Scientia

Factors considered for the passage of the fetus to the pelvis:

Three Anteroposterior Diameters of the Pelvic Inlet:

slightly longer than

A Legacy of Excellent Education in Virtus et Scientia

Importance of sutures and fontanels:

Skull’s Flexibility Sutures of the fetal skull

Molding of the Fetal skull

A Legacy of Excellent Education in Virtus et Scientia

Passenger: Fetopelvic relationships

o Normal attitude – flexion

o Fetal attitude changes

cause larger diameter of

A Legacy of Excellent Education in Virtus et Scientia

TYPES OF BREECH PRESENTATION

A Legacy of Excellent Education in Virtus et Scientia

A Legacy of Excellent Education in Virtus et Scientia

Mechanisms (Cardinal Movements) of Labor

A Legacy of Excellent Education in Virtus et Scientia

B.3.POWER ► Contractions + Maternal pushing

Initiate by pacemakers ~ uterotubal junction Additional force

Shortening of muscle fibres ⁭