MIDWIFERY AND

OBSTETRICAL
NURSING
Unit IV:ASSESSMENT AND MANAGEMENT OF INTRANATAL PERIOD
By:Mrs Bemina JA,PhD Scholar
Assisstant Professor
ESIC College of Nursing
Kalaburagi
CONTENTS
 Introduction
 Definitions
 Normal and abnormal labour
 Onset of labour
 Causes of onset of labour
 False labour pain and true labour pain
 Normal Female pelvis
 The fetal skull
 Stages of labour
 Physiology of first stage of labour and its mangement
 Physiology of second stage of labour and its mangement
 Mechanism of normal labour
 Physiology of third stage of labour and its mangement
 Fourth stage and its mangement
INTRODUCTION

 Labor is the process that leads to childbirth.

It begins with the onset of regular uterine
contractions and ends with delivery of the
newborn and expulsion of the placenta.
Pregnancy and birth are physiological
processes, and thus, labor and delivery
should be considered normal for most
women.
TERMINOLOGIES
 Parturiant : is a patient in labor and
 Parturition : is the process of giving birth.
 Delivery: is expulsion of the viable fetus out
of the womb/ uterus. It is not synonymous
with labor; delivery can take place without
labor as in elective caesarean section.
Delivery may be vaginal, either spontaneous
or aided or it may be abdominal.
DEFINITION
 LABOUR
  “Labour is the physiological process by which fetus, placenta
and membranes are expelled through the birth canal after
viability (22nd week of pregnancy).” WHO 
 It is defined as series of events that takes place in the genital
organ in an effort to expel the viable products of conception out
of the womb through the vagina into the outer world is called
labour.
 Labor may be
Spontaneous or induced
Term or preterm
Preterm labor – Prior to 37 weeks
Term – 37 to 42 weeks
Post term – After 42 weeks Post dates – After 40 weeks 
NORMAL LABOR (EUTOCIA)
• Physiological process by which the fetus, placenta
and membrane are expelled through birth canal
after full term of of pregnancy.
CRITERIA OF NORMAL LABOUR

 Spontaneous in onset
 At term.
 Single fetus
 With vertex presentation.
 Without undue prolongation.
 Natural termination with minimal aids.
 With no maternal & fetal complication affecting
the health of the mother and or the baby.
FACTORS AFFECTING NORMAL
LABOUR
 Psychological response
 Passage
 Power
 Passenger
 Position
 POWER
Primary power: Involuntary uterine contraction
Responsible for effacement and dilation of cervix
Secondary powers Contraction changes to expulsive. Voluntary bearing
down of mothers. No efforts in cervical dilation. Primary and secondary force
to expel fetus.
 PASSAGE
• Soft tissue passage: change in uterus, cervix, vagina , pelvic floor
• Bony Passage: true pelvis, outlet
 PASSANGER
• Fetus, placenta, membrane, liquor amnii, cord.
• The passage of fetus is determined by various factors:
The size of the fetal head, fetal presentation, fetal lie, fetal attitude
 POSITION OF A LABOURING WOMEN
• Frequent change in position relief fatigue, increase comfort and improve
circulation.
• An upright position (walking, sitting, kneeling or squatting offers a number
of advantage.
• If women wishes to lie down left lateral position is suggested.
ABNORMAL LABOUR
(DYSTOCIA)
 DEFINITION
 Any deviation from the normal labour is
called abnormal labour.
• Fetal presentation other than vertex or
having some complications even with vertex
presentation affecting the course of labour
or modifying the nature of termination or
adversely affecting the maternal and fetal
prognosis is called an abnormal labour.
ONSET OF LABOUR
 Onset of labour
 Based on naegel’s formula labour starts
approximately as follow.
 In the expected date of delivery in 4% of
cases
 One week on either side in 50% of cases
 Two weeks earlier and one week later on 80%
of cases
 At 42 weeks in 10% of cases
 At 43 weeks plus in 4% of cases
CAUSES OF ONSET OF LABOUR
 MECHANICAL FACTORS
Uterine distension
 FETO-PLACENTAL CONTRIBUTION

 HORMONAL FACTORS (ENDOCRINE)

1. Maternal :
Estrogen
Progesterone withdrawal
Oxytocin stimulation
Prostaglandins
Serotonin
2. Fetal:
Fetal cortisol
Fetal membranes

 NEUROLOGICAL FACTORS
Sympathetic- alpha receptor stimulation
THEORIES AND CAUSES OF
ONSET OF LABOR
 MECHANICAL FACTORS
 ↑ Uterine activity Mechanical stimulation Overstretching of the uterus
and pressure of presenting part on the lower segment Mechanical
factors
 FETO PLACENTAL CONTRIBUTION

Cascade of events activates the fetal hypothalamic pituitary adrenal

axis prior to the onset of labour.
↑ Production of oestrogen and prostaglandin from placenta
↑ cortisol secretion from fetal adrenal
↑ Fetal adrenal activity
↑ release of adrenocorticotrophic hormone
↑ corticotrophic Releasing hormone
Accelerated production of oestrogen and PG from the placenta
Fetal hypothalamic pituitary adrenal axis stimulated prior onset of labour
 ESTROGEN Theory
MODE OF ACTION Increase prostaglandin synthesis
Increase myocardial contractile protein Increase
excitability of myometrial cell membrane Promotes
synthesis of receptors for oxytocin in the myometrium
and decidua Release of oxytocin from maternal pituitary
PROGESTERONE
 ↑ Fetal production of DHEA-S( dehydroepiandrosterone
sulphate and cortisol ) inhibit the conversion of fetal
pregnenolone to progesterone there fore decrease
Progesterone synthesis
Alteration of oestrogen, progesterone ratio Increase
Uterine contraction
During pregnancy, inhibits myometrial contraction, but
in late pregnancy
 Myometrial contractile system
Enhances gap junction, Increase of oxytocin
receptors in decidua ↑ Prostaglandin (from
placenta, fetal membranes, decidual cells and
myometrium)
HORMONAL FACTOR
Prostaglandin synthesis is triggered by
• Rise In Oestrogn Level
• Glucocorticoids
• Mechanical Stretching In Late Pregnancy
• Increase In Cyotokines
• Infection
• Vaginal Examination
• Rupture of the Membrane.
  OXYTOCIN THEORY
• Oxytocin receptors are present in the uterus; they
increase in uterus with the onset of labour. • It promotes
the release of prostaglandins from the decidua.
• Vaginal examination and amniotomy cause rise in
maternal plasma oxytocin level (Ferguson reflex).
• Oxytocin level reach maximum at the moment of birth.

 3. NEUROLOGICAL FACTORS

• Labor may also be initiated through the nerve
pathways.
• α and β adrenergic receptors are present in the
myometrium.
• Estrogen acts on the α and progesterone acts on the β
• The contractile response is initiated through the α
receptors of the postganglionic nerve fibers in and around
the cervix and lower part of the uterus.
SIGNS AND SYMPTOMS OF ONSET
OF SPONTANEOUS NORMAL LABOR

• Lightening
• Cervical changes
• Appearance of false pain
• Taking up of the cervix
Lightening
• This is sinking of the presenting part into the true pelvis, which
takes about 2-3 weeks before onset of labor in primigravida
and during onset of labor in multigravida.
• It is due to the active pulling up of the lower pole of the uterus
around the presenting part.
• It signifies incorporation of the lower uterine segment into wall
of the uterus, it may be gradual process or may be felt
abruptly.
Lightening
• This diminishes the fundal height and hence minimizes the
pressure on the diaphragm.
• The mother experiences a sense of relief from the mechanical
cardiorespiratory problems.
• Breathing is easier, the heart and the stomach can function
better and the relief experienced by the women is described as
lightening.
 APPEARANCE OF FALSE PAIN
• Erectile and irregular pain, causing the
uterus to contract and relax, where as in the
labor the uterus contract and retracts
regularly.
 TAKING UP OF THE CERVIX Taking up of the
cervix occurs because it is being and merged
into the lower uterine segment. 
FALSE LABOUR PAIN (SPURIOUS
LABOUR)
 Period of irregular (but sometimes) regular contractions
that occur without progressive cervical dilation.
 Contractions usually do not progress in their frequency,
duration or intensity.
 Usually appears prior to the onset of true labor pain by
one or two weeks in primigravida and by few days in
multipara.
 Found more in primigravida than multigravida women.

CHARACTERISTICS
• Dull in nature and usually confined to the lower abdomen
and groin.
• Continuous and unrelated with hardening of the uterus.
• Without any effect on dilatation of the cervix.
• Pain relives by use of sedatives and position changes.
TRUE LABOUR PAIN
 • Onset of regular uterine contractions (pain)
that become more frequent and forceful in
later weeks of pregnancy characterized by:
1. Painful uterine contractions with regular
interval and increasing intensity (labour
pain) 2. Appearance of show
3. Progressive effacement and dilatation of
the cervix.
4. Formation of the ‘bags of waters’
STAGES OF LABOR
 First stage of labour or Dilatation stage
 Second stage of labour or Pushing stage
 Third stage of labour or Placental stage
 Fourth stage of labour or Recovery stage
FIRST STAGE OF LABOUR
 This starts from the onset of true labour pain
and ends with full dilatation of cervix.
It is in other words, the ―cervical stage of
labour.
Duration
Primigravida Its average duration is 11-12 hrs
Multigravida 6-8 hrs in.
 There are Three phases of first stage of labour:
 Latent phase
 Active phase
 Tansition phase
 MATERNAL PROGRESS IN FIRST STAGE OF
LABOUR BY BEMINA ESIC NURSING COLLEGE

Criteria Latent phase Active phase Transition phase

Duration
Primi gravida 8-10 hours 3-6 hours 2 hours
Multi gravida 5 hours 4 hours 1 hours

Contraction
Strength Mild –Moderate Moderate-Strong Strong –Very strong
Rhythm Irregular More regular Regular
Frequency 5-30 minutes 3-5 minutes 2-3 minutes
Duration 30-45 seconds 40-70 seconds 45-90 seconds

Cervical
Dilatation 0-3 cm 4-7 cm 8-10 cm
Station of head
Primi gravida 0 +2 cm +3 cm and Above
Multi gravida -2 to 0 cm +1 to +2 cm
Show Brownish pale Pink to bloody Bloody mucus
pink discharge mucus
PHYSIOLOGY OF FIRST STAGE
OF LABOUR
 I Uterine actions
 II Mechanical factors
 I UTERINE ACTIONS
 Fundal dominance
 Polarity
 Contraction and retraction
 Formation of upper and lower uterine segment
 Retraction Ring
 Cervical effacement
 Cervical dilatation
 Show
 II. MECHANICAL FACTORS
 Formation of the fore waters
 General fluid pressure
 Rupture of the membrane
 Fetal Axis pressure
 RECOGNITION OF I STAGE OF LABOR

 Show
 Uterine Contraction
 Rupture of membrane
PHYSIOLOGY OF FIRST STAGE
LABOUR
 Pace maker: situated in the region of tubal ostia from
where wave of contraction spread downwards.
Sometimes there is emergence of multiple pace maker
foci leading to less efficient contractions and hence
causing primary dysfunction labour
 Fundal dominance:

Each uterine contraction starts in the fundus near one of

the cornua and spreads across and downwards.
The contraction lasts longest in the fundus where it is
also most intense, but the peak is reached
simultaneously over the whole uterus and the
contraction fades from all parts together.
FUNDAL DOMINANCE
 Polarity
Polarity is the term used to describe the
neuromuscular harmony that prevails between the
two poles or segments of the uterus throughout
labour.
During each uterine contraction, these two poles act
harmoniously.
The upper pole contracts strongly and retracts to
expel the fetus; the lower pole contracts slightly
and dilates to allow expulsion to take place.
If polarity is disorganized then the progress of labour
is inhibited.
 Contractions (tightening) and retraction (shortening)
of myometrial muscle fibres increase in length,
strength and frequency as labour progresses.
The mucous plug (show) is expelled as the cervix
opens and the membrane sac (amnion and chorion)
often spontaneously ruptures, allowing amniotic fluid
to drain.
 Retraction Permanent shortening of uterine muscle net
effects are :
 Formation of lower uterine segment.
 Maintain advancement of presenting part made
during contractions
 Reduce the surface area of uterus and hence
favouring placental separation.
 Effective haemostasis after separation of placenta.
CONTRACTION AND
RETRACTION
FORMATION OF UPPER AND LOWER
UTERINE SEGMENTS
 The upper uterine segment, having been formed from
the body of the fundus, is mainly concerned with
contraction and retraction; it is thick and muscular.
 The lower uterine segment is formed of the isthmus
and the cervix, and is about 8-10 cm in length. The
lower segment is prepared for distention and
dilatation.
 The muscle content reduces from the fundus to the
cervix, where it is thinner.
 When the labour begins, the retracted longitudinal
fibres in the upper segment pull on the lower segment
causing it to stretch; this is aided by the descending
presenting part.
 The Retraction ring
 The ridge forms between the upper and lower
uterine segments; this is known as the
retraction ring.
 The physiological ring gradually rises as the
upper uterine segment contracts and retracts
and the lower uterine segment thins out to
accommodate the descending fetus.
Once the cervix is fully dilated and the fetus
can leave the uterus, the retraction ring rises
no further.
 CERVICAL EFFACEMENT
 It takes place from above downward; that is, the muscle
fibres surrounding the internal os are drawn upwards by the
retracted upper segment and the cervix merges into the
lower uterine segment.
 Effacement refers to the inclusion of the cervical canal
into the lower uterine segment.
 The cervical canal widens at the level of the internal os,
where the condition of the external os remains unchanged.

CERVICAL DILATATION
Dilatation of cervix is the process of enlargement of the os
uteri from a tightly closed aperture to an opening large
enough to permit the passage of the fetal head.
Dilatation is measured in centimeters and full dilatation at
term equates to about 10 cm.
 Show
  As a result of the dilatation of the cervix,
the operculum, which formed the cervical
plug during pregnancy, is lost.
 The woman may see a blood stained mucoid
discharge a few hours before, or within a few
hours after, labour starts.
  The blood comes from the ruptured
capillaries in the parietal decidua where the
chorion has become detached from the
dilating cervix.
Formation of fore water
 As the lower uterine segment forms and stretches,
the chorion becomes detached from it and the
increased intrauterine pressure causes its loosened
part of the sac of fluid to bulge downwards into the
internal os, to the depth of 6-12 mm.
 The well flexes head fits snugly into the cervix
and cuts off the fluid in front of the head from that
which surrounds the body.
 The former is known as forewaters‘ and the latter
the hindwaters‘.
 GENERAL FLUID PRESSURE
 While the membranes remain intact, the pressure
of the uterine contractions is exerted on the fluid
and, as fluid is not compressible, the pressure is
equalized throughout the uterus and the fetal body;
it is known as general fluid pressure‘.
  RUPTURE OF MEMBRANE

 The optimal physiological time for the membranes

to rupture spontaneously is at the end of the first
stage of labour after the cervix becomes fully
dilated and no longer supports the bag of
forewaters.
FETAL AXIS PRESSURE
 During each contraction
the uterus rises forward and
the force of the fundal
contraction is transmitted to
the upper pole of the fetus
down the long axis of the
fetus and applied by the
presenting part to the cervix.
This is known as fetal axis
pressure.
NURSING MANAGEMENT OF FIRST
STAGE OF LABOUR
NURSING MANAGEMENT IN I
STAGE OF LABOR
 
 I] LATENT PHASE :
•Complete admission procedures
•Physical examination
•Monitor maternal vital signs
•Monitor FHR
•Status of amniotic fluid
•Status of membrane
•Observe voiding
•Assess coping ability
•Encourage walking
•Encourage visiting , watching TV
•Encourage relaxation
•Change position every ½ hours
•Effleurage
•Monitor Cervicogram
 II] ACTIVE PHASE
•Continue monitor maternal vital signs
•Status of amniotic fluid
•Encourage voiding every 1 hour
•Observe for full bladder
•Asses progress of labor
•Provide comfort measures
•Moist lips or give ice chips
•Apply cool , damp cloth to woman’s face
•Keep bed linens dry
•Sacral support
•Oral hygiene
•Inform the progress
•Administer medication if necessary
•Explain electronic fetal monitor
•Encourage breathing and relaxation technique
•Frequent perineal care
•Protect from aspiration and injury
 III] TRANSITION PHASE
•Continue the active phase management
•Do not allow alone
•Accept the behaviour of the mother
•Change chux ( pad ) frequently
•Keep bed linen dry
•Get blanket if cold
 NURSING DIAGNOSES IN THE FIRST STAGE OF
LABOUR
 Acute pain / Impaired comfort related to contraction – related hypoxia,
dilatation of tissues and pressure on adjacent structures as evidenced by
verbal reports, restlessness, muscle tension and narrowed focus
 Impaired urinary elimination related to altered intake, dehydration as
evidenced by urinary retention / slow progression o f labour
 Fatigue related to discomfort / pain / increased energy requirement / altered
coping ability
 Risk for mild anxiety related to situational crisis, unmet needs, stress Risk
for ineffective coping (individual / couple) related to situational crises /
personal vulnerability / use of ineffective coping mechanism / inadequate
support system / pain
 Risk for decreased cardiac output related to decreased venous return /
hypovolemia / changes in systemic vascular resistance
 Deficient knowledge regarding progression of labour and available options
related to lack of exposure / recall / information misinterpretation /
evidenced by questions / statement of misinterpretation / inadequate follow
through of instructions
THE SECOND STAGE OF LABOUR AND ITS
NURSING MANAGEMENT WITH NURSING
DIAGNOSIS
MADE EASSY
THE SECOND STAGE OF
LABOUR
 INTRODUCTION
The second stage of labour has traditionally been defined as the
phase between full dilatation of the cervical os and the birth
of the baby.
However, there is a transitional period between the first stage of
labour and the actual time when active maternal pushing efforts
begin.
This period is typically characterised by
maternal restlessness,
discomfort,
desire for pain relief,
a feeling that the process is never ending and demands to birth
attendants to get the birth process over as quickly as possible.
DEFINITION
 It starts from the full dilation of the cervix and ends with
expulsion of fetus from the birth canal.
 IT HAS GOT TWO PHASES
1. Propulsive phase-starts from full dilatation upto the
descent of the presenting part to the pelvic floor
2. Expulsive phase- is distinguished by maternal bearing
down efforts and ends with delivery of the baby.
DURATION
Average duration is
2 hours in primigravida .
1 hour in multipara.
Presumptive signs of second stage of labour
 Expulsive uterine contraction
 Rupture of forewaters
 Dilatation and gaping of the anus
 Appearance of the rhomboid of Michaelas
 Show
 Appearance of presenting part
PHYSIOLOGY OF SECOND STAGE OF LABOUR
 UTERINE ACTION
 Contractions become stronger and longer but may be less frequent,
allowing both mother and fetus regular recovery periods.
 The membrane often rupture spontaneously towards the end of the first
stage or during transition to the second stage.
 The consequent drainage of liquor allows the hard, round fetal head to
be directly applied to the vaginal tissues. This pressure aids distension.
 Fetal axis pressure increases flexion of the head, which results in smaller
presenting diameters, more rapid progress and less trauma to both mother
and fetus.
 The contraction becomes expulsive as the fetus descends further into
the vagina.
 Pressure from the presenting part stimulates nerve receptors in the
pelvic floor this is termed the Ferguson reflex‘ and the woman
experiences the need to push.
 The mother‘s response is to employ her secondary powers of expulsion by
contracting her abdominal muscles and diaphragm.
 SOFT TISSUE DISPLACEMENT
 As the hard fetal head descends, the soft tissues of the
pelvis becomes displaced.
 Anteriorly-Bladder
 Posteriorly- Rectum
 The levator ani muscles
 Perineal body
 The fetal head becomes visible at the vulva, advancing
each contraction and receding between contractions until
crowning takes place.
 The head is then born.
 The shoulders and body follow with next contraction,
accompanied by gush of amniotic fluid and sometimes of
blood.
 The second stage culminates in the birth of the baby.
MECHANISM OF LABOUR
 OBJECTIVES
 Define the term mechanism of labor.
 State the principles common to all labor.
 Enlist the normal conditions that is followed
during normal mechanism.
 List out the cardinal movements during
mechanism of labor.
 Explain in detail the mechanism of labor. 
MECHANISM OF NORMAL
LABOUR
 •The series of movements that occur on the
head in the process of adaptation during its
journey through the pelvis is called
mechanism of labor.
 Is a series of passive movements of the fetus
in the passage through the birth canal.
TERMINOLOGY :
1.LIE: It refers to the relationship of the long axis of the fetus to the
long axis of the centralized uterus or maternal spine.
 longitudinal lie
 transverse lie
2.ATTITUDE: posture of the fetus. The relation of the different
parts of the fetus to one another is called attitude of the fetus. The
universal attitude is that of flexion.
 Head flexed over the chest
 Arms/hands flexed over the chest
 Thighs/legs flexed over the abdomen
3.PRESENTATION: Is defined as the part of the presentation
which overlies the internal os and is felt by the examining finger
through the cervical opening.
4.POSITION : the relation of an arbitrary chosen
point of the fetal presenting part to the right or left
side of the maternal birth canal.
5.DENOMINATOR : It is an arbitrary bony fixed
point on the presenting part which comes in
relation with the various quadrants of the maternal
pelvis.
 The following are denominators of the different
presentations-
occiput in vertex,
mentum in face,
frontal eminence in brow,
sacrum in breech and
acromion in shoulder
WHY IT IS IMPORTANT TO UNDERSTAND
THE MECHANISM OF NORMAL LABOR?
 Knowledge and recognition of the normal
mechanism enables midwife to anticipate
next step in the process of descent.
 Helps to ensure that the normal process is
recognized,
 That woman gives birth safely and positively
or
 Early assistance can be sought if any
problem arises. 
PRINCIPLES COMMON TO ALL
LABOUR
 Descent takes place.
 Which ever part leads and first meets the pelvic
floor will rotate forwards until it comes under the
symphysis pubis.
 Whatever emerges from the pelvis will pivot
around the pubic bone.
PRINCIPLE MOVEMENTS IN
NORMAL MECHANISM OF LABOUR
 • Engagement
 • Descent
 • Flexion
 • Internal rotation of head
 • Crowning
 • Extension of head
 • Restitution
 • Internal rotation of shoulders
 External rotation of head
 • Delivery of body by lateral flexion
NEMONICS TO REMEMBER
MECHANISM OF LABOUR
 END FLICER ICED (flicer means very bright )
so flicer company ke end hone se uska
manager iced ho gya.
 ENGAGEMENT – Engagement takes place when
the bipareital diameter of the fetal head has passed
through the pelvic inlet.
In primigravida , it usually occurs 12hours. In multi
it will occur within 6hrs.
Engages with sagittal sutures in right oblique and
biparietal diameter in left oblique – Occiput points
to left ileo pectineal eminence
 DESCENT – It is a continuous movement
throughout the process of delivery.
Descent result in number of forces including
contractions, and maternal pushing effort with
contraction of her abdominal muscles Fetus descent
due to contraction and retraction of uterine muscle
 FLEXION – As the head descends , it meets
resistance from the pelvic walls and floor and this
leads to increased flexion of the head.
As the head flexed it brings the shortest
longitudinal diametre of the head ( sub – occipito –
bregmatic 9.5cm ) to pass through the birth canal.
Engaging diameter is sub occipito frontal (10cm) –
Changes to sub occipito bragmatic (9.5cm)
 • INTERNAL ROTATION OF HEAD –The occiput
leads and meets the pelvic floor first and rotates anteriorly
1/8 of a circle.
Occiput is the leading part – Rotates one by eighth of the
circle – Sagittal suture comes in APD – Slight twist in the
neck of the fetus
 • CROWNING – After internal rotation of head, further
descent occurs until the occiput lies underneath the pelvic
arch.
At this stage, the maximum diametre of the head
( biparietal diametre ) stretches the vulval outlet.
Biparietal diameter stretches at vulval outlet
 • EXTENSION OF HEAD – Once crowning has occurred
, the fetal head is pivot under the symphysis pubis and the
sinciput, face and chin sweep over the perinium.
Releases Sinciput face and chin – Head is born by flexion
 • RESTITUTION – with restitution , the occiput moves 1/8 of a circle
towards the side from which it started.
Twist in the neck of the fetus is corrected by slight untwisting
movement – Occiput turns one by eighth of the circle towards the
maternal side
 • INTERNAL ROTATION OF SHOULDERS –
The anterior shoulder reaches the pelvic floor and rotates anteriorly 1/8
th of a circle.
The shoulder come to lie in the anterio posterio diametre of the pelvic
outlet.
Shoulders rotate one by eighth of a circle to lie under symphysis pubis
 • EXTERNAL ROTATION OF HEAD –
The head rotates 1/8 th of a circle towards the symphysis pubis from
the oblique diameter.
Occiput rotates further one by eighth to the mothers left side
 • DELIVERY OF BODY BY LATERAL FLEXION –Anterior
shoulder escapes under symphysis pubis –Posterior shoulder sweeps
the perineum –Body is born by lateral flexion
MANAGEMENT OF SECOND
STAGE OF LABOUR
STHIRD STAGE OF LABOUR AND ITS NURSING
MANAGEMENT
MADE ESSAY
THIRD STAGE LABOUR
 DEFINTION:
3rd stage of labor commences with the delivery of
the fetus and ends with delivery of the placenta
and its attached membranes.
 DURATION:-
Normally 5 to15 minutes.
30 minutes have been suggested if there is no
evidence of significant bleeding.
CAUSE OF PLACENTAL SEPARATION
 After delivery of the fetus, the uterus retracts and the
placental bed diminished.
 As the placenta is inelastic and does not diminish in
size it separates.
  PRIMARY AND SECONDARY MECHANISM
FOR PLACENTAL SEPARATION
  Primary mechanism is the reduction in surface area of
placental site as the uterus shrinks
 Secondary mechanism is the formation of haematoma
due to venous occlusion and vascular rupture in the
placental bed caused by uterine contractions
 Placental Site during Separation
PHYSIOLOGICAL PROCESSES OF PLACENTAL
SEPERATION AND EXPULSION
 Placental separation.
 Descend of the placenta.
 Expulsion of the placenta.
 PLACENTAL SEPERATION
Result of the abrupt decrease in size of the
uterine cavity .
The retraction process accelerates.
The formation of retro placental clot.
 BEFORE SEPARATION
Per abdomen:
Uterus become discoid in shape, firm in feel and ballottable.
Fundal height reaches slightly below the umbilicus.
Per vaginum:
There may be slight trickling of blood.
Length of the umbilical cord as visible from outside remains
static.
 AFTER SEPARATION
Per abdomen:
Uterus become globular, firm and ballottable.
fundal height is slightly raised.
supra pubic bulging
Per vaginum:
Slight gush of vagina bleeding.
Permanent lengthening of the cord.
 DESCEND OF THE PLACENTA
Sudden trickle or gush of blood.
Lengthening of the umbilical cord.
Change in the shape of the uterus, globular.
Change in the position of the uterus.
 EXPULSION OF THE PLACENTA

The Schultz mechanism

Mathew Duncan mechanism
 HEMOSTASIS

Retraction of the oblique uterine muscle fibres

Vigorous uterine contraction following placental
separation.
Transitory activation of the coagulation and fibrinolytic
systems
CENTRAL SEPARATION (SCHULTZE):
 Detachment of placenta from its uterine
attachment starts at the centre resulting in opening
up of few uterine sinuses and accumulation of
blood behind the placenta (retro placental
hematoma).
With increasing contraction, more and more
detachment occurs facilitated by weight of the
placenta and retro placental blood until whole of
the placenta gets detached.
MATTHEWS DUNCAN
METHOD
 The placenta may begin to separate unevenly at
one of its lateral borders.
 The blood escapes so that separation is unaided by
the formation of a retro placental clot.
 The placenta descends, slipping sideways,
maternal surface first.
 This process takes longer and is associated with
ragged, incomplete expulsion of the membranes
and a higher fluid blood loss.
SEPARATION OF FETAL MEMBRANES
 The great decrease in uterine cavity surface area
simultaneously throws the fetal membranes—the
amnion, chorion and the parietal decidua—into
innumerable folds.
 Membranes usually remain in situ until placental
separation is nearly completed.
 These are then peeled off the uterine wall, partly
by further contraction of the myometrium and
partly by traction that is exerted by the separated
placenta, which lies in the lower segment or upper
vagina.
MANAGEMENT OF THIRD
STAGE OF LABOUR
OBJECTIVES
To promote natural separation of the placenta and
membranes and their complete expulsion
To arrest haemorrhage
To secure good and permanent contraction and
retraction of the uterus
Expectant management
Signs of placental separation and delivery of placenta
spontaneously.
Active management
 Advantages are

 To minimize blood loss in third stage approximately to

1/5th
 To shorten the duration of third stage to half
Disadvantage
Is slight incidence of retained placenta and consequent
increased incidence of manual removal.
Accidental administration during delivery of the first baby
in undiagnosed twins produces grave danger to the unborn
second baby caused by asphyxia due to tetanic contraction
of the uterus, thus, it is imperative to limit its use in twins
only during the delivery of the second baby.
 Inj. Ergometrine 0.25 mg or methergin 0.2mg is given
intravenously following the birth of anterior shoulder.
 The palmar surface of the fingers of the left hand is
placed approximately at the junction of upper and lower
uterine segment.
 The body of the uterus is pushed upwards and backwards,
towards the umbilicus while by the right hand steady
tension is given in downward and backward direction
holding the clamp until the placenta comes outsides the
introitus.
 It is thus more a uterine elevation which facilitates
expulsion of the placenta. The procedure is to be adopted
only when the uterus is hard and contracted.
 The fundus is pushed downwards and backwards after
placing four fingers behind the fundus and the thumb in
front using the uterus as a sort of piston.
 The pressure must be given only when the uterus become
hard. If it is not, then make it hard by gentle rubbing.
 The pressure is to be withdrawn as soon as the placenta
passes through the introitus.
 Steps-1: the operation is done under general anaesthesia.
The patient is placed in lithotomy position. With all aseptic
measures the bladder is catheterized.
 Steps-II: one hand is introduced into the uterus after
smearing with the antiseptic solution in cone shaped manner
following the cord, which is made taut by the other hand.
 While introducing the hand, the labia are separated by the
fingers of the other hand. The fingers of the uterine hand
should locate the margin of the placenta.
 counter pressure on the uterine fundus is applied by the other hand placed
over the abdomen.
The abdominal hand should steady the fundus and guide the movements of
the fingers inside the uterine cavity till the placenta is completely separated
  Steps-IV: as soon as the placenta margin in reached, the fingers are
insinuated between the placenta and the uterine wall with the back of the
hand in contact with the uterine wall.
The placenta is gradually separated with a side ways slicing movements of
the fingers, until whole of the placenta is separated.
 Steps-V: when the placenta is completely separated, it is extracted by
traction of the cord by the other hand.
The uterine hand is still inside the uterus for exploration of the cavity to be
sure that nothing is left behind.
 Steps-VI: intravenous ergometrine 0.25mg is given and the uterine hand
is gradually removed while massaging the uterus by the external hand to
make it hard.
After the completion of manual removal, inspection of the cervico-vaginal
canal is to be made to exclude any injury.
 Steps-VII: the placenta and membranes are to be inspected for
completeness and be sure that the uterus remains hard and contracted
 COMPLICATION
 Hour glass contraction –leading to difficulty in
introducing the hand Morbid adherent placenta – which
may cause difficulty in getting to cleavage of placental
separation.
 EXAMINATION OF PLACENTA
 The maternal surface is first inspected for incompleteness and
anomalies. The maternal surface is covered with grayish decidua
(spongy layer of the deciduas basalis).
Normally the cotyledons are placed in close approximation and
any gap indicates a missing cotedyldon.
 The membrane chorion, amnions are to be examined carefully
for completeness and presence of abnormal vessels indicative of
succenturiate lobe.
 The cut end of the cord is inspected for number of blood vessels.
Normally there are two umbilical arteries and one umbilical vein.
 An oval gap in the chorion with torn ends of blood vessels
running up to the margin of the gap indicates a missing
succenturiate lobe.
 The absence of a cotyledon or evidence of a missing
succenturiate lobe or evidence of significant missing membranes
demands exploration of the uterus urgently.
EXAMINATION OF PERINIUM
PRINCIPLES
 hemostasis
 Anatomical restoration
 Vaginal and submucosa - continuous suture
 In the third or fourth degree of perineal lacerations,
in which the anal sphincters and the anterior rectal
wall are torn, it is first necessary to isolate the torn
ends of the sphincter after which the tear in the
anterior rectal wall is closed with fine interrupted
catgut sutures tied within the lumen of the bowel.
 The end of the rectal sphincter are reapproximated
with interrupted catgut sutures.
 Then the laceration in the more superficial
structures
COMPLICATIONS OF THIRD
STAGE OF LABOUR
  Haemorrhage
 Shock
 Injury to uterus
 Infection
 Inversion
 Subinvolution
 Thrombophlebitis
 Embolism
NURSING DIAGNOSIS
 Risk for deficient fluid volume related to : - Blood
loss occurring after placental separation and
expulsion. - Inadequate contraction of the uterus.
 Anxiety related to : -Lack of knowledge regarding
separation and expulsion of the placenta. -
Occurrence of perineal trauma and the need for
repair.
 Fatigue related to : -energy expenditure associated
with childbirth and the bearing-down efforts of the
second stage.
 FOURTH STAGE OF LABOUR AND ITS
MANAGEMENT
INTRODUCTION
 The recovery phase immediately after delivery of
the placenta often is referred to as the fourth stage
of labor.
 This is misnomer because labor and delivery are
completed with the expulsion of the placenta.
 The fourth stage is critical time that begins after
delivery of the placenta and ends when the
mother’s system has stabilized, usually 1 to 4
hours later.
DEFINITION
 FOURTH STAGE:-
It is the stage of observation for at least one hour
after complete expulsion placenta.
It is the stage of early recovery
Begins immediately after expulsion of the
placenta and membranes and lasts for one hour.
During which careful observation for the patient,
particularly for signs of postpartum haemorrhage
is essential.
Routine uterine massage is usually done every 15
minutes during this period.
 DURATION
The fourth stage of labor is 1 to 4 hrs after birth
 PHYSIOLOGY OF FOURTH STAGE LABOUR

The physiologic readjustment of mothers body begins.

 Blood is redistributed
 B/P drops
 Mild tachycardia occurs
 Uterus is midway between symphysis pubis and the
umbilicus
 Cervix is widely spread and thick
 Hypotonic bladder due to trauma which causes urinary
retention may be treated with anesthetics.
 Woman is tired, hungry and may experience a shaking
chill.
 Evaluation & Inspection
Pain
•Evaluation of Uterus
•Inspection of Cervix
•Repair
•Perineal Cleansing & Positioning Of Leg
 Continuing Case Monitoring

Vital sign check

Palpation of the fundus of uterus for contractility
Massage of uterus and expression of clots
Measurement of fundus
Inspection of the perineum
Inspection of bladder Inspection and change of
perineal pad
FOURTH STAGE OF LABOUR
 BLOOD PRESSURE
Measure blood pressure every 15 mts.
 PULSE
Assess rate and regularity.
Measure every 15 mts for first hour.
 TEMPERATURE
Determine the temperature at the begining of the
recovery period and after the first hour of recovery
period and after the first hour of recovery.
 PAIN • Assess the type, location and intensity of pain.
• Look for signs of discomfort.
 Evaluation of Uterus FUNDUS
Just below the umbilicus, cup the hand and press firmly in to
the abdomen. At the same time, stabilize the uterus at the
symphisis with opposite hand.
 If the fundus is firm, with uterus in midline, measure its position
relative to women’s umbilicus.
 Lay finger flat on abdomen under the umbilicus; measure how
many finger breadths or centimeters fit between the umbilicus,
the value is plus(+) if the fundus is above the umbilicus and if
below it is valued as (-).
 The fundus is not firm, massage it gently to contract
 Expel clots while keeping hands placed.
 With upper hand , firmly apply pressure downward toward
vagina, observe the perineum for amount and size expelled clots.
 INSPECTION OF CERVIX AND UPPER VAGINAL
VAULT
• The uterus is well contracted but there continues to be
steady trickle or flow of blood from the vagina.
• The mother was pushing prior to complete dilatation of the
cervix.
• The labor and delivery were rapid and precipitous.
• Traumatic second stage of delivery such as prolonged
shoulder dystocia or large baby.
INSPECTION AND EVALUATION OF THE PLACENTA,
MEMBRANES AND UMBILICAL CORD
• They are done before repairing any laceration or episiotomy.
• This is because, if during the examination of the placenta, the
midwife determines that the uterus needs to exposed manually
because of a retained placental fragment, it needs to be done
as soon as possible since it has the potential for causing
hemorrhage
  BLADDER
 Assess the distention by noting the location and firmness of
the uterine fundus and by observing and palpating the bladder.
 A distended bladder is seen as suprapubic rounded bulge that
is dull to percussion and fluctuates similar to a water filled
balloon.
 When the bladder is distended, the uterus is usually boggy in
consistency, well above the umbilicus, and to the woman’s
right side.
 Assist the woman to void spontaneously.
Measure the amount of urine voided.
 Catheterize if the bladder is distended and woman is unable
to void spontaneously.
 Reassess after voiding or catheterization to make sure the
bladder is not palpable and the fundus is firm and in the
midline.
  LOCHIA
 Observe lochia on perineal pads and on linen under
mothers buttocks.
Determine the amount and colour ; note the size and
number of clots; note any odour.
PERINEUM
 Observe the perineum for source of bleeding (e.g,
episiotomy, lacerations)
 Ask or assist the woman to turn on her side and flex the
upper leg on the hip.
 Lift the upper buttocks
 Observe the perineum in good lighting
 Assess episiotomy or laceration repair for intactness,
heamatoma, edema, bruising, red ness and drainage.
 Assess the presence of hemorrhoids.
 REPAIRS
• The repair of any laceration or an episiotomy is done
after the examination of the placenta and membranes.
If a uterine exploration for retained placental fragments
is necessary, it is done prior to the repair.
The uterus is checked again for consistency and repair is
begun.
 PERINEAL CLEANSING AND POSITIONING OF
LEGS
• The next nursing action is wash off the mother’s entire
perineal area including the perineum, vulva, inner
thighs, buttocks and the rectal area.
• A perineal pad is then placed against the perineum and
mother assisted to put her legs together.
•
 CONTINUING CARE AND MONITORING
• Vital signs check
• Palpation of the fundus of the uterus for contractility
• Massage of the fundus, and expression of the clots and
free bloom from the uterus
• Measurement of the fundus in relation to the umbilicus
• Inspection of the perineum for discoloration and
swelling
• Inspection of the bladder
• Inspection of the perineal pad and change, if necessary
• Offering food and fluids if allowed and comfort and
safety measures.
 POTENTIAL COMPLICATIONS
Hypothermic Reaction
PPH
Neonatal Observation
  APGAR SCORE
 • Taken at 1 and 5 minutes after birth • Heart rate,
respiratory rate, and color are used as the basis for
resuscitation need • TOTALS: • 0-2 = Severe
distress • 3-6 = moderate distress • 7-10 = minimal
distress
 VITAL SIGNS AND GENERAL
MEASUREMENTS
• General Appearance: Well-flexed, full range of
motion, spontaneous movement
• General Measurements: Head circumference- 33 to
35 cm, Chest circumference- 30.5 to 33 cm
• Skin reddish in color, smooth and puffy at birth
• Turgor good with quick recoil
• Vernix cadeosa- The white, cheesy substance
covering the newborn’s body.
• Lanugo – Fine downy body hair
 OTHER FINDINGS
• ACROCYANOSIS The result of sluggish peripheral circulation.
• PHYSIOLOGICAL JAUNDICE
  HEAD

• Anterior fontanel diamond shaped 2-3 - 3-4 cms

• Posterior fontanel triangular 0.5 - 1 cm
• Fontanels soft, firm and flat
• Sutures palpable with small separation between each
 EYES

• Slate gray , black, brown or blue eye colour

• No tears
• Fixation at times - with ability to follow objects to midline
• Blink reflex
• Distinct eyebrows
• Cornea bright and shiny • Pupils equal and reactive to light
 EARS
• Loud noise elicits Startle Reflex
• Flexible pinna with cartilage present
• Pinna top on horizontal line with outer canthus of eye
  NOSE Expected findings:
• Nostrils patent bilaterally
• Obligate nose breathers
• No nasal discharge
  MOUTH AND THROAT Expected Findings:
• Uvula midline
• Minimal or absent salivation
• Tongue moves freely and does not protrude
• Well developed fat pads bilateral cheeks
 NECK Expected findings:
• Short and thick
• Turns easily side to side
• Clavicles intact
• Some head control
 CHEST Expected findings:
• Evident xiphoid process
• Equal anteroposterior and lateral diameter
• Bilateral synchronous chest movement
• Symmetrical nipples
 ABDOMEN Expected findings:

• Dome-shaped abdomen
• Abdominal respirations
• Soft to palpation
• Well formed umbilical cord
• Three vessels in cord • Cord dry at base
 • Liver papable 2 - 3 cms below right costal margin
• Bowel sounds auscultated within two hours of birth
• Voiding within 24 hours of birth
• Meconium within 24 - 48 hours of birth
 FEMALE GENITALIA Expected findings:
• Edematous labia and clitoris
• Labia majora are larger and surrounding labia
minora
• Vernix between labia
 MALE GENITALIA Expected findings:
• Urinary meatus at tip of glans penis
• Palpable testes in scrotum
• Large, edematous, pendulous scrotum, with rugae
• Stream adequate on voiding
 EXTREMITIES Expected findings:
• Maintains posture of flexion
• Equal and bilateral movement and tone
• Full range of motion all joints
• Ten fingers and ten toes
• Grasp reflex present
• Legs appear bowed
• Palmar creases present
  REFLEXES
• Tonic neck reflex
• Grasp reflex
• Step reflex
• Crawl reflex
• Sucking reflex
• Babinskis reflex
NURSING DIAGNOSIS IN FOURTH
STAGE OF LABOUR
 Acute Pain related to physiological response to
Labour
 Deficient fluid volume related to uterine atony
after child birth.
 Deficient Knowledge related to information about
birth process
 Ineffective coping related to labour and delivery
 Anxiety related to hospitalization and birth
process.
MANAGEMENT OF FIRST
STAGE LABOUR
 Enema
 Perineal shave
 Food & Fluids by mouth
 Intravenous infusion
 Position & Ambulation
 Medication
 Monitoring Maternal physiological changes
 Vital sign
 Renal system
 GI changes
 Haematological changes
 Monitoring Of Fetal Wellbeing
 Evaluation Of Maternal Wellbeing
 Vital sign
 Bladder care
 Urine test
 Hydration
 Bodily Care Of Progress Of Labour
 Back rub
 Abdominal rub
 Effleurage
PARTOGRAM
 EVALUTION OF PROGRESS OF LABOUR:– Partogram
is a graphic recording of the salient features of labour status.
 In the management of women in labour partogram serves to
validate the normal progress of labour and to facilitate early
identification of deviations from normal pattern.
 Maternal vital signs
 Uterine contractions
 Fetal heart rate
 Vaginal examination findings
 Fluid balance
 Urine analysis
 Drugs administered
MANAGEMENT OF SECOND
STAGE OF LABOUR:
  Vital Sign
 Bladder care
 Hydration & General condition
 Maternal pushing effort
 Analgesia & Anaesthesia
 Perineal integrity
 Episiotomy
 Evaluation of progress of labor
 Contraction Pain
 Length of Second Stage
 Descend & Station
 Progress through the mechanism labor
PREPARATION FOR THE DELIVERY:
Location of the delivery
Position for the delivery
General preparation
CONDUCTION OF DELIVERY:
Clamping and cutting the Umbilical cord
Immediate care of the Newborn
 MANAGEMENT OF THIRD
STAGE OF LABOUR:
 Delivery of the Placenta & Membrane.
 Sign of placental separation

•Fresh blood loss

•Lengthening of the cord
•Fundus becomes rounder, smaller & more mobile in the
abdomen
 Expectant management
 Assisted expulsion

•Controlled cord traction

•Expression by fundal pressure
Use of Oxytocic agent.
Examination of Placenta & Membrane.
Immediate care to mother & baby.