References:
- Dr. RPS Maternal and Newborn Care: A Comprehensive Guide and Source Book for Teaching and Learning, 2nd Edition, ISBN 978-971-98-2265-3, by Rosalinda Parado Salustiano (pp. 222-261)
Dilatation Stage
The Dilatation Stage begins with the onset of the first true labor contraction up to full cervical dilatation (10 cm). Power comes from uterine contractions. This stage is further subdivided into three phases:
| Latent | Active | Transition | |
|---|---|---|---|
| Dilatation | 1 cm - 4 cm | 4 cm - 8 cm | 8 cm - 10 cm |
| Effacement | Usually complete in primigravidae | Complete effacement | Complete effacement |
| Frequency | >10 min | 3 min - 5 min | 2 min - 3 min |
| Duration | 30 sec | 45 sec - 60 sec | 60 sec - 90 sec |
| Intensity | Mild | Moderate | Strong |
| Behavior | Cooperative | Anxious | Uncooperative |
| Discomforts | - Backache - Abdominal Cramps | - Hyperventilation - Respiratory Alkalosis | - Backache - Pressure on the bladder and rectum - Leg trembling |
| Interventions | - Positioning, Backrub - Companion of Choice | - Drugs for comfort (4 to 6 cm, avoids fetal distress) - Encourage slow breaths or rebreathing with a paper bag or cupped hands. | - Physical comfort with dry linens and cool clothes - Clean up vomitus - Provide a backrub - Coach on breathing technique: pant-blow pattern - Provide psychologic comfort |
Every pregnancy and birth is unique, so the best intrapartum care for each woman and her baby is individualized, person-centered, respectful, and evidence-based. In the first stage of labor upon admission to the labor unit, greet the patient, admit and orient them to the physical setting and common procedures, and take their history (GPTPALM, EDC/EDD, last meal, allergies, onset of labor, status of bag of waters, intent to breastfeed). Assess their knowledge about labor and preparedness. Take initial vital signs and FHT.
- Perform Leopold’s Maneuver. Remember to empty the bladder, flex the knees, and warm hands.
- Do perineal preparation; observe the principles of asepsis.
- Render an enema only if ordered. Removal as a routine procedure reduces infection, labor retardation, and postpartum discomfort.
- Obtain specimens for laboratory: urine (sugar, protein, acetone) and blood (Hgb, Hct, WBC, serology, cross-matching).
Monitor for uterine contractions, the bladder, FHT, perineum (Show), rupture of BOW, presenting part, bulging, cord prolapse, bleeding; ability to manage pain.
- BP, PR, and RR every hour in the latent and active phases, and every 30 minutes in the transition phase (if normal).
- Temperature every 4 hours (if normal), and hourly if above 37.5°C or if membranes rupture (leading complication of prolonged rupture of the bag of water is infection).
- FHR: every 30 minutes in the latent phase, every 15 minutes after (if normal).
Prevent supine hypotensive syndrome. Position the patient in a left lateral recumbent position. Employ physical and psychologic comfort and support; comfort measures such as assisting with positional change, keeping clean and dry, and promoting sleep and adequate rest are observed.
- Distraction is one of the methods used to increase relaxation and cope with the discomfort of labor when contractions are mild to moderate. Examples include “happy thoughts”, conversation, light activities (reading, card play, ambulation), and visualization.
- Massages, particularly effleurage, is a light abdominal stroking, which may be used in the first stage to maintain relaxation of the abdominal muscle; effective for mild to moderate pain.
- Back ache is particularly severe in occipitoposterior positions. Pain may be relieved by counter-sacral pressure and a side-lying position.
Always watch for DANGER SIGNALS
- Hypertonic or hypotonic contractions
- Bleeding (placenta previa, abruptio placenta, uterine rupture)
- Passing of meconium-stained amniotic fluid (fetal distress)
- Severe headache, dizziness, and blurring of vision (PIH)
Delivery/Expulsion Stage
The Delivery/Expulsion Stage lasts from full cervical dilatation to the delivery or expulsion of the baby. This stage features the inclusion of secondary powers (maternal pushing, intraabdominal pressure) in the birthing process.
Pushing in the Crowning Stage
Pushing spontaneously occurs with contractions, but panting should be done during interval and at crowning time. Crowning is the hallmark of the second stage. At this period, pushing is not recommended as the fetus undergoes extension, and alteration with pushing can cause perineal lacerations, and meconium aspiration.
- The strength, duration, and frequency of contractions do not vary from the transition phase.
- The perineum bulges; the mother grunts when pushing. There is an increase in show, leg cramps can occur, and the bag of water ruptures; this stage is the best time for rupture. The first nursing action after rupturing is to check the FHT.
Assisting Deliveries
Also refer to the Essential Newborn Care protocol (Unang Yakap) as advocated by the Department of Health.
| Indication | Action | Rationale |
|---|---|---|
| Extension of the head | Feel the nape for cord presence | Detection of cord coil. Unloop the cord over the head if possible, but double clamping and cutting is necessary if the coiling is tight. |
| Clear the mouth and nose with shallow suctioning via bulb syringe | Prevention of meconium aspiration. Routine (deep) suctioning is not done without proper indications. | |
| Expulsion | Delay clamping and cutting until pulsations disappear. | Improve initial respiratory efforts and prevent anoxia at the time of birth. |
| Dry and wrap the newborn to keep it warm. | Warmth. Neonatal thermoregulation is not yet fully functional. | |
| Place the wrapped newborn on the maternal abdomen. | The provision of warmth, mother-child closeness or bonding, and aid in uterine contraction from the weight of the baby. | |
| Proper identification | A legal and ethical responsibility if the newborn is to be separated from the mother. |
Nursing Implementation
- Continue to offer a psychological support and inform the mother of progress. Use (mn. PRAISE) Praise, Reassurance, Encouragement, Informing the mother of progress, Support System (COC), and Therapeutic Touch.
- Assist/Coach through labor, about when to push or to pant.
- Monitor FHT during intervals (period of rest). If there is a continuous fetal heart electronic monitor, check the FHT during and after a contraction. Be alert for late decelerations.
- Transfer the mother to the delivery room. For primigravidas, with slower progress of labor, they are transferred at 10 cm of dilatation with a certain degree of bulging with contractions. For multigravidas, they are transferred at 8 to 9 cm.
- Positioning: lithotomy with padded, equal stirrups, with no pressure on the popliteal region. The legs are placed on the stirrups simultaneously. Alternatively, Fowler’s, side-lying, or squatting can be used if desired, indicated, or supported by the unit policy.
- Perineal Preparation: cleaning of the perineum to prepare for delivery. A front-to-back motion is used.
Cardinal Movements/Mechanisms of Labor
During labor, the fetal head and body must change positions to accommodate the irregular maternal pelvis. These positional changes are termed the cardinal movements, otherwise called the mechanisms of labor, namely: (mn. D-FIRE-ERE)
- Engagement: the mechanism by which the greatest transverse diameter of the fetal head (biparietal diameter) passes through the pelvic inlet; the head is fixed in the pelvis.
- Descent: the first requisite for the birth of the baby: the progression of the fetal head through the pelvis. This may occur earlier in a nulliparous woman, and usually begins with engagement in a multiparous woman. The degree of descent is measured by station. It spans from -5 to +5, with 0 at the level of the ischial spines. Each interval measures 1 cm above or below the ischial spines. There are four forces of descent:
- Amniotic fluid pressure; thus, some obstetricians elect to rupture the bag of water with an amniotone (amniotomy) to enhance labor progress
- Direct pressure of the contracting fundus/uterus upon the breech
- Effects of contractions on the diaphragm and abdominal muscle contraction
- Fetal body extension and straightening
- Flexion: the mechanism that occurs when the head meets resistance from the cervix, pelvic floor, and pelvic walls, causing the head to flex so that the chin is brought into contact with the chest. This results in the smallest anteroposterior diameter of the fetal head (suboccipitobregmatic diameter: 9.5 cm) to present into the maternal pelvis.
- Internal Rotation: this mechanism involves the turning of the fetal head from left to right, aligning it with the long axis of the maternal pelvis and causing the occiput to move anteriorly toward the symphysis pubis.
- In internal rotation, the fetal skull rotates from transverse to anteroposterior at the pelvic outlet, which is associated with descent.
- After internal rotation, the occiput is just under the symphysis pubis.
- Not accomplished until the head is engaged; occurs mainly during the second stage of labor.
- Extension: the delivery of the head in vertex presentation, or when the head leaves the pelvic outlet.
- There is a gradual emergence of the occiput just under the symphysis pubis, followed by the face and then the chin.
Meconium Aspiration
As soon as the head is out, even before the chest is born, the mouth and then the nose are wiped clear of secretions to prevent meconium aspiration. Routine suctioning of the newborn is no longer performed in the immediate care of the newborn.
- Restitution: after the head is extended, the neck is twisted, so the head needs to externally rotate to realign with the long axis of the fetus.
- External Rotation: as a continuation of restitution, the shoulders align with the anteroposterior diameter, causing the fetal head to continue to rotate. The trunk navigates through the pelvic cavity, with the anterior shoulder descending first.
- Expulsion: final birth of the baby. A gentle but firm downward pressure/traction of the head is done to deliver the anterior shoulder. Then, the head is gently raised to deliver the posterior shoulder, and the entire body follows without much difficulty. The head is the biggest part of the baby; after the head passes out, the rest of the body follows with no difficulty.
- When the entire body of the baby emerges from the birth canal, birth is complete. The time of birth is recorded and entered in the birth certificate.
- Apply Unang Yakap or the Essential Newborn Care (ENC) protocol if part of the institutional practice.
Contact the Healthcare Provider or Go to the Hospital
- When contractions are regular and becoming increasingly frequent: their duration is 30 seconds and they occur every 5 minutes.
- When show is present.
- When the bag of water ruptures. The rupture of the bag of water is always an indication for seeking medical help.
| Labor Stage | Primigravida | Multigravida |
|---|---|---|
| First Stage: Phases Latent phase (0-4 cm cervix) Active phase (4-8 cm cervix) Transitional phase (8-10 cm cervix); the most difficult for the mother | 8-10 hours 6 hours 2 hours | 5 hours 4 hours 1 hour |
| Second Stage: most difficult for the fetus | Mean: 50 minutes (1 hour) | 20 minutes (0.5 hour) |
| Third Stage: watchful waiting for signs of placental separation and delivery is the most important nursing action | 5-15 minutes, average 5 minutes | 5-10 minutes |
| Fourth Stage: most dangerous for the mother. When the fundus fails to contract and remains atonic in spite of management, the woman can hemorrhage. Postpartum hemorrhage is the leading cause of maternal mortality. | The period of recovery, stabilization, or homeostasis is usually 1 to 2 hours, at most up to 4 hours. |
Placental Stage
The Placental Stage is the period from the delivery of the baby to the delivery of the placenta. The powers involved in the delivery of placental delivery is from strong uterine contractions, and maybe maternal pushing once the placenta has fully detached. There are four primary signs of placental separation:
- Calkin’s sign: the first sign; when the uterus changes shape (from discoid to globular) and consistency (becomes firm).
- Uterine mobility: the uterus rises up into the abdomen. Immediately after placental detachment, the fundus is midway between the symphysis pubis and umbilicus, then rises to the level of the umbilicus.
- Sudden gushing of blood from the open blood vessels once connected to the placenta. It is important to distinguish between the normal sudden gushing of blood, and the abnormal “increasing bleeding”.
- Slight lengthening of the cord: the most definitive sign that the placenta has detached.
The placental delivery can be typed according to which side of the placenta appears first:
- Schultze Mechanism: more common; present in 80% of cases. The shiny, “clean”, bluish side is first delivered. Less external bleeding occurs because blood is usually concealed behind the placenta. The separation for the placenta in this type starts with the middle, then to the edges, which gives it an “inverted umbrella” appearance.
- Matthew Duncan Mechanism: present in the remaining 20% of cases. The rough, “dirty”, reddish side is first delivered. More external bleeding occurs, giving the delivery a “bloody” appearance. The separation for the placenta in this type starts with the side, giving it an “umbrella” appearance.
Postpartal Hemorrhage
The normal amount of blood lost in the entire process of delivery is 250 to 300 mL. Blood loss of more than 500 mL is considered postpartal hemorrhage, the leading cause of maternal mortality.
Nursing Implementation
Observe the principles of the placental delivery stage:
- Watchful Waiting (watch and wait for signs of placental separation)
- Not Increasing Fundal Pressure with a pull at the cord, especially if the uterus is relaxed, as these actions could cause uterine inversion, a leading cause of hemorrhage in the third stage of labor.
- Gradual Delivery of the Placenta
- Inspect the placenta for completeness. The major components of a placenta are cotyledons (15 to 20), cord vessels (two arteries and one vein), and complete membranes. This ensures the reduction of potential placental fragment retention, causing hemorrhaging.
Assess the uterus for contraction or firmness. The terms “soft,” “boggy,” and “non-palpable” mean uterine atony. The initial activity of the nurse is to massage the fundus until it is firm. An ice cap may be applied to further contract the uterus, but never a hot water bag. This promotes vasodilation, increasing bleeding.
Oxytocin is ordered by the physician and administered by the nurse after placental delivery. Commonly used drugs include methergine (Methylergonovine maleate) and ergotrate (Ergonovine maleate/Ergometrine). These increase uterine motor activity by direct stimulation of the uterine musculature. Contraction prevents postpartum bleeding from uterine atony and subinvolution. Evaluate for a firm fundus to determine effectivity. This may cause nausea, vomiting, dizziness, headache, hypertension, tinnitus, and hypersensitivity.
After the birthing process, assess vital signs, presence of lacerations, completeness of the placenta, and bleeding. Lower legs slowly. If allowed by the institution, allow mother time with the infant to promote attachment or bonding; breastfeed right on the delivery table.
Recovery
The Recovery Stage is the period of recovery, stabilization, or homeostasis; usually 1 to 2 hours or at most up to 4 hours. Power still remains from uterine contractions that prevent bleeding from the placental site.
- Vital signs every 15 minutes. Blood loss averages 250 mL during delivery. A normal upper limit is 500 mL. More than this amount is defined as postpartum bleeding.
- Blood pressure changes (lower in both systolic and diastolic, increased pulse pressure, slight to moderate tachycardia) occur from blood loss, lifting of the uterus, and redistribution of blood to the venous beds.
- Palpate the fundus every 15 minutes. Check fundal height and position in relation to the umbilicus, and its consistency. In a normal delivery during the recovery stage, the fundus is firm, midline, and at the level of the umbilicus.
- Ask the mother to void prior to any palpation. This promotes maternal comfort and improves finding accuracy from palpation.
- Displacement of the uterus to the side is often due to a distended bladder. Palpate the lower abdomen for a distended bladder, and if it is, stimulate voiding. Displacement can contribute to uterine atony.
- Assess Lochia. Lochia is bright-red during the fourth stage, and can saturate one to two pads in one hour. A reddish color may be maintained for two weeks, but longer periods indicates either retention of small portions of the placenta or imperfect involution of the placental site, or both.
| Parameter | Rubra | Seroa | Alba |
|---|---|---|---|
| Color | Red | Brownish | White |
| Amount | Moderate | Scanty | Slight |
| Time Present | 1 to 3 days | 4 to 10 days (average and at least 7 days) | 10 to 14 days (at most 21 days) |
- Assess the perineum. Note its general appearance, redness, swelling, bruising, and vaginal and suture line bleeding.
- Administer oxytocin medication as ordered. Check blood pressure before and at intervals after; monitor fundal contraction and lochia after administration.
- Check the episiotomy wound or lacerated wound for bleeding, hematoma, or edema. An ice bag applied to the perineum immediately after delivery (and in the first 24 hours) can reduce edema and swelling.
- Promote sleep and comfort. Keep the mother warm, as chills are common in the fourth stage. This may be due to maternal excitement, a sudden drop in maternal hormones (progesterone is thermogenic), the release of intra-abdominal pressure, and fetal blood in circulation.
- Perform a partial bath and peri-care (front to back), and changing wet linens.
- Assess for afterpains; pains that occur upon uterine contraction. Reassure that these are secondary to uterine contractions. An icecap may be placed on the abdomen overlying the fundus for relief, or analgesics may be given as ordered.
- Provide nourishment. The mother may be thirsty and hungry.
Always Provide Respectful Care
Remember that the care of maternity clients should always be respectful. Respectful intrapartum care maintains women’s dignity, privacy, and confidentiality, ensuring freedom from harm and mistreatment, and enabling informed choice during labor and childbirth. This WHO model of intrapartum care provides a basis for empowering all women to access and demand the type of care that they want and need (WHO, 2020c).