1. Lecturer of maternity & Neonatal Nursing
Nursing Management Of
Labor stages
Dr/Sahar Elkheshen
Lecturer of maternity & Neonatal Nursing

2. OBJECTIVES: at the end of the following lecture the student will be able to:
Define three stages of normal vaginal delivery.
Identify care items needed during first stage of labor.
Define the key terms related to labor process.
Mention cardinal movements of the second stage of labor.
Describe tow methods of placental separation.
Provide necessary care required for the second and third stages of labor.

3. Prepare equipment:
Fetal heart monitoring set
P.V Set
Supplies
I.V Solutions
Enema set
Medication set
Linens, Gowns, Towels

4. Labour stages
There are three stages of labor, each of which is considered separately. The first stage (stage of dilatation of the cervix) is from the onset of true labor (regular uterine contractions) to complete dilatation of the cervix.

5. Contin.,
The second stage (stage of fetal delivery ) is from complete dilatation of the cervix to the birth of the baby.
The third stage (stage of placental delivery) is from the birth of the baby to delivery of the placenta.

6. TRUE LABOR Contractions are regular.
Frequency and duration of the contractions also change; they get closer together and last longer.
There is cervical dilation and effacement.
Discomfort begins in the back and radiates to the abdomen.
Interventions such as rest and warm baths do not decrease contractions.

7. FALSE LABOR Contractions are irregular.
There is no change in frequency and duration.
There is no cervical dilation and effacement.
Usually, discomfort is solely in the abdomen.
Rest and warm baths lessen contractions.

8. THE FIVE “P”s Passenger Passageway Powers Position
Psychological response

9. PASSENGER Passenger = Fetus (and placenta) Fetal head
– Fontanels, molding
Fetal presentation
– Cephalic, breech, shoulder
– Presenting part: occiput, sacrum, scapula
Fetal lie
Fetal attitude
Fetal position
– Station, engagement

10. Passageway = Birth canal
Bony pelvis: true and false pelvis
Type of pelvis:
– Gynecoid
– Android
– Anthropoid
– Platypelloid
Soft tissues of cervix & vagina

11. Powers = Forces that expel fetus
–Uterine contractions
Primary Powers (involuntary)
–Dilation, effacement,
– Valsalva maneuver

12. PSYCHOLOGIC RESPONSE Preparation for childbirth – child education
classes
Sociocultural background
Anxiety
Comfort
Support from significant others
Ability to communicate with others
Previous childbirth experience
Environment
Emotional integrity

13. POSSIBLE CAUSES OF LABOR ONSET
Mature fetus: weeks
Hormonal changes:
–Progesterone withdrawal
–Increased level of prostaglandins
–Increased level of estrogen & oxytocin
–Fetal secretion of cortisol steroids
Placental aging

15. Station
This is the relationship between the presenting part of the baby -- the head, shoulder, buttocks, or feet -- and two parts of the mother's pelvis called the ischial spines.

16. Fetal Lie
This is the relationship between the head to tailbone axis of the fetus and the head to tailbone axis of the mother.
If the two are parallel, then the fetus is said to be in a longitudinal lie.
If the two are at 90-degree angles to each other, the fetus is said to be in a transverse lie.
Nearly all (99.5%) fetuses are in a longitudinal lie.

17. Fetal Attitude
The fetal attitude describes the relationship of the fetus' body parts to one another.
The normal fetal attitude described as the head is tucked down to the chest, with arms and legs drawn in towards the center of the chest.

18. Presentation Cephalic presentations Breech presentation
Shoulder presentation

22. Admission:
Welcome the woman,
Explain all procedures,
Seek informed consent,
Help her undress,
Ensure privacy,
Wash hands before each procedure.

23. Take complete history: Family history,
Assessment:
Take complete history:
Family history,
Obstetric history: previous and recent.
Menstrual history,
Contraceptive history.

24. Determine whether the woman in labor or not:
Uterine contraction (10/30 minutes),
Show,
Membranes,
Frequency of micturation,
Cervical changes.

27. Examination of the woman in labor:
Explain all the procedure;
Inform her of the procedures results;
Perform general examination:
Observe general condition weight , hight, limbs edema, ….).
Measure vital signs accurately in between contractions,
Test urine for sugar and albumin.

28. Perform Local Examination:
Examination of the abdomen (abdominal Maneuver).
Examination of the Vulva(gapping of the entroitus, presence meconium, presence of offensive odor, presence of blood).
Vaginal examination

29. Nutrition and hydration:
Meet women's needs of energy through oral fluids.
In case of vomiting, ketosis and possible use of anesthesia, I.V fluids are given.
Maintain intake and output chart.
Solid food is usually avoided (???).

30. Rest and sleep: Latent phase Active phase
Effect of ambulation on the progress of labor

31. Apply measures of infection control:
Follow aseptic technique
Provide dry and clean clothes
Trimming hair
Bathing
Nails
Swapping the perineum

32. Posture of the woman:
Lying
walking

33. Frequency of micturation Effect of full bladder:
Care of bladder:
Frequency of micturation
Effect of full bladder:
Its effect on descent
In relation to uterine contractions
Complication of full bladder

34. Observe signs of maternal distress:
Increased pulse rate ????
Elevated temperature ????
Decreased blood pressure
Sweating
Signs of dehydration
Dark vomitus
Anxious & depression

35. Second stage of labor

36. MECHANISM OF LABOR: 7 CARDINAL MOVEMENTS Engagement Descent Flexion
Internal rotation
Extension
Restitution/external rotation
Expulsion

37. 1 - Engagement:
It’s a state that the infant head entered the true pelvis inlet. The biparietal diameter (BPD) is inside the inlet. At this time the head partially flexed and the occipito-frontal diameter is on the right-oblique diameter of the inlet.

38. 2 - Descent:
Descent continued progressively during labor until baby is delivered. It is brought about by the contractions of uterus and the bearing-down efforts. Other movements are superimposed on it .

39. 3 - Flexion:
Partial flexion of the head exists before labor and on engagement .
When the fetus descents, the head meets the resistance of the pelvic floor, especially the levator ani, the fetus neck vertebra further flexed, and the chin approach the chest, at this time, the fetus suboccipito-bregmatic diameter(9.5cm) is on the diameter of mid plane of true pelvis .

40. 4 - Internal Rotation
When the infant descends continually the head meet the resistance of the pelvic floor, when the uterus contracts, the pressure inside the uterus cavity will made the head turn anteriorly towards the symphysis pubis, the sagittal suture is in anterior-posterior direction. It will be finished by the end of first stage.

41. 5 - Extension :
The flexed head in a occipital anterior position continues to descend through the passage. Since the vaginal outlet is directed upwards and forwards, so with the contraction of uterus and contractions of levater ani, the baby's head may extend under the pubic arch, the occiput come out first, then the brow 、the face、the chin.

42. 6.Restitution and external rotation:
The shoulder was in the oblique diameter of the inlet when it enter the pelvis. When the head is delivered from under the pubic arch, the neck twisted, and the shoulder can not move, so the occiput will have to turn back to the position of LOA, make the body of the baby in the same longitudinal axis. This action call restitution.

43. 7. Expulsion (Delivery):
After the external rotation when the uterus contract, the anterior shoulder (right shoulder) slip from under the pubis followed by the left shoulder over the perineum and then the body.

44. Signs of progress Transition signs: Loss of control Fearfulness
Disorientation
Nausea
Uncontrollable shivering
Demands for pain relief
Need to shout
Variable urge to bear down

45. Nursing Care Hygiene and comfort measures Support during transition
Support during expulsive phase :
early & delayed bearing down efforts.
Pushing techniques
Perineal practices.
Assessing need for episiotomy

46. Third Stage of Labor

47. Process of Placental Separation

48. Nursing management Signs of placental separation:
Elongation of the umbilical cord
Formation of suprapubic pulg
Absence of pulsation in the umbilical cord.
Gushing of blood from the vagina

49. Examination of Normal Placenta

50. Fourth Stage of Labor

51. First 2-4 hours post partum
Check vital signs
Check fundal level and uterine status
Assess lochia
Assess perineal state
Observe for vaginal bleeding
Observe warning signs and symptoms

52. Health Educational topics
Personal hygiene
Psychological changes
Importance of birth spacing
Breast feeding
Baby care
Warning signs and symptoms

53. Thank You