STAGES OF LABOR & DELIVERY

ESSENTIAL INTRAPARTUM and NEWBORN CARE (EINC)

-Evidenced-based standards for safe and quality care of birthing mothers and their newborns,
within the 48 hours of Intrapartum period(labor and delivery) and a week of life for the
newborn

 Mother= Essential Intrapartum Care(EIC)

 Newborn= Essential Newborn Care (ENC)

ESSENTIAL INTRAPARTUM and NEWBORN CARE (EINC)

-December 2009
-DOH Secretary Francisco Doque signed Administrative order 2009-0025, mandates
implementation of EINC protocol in public and private hospitals.
-Then Unang Yakap campaign was launched

STAGES OF LABOR
Stage 1 = Stage of Cervical Dilatation
Stage 2 = Stage of Fetal Expulsion
Stage 3 = Stage of Placental Expulsion
Stage 4 = Stage of Puerperium
 FIRST STAGE OF LABOR
“STAGE OF CERVICAL DILATATION”
-From the onset of true labor contractions & ends with complete or full cervical dilatation (10 cm)

DILATATION
-Progressive, opening/widening of the cervical canal
-Expressed in centimeters(cms)
-10 cm = fully dilated cervix
-Primigravida= 1.2 cm/hr
-Multigravida= 1.5 cm/hr

EFFACEMENT
-shortening and thinning of the cervical canal
-Expressed in percentage (%)
ANALGESIA COMMONLY USED DURING CHILDBIRTH

Narcotic Analgesics
-may be given during labor because of their potent analgesic effect

Example:
• Meperidine Hydrochloride (Demerol)
• Nalbuphine (Nubain)
• Fentanyl (Sublimaze)
• Butorphanol tartrate (Stadol)

Meperidine Hydrochloride (Demerol)

-most commonly used
-Has sedative and antispasmodic effect (Relieves pain and helps relax the cervix)
-given either intramuscularly or intravenously
-Dose: 25 –100 mg depending on woman’s weight & route of administration.
-Onset of action:
• 30 minutes after intramuscular (IM) injection
• 5 minutes after intravenous (IV) administration
-Duration of action: 2 - 3 hours

SPECIAL CONSIDERATIONS IN GIVING DEMEROL:

• Not given early in labor due to possible effect on contractions (delays progress)
• Given if cervical dilatation is 6 – 8 cms. (More than 3 hours away from birth)
• Not given too late (1-2 hours before delivery) because it can cause respiratory depression in
the newborn
• Narcotic Antagonist:
 Naloxone Hydrochloride (Narcan) - used to counteract newborn respiratory
depression when a mother has received a narcotic analgesic during labor.
ESSENTIAL INTRAPARTUM CARE (EIC) PRACTICES DURING FIRST STAGE OF
LABOR
-Mobility= allow the mother to walk to increase the descent of fetus only if BOW is intact
-Food and drinks= light carbohydrates food
-Non pharmacologic pain relief (effleurage, positioning)
-Companion in labor= shorter labor
-Use of partograph (begins at 4cm (active labor), IE done every 4 hours (not to exceed 5x
because it might lead to infection)

NOT RECOMMENDED PRACTICES

• No perineal shaving
• No enema
• No IV fluids
• No NPO
• No lying down
• No artificial rupture of membrane or BOW/ Amniotomy
• No drug induce labor

 SECOND STAGE OF LABOR

“STAGE OF FETAL EXPULSION / DELIVERY STAGE”
-from complete cervical dilatation (10 cm) & ends with the delivery of the fetus.
Primigravida: 30 minutes to 2 hrs.
Multigravida: 20 minutes to 1 hr.

Crowning is the hallmark

-Newborn’s head or presenting part appears at the vaginal opening

CARDINAL MOVEMENTS IN THE SECOND STAGE OF LABOR

• ED FIRE ERE
 Engagement
 Descent
 Flexion
 Internal rotation
 Extension
 External rotation
 Expulsion
ENGAGEMENT
-synonymous to station 0
- Passage of the biparietal diameter of fetal head through the maternal ischial spine/pelvic inlet

DESCENT
- Downward movement of the biparietal diameter of the fetal head to the pelvic inlet.
- Measured by “station”

FLEXION
- Fetal head bends forward unto the chest
- Presenting diameter changes from Occipitofrontal (11cm) to the smallest AP diameter
suboccipitobregmatic diameter (9.5 cm) to present in the pelvic outlet.

INTERNAL ROTATION
- fetal skull rotates from transverse to anteroposterior diameter at pelvic outlet; associated with
descent
- Occiput rotates 45 degrees; is just under the symphysis pubis
- Sinciput near the sacrum

 CROWNING
-Fetal head is visible at vaginal outlet Encirclement of the largest diameter of the fetal head in
the vulvar ring

EXTENSION
- fetal head reaches the perineum
- Occiput passes under the lower border of the symphysis pubis first
- Head emerges by extension: first occiput, next face, finally the chin

 RITGEN’S MANEUVER
- Sterile towel over the perineum and press forward on the fetal chin while the other
hand is pressed downward on the occiput
- helps fetal extension
- Controls the rate at which the head is born

(EXTERNAL ROTATION/RESTITUTION)
- After head is delivered, it rotates briefly to the position it occupied when it was engaged in the
inlet
- 45 degree turn realigns fetal head with his back and shoulders
- Anterior shoulder descends first followed by posterior shoulder
EXPULSION
- Head and shoulders are lifted up toward the mother’s pubic bone and the trunk of the fetus is
born by flexing it laterally in the direction of the symphysis pubis.

PERINEAL ASSESSMENT DURING 2ND STAGE OF LABOR

 LACERATIONS
-Injury or tear in the vaginal canal and perineum that occurs during delivery of the fetus

 First Degree Laceration

-A tear on the fourchette, perineal skin, vaginal mucous membrane

 Second Degree Laceration

-tear on the fourchette, perineal skin, vaginal mucous membrane, fascia and perineal
muscles

 Third Degree Laceration

-A tear on the fourchette, perineal skin, vaginal mucous membrane, fascia and
perineal muscles, perineal body, anal sphincter

 Fourth Degree Laceration

- tear on the fourchette, perineal skin, vaginal mucous membrane, fascia and perineal
muscles, perineal body, anal sphincter and rectum

 EPISIOTOMY
- Surgical incision into the perineum to enlarge the vaginal opening
- To prevent tearing of the perineum and release pressure on the fetal head with birth
- Done during or prior crowning

 Midline/Median episiotomy
- Incision is made straight in the midline of the perineum
- Easily repaired, less discomfort
- allows faster and less painful healing
- DISADVANTAGE: may extend up to rectum

 Mediolateral episiotomy
- Incision directed laterally away from the rectum
- Rectal structures are avoided
- cause more pain during healing
  EPISIORRHAPHY
-Repair of perineal laceration or of episiotomy
-stitching together the margins of a tear in the tissues lacerated during vaginal delivery

EIC PRACTICES DURING SECOND STAGE OF LABOR

-Spontaneous bearing down/pushing of the mother
-Place mother on semi upright
- Restrictive episiotomy/indicated episiotomy (do not do as a routine in Primi)

NOT RECOMMENDED PRACTICES:

•No perineal sweeping
•No fundal pushing

 THIRD STAGE OF LABOR

“STAGE OF PLACENTAL EXPULSION”
-begins with the delivery of the fetus to the delivery of the placenta.
-Occurs within 30 minutes

SIGNS OF PLACENTAL SEPARATION

 Calkin’s sign
-earliest sign; uterus becoming firm, round, globular again
-Immediately after delivery fundus at midway between the symphysis pubis and
umbilicus, then rises to the level of the umbilicus-midline.

 sudden gush of blood

 lengthening of the umbilical cord
 Firm contraction of the uterus

 Appearance of the placenta at the vaginal opening

TYPES OF PLACENTAL PRESENTATION

 SCHULTZE PRESENTATION
-“SHINY/CLEAN SIDE FIRST” (Fetal Side)
-Shiny, clean, bluish side is first delivered
 -Common (80% )
-placenta separates first at its center & last at its edges
-Folds like an inverted umbrella

 DUNCAN PRESENTATION
-Less common (20%) (Maternal Side)
-Rough, “dirty”, reddish, irregular, with ridges or cotyledons;
- Placenta separates first at its edges and last at its center

TECHNIQUES FOR PLACENTAL EXPULSION

CREDE’S MANEUVER AND BRANDT ANDREW MANEUVER

• Gentle pressure is exerted with the hand on the contracted uterine fundus and the placenta is
gently guided out of the vagina
• Gentle traction is made on the 4 fingers pressed the midline of the contracted uterus pushing
it upward
• Slowly pull cord and wind the cord around the clamp until placenta is delivered
• Placenta is held and rotated gradually to ensure that no membranes are retained

EIC PRACTICES DURING THE THIRD STAGE OF LABOR

 Wait for placental separation, deliver the placenta only if the uterus is contracted

 Expel placenta via BAM (Crede’s Maneuver and Brandt Andrew maneuver); Use of controlled
traction Inject oxytocin (Check BP first )

 Gentle Massage of the uterus

AMTSL (Active Management of Third Stage of Labor)

 After delivery of baby check if there is a second baby

 If none, oxytocic drugs are given IM or IV

 Oxytocics-drugs that contracts the uterus thereby controls uterine bleeding

 Oxytocin, Pitocin, Syntocinon

 Ergotrate Maleate, Methergine
 Carboprost (given if uterus is still unable to contract after oxytocin is given)

Note: Check first the Blood Pressure before giving these Oxytocic drugs

 FOURTH STAGE OF LABOR

“Immediate Postpartum Period”
-First 1-4 hours after delivery
-Period of recovery, stabilization or homeostasis
-Follows placental expulsion and lasts until maternal vital signs and conditions are stable

Uterus
Immediately after deliverymidway between the umbilicus and symphysis pubis.

KEEP THE UTERUS FIRM

• If relaxed, soft and not contracted, gently massage until it contracts and becomes firm.

• Do not OVER MASSAGE as this can tire the uterine muscles, causing relaxation

• A boggy uterus many indicate uterine atony or retained placental fragments.

• Boggy - being inadequately contracted and having a spongy rather than firm feeling. • Administer
oxytocin medications if ordered.

• Check BP, uterine contraction and lochia after administration

IF UTERUS IS DISPLACED TO THE SIDE

• First action: Check bladder distention

• feel the lower abdomen for a distended bladder

• When the bladder is distended, stimulate voiding

DOCUMENT LOCHIA FLOW WHEN THE FUNDUS IS MASSAGED

• Every fifteen (15) minutes for the first hour.

• Every thirty (30) minutes for the next one hour.

• Every hour until ready for transfer.

MONITOR VITAL SIGNS

• Every 15 minutes for the first one hour

• Every 30 minutes for the next two hours

• Every hour until thereafter until stable

CHECK PERINEUM

• Appearance

• Redness, swelling, bruising

• Vaginal & suture line bleeding

CHECK EPISIOTOMY OR LACERATED WOUND

• Bleeding

• Hematoma
• edema

MONITOR BLOOD LOSS DURING DELIVERY

• Normal Spontaneous Vaginal Delivery (NSVD): 300-500 ml average 250 ml

• Cesarean Birth : <1000ml

ASSESS LOCHIA

• The maternal discharge of blood, mucus, and tissue from the uterus

• Bright red and can saturate 1 to 2 perineal pads in one hour

• If Reddish persists more than 2 weeks, it indicates either retention of small portions of the
placenta or imperfect involution of the placental site

ASSESSMENT

• Keep a pad count. Record the number of pads soaked with lochia during recovery.

• Identify presence of bright red bleeding or blood clots.

• Document thick, foul-smelling lochia.

• Observe for constant trickle of bright red lochia. This may indicate lacerations.

• Identify lochia amounts as small, moderate, or heavy (large)

PROMOTE SLEEP AND COMFORT

• Keep warm. Chills are common in fourth stage of labor

• Give partial bath, perineal care( front to back) change wet linens.

• Assess afterpains

PROVIDE NOURISHMENT

• The woman may be thirsty and hungry

PROMOTE BONDING

• Early feeding can contract the uterus and promote bonding (LATCHON)

• Breastfeeding started: 30 minutes after a normal delivery

STABLE MATERNAL CONDITION

 Firm fundus

 Lochia moderate in amount

 No bladder distention

 Alert and responsive

 Stable vital signs

 No signs of bleeding