TRANS 23b, EXAM 3

Conduct of Normal Labor and Delivery

WILHELMINA-MA. S. PINEDA MD
03/20/2018

OUTLINE  Though not needed in most pregnancies, acquired measurements

I. Diagnosis of Delivery A. Position in Labor from screening and tracing via CTG can determine if the mother and
A. Perceptions of Labor B. Maternal Expulsive Efforts fetus is safe to subject in labor
B. Onset of Labor C. Monitoring Fetal Heart
C. Stages of Labor Tones
II. Management of First Stage D. Episiotomy B. HISTORY, P.E, AND REVIEW OF REVIEW OF ANTENATAL
Labor E. Delivery RECORD
A. Fetal Admission Test IV. Management of Third Stage
B. History, PE, and Review of Labor
 Survey the general condition of the mother
Antenatal Period A. Signs of Placental  General condition of the mother: Does she appear edematous?
C. Vaginal Examination Separation Does she appear with severe stress?
D. Monitoring the Fetus B. Inspection of Placenta  Get the antenatal history, antepartum care and review her records:
E. Oral Intake C. Active Management  Illness, complete immunizations, infections, antibiotic intake
F. Laboratory Examinations D. Repair of Lacerations
G. Position During Labor V. “Fourth Stage of Labor”
 Get vital signs and complete PE. PE should include not just an
H. Bladder Infection Quick Review abdominal and internal examination, but an examination of the
I. Analgesia Review Questions whole body starting from the head all the way down
J. Amniotomy References
III. Management of Second Stage Appendix Prenatal Record involves the use of pertinent definitions:
Labor Nulligravida: a woman who currently is not pregnant, nor she ever
been pregnant.
I. DIAGNOSIS OF DELIVERY Gravida: a woman who currently is pregnant or she has been in
A. PERCEPTIONS OF LABOR the past, irrespective of the pregnancy outcome. With the
 Work, pain, suffering, toil, trouble, bodily exertion establishment of the first pregnancy, she becomes a primigravida,
 Definition: Regular uterine contractions that bring about and with successive pregnancies, a multigravida.
demonstrable dilation and effacement of the cervix Nullipara: a woman who has never completed a pregnancy beyond 20
weeks’ gestation. She may or may not have been pregnant or may
B. ONSET OF LABOR have had a spontaneous or elective abortion(s) or an ectopic
 Painful uterine contractions plus one or more of the following signs: pregnancy.
Primipara: a woman who has been delivered only once of a fetus or
 Ruptured membranes – burst water bag
fetuses born alive or dead with an estimated length of gestation of
 Bloody show – blood-tinged mucous discharge coming from the
20 or more weeks or more.
cervical mucus plug
Multipara: a woman who has completed two or more pregnancies to 20
 Complete cervical effacement weeks or more
Table 1. True labor versus False labor
True Labor False Labor Leopold Maneuvers
Regular contractions Irregular contractions  This is the focus of abdominal examination of pregnant patient
Shortened contraction intervals Long contraction intervals  Part of the pelvic examination
Increasing contraction intensity Unchanged contraction intensity  Patient position:
Discomfort (back and abdomen) Discomfort (lower abdomen)  Mother lies supine and comfortably positioned
Cervical dilation No cervical dilation  Abdomen bared
Labor unaffected by sedation Relieved by sedation  Difficult to perform and/or interpret if:
 Patient is obese
C. STAGES OF LABOR  Excessive amniotic fluid
 Labor is the third stage of parturition  Placenta is anteriorly planted
 Further divided into stages:  Leopold maneuver 1 (Fundal Grip)
 Stage 1 – start of regular uterine contractions to full cervical  Identification of the pole of the fetus, which occupies the fundus
dilation  Determination of which side of the fetus is occupying the
 Stage 2 – full cervical dilation to actual delivery of fetus mother’s convex back or nodular soft parts
 Stage 3 – expulsed fetus to placental separation and placental  Leopold Maneuver 2 (Umbilical Grip)
expulsion  Determination of the fetus’s back (hard) and numerous,
small, irregular parts that are mobile (fetal limbs)
II. MANAGEMENT: STAGE 1 OF LABOR  NTK: the loudest sound of the fetal heart tone is found at the
 Start: start of regular uterine contractions back of the fetus
 End: full of cervical dilation  Leopold Maneuver 3 (Pawlick’s Grip)
 Grasping of the fetal parts that occupy the area above the pubic
A. FETAL ADMISSION TEST symphysis of the level of pelvic inlet
 First thing that is done in most institutions  The presenting part is the part of the fetus that occupies the area
along the pubic symphysis (overlying the inlet)
 Not needed if the mother is going through low-risk pregnancy
 The transverse line shows what the presenting part overlies the
 Able to tell the condition of the fetus and any abnormalities (if
inlet
present)
 Leopold Maneuver 4 (Pelvic Grip)
 Mother is hooked up to a fetal monitor machine called
cardiotocograph (CTG), which will be attached to the foldings of  Appreciation of the extent of fetal descent
the uterus for uterine contractions and side where fetal back is for  Whether the head is flexed or extended
fetal heart pattern (fetal heart tones)  Cephalic prominence of the fetus
 The CPG shows the uterine contractions and fetal heart tones  If the cephalic prominence is at the same side of the small
parts the head is flexed
 The tracings have 2 wave, the one on top will reflect the fetal
 If the cephalic prominence is at the same side of the back,
heart pattern (Normal range: 110-160 bpm) and lower graph will
that means head is extended
correspond to uterine contractions
 If the examiner’s hands meet at the center of the mother’s

Trans #10 Group #10: Anonas, Bangayan, Go, Liberato, Pineda, Talla 1 of 8
 abdomen, the head is not yet engaged (referred as floating
presenting part)
 When one hand of the examiner is arrested before the other, a
portion of the head is said to be engaged
 If hands do not touch, the presenting part is not engaged

Figure 3. A. Footling presentation (a type of breech); B. Shoulder presentation;

C. Breech presentation (Source: https://www.repropedia.org; Williams Obstetrics,
24th edition).
 Fontanelles
 Sagittal suture in the midline is used as the reference
 Anterior fontanelle
 Diamond shape
 Closes at 18 months and becomes the bregma
 Posterior fontanelle
 Triangular shape
 Closes at 12 months and becomes the lambda

Ruptured Membranes
 Inspected with the use of a speculum
 Pooling in the fornix (amniotic bag rupture)
 accumulation of amniotic fluid
Figure 1. Leopold Maneuvers. (A) Fundal Grip, (B) Umbilical Grip, (C) Pawlick’s  Fluid, which has accumulated in the posterior fornix, indicating
Grip, (D) Pelvic Grip. (Cunningham et al., 2014) the integrity of the membranes whether they are ruptured or not.
 The pH of amniotic fluid is ≥6.5.
C. VAGINAL EXAMINATION  Normal vaginal pH ranges from 4.5-5.5.
 Can get a lot of information by vaginal examination  Arborization or ferning
 Note the discharge:  Presence of fern-like, salt-like crystals in the amniotic fluid
 Watery (seen under microscopes) (Figure 4)
 Bloody (scanty or profuse bleeding)  Due to high levels of estrogen: increases salt content found in
 If profuse, may be an indication of an abnormally located the amniotic fluid. − Salt content induces crystallization
placenta.
 Do not perform vaginal examination as it may induce further
bleeding, possibly killing both the fetus and the mother
 Contact with anal region is avoided.
 This may deliver feces, and thus microbes, into the vagina.
 Number of internal examinations
 Determined by how far the patient is in labor.
 No standard number of vaginal examination is required

Presenting part
 Nature of presentation
 Vertex Figure 4. Cervical mucus arborization or ferning (Source: Williams Obstetrics,
 Face 24th edition).
 Footling or breaching
 Transverse line  Ruptured membranes are significant for:
 Position for presenting part  Cord prolapse
 Occiput of the vertex presentation  when the umbilical cord comes ahead of the fetal head
 Face for the face presentation  It can get in the way of the delivery of the baby
 Legs for the footling presentation  If the cord is constricted, it can cause hypoxia in the baby
 Shoulder if the baby is in the transverse line because of inadequate blood supply
 Sacrum for the breech  Impending labor
 Infection of both mother and fetus (if > 24hrs)
 Vaginal flora can go up to the uterus
 Can lead to sepsis and death

Cervical Effacement and Labor

 Progressive shortening of cervical canal during labor
 Before labor: length of cervix is around 3 cm
 Close to labor: cervix is almost paper-thin.
 Dilatation: opening of opening of cervix
 Effacement
 loss of cervical canal due to thinning of the lips of the cervix
 shortening
 Upon examination, a cervical thickness of 3 cm is either
Figure 2. Different longitudinal positions (first and last is the vertex and face
beginning effacement or hardly effaced, while that of 1.5 cm is
position respectively) (Source: Williams Obstetrics, 24th edition) 50% effaced.

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 Figure 8. Cervical Stations. (Baby Center, 2013)

Clinical Pelvimetry and Pelvic Architecture

 Estimating pelvic capacity gives one an idea of the probability that
the baby will be delivered normally or not.
 Clinical estimation: you need to approximate the likelihood that the
mother will deliver successfully or vaginally
 Need knowledge of cervical planes (Inlet, Midpelvis, Outlet)
 Inlet
 Level: linea terminalis
 Continuous oblique ridge consisting of the arcuate line, pectin
pubis, and pubic crest
 Diagonal conjugate: at least 11.5 cm
 Only clinical diameter that can be estimated
 Internal examination: Contact between tip of middle finger (9
cm distance between knuckle and tip of finger) with sacral
promontory indicates inadequacy of the inlet; because its
Figure 5. Cervical effacement and dilatation (Source: McKesson Health minimum length should be 11.5 cm (this is the diagonal
Solutions) conjugate). Normally it is not accessible
 Midpelvis
Position of the Cervix  Sacral curvature
 Not in labor: directed posteriorly (directed towards the rectum)  Should be deep and well-curved
 True labor: directed anteriorly, facing the vaginal wall  Scaro-sciatic notch
 2 fingers should be able to fit into it and depress it
 Ischial spines
 Must be 10 cm
 Should not be able to appreciate since it will narrow the canal
sidewalk
 Should not be protuberant if it is too sharp, the birth canal will
make pelvic capacity smaller

Table 1. Adequacy cervical midpelvis structures for childbirth

Area/Structures
Sacral curvature
Figure 6. Normal Cervix directed towards the rectum (Source: Sacro-sciatic notch
http://women.texaschildrens.org).
Ischial spines (Narrowest portion
of the pelvis for childbirth)
Pelvic sidewalls
 Outlet
 sub pubic arch at least 90 degrees
 bituberous diameter
Figure 7. Cervix in labor (Source: https://myhealth.alberta.ca)  mobility of coccyx
Adequate if
Well-curved
Can admit the breadth of 2
fingers
Distance between 2 ischial spines
is at least 10 cm (can
accommodate fetal biparietal
diameter of 9.5 cm)
Not converging (measured by
sweeping your fingers on each
side to assess if walls are parallel
or converging)

Station Table 2. Adequacy cervical outlet structures for childbirth

 Landmark: Ischial spine (Station 0) Area/Structures Adequate if
 Level of the midpelvis Sub-pubic arch Angle is > 90 degrees
 Divided into fifths (more updated) Bi-tuberous diameter If a fist can fit between the two
 Older sources had stations divided by thirds. ischial tuberosities
 Stations are measured per cm labeled from -5 to +5. Coccyx Mobile (can be moved up and
down)
 Station +5: has the fetal head very near the introitus.
 Station 0: level of the mid-pelvis
 Recorded in a graph called partograph which shows the descent
curve and the dilatation curve

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  Moisturizers
 Intravenous fluids
 Seldom necessary until analgesia
 60-120 mL/hour

F. LABORATORY EXAMINATIONS
 For possible comparison after delivery
 Hemoglobin
 Hematocrit
 Urinalysis
 Blood typing
Figure 9. Measurements using the sub-pubic arch and the bituberous diameter  Important in case of hemorrhagic outcome
(Source: https://web.duke.edu)  Levels could have changed from pre-natal examination until the
admission

G. POSITION DURING LABOR

 Lying on their back
 Can squat, kneel

Figure 10. Cervical Planes (Source: Pineda, 2017) Figure 11. Lithotomy: usual position in a lying-in/birthing facility

D. MONITORING THE FETUS

 Success of fetal delivery is dependent on fetal size relative to pelvic
size

Methods of Estimating Fetal Weight

 Johnson’s rule
 Weight (g) = (FH (cm) – n) x 155
 Where
 W = fetal weight
 FH = fundic height
 n = 12, if vertex is above ischial spines
 n = 11, if below the ischial spines
 Palmar method
 500 grams/palmar surface
 Example: It takes 8 palmar surfaces to cover the abdomen, the
Figure 12. Other labor positions used when giving birth at home
weight of the baby using the palmar method would be (500 x 8) =
4000 grams
 The goal should be the comfort of the mother
 Fundic Height (FH) + Station x 100 = weight in grams
H. BLADDER FUNCTION
Monitoring Contractions
 Avoid distention
 When you are in the lying-in clinic, the contractions are monitored
manually/by the putting the palm lightly over fundus  Bladder sits right under the head of the fetus
 Check:  Distention during labor may injure bladder walls and eventually
lead to urinary bladder dysfunction
 Duration: from start of stiffening of the fundus until it softens
again  Encourage voiding
 Intensity  This minimizes the need to use instrumentation to void the urine
 Strong contractions if fundus feels like one’s nose or forehead
 Mild contractions if fundus feels like one’s lips I. ANALGESIA
 Interval: length from one contraction to another  Given depending on need and desire of parturient or the mother’s
pain threshold
Monitoring Fetal Heart Tones  It is recommended for the mothers to have a companion during
 Check fetal heart rate after a contraction delivery since this decreases the need for analgesia
 Fetal heart rate is expected to be low during contractions
 Normal range is 110-160 bpm J. AMNIOTOMY
 Low risk: every 30 minutes  Procedure that artificially ruptures the bag of water
 High risk: every 15 minutes  Must be done between contractions
 Amniotome
E. ORAL INTAKE  a puncturing instrument to check the character, color, thickness,
 Fully awake parturient: give easily digestible food to avoid aspiration and consistency of amniotic fluid
and vomiting because she might be anesthetized  Preferably, artificial rupture of the membrane is withheld until it
 For low-risk mothers only spontaneously ruptures.
 Easily digestible food  Benefits
 Sips of clear liquids  Can improve speed of labor since this releases prostaglandins
which induce contractions
 Ice chips
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  Done when labor is starting to lag since rupturing the
membrane can help hasten the course of labor minimally
 Check the character when fetus is showing signs of jeopardy

Stage 1 Summary: ADMIT

 Admit
 Diet
 Monitoring contractions and fetal heart tones
 Intravenous fluids
 Therapeutic measures in the form of analgesia or anesthesia

III. MANAGEMENT: STAGE 2 OF LABOR

 Full cervical dilatation to fetal expulsion
Figure 14. Median and Mediolateral Episiotomy (Trans 2020)
A. POSITION IN LABOR
 Lithotomy Table 1. Median cut vs. Mediolateral cut
 Etymology: “litho” = stone; “tomy” = to remove Median Cut Mediolateral Cut
 Usual position ideal for giving birth Less bloody More bloody
 Position assumed by patients when urethral or bladder stone is Easier to repair More difficult to repair
to be removed (Trans 2020) Rare faulty healing (improved Long-term discomfort
 Patients can squat, lean on pillows, or partially supported by healing)
partner Minimal pain More painful after delivery
 Idea is to provide ample space for the expulsion of the baby from Less dyspareunia*
mother’s womb in a comfortable position Rectal extension** Less likely to involve the anal
sphincter and rectum
*painful sexual intercourse
**can cause fecal incontinence or a recto-vaginal fistula
C ***Advantages are italicized

E. DELIVERY
Delivery of the Head
 Crowning
A B  Largest head diameter encircled by vulvar ring
 Needs assistance to make sure the head popping out does not
cause lacerations on mother’s pelvic floor
Figure 13. Birthing Positions (Pineda, 2018)  Assisted using Ritgen Maneuver
Lithotomy (A), squat (B), leaning on pillows (C)
 Involves the manual control of the delivery of the head
 One hand is wrapped in a towel, the other hand on the
B. MATERNAL EXPULSIVE EFFORTS occiput
 Spontaneous  Following the contractions, baby is pushed in the direction of
 There is a reflex that triggers the urge to push the coccyx towards the fetal chin
 Mother will be forced to push (pag-ire) unless anesthesia is  Exit of the head is controlled through the occiput facilitating
present the movement of extension preventing perineal trauma to the
 Reflexive urge brought about by the impingement of the head on mother
rectal area (Trans 2020)
 Push during contraction
 Mother is coached to gather enough air then hold her breath
before pushing with all her might
 effectively increase the intra-abdominal pressure and contract
the muscles facilitating faster expulsion of the baby

C. MONITORING FETAL HEART TONES

 Low risk: check every 15 minutes
 High risk: check every 5 minutes
 Fetal monitor can be used to read tracings of fetal heart tones or Figure 15. Ritgen Maneuver (Pineda, 2018)
use the stethoscope
Nice to know:  Delivery can also be spontaneous
“Hemorrhoid is one of the common findings in pregnant patients
because of the eversion on the big vessels.” (Pineda, 2018)

D. EPISIOTOMY
 Incision of the pudendum to widen opening for the successful
delivery (especially during nullipara)
 Done if the baby is too large for the opening and to shorten the
course of labor
 Done for women with too short frenulum of labia minora (fourchette)
 Can be:
 Median cut
 done by those who have proper training in repairing the
rectum
 Mediolateral cut
 Done at about 45 degrees
Figure 16. Spontaneous Delivery (Pineda, 2018)

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Clearing of the Nasopharynx  Provide oxytocin to the mother (intramuscularly) to favor uterine
 Clearing of the Nasopharynx (i.e. suctioning the nose of the baby to contraction
stimulate breathing) is NO LONGER done  Constricts blood vessels
 Replaced by “Unang Yakap” protocol  Lessening postpartum hemorrhage
 Wiping of the face quickly should be done instead  Keep the mother and baby in uninterrupted skin-to-skin contact
(SSC)
 Provide support for the initiation of breastfeeding
Delivery of the Shoulders
 Direction: DOWNWARD then UPWARD
Special Population
 When the head does not come out rapidly, delivery is assisted by
pulling the sides of the neck
 Patients who have difficulty giving birth vaginally due to contractures
 Pulled downward, delivering the anterior shoulder
 Female Genital Mutilation
 Then, upward to deliver the posterior shoulder
 Warts
 Not necessary to perform if the baby come out soon after
 Prior Pelvic Reconstructive Surgery
 e.g. tightening of perineum, repairing of muscles prior to
approximation of pre-pregnant musculature of the vaginal floor
 Anomalous Fetuses

IV. MANAGEMENT: STAGE 3 OF LABOR

 Fetal expulsion to placental separation and expulsion
 After delivery:
 Uterine size becomes markedly smaller causing the constriction
of the placenta
 Blood forms between the placenta and uterine wall, which forms
the basis for placental separation

Signs of Placental Separation

 Uterus becomes globular
 Sudden gush of blood
 Uterus rises in the abdomen
 Umbilical cord lengthens within 1-3 minutes after the baby comes
out

Figure 17. Delivery of the Shoulders (Pineda, 2018)

Delivery of the Whole Fetus

 Grasp the ankles
 Slide hand down the back of the baby then grasp the ankles
 Put a finger in between for a better grasp to prevent the baby
from falling (newborn babies can be oily and slippery)
 Call out the time of delivery

Unang Yakap (DOH Protocol)

 Focuses on newborn care to the vulnerable infant life within the first
week (in accordance to MDG 4 and 5)
 Steps:
 Wipe baby with dry towel
 Vernix is not completely wiped off
 to stimulate breathing and prevent hypothermia
 Wait for cord pulsations to stop before clamping the umbilical
cord Figure 19. Expulsion of the Placenta (Trans 2020)
 80 cc of blood gives about 50 mg more iron, prevents the
occurrence of anemia “Dirty” Duncan Mechanism
 Clamp 2 and 5 cm from abdomen, then cut in between two  Starts from periphery (one edge of placenta) and is rough and red
clamps looking
 Placenta descends sideways, maternal surface appears first
 Bloodier than Schultze mechanism and frequently followed by
retained fragments of the fetal membrane
“Shiny” Schultze Mechanism
 Capsule-like, inverted umbrella showing a glistening and shiny fetal
side as the fetal membrane appear at the introitus (opening leading
to vaginal canal)
 Blood from placental side pours into the inverted sac, not
escaping until placental extrusion

Figure 18. Nuchal cord (if there is) should be clamped immediately to prevent
more complications (Pineda, 2018)

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 Repair of Episiotomy/Laceration
 Repair of episiotomy
 Median episiotomy repair is done in layers: vaginal mucosa,
muscle, skin
 Lacerations are categorized by degree (summarized below)

Table 2. Degrees of Laceration

LACERATION
Degree Description
First Degree Smallest or most simple
episiotomy
Extending only through the
vaginal mucosa
Does not involve underlying
tissues
Fourchette, perineal skin, vaginal
skin
Second Degree Most common type
Figure 20. Schultze Mechanism (top) vs. Duncan Mechanism (below) Extends through vaginal mucosa
(http://media.atitesting.com/RM/05_MNB/Media_01/RM_MNB_CH11_schultze_di and into submucosal tissues but
rty_duncan_placenta/index.html) does not involve rectal sphincter
or mucosa
Manual Removal of the Placenta Fascia, muscles of perineal body
 Some mothers require manual removal of the placenta but not the anal sphincter
 Manually remove if it has not separated within 30 minutes after Third Degree Involves vaginal mucosa,
delivery submucosal tissues, and a partial
 Indications for manual removal is dependent on: or complete transection of anal
 Sudden occurrence of hemorrhage but the placenta gives no sphincter muscle
indication of delivering Includes rectal sphincter
 This might mean a partial separation Fourth Degree Most severe type
 Hemorrhage after birth of the placenta Extends up to the rectal mucosa
 Missing placental fragments, membranes or a cotyledon upon Includes incision of vaginal
examination of placenta mucosa, submucosal tissues, and
 Possibly indicate retained tissue within uterus anal sphincter, and it also
 Imagine checking if there is a missing portion in the patty of involves the lining of the rectum
your Big Mac™ when cooked (eeew)

Uterine Inversion V. “FOURTH STAGE OF LABOR”

 Extra care sure be observed to prevent too much traction that might  The hour immediately after delivery – it is very important that this
lead to uterine inversion must be observed carefully
 Happens when obstetrician pulls too soon and the placenta has  Gentle uterine massage and ice packs are placed on the abdomen
not yet separated hypogastric to stimulate contractions
 Might cause death of mother  Must check for:
 Excessive bleeding
 Maternal vital signs
 Bladder
 Clots in the uterine cavity, which should be checked internally
 Hematomas (accumulation of blood beneath the skin) in the
vaginal or lower genital tract area
 Note: Bladder and clots in uterine cavity must be evacuated, and
you must observe patient for hematomas since they might not be
readily apparent
 Atony
 Loss of tone in uterine musculature
 Uterus does not contract as efficiently
 May lead to excessive bleeding or postpartum hemorrhage

QUICK REVIEW
SUMMARY OF TERMS
Figure 21. Manual Separation of Placenta (Pineda, 2018)
 Labor: Regular uterine contractions that bring about demonstrable
dilation and effacement of the cervix
Active Management of the 3rd Stage of Labor  Onset of Labor: Painful uterine contractions +
 Hemostasis  Ruptured membranes
 Vasoconstriction of placental site  Bloody show
 Uterotonics  Complete cervical effacement
 Oxytocin  True labor vs. False labor
 Anti-diuretic  Leopold maneuvers
 Ergonovine maleate  Leopold maneuver 1 (Fundal Grip)
 For contraction of uterus in the treatment or prevention of  Leopold Maneuver 2 (Umbilical Grip)
postpartum or post-abortion hemorrhage caused by uterine  Leopold Maneuver 3 (Pawlick’s Grip)
atony  Leopold Maneuver 4 (Pelvic Grip)
 Methylergonovine maleate

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 Stages of Labor Answers: 1A, 2E, 3B, 4A, 5B
 Stage 1 (ADMIT)
 Admit REFERENCES
 Diet (1) ASMPH Batch 2022. 2017. Trans Format.
 Monitor (2) Cunningham, F.G., Leveno, K.J., Bloom, S.L., Spong, C.Y., Dashe,
 Intravenous Fluids J.S., Hoffman, B.L., Casey, B.M., Sheffield, J.S. (2014). Williams
 Therapeutic measures obstetrics (24th ed.)
 Stage 2 (3) Lennoxa, C.E., Kwastb, B.E., & Farleyc, T.M.M. (1998). Breech
 Cervix is fully dilated labor on the WHO partograph. International Journal of Gynecology
 Baby is ready to be delivered & Obstetrics, 62(2), 117-127.
 Maternal expulsive efforts
 Spontaneous
 Push during contraction
 Episiotomy
 Johnson’s rule - Weight (g) = FH (cm) – n x 155
 Palmar method - 500 grams/palmar surface
 Stage 3
 Fetal expulsion to placental separation and expulsion
 “Dirty” Duncan Mechanism
 “Shiny” Schultze Mechanism
 Manual Removal of the Placenta
 Lacerations
 First Degree – most simple, until vaginal mucosa
 Second Degree – most common, until submucosal tissues
but not anal sphincter
 Third Degree – involves partial/complete transection of
anal sphincter muscle
 Fourth Degree – most severe, until rectal mucosa
 “Fourth Stage of Labor”
 The four immediately after delivery
 Gentle uterine massage and ice packs are placed on the
hypogastric to stimulate contractions

REVIEW QUESTIONS
1. The following characterize False labor
a. No cervical dilation
b. Not relieved by sedation
c. Shortened contraction intervals
d. Discomfort in the upper abdomen

2. You must check for the following during the fourth stage of labor:
a. Excessive bleeding
b. Maternal vital signs
c. Clots in the vaginal or lower genital tract area
d. AOTA
e. A and B only

3. Aling Luzviminda Jr. had a fourth degree laceration after an

episiotomy was done during her delivery. Which one of the following
does not describe a fourth degree laceration?
a. The most severe out of all the lacerations
b. Extends until the anal sphincter only
c. Is very very very very very painful
d. AOTA

4. A puncturing instrument to check the character, color, thickness,

and consistency of amniotic fluid
a. Amniotome
b. Amnion
c. Aminoty
d. Amen

5. Using the Johnson’s rule, if the fundic length of a baby with a vertex
above the ischial spines is 35 cm, what is the weight of the baby?
a. 3720 g
b. 3565 g
c. 3875 g
d. 1550 g

Reproductive 11.23b: Conduct of Normal Labor and Delivery 8 of 8