CARE OF A WOMAN

DURING THE FIRST

STAGE OF LABOR
CONCEPTS:
1. Labor should begin on its own, not be
artificially induced
2. Women should be able to move about
freely throughout labor, not be confined
to bed
3. Women should receive continuous
support during labor
4. No interventions such as intravenous
fluids should be used routinely
5. Women should be allowed to assume a
non-supine position for birth
6. Mother and baby should be housed
together after the birth, with unlimited
opportunity for breastfeeding.
Management:
1. Respect contraction time
2. Promote change of position
 Reassure woman that she may move about as needed
 When rupture of membranes occur, women should lie on
her side until she has been checked
1. Promote voiding and provide bladder care
 Full bladder can impede fetal descent
 Encourage woman to void every 2 – 4 hours
 If she cannot void, she may need to be catheterized
4. Halt/prevent hyperventilation
 Have a paper bag nearby
 Teach proper breathing techniques
4. Offer support
 Toalleviate anxiety
4. Respect and promote the support
person’s activities
5. Support woman’s pain management
effort
8. Provide comfort caused by decreased
water intake
 Apply cream to lips or suggest sucking on
hard candy or ice chips
 Offer isotonic sports drinks if possible
 IV glucose solution as prescribed
Amniotomy
 Artificial rupturing of membarnes
 Done if membrane does not rupture
spontaneously
 Patient’s cervix must be dilated at least
3 cm
 Always measure the FHR immediately
after the rupture of membranes
CARE OF A WOMAN DURING THE
SECOND STAGE OF LABOR
PREPARING THE PLACE OF
BIRTH
 MULTIPARA
 Prepare equipment when the cervix has
dilated to 7 – 9 cm
 PRIMIPARA
 Prepare equipment when the has crowned
 Make sure that drapes and materials
used for birth are sterile
 Prepare newborn care area
POSITIONING FOR BIRTH
 Lithotomy position
 Position woman into the table stirrups while
the physician is scrubbing and donning a
sterile mask, gown, and gloves
 Raise both legs at the same time
 Strap legs snugly but no too tight
 Pad the stirrups to prevent thromboplebitis
 Head part may be elevatedto promote
effective pushing
 Make sure that there is always someone at
the foot of the table so that if birth should
occur precipitously, the infant will not fall and
be injured
 Lateral/ sim’s position
 Dorsal recumbent position
 Semisitting position
 Squatting position
 standing
Promoting Effective Second
Stage Pushing
 Woman should push with contractions
and rest between them
 Tell patient to prevent holding her
breath during pushing. Urge her to
breathe out during a pushing effort.
 For multipara, ask patient to pant with
contractions
Perineal Cleaning
 Clean perineum with a warmed
antiseptic, and then rinse with a
designated solution before birth.
 Always clean from the vagina outward
 If the patient defecates, clean/sponge
the area as it occurs to prevent
contamination of the birth cana (from
front to back)
EPISIOTOMY
 A surgical incision of the perineum that is
made both to prevent tearing of the
perineum and to release pressure on the
fetal head with birth
 Advantage:
 Substitutes a clean cut for a ragged tear
 Minimizes pressure on the fetal head

 Shorten the last portion of the second stage of

labor
 done without anesthesia
 Types:
 Midline episiotomy
 Advantages:
 Heals easily
 Cause less blood loss
 Less postpartal discomfort
 Mediolateral episiotomy
 Advantage:
 If tearing occurs beyond the incision, it will be
away from the rectum
BIRTH
 RITGEN’S MANEUVER
 As soon as the head of the fetus is
prominent at the vaginal opening, place a
sterile towel over the rectum and press
forward on the fetal chin while the other
had is press downward on the occiput
 Helps fetus achieve extension

 Do not apply pressure over the fundus

because uterine rupture may occur
 Suction out infant’s mouth immediately
after the birth of the baby’s head and
then check if there is a nuchal cord
 A child is considered born when the
whole body is born – this the time that it
should be noted and recorded as the
time of birth
CUTTING AND CLAMPING THE
CORD
 Baby is laid on the abdominal drape of the
mother while the cord is cut
 Best time to cut the cord:
 Depends on the physician or the midwife’s
preference
 Delay cutting until pulsation ceases and
maintaining the infant at uterine level
 Allows as much as 100 mL of blood to pass from
the placenta to the fetus
 Danger: delay in clamping could cause
overinfusion with placental blood  can cause
polycythemia and hyperbilirubinemia
 Cord is clamped with 2 kelly hemostats
placed 8 – 10 inches from the infant’s
umbilicus and then is cut between them
 Count the vessle cord to be certain that
3 are present
 Cutting the cord is part of the stimulus
that initiates a first breath.
CARE OF THE WOMAN DURING THE
THIRD AND FOURTH STAGES OF
LABOR
OXYTOCIN
 Given IM or IV or through IVF infusion
 IVF infusion: 20 – 30 units/L
 Increases uterine contractions
 Methylergonovine maleate
(methergine)
 Semisyntheticc derivative of ergonovine
 Produces strong and effective contractions
 Nursing Responsibilities:
 Give only as prescribed
 Be sure to obtain baseline blood pressure

 Document administration
Placental Delivery
 Through spontaneous delivery or manual
extraction
 Inspect completeness of placenta
 Weight: 1/6th weight of the infant
Perineal Repair
 Episiorrhapy
 Woman might need some type of
medication to make her comfortable
 Pudendal block
Immediate Postpartal Assessment and
Nursing Care
 Vital signs
 15minutes for one hour then according to
agency’s policy
 Palpate the fundus for size, consistency,
and position and observe the amount
and characteristics of the lochia
 Perform perineal care and apply perineal
pad
 Offer clean gown and warm blanket
 Motheroften experiences chill and shaking
sensation
NURSING CARE OF
THE POSTPARTAL
WOMAN AND FAMILY
Puerperium
 Postpartal Period
 Fourth trimester of pregnancy
 Refers to the 6-week period after
childbirth
PSYCHOLOGICAL CHANGES PF THE
POSTPARTAL PERIOD
Phases of Puerperium (Reva
Rubin)
A. TAKING-IN PHASE
 First 2 – 3 days
 Time of reflection for a woman
 Woman is largely passive and dependent
 Physical discomfort
 Uncertainty
 Extreme exhaustion
B. TAKING-HOLD PHASE
 Woman begins to initiate action
 Strong interest in caring for her child
 Give the woman brief demonstration of
baby care then allow her to care for her
child herself
C. LETTING-GO PHASE
 Woman finally defines her new role
 Woman faces the reality of motherhood
PHYSIOLOGICAL CHANGES OF THE
POSTPARTAL PERIOD
REPRODUCTIVE SYSTEM
CHANGES
 INVOLUTION
 Process whereby the reproductive organ
return to their nonpregnant state
 Changes in the uterus, cervix, vagina,
and perineum
The Uterus
 Two processes of uterine involution:
 area where the placenta was implanted is sealed
off
 Rapid contraction of uterus
 Organ is reduced to its approximate pregestational
size
 Immediately after birth uterus weighs 1000g
 End of first week uterus weighs 500 g
 After 6 weeks (involution has completed)
uterus weighs 50 g (prepregnant state)
Uterine Involution
 Immediately after birth uterus is at half-way
between umbilicus and the symphysis pubis
 First few hours – 24 hours fundus can be
palpated at the level of the umbilicus then
decreases 1 fingerbreadth per day
 9th – 10th day: uterus have already receded under
the pubic bone and is no longer palpable
 Causes of delayed involution
 Multiple fetuses
 Hydramnios

 Exhaustion from prolonged or difficult labor

 Grand multiparity

 Excessive analgesia
 First hour postpoartum is potentially the
most dangerous time for the woman
 Uterine atony
 Uterus becoms relaxed
 Patient will bleed very rapidly

 Afterpains
 Intermittentcramping after childbirth
 Due to contraction of the uterus

 Increase with breastfeeding

Lochia
 Uterine flow consisting of blood,
fragments of decidua, blood cells,
mucus, and some bacteria
 CHARACTERISTICS OF LOCHIA

TYPE OF COLOR DURATION COMPOSITION

LOCHIA
Lochia Rubra Red 1 – 3 days Blood, fragments
of decidua, and
mucus
Lochia Serosa Pink 3 – 10 days Blood, mucus, and
invading
leukocytes
Lochia alba White 10 – 14 days Largely mucus;
leuckocyte count
high
CERVIX
 By the end of 7 days, the external os is
narrowed to the size of a pencil opening
 Cervix becomes firm and nongravid
again
 External os now appears as slitlike or
stellate (star-shaped)
VAGINA
 Vaginal outlet will remain slightly
distended than before
 Let woman perform Kegel Exercises to
increase strength and tone of the vagina
Perineum
 Edema and generalized tenderness after
delvery
 Labia majora and labia minora typically
remain atrophic, never returning to their
prepregnant state
SYSTEMIC CHANGES
HORMONAL SYSTEM
 Decrease of pregnancy hormones due to
absence of placenta
URINARY SYSTEM
 Difficult voiding
 Transient loss of bladder tone
 No sensation of having to void
 Edema of the urethra
 Assess woman’s abdomen frequently
 Full
bladder is felt as hard or firm area just
above the symphysis pubis
 Overdistended bladder can cause non-
contraction of uterus
 Displaces the uterus to the side
 Extensive diuresis  to get rid of excess
fluid in the body
 Urine tends to contain more nitrogen
than normal
CIRCULATORY SYSTEM
 Blood volume has returned to its
prepregnancy level during the first to
second week postpartum
 Due to:
 Blood loss a tbirth
 Diuresis

 High level of plasma fibrinogen

 Protective measure against hemorrhage
 Increase risk of thrombus formation
 Leukocytosis
 Body’s defense against infection and an aid
to healing
 Varicosities will recede
 Spider angiomas will fade slightly
GASTROINTESTINAL
SYSTEM
 Digestion and absorption begin to be
active again
 Woman feels hungry and thirsty almost
immediately after delivery
 Bowel evacuation may be difficult due to
pain of episiotomy sutures or
hemorrhoids
INTEGUMENTARY SYSTEM
 Striae gravidarum still appears redenned
 Will lighten in the next 3 – 6 months
 Chloasma and linea nigra will disappear
in 6 weeks time
 If diastasis recti occur, the area will
appear slightly indented
 Abdominalexercises to strengthen
abdominal muscles
Vital Sign Changes
 Temperature
 Slight increase of temperature during the
first 24 hours of peurperium due to
dehydration during labor
 Temperature above 100.4F (38C) after 24
hours is abnormal  may be a sign of
postpartal infection
 Pulse
 Slightly slower than normal
 Due to increase stroke volume
 By end of first week, the pulse rate has
returned to normal
 Rapid and thready pulse during the
postpartal period is a possible sign of
hemorrhage
 Blood Pressure
 Reading above 140 mmHg systolic or 90
mmHg diastolic may indicate postpartal PIH
 Oxytocin administration can also cause
increase blood pressure
 Orthostatic hypotension
 Dizzinessthat occurs on standing
 Due to acute blood loss
 Prevention of orthostatic hypotension
 Advise patient to sit up slowly and “dangle” on
the side of her bed before attempting to walk
PROGRESSIVE CHANGES
 LACTATION
 Formation of breastmilk
 Colostrum is continually excreted for the
first 2 days postpartum
 Breasts tends to become full and tense or
tender as milk forms
 Primary Engorgement
 Feeling of tension in the breast on the third or
fourth day postpartum
 Fades as the infant begins effective sucking
and empties the breast of milk
 Milk production depends on:
 nipple stimulation
 the infant sucking at the breast
 use of breast pump
 ability of the milk to come forward in the breast
(let-down relfex)
Return of Menstrual Flow
 If woman is not breastfeeding 6 – 10
weeks after birth
 If breastfeeding  3 – 4 months
 Absence of lactation does not guarantee
that a woman will not conceive during
this time
POSTPARTUM ASSESSMENT
 B – BREAST
 U – UTERUS
 B – BLADDER
 B – BOWEL
 L – LOCHIA
 E – EPISIOTOMY
 H – HOMAN’S SIGN
 E – EMOTIONAL STATUS
Breasts
 Soft, firm, can be lumpy
 Secretion of Colostrum
 Engorgement
 Assessment of:
 Breasts
 Size, shape, color
 Engorgement
 Large and reddened with taut, shiny skin
 May feel hard, tense and painful
 Nipples
 Assess for a crack, fissure, presence of caked milk
 Nursing Responsibilities:
 Advise woman to use well-fitting bra to
support breast tissue
 Avoid unecessary manipulation of the
breast
Uterus
 Process of Involution
 Height
 First
Day = at Umbilicus
 Decreases 1 FB per Day
 Consistency
 Firm,Round, Smooth;
 Not “Boggy”
 Atony
 Retained placenta
 Presence of blood clots
 Distended bladder
 Location
 Midline
 Caution: Never palpate uterus without
supporting the lower uterine segment 
can cause uterine invertion
 How to keep uterus contracted:
 Massage in a gentle rotating motion
 Breastfeeding

 Let the patient void/catheterize patient

 Administration of oxytocin
 Assess uterus every 10 – 15 minutes
during the first hour after delivery
Bladder
 Often times will be catheterized during
labor and delivery
 Assess for Bladder Distention:
 Uterine Atony
 UTI

 Recatheterize in 6 hours if not voided 

if with Dr’s order
 Measure Urine Output
Bowel
 Assessment for Bowel Sounds
 Complaints of Gas Pains
 Usually has Stool 2-3 days post delivery
 May need medication for gas pains,
laxatives, stool softeners, enemas
Lochia
 Duration: 2 – 6 weeks
 Amount
 Estimateof Drainage
 Number of Pads
 Bleeding is excessive if perineal pad is soaked
within 60 minutes
 Color
 Rubra
 Serosa
 Alba
 Odor
 Presence of any clots
 Assess every 15 minutes for the first
hour
 Encourage women to change perineal
pads frequently
 Inform woman to avoid using tampons
until she returns for her postpartal
checkup to preven risk of infection
Episiotomy
 Assessment for:
 Hematomas

 Ecchymosis

 Edema

 Erythema

 IntactSuture Line
 Signs of Infection
Homan’s Sign
 Assessment for Thrombophlebitis
 Swelling

 Reddness

 Warmth

 Pain

 Unilateral Findings
 C/S Mother at Higher Risk
Emotional Status
 Can have Mood Swings

 Observing Bonding Behavior & Ability to

give Infant Care
 Rubin’s Phases
NURSING INTERVENTIONS DURING
POSTPARTAL STAGE
Provide Pain Relief for
Afterpains
 Assure woman that this is normal and
rarely lasts more than 3 days
 Give Ibuprofen or Acetaminophen as
ordered
 Do not place warm compress over the
abdomen  can cause uterine relaxation
Relieve Muscular Aches
 Give acitamenophen as prescribe
 Assess pain carefully
 Pain
in the calf when standing  suggests
thrombophlebitis
Give Episiotomy Care
 Assure woman that episiotomy pain does
not usually last more than 5 – 6 days
 Cortisone-based cream or sitz-bath can
reduce inflammation
 Explain to the woman that sutures are
made of absorbable material that will
not need to be removed, and usually
dissolve within 10 days
Promote Perineal Exercises
 Kegel Exercises
 Relievesperineal discomfort
 Improves circulation to the area

 Decreases edema

 Regain prepregnant muscle tone and form

Administer Hot and Cold
Therapy
 Ice pack to the perineum during the first
24 hours reduces perineal edema
 Wrapice first in a towel to decrease
thermal injury
 Ice pack after 24 hours is not advisable
 delay healing; use hot packs or moist
heat instead  increase blood flow to
the area
Perineal Care
 Should be done as part of daily bath and
after each voiding or bowel movement
 Let the patient perform perineal care
 Caution women not to flush the toilet
until she is standing upright
Promote Rest
 Give analgesics as prescribed
 To regain strength
Promote Adequate Fluid
Intake
 To prevent dehydration
 At least 3 – 4 8-oz glasses of fluid a day
Promote urinary Elimination
 A full bladder may interfere wtih
effective uterine contraction
 An overdistended bladder may damage
bladder function
 Encourage woman to walk to the
batroom and void at the end of the first
hour postpartum
 Stimulate voiding:
 Provide privacy
 Running water at the sink

 Offering woman a drink of water

 Pour warm tap water over the vulva

 Refer if patient has not voided 4 – 8

hours after birth
Prevent Constipation
 Early ambulation
 High roughage diet
 Adequate fluid intake
 Stool softener may be necessary
 If woman has not moved her bowels by
the third day a mild laxative may be
ordered
Prevent/Alleviate Breast
Engorgement
 Encourage breastfeeing
 Maintreatment for relief of tenderness and
soreness
 Warm compress or standing under a
warm show
 Wearing of bra with good support
 Oral analgesics may be needed
Promote Breast Hygiene
 Wash breast daily with clear water
 Soaps should be avoided  can cause
cracking and fissuring of the nipples
 Insert clean gauze squares or
commercial nursing pads in bra to
absorb moisture
Methods to Promote Uterine
Involution
 Lying on the abdomen gives support to
abdominal muscles and ids in involution
 Placea small pillow under the stomach to
avoid too much pressure on the breast
 Avoid knee-chest position until a
postpartum examination has revealed a
closed cervix
Sexual Activity
 Coitus may be resumed as soon as
lochia serosa has stopped  1 – 2 weeks
after birth