Procedural Manual For Delivery Cases

Symptoms and Signs of Labor

• Initial Symptoms of Imminent Labor:
• Descent of the Fundus: By week 36, the fundus of the uterus reaches the rib cage, then it drops before labor to a level of 32-34 weeks, due to the head of the baby being engaged in the true pelvis. The mother will feel easier breathing and less pressure in the stomach, but she will experience symptoms of pressure on the lower part of the body, such as difficulty moving and pain in the back, abdomen, and thighs.
• Frequent Urination: This occurs because the baby's head presses on the bladder, reducing its capacity and requiring frequent emptying.
• False Labor Pains: These are irregular contractions that the mother feels in the lower abdomen but do not affect the dilation of the cervix.
• Shortened Cervix: This occurs due to uterine contractions (true labor pains)

Stages of Labor:

1. First Stage: Begins with true uterine contractions and ends with full dilation of the cervix.
2. Second Stage: Begins with full dilation of the cervix and ends with the birth of the baby.
3. Third Stage: Begins after the baby is born and ends with the delivery of the placenta.
4. Fourth Stage: Lasts for about two hours after the delivery of the placenta, involving post-birth monitoring.

First Stage of Labor:

The first stage of labor begins with the onset of real labor pains and lasts until the cervix is fully dilated (10 cm).

• Real labor pains: These are uterine contractions that cause the cervix to dilate and help push the baby through the birth canal.
• Initially, contractions occur at long intervals (every 30 minutes), but the time between each contraction shortens as labor progresses. Contractions last around 45 seconds, starting mildly and increasing in intensity towards the end.

Nursing Care During the First Stage:

• Preparation of the delivery room.
• Assessment of the mother's condition:
• Taking a history of the pregnancy and previous births.
• Ask the mother about the onset and frequency of labor pains (regular, felt in the lower abdomen and back).
• Check for signs of early labor, such as the passage of mucus with blood (bloody show).
• Ask if the water has broken (amniotic sac rupture).
• Inquire about the mother's sleep, rest, and food intake in the last 6 hours.
• Assess for any pregnancy complications like preeclampsia, anemia, diabetes, etc.
• Physical examination:
• General assessment: Check vital signs, edema, blood pressure, and perform a urine test.
• Abdominal examination: Assess the shape, size, and any past surgeries or infections.
• Fetal heartbeat: Normal fetal heart rate is 120-160 beats per minute.
• Preparation for delivery:
• Ensure the mother is clean, bladder is empty, and she is resting.
• If the mother is in the early stages, she may have light drinks or glucose IV for hydration.

Second Stage of Labor:

The second stage begins when the cervix is fully dilated and ends with the birth of the baby.

• Signs of the second stage:
• Involuntary pushing or bearing down.
• Increase in the amount of bloody show.
• Rupture of the amniotic sac.
• Increased breathlessness.
• Appearance of the perineum and anus.
• Sweating on the neck, forehead, and face.
• The mother's urge to urinate or defecate.
• The baby’s head begins to show (crowning).
• Mechanics of labor: This involves the baby adjusting to the shape of the pelvis and birth canal. The steps include:

• The baby descending into the pelvis.
• Flexion and rotation of the baby’s head.
• Delivery of the head, followed by the rest of the body.
• Nursing care during the second stage:

• Help the mother into the delivery room, change into a gown.
• Prepare the delivery room and help the mother get into a comfortable position, usually on her back with legs in stirrups.
• Evaluation: Monitor the baby’s heart rate every 5 minutes between contractions, check the mother’s pulse, observe the amniotic fluid color, empty the bladder, and assist with breathing exercises.
• Preventing perineal tears:
• Support the perineum during contractions to prevent tearing.
• Guide the mother to breathe and not push too hard during crowning.
• Check for umbilical cord entanglement around the baby’s neck.

Third Stage of Labor:

This stage begins after the baby’s birth and ends with the delivery of the placenta.

• Signs of placenta detachment:
• Uterus becomes firm and easily movable.
• The top of the uterus rises and bulges due to the placenta.
• A sudden gush of blood when the placenta detaches.
• The umbilical cord lengthens.
• Nursing care during the third stage:
• Administer oxytocin or methylergonovine as per the doctor’s instructions.
• Monitor for signs of placenta separation.
• Gently pull the umbilical cord while massaging the uterus to help deliver the placenta.
• Inspect the placenta to ensure complete delivery.
• Monitor uterine tone, check for any vaginal tears, and apply antiseptic to the genital area.

Fourth Stage of Labor:

This stage lasts for two hours after the placenta is delivered and is critical for monitoring postpartum bleeding.

• Nursing care during the fourth stage:
• Monitor vital signs every 15 minutes during the first hour and every 30 minutes during the second hour.
• Perform uterine massage to prevent hemorrhage.
• Monitor for vaginal bleeding every 10 minutes.
• Encourage the mother to void regularly (full bladder can hinder uterine contractions).
• Ensure the mother rests, maintains hygiene, and begins breastfeeding to encourage uterine contractions.
• Monitoring complications:
• For the mother: Excessive bleeding (more than 500 mL), difficulty urinating, seizures, or pain in the genital area.
• For the baby: Difficulty breathing, weak pulse, or low birth weight.