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Course: Maternity Nursing�Topic: Overview of the Labour and Birth Process

The Nurses International Community

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Module Goals

The learner will be able to:

Define labour and birth
Define the 4 stages of labour and delivery
List 5Ps of labour and delivery
Describe the evidence based practice on frequency of vaginal examination in labour
Explain use of partograph in labour and birth

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Labour and Birth

Labour and birth is a physiologic process by which the fetus, placenta and membranes are expelled through the birth canal
Labour and birth process varies in duration and in discomfort levels; It is different for every individual
All labour follows a basic pattern:

Contractions (labour pains) open the cervix
The woman pushes the baby out of the uterus through the dilated cervix and down through the vagina
The baby is born
The placenta (afterbirth) is delivered

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Labour

Labour is defined as the presence of regular uterine contractions with progressive cervical dilation and effacement
Braxton Hicks contractions may be mistaken as labour.

True labour contractions

Become regular and predictable
Felt in lower back that sweep around to the abdomen in a wave
Continue regardless of activity
Increase in duration, frequency, and intensity
Achieve cervical dilatation, effacement

False labour contractions

Remain irregular
Remain confined to abdomen
Often disappear with ambulation
Do not increase in duration, frequency, or intensity
Do not achieve cervical dilatation

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Stages of Labour and Delivery

Labour and birth are divided into 3 stages:

1st Stage: Begins with onset of labour and ends at full dilation of the cervix (about 10 cm)
2nd Stage: Begins after full dilation of the cervix and ends at birth of the baby
3rd Stage: Begins after delivery of the baby and ends at delivery of the placenta
4rth Stage: The first hour post placental delivery

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Factors Affecting the Process of Labour and Delivery: 5 P’s

Following factors must be carefully evaluated by the care provider during labour and delivery:

Passenger (fetus and placenta)
Passageway (birth canal)
Power (contractions)
Position (maternal)
Psychological (response of mother)

If there is an issue with any of these powers, labour will not proceed normally

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Passenger : Fetal Lie

Fetal lie is the relationship between the fetal and maternal dorsal columns (the longitudinal axis of the human body)

Longitudinal(vertical) lie: Fetal and maternal dorsal columns are parallel to each other; most common lie of fetus in labour
Transverse lie: Fetal dorsal column is positioned 90 degree with respect to that of mothers.
Oblique lie: Fetus may be in transition from vertical to a transverse lie.
Variable lie: Unstable fetal lie when head is unengaged and floating

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Passenger : Fetal Attitude

Fetal attitude is defined as the relation of various parts of the fetus to each other
Normal attitude is when fetus is in universal flexion
Extremely difficult to assess without the help of an ultrasound exam

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Passenger : Fetal Attitude

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Passenger : Fetal Presentation

Presentation is the lowermost structure of the fetus in the maternal pelvis
Cephalic presentation (head down):

Vertex presentation: well flexed head
Sinciput presentation: Incomplete flexion
Brow presentation: partially extended head
Face presentation: complete extension

Breech presentation (bottom down):

Frank breech: hip flexion and knee extension
Complete breech: flexion of hip and knee
Incomplete breech/footling breech: one or both hips and knees in partial or intermediate extension

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Reminder: Please refer to slide deck ‘Maternal physical assessment’ and ‘Fetal assessment’ for information on assessment of presentation.

Glossary:

· Vertex: part bounded by posterior fontanelle, the parietal eminences, and the anterior fontanelle. https://www.cartercenter.org/resources/pdfs/health/ephti/library/lecture_notes/nursing_students/ob-gyn-body.pdf

· Sinciput: Forehead

· Mentum: Chin

Fetal skull: (Obstetric and Gynecological Nursing, 2003)

· The largest structural part of the fetus, thus most difficult to deliver.

· Some adaptation between the skull and pelvis must take place during labour.

· Understanding landmarks and measurements of the fetal skull enables one to recognize normal presentation and positions and to facilitate delivery with the least possible trauma to mother and infant.

· Important landmarks of the fetal skull in a cephalic presentation:

o The occiput: lies between the foramen magnum and the posterior fontanelle. Below the occipital protuberance is the suboccipital region.

o The vertex: bounded by the posterior fontanelle, the parietal eminences, and the anterior fontanelle.

o The sinciput or brow: Extends from the anterior fontanelle and the coronal suture to the orbital ridges.

o The face: Extends from the orbital ridges, the root of the nose to the junctions of chin and neck. The point between the eyebrows is known as the glabella.

o Chin is termed mentum and is an important landmark.

As the bones grow in the fetal skull, they remain separated from each other by large areas of dense connective tissue, each of which is called a fontanelle (Image in the slide). The fontanelles are the soft spots on an infant’s head. They are important during birth because these areas allow the skull to change shape as it squeezes, also called moulding, through the birth canal. https://opentextbc.ca/anatomyandphysiology/chapter/7-5-embryonic-development-of-the-axial-skeleton/

According to The Global Library of Women’s Medicine (GLOWM), Presentations other than cephalic or breech in a singleton pregnancy require a cesarean delivery. Abnormal presentations occur more often in cases of multiple gestations, usually affecting the second twin. Vaginal delivery of a abnormally presenting second twin is possible. www.glowm.com

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Passenger : Cephalic and Breech Presentation

Vertex presentation

(favourable presentation)

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Case Study:

A woman who is 38 weeks pregnant, arrives at the clinic and is complaining of “labour pains” for the past 4 hours.

How would the nurse identify if the woman is in true labour?

What factors of labour and delivery would the nurse assess to determine if she was in true labour?

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How would the nurse identify if the woman is in true labour?

The nurse would identify that the woman is in true labour if the uterine contractions are:

regular and predictable
felt in the lower back that sweeps around to the abdomen in a wave
Continue regardless of activity
Increase in duration, frequency, and intensity
Achieve cervical dilatation

Note

It is important to ask the woman is she has any leaking of fluid from the vagina,which could indicate rupture of the amniotic membranes (water breaking).

Additional information that the nurse would want to know is if the woman has had a ‘bloody show.’ At term, this indicates that labour is eminent (within 72 hours)

What factors of labour and delivery would the nurse assess if she was in true labour?

Once it is identified that the woman is in true labour, the nurse would assess factors relating to the following:

Passenger (fetal lie, station)
Passageway (vaginal exam)
Power (strength and timing of contractions)
Position (fetal facing)
Psychological (response of mother)

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Passenger : Fetal Position

Relationship of the presenting part of fetus to the maternal pelvis
In case of the longitudinal lie with the vertex presentation, occiput of the fetal calvarium is the landmark used to describe position

Direct occiput anterior: occiput facing maternal pubic symphysis
Right or left occiput anterior: occiput between ischial spines and symphysis
Left or right occiput transverse: occiput halfway between the promontory of sacrum and the symphysis
Right or left posterior: occiput approaches the sacrum
Direct occiput posterior: occiput is straight down i.e facing sacrum or coccyx (causes intense feeling of back pain in labour)

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Maternal Pelvis

Pelvic inlet

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Passenger: Station (Internal Examination)

Station is described as the descent and engagement of fetal head in relation to pelvic cavity
Engagement: Vertex is engaged when biparietal diameter of the infant’s head is at the level of the pelvic inlet or lower
It is the essential part of every vaginal examination and is used to assess progress of labour

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Descent and Engagement of Fetal Head

(External Examination)

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Assessment of descent and engagement of head is assessed by feeling how many fifths of the head are palpable above the brim of the pelvis: (Bettercare/Maternal Care/ 8a. Skills Examination of the abdomen in labour)

· 5/5 of the head palpable means the whole head is above the inlet of the pelvis.

· 4/5 of the head palpable means that a small part of the head is below the brim of the pelvis and can be lifted out of the pelvis with a deep pelvic grip

· 3/5 of the head palpable means that the head cannot be lifted out of the pelvis. On doing a deep pelvic grip, fingers will move outwards from the neck of the fetus, then inwards before reaching the pelvic brim.

· 2/5 of the head palpable means that most of the head is below the pelvic brim, and on doing a deep pelvic grip, your fingers only splay outwards from the fetal neck to the pelvic brim.

It also means engagement has taken place and the possibility of disproportion at the pelvic inlet can be ruled out.

· 1/5 of the head palpable means that only the tip of the fetal head can be felt above the pelvic brim.

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Passageway

Passageway refers to parts of the birth canal and factors associated with them that affect labour and delivery

Bony pelvis
Cervical dilation
Cervical effacement

Bony Pelvis Types:

Gynecoid, Android, Anthropoid, and Platypelloid
Each type has a different capacity, obstetric significance, and resulting prognostic importance
The gynecoid and anthropoid are favourable for vaginal delivery, whereas the android and platypelloid are suboptimal

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Pelvis Types

Gynecoid pelvis.

A. Inlet view. B Lateral view. C. suppubic View

Android. pelvis.

A. Inlet view. B Lateral view. C. suppubic View

Anthropoid pelvis. A. Inlet view. B Lateral view. C. suppubic View

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Knowledge of the type of maternal pelvis is critical for proper monitoring of the labour process because the position of the presenting part goes through series of changes needed for the fetus to pass through the maternal pelvis.

Four major types of maternal pelvises and their characteristics are as follows: https://www.glowm.com/section_view/item/126

Gynecoid Pelvis:

A spacious and well-rounded posterior segment
An inlet with a slightly ovoid or round shape
A wide, well-rounded forepelvis (anterior segment)
A sacrosciatic notch of medium size
An average sacral inclination and curvature
A wide subpubic arch
Wide interspinous and intertuberous diameters
Bones ranging from medium to delicate in structure�Engagement in this type of pelvis occurs most frequently with the fetus in a transverse position, followed in frequency by the anterior and posterior positions.

Android pelvis

A wedge-shaped inlet
A narrow retropubic angle (anterior segment)
A flat, wide posterior segment
A narrow sacrosciatic notch
A forward sacral inclination
A narrow wedge-shaped “gothic” subpubic arch
Converging side walls, narrow interspinous and intertuberous diameters
Bones ranging from medium to heavy in structure�Engagement in this type of pelvis occurs most frequently with the fetus in a transverse position, followed in frequency by the posterior and anterior positions. The clinician should be alerted by this type of pelvis that the possibility of posterior positions exists.

Anthropoid pelvis

A long, narrow, oval-shaped inlet
A long, narrow, well-rounded anterior segment
A long, narrow posterior segment
A very wide, shallow sacrosciatic notch
A long, narrow sacrum with average inclination and curvature
A slightly narrow subpubic arch
Straight side walls with below-average interspinous and intertuberous diameters
Medium to delicate bones�Engagement in this type of pelvis occurs with the fetus in either an anterior or transverse position, but the anterior position appears to be more characteristic.

Platypelloid pelvis

A transverse, oval-shaped inlet
A very wide, round retropubic angle
A very wide, flat posterior segment
A narrow sacrosciatic notch
Average sacral inclination
A very wide subpubic arch
Straight side walls with very wide interspinous and intertuberous diameters
Bones ranging from medium to delicate in structure

Engagement in this type of pelvis will almost always occur with the fetus in a transverse position. Because of the flatness of the shape of this pelvis, the internal rotation of the vertex can be limited, causing a deep transverse arrest.

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Pelvis Types

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Passageway

Cervix dilation:

Opening of the cervix to allow the fetus through birth canal
Recorded in centimeters as the diameter of a circle
10 cm is considered complete dilation
Most important marker of how labour is progressing

Cervical effacement:

Involves cervical shortening as well as thinning
Estimated in percentages, from zero to 100%

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Power

Power during labour and delivery is described by

Primary - Involuntary uterine contractions

Strength of contraction is assessed by its duration and frequency and its ability to efface (thin out) and dilate the cervix

Secondary- Voluntary pushing or bearing down by mother

after cervix is “fully” dilated, typically 10cm

Manual assessment of contraction:

Place a hand on the abdomen
Feel when the uterus becomes hard (beginning contraction) and when it relaxes (end of contraction)
Record time between beginning of the contraction to the beginning of the next contraction

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Power

Important factors of uterine contractions during labour and birth process:

Adequate contraction: How long a contraction last?
Frequency of contraction: How often the contraction occur in given interval of time?
Effective contraction: Cervical dilation and descent progressing?

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According to Bettercare/Maternal Care/ Monitoring and managing the first stage of labour:

Uterine contractions may either be inadequate or ineffective causing poor progress of labour

Inadequate uterine contractions: Inadequate uterine contractions can be the cause of poor progress of labour. Such contractions:
lasts less than 40 seconds, and/or
there are fewer than 2 contractions per 10 minutes. *

Ineffective uterine contractions: The uterine contractions may be adequate but not effective, as poor progress can occur even in the presence of apparently good pain contractions (i.e 2 or more in 10 minutes with each contractions lasting 40 seconds or longer), without disproportion being present (i. e no moulding of the fetal skull). The problems of ineffective contractions occurs only in primigravidas.

Dysfunctional uterine contractions are diagnosed when the uterine contractions appear to be ineffective.

*According to the WHO 2017 Managing complications in pregnancy and childbirth,pg. S-82:

If contractions are inefficient (less than three contractions in 10 minutes, each lasting less than 40 seconds), suspect inadequate uterine activity.
If contractions are efficient (three or more contractions in 10 minutes, each lasting more than 40 seconds), suspect cephalopelvic disproportion, obstruction, malposition or malpresentation.

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Position (Maternal)

Maternal comfort and preferences is a priority when recommending positions for labour and delivery
Movement and upright positions advance ease of birth using gravity, increasing the strength of contractions, and helping to turn the baby to a favourable position
Women may squat, sit, kneel, stand, walk, sway, rock or even dance if she finds it relaxing
When lying down, choose lateral position with pillow between knees
Mother should not lie in supine position during labour and delivery

Compression of maternal inferior vena cava decreases blood supply to fetus by decreasing placental perfusion and may cause fetal distress

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Glossary:

Supine: Flat on the back

Maternal position affects the frequency and intensity of uterine contractions during labour
Caldeyro-Barcia and colleagues demonstrated that lateral positions were associated with more effective uterine contractions (i.e stronger intensity and lower frequency) than the supine position (lying on back)
there is evidence that lateral positions are associated with a higher cardiac output, decreased heart rate, and increased stroke volume compared with the supine position.
Several reports indicated that intrapartum ambulation may improve labour
Squatting has been advocated to increase the diameter of the pelvic outlet by as much as 2.0 cm, to increase the bearing down urge, to facilitate the delivery of the placenta, and to prevent supine hypotensive syndrome.
In additions standing, kneeling, squatting, and lateral positions have been associated with maintaining an intact perineum as a result of more even application of fetal head at the introitus, which distributes pressure across the perineum, rather than concentrating the pressure at a single point.

Harrington, L, Glob. libr. women's med.,(ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10127

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Maternal Positions During Labour and Delivery

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Case study:

A 39-week pregnant woman presents at the clinic complaining of labour pains. After establishing the woman was indeed in true labour, the nurse assesses for different aspects of the 5 P’s of labour and delivery through abdominal and vaginal examinations.

What aspects of passenger and passageway would the nurse assess?

Which positions would the nurse encourage the woman to be in during labour and delivery? Why?

Contact info: info@nursesinternational.org

What aspects of the passenger and passageway would the nurse assess?

The nurse would assess for following aspects of the passenger:

Fetal lie
Fetal attitude
Fetal presentation
Fetal position
Station for fetal descent and engagement

The nurse would assess for following aspects of the passageway:

Bony pelvis
Cervical dilation
Cervical effacement

Which positions would the nurse encourage the woman to be in during labour and delivery? and why?

The nurse would encourage the woman to be in any position she feels comfortable to be in except lying supine (flat on her back).

She would encourage her to stand, walk, sit, squat, sway, or even dance during labour.

Movement and upright positions advance ease of birth for reasons of gravity, increase the strength of contractions and help turn baby to a favorable position.

If the woman wants to rest, the nurse would encourage her to lie in a lateral position with pillow support between her knees.

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Labour and Delivery 5P’s: Psychological

(Response of Mother)

Maternal psychological and emotional state during labour affects the progress of labour, the outcome, and the experience of childbirth
According Bohren, et al. (2017), women who received continuous labour support:

Had shorter labours
Were more likely to give birth vaginally, had fewer caesarean, forceps or assisted vacuum births
Were less likely to use pain medications
Were more likely to be satisfied with their birth experiences

Provide emotional support to the labouring woman to reduce anxiety and fear

Source: Bohren et al. (2017)

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Vaginal Examination in Labour

Purpose of the vaginal exam during labour

Assess cervical dilation and effacement
Determine status of membranes (intact or not)
Determine presenting part, position, station
Check for prolapsed umbilical

Vaginal exams are contraindicated in certain circumstances
A vagina exam is deferred when:

Water has broken, unless it is late in labour or there is emergency
Presence of vaginal bleeding or infection

A pelvic exam may include a digital vaginal exam (using fingers) or using speculum to visualize the cervix

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Vaginal Exam - Preparation

Equipments needed for digital vaginal exam during labour:

Swabs
Tap water
Sterile gloves

Preparation of the patient for vaginal exam:
Explain the procedure and that it may be uncomfortable
Request the woman’s verbal/written consent for the procedure
Put her on lithotomy position
Vulva and perineum are swabbed with tap water or antiseptic per facility, i.e swabbing labia majora and groin on both sides then swabbing introitus keeping labia majora apart with thumb and forefinger

Antiseptic vaginal cream or sterile lubricant
Suitable instrument for rupturing the membranes (if need)

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Vaginal Exam: Vulva and Vagina

Examining vulva and vagina are important when the patient is first admitted
A speculum examination is done in case of suspected preterm or prelabour rupture of membranes.
While examining vulva observe for
Ulceration, condylomata, varices, and any perineal scarring or rigidity
While examining vagina, observe for

Vaginal discharge
Full rectum
Vaginal stricture or septum
Presentation or prolapse of umbilical cord

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Vaginal Exam: Cervix

Cervix is examined through digital examination
Measure length endocervical canal:

Distance between the internal os and the external os
Uneffaced cervix is approximately 3 cm long
When fully effaced, only a ring of thin cervix is palpated

Measure cervical dilatation:
Best measured by comparing the degree of separation of the fingers

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It may be difficult to feel the cervix if it is very thin, and the patient might be misdiagnosed as being fully dilated when she is not. It is easy to stretch the rim of the cervix, or pass the fingers through the cervix and feel it with the side of the fingers. Both result in the recording of dilation to be more than it really is. The correct method is to place the tips of the fingers on the edges of the cervix as shown in the slide above. (See text, According to Bettercare/Maternal Care/8b Skills; Vaginal examination in labour measurements are

· 1 cm is about the width of one finger

· 3 cm is the width of two fingers together

· 4 cm is when fingers are about 1 cm apart

· The widest stretch is about 7-8 cm. When dilatation is 8 cm a 1 cm rim of the cervix should be palpable all around the presenting part.

· at 9 cm a 0.5 cm rim should be felt all around or a 1cm rim on one side

(Royal College of Obstetrician and Gynaecologists- Dilatation (https://elearning.rcog.org.uk//easi-resource/maternal-and-fetal-assessment/examination/dilatation)

Always explain the procedure to the woman and share the results with her and her companion

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Vaginal Exam: Membranes and Liquor/Amniotic fluid

Spontaneous rupture of membrane (ROM) is obvious if there is fluid draining
Assess if the fluid is meconium stained, and note the time of ROM
Always feel for the presence of membranes overlying the presenting part

If the presenting part is high, it is quite easy to feel the intact membrane
If presenting part is well applied to the cervix, wait for a contraction when some fluid often flows to the front of the presenting part allowing membranes to be felt

**Assess if the umbilical cord is felt in front of presenting part

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Vaginal Exam: Presenting Part

Ask following question while assessing for the presenting part:

What is presenting part, e.g head, breech, or shoulder?
If the head is presenting, what is the presentation e.g occiput, brow, or face presentation?
What are the features of fetal attitude?
Is moulding present?

Face presentation

Occiput presentation

Brow presentation

Breech presentation

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According to Bettercare/Maternal Care/8b. Skill: Vaginal examination during labour:
The abdominal examination must precede the vaginal examination to determine the lie of the fetus and presenting part
If the presenting part is head, the number of fifths palpable above the pelvic brim must first be determined.

Features of an occiput presentation:

· In a well-flexed head, the posterior fontanelle is normally felt which is a small triangular space in contrast to the anterior fontanelle which is diamond-shaped.

· If the anterior fontanelle can be easily felt, the head is deflexed and the presenting part is the vault.

Features of a face presentation:

· On abdominal examination, the presenting part is the head that has not yet engaged.

· On vaginal examination:

o Instead of a firm skull, the presenting part is soft

o the gum margins distinguish the mouth from the anus (breech presentation)

o the cheekbones and mouth form a triangle

o The orbital ridges above the eyes can be felt

o The ears may be felt

Features of brow presentation:

· presenting part is high

· the anterior fontanelle is felt on one side of the pelvis, the root of the nose on the other side, and orbital ridges may be felt laterally

Features of breech presentation:

· On abdominal examination, the presenting part is the breech (soft and triangular) and the fetal head is ballotable in the fundus.

· On vaginal examination:

o instead of a firm skull, the presenting part is soft

o The anus does not have gum margins (face presentation)

o The anus and the ischial tuberosities form a straight line.

Features of shoulder presentation:

· On abdominal examination, the lie will be transverse or oblique.

· On vaginal examination

o quite easy to distinguish if the arm has prolapsed

o the shoulder is not always that easy to identify unless the arm can be felt.

o The presenting part is usually very high.

Determining the position of the presenting part:

Determined through a vaginal exam, the position is the relationship of a fixed point on the presenting part (i.e the point of reference or the denominator) to the symphysis pubis of the mother’s pelvis.

Point of references for different presentations:

· in vertex presentation - posterior fontanelle (the occiput)

· in face presentation - chin (mentum)

· in breech presentation - sacrum of the fetus

Moulding

Moulding is an overlapping of the fetal skull bones at the sagittal sutures which may occur during labour due to the head being compressed as it passes through the pelvis of the mother.

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Vaginal Exam: Assessing Pelvis

Assess size and shape of :

Pelvic inlet
Mid-pelvis
Pelvic outlet

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According to Bettercare/Maternal Care/8b. Skill: Vaginal examination during labour:

Step by step method of assessing pelvis:

Step 1 The sacrum

start with a sacral promontory and follow the curve of the sacrum down the midline

a. An adequate pelvis: The promontory cannot be easily palpated, the sacrum is well curved and the coccyx cannot be felt

b. A small pelvis: The promontory is easily palpated and prominent, the sacrum is straight, and the coccyx is prominent and/or fixed.

Step 2: The ischial spines and sacrospinous ligaments

Lateral to the mid sacrum, the sacrospinous ligaments can be felt. If these ligaments are followed laterally, the ischial spines can be palpated.

a. An adequate pelvis: 2 fingers can be placed on the sacrospinous ligaments (i.e. they are 3 cm or longer) and the spines are small and round.

b. A small pelvis: The ligaments allow less than 2 fingers and the spines are prominent and sharp.

Step 3: Retropubic area

With the palm facing upwards, put 2 examining fingers behind the symphysis pubis and then move them laterally to both sides:

a. An adequate pelvis: The retropubic area is flat

b. A small pelvis: The retropubic area is angulated.

Step 4: Subpubic angle and intertuberous diameter

Examining fingers are removed from the vagina and turned so that the palm faces upward, a third finger is held at the entrance of the vagina and the angle under the pubis is felt to measure the subpubic angle.

Then the intertuberous diameter is measured with the knuckles of a closed fist placed between the ischial tuberosities.

a. An adequate pelvis: The subpubic angle allows 3 fingers (i.e an angle of about 90 degrees) and the intertuberous diameter allows four knuckles.

b. A small pelvis: the subpubic angle allows only 2 fingers (i.e an angle of about 60 degrees) and the intertuberous diameter allows only three knuckles.

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Vaginal Exam: Assessing Pelvis

Lateral view of pelvis

The pelvic outlet

Brim of the pelvis

Contact info: info@nursesinternational.org

According to Bettercare/Maternal Care/8b. Skill: Vaginal examination during labour:

Step by step method of assessing pelvis:

Step 1 The sacrum

start with a sacral promontory and follow the curve of the sacrum down the midline

a. An adequate pelvis: The promontory cannot be easily palpated, the sacrum is well curved and the coccyx cannot be felt

b. A small pelvis: The promontory is easily palpated and prominent, the sacrum is straight, and the coccyx is prominent and/or fixed.

Step 2: The ischial spines and sacrospinous ligaments

Lateral to the mid sacrum, the sacrospinous ligaments can be felt. If these ligaments are followed laterally, the ischial spines can be palpated.

a. An adequate pelvis: 2 fingers can be placed on the sacrospinous ligaments (i.e. they are 3 cm or longer) and the spines are small and round.

b. A small pelvis: The ligaments allow less than 2 fingers and the spines are prominent and sharp.

Step 3: Retropubic area

With the palm facing upwards, put 2 examining fingers behind the symphysis pubis and then move them laterally to both sides:

a. An adequate pelvis: The retropubic area is flat

b. A small pelvis: The retropubic area is angulated.

Step 4: Subpubic angle and intertuberous diameter

Examining fingers are removed from the vagina and turned so that the palm faces upward, a third finger is held at the entrance of the vagina and the angle under the pubis is felt to measure the subpubic angle.

Then the intertuberous diameter is measured with the knuckles of a closed fist placed between the ischial tuberosities.

a. An adequate pelvis: The subpubic angle allows 3 fingers (i.e an angle of about 90 degrees) and the intertuberous diameter allows four knuckles.

b. A small pelvis: the subpubic angle allows only 2 fingers (i.e an angle of about 60 degrees) and the intertuberous diameter allows only three knuckles.

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Partograph

A graphical presentation of the progress of labour, and of fetal and maternal condition during labour
Helps to detect whether labour is is progressing normally or abnormally
Partograph charting must be started at the onset of true labour for all women in labour
Information assessed and recorded in partogram:

Condition mother
Condition of the fetus
Progress of labour
Intravenous fluid and drugs administered

Contact info: info@nursesinternational.org

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Case study:

A 39-week pregnant woman came to the clinic complaining of “labour pains.” After establishing the woman was indeed in true labour, the nurse assessed for different aspects of the 5 P’s of labour and delivery using abdominal and vaginal examinations.

What would the nurse do next after the assessment of 5 P’s?

How can nurse promote emotional comfort to the woman during labour?

Contact info: info@nursesinternational.org

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Red Flags

Always verify the type of incision performed on a woman’s uterus who has had a previous cesarean section
Midline (vertical) incision on the uterus requires that the patient not be delivered vaginally as it may cause a rupture in the uterus

The client must be delivered by cesarean section

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Cultural Considerations

Be sensitive to the labour practices associated with different cultures
Who does the patient want to be present during labour?
In some cultures, women are not permitted to have a male health care person as an attendant
Jehovah Witnesses do not accept blood transfusions

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Reference:

Assegid, M. (2003). Obstetric and Gynecological Nursing: Lecture notes for nursing students. In collabouration with The Ethiopia Public Health Training Initiatives, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education. Retrieved from: https://www.cartercenter.org/resources/pdfs/health/ephti/library/lecture_notes/nursing_students/ob-gyn-body.pdf

Bettercare. (n.d.). Maternal Care/8a. Skill: Examination of the abdomen in labour. Retrieved from: https://bettercare.co.za/learn/maternal-care/text/08a.html#8a-skills-examination-of-the-abdomen-in-labour

Contact info: info@nursesinternational.org

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Reference:

Bettercare. (n.d.). Maternal Care/ 8c. Skills: Recording observations on the partogram. Retrieved from: https://bettercare.co.za/learn/maternal-care/text/08c.html

Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2017, Issue 7. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub6. Retrieved from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003766.pub6/full

Contact info: info@nursesinternational.org

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Reference:

Harrington, Lisa. Normal labour and Delivery, Global Library of Women’s Medicine. (ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10127 Retrieved on 24 September 2020, from: https://www.glowm.com/section_view/item/127

Klein, S., Miller, S., & Thomson, F. (2020). A book for midwives: care for pregnancy, birth, and women’s health. California: Hesperian Health Guides. Retrieved from: https://en.hesperian.org/hhg/A_Book_for_Midwives:Care_for_the_mother_during_labor

Contact info: info@nursesinternational.org

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Reference:

López-Zeno, J. Presentation and Mechanisms of labour, Glob. libr. women's med.,(ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10126. Retrieved from: https://www.glowm.com/section_view/item/126

World Health Organization (2017). Managing complications in pregnancy and childbirth: a guide for midwives and doctors – 2nd ed. Geneva: Licence: CC BY-NC-SA 3.0 IGO. Retrieved from: https://apps.who.int/iris/handle/10665/255760

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