UNIVERSITY OF BAGUIO

COLLEGE OF NURSING
GENERAL LUNA ROAD, BAGUIO CITY

A Delivery Write Up
Presented to the Faculty
Of the College of Nursing

In partial fulfillment
Of the requirements
In Nursing Care Management 104 RLE
Of the Course Bachelor of Science in Nursing

Submitted to:
Ms. Maria Rhodessa M. Estacio, RN

Submitted by:

NPG – 3

Agustin, Henrizza
Cumahling, Melody
Daytec, Keziah
Escobar, Kimverley
Estacio, Jansen
Lorenzana, Diane Mei
Massey, Hamed
Mose, Angelica Joy
Osillo, Hazel
Rosquita, Gianelli
Sanchez, Rod Anthony
Torrado, Suzette

September 2009
 T A B L E O F C O N T E N T S

I. Patient's Profile

II. Pathophysiology

III. Preparation of the Patient

• Position
• Skin Preparation
• Draping
• Anesthesia

IV. Discussion

V. Instrumentation
 PATHOPHYSIOLOGY

Stages of labor
1. Ist stage

Phase I: latent, dilation= 0-3, duration/interval=20-40 sec. /5-

30 minutes, mild to moderate
Phase II: active, dilation=4-7cm, duration/interval=40-60 sec. /
3-5 minutes, moderate to strong
Phase III: transition, dilation=8-10cm, duration=60-90 sec. /2-3
minutes, strong
2. 2nd stage

Phase I: station= 0 to + 2, contraction=2-3 minutes apart

Phase II: station= + to +4, contraction= 2 to 2.5 mins. Apart
with urgency to bear down
Phase III: station= +4 to birth, contraction= to 2 mins. Apart;
fetal head visible increased.

Mechanisms of labor/cardinal movements

1. Engagement
➢ fetal presenting part (normally the head) as its widest
diameter reaches the level of the ischial spines of the
pelvis
1. Descent
➢ Downward movement of the biparietal diameter of the fetal
head until it reaches the pelvic inlet
➢ Occurs bec. Of pressure on the fetus by the uterine
fundus
➢ Pressure of the fetal head on the sacral nerve produces a
pushing sensation which is experienced by the mother in
labor
1. Flexion
➢ Shortest head diameter pass through the pelvis
➢ Fetal head reaches the pelvic floor; head bends forward
onto chest, presenting the smallest anteroposterior
diameter
1. Internal rotation
➢ allows the longest fetal head diameters to match the
longest maternal pelvic diameter
➢ fetus enters the pelvic inlet
1. Extension
 ➢ Internal rotation is complete
➢ Fetal head passes beneath the symphysis pubis while in
flexion; there is a resistance from tissues of the pelvic
floor in the fetal head. Fetal neck stops and act as a
pivot. This combination causes the fetal head to move
anteriorly, or extend, while mother is pushing
1. External rotation
➢ Allow the shoulders to rotate internally to fit the
pelvis
1. Expulsion
➢ Expulsion occurs first as the anterior, ten posterior
shoulder passes under the symphysis pubis
➢ After the shoulder delivery, rest of the body will follow

1. 3rd stage

Placental delivery = 2 phases (placental separation and

placental expulsion)
• Sudden gush of blood
• Lengthening of the cord
• rising of the fundus
• globular uterus
1. 4th stage

First four hours after delivery of the placenta.

 Stage I
↓
Latent phase
↓
Active phase
↓
Transition phase
↓
Stage II
↓
Engagement
↓
Descent
↓
Flexion
↓
Internal rotation
↓
Extension
↓
External rotation
↓
Expulsion
↓
Stage III
↓
Signs of placental separation
Sudden gush of blood, lengthening of the cord, calkin’s sign
↓
Stage IV
↓
Expulsion of the placenta
 PREPARATION OF THE PATIENT

DRAPING THE PATIENT

a. The procedure of covering a patient and surrounding areas
with a sterile barrier to create and maintain a sterile field
during a surgical procedure is called draping. The purpose of
draping is to eliminate the passage of microorganisms between
nonsterile and sterile areas. Draping materials may be
disposable or no disposable. Disposable drapes are generally
paper or plastic or a combination and may or may not be
absorbent. No disposable drapes are usually double-thickness
muslin. Drapes, of course, must be sterile.
b. Since draping is very important in preparing a patient for
delivery, it must be done correctly. The entire team should be
familiar with the draping procedure. The scrub must know the
procedure perfectly and be ready to assist with it. During the
draping procedure, the circulator should stand by to direct the
scrub as necessary and to watch carefully for breaks in sterile
technique.
(1) The first step in draping is the placing of a drape sheet
from the foot to the knees. The scrub will select the sheet and
hand one end to the surgeon across the operating table,
supporting the folds, keeping it high, and holding it taut until
it is opened, then drop it (open fingers and release sheet). The
second drape sheet is handled in the same manner. This sheet is
placed below the site with the edge of the sheet just below the
site. This draping sheet provides extra thickness of material
under the area from the Mayo tray to the incision where
instruments and sponges are placed.
(2) When disposable drapes are used, the towels usually have a
removable strip with an adhesive on the folded edge. The third
step in draping is placing the four sterile towels around the
line of incision. The scrub unfolds first towel, passes the
towel drape to the surgeon with the strip side facing the scrub,
and then removes the adhesive strip. The surgeon places the
towel within the scrubbed area on the near side of the line of
incision, leaving only enough exposed skin for the incision. The
second towel is placed in the same way, except the towel is
placed on the lower side (toward feet) of the line of incision.
The third towel is passed the same way, except the towel is
placed on the upper side (toward head) the line of incision. The
last towel is passed to the surgeon with the adhesive strip
facing the surgeon and is placed on the far side of the line of
site. The adhesive area holds the towel drapes in place.
(3) Finally, the scrub will select the surgical drape (lap
sheet). This lap sheet has a fenestration (opening) in the
drape. The scrub places the opening directly over the skin area
outlined by the drape towels and in the direction indicated for
the foot or head of the table. The lap sheet will have an arrow
or some other indication to identify the head or foot portion of
the drape. Drop the folds over the sides of the table, and then
open it downward over the patient's feet and upward over the
anesthetist screen.

Draping procedure:
1. The sterile drape is placed on the instrument table.
2. The drape, without the pouch, is handed to the circulating
nurse, who places the drape on the operating room table and
secures it in place by removing the adhesive backing.
3. The clear envelope containing the sterile blue accordion
drape must be at the end of the table, or the brake in the
table, when fixing the remainder of the drape towards the head
of the patient.
4. The patient is placed on the drape with the buttocks on the
clear portion of the closed envelope.
5. The patient is placed in stirrups and prepped, following
which the protective clear envelope is opened by removing the
perforated strip located on the patient's right.
6 .This will expose the sterile blue accordion poly, which is
pulled to its full extent by pulling the center tab.
7. Leggings are applied to the lower extremities.
8. The self adhesive catch pouch is applied by the scrub nurse
or surgeon at a convenient location.
9. At the termination of the procedure, the dirty blue poly
drape is removed along its perforation, before the table is
raised back into position to place the legs on the table.
 DISCUSSION
NORMAL SPONTANEOUS DELIVERY
Many obstetric units now use a combined labor, delivery,
recovery, and postpartum (LDRP) room, so that the woman, support
person, and neonate remain in the same room throughout their
stay. Some units use a traditional labor room and separate
delivery suite, to which the woman is transferred when delivery
is imminent. The father or other support person should be
offered the opportunity to accompany her. In the delivery room,
the perineum is washed and draped, and the neonate is delivered.
After delivery, the woman may remain there or be transferred to
a postpartum unit. Management of complications during delivery
requires additional measures
Anesthesia
Options include regional, local, and general anesthesia. Local
anesthetics and opioids are commonly used. These drugs pass
through the placenta; thus, during the hour before delivery,
such drugs should be given in small doses to avoid toxicity (eg,
CNS depression, bradycardia) in the neonate. Opioids used alone
do not provide adequate analgesia and so are most often used
with anesthetics.
Regional anesthesia: Several methods are available.
Lumbar epidural injection of a local anesthetic is the most
commonly used method. Epidural injection is being increasingly
used for delivery, including cesarean section, and has
essentially replaced pudendal and paracervical blocks. The local
anesthetics often used for epidural injection (eg, bupivacaine
Some Trade Names MARCAINE, SENSORCAINE) have a longer duration
of action and slower onset than those used for pudendal block
(eg, lidocaine Some Trade Names XYLOCAINE).
Other methods include caudal injection (into the sacral canal),
which is rarely used, and spinal injection (into the paraspinal
subarachnoid space). Spinal injection may be used for cesarean
section, but it is used less often for vaginal deliveries
because it is short-lasting (preventing its use during labor)
and has a small risk of spinal headache afterward. When spinal
injection is used, patients must be constantly attended, and
vital signs must be checked every 5 min to detect and treat
possible hypotension.
Local anesthesia: Methods include pudendal block, perineal
infiltration, and paracervical block.
Pudendal block, rarely used because epidural injections are used
instead, involves injecting a local anesthetic through the
vaginal wall so that the anesthetic bathes the pudendal nerve as
it crosses the ischial spine. This block anesthetizes the lower
vagina, perineum, and posterior vulva; the anterior vulva,
innervated by lumbar dermatomes, is not anesthetized. Pudendal
block is a safe, simple method for uncomplicated spontaneous
vaginal deliveries if women wish to bear down and push or if
labor is advanced and there is no time for epidural injection.
Infiltration of the perineum with an anesthetic is commonly
used, although this method is not as effective as a well-
administered pudendal block.
Paracervical block is rarely appropriate for delivery because
incidence of fetal bradycardia is > 15%. It is used mainly for
1st- or early 2nd-trimester abortion. The technique involves
injecting 5 to 10 mL of 1% lidocaine Some Trade Names
XYLOCAINE at the 3 and 9 o'clock positions; the analgesic
response is short-lasting.
General anesthesia: Because potent and volatile inhalation drugs
(eg, isoflurane) can cause marked depression in mother and
fetus, general anesthesia is not recommended for routine
delivery. Rarely, nitrous oxide 40% with O2 may be used for
analgesia during vaginal delivery as long as verbal contact with
the woman is maintained. Thiopental Some Trade Names
PENTOTHAL, a hypnotic, is commonly given IV with other drugs
(eg, succinylcholine Some Trade Names ANECTINE, QUELICIN,
nitrous oxide plus O2) for induction of general anesthesia during
cesarean delivery; used alone, thiopental Some Trade Names
PENTOTHAL provides inadequate analgesia. With thiopental Some
Trade Names PENTOTHAL , induction is rapid and recovery is
prompt. It becomes concentrated in the fetal liver, preventing
levels from becoming high in the CNS; high levels in the CNS may
cause neonatal depression. Increased interest in preparation for
childbirth has reduced the need for general anesthesia except
for cesarean section.
Delivery Procedures
A vaginal examination is done to determine position and station
of the fetal head; the head is usually the presenting part (see
Fig. 2: Normal Pregnancy, Labor, and Delivery: Sequence of
events in delivery for vertex presentations. ). When effacement
is complete and the cervix is fully dilated, the woman is told
to bear down and strain with each contraction to move the head
through the pelvis and progressively dilate the vaginal introitus
so that more and more of the head appears. When about 3 or 4 cm
of the head is visible during a contraction in nulliparas
(somewhat less in multiparas), the following maneuvers can
facilitate delivery and reduce risk of perineal laceration.
• The clinician, if right-handed, places the left palm over
the infant's head during a contraction to control and, if
necessary, slightly slow progress.
• Simultaneously, the clinician places the curved fingers of
the right hand against the dilating perineum, through which
the infant's brow or chin is felt.
• To advance the head, the clinician can wrap a hand in a
towel and, with curved fingers, apply pressure against the
underside of the brow or chin (modified Ritgen maneuver).
Thus, the clinician controls the progress of the head to effect
a slow, safe delivery.
Forceps or a vacuum extractor is often used for vaginal delivery
when the 2nd stage of labor is likely to be prolonged (eg,
because the mother is too exhausted to bear down adequately or
because regional epidural anesthesia precludes vigorous bearing
down). If anesthesia is local (pudendal block or infiltration of
the perineum), forceps or a vacuum extractor is usually not
needed unless complications develop; local anesthesia may not
interfere with bearing down. Indications for forceps and vacuum
extractor are essentially the same.
An episiotomy is not routine and is done only if the perineum
does not stretch adequately and is obstructing delivery, usually
only for first deliveries at term. A local anesthetic can be
infiltrated if epidural analgesia is inadequate. Episiotomy
prevents excessive stretching and possible tearing of the
perineal tissues, including anterior tears. The incision is
easier to repair than a tear. The most common type is a midline
incision made from the midpoint of the fourchette directly back
toward the rectum. Extension into the rectal sphincter or rectum
is a risk, but if recognized promptly, the extension can be
repaired successfully and heals well. Tears or extensions into
the rectum can usually be prevented by keeping the infant's head
well flexed until the occipital prominence passes under the
symphysis pubis. Another type of episiotomy is a mediolateral
incision made from the midpoint of the fourchette at a 45° angle
laterally on either side. This type usually does not extend into
the sphincter or rectum, but it causes greater postoperative
pain and takes longer to heal than midline episiotomy. Thus, for
episiotomy, a midline cut is preferred. However, use of
episiotomy is decreasing because extension or tearing into the
sphincter or rectum is a concern. Episioproctotomy
(intentionally cutting into the rectum) is not recommended
because rectovaginal fistula is a risk.
When the head is delivered, the clinician determines whether the
umbilical cord is wrapped around the neck. If it is, the
clinician should try to unwrap the cord; if the cord cannot be
rapidly removed this way, the cord may be clamped and cut. After
delivery of the head, the infant's body rotates so that the
shoulders are in an anteroposterior position; gentle downward
pressure on the head delivers the anterior shoulder under the
symphysis. The head is gently lifted, the posterior shoulder
slides over the perineum, and the rest of the body follows
without difficulty. The nose, mouth, and pharynx are aspirated
with a bulb syringe to remove mucus and fluids and help start
respirations. The cord should be double-clamped and cut between
the clamps, and a plastic cord clip should be applied about 2 to
3 cm distal from the cord insertion on the infant. If fetal or
neonatal compromise is suspected, a segment of umbilical cord is
doubly clamped so that arterial blood gas analysis can be done.
An arterial pH > 7.l5 to 7.20 is considered normal. The infant
is thoroughly dried, then placed on the mother's abdomen or, if
resuscitation is needed, in a warmed resuscitation bassinet.
After delivery of the infant, the clinician places a hand gently
on the abdomen over the uterine fundus to detect contractions;
placental separation usually occurs during the 1st or 2nd
contraction, often with a gush of blood from behind the
separating placenta. The mother can usually help deliver the
placenta by bearing down. If she cannot and if substantial
bleeding occurs, the placenta can usually be evacuated
(expressed) by placing a hand on the abdomen and exerting firm
downward (caudal) pressure on the uterus; this procedure is done
only if the uterus feels firm because pressure on a flaccid
uterus can cause it to invert. If this procedure is not
effective, the umbilical cord is held taut while a hand placed
on the abdomen pushes upward (cephalad) on the firm uterus, away
from the placenta; traction on the umbilical cord is avoided
because it may invert the uterus. If the placenta has not been
delivered within 45 to 60 min of delivery, manual removal may be
necessary; the clinician inserts an entire hand into the uterine
cavity, separating the placenta from its attachment, then
extracts the placenta. In such cases, an abnormally adherent
placenta should be suspected.
The placenta should be examined for completeness because
fragments left in the uterus can cause hemorrhage or infection
later. If the placenta is incomplete, the uterine cavity should
be explored manually. Some obstetricians routinely explore the
uterus after each delivery. However, exploration is
uncomfortable and is not routinely recommended. Immediately
after delivery of the placenta, an oxytocic drug ( oxytocin Some
Trade Names PITOCIN, SYNTOCINON 10 units IM or as an infusion of
20 units/1000 mL saline at 125 mL/h) is given to help the uterus
contract firmly. Oxytocin Some Trade Names PITOCIN, SYNTOCINON
should not be given as an IV bolus because cardiac arrhythmia
may occur.
The cervix and vagina are inspected for lacerations, which, if
present, are repaired, as is episiotomy if done. Then if the
mother and infant are recovering normally, they can begin
bonding. Many mothers wish to begin breastfeeding soon after
delivery, and this activity should be encouraged. Mother,
infant, and father should remain together in a warm, private
area for an hour or more to enhance parent-infant bonding. Then,
the infant may be taken to the nursery or left with the mother
depending on her wishes. For the first hour after delivery, the
mother should be observed closely to make sure the uterus is
contracting (detected by palpation during abdominal examination)
and to check for bleeding, BP abnormalities, and general well-
being. The time from delivery of the placenta to 4 h postpartum
has been called the 4th stage of labor; most complications,
especially hemorrhage occur at this time, and frequent
observation is mandatory.
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