UNIT 4 Physiology, management and care during labour

🌼 I. PHYSIOLOGY OF LABOUR.

Labour is the process by which the fetus, placenta, and membranes are expelled through the birth canal. It is divided into three main stages.

1. Signs of True Labour

• Regular painful uterine contractions.
• Cervical effacement and dilatation.
• Show (blood-tinged mucus discharge).
• Rupture of membranes (may occur early or later).

2. Hormonal Triggers

• Oxytocin: Stimulates uterine contractions.
• Prostaglandins: Help soften and efface the cervix.
• Estrogen: Increases uterine sensitivity.
• Relaxin: Softens the cervix and ligaments for delivery.

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🌼 II. STAGES OF LABOUR

1st Stage: Cervical Dilatation (Latent & Active Phase)

• Latent phase: 0–4 cm dilation, mild contractions.
• Active phase: 4–10 cm dilation, stronger and more regular contractions.
• Duration: ~12-14 hours in primigravida; shorter in multipara.

🔹 Physiological Changes:

• Cervical effacement and dilatation.
• Descent of fetal presenting part.
• Uterine contractions become rhythmic and more intense.

🔹 Midwifery/Nursing Care:

• Monitor maternal and fetal vitals.
• Encourage ambulation (if safe).
• Assess pain and provide relief (breathing, relaxation, analgesia if needed).
• Provide emotional support.
• Monitor contractions, vaginal discharge, fetal heart rate (FHR).
• Maintain hydration and hygiene.
• Observe for signs of complications (meconium-stained liquor, abnormal FHR).

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2nd Stage: Expulsion of Baby

• Begins at full cervical dilation (10 cm) and ends with delivery of the baby.
• Duration: ~1 hour in primigravida, ~30 minutes in multipara.

🔹 Physiological Changes:

• Strong bearing-down efforts due to Ferguson reflex (pressure on cervix).
• Increased urge to push.
• Crowning of fetal head.

🔹 Midwifery/Nursing Care:

• Position mother appropriately (lithotomy/squatting).
• Instruct effective pushing techniques during contractions.
• Support the perineum to prevent tears.
• Prepare for newborn care and resuscitation.
• Observe for signs of fetal distress.
• Perform episiotomy if required and with consent.
• Deliver the baby gently, clear airway, and ensure APGAR scoring.

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3rd Stage: Placental Delivery

• From birth of the baby to expulsion of placenta and membranes.
• Duration: Usually within 5–30 minutes.

🔹 Physiological Changes:

• Uterine contractions help separate and expel the placenta.
• Hemostasis is achieved via uterine contraction and retraction.

🔹 Midwifery/Nursing Care:

• Administer uterotonic (e.g., oxytocin) to facilitate placental separation and prevent hemorrhage.
• Controlled cord traction (CCT) using Brandt–Andrews technique.
• Inspect placenta for completeness.
• Monitor bleeding and uterine tone.
• Record blood loss to detect postpartum hemorrhage (PPH).

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🌼 III. FOURTH STAGE OF LABOUR (Immediate Postpartum – 1st Hour)

Midwifery/Nursing Care:

• Observe for signs of hemorrhage (fundal height, firmness, lochia).
• Monitor maternal vitals every 15 mins for 1st hour.
• Encourage skin-to-skin contact and initiate breastfeeding.
• Ensure bladder is empty (prevent uterine atony).
• Comfort and reassure mother.

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🌼 IV. PAIN MANAGEMENT DURING LABOUR

Non-Pharmacological Methods:

• Breathing exercises and relaxation techniques.
• Continuous labour support.
• Warm baths, massages, position changes.

Pharmacological Methods:

• Analgesics: Pethidine, Tramadol.
• Epidural analgesia.
• Inhalation agents (Entonox).
• Local anesthesia (for episiotomy/laceration repair).

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🌼 V. COMPLICATIONS TO WATCH FOR

• Prolonged/obstructed labour.
• Fetal distress (abnormal FHR patterns).
• Meconium-stained amniotic fluid.
• Postpartum hemorrhage.
• Shoulder dystocia.
• Retained placenta.

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🌼 VI. ROLE OF MIDWIFE/NURSE DURING LABOUR

🌀 Assessment & Monitoring

• Maternal vitals, uterine contractions, FHR (every 30 mins or more).
• Vaginal examination as needed (sterile conditions).
• Use of Partograph to monitor labour progression.

💠 Communication & Support

• Inform and involve the woman in decision-making.
• Provide emotional reassurance.
• Maintain privacy and dignity.
• Support cultural and individual preferences.

🧿 Documentation

• Accurate recording of time, observations, interventions.
• Partograph entries.
• Events during labour, medications given, baby’s condition.

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🌼 VII. POST-DELIVERY NURSING CARE FOR MOTHER AND BABY

• Monitor for bleeding, fundal firmness, uterine involution.
• Encourage bonding and breastfeeding within the first hour.
• Newborn assessment: APGAR, respiration, temperature.
• Prevent hypothermia and infection in newborn.
• Educate mother on postpartum hygiene, breastfeeding, danger signs.

🌼 Normal Labour and Birth.

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🔹 Definition of Normal Labour

Normal labour is the spontaneous onset, at term (37–42 weeks), with regular uterine contractions that lead to progressive cervical dilation and effacement, resulting in the vaginal birth of a single fetus, head-first (cephalic), without any instrumental or surgical assistance, and minimal risk to mother and baby.

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🔹 Characteristics of Normal Labour

• Spontaneous in onset.
• Singleton pregnancy.
• Cephalic presentation.
• Gestational age: 37–42 weeks.
• Progressive cervical dilatation.
• No complications (e.g., hemorrhage, fetal distress).
• Short duration (~12–16 hrs in primigravida, shorter in multipara).
• Spontaneous delivery of fetus and placenta.
• Minimal assistance or intervention.

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🌀 Stages of Normal Labour

🔸 1st Stage – Cervical Dilatation

• Latent Phase: 0–4 cm dilatation; mild, irregular contractions.
• Active Phase: 4–10 cm dilatation; stronger, more frequent contractions.
• Duration:
  • Primigravida: 6–12 hrs
  • Multipara: 4–8 hrs

💠 Midwifery Role:

• Monitor vitals, contractions, fetal heart rate.
• Use partograph.
• Provide comfort and emotional support.
• Encourage oral fluids and ambulation (if safe).
• Maintain hygiene and bladder emptying.

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🔸 2nd Stage – Delivery of Baby

• From full dilation (10 cm) to delivery of the baby.
• Strong urge to bear down.
• Duration:
  • Primigravida: up to 1 hour
  • Multipara: 15–30 minutes

💠 Midwifery Role:

• Guide effective pushing with contractions.
• Position mother comfortably (lithotomy or squatting).
• Monitor fetal descent and heart rate.
• Perform episiotomy if required.
• Gently deliver baby (head first, clear airways).
• APGAR scoring at 1 and 5 minutes.

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🔸 3rd Stage – Delivery of Placenta

• Time between birth of the baby and complete expulsion of placenta and membranes.
• Usually completed within 5–30 minutes.

💠 Midwifery Role:

• Administer oxytocin to help uterine contractions.
• Perform controlled cord traction (CCT).
• Inspect placenta and membranes for completeness.
• Monitor mother for excessive bleeding.
• Massage fundus to promote uterine contraction.

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🔸 4th Stage – Immediate Postpartum (1st Hour)

• Observation period for signs of hemorrhage, uterine tone, and bonding initiation.

💠 Midwifery Role:

• Monitor vital signs every 15 minutes.
• Check firmness and position of uterus.
• Monitor vaginal bleeding (lochia).
• Encourage breastfeeding and skin-to-skin contact.
• Educate mother on self-care, perineal hygiene.

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🔹 Mechanism of Labour (Cardinal Movements of Labour)

Occurs in vertex presentation:

1. Engagement – Biparietal diameter enters pelvic brim.
2. Descent – Fetal head moves downwards.
3. Flexion – Chin touches chest for easier passage.
4. Internal Rotation – Occiput rotates to anterior.
5. Extension – Head passes under pubic symphysis and is born.
6. Restitution – Head realigns with shoulders.
7. External Rotation – Shoulders rotate for delivery.
8. Expulsion – Rest of the body is delivered.

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🔹 Signs of Onset of True Labour

• Regular painful contractions (every 3–5 minutes).
• Cervical dilatation and effacement.
• “Show” – blood-tinged mucus.
• Rupture of membranes (SROM).
• Fetal head descends.

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🔹 Monitoring Tools

• Partograph – To monitor labour progress.
• Fetal Doppler or Pinard stethoscope – To monitor fetal heart rate.
• Palpation – For uterine contractions and fetal position.
• Vaginal examination – For cervical changes.

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🔹 Role of Midwife/Nurse During Normal Labour

• Provide continuous emotional and physical support.
• Maintain aseptic technique.
• Ensure hydration, rest, pain relief, and privacy.
• Prepare for neonatal care and resuscitation.
• Educate and empower the mother.

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🔹 Care of the Newborn After Birth

• Clear airway, dry baby, maintain warmth.
• APGAR score at 1 & 5 minutes.
• Initiate breastfeeding within 30–60 minutes.
• Monitor breathing, color, activity.
• Identify the baby (ID bands).
• Vitamin K injection and cord care.

🌼 Onset of Labour (or Birth).

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🔹 Definition of Onset of Labour

The onset of labour is defined as the beginning of true, regular uterine contractions that result in progressive cervical effacement and dilation, leading to the delivery of the fetus, placenta, and membranes.

It marks the transition from pregnancy to childbirth and the start of the first stage of labour.

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🔹 Physiology Behind the Onset of Labour

Labour begins due to a complex interaction of maternal, fetal, and placental hormones.

🧬 Key Hormonal Changes:

• Oxytocin: Stimulates rhythmic uterine contractions.
• Prostaglandins (PGs): Soften the cervix (cervical ripening).
• Estrogen: Increases sensitivity of the uterus to oxytocin.
• Relaxin: Softens pelvic ligaments and cervix.
• Fetal signals (e.g., cortisol): Trigger readiness for birth.

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🔹 Preliminary/Pre-Labour Signs (Seen Days Before True Labour)

1. Lightening (Engagement)
   • Fetal head descends into the pelvis.
   • Seen more commonly in primigravida.
   • Relieves pressure on diaphragm → easier breathing.
   • Increases pelvic pressure → frequent urination.
2. False Labour Pains (Braxton Hicks Contractions)
   • Irregular, mild contractions without cervical changes.
   • Do not increase in intensity or duration.
   • Subsides with rest or change in position.
3. Increased Vaginal Discharge
   • Due to estrogenic stimulation and cervical ripening.
4. Bloody Show
   • Expulsion of mucus plug mixed with blood (due to cervical capillary rupture).
   • Indicates cervix is beginning to efface and dilate.
5. Backache & Pelvic Pressure
   • Due to fetal descent and softening of joints.

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🔹 True Labour – Characteristics at Onset

Feature	True Labour	False Labour
Contractions	Regular, increasing in intensity	Irregular, mild, no progression
Pain location	Begins in back, radiates to abdomen	Lower abdomen only
Cervical change	Dilatation and effacement present	No cervical change
Effect of rest	Not relieved by rest	Disappears with rest/hydration
Show	Present (mucus plug with blood)	Absent
Membrane rupture	May occur	Not usually

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🔹 Initial Nursing Assessment at Onset of Labour

At first contact with the mother:

🩺 Assessment

• Vital signs (BP, pulse, temp, respiration)
• Obstetric history (Gravida, Para, previous deliveries)
• Fetal movements
• Abdominal palpation (Leopold’s maneuvers)
• Fetal heart rate (FHR) monitoring
• Vaginal examination to assess:
  • Cervical dilatation
  • Effacement
  • Station of presenting part
  • Presence of show or amniotic fluid

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🔹 Types of Labour Pain

• Visceral pain: Due to uterine contractions (felt in abdomen/back).
• Somatic pain: Stretching of vagina and perineum during later stages.
• Pain is subjective and varies; influenced by fear, anxiety, support, and previous experience.

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🔹 Nursing/Midwife Responsibilities at Onset

• Confirm true labour.
• Start Partograph to monitor labour progression.
• Ensure privacy and reassure the mother.
• Provide supportive care and non-pharmacologic pain relief (breathing, position changes).
• Encourage emptying of bladder.
• Check for rupture of membranes – note time, color, amount, odor.
• Alert physician if complications are suspected.
• Prepare delivery tray and baby resuscitation corner.

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🔹 Documentation

• Time of labour onset.
• Characteristics of contractions.
• Fetal heart rate.
• Vaginal findings (show, dilatation).
• Condition of membranes (intact/ruptured).
• Any medications or interventions.

🌼 Per Vaginal Examination (P/V Exam).

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🔹 Definition

A Per Vaginal Examination is a clinical procedure performed to assess the status of the cervix, presenting part of the fetus, and progression of labour by inserting sterile gloved fingers into the vagina.

It is a crucial part of intrapartum care in obstetrics and midwifery.

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🔹 Purpose of P/V Examination

• Confirm the onset and progress of labour.
• Assess cervical dilatation and effacement.
• Determine the presenting part and its position.
• Check the station of the presenting part (descent into pelvis).
• Evaluate the status of membranes (intact/ruptured).
• Detect abnormalities like cord prolapse, malpresentation.
• Help in making decisions regarding delivery timing/method.

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🔹 Indications

• At admission in labour.
• To assess progress during active labour (every 4 hours or as indicated).
• Before giving analgesia or anesthesia.
• If the mother feels the urge to push (to check full dilatation).
• Suspected obstruction or malpresentation.
• To confirm rupture of membranes.

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🔹 Contraindications

• Placenta previa (unless in controlled medical setting with imaging confirmation).
• Active genital herpes infection.
• Excessive frequency (can increase infection risk).
• Use cautiously in ruptured membranes.

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🔹 Pre-Procedural Nursing Care

1. Explain the procedure to the woman — gain consent.
2. Ensure privacy and use screen or curtain.
3. Ask her to empty the bladder before the exam.
4. Maintain aseptic technique — sterile gloves, lubricant, antiseptic solution.
5. Assist the woman into dorsal or lithotomy position.

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🔹 Steps of the Procedure

1. Wash hands and wear sterile gloves.
2. Separate labia with one hand.
3. Insert index and middle fingers of the gloved hand gently into the vagina.
4. Assess:
   • Cervical dilatation (0–10 cm).
   • Effacement (% thinning of cervix).
   • Station (–5 to +5) — relation to ischial spines.
   • Presenting part and position (e.g., vertex, breech, face).
   • Status of membranes (intact or ruptured).
   • Any abnormalities: caput, molding, cord.

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🔹 Key Findings and Terms

Parameter	Normal Findings
Cervical dilatation	0–10 cm (10 cm = fully dilated)
Effacement	0–100% (100% = fully effaced)
Station	–5 to +5 (0 = at ischial spines)
Presenting part	Vertex (head), breech, shoulder
Position	Occiput Anterior (OA) is ideal
Membranes	Intact or ruptured
Caput/molding	Present in prolonged labour

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🔹 Aftercare & Documentation

• Wipe and clean the perineum if needed.
• Help the woman back to a comfortable position.
• Discard gloves and wash hands.
• Document the findings clearly in labour record or partograph:
  • Cervical dilatation and effacement.
  • Station and position.
  • Membrane status.
  • Fetal presentation.
  • Time and reason for exam.
• Inform senior/doctor if abnormal findings.

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🔹 Nursing Responsibilities

• Always maintain infection control (clean technique).
• Be gentle and communicate throughout the procedure.
• Reassure and support the woman emotionally.
• Avoid repeated unnecessary exams (risk of infection).
• Report any abnormal findings immediately.

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🔹 Precautions

• Avoid excessive frequency of P/V exams.
• Use minimum force to prevent trauma.
• Do not perform blindly—must know when and why.
• Use sterile lubricant to minimize discomfort.

🌼 Stages of Labour –

Labour is divided into 4 stages, each with distinct characteristics and nursing responsibilities.

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🟪 Stage 1: Dilation Stage (Onset of labour to full cervical dilatation)

🔹 Definition:

This stage begins with the onset of true labour pains and ends when the cervix is fully dilated to 10 cm.

🔸 Phases of 1st Stage:

Phase	Features	Duration (Primigravida)	Duration (Multipara)
Latent Phase	Mild, irregular contractions. Cervix dilates from 0 to ~4 cm.	6–8 hrs	4–6 hrs
Active Phase	Stronger, more regular contractions. Cervix dilates from 4–10 cm.	6–8 hrs	4–6 hrs
Transition Phase	Cervix completes dilation (8–10 cm). Strong urge to push.	Variable	Shorter

🔹 Physiological Changes:

• Uterine contractions cause cervical effacement and dilation.
• Fetus begins descent into pelvis.
• Possible rupture of membranes.

💠 Midwifery/Nursing Care:

• Monitor contractions, FHR, vitals, cervical changes.
• Encourage relaxation, breathing techniques, ambulation.
• Provide hydration and emotional support.
• Record progress on partograph.
• Ensure bladder is emptied regularly.

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🟪 Stage 2: Expulsion Stage (Full dilation to delivery of the baby)

🔹 Definition:

Begins with full cervical dilatation (10 cm) and ends with delivery of the baby.

🔹 Duration:

• Primigravida: 30 mins to 1 hour
• Multipara: 15–30 minutes

🔹 Physiological Changes:

• Strong uterine contractions and maternal bearing-down efforts.
• Baby’s head crowns and is delivered.

💠 Midwifery/Nursing Care:

• Position mother appropriately (lithotomy/squatting).
• Guide and encourage effective pushing.
• Support perineum to prevent tears.
• Monitor FHR every 5 minutes or after each contraction.
• Prepare for neonatal care and resuscitation.
• Note time of birth and perform APGAR scoring.

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🟪 Stage 3: Placental Stage (After birth of baby to delivery of placenta)

🔹 Definition:

Begins after baby is born and ends with expulsion of placenta and membranes.

🔹 Duration:

• Usually within 5–30 minutes

🔹 Signs of Placental Separation:

• Gush of blood.
• Lengthening of umbilical cord.
• Uterus becomes firm and globular.
• Fundus rises in abdomen.

💠 Midwifery/Nursing Care:

• Administer oxytocin (10 units IM) to promote uterine contraction.
• Perform controlled cord traction (CCT).
• Check placenta and membranes for completeness.
• Massage uterus gently to prevent PPH.
• Observe for excessive bleeding.

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🟪 Stage 4: Recovery Stage (First hour post-delivery)

🔹 Definition:

First 1–2 hours after delivery — critical period for maternal monitoring.

🔹 Purpose:

Ensure hemostasis, monitor for postpartum hemorrhage (PPH), and support bonding and breastfeeding.

💠 Midwifery/Nursing Care:

• Monitor:
  • Vital signs every 15 mins.
  • Uterine tone and position.
  • Vaginal bleeding (lochia).
• Encourage breastfeeding and skin-to-skin contact.
• Ensure mother’s comfort and hygiene.
• Observe for bladder fullness.
• Provide emotional reassurance and information.

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🧿 Quick Summary Table:

Stage	Duration	Key Events	Midwifery Focus
1st	6–12 hrs (Primigravida)	Cervical dilation to 10 cm	Monitor progress, support
2nd	30–60 mins	Delivery of baby	Guide pushing, prepare for birth
3rd	5–30 mins	Delivery of placenta	Prevent PPH, examine placenta
4th	1–2 hrs	Recovery	Monitor mother, encourage bonding

🌼 First Stage of Labour.

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🔷 Definition

The First Stage of Labour begins with the onset of true labour pains and ends when the cervix is fully dilated to 10 cm. It is the longest of all the stages and includes progressive uterine contractions, cervical effacement, and dilatation.

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🔷 Duration

Woman Type	Duration (Approx.)
Primigravida	12–14 hours
Multipara	6–8 hours

💡 Can vary depending on the individual, strength of contractions, fetal position, and maternal factors.

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🔷 Phases of the First Stage

The 1st stage is subdivided into three phases:

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🔹 1. Latent Phase (Early Labour)

• Cervical Dilatation: 0 to 4 cm
• Contractions: Mild, irregular (every 10–20 mins, lasting 30–40 secs)
• Duration:
  • Primigravida: ~6–8 hours
  • Multipara: ~4–6 hours

💠 Observations:

• Mild backache or abdominal cramps
• Blood-tinged mucus (“show”)
• Cervix begins to efface and dilate
• Woman may be anxious but calm

💠 Nursing Care:

• Reassure and explain process
• Encourage rest, deep breathing, and hydration
• Monitor contractions and fetal heart rate (FHR)
• Allow walking or light movement
• Avoid unnecessary vaginal exams
• Maintain privacy and support

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🔹 2. Active Phase

• Cervical Dilatation: 4 to 7 cm
• Contractions: Stronger, more frequent (every 3–5 mins, lasting 45–60 secs)
• Duration:
  • Primigravida: ~3–5 hours
  • Multipara: ~2–4 hours

💠 Observations:

• Increasing pain and anxiety
• Fetal head descends into pelvis
• Membranes may rupture (SROM or AROM)
• More vaginal discharge (show)

💠 Nursing Care:

• Monitor FHR every 30 mins (or after each contraction if high risk)
• Record cervical changes and contractions on partograph
• Provide emotional support, massage, breathing techniques
• Offer pain relief (non-pharmacological or pharmacological)
• Encourage voiding every 2 hrs
• Observe for signs of complications (meconium-stained liquor, abnormal FHR)

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🔹 3. Transition Phase

• Cervical Dilatation: 8 to 10 cm (complete dilatation)
• Contractions: Very strong, every 2–3 mins, lasting 60–90 secs
• Duration: Usually short (15–60 mins)

💠 Observations:

• Woman may become irritable, restless, or emotional
• Strong urge to push or bear down
• Increased rectal pressure and bloody show
• Nausea, vomiting, sweating may occur

💠 Nursing Care:

• Do NOT allow pushing until full dilation is confirmed
• Continuous FHR monitoring
• Provide focused coaching and calm reassurance
• Maintain clean perineum and prepare delivery area
• Notify the birth attendant that full dilatation is near

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🔷 Physiological Changes in First Stage

• Uterus contracts rhythmically to dilate cervix.
• Cervix softens, thins (effaces), and opens (dilates).
• Fetal head descends and rotates.
• Hormonal surge of oxytocin and prostaglandins.

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🔷 Assessment Tools

1. Partograph – To track labour progress (cervical dilation, contractions, fetal/maternal status)
2. Leopold’s Maneuvers – To assess fetal lie and presentation
3. Vaginal Examination – To check dilation, effacement, station, membranes
4. Fetal Heart Rate Monitoring – Every 30 minutes in low-risk labour

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🔷 Signs That the First Stage is Ending

• Full cervical dilatation (10 cm)
• Strong, frequent contractions
• Urge to bear down
• Fetal head visible at perineum (soon in 2nd stage)

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🔷 Midwife/Nurse Responsibilities in 1st Stage

✅ Monitor mother and fetus closely
✅ Encourage hydration and nutrition (light foods)
✅ Provide continuous support and comfort
✅ Assist with breathing and coping techniques
✅ Maintain aseptic technique during vaginal exams
✅ Prepare for delivery (clean environment, supplies ready)
✅ Document all findings accurately

🌼 Second Stage of Labour.

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🔷 Definition

The Second Stage of Labour begins with full cervical dilatation (10 cm) and ends with the complete expulsion of the fetus (baby) from the birth canal.

This is the stage of active pushing and delivery of the baby.

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🔷 Duration

Mother Type	Duration (Approx.)
Primigravida	30 minutes to 1 hour
Multipara	15 to 30 minutes

🔔 Prolonged second stage can lead to fetal distress and maternal exhaustion.

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🔷 Physiological Changes

• Intense uterine contractions every 2–3 minutes, lasting 60–90 seconds.
• Strong bearing-down reflex (Ferguson reflex) as the fetal head stretches the perineum.
• Descent and rotation of the fetus through the birth canal.
• Crowning: When the largest diameter of the fetal head stretches the vulva and remains visible between contractions.
• Delivery of the baby.

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🔷 Signs of Second Stage

• Strong, regular contractions
• Urge to bear down or defecate (due to pressure on rectum)
• Bulging perineum
• Visible presenting part
• Anal gaping
• Bloody show increases

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🔷 Mechanism of Labour (Cardinal Movements)

In a vertex presentation, the baby undergoes the following movements during second stage:

1. Descent – Fetal head moves down into pelvis.
2. Flexion – Fetal chin moves toward chest.
3. Internal Rotation – Head rotates to align with the pelvic outlet.
4. Extension – Head emerges under the pubic bone.
5. Restitution – Head realigns with shoulders.
6. External Rotation – Shoulders rotate in pelvis.
7. Expulsion – Baby is completely delivered.

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🔷 Nursing and Midwifery Responsibilities

💠 Preparation:

• Inform the mother and birth team.
• Prepare sterile delivery tray and neonatal resuscitation unit.
• Ensure clean, well-lit environment.
• Encourage mother to empty bladder.

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💠 During Delivery:

• Position the mother: Lithotomy, squatting, or left lateral (as preferred or appropriate).
• Guide pushing: Encourage pushing only during contractions.
• Support perineum: Use warm compress or hand to reduce risk of tears.
• Monitor FHR: Every 5 minutes or after every contraction.
• Check for crowning and prepare for controlled delivery.
• Perform episiotomy only if indicated and with consent.
• Deliver baby gently: Support the head and shoulders.
• Suction mouth and nose if needed (prefer wiping over deep suction).

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💠 Immediately After Birth:

• Note time of birth.
• Place baby on mother’s chest (skin-to-skin).
• Dry the baby and stimulate breathing.
• Perform APGAR scoring at 1 and 5 minutes.
• Clamp and cut the cord (after pulsation stops or as per delayed clamping guidelines).
• Observe for signs of placental separation (start of 3rd stage).
• Assist with initiating breastfeeding.

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🔷 Documentation

• Exact time of full dilatation and time of delivery.
• Condition of baby (crying, tone, color, APGAR).
• Fetal heart rate before delivery.
• Medications given, interventions done.
• Tears or episiotomy, if any.

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🔷 Complications to Watch For

• Prolonged second stage.
• Fetal distress (bradycardia, meconium).
• Shoulder dystocia.
• Perineal tears or trauma.
• Cord prolapse or tight nuchal cord.

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🔷 Key Role of Midwife/Nurse

✅ Provide emotional support and positive reinforcement.
✅ Maintain aseptic technique.
✅ Be alert, calm, and encouraging — guide the mother effectively.
✅ Observe fetal descent, presentation, and perineal status closely.
✅ Prepare for immediate newborn care and emergency interventions if needed.

🌼 Third Stage of Labour.

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🔷 Definition

The Third Stage of Labour begins after the delivery of the baby and ends with the expulsion of the placenta and membranes from the uterus.

It is a critical stage, as the risk of postpartum hemorrhage (PPH) is highest here.

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🔷 Duration

Mother Type	Normal Duration
All mothers	5 to 30 minutes

⏰ If the placenta is not delivered within 30 minutes, it is considered a retained placenta, and medical intervention is required.

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🔷 Types of Management

✅ 1. Active Management of Third Stage of Labour (AMTSL)

Widely practiced in modern midwifery to reduce the risk of PPH.

Steps of AMTSL:

1. Administer oxytocin (10 IU IM) within 1 minute of baby’s birth.
2. Controlled cord traction (CCT) using Brandt–Andrews technique.
3. Uterine massage after placenta delivery to ensure tone.

🔸 Oxytocin is the drug of choice — promotes strong uterine contractions to aid placental separation.

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✅ 2. Physiological (Expectant) Management

• No oxytocic given.
• Mother pushes out the placenta spontaneously.
• Uterus contracts naturally.
• Rarely used in high-risk deliveries.

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🔷 Signs of Placental Separation

Midwives must carefully observe for the following signs:

Sign	Description
Gush of blood	Sudden bleeding as placenta detaches
Cord lengthening	Umbilical cord appears to become longer
Uterus rises	Fundus moves upward in abdomen
Uterus becomes globular	Firm, rounded uterus can be palpated

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🔷 Mechanism of Placental Expulsion

• Schultze Mechanism: Central separation → shiny fetal side comes out first.
• Matthews Duncan Mechanism: Marginal separation → dirty maternal side appears first.

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🔷 Midwifery/Nursing Responsibilities in Third Stage

💠 Before Placenta Expulsion:

• Observe for signs of placental separation.
• Do not pull the cord unless signs are present.
• Keep one hand on fundus during CCT to avoid uterine inversion.
• Prepare kidney tray to receive placenta.

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💠 After Placenta Expulsion:

1. Inspect the placenta:
   • Ensure it is complete — check two membranes, three vessels in cord, and no missing lobes.
   • Check cotyledons and membranes.
2. Massage the uterus:
   • Ensure it is firm and contracted.
3. Observe vaginal bleeding:
   • Normal loss: ~250–500 ml.
   • If excessive → suspect PPH and intervene immediately.
4. Examine perineum:
   • Check for tears or episiotomy.
   • Repair if needed.
5. Encourage breastfeeding:
   • Releases natural oxytocin, helps uterine contraction.

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🔷 Complications to Watch For

• Postpartum Hemorrhage (PPH)
• Retained placenta
• Uterine inversion
• Shock
• Tears in cervix/vagina

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🔷 Documentation

• Time of placental delivery.
• Type of management used (active/physiological).
• Estimated blood loss (EBL).
• Any medications given.
• Condition of the placenta and membranes.
• Condition of the mother (vitals, uterine tone).

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🔷 Important Instruments for 3rd Stage

• Oxytocin injection
• Sterile cord clamp and scissors
• Kidney tray
• Delivery mat and gauze pads
• Suture material (if episiotomy/tear)
• IV fluids and emergency tray (if PPH risk)

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✅ Summary Table

Feature	Details
Start	After baby is delivered
End	After placenta is expelled
Duration	5–30 minutes
Main Risks	Postpartum hemorrhage, retained placenta
Management Options	Active (preferred) or Physiological
Midwife’s Role	Observe, assist with delivery, assess placenta, prevent bleeding

🌼 Fourth Stage of Labour.

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🔷 Definition

The Fourth Stage of Labour is the immediate recovery period after the expulsion of the placenta, typically lasting 1–2 hours. It is a critical observation period for both mother and baby to ensure stabilization, bonding, and early detection of complications — especially postpartum hemorrhage (PPH).

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🔷 Duration

Mother Type	Duration
All deliveries	~1 to 2 hours

🔔 The first 1 hour post-delivery is often referred to as the “golden hour” for maternal stabilization and infant bonding.

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🔷 Physiological Events During This Stage

• Uterine involution begins (uterus starts contracting and shrinking).
• Hemostasis is achieved at the placental site (through contraction and clotting).
• Breastfeeding reflex is stimulated (releasing natural oxytocin).
• Maternal vital signs stabilize.
• Initiation of bonding and breastfeeding.

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🔷 Objectives of Fourth Stage Monitoring

• Detect and prevent postpartum hemorrhage (PPH).
• Ensure firm contraction of uterus.
• Monitor vital signs and bleeding.
• Support mother–infant bonding and breastfeeding.

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🔷 Midwifery & Nursing Responsibilities

💠 1. Maternal Monitoring

Parameter	Frequency
Vital signs	Every 15 mins (1st hour)
Uterine fundus	Palpate for firmness, midline position
Vaginal bleeding (lochia)	Check amount, color, odor
Bladder status	Encourage voiding
Perineum	Check episiotomy/tear site
Pain and comfort	Provide relief and reassurance

🔹 A firm, midline fundus indicates effective uterine contraction.
🔹 A boggy or deviated uterus may indicate uterine atony or a full bladder (→ increased bleeding risk).

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💠 2. Neonatal Care

• Dry and wrap the baby to prevent hypothermia.
• Perform APGAR scoring at 1 and 5 minutes.
• Initiate breastfeeding within 30–60 minutes.
• Observe:
  • Respiratory rate and effort
  • Color (pink vs cyanosis)
  • Activity and tone
• Identify baby (name tag, record birth time and weight).
• Administer Vitamin K (1 mg IM) if protocol permits.

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💠 3. Emotional & Psychological Support

• Reassure the mother about the process.
• Encourage skin-to-skin contact.
• Promote rooming-in and mother-infant bonding.
• Provide privacy and allow family support if appropriate.

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💠 4. Immediate Interventions (If Needed)

Complication	Intervention
Excessive bleeding	Uterine massage, oxytocin IV/IM, alert doctor
Uterine atony	Massage, empty bladder, oxytocics
Shock	Elevate legs, IV fluids, oxygen, urgent referral
Perineal pain/tear	Ice packs, analgesics, suture if necessary
Neonatal distress	Suction, warm, oxygen, resuscitation if needed

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🔷 Documentation During Fourth Stage

• Time of placental delivery.
• Estimated blood loss (EBL).
• Maternal vital signs and fundal status.
• Neonatal condition (APGAR, breathing, activity).
• Initiation of breastfeeding.
• Medications given.
• Any abnormal findings or interventions done.

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🔷 Checklist Summary: Midwife’s Key Tasks

✅ Monitor vital signs and bleeding
✅ Palpate uterus for firmness
✅ Observe newborn’s breathing, color, activity
✅ Assist with breastfeeding and skin-to-skin
✅ Ensure perineal hygiene and comfort
✅ Educate mother about danger signs
✅ Document everything accurately

🌼 Organization of Labour Room.

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🔷 Definition

The labour room is a specialized area within a hospital or maternity center where pregnant women are admitted for delivery. It must be well-organized, hygienic, well-equipped, and staff-ready to handle normal and emergency deliveries, including postpartum care.

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🔷 Objectives of Labour Room Organization

• Provide safe and clean environment for mother and baby.
• Ensure privacy, comfort, and emotional support.
• Enable efficient management of normal and high-risk deliveries.
• Ensure infection prevention and emergency readiness.
• Promote early neonatal care and breastfeeding.

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🔷 Ideal Location of Labour Room

• Close to the emergency entrance and operation theatre (OT).
• On the ground or easily accessible floor.
• Should be part of the Maternity or Obstetric Unit.
• Near NICU or Newborn Care Corner (NBCC).

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🔷 Layout and Zoning of Labour Room

The labour room should be divided into well-defined functional areas (zones) to ensure smooth workflow and infection control.

🟩 1. Reception/Admission Area

• For initial maternal assessment, registration, and triage.
• Basic assessment: vitals, history, fetal heart rate.

🟧 2. Pre-Labour/First Stage Room

• Comfortable beds/cots with side rails.
• Women are kept here during early/active first stage.
• Equipped for monitoring: fetal doppler, BP machine, partograph.

🟥 3. Delivery/Second Stage Room

• Fully sterile delivery beds (2 or more).
• Emergency resuscitation facilities.
• Sufficient space for staff movement.

🟦 4. Post-Delivery Observation Room (Fourth Stage)

• Separate room or curtained beds.
• Mother and baby monitored for 1–2 hours.
• Close to nurses’ station.

🟪 5. Newborn Care Corner

• Radiant warmer or resuscitation table.
• Suction machine, oxygen supply.
• Neonatal resuscitation kit, weighing scale, Vitamin K, identification tags.

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🔷 Essential Equipment in Labour Room

🩺 Maternal Equipment

• Delivery table with adjustable stirrups
• BP apparatus, stethoscope, fetal Doppler
• Sterile delivery kits (gloves, blades, pads, forceps)
• Episiotomy and suturing sets
• Oxygen cylinder, suction machine
• IV stand and fluids (RL, NS)
• Emergency drug tray (Oxytocin, Misoprostol, Methergine, Adrenaline)

👶 Neonatal Equipment

• Radiant warmer or heater
• Resuscitation bag and mask (size 0 and 1)
• Suction bulb or machine
• Oxygen source and tubing
• Thermometer and digital scale
• APGAR chart and identification tags

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🔷 Infection Control Measures

• Strict hand hygiene protocols
• Sterile gloves, gowns, masks, shoe covers
• Sterilization room or autoclave nearby
• Color-coded waste bins for biomedical waste
• Cleaning schedule (after every delivery and at shift end)
• Disinfection of instruments and surfaces

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🔷 Staffing Pattern in Labour Room

Staff Member	Role
Obstetrician	Supervises deliveries and handles complications
Staff Nurse/Midwife	Monitors labour, assists in delivery, postpartum care
Pediatrician (on-call)	For high-risk or resuscitation needs
Cleaning Attendant	For environmental hygiene
Anesthetist (on-call)	For C-sections or epidurals

Minimum: 1 trained nurse per woman in active labour

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🔷 Protocols and Documentation

• Use of Partograph to monitor labour progress.
• Maintain:
  • Labour and delivery register
  • Mother and baby care records
  • Consent forms (episiotomy, emergency interventions)
  • APGAR score and newborn documentation
• Display emergency drug dosage charts and PPH management protocols.
• Keep Standard Operating Procedures (SOPs) visible for:
  • Neonatal resuscitation
  • AMTSL
  • Eclampsia management

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🔷 Nursing Responsibilities in Labour Room

✅ Receive, assess, and triage patients.
✅ Maintain asepsis and prepare sterile trays.
✅ Monitor labour with partograph.
✅ Conduct deliveries and assist obstetrician.
✅ Perform immediate newborn care and resuscitation if needed.
✅ Monitor mother and baby during 4th stage.
✅ Administer medications as per protocol.
✅ Maintain proper documentation and handover.
✅ Provide emotional support, privacy, and counseling to mother and family.

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🔷 Emergency Preparedness

• Keep PPH tray, eclampsia kit, and neonatal resuscitation kit ready.
• Ensure 24-hour electricity and water supply.
• Emergency referral and transport plan in place.

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🔷 Display and Communication

• Display labour protocols, infection control posters, and emergency contact numbers.
• Educate mothers and birth companions about:
  • Birth process
  • Danger signs
  • Breastfeeding and newborn care

🌼 Triage in Labour Room.

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🔷 Definition of Triage

Triage is the process of prioritizing patients based on the urgency and severity of their condition to ensure that the most critical cases receive immediate care.

In the labour room, triage is essential to:

• Identify high-risk pregnancies
• Detect complications
• Ensure safe and timely delivery

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🔷 Objectives of Triage in Obstetric Care

• Early identification of life-threatening conditions in mother or fetus.
• Classify women into emergency, urgent, or non-urgent categories.
• Initiate timely intervention to reduce maternal and neonatal morbidity/mortality.
• Improve workflow and resource allocation in the labour room.

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🔷 Where is Triage Performed?

Usually done in a designated Triage Area or Admission Room located at the entrance of the labour room or maternity ward.

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🔷 Triage Assessment Components

A trained nurse or midwife evaluates:

💠 1. Maternal Assessment

• Vital signs: BP, pulse, respiration, temperature
• Pain level and contraction pattern
• Vaginal bleeding or leaking
• Obstetric history (G, P, L, A)
• Gestational age
• Presence of danger signs (e.g., convulsions, severe headache, breathlessness)

💠 2. Fetal Assessment

• Fetal heart rate (FHR)
• Fetal movements
• Presentation and lie (if assessable)

💠 3. Other Observations

• Cervical dilation (if indicated)
• Condition of membranes (ruptured/intact)
• Color of amniotic fluid (clear, meconium-stained)

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🔷 Triage Classification in Maternity Care

Category	Condition Examples	Action Needed
Red (Emergency)	Eclampsia, severe bleeding, obstructed labour, fetal distress, cord prolapse, shock	Immediate intervention – transfer to delivery or OT
Yellow (Urgent)	Active labour, PROM (without distress), moderate bleeding, hypertension	Monitor closely, prepare for delivery
Green (Non-urgent)	False labour, mild pain, routine antenatal visit	Wait and observe; manage conservatively
Blue (Post-delivery issues)	Stable postpartum mothers, breastfeeding assistance	Provide routine postpartum care

Color coding may vary depending on hospital protocols.

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🔷 Triage Tools and Forms

• Triage Checklist or Chart
• Partograph (if labour is progressing)
• Triage register/logbook
• Referral slips if transferring to higher facility

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🔷 Role of Nurse/Midwife in Triage

✅ Receive and assess all incoming pregnant women
✅ Record vital signs and symptoms accurately
✅ Quickly identify danger signs
✅ Prioritize and guide the woman to appropriate area (labour room, OT, ward, or referral)
✅ Communicate findings to the doctor or senior nurse
✅ Reassure and support the woman and family
✅ Maintain proper documentation

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🔷 Common Obstetric Emergency Conditions Detected in Triage

• Antepartum hemorrhage (placenta previa, abruption)
• Preeclampsia/eclampsia
• Prolonged/obstructed labour
• Premature rupture of membranes (PROM)
• Meconium-stained liquor
• Cord prolapse
• Severe anemia in labour

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🔷 Benefits of Effective Triage in Maternity Care

• Reduces maternal and newborn mortality
• Ensures timely care for emergencies
• Improves labour room efficiency
• Helps avoid overcrowding or delay
• Ensures patient satisfaction and safety

🌼 Preparation for Birth.

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🔷 Definition

Preparation for birth refers to all planned and coordinated activities done by the pregnant woman, healthcare team, and family to ensure a safe, smooth, and positive childbirth experience. It includes physical, psychological, environmental, and clinical readiness for labour, delivery, and immediate newborn care.

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🔷 Types of Birth Preparation

1. Antenatal preparation (during pregnancy)
2. Labour room preparation (hospital-based)
3. Immediate pre-delivery preparation (when woman is in active labour)

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🔷 I. Antenatal Preparation for Birth (during ANC visits)

💠 1. Health Education for Mother

• Importance of regular antenatal checkups
• Nutrition, rest, hydration, and hygiene
• Birth plan discussion (preferred hospital, delivery method)
• Danger signs in pregnancy
• Breastfeeding awareness
• Newborn care basics
• Importance of support person during labour

💠 2. Physical Preparation

• Iron, calcium, folic acid supplements
• Routine investigations (HB, BP, blood group, urine, HIV, HBsAg)
• TT immunization
• Perineal massage (from 36 weeks onward)
• Light exercise, walking

💠 3. Psychological Preparation

• Reassure and reduce anxiety about labour pain
• Birth preparedness classes (Lamaze, breathing techniques)
• Encourage participation of spouse or birth companion

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🔷 II. Preparation on Admission to Labour Room

💠 Initial Assessment

• General and obstetric history
• Vital signs, weight, gestational age
• Abdominal palpation (Leopold’s)
• Fetal heart rate (FHR) and fetal movement
• Vaginal examination (cervical status)

💠 Admission Checklist

✅ Hospital records/ANC card
✅ Consent forms signed
✅ Personal hygiene items
✅ Empty bladder
✅ Remove jewelry/dentures
✅ Wear clean maternity gown

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🔷 III. Environmental Preparation (Labour Room Setup)

💠 1. Cleanliness & Asepsis

• Clean and disinfected bed with mackintosh and linen
• Sterile delivery tray
• Handwashing and PPE setup for staff

💠 2. Equipment Ready

• Delivery table and light
• Sterile gloves, gauze, cotton, scissors
• Episiotomy and suture tray
• Suction machine and oxygen supply
• Neonatal resuscitation equipment (radiant warmer, bag-mask)
• IV fluids, oxytocin, emergency drugs

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🔷 IV. Immediate Pre-Delivery Preparation (Before Second Stage)

🟪 For the Mother:

• Provide emotional support and explanation
• Ensure she is in appropriate position (lithotomy or alternative)
• Empty bladder
• Perineal cleaning with antiseptic
• Drape and maintain privacy
• Encourage breathing and not to push until instructed

🟦 For the Baby:

• Prepare radiant warmer
• Keep cord clamp, towel, suction, vitamin K injection, ID tags ready
• Check functionality of bag and mask
• Warm wraps and cap for newborn

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🔷 Nurse/Midwife Responsibilities in Birth Preparation

Task	Description
Physical Assessment	Vitals, fetal status, labour progress
Environmental Readiness	Ensure aseptic, organized labour room
Emotional Support	Reassure, encourage breathing techniques
Sterile Field Setup	Delivery tray, newborn care corner ready
Documentation	Labour record, partograph, consent forms
Communication	Inform doctor and alert team if high-risk

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🔷 Checklist Summary: Birth Preparedness

Component	Prepared? ✅
Clean, ready labour bed
Sterile delivery set
Neonatal resuscitation kit
Emergency drug tray
Consent obtained
Mother briefed & supported
FHR and vitals checked
Perineum cleaned & draped

🌼 Positive Birth Environment.

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🔷 Definition

A Positive Birth Environment is a safe, supportive, respectful, and empowering space where a woman can give birth with privacy, dignity, comfort, and confidence, surrounded by caring, competent healthcare providers.

It encompasses the physical surroundings, emotional climate, attitudes of caregivers, and respect for the woman’s choices and culture.

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🔷 Importance of a Positive Birth Environment

• Enhances natural labour progression
• Reduces fear, anxiety, and stress
• Increases release of oxytocin and endorphins (natural pain relief)
• Promotes maternal satisfaction with childbirth
• Reduces medical interventions and complications
• Encourages mother-infant bonding and breastfeeding

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🔷 Key Elements of a Positive Birth Environment

💠 1. Physical Environment

• Clean, calm, and quiet labour room
• Adjustable lighting (soft, dim light preferred)
• Comfortable bed and supportive birth positions (not only lithotomy)
• Access to clean bathroom or toilet
• Temperature control (warm, not too cold)
• Privacy curtains or individual labour suites
• Soothing wall colors and decor (if possible)

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💠 2. Emotional and Psychological Support

• Respectful, kind, and non-judgmental caregivers
• Continuous support from midwife, nurse, or birth companion
• Encouragement and clear communication
• Reassurance and informed choice
• Respect for cultural and personal preferences
• Presence of a trusted birth companion or spouse

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💠 3. Communication and Respect

• Addressing the woman by her name
• Listening to her concerns, pain, or preferences
• Providing information and consent before procedures
• Ensuring confidentiality and dignity
• No shouting, rough handling, or ignoring the woman

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💠 4. Labour Tools and Comfort Aids

• Birthing balls, mats, pillows, chairs
• Hot water bottles or heating pads
• Music (if the woman wishes)
• Massage, breathing techniques
• Access to fluids or light snacks (if allowed)

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💠 5. Safe Clinical Practices

• Well-trained staff available 24/7
• Emergency equipment (resuscitation, PPH tray)
• Infection prevention protocols
• Fetal and maternal monitoring tools (FHR, BP, partograph)
• Respectful handling of complications without panic

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🔷 Role of Midwife/Nurse in Creating a Positive Birth Environment

Role	Description
Supportive Presence	Be present and attentive; do not leave the woman alone
Effective Communication	Explain what’s happening and why; answer her questions
Respectful Maternity Care	Avoid harsh language, unnecessary exposure, or rough exams
Encouragement and Coaching	Use calm voice, guide breathing, encourage pushing
Uphold Dignity	Maintain privacy and cover her body appropriately
Empower Her Choices	Respect her birthing preferences (positions, companion, etc.)

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🔷 Barriers to a Positive Birth Environment (To be Avoided)

🚫 Overcrowded and noisy rooms
🚫 Unclean or poorly lit settings
🚫 Lack of privacy or exposure
🚫 Verbal abuse or neglect
🚫 Frequent unnecessary vaginal exams
🚫 Ignoring the woman’s pain or emotional state
🚫 No space for birth companion

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✅ Summary: Features of a Positive Birth Environment

Feature	Description
Privacy	Curtains, respectful handling
Clean and safe space	Infection control, clean equipment
Supportive care	Compassionate staff, continuous presence
Empowering atmosphere	Woman involved in decision-making
Respect and dignity	Non-discriminatory, gentle care
Low-stress environment	Calm lighting, minimal noise

🌼 Respectful Maternity Care and Communication.

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🔷 Definition

Respectful Maternity Care (RMC) is an approach that emphasizes dignity, privacy, informed consent, non-discrimination, and support during pregnancy, labour, birth, and postpartum care.

It ensures that every woman is treated with kindness, empathy, and equality, irrespective of her background, and is actively involved in her care decisions.

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🔷 Importance of Respectful Care

• Enhances trust between the woman and care provider
• Reduces fear, trauma, and anxiety during childbirth
• Promotes positive birth experiences
• Reduces risk of maternal and neonatal complications
• Increases facility-based deliveries and community trust in health systems

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🔷 Key Principles of Respectful Care

Principle	Explanation
Dignity and Respect	Treat every woman as a human being, not a case
Privacy and Confidentiality	Use curtains, keep personal information private
Informed Consent	Explain procedures and ask for permission
Freedom from Harm/Abuse	No verbal, emotional, or physical abuse
Supportive Care	Emotional support, continuous presence
Non-Discrimination	Equal care for all women regardless of caste, religion, class, or age
Right to Information	Keep the woman informed at all stages
Right to a Birth Companion	Encourage involvement of spouse or support person

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🔷 Respectful Communication Skills for Nurses and Midwives

💬 1. Verbal Communication

• Greet by name, introduce yourself
• Speak calmly and clearly
• Explain procedures before doing them
• Ask, “Is it okay if I proceed?” or “Do you have any questions?”
• Use reassuring phrases like:
  • “You are doing great.”
  • “I am here with you.”
  • “Tell me how you feel.”

🤝 2. Non-Verbal Communication

• Smile warmly
• Maintain gentle eye contact
• Use soothing tone and relaxed posture
• Offer a hand to hold, gentle touch (with consent)

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🔷 Respectful Behaviour Examples in Labour Room

Respectful Care ✅	Disrespectful Care ❌
Asking permission before exams	Doing internal exam without explaining
Covering woman’s body during procedures	Leaving woman exposed
Encouraging words and coaching	Scolding, yelling, or blaming
Allowing companion during labour (if policy allows)	Isolating woman from family
Explaining delay or change in plan	Ignoring woman’s questions or concerns
Using her preferred language or dialect	Speaking rudely or in unfamiliar language

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🔷 Nurse/Midwife Responsibilities in Providing Respectful Care

✅ Treat all women equally
✅ Maintain privacy and confidentiality
✅ Use polite and clear language
✅ Respect cultural beliefs and choices
✅ Encourage birth companion if allowed
✅ Educate, involve, and empower the woman
✅ Document informed consent and care provided

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🔷 Barriers to Respectful Care (to be avoided)

🚫 Overcrowding and lack of privacy
🚫 High workload leading to neglect
🚫 Discrimination based on religion, caste, poverty
🚫 Verbal or physical abuse
🚫 Ignoring woman’s pain, fear, or voice

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✅ Quick Checklist: Are You Providing Respectful Maternity Care?

• ☑ Did you greet the woman respectfully?
• ☑ Did you explain each procedure?
• ☑ Did you cover her body and ensure privacy?
• ☑ Did you encourage questions or feedback?
• ☑ Did you avoid shouting or scolding?
• ☑ Did you promote skin-to-skin and breastfeeding?
• ☑ Did you allow a birth companion (if policy permits)?

🌼 Drugs Used in Labour.

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🔷 1. Oxytocin (Pitocin)

✅ Action:

• Stimulates uterine smooth muscle → increases frequency and intensity of contractions.

✅ Uses/Indications:

• Induction or augmentation of labour
• Management of postpartum hemorrhage (PPH)
• Facilitate placental expulsion

🚫 Contraindications:

• Cephalopelvic disproportion (CPD)
• Malpresentation (breech, transverse)
• Previous classical C-section
• Fetal distress

⚠️ Side Effects:

• Uterine hyperstimulation
• Fetal distress (due to decreased placental perfusion)
• Uterine rupture (rare but serious)
• Water intoxication (with prolonged infusion)

🧑‍⚕️ Role of Nurse:

• Monitor FHR and uterine contractions closely
• Administer via IV infusion with controlled dose
• Discontinue if signs of fetal distress or hypertonic uterus
• Keep emergency resuscitation tray ready

✳️ Key Points:

• Always dilute before IV use
• Never give bolus IV injection
• Monitor vitals, contraction pattern, and fetal status

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🔷 2. Misoprostol (Cytotec)

✅ Action:

• Prostaglandin E1 analogue – softens cervix and stimulates uterine contractions.

✅ Uses/Indications:

• Induction of labour (especially in unripe cervix)
• Medical abortion
• Prevention and treatment of PPH

🚫 Contraindications:

• Previous uterine scar
• Hypersensitivity to prostaglandins
• Non-viable fetus (in live induction)

⚠️ Side Effects:

• Fever, chills, diarrhea
• Uterine tachysystole
• Uterine rupture (especially with prior C-section)

🧑‍⚕️ Role of Nurse:

• Ensure correct route (oral, sublingual, or vaginal)
• Monitor uterine activity and fetal response
• Do not repeat dose too early (min 4-6 hrs apart for induction)
• Educate patient about expected effects

✳️ Key Points:

• Cheap and effective drug for labour use
• Store in a dry, room-temperature place
• Vaginal route is most effective for induction

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🔷 3. Dinoprostone (Prostaglandin E2 – Cerviprime gel)

✅ Action:

• Ripens (softens) cervix and stimulates myometrial contractions.

✅ Uses/Indications:

• Cervical ripening prior to labour induction
• Induction of labour

🚫 Contraindications:

• Previous uterine scar
• Active labour
• Hypersensitivity
• Malpresentation

⚠️ Side Effects:

• Nausea, vomiting
• Diarrhea, cramping
• Hyperstimulation of uterus

🧑‍⚕️ Role of Nurse:

• Store in refrigerator (2–8°C)
• Insert intracervically under aseptic precautions
• Monitor FHR and uterine contractions
• Observe for signs of hypertonicity or fetal distress

✳️ Key Points:

• Not for use in women with uterine surgery history
• Monitor closely after insertion (2–3 hrs)

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🔷 4. Methylergometrine (Methergine)

✅ Action:

• Causes sustained uterine contraction via smooth muscle stimulation.

✅ Uses/Indications:

• Prevention and treatment of PPH due to uterine atony

🚫 Contraindications:

• Hypertension or pre-eclampsia
• Heart disease
• Peripheral vascular disease

⚠️ Side Effects:

• Hypertension
• Nausea, vomiting
• Headache
• Chest pain

🧑‍⚕️ Role of Nurse:

• Give IM slowly, preferably after delivery of placenta
• Monitor BP before and after administration
• Avoid use in hypertensive women
• Report headache, dizziness, chest pain

✳️ Key Points:

• Store in refrigerator
• Not for use in labour (only postpartum)

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🔷 5. Lignocaine (Lidocaine)

✅ Action:

• Local anesthetic: blocks nerve impulse conduction.

✅ Uses/Indications:

• Episiotomy and tear repair
• Local infiltration anesthesia during vaginal delivery

🚫 Contraindications:

• Allergy to local anesthetics
• Severe liver dysfunction (in systemic use)

⚠️ Side Effects:

• Local swelling, redness
• Rare systemic toxicity (if given intravascularly)

🧑‍⚕️ Role of Nurse:

• Confirm no allergy before use
• Use sterile technique
• Observe for numbness and pain relief
• Monitor site for infection or hematoma

✳️ Key Points:

• Use 1% or 2% lignocaine for infiltration
• Always aspirate before injecting (avoid vessel entry)

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🔷 6. Magnesium Sulphate (MgSO₄)

✅ Action:

• CNS depressant; prevents seizures in eclampsia; smooth muscle relaxant.

✅ Uses/Indications:

• Eclampsia and severe preeclampsia
• Neuroprotection in preterm labour

🚫 Contraindications:

• Heart block
• Renal failure
• Myasthenia gravis

⚠️ Side Effects:

• Respiratory depression
• Flushing, warmth
• Loss of deep tendon reflexes
• Decreased urine output

🧑‍⚕️ Role of Nurse:

• Monitor respiratory rate, urine output, and reflexes
• Keep calcium gluconate ready as antidote
• Administer via IV slowly with proper dilution
• Educate woman on possible side effects

✳️ Key Points:

• Therapeutic range: 4–7 mEq/L
• Monitor every 2 hrs during infusion

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🔷 7. Antibiotics (e.g., Ampicillin, Ceftriaxone)

✅ Action:

• Kill or inhibit growth of bacteria

✅ Uses/Indications:

• Prophylaxis in PROM or infection
• Maternal fever during labour
• GBS colonization

🚫 Contraindications:

• Known allergy to specific antibiotics

⚠️ Side Effects:

• Rash, diarrhea, allergic reaction
• Nausea

🧑‍⚕️ Role of Nurse:

• Confirm no allergy history
• Administer on time (especially in PROM or GBS cases)
• Monitor for allergic reactions
• Document administration and response

✳️ Key Points:

• Use as per physician’s order
• Ensure full course is completed

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✅ Summary Table: Quick Reference

Drug Name	Use in Labour	Key Caution
Oxytocin	Induction, PPH prevention	Uterine rupture, monitor FHR closely
Misoprostol	Induction, PPH	Avoid in scarred uterus
Dinoprostone	Cervical ripening	Risk of hyperstimulation
Methergine	Postpartum bleeding control	Avoid in hypertension
Lignocaine	Local anesthesia (episiotomy)	Check allergy before use
Magnesium sulphate	Prevent eclamptic seizures	Monitor reflexes, respiration, urine
Antibiotics	PROM, fever, infection	Check allergy and infection signs

🌼 First Stage of Labour – Physiology of Normal Labour.

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🔷 Definition

The first stage of labour begins with the onset of regular, painful uterine contractions and ends with complete cervical dilatation (10 cm). It is marked by cervical effacement and dilation, along with fetal descent.

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🔷 Phases of the First Stage

1. Latent Phase: 0–4 cm cervical dilation
2. Active Phase: 4–7 cm cervical dilation
3. Transition Phase: 8–10 cm cervical dilation

Each phase represents progressive intensity of uterine contractions and structural changes in the cervix and uterus.

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🔷 Physiological Events in First Stage of Labour

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🔹 1. Role of Hormones

a. Oxytocin:

• Released by the posterior pituitary.
• Stimulates uterine contractions by acting on oxytocin receptors in the uterus.
• Positive feedback loop: Contractions → Cervical stretch → More oxytocin.

b. Prostaglandins (E2, F2α):

• Cause softening and ripening of the cervix (cervical effacement).
• Stimulate mild uterine contractions.
• Produced locally in amniotic membranes and decidua.

c. Estrogen:

• Increases uterine sensitivity to oxytocin.
• Promotes prostaglandin production.
• Enhances uterine contractility.

d. Relaxin:

• Softens the cervix and pelvic ligaments.
• Helps accommodate fetal descent.

e. Fetal Cortisol:

• Produced by maturing fetal adrenal glands.
• Triggers production of placental estrogens and prostaglandins → initiates labour.

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🔹 2. Uterine Contractions

• Involuntary, rhythmic, and coordinated.
• Originates from the pacemaker zone at the fundus.
• Spread downward in fundal dominance (strongest at the top).
• Cause retraction of upper uterine segment and dilation of cervix.
• Lower segment becomes thinner and more passive.

🔸 Characteristics of Normal Labour Contractions:

Feature	Early Labour	Active Labour
Frequency	10–15 mins apart	2–5 mins apart
Duration	30–45 seconds	60–90 seconds
Intensity	Mild–Moderate	Moderate–Strong

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🔹 3. Cervical Changes

a. Effacement:

• Thinning and shortening of the cervix.
• Measured in percentage: 0% (thick) to 100% (fully effaced).

b. Dilatation:

• Opening of cervical os from 0 to 10 cm.
• Facilitated by:
  • Uterine contractions
  • Fetal head pressure
  • Enzymatic changes and prostaglandins

💡 Effacement usually precedes dilation in primigravidas, but both may happen simultaneously in multiparas.

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🔹 4. Formation of Lower Uterine Segment

• During labour, the upper segment contracts and retracts.
• The lower segment stretches and forms a soft passage to facilitate fetal descent.

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🔹 5. Descent and Engagement of Fetus

• The presenting part (usually head) moves into the pelvis.
• Engagement occurs when the biparietal diameter (largest head width) passes the pelvic brim.
• Occurs before labour in primigravidas, during labour in multiparas.

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🔹 6. Show and Rupture of Membranes

• Show: Blood-tinged mucus due to rupture of cervical capillaries and mucous plug discharge.
• Rupture of membranes (ROM):
  • Spontaneous (SROM): Normal event during labour.
  • Artificial (AROM): May be done to augment labour.

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🔹 7. Fetal Movements and Positioning

• During descent, the fetal head undergoes flexion, which allows the smallest diameter to pass.
• Rotation and alignment of the fetal head begins in this stage to prepare for birth.

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🔹 8. Maternal Systemic Responses

• Increased cardiac output: Due to pain and contractions.
• Increased respiratory rate: Due to anxiety and energy expenditure.
• Elevated WBC count: Normal in labour due to stress response.
• Pain perception: Due to cervical dilation, ischemia of uterine muscle, and stretching of perineum.
• Psychological responses: Anxiety, excitement, fear — depend on support, environment, and preparation.

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🔷 Midwifery Focus: Monitoring During First Stage

Component	Action
Maternal Vitals	Every 2–4 hrs (BP, pulse, temp)
Uterine Contractions	Frequency, duration, intensity
Fetal Heart Rate	Every 30 minutes (intermittent auscultation)
Cervical Dilatation	Assessed through vaginal exam
Bladder care	Encourage emptying every 2 hours
Pain support	Reassurance, breathing, massage
Partograph	To monitor and record progress

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✅ Summary of First Stage Labour Physiology

Process	Description
Uterine contractions	Trigger cervical changes and fetal descent
Hormonal activity	Oxytocin and prostaglandins regulate labour
Cervical effacement	Thinning of cervix to allow dilation
Cervical dilation	From 0 to 10 cm due to pressure and contractions
Fetal descent and engagement	Head enters pelvis and rotates
Maternal response	Physical and psychological adjustments to labour

🌼 Monitoring Progress of Labour Using Partograph.

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🔷 What is a Partograph?

A Partograph (or Partogram) is a simple, graphical tool used to monitor labour, plot its progress, and identify abnormal labour patterns early. It helps in decision-making to ensure safe delivery and prevent complications like prolonged labour, obstructed labour, or fetal distress.

Originally introduced by the World Health Organization (WHO), it is a key component of respectful, evidence-based intrapartum care.

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🔷 Objectives of Using a Partograph

• Monitor the progress of labour
• Monitor maternal and fetal condition
• Identify deviations from normal labour
• Guide timely and appropriate interventions
• Prevent prolonged labour and complications

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🔷 When to Start the Partograph?

Start the partograph when:

• Cervical dilatation is ≥ 4 cm (active phase of labour begins)
• Regular uterine contractions are established

✳️ Do not use the partograph during the latent phase (<4 cm).

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🔷 Main Sections/Components of the WHO Partograph

The partograph is divided into three major sections:

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🟪 1. Fetal Condition

Parameter	Details
Fetal heart rate (FHR)	Every 30 mins – plotted in beats/min
Amniotic fluid (Liquor)	I = Intact; C = Clear; M = Meconium-stained; B = Blood-stained
Moulding of fetal skull bones	Degree of overlapping of sutures (0 to +++)

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🟩 2. Labour Progress

Parameter	Details
Cervical dilatation	Plotted as X every 4 hrs or sooner
Alert line	Indicates normal expected progress (1 cm/hr)
Action line	4 hrs to the right of alert line – intervention needed if crossed
Descent of head	Plotted as O (5/5 to 0/5 palpable above symphysis pubis)

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🟨 3. Maternal Condition

Parameter	Frequency
Pulse	Every 30 mins
BP and Temperature	Every 4 hours
Urine output, protein, acetone	As indicated
Contractions (duration & frequency)	Every 30 mins:
• One square = 10 mins
• Mark number and strength
(Weak, Moderate, Strong)

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🔷 How to Plot a Partograph – Step-by-Step

💠 1. Identify the woman

• Name, gravida, para, hospital number, date, time of admission

💠 2. Start plotting

• When active labour (≥ 4 cm dilation) begins
• Place first “X” for cervical dilation at the correct hour/time
• Plot corresponding descent with an “O”

💠 3. Monitor and update regularly

• FHR every 30 mins
• Contractions every 30 mins
• Cervical exam every 4 hours (or sooner if needed)
• Vitals, urine output, and other maternal signs

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🔷 Interpretation of the Partograph

Position of Dilatation Plot	Action Required
On or left of alert line	Labour is progressing normally
Between alert and action lines	Observe closely and prepare for possible intervention
Crossing the action line	Intervene – consider augmentation, referral, or cesarean section

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🔷 Nursing and Midwifery Responsibilities

✅ Start the partograph at the right time (4 cm dilatation)
✅ Update it accurately and timely
✅ Observe and report any deviations from normal
✅ Monitor FHR, contractions, vitals regularly
✅ Communicate findings to senior staff/obstetrician
✅ Maintain asepsis during vaginal examinations
✅ Educate and support the labouring woman emotionally

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🔷 Advantages of the Partograph

• Early identification of prolonged or obstructed labour
• Prevents maternal and neonatal complications
• Aids in clinical decision-making
• Encourages evidence-based and respectful maternity care
• Helps maintain complete labour records

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✅ Key Points to Remember

• Only start once active labour begins (≥4 cm)
• Always mark FHR, dilation, contractions, vitals
• Alert line = guide; Action line = act
• Should be used for every labouring woman in a facility
• Keep partograph in mother’s record/file for reference

🌼 Assessing and Monitoring Fetal Well-Being.

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🔷 Definition

Fetal well-being assessment involves the systematic monitoring of the fetus to ensure it is healthy, growing properly, and not in distress, especially during labour and antenatal care. The goal is to ensure a safe outcome for the baby and timely intervention if complications arise.

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🔷 Why is Monitoring Fetal Well-Being Important?

• Detect fetal distress early
• Prevent intrauterine hypoxia, stillbirth, or brain damage
• Ensure timely decision-making (e.g., cesarean section if needed)
• Evaluate effectiveness of labour and maternal oxygenation
• Provide reassurance to the mother

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🔷 When to Assess Fetal Well-Being?

1. During Antenatal Period (ANC visits)
2. On Admission in Labour
3. Throughout Labour (especially during 1st and 2nd stages)
4. High-Risk Pregnancies (e.g., hypertension, diabetes, oligohydramnios)

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🔷 Methods of Assessing Fetal Well-Being

🟩 A. During Antenatal Period (Before Labour)

1. Fetal Movement Count (Kick Count)

• Woman counts movements: should feel 10 movements in 12 hours or 3 movements in 1 hour after meals.
• ↓ Movements → suspect distress → refer for NST or ultrasound.

2. Non-Stress Test (NST)

• External monitoring of FHR and fetal movements for 20 minutes.
• Reactive NST: ≥2 accelerations (≥15 bpm for ≥15 secs) → reassuring.
• Non-reactive NST → needs further testing.

3. Biophysical Profile (BPP)

• Combination of NST and ultrasound.
• Scored out of 10 (includes fetal breathing, movement, tone, amniotic fluid).

4. Doppler Ultrasound

• Measures blood flow in umbilical artery.
• Used in growth-restricted or high-risk pregnancies.

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🟨 B. During Labour

1. Intermittent Auscultation (IA)

• Using fetoscope or Doppler to listen to FHR.
• Every 30 minutes in first stage, every 5 minutes in second stage.
• Normal FHR = 110–160 beats/min

2. Continuous Electronic Fetal Monitoring (EFM/CTG)

• Monitors FHR and uterine contractions via machine.
• Used in high-risk or prolonged labours.
• Traces baseline, variability, accelerations, decelerations.

3. Assessment of Amniotic Fluid (Liquor)

• Clear = reassuring
• Meconium-stained = possible fetal distress
• Blood-stained = possible abruption

4. Fetal Scalp Stimulation (In Labour)

• During vaginal exam – touching fetal scalp may cause acceleration.
• No acceleration → could suggest hypoxia.

5. Fetal Scalp Blood Sampling (Advanced)

• For pH testing if fetal distress suspected.
• Rare in basic midwifery settings.

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🔷 Normal Fetal Findings (Reassuring Signs)

Parameter	Normal/Healthy Value
FHR (Baseline)	110–160 bpm
Variability	Moderate (6–25 bpm)
Accelerations	Present (≥15 bpm for ≥15 sec)
Decelerations	Absent or early only
Fetal movements	10 or more in 12 hours
Liquor	Clear, adequate quantity

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🔷 Signs of Fetal Distress

⚠️ Take immediate action if any of the following are observed:

• FHR <110 bpm (bradycardia) or >160 bpm (tachycardia)
• Late or variable decelerations on CTG
• Decreased or absent fetal movements
• Meconium-stained or foul-smelling liquor
• Persistent loss of beat-to-beat variability
• Prolonged labour with poor progress

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🔷 Nursing Responsibilities in Fetal Monitoring

Task	Role of Nurse/Midwife
Check and record FHR regularly	IA or CTG as per protocol
Interpret FHR patterns and variability	Know normal and abnormal signs
Communicate abnormal findings	Inform doctor/supervisor immediately
Maintain partograph	Plot FHR, dilation, contractions
Provide emotional support	Reassure the mother during monitoring
Monitor and document amniotic fluid	Color, amount, odor
Prepare for resuscitation if needed	Newborn care corner ready

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✅ Key Points to Remember

• Normal FHR: 110–160 bpm
• Always monitor before, during, and after contractions
• Never ignore reduced fetal movements or abnormal heart rate
• Be vigilant during high-risk pregnancies
• Keep neonatal resuscitation kit ready
• Accurate documentation is essential

🌼 Care During the First Stage of Normal Labour.

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🔷 Definition

The first stage of labour starts with the onset of regular uterine contractions and ends when the cervix is fully dilated (10 cm). The goal of care during this stage is to support the mother, monitor labour progress, and identify complications early, while ensuring the well-being of both mother and fetus.

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🔷 Objectives of Care

• Monitor progress of labour
• Ensure fetal and maternal well-being
• Provide emotional support and pain relief
• Prevent complications
• Maintain clean and safe delivery environment

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🔷 Key Areas of Care During First Stage

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🟪 1. Maternal Assessment and Monitoring

Parameter	Frequency
Vital Signs (BP, pulse, temp)	Every 4 hours (BP more frequently if needed)
Uterine contractions	Every 30 minutes
Pain level and coping	Continuous observation
Bladder status	Encourage voiding every 2 hrs
Hydration & nutrition	Oral fluids/light diet if allowed

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🟩 2. Fetal Monitoring

Parameter	Frequency
Fetal Heart Rate (FHR)	Every 30 minutes (or continuously if high-risk)
Amniotic fluid	Observe for color, odor, amount
Fetal movements	Ask mother periodically
Partograph	Used to plot FHR, cervical dilation, contractions, etc.

🟨 Meconium-stained liquor or abnormal FHR should be reported immediately.

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🟦 3. Monitoring Labour Progress

• Use of Partograph:
  • Plot cervical dilatation (every 4 hrs)
  • Monitor descent of fetal head
  • Record uterine contractions (strength, frequency, duration)
  • Note maternal vitals and urine output

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🟨 4. Pain Management and Comfort Measures

Non-Pharmacological Methods	Details
Breathing techniques	Slow, deep breathing during contractions
Position changes	Walking, sitting, side-lying, squatting
Back massage	Helps relieve pain and anxiety
Warm bath or compress	If facility allows
Emotional support	Reassurance, continuous presence

Pharmacologic pain relief (e.g., pethidine, epidural) should be used only if indicated and under supervision.

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🟧 5. Infection Prevention and Hygiene

• Use clean linens and sterile gloves
• Perform vaginal examinations only when necessary
• Clean the perineum gently and regularly
• Follow handwashing and PPE protocols
• Encourage hand hygiene for birth companions (if present)

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🟥 6. Emotional Support and Communication

• Explain each step and progress of labour
• Reassure and reduce anxiety
• Encourage the presence of a birth companion (if allowed)
• Treat the woman with respect, privacy, and dignity
• Use calm, positive language during pain or panic

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🔷 Encouraged Practices During First Stage

✅ Encourage walking/mobility unless contraindicated
✅ Allow light food or oral fluids (as per protocol)
✅ Ensure bladder is emptied frequently
✅ Educate on breathing and relaxation
✅ Promote positive birthing mindset

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🔷 What to Avoid

🚫 Frequent unnecessary vaginal examinations
🚫 Leaving the woman unattended
🚫 Shouting, scolding, or blaming
🚫 Withholding fluids without medical indication
🚫 Ignoring pain or distress

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🔷 Documentation

• Start and update Partograph
• Record:
  • Time of admission and cervical status
  • Uterine contraction pattern
  • FHR and maternal vitals
  • Time and findings of vaginal examinations
  • Any medications or interventions
  • Emotional status and coping ability

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✅ Nurse/Midwife’s Role Summary

Task	Description
Monitor maternal and fetal health	Vitals, contractions, FHR, bladder, hydration
Provide comfort and support	Emotional care, breathing techniques
Detect abnormal signs early	Meconium-stained liquor, FHR <110 or >160 bpm
Ensure respectful care	Privacy, dignity, consent
Document accurately	Maintain clear and complete records

🌼 Non-Pharmacological Pain Relief in Labour.

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🔷 Definition

Non-pharmacological pain relief methods are natural, supportive techniques used to help a woman cope with labour pain without using medications. These methods enhance a sense of control, reduce fear and anxiety, and stimulate the body’s natural pain relief mechanisms like endorphins and oxytocin.

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🔷 Why Use Non-Pharmacological Methods?

• Promotes physiological labour
• Avoids side effects of drugs
• Enhances maternal satisfaction
• Supports woman-centered care
• Encourages active participation and empowerment
• Useful in low-resource settings

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🔷 Common Non-Pharmacological Methods for Labour Pain Relief

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🟪 1. Breathing Techniques

💠 Types:

• Slow-paced breathing: Inhale slowly through the nose, exhale through the mouth.
• Patterned breathing: Rhythmic breathing with each contraction.
• Blowing or panting: Used in transition phase to avoid early pushing.

💠 Benefits:

• Keeps mother calm and focused
• Improves oxygenation for mother and baby
• Reduces tension and perception of pain

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🟩 2. Position Changes and Mobility

Position	Benefits
Upright (walking, standing)	Gravity helps fetal descent, less pain
Sitting on birthing ball	Eases back pressure
Squatting	Widens pelvic outlet
Side-lying (left lateral)	Improves circulation, rest
Kneeling or on all fours	Relieves back pain, helps rotation of baby

🔸 Encourage the woman to change positions frequently based on comfort.

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🟦 3. Continuous Labour Support

💠 By: Nurse, midwife, doula, or birth companion

💠 Includes:

• Reassurance, encouragement
• Holding hands, eye contact
• Speaking gently and positively

✅ Proven to shorten labour and reduce need for interventions.

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🟨 4. Massage and Touch Therapy

Area	Technique
Lower back	Firm circular massage (counterpressure)
Shoulders, arms	Gentle stroking
Feet	Light rubbing or reflexology

💠 Benefits:

• Relaxes muscles and reduces tension
• Stimulates endorphin release
• Helps woman feel cared for and safe

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🟧 5. Warmth Application (Heat Therapy)

• Use of warm compress or hot water bag on:
  • Lower back
  • Lower abdomen
  • Perineum

💠 Effects:

• Relaxes muscles
• Reduces pain perception
• Improves blood flow

✅ Avoid overheating and always test temperature to prevent burns.

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🟥 6. Hydrotherapy

• Warm water immersion in bathtub or shower
• Often used in early labour

💠 Benefits:

• Soothes muscles
• Promotes relaxation
• Enhances feeling of buoyancy

⚠️ May not be available in all facilities.

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🟫 7. Cold Compresses

• Applied to face, neck, lower back, or perineum.
• Useful in swollen areas or for comfort in hot environments.

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🔷 8. Distraction and Mental Techniques

• Visualization (e.g., imagining waves or calming scenes)
• Music therapy
• Counting, chanting, or repeating mantras
• Guided imagery

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🔶 9. Acupressure and Reflexology

• Pressure points on hands, feet, lower back, shoulders
• Stimulates energy flow and reduces tension

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🟪 10. Aromatherapy (If Allowed and Safe)

• Essential oils like lavender, clary sage, or peppermint
• Can be used via diffuser or cotton ball

⚠️ Always check for allergies and contraindications.

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🔷 Nurse/Midwife’s Role in Non-Pharmacological Pain Relief

Responsibility	Action
Assess pain level	Use pain scale (0–10), verbal cues
Educate and guide	Teach breathing and comfort techniques
Provide emotional support	Stay with the woman, use calming words
Maintain safety and comfort	Adjust bed, check hydration, prevent falls
Encourage birth companion	Allow supportive person (if permitted)
Promote privacy and dignity	Use curtains and speak respectfully

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✅ Key Points to Remember

• Begin pain relief early in labour
• Encourage movement, position changes, and breathing
• Maintain a calm, clean, private, and supportive environment
• Always respect the woman’s preferences
• Combine multiple techniques based on individual comfort

🌼 Pharmacological Pain Relief in Labour.

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🔷 Definition

Pharmacological pain relief in labour refers to the use of medications to manage and reduce labour pain, helping the mother cope with contractions and maintain comfort during childbirth.

These medications include systemic analgesics, regional anesthesia, and local anesthesia.

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🔷 Goals of Pharmacological Pain Relief

• Reduce or eliminate pain perception
• Provide relaxation and rest
• Support positive birth experience
• Allow mother to participate actively in labour

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🔷 Classification of Pharmacological Pain Relief in Labour

🟪 1. Systemic Analgesics (Injectable Pain Relief)

🔸 a. Pethidine (Meperidine)

• Route: IM or IV
• Dose: 50–100 mg IM every 4 hours

✅ Uses: Moderate pain relief during early labour
🚫 Contraindications: Severe fetal distress, respiratory issues
⚠️ Side Effects:

• Nausea, vomiting
• Drowsiness
• Neonatal respiratory depression (if given near delivery)

🔹 Nursing Role:

• Monitor FHR and maternal vitals
• Give antiemetic (e.g., promethazine) to reduce nausea
• Do not give within 2 hours of expected delivery

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🔸 b. Tramadol

• Mild to moderate pain relief
• Longer-acting than pethidine

✅ Less neonatal respiratory depression
⚠️ May cause nausea, dizziness, and drowsiness

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🟩 2. Regional Analgesia/Anesthesia

🔸 a. Epidural Analgesia

• Administered into epidural space of spine
• Mixture of local anesthetic (bupivacaine) + opioid (fentanyl)
• Most effective form of labour pain relief

✅ Uses:

• Severe labour pain
• Women requesting full pain relief
• High-risk pregnancies (preeclampsia, heart disease)

🚫 Contraindications:

• Low platelets, bleeding disorders
• Infection at site
• Spinal abnormalities

⚠️ Side Effects:

• Hypotension
• Prolonged labour or reduced pushing urge
• Urinary retention
• Headache (rare)

🔹 Nursing Role:

• Monitor BP every 15 mins
• Monitor FHR continuously
• Assist with positioning and bladder care
• Support mother’s mobility (may need help walking)

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🔸 b. Spinal Anesthesia

• Given into subarachnoid space
• Rapid onset, used mostly for C-sections

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🟨 3. Inhalational Analgesia

🔸 Entonox (Nitrous Oxide + Oxygen, 50:50)

• Inhaled via mask or mouthpiece during contractions
• Fast onset, short-acting, self-administered

✅ Uses: First stage of labour, short procedures
⚠️ Side Effects:

• Dizziness
• Light-headedness
• Nausea

🔹 Nursing Role:

• Teach correct breathing technique
• Ensure equipment is functioning
• Monitor for overuse or side effects

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🟥 4. Local Anesthesia

🔸 a. Lignocaine (Lidocaine)

• Used for:
  • Episiotomy
  • Perineal tear repair
  • Local infiltration before delivery

✅ Safe and effective for perineal procedures
⚠️ Avoid intravascular injection

🔹 Nursing Role:

• Check for allergy
• Assist with sterile preparation
• Monitor local swelling or allergic reaction

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🔷 Comparison Table of Common Pharmacological Pain Relief Options

Method	Route	Onset	Used in	Side Effects
Pethidine	IM/IV	10–20 min	Early labour	Drowsiness, Nausea, Neonatal depression
Tramadol	IM	15–30 min	Moderate pain	Dizziness, Dry mouth
Epidural	Injection into spine	15–30 min	Active labour	Hypotension, Urinary retention
Entonox	Inhalation	Immediate	All stages	Light-headedness, Nausea
Lignocaine	Local injection	2–5 min	Episiotomy	Local allergy or swelling

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🔷 General Nursing Responsibilities for Pain Relief in Labour

Task	Details
Assess pain level and labour stage	Choose suitable method accordingly
Educate mother	Explain effects, options, and safety
Obtain consent	Especially for regional anesthesia
Monitor vitals	BP, pulse, FHR regularly
Watch for side effects	Especially hypotension or fetal bradycardia
Provide emotional reassurance	Pain relief is more effective with support
Document drug, dose, time	Essential for safety and evaluation

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✅ Key Points to Remember

• Always assess maternal and fetal condition before giving any pain relief
• Avoid systemic opioids near time of delivery
• Monitor FHR and uterine contractions during and after administration
• Respect the woman’s pain perception and choice
• Combine with non-pharmacological methods for best results

🌼 Psychological Support in Labour – Managing Fear.

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🔷 Definition

Psychological support during labour refers to the emotional and mental care provided to the woman to help her cope with anxiety, fear, and pain, enhancing her sense of safety, confidence, and control.

Managing fear in labour is a vital component of respectful maternity care, improving both maternal satisfaction and labour outcomes.

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🔷 Causes of Fear in Labouring Women

Cause	Description
Fear of pain	Intense contractions, unknown sensations
Fear of the unknown	First-time mothers or traumatic past experiences
Fear of death/complications	Worry about own or baby’s safety
Fear of losing control	Feeling overwhelmed or helpless
Hospital environment	Noisy, cold, unfamiliar settings
Negative stories or beliefs	From other women or media
Lack of support	Absence of birth companion or kind staff

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🔷 Effects of Fear on Labour

• Increased adrenaline and stress hormones → interferes with oxytocin production
• Delayed labour progress → cervical dilation slows
• Pain perception increases
• Higher risk of interventions or cesarean section
• May result in traumatic birth experience
• Can impact bonding and postpartum mental health

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🔷 Goals of Psychological Support

• Reduce anxiety, fear, and tension
• Promote emotional well-being and confidence
• Encourage active participation in labour
• Improve maternal and fetal outcomes

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🔷 Supportive Strategies to Manage Fear

🟩 1. Building Trust and Rapport

• Greet with warmth and introduce yourself
• Use her name, maintain eye contact, and speak calmly
• Reassure her that she is safe and supported

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🟦 2. Provide Clear and Honest Information

• Explain each stage of labour and what to expect
• Use simple language to describe any procedures
• Address myths and misconceptions
• Encourage her to ask questions

✅ Information reduces fear by creating understanding and control.

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🟨 3. Involve the Woman in Decision-Making

• Respect her birth preferences and choices
• Ask for consent before exams or interventions
• Keep her informed about progress and any changes
• Empower her to express needs or concerns

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🟥 4. Encourage a Supportive Environment

• Allow presence of a birth companion (partner, mother, friend)
• Provide privacy with curtains/screens
• Reduce noise and harsh lights
• Allow personal items like shawl, music, prayer beads

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🟪 5. Use Comfort Techniques to Calm the Mind

• Breathing techniques: Slow and deep breathing to reduce tension
• Massage: Gentle back or hand massage
• Positive affirmations: “You are doing well,” “Your body knows what to do.”
• Visualization: Encourage her to imagine a peaceful place or baby’s arrival
• Distraction: Music, soft touch, rhythmic counting

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🟫 6. Respect Cultural and Personal Beliefs

• Be sensitive to religious or cultural preferences
• Allow specific birthing positions or customs if safe
• Avoid judgmental language or behavior

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⚪ 7. Remain Present and Available

• Stay with her or check frequently
• Touch her hand, speak softly
• Offer empathy, not just medical care

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🔷 Nurse/Midwife’s Role in Managing Fear

Role	Responsibilities
Emotional support	Listen, reassure, and stay calm
Communication	Clear, kind, and respectful dialogue
Education	Teach about breathing, labour, birth
Empowerment	Let her make choices and express herself
Monitoring	Observe for extreme distress or panic
Documentation	Note emotional status, responses, interventions

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✅ Key Phrases to Use for Psychological Support

• “You are not alone. I am here with you.”
• “You’re strong, and your body is working beautifully.”
• “Let’s breathe together.”
• “Tell me how you are feeling.”
• “You can do this.”

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❌ What to Avoid

• Harsh words or shouting
• Ignoring her emotional needs
• Performing procedures without explanation
• Leaving her alone for long periods
• Mocking her fears or crying
• Forcing positions or decisions

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✅ Summary: Supporting a Woman Emotionally in Labour

What to DO ✅	What to AVOID ❌
Use gentle voice, soft touch	Yelling or scolding
Explain everything	Ignoring her questions
Encourage and reassure	Saying “stop crying” or “don’t be scared”
Stay close or check frequently	Leaving her alone
Respect cultural needs	Forcing own methods
Involve companion if allowed	Keeping woman isolated

🌼 Activity and Positioning During First Stage of Labour.

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🔷 Definition

During the first stage of labour, encouraging mobility and appropriate positioning helps the woman cope with pain, facilitates fetal descent, promotes cervical dilatation, and enhances maternal comfort.

Labour is more efficient and less painful when the mother is active and upright, rather than lying flat on her back.

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🔷 Goals of Activity and Positioning

• Promote physiological labour progression
• Enhance comfort and pain management
• Use gravity to aid fetal descent
• Support maternal autonomy and confidence
• Reduce the risk of prolonged labour and interventions

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🔷 Recommended Activities During First Stage

✅ Encouraged Activities

• Walking in or near the labour room
• Swaying, rocking, or dancing gently
• Using birthing ball (sitting or bouncing lightly)
• Showering or bathing (if facility allows)
• Leaning forward on bed or partner for contractions
• Pelvic tilts or light stretches

🔸 Activities should be done based on comfort and no contraindications (e.g., bleeding, fetal distress).

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🔷 Labour Positions in First Stage and Their Benefits

Position	Benefits
Upright (Standing/Walking)	Uses gravity to assist fetal descent, shortens labour
Sitting (on bed, chair, ball)	Reduces back pressure, promotes pelvic flexibility
Squatting	Opens pelvic outlet, effective for active labour
Side-lying (Left lateral)	Conserves energy, improves uterine blood flow
Hands-and-knees (all fours)	Eases back pain, helps rotate posterior baby
Kneeling or leaning forward	Relieves pressure on back and sacrum
Resting between contractions	Conserves strength, promotes relaxation

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🔷 Positions to Avoid for Long Periods

Position	Reason to Avoid Prolonged Use
Supine (flat on back)	Reduces uterine blood flow and oxygen to baby, may cause maternal hypotension
Lithotomy (legs raised)	Should be reserved for second stage or delivery only

🔺 Supine hypotension syndrome can occur due to compression of the inferior vena cava by the gravid uterus.

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🔷 Role of Nurse/Midwife in Promoting Activity and Positioning

Task	Role of Nurse/Midwife
Assessment	Ensure maternal and fetal condition is stable before encouraging activity
Educate	Teach about benefits of upright positions and movement
Assist	Support the woman with moving, walking, or using birthing aids
Encourage	Motivate the woman to try different positions for comfort
Monitor	Check FHR, contraction pattern, and maternal vitals regularly
Provide safety	Prevent falls or injury, assist with balance or fatigue
Respect choice	Always consider the woman’s comfort and cultural preferences

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🔷 Tips for Supporting Positioning in Labour

• Use pillows or rolled towels to support the body
• Offer birth ball or sturdy chair with back support
• Provide massage in back-leaning positions
• Use curtains or drapes for privacy while walking or squatting
• Adjust position every 30–60 minutes or as needed

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✅ Summary: Ideal Positions in First Stage of Labour

Position	When to Use	Benefits
Walking	Early labour	Encourages descent, reduces pain
Sitting (chair/ball)	Active phase	Comfort, pelvic opening, gravity use
Kneeling or leaning	With back pain	Eases pressure on spine and sacrum
Side-lying	Fatigue or high BP	Promotes rest and circulation
Squatting	Transition phase	Opens pelvis, encourages descent

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🔷 Key Points to Remember

• Activity should always be guided by maternal comfort and safety
• Encourage freedom of movement unless medically restricted
• Avoid prolonged lying on the back
• Position changes can help manage labour pain naturally
• Combine with breathing techniques and emotional support

🌼 Nutrition During Labour.

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🔷 Definition

Nutrition during labour refers to the intake of fluids and foods that provide the mother with energy, hydration, and stamina to cope with the physical demands of labour and childbirth.

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🔷 Importance of Nutrition in Labour

• Labour is a high-energy process involving prolonged muscle activity (especially the uterus).
• Adequate energy and hydration:
  • Help maintain uterine contractions
  • Prevent maternal fatigue and dehydration
  • Reduce risk of prolonged labour
  • Improve maternal comfort and coping
  • Support better fetal oxygenation

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🔷 General Guidelines for Nutrition During Labour

Stage of Labour	Recommended Intake
Early Labour (Latent Phase)	Light, easy-to-digest foods and fluids
Active Labour	Mostly fluids and energy drinks
Transition Phase	Ice chips, sips of water or juice

⚠️ Nutrition may be restricted or modified in high-risk or complicated cases (e.g., if general anesthesia might be needed).

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🔷 Recommended Nutritional Options During Labour

🟩 Fluids (Most important!)

• Plain water
• Oral rehydration solution (ORS)
• Coconut water
• Diluted fruit juices
• Clear soups or broths
• Electrolyte drinks (non-carbonated)

🟦 Light Snacks (Early Labour Only)

• Soft fruits (banana, apple slices)
• Dry toast, plain biscuits
• Rice porridge (khichdi), idli
• Yogurt or curd
• Glucose-based sweets or energy bars (in moderation)
• Dried fruits (dates, raisins)

🍽️ Foods should be low-fat, low-fiber, and easy to digest.

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🔷 Foods and Drinks to Avoid

🚫 Oily, spicy, heavy meals
🚫 Carbonated beverages
🚫 Caffeinated drinks in excess (coffee, tea)
🚫 Fried foods or red meat
🚫 Foods that produce gas or discomfort

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🔷 When to Restrict Food Intake

Nutrition may be limited or stopped in certain cases:

Condition	Reason
High-risk delivery	In case surgery or anesthesia is expected
Planned or emergency C-section	Risk of aspiration under general anesthesia
Continuous vomiting	To avoid dehydration or choking
Severe pre-eclampsia, eclampsia	Close monitoring of fluid balance

🔔 In such cases, IV fluids may be given as prescribed.

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🔷 Nurse/Midwife’s Role in Ensuring Nutrition During Labour

Task	Responsibility
Assess maternal condition	Ensure she is low-risk and can take oral intake
Offer and encourage fluids	Every 30–60 minutes, small sips
Provide light, suitable foods	In early labour or on request
Prevent dehydration	Monitor urine output and signs of dry mouth
Monitor for nausea or vomiting	Adjust intake accordingly
Educate family	Explain what foods/drinks are safe
Document	What the woman eats/drinks and how she tolerates it

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🔷 Benefits of Good Nutrition in Labour

✅ Maintains energy and stamina
✅ Reduces ketosis and fatigue
✅ Supports strong uterine contractions
✅ Enhances coping ability and pain tolerance
✅ Promotes a positive birth experience

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✅ Quick Checklist: Safe Nutrition During Labour

✅ Safe & Recommended	❌ To Be Avoided
Water, ORS, juices	Carbonated sodas
Dry toast, soft fruits	Fried, spicy foods
Soups, light porridge	Heavy or gas-producing items
Dates, yogurt, biscuits	Chocolates, coffee in excess

🌼 Promoting a Positive Childbirth Experience.

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🔷 Definition

A positive childbirth experience is one where the woman feels safe, respected, informed, in control, and supported, regardless of whether her birth was natural, induced, medicated, or surgical. It results in emotional satisfaction, healthy maternal and newborn outcomes, and psychological well-being.

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🔷 Key Elements of a Positive Birth Experience

1. Respect and dignity
2. Emotional and physical support
3. Effective communication
4. Involvement in decision-making
5. Comfortable and safe environment
6. Cultural sensitivity and informed care
7. Freedom to move, eat, and choose positions
8. Presence of a birth companion (if allowed)

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🔷 Why It Matters

• Reduces fear, anxiety, and trauma
• Encourages trust in health services
• Promotes early bonding and breastfeeding
• Supports mental health and confidence in motherhood
• Reduces risk of postpartum depression and PTSD
• Leads to higher maternal satisfaction

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🔷 Strategies to Promote a Positive Childbirth Experience

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🟪 1. Ensure Respectful and Dignified Care

• Greet the woman by her name.
• Maintain privacy and cover her appropriately.
• Use gentle and respectful language.
• Avoid shouting, scolding, or rushing.
• Treat every woman with equality, regardless of background.

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🟩 2. Provide Clear and Supportive Communication

• Explain all procedures before performing them.
• Offer choices and information on what’s happening.
• Use simple language and repeat if needed.
• Encourage questions and answer with patience.

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🟦 3. Support Autonomy and Decision-Making

• Ask for informed consent before interventions.
• Allow the woman to choose her labour position, birth companion, and pain relief.
• Respect her birth plan (if safe and feasible).

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🟨 4. Create a Positive Environment

• Reduce noise and bright lights.
• Allow music or personal comfort items.
• Keep the room clean and calm.
• Provide labour aids like birthing balls or warm compresses.

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🟥 5. Encourage Emotional and Physical Support

• Offer continuous presence or check in regularly.
• Reassure her: “You are doing great,” “We’re here for you.”
• Support with breathing, relaxation, massage, and position changes.
• Include birth companion for emotional strength (if policy allows).

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🟫 6. Promote Mobility and Comfort

• Encourage walking, squatting, or upright positions.
• Allow light fluids or snacks (if not contraindicated).
• Help her to change positions to cope with contractions.
• Offer pain relief options (non-pharmacologic or pharmacologic).

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⚪ 7. Involve the Woman in Newborn Care

• Encourage skin-to-skin contact and early breastfeeding.
• Explain baby’s condition clearly after birth.
• Give time for mother and baby bonding.

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🔷 Nurse/Midwife’s Role in Promoting Positive Birth

Role	Key Responsibilities
Caregiver	Monitor maternal and fetal well-being
Supporter	Provide continuous reassurance
Educator	Explain labour process and what to expect
Advocate	Ensure the woman’s rights are upheld
Communicator	Speak respectfully and listen actively
Protector	Prevent disrespect, abuse, or neglect

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✅ Summary: DOs and DON’Ts for Positive Childbirth Care

✅ DOs	❌ DON’Ts
Ask for consent before exams	Perform procedures without explanation
Speak gently and encourage	Scold, ignore, or shout
Maintain privacy	Leave the woman exposed
Allow her to express feelings	Dismiss her emotions
Encourage active participation	Take control without her input
Keep her informed	Hide information or make assumptions

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💬 Empowering Phrases for Labour Support

• “You are strong and capable.”
• “Each contraction brings you closer to your baby.”
• “We are here with you every step.”
• “Your body knows what to do.”

🌼 Birth Companion During Labour.

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🔷 Definition

A birth companion is a trusted person chosen by the labouring woman to provide her with continuous emotional, psychological, and sometimes physical support throughout labour and childbirth. This could be the spouse, mother, sister, friend, doula, or any supportive person.

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🔷 WHO Recommendation

The World Health Organization (WHO) strongly recommends that every woman be offered the option of having a birth companion of her choice during labour and childbirth.

✅ “The presence of a birth companion is associated with more positive childbirth experiences and better clinical outcomes.”

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🔷 Objectives of Allowing a Birth Companion

• Enhance emotional support
• Reduce fear and anxiety
• Improve labour progress
• Strengthen woman’s sense of control
• Increase satisfaction with the birthing experience
• Promote respectful maternity care

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🔷 Who Can Be a Birth Companion?

Eligible Companions	Should Be…
Husband or partner	Supportive and reassuring
Mother or sister	Emotionally close to the woman
Friend or neighbor	Known and trusted by the woman
Doula (trained birth support)	Skilled in non-clinical support

⚠️ Should be chosen by the woman herself
⚠️ Should not interfere with clinical decisions

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🔷 Benefits of Having a Birth Companion

🟢 For the Woman:

• Reduced anxiety, stress, and fear
• Less need for pain relief medications
• Shorter labour duration
• Less likelihood of cesarean or instrumental delivery
• Greater satisfaction and emotional well-being

🔵 For the Baby:

• Better Apgar scores
• Early initiation of breastfeeding
• Improved bonding

🟣 For the Healthcare Team:

• Improved cooperation and communication
• Reduced need for constant reassurance from staff

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🔷 Role of the Birth Companion

Area of Support	Role of Companion
Emotional	Encouragement, presence, reassurance
Physical	Holding hands, massage, helping change positions
Comfort	Providing water, wiping sweat, adjusting pillows
Informational	Helping understand what the staff says
Advocacy	Supporting the woman’s wishes and preferences

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🔷 Preparation and Guidelines for a Birth Companion

✅ The Companion Should:

• Be clean, healthy, and cooperative
• Wear appropriate gown/PPE if required
• Not interfere with medical procedures
• Respect privacy and staff instructions
• Be calm, composed, and supportive

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🔷 Nurse/Midwife’s Responsibilities Related to Birth Companions

Responsibility	Description
Educate the woman antenatally	Inform her of the option to have a companion
Allow the woman to choose freely	No pressure or forced choices
Orient the companion	Basic labour process, do’s and don’ts
Monitor their presence	Ensure they are helpful, not disruptive
Maintain privacy and hygiene	Provide gown, slippers, hand hygiene
Respect cultural preferences	Some cultures prefer female companions only

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✅ Key Points to Remember

• A birth companion is not a substitute for medical staff, but a valuable emotional resource.
• Their presence should be encouraged in all low-risk deliveries.
• Staff should support and not resist their involvement.
• It aligns with Respectful Maternity Care and woman-centered care principles.

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❌ Common Myths and Facts

Myth	Fact
“They will interfere with staff work.”	Properly guided companions are helpful.
“Men should not be in the labour room.”	It depends on the woman’s cultural choice.
“Companions increase infection risk.”	Not if proper hygiene is maintained.

🌼 Role of Doula and ASHA in Maternal Care.

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🔷 1. Who is a Doula?

✅ Definition:

A Doula is a trained, non-medical support person who provides continuous physical, emotional, and informational support to a woman before, during, and shortly after childbirth.

🔔 A doula does not perform clinical procedures, but complements the healthcare team by offering comfort and companionship.

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🔷 Roles and Responsibilities of a Doula

Area of Support	Doula’s Contribution
Emotional Support	Reassures, calms, encourages the woman
Physical Comfort	Provides massage, suggests positions, helps breathing
Informational Support	Explains labour stages, birth process, options
Advocacy	Helps communicate woman’s birth preferences to staff
Partner Support	Supports husband/family and includes them
Postpartum Support	Encourages breastfeeding, baby care, maternal rest

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🔷 Benefits of Doula Support in Labour

• Reduces labour pain and anxiety
• Shortens duration of labour
• Decreases need for cesarean and epidural
• Improves maternal satisfaction
• Promotes bonding and breastfeeding
• Encourages positive birth experience

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🔷 2. Who is an ASHA (Accredited Social Health Activist)?

✅ Definition:

An ASHA is a trained female community health worker instituted under India’s National Rural Health Mission (NRHM) to act as a link between the community and the public health system.

🔔 ASHAs are not medical professionals, but community-level facilitators and health educators, especially in rural areas.

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🔷 Roles and Responsibilities of ASHA in Maternal Care

Stage	ASHA’s Role
Antenatal Period	Educates women about pregnancy care, diet, danger signs, TT injections, iron/calcium tablets, and birth preparedness. Registers pregnant women and ensures ANC checkups.
During Labour	Accompanies the woman to a health facility. Arranges transport. Provides emotional support and communicates with staff.
Postnatal Period	Visits home for postnatal checkups, newborn care advice, breastfeeding support, immunization follow-up, and identifies complications.

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🔷 Other Key Functions of ASHA

• Mobilize community for institutional deliveries
• Encourage spacing and family planning methods
• Create awareness on nutrition, hygiene, safe childbirth
• Maintain records and registers (Mother and Child Tracking)
• Promote government schemes (e.g., Janani Suraksha Yojana)

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🔷 Skills and Tools Used by ASHA

• Home visit kits
• IEC materials
• Referral slips
• HBNC (Home-Based Newborn Care) kits
• Mobile-based reporting in some areas

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🔷 Comparison: Doula vs ASHA

Feature	Doula	ASHA
Training	Trained in childbirth support (non-medical)	Trained under NRHM/MOHFW guidelines
Primary Role	Emotional & physical labour support	Community health educator & link worker
Clinical Skills	None (non-medical)	Basic health promotion and first aid
Place of Work	At hospital or home during birth	In the community and health centers
Focus	Labour & postpartum companionship	Full spectrum of maternal and child health

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🔷 Nursing/Midwife’s Collaboration with Doulas/ASHAs

Task	Collaboration Action
Educate & guide doula/ASHA	On labour room rules, infection control
Encourage respectful teamwork	Avoid conflict or undermining roles
Involve them in care	Allow participation in emotional support
Update them post-delivery	Share maternal and newborn health needs
Recognize cultural value	Respect their connection with the mother

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✅ Key Points to Remember

• Doula = Emotional + Physical labour support companion
• ASHA = Community health activist & maternal care facilitator
• Both play vital roles in humanized, respectful maternity care
• Enhance access, quality, and acceptability of services
• Nurses and midwives should work in coordination with them

🌼 Second Stage of Labour – Physiology and Mechanism of Labour (Cardinal Movements)

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🔷 Definition of Second Stage of Labour

The second stage of labour begins with full cervical dilatation (10 cm) and ends with the delivery of the baby. It is the stage of active pushing, where the fetus navigates through the birth canal and is born.

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🔷 Duration

Woman Type	Duration (Approx.)
Primigravida	30 minutes to 1 hour
Multipara	15 to 30 minutes

⚠️ Prolonged second stage may lead to maternal exhaustion, fetal distress, or obstructed labour.

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🔷 Physiological Changes in Second Stage

• Strong, regular uterine contractions every 2–3 minutes.
• Voluntary bearing down efforts by the mother (Ferguson reflex).
• Descent of the fetal presenting part.
• Stretching and distension of pelvic floor muscles, vagina, and perineum.
• Crowning of the fetal head.
• Expulsion of the fetus.

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🔷 Mechanism of Labour (Cardinal Movements)

The mechanism of labour refers to the sequential, spontaneous movements that the fetus undergoes to successfully pass through the birth canal during the second stage. These occur primarily in cephalic (vertex) presentation.

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✅ The Seven Cardinal Movements of Labour:

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1. Engagement

• The biparietal diameter (largest transverse diameter of the fetal head) enters the maternal pelvic inlet.
• Indicates that the fetal head has entered the true pelvis.
• Occurs before labour in primigravidas and during labour in multiparas.

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2. Descent

• The fetal head moves downward through the pelvis.
• Occurs due to:
  • Uterine contractions
  • Bearing down efforts
  • Amniotic fluid pressure
  • Straightening of fetal body

Descent continues throughout labour but is more rapid in second stage.

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3. Flexion

• As the head meets resistance in the birth canal, the fetal chin tucks toward the chest.
• This brings the smallest diameter (suboccipitobregmatic ~9.5 cm) into alignment with the pelvic canal.
• Flexion allows easier passage through the pelvis.

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4. Internal Rotation

• The fetal head rotates from occiput transverse to occiput anterior (most common) to align with the maternal pelvis.
• Occurs when the head reaches the pelvic floor.
• Facilitates alignment of the head with the anteroposterior diameter of the pelvis.

🔄 Occiput anterior (OA) is the ideal position for delivery.

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5. Extension

• As the fetal head reaches the vaginal opening, it extends to pass under the pubic symphysis.
• The head is born through a process of extension of the neck, delivering:
  • Occiput → Brow → Face → Chin

🎯 This is the moment of birth of the head.

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6. Restitution (External Rotation I)

• After the head is born, it turns back to the original position relative to the fetal shoulders.
• Head realigns with the body (which has not yet rotated).
• This is called restitution.

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7. External Rotation (Shoulder Rotation)

• As shoulders rotate to fit the pelvis, the head rotates further externally.
• Allows the anterior shoulder to slip under the pubic bone first.

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8. Expulsion

• After the shoulders are delivered, the rest of the body follows quickly.
• This marks the end of the second stage.

🎉 Baby is born!

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🔷 Summary of Cardinal Movements

Step #	Name of Movement	Description
1	Engagement	Head enters pelvis
2	Descent	Moves downward
3	Flexion	Chin to chest
4	Internal Rotation	Occiput rotates anteriorly
5	Extension	Head delivered under pubic bone
6	Restitution	Head realigns with body
7	External Rotation	Shoulders rotate, head turns outward
8	Expulsion	Full body delivery

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🔷 Nursing/Midwifery Responsibilities During Second Stage

Task	Role
Monitor FHR	Every 5 minutes or after each contraction
Guide pushing efforts	Instruct when to push and when to rest
Support perineum	To prevent tears
Prepare for birth	Clean tray, neonatal corner, resuscitation
Assist with delivery	Gentle delivery of head and body
Note time of birth	Record accurately
Perform APGAR scoring	At 1 and 5 minutes post-birth
Promote skin-to-skin	Place baby on mother’s chest if stable

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✅ Key Points

• Second stage is critical for safe delivery of the baby.
• Fetal head and body undergo complex, natural movements.
• Midwife should monitor closely, support the woman, and respect her birthing process.
• Use clean technique, be alert to signs of obstruction or fetal distress.

🌼 Signs of Imminent Labour.

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🔷 Definition

Imminent labour refers to the stage when childbirth is about to occur, particularly during the late second stage of labour, and the baby’s delivery is close. Recognizing these signs is crucial for the timely preparation of the birth team, safe delivery, and emergency readiness.

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🔷 Importance of Recognizing Imminent Labour

• Prevent sudden, unassisted deliveries
• Ensure safe environment and aseptic technique
• Activate emergency birth protocols if needed
• Prepare for immediate newborn care
• Reduce maternal and neonatal risks

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🔷 General Signs of Imminent Labour

These signs indicate that the woman is entering active labour and approaching the second stage:

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✅ 1. Strong and Frequent Contractions

• Regular uterine contractions every 2–3 minutes
• Each lasting 60–90 seconds
• Increasing in intensity and frequency

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✅ 2. Full Cervical Dilation (10 cm)

• Confirmed by vaginal examination
• No cervix felt around the presenting part

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✅ 3. Urge to Bear Down (Ferguson Reflex)

• Sudden, strong urge to push
• Feels like passing stool
• Caused by pressure of fetal head on rectum

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✅ 4. Bulging of the Perineum

• Perineum becomes stretched, shiny, and tense
• Indicates descent of fetal head

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✅ 5. Anal Gaping and Flattening

• Anus dilates and may open visibly
• Often seen just before crowning

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✅ 6. Visible Presenting Part (Crowning)

• Fetal head becomes visible at vulva and does not recede between contractions
• Indicates delivery is imminent
• May cause burning or stinging sensation for the mother

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✅ 7. Bloody Show or Increased Vaginal Discharge

• Expulsion of blood-tinged mucus plug
• Associated with cervical dilation

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✅ 8. Restlessness and Vocalizations

• Woman may express panic, irritability, or fear
• Grunting or involuntary pushing sounds

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🔷 Additional Signs in Multiparous Women (May Progress Quickly)

• Labour progresses faster, signs may appear suddenly
• Always observe for rapid crowning
• Important to act quickly to prevent unattended delivery

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🔷 Nurse/Midwife’s Immediate Actions Upon Seeing Signs of Imminent Labour

Task	Action
Do not leave the woman alone	Stay and reassure
Call for assistance	Inform senior nurse or obstetrician
Prepare delivery tray	Sterile gloves, pads, scissors, cord clamp
Support the perineum	Use clean towel to guide delivery
Prepare for neonatal care	Warm wraps, suction, radiant warmer
Monitor FHR	Every 5 minutes or after each contraction
Document findings	Time, observations, actions taken

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⚠️ Warning Signs – Call for Help Immediately If:

• Cord prolapse
• Fetal distress (FHR <110 or >160 bpm)
• Shoulder dystocia
• Excessive bleeding
• Malpresentation (e.g., breech, face)
• No facility readiness for delivery

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✅ Quick Reference: Signs of Imminent Birth

Sign	Description
Urge to push	Intense pressure on rectum
Crowning	Fetal head visible at vulva
Bulging perineum	Perineum stretched and shiny
Anal gaping	Anus opens due to pressure
Involuntary grunting	Woman cannot help but bear down
Contractions 2-3 min apart	Active, intense labour

🌼 Intrapartum Monitoring.

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🔷 Definition

Intrapartum monitoring is the systematic observation and assessment of both the mother and fetus during labour and childbirth to ensure safety, timely interventions, and optimal outcomes.

It involves continuous and intermittent assessments to detect any abnormal signs early and guide appropriate action.

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🔷 Objectives of Intrapartum Monitoring

• Ensure maternal and fetal well-being
• Track progress of labour
• Detect labour complications early
• Guide timely decision-making
• Prevent birth injuries, asphyxia, maternal exhaustion, and PPH
• Promote safe and respectful maternity care

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🔷 Phases Covered in Intrapartum Monitoring

• First stage: Onset of labour to full cervical dilation (0–10 cm)
• Second stage: Full dilation to birth of baby
• Third stage: Birth of baby to delivery of placenta
• Fourth stage: First 1–2 hours postpartum

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🔷 Key Components of Intrapartum Monitoring

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🟩 1. Maternal Monitoring

Parameter	Frequency & Details
Vital signs (BP, Pulse, Temp, Resp)	BP & Pulse – Every 4 hrs (more often if high risk); Temp – every 4 hrs
Contractions	Every 30 mins – Assess frequency, duration, intensity
Pain level and coping	Observe discomfort, fatigue, anxiety
Bladder status	Encourage voiding every 2 hrs to avoid bladder distension
Hydration and nutrition	Encourage oral fluids/light diet unless contraindicated
Bleeding/Show	Check for any excessive bleeding or abnormal discharge
Behavioural signs	Watch for signs of distress, exhaustion, fear

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🟦 2. Fetal Monitoring

Parameter	Frequency & Methods
Fetal Heart Rate (FHR)	Every 30 mins in 1st stage, every 5 mins in 2nd stage. Use Doppler or fetoscope
Fetal movements	Ask mother, especially if high-risk
Amniotic fluid	Observe color (clear, meconium-stained, blood-stained), amount, and odor
Descent of head	Assess abdominally or during vaginal exam
CTG (Cardiotocography)	If high-risk or available, for continuous monitoring

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🟨 3. Labour Progress Monitoring – Partograph Use

• Cervical dilation (every 4 hrs via vaginal examination)
• Uterine contractions (frequency, duration, strength)
• Descent of fetal head (abdominal or vaginal)
• Plot on WHO partograph
• Compare against alert and action lines

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🟧 4. Monitoring During Second Stage

Action	Frequency/Technique
FHR	After every contraction
Urge to push	Guide bearing down only when cervix is fully dilated
Perineal changes	Watch for bulging, crowning
Maternal vitals	Every 15–30 minutes

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🟥 5. Monitoring During Third & Fourth Stage

Stage	Monitoring Actions
Third stage	Watch for signs of placental separation, uterine tone, bleeding
Fourth stage	Every 15 mins – BP, pulse, bleeding, fundal height and tone, bladder status

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🔷 Tools Used for Intrapartum Monitoring

• Partograph
• Fetoscope/Doppler
• BP apparatus, stethoscope
• CTG machine (if available)
• Thermometer
• Watch/clock to track contractions
• Delivery and newborn care kit

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🔷 Nurse/Midwife’s Responsibilities in Intrapartum Monitoring

Task	Details
Observe regularly	Record and interpret maternal and fetal signs
Start and update partograph	Monitor dilation, contractions, FHR, vitals
Communicate abnormalities	Report fetal distress, abnormal vitals, or stalled labour immediately
Provide emotional support	Stay with the woman, encourage, reassure
Maintain asepsis	During vaginal exams and deliveries
Document everything	Accurately in labour record and birth register
Prepare for delivery	Ensure readiness of delivery tray and newborn corner

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🔷 Abnormal Signs to Watch For

Maternal	Fetal
BP >140/90 or <90/60	FHR <110 or >160 bpm
High temperature (>38°C)	Meconium-stained liquor
Excessive bleeding	Absent fetal movement
No progress of labour	Persistent variable or late decelerations (on CTG)

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✅ Summary: Intrapartum Monitoring at a Glance

Aspect	Monitored by	Frequency
FHR	Doppler/Fetoscope	Every 30 mins (1st stage), 5 mins (2nd stage)
Contractions	Observation/palpation	Every 30 mins
Cervix	Vaginal exam	Every 4 hrs
Vitals	BP, pulse, temp, resp	Every 2–4 hrs
Urine	Output, protein, ketones	When voided
Baby	Liquor, descent, tone	Continuously observed

🌼 Birth Position of Choice.

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🔷 Definition

Birth position of choice refers to the freedom of the labouring woman to choose a position she finds most comfortable, safe, and effective for the second stage of labour and the delivery of the baby.

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🔷 WHO Recommendation

The World Health Organization (WHO) and many national maternity guidelines recommend allowing women to give birth in the position of their choice, unless medically contraindicated.

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🔷 Benefits of Letting the Woman Choose Her Position

• Promotes comfort and control
• Encourages physiological labour
• Enhances satisfaction and dignity
• May lead to shorter labour
• Improves fetal descent and pelvic alignment
• May reduce the need for instrumental delivery or episiotomy
• Promotes better oxygenation and blood flow

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🔷 Common Birth Positions

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🟩 1. Upright Positions

(e.g., Standing, Squatting, Sitting, Kneeling, Hands-and-Knees)

Advantages

• Uses gravity to assist fetal descent
• Increases pelvic diameter
• Improves uterine efficiency
• Decreases pressure on major blood vessels
• May reduce duration of second stage

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🟦 2. Lateral (Side-Lying) Position

Advantages

• Useful when mother is tired
• Maintains blood flow and oxygenation
• Reduces risk of perineal tears
• Comfortable and dignified

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🟨 3. Lithotomy Position (Semi-recumbent, on back with legs raised)

Most commonly used in hospitals

Advantages	Disadvantages

• Easy access for healthcare provider | Reduces pelvic space
• Good for assisted deliveries | Compresses vena cava → hypotension
• Familiar and controllable | Increases chance of perineal trauma

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🟥 4. Squatting

Advantages

• Widens pelvic outlet
• Uses gravity to assist birth
• Effective pushing position
• May shorten second stage

🔔 May need support or squatting bar.

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🟪 5. Kneeling or Hands-and-Knees

Advantages

• Reduces back pain
• Helpful in posterior positions (baby facing mother’s front)
• Allows natural rotation of fetus
• Decreases perineal pressure

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🔷 Factors Influencing Choice of Position

Factor	Example
Cultural preference	Some cultures prefer upright or squatting positions
Comfort and pain	Side-lying for tired women, kneeling for back pain
Medical condition	Preeclampsia may need side-lying; epidural limits mobility
Fetal condition	Fetal distress may require semi-recumbent or assisted birth
Stage of labour	Upright helpful in early 2nd stage, lithotomy for assisted delivery

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🔷 Nurse/Midwife’s Role in Supporting Birth Position of Choice

Responsibility	Action
Educate the mother	Inform her of options and benefits
Encourage mobility	Allow walking, sitting, changing positions
Respect her comfort and dignity	Avoid forcing positions unless necessary
Assess maternal and fetal condition	Ensure safety in chosen position
Support with positioning aids	Provide pillows, birthing stool, mats
Assist during birth	Be flexible and adapt to the woman’s chosen position

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✅ Summary: Birth Positions and Their Effects

Position	Benefits	When Useful
Standing/Walking	Gravity aids descent, speeds up labour	Early labour
Squatting	Opens pelvis, effective pushing	Second stage
Side-lying	Conserves energy, safe for high BP	When exhausted or high-risk
Hands-and-knees	Eases back pain, rotates baby	Occiput posterior or backache
Lithotomy	Provider access, assisted birth	Instrumental deliveries, emergencies

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❌ Avoid Forcing One Position On All Women

• Not all women are comfortable in lithotomy position
• Encourage them to listen to their body
• Use clinical judgment only when position change is necessary for safety

🌼 Vaginal Examination.

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🔷 Definition

Vaginal Examination (Per Vaginal / PV Exam) is a manual internal examination performed by a trained midwife or doctor by inserting sterile fingers into the vaginal canal to assess the progress of labour, cervical changes, and fetal position.

🩺 It is a critical skill for assessing the progress of labour but must be used judiciously and under strict aseptic conditions.

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🔷 Purposes of Vaginal Examination

1. Assess cervical effacement and dilation
2. Determine presenting part and its station
3. Assess membrane status (intact or ruptured)
4. Evaluate pelvic adequacy (in early labour)
5. Monitor labour progression and effectiveness of contractions
6. Detect abnormal presentations (breech, face, shoulder)
7. Confirm onset of second stage of labour
8. Check for cord prolapse or presence of meconium-stained liquor

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🔷 When to Perform Vaginal Examination

✅ At:

• Onset of labour (for baseline assessment)
• Every 4 hours in active first stage (unless indicated earlier)
• On urge to bear down (to confirm full dilation)
• Before administering epidural analgesia
• To assess labour progress or after change in contractions

🚫 Avoid in:

• Preterm labour with bleeding
• Placenta previa
• Unnecessary frequent exams (risk of infection)

🔔 Always perform only when clinically indicated and with consent.

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🔷 Preparation for Vaginal Examination

✅ Before the Procedure:

• Explain the procedure and get informed consent
• Provide privacy and draping
• Ask the woman to empty her bladder
• Wash and sanitize hands thoroughly
• Wear sterile gloves
• Prepare sterile lubricant (KY jelly)
• Ensure adequate lighting and positioning (usually dorsal, semi-recumbent, or left lateral)

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🔷 Technique of Vaginal Examination

1. Wash hands and wear sterile gloves
2. Position the woman comfortably (usually dorsal or left lateral)
3. Separate the labia with non-dominant hand
4. Gently insert the index and middle fingers of the dominant gloved hand into the vagina
5. Assess each of the following:

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🔷 Findings During Vaginal Examination

Parameter	What to Assess
Cervical Dilatation	0–10 cm (use fingers to estimate opening)
Cervical Effacement	Thickness of cervix: 0% (thick) to 100% (fully thinned)
Consistency of Cervix	Soft, medium, or firm
Position of Cervix	Anterior, central, or posterior
Membranes	Intact or ruptured; presence of liquor
Presenting Part	Head, breech, face, shoulder
Station of Presenting Part	Relationship to ischial spines: from –5 to +5
Moulding and Caput	Overlapping skull bones or swelling on fetal head
Pelvic assessment	Shape, adequacy, and abnormalities (in early labour)
Cord prolapse or bleeding	Presence of umbilical cord or abnormal discharge

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🔷 Interpretation of Key Terms

Term	Meaning
Fully Dilated	10 cm – ready for pushing/birth
Effaced	Thinned cervix – 100% = paper-thin
Station 0	Presenting part at ischial spines
+1 to +5	Below ischial spine – approaching delivery
Caput	Swelling of fetal scalp from pressure
Moulding	Overlapping skull bones – mild is normal

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🔷 Infection Prevention During Vaginal Examination

• Use sterile gloves every time
• Avoid unnecessary frequent exams
• Clean perineum if blood or discharge present
• Use aseptic technique
• Minimize exams after rupture of membranes
• Document clearly after each exam

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🔷 Documentation After PV Exam

Record in the labour notes or partograph:

• Date and time of examination
• Cervical dilatation and effacement
• Presenting part and station
• Membrane status and liquor (clear/meconium/blood-stained)
• Fetal position (if known)
• Any complications (e.g., prolapse, abnormal presentation)
• Name/designation of the examiner

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🔷 Nurse/Midwife’s Responsibilities

Task	Action
Explain and reassure	Reduce anxiety and gain cooperation
Ensure privacy and consent	Maintain dignity and comfort
Perform aseptic examination	Prevent infection to mother and fetus
Interpret and report findings	Communicate abnormal findings quickly
Chart findings on partograph	Track labour progress
Support emotionally	Be gentle, use calming language
Limit unnecessary exams	Follow 4-hourly guideline unless indicated

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✅ Key Points to Remember

• Perform only when medically indicated
• Always use clean, sterile technique
• Be gentle, respectful, and communicative
• Findings are crucial for labour decision-making
• Monitor for signs of obstruction, distress, or abnormal progress

🌼 Psychological Support.

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🔷 Definition

Psychological support refers to the emotional, mental, and social care provided to a woman during pregnancy, labour, childbirth, and postpartum to help her feel safe, respected, understood, and empowered.

It includes empathy, reassurance, encouragement, clear communication, and maintaining a calm, supportive environment.

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🔷 Why Psychological Support is Important in Labour

• Reduces fear, anxiety, and stress
• Promotes confidence and control
• Encourages positive birth experience
• Enhances labour progress (stress inhibits oxytocin)
• Improves maternal and neonatal outcomes
• Supports mental health and prevents birth-related trauma
• Builds trust between mother and caregiver

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🔷 Common Emotional Needs of Women in Labour

Emotional Need	Examples
Reassurance	“You’re doing great,” “We are here for you.”
Security	Feeling safe and cared for
Respect	Being heard and treated with dignity
Information	Knowing what’s happening and why
Involvement in decisions	Making choices about care and comfort
Companionship	Not feeling alone during labour

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🔷 Key Strategies for Providing Psychological Support

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🟢 1. Establish Rapport and Trust

• Greet warmly, use her name
• Introduce yourself and your role
• Listen to her fears, concerns, or past experiences
• Maintain eye contact and a calm tone

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🔵 2. Give Clear and Supportive Communication

• Use simple, non-technical language
• Explain each step or procedure clearly
• Provide updates on labour progress
• Answer questions patiently
• Offer realistic encouragement (e.g., “Each contraction brings you closer to your baby”)

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🟡 3. Encourage Autonomy and Involvement

• Involve the woman in decisions (e.g., birth position, pain relief)
• Respect her preferences and choices
• Support her right to have a birth companion
• Ask: “What do you need right now?” or “Would you like to try a new position?”

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🟠 4. Provide Emotional Reassurance and Encouragement

• Use positive affirmations:
  • “You are strong.”
  • “Your body knows what to do.”
  • “We are here with you.”
• Encourage deep breathing and relaxation
• Acknowledge her efforts and progress

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🔴 5. Support Physical Comfort

• Offer comfort measures like:
  • Massage
  • Warm compress
  • Changing positions
  • Breathing techniques
• Help her feel in control of her environment

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🔷 Role of the Nurse/Midwife in Psychological Support

Responsibility	Action
Observe emotional state	Watch for fear, restlessness, crying
Create a calm environment	Dim lights, reduce noise, ensure privacy
Be present and attentive	Avoid leaving her alone during active labour
Be non-judgmental	Respect cultural, emotional, and personal beliefs
Provide continuity of care	Try to remain with her throughout active labour
Empower and educate	Guide through breathing, labour stages, and what to expect

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🔷 Psychological Support in Special Situations

Situation	Supportive Action
Teenage mother	Extra reassurance and patience
High-risk or complicated labour	Clear explanation and stress reduction
Previous birth trauma	Ask about past experience and respect preferences
Lack of family support	Offer companionship and extra presence

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✅ Key Phrases for Psychological Support

• “You are not alone.”
• “This feeling is normal, and you’re doing really well.”
• “Breathe with me… in and out.”
• “Do you want to change positions?”
• “Let me know what you need.”

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❌ What to Avoid

Don’t Do	Why It’s Harmful
Ignoring her questions	Increases fear and mistrust
Using harsh or rushed language	Feels disrespectful
Scolding or blaming	Causes shame or anxiety
Leaving her alone in active labour	Leads to panic and fear
Dismissing pain or distress	Reduces confidence and support

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✅ Summary: Essentials of Psychological Support

Aspect	Action/Goal
Empathy	Be emotionally present
Respect	Preserve dignity and comfort
Communication	Be clear, gentle, and honest
Encouragement	Offer continuous reassurance
Involvement	Empower her with choices
Continuity	Provide ongoing presence and attention

🌼 Non-Directive Coaching.

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🔷 Definition

Non-directive coaching is a supportive communication technique in which the caregiver guides and supports the woman without giving orders, commands, or making decisions for her. It focuses on empowering the woman to make her own choices, helping her feel in control, confident, and respected during labour and childbirth.

🧠 It is woman-centered, respectful, and enhances self-efficacy and satisfaction.

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🔷 Objectives of Non-Directive Coaching

• Encourage the woman’s autonomy and confidence
• Provide emotional reassurance without forcing decisions
• Support physiological labour without unnecessary intervention
• Promote relaxation, focus, and active coping
• Help the woman feel heard, safe, and respected

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🔷 Principles of Non-Directive Coaching

Principle	Meaning
Active listening	Fully hear and understand what the woman expresses
Empowerment	Help her trust her body and choices
Respect for autonomy	Let her make decisions about her body and care
Support without pressure	Offer information and comfort, not orders
Calm, encouraging language	Guide without commanding

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🔷 Examples of Non-Directive Coaching Phrases

Instead of Saying (Directive) ❌	Say This Instead (Non-Directive) ✅
“Lie down now.”	“Would you like to rest or change position?”
“Push now!”	“When you feel the urge, go ahead and push.”
“Don’t scream, breathe!”	“Try to take a slow breath with me.”
“Stop crying, you’re fine.”	“I hear you. You’re doing really well.”
“Just do what I say.”	“Let’s work together—how can I help you right now?”

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🔷 Techniques Used in Non-Directive Coaching

✅ 1. Open-Ended Questions

• “How are you feeling now?”
• “What do you need?”
• “Is there anything that’s helping with the pain?”

✅ 2. Gentle Encouragement

• “You’re doing great.”
• “Trust your body—each contraction brings your baby closer.”
• “You’re strong—you can do this.”

✅ 3. Breathing Guidance (Without Commands)

• “Try taking a deep breath with me.”
• “Would you like to try breathing more slowly?”
• “Let’s breathe through this one together.”

✅ 4. Respect for Choices

• Let her choose birth position, companion, or comfort measure
• Provide options: “Would you prefer to sit, stand, or walk?”

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🔷 Nurse/Midwife’s Role in Non-Directive Coaching

Role	Action
Supporter	Be present, listen, encourage
Facilitator	Help her express needs and preferences
Educator (when needed)	Give information, not commands
Empathic communicator	Understand her emotions and respond supportively
Observer	Watch for fatigue, anxiety, and physical signs

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🔷 Benefits of Non-Directive Coaching

For the Woman	For the Care Team
Feels respected and in control	Easier cooperation during labour
Better coping with pain	Reduced need for interventions
Lower anxiety and stress	Builds trust and rapport
Positive birth experience	Improves patient satisfaction

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✅ Summary: Characteristics of Non-Directive Coaching

Feature	Description
Empowering	Encourages self-trust and decision-making
Supportive	Provides reassurance without controlling
Respectful	Honors preferences, autonomy, and dignity
Flexible	Adjusts to the woman’s emotional and physical state
Non-judgmental	Accepts all emotions (fear, crying, vocalization) as normal

🌼 Management of Birth / Conduction of Delivery.

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🔷 Definition

Conduction of delivery refers to the systematic, safe, and hygienic process by which a trained midwife or health professional assists a woman in delivering her baby and placenta, ensuring safety for both mother and newborn, and providing immediate postpartum care.

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🔷 Goals of Safe Birth Management

• Ensure maternal and fetal well-being
• Assist in normal vaginal delivery
• Prevent and manage complications
• Maintain infection control
• Provide emotional support
• Ensure early newborn care and bonding

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🔷 Steps in Conducting a Normal Vaginal Delivery

🟩 1. Preparation Before Delivery

✅ Environment

• Quiet, clean, warm labour room
• Adequate lighting and ventilation

✅ Equipment

• Sterile delivery tray:
  • Gloves, cord clamp, scissors, sterile gauze, cotton, antiseptic
• Maternity pads, baby towel, suction bulb
• Neonatal resuscitation equipment
• Warm radiant warmer or heat source

✅ Maternal Preparation

• Reassure the woman
• Position her comfortably (lithotomy or position of choice)
• Ensure bladder is empty
• Clean perineum with antiseptic solution
• Drape to maintain privacy

✅ Monitoring

• Fetal heart rate (every 5 mins)
• Maternal vitals (pulse, BP)

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🟦 2. Delivery of the Baby – Second Stage

✅ A. Crowning

• Fetal head becomes visible at the vulva and does not recede
• Ask the woman not to push during crowning to prevent perineal tear

✅ B. Support Perineum

• Use sterile towel to support the perineum
• Control speed of delivery of head

✅ C. Delivery of Head

• Allow slow extension of head
• After head is out, check for nuchal cord (cord around neck)
  • If loose → slip it over the head
  • If tight → clamp and cut

✅ D. Delivery of Shoulders and Body

• Wait for next contraction
• Apply gentle downward traction to deliver anterior shoulder
• Lift the baby gently to deliver posterior shoulder and body
• Hold baby securely and place on mother’s abdomen

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🟨 3. Immediate Care of the Newborn

• Dry the baby thoroughly with warm towel
• Stimulate breathing (rub back, suction if needed)
• Assess Apgar score at 1 and 5 minutes
• Clamp and cut the umbilical cord (after 1–3 minutes or when pulsation stops)
• Promote skin-to-skin contact
• Encourage early breastfeeding

🔔 If baby is not breathing → start resuscitation immediately.

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🟥 4. Delivery of Placenta – Third Stage

✅ Watch for Signs of Placental Separation

• Sudden gush of blood
• Lengthening of the cord
• Uterus becomes firm and globular

✅ Controlled Cord Traction (CCT)

• Guard uterus and gently pull the cord while applying suprapubic pressure
• Deliver placenta and membranes gently
• Inspect for completeness

✅ Administer Uterotonics

• Give 10 IU oxytocin IM immediately after delivery of baby (Active Management of Third Stage of Labour – AMTSL)

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🟪 5. Examination and Immediate Postpartum Care – Fourth Stage

✅ Inspect Mother

• Perineum, vaginal wall, and cervix for lacerations
• Repair episiotomy or tears under aseptic technique
• Clean and dress the perineal area

✅ Monitor Mother and Baby

• Vitals, uterine tone, vaginal bleeding
• Every 15 mins for the first hour
• Ensure bladder is empty

✅ Initiate Breastfeeding

• Within 1 hour of birth
• Promote bonding and uterine contraction

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🔷 Nurse/Midwife Responsibilities During Birth

Phase	Responsibility
Before Delivery	Prepare equipment, reassure and position woman, monitor vitals and FHR
During Delivery	Conduct delivery aseptically, support perineum, control head delivery
Newborn Care	Dry, suction, stimulate, assess Apgar, clamp cord, promote skin-to-skin
Placenta Delivery	Perform controlled cord traction, check completeness
Post-Delivery	Monitor bleeding, uterine tone, repair tears, encourage breastfeeding
Documentation	Time of birth, sex, Apgar, medications, placenta details, mother’s status

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🔷 Infection Prevention Measures

• Perform hand hygiene and wear sterile gloves
• Use clean delivery kit
• Avoid frequent vaginal exams
• Use aseptic technique for episiotomy or repair
• Properly dispose of waste and sharps
• Clean all instruments post-delivery

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✅ Key Points for Safe and Respectful Birth Conduction

• Maintain privacy and dignity
• Communicate clearly and respectfully
• Be gentle and supportive
• Monitor closely for any signs of complication
• Prepare for emergency management if needed
• Encourage the woman and her companion throughout the process

🌼 Preparation and Supporting Physiological Birthing.

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🔷 What is Physiological Birth?

A physiological birth is a natural process of labour and birth that occurs without unnecessary medical interventions and allows the body to progress spontaneously. It relies on the woman’s instincts, hormonal regulation, and supportive environment to achieve a safe and satisfying delivery.

✅ It is guided by the body, not controlled by drugs or surgery (unless necessary).

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🔷 Objectives of Supporting Physiological Birth

• Promote natural onset and progress of labour
• Avoid unnecessary interventions
• Support the woman’s confidence, movement, and autonomy
• Enhance maternal satisfaction and safety
• Ensure optimal fetal outcomes
• Encourage emotional, mental, and physical readiness

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🔷 Preparation for Supporting Physiological Birthing

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🟢 1. Antenatal Education

Topic	Goal
Stages of labour	Help woman understand what to expect
Relaxation and breathing techniques	Build coping strategies
Birth plan and preferences	Empower informed choices
Position changes and movement	Promote comfort and fetal descent
Nutrition and hydration	Ensure energy and endurance
Signs of true labour	Reduce false alarms or panic

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🔵 2. Birth Environment Setup

Feature	Importance
Quiet and calm space	Reduces stress and fear
Dim lighting	Supports oxytocin release
Privacy and dignity	Enhances confidence and comfort
Birth aids	Balls, mats, stools for free movement
Access to fluids/snacks	Supports energy and hydration
Skilled and kind attendants	Builds trust and safety

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🟡 3. Midwife and Team Preparation

Preparation	Action
Emotional readiness	Be calm, supportive, and non-judgmental
Knowledge of physiological labour	Understand normal progress and variations
Resuscitation readiness	Be prepared in case of emergency
Respectful care training	Uphold woman’s rights and choices
Communication skills	Reassure, guide, and encourage

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🔷 How to Support Physiological Birth – Step-by-Step

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✅ 1. Encourage Freedom of Movement

• Let the woman walk, squat, rock, or change positions
• Upright positions help fetal descent and dilation
• Avoid confining her to bed unless medically necessary

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✅ 2. Provide Continuous Emotional Support

• Stay with her or check frequently
• Use phrases like: “You’re doing beautifully,” “I’m here for you,” “Your body knows what to do”
• Encourage presence of a birth companion

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✅ 3. Promote Natural Pain Coping

• Use breathing techniques
• Apply massage, warm compress, or water therapy if available
• Avoid unnecessary drugs unless requested or needed

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✅ 4. Limit Unnecessary Interventions

• Avoid routine episiotomy, IV fluids, or constant monitoring
• Use vaginal exams only when needed
• Avoid artificial rupture of membranes unless indicated

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✅ 5. Encourage Spontaneous Pushing

• Let her push when she feels the urge
• Avoid directed or forceful pushing unless medically necessary
• Guide breathing and position gently

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✅ 6. Respect the Birth Process

• Support perineum during delivery
• Allow slow, controlled birth of the head
• Avoid forceful pulling or traction
• Allow delayed cord clamping (1–3 minutes)

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✅ 7. Early Skin-to-Skin and Breastfeeding

• Place baby on mother’s chest immediately after birth
• Encourage breastfeeding within the first hour
• Supports bonding, temperature regulation, and oxytocin release

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🔷 Midwife/Nurse’s Role in Physiological Birth

Responsibility	Actions
Educator	Teach about normal birth
Supporter	Reassure and stay present
Protector of the natural process	Limit interventions, maintain trust
Advocate for woman’s choice	Respect preferred birth position, companion, and comfort measures
Skilled observer	Monitor fetal and maternal well-being without interfering
Documenter	Record vital signs, FHR, labour progress, and birth details

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🔷 Benefits of Supporting Physiological Birth

For the Mother	For the Baby
More satisfaction and control	Less chance of birth trauma
Reduced pain and shorter labour	Better Apgar scores
Quicker recovery	Improved bonding and breastfeeding
Less need for cesarean or drugs	Better thermoregulation and oxygenation

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✅ Summary: Key Features of Physiological Birth Support

Element	What to Do
Environment	Calm, private, low-light
Support	Stay with the woman, reassure
Movement	Encourage walking, squatting, rocking
Intervention	Avoid unless medically needed
Pain relief	Use natural coping methods
Birth process	Let the body lead, protect the perineum
After birth	Skin-to-skin, breastfeeding, bonding

🌼 Essential Newborn Care (ENBC).

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🔷 Definition

Essential Newborn Care (ENBC) refers to the basic, evidence-based care provided to all newborns immediately after birth and during the first hours and days of life, regardless of place of birth or risk level, to ensure survival, prevent complications, and promote healthy development.

🍼 ENBC is crucial for reducing neonatal mortality and morbidity, especially in low-resource settings.

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🔷 Objectives of ENBC

• Ensure the baby breathes and stays warm
• Prevent infections
• Support breastfeeding and bonding
• Monitor for danger signs
• Provide routine care and early interventions

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🔷 The 5 Pillars of Essential Newborn Care

According to WHO and Government of India guidelines, ENBC consists of the following core components:

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✅ 1. Immediate and Thorough Drying

• Dry the baby with a warm, clean towel as soon as born
• Remove wet linen and cover with dry cloth
• Prevents heat loss and hypothermia

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✅ 2. Skin-to-Skin Contact (Kangaroo Care)

• Place baby on mother’s bare chest immediately after birth
• Cover both with a warm blanket
• Maintains warmth, stabilizes heartbeat and breathing
• Promotes early breastfeeding and bonding

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✅ 3. Delayed Cord Clamping (1–3 minutes)

• Wait until cord stops pulsating (usually 1–3 minutes)
• Increases baby’s iron stores and hemoglobin levels
• Reduces risk of anemia

⚠️ If baby is not breathing, cut the cord earlier and start resuscitation.

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✅ 4. Early Initiation of Breastfeeding (within 1 hour)

• Encourage baby to latch onto breast in first hour
• Provide colostrum – rich in antibodies and nutrients
• Prevents hypoglycemia and builds immunity
• Delays introduction of other feeds (exclusive breastfeeding)

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✅ 5. Prevention of Infection (Clean Cord and Eye Care)

• Do not apply anything to the cord stump
• Keep stump clean and dry
• Eye care: Clean both eyes from inner to outer using sterile gauze
• Use Tetracycline eye ointment if recommended (to prevent ophthalmia neonatorum)

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🔷 Additional Components of ENBC

🟩 Temperature Maintenance

• Ensure warm delivery room (≥25°C)
• Avoid exposure to cold air or surfaces
• Use hat/cap for baby’s head
• Monitor for hypothermia (Temp <36.5°C)

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🟦 Assessment and Monitoring

• Apgar Score at 1 and 5 minutes: assess breathing, heart rate, tone, reflexes, and color
• Check for congenital anomalies, birth injuries
• Count respirations, heart rate, and check tone
• Watch for danger signs:
  • Difficulty breathing
  • Poor feeding
  • Fever or low temperature
  • Jaundice, seizures, or lethargy

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🟨 Vitamin K Administration

• IM injection of 1 mg in thigh (for term babies)
• Prevents hemorrhagic disease of newborn

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🟧 Immunization

• Within 24 hours:
  • BCG
  • OPV-0 (Oral Polio Vaccine)
  • Hepatitis B (birth dose)

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🔷 Infection Prevention During Newborn Care

Area	Action
Hand hygiene	Wash hands before handling baby
Sterile instruments	For cord cutting/clamping
Clean surface	Use clean towel/sheet
Avoid harmful practices	No application of ash, oil, or powder on cord

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🔷 Role of Nurse/Midwife in ENBC

Phase	Responsibilities
Immediately after birth	Dry baby, assess breathing, initiate skin-to-skin
First hour	Support breastfeeding, monitor vitals, record Apgar
Ongoing care	Teach mother about cord care, feeding, warmth
Documentation	Birth time, weight, sex, Apgar, immunizations, feeding
Education	Counsel on danger signs and exclusive breastfeeding

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✅ Summary Checklist: ENBC at Birth

Task	Done? ✅
Baby dried and kept warm
Skin-to-skin contact started
Cord clamped after 1–3 minutes
Breastfeeding initiated within 1 hour
Cord care done (nothing applied)
Vitamin K given
Immunizations given
Danger signs monitored

🌼 Assessment and Care of the Newborn Immediately After Birth.

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🔷 Objectives

• Ensure the baby is breathing and stable
• Maintain warmth and prevent infection
• Promote early bonding and breastfeeding
• Identify any abnormalities or danger signs early
• Provide routine newborn care as per Essential Newborn Care (ENBC) guidelines

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🔷 Immediate Steps at Birth (Golden Minute)

Immediately after delivery (within the first minute), follow “The First Look” approach:

Step	Action
1. Drying	Use warm, sterile towel; remove wet linen
2. Warming	Place baby under radiant warmer or on mother’s chest (skin-to-skin)
3. Clearing airway (if needed)	Suction mouth first, then nose only if baby not breathing properly
4. Assess breathing	Look for chest movement and crying
5. Stimulate if no cry	Rub back, flick soles of feet
6. Clamp and cut cord	After 1–3 minutes or once pulsation stops

🔔 If baby is not breathing: Start resuscitation using the Helping Babies Breathe (HBB) protocol.

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🔷 Apgar Score Assessment (At 1 and 5 minutes)

Component	0 points	1 point	2 points
Appearance (color)	Blue/pale	Body pink, limbs blue	Completely pink
Pulse (heart rate)	Absent	<100 bpm	≥100 bpm
Grimace (reflex)	No response	Grimace	Cough/sneeze/cry
Activity (muscle tone)	Limp	Some flexion	Active movement
Respiration	Absent	Slow/irregular	Good cry

• Normal Apgar: 7–10
• Moderate distress: 4–6
• Severe distress: 0–3 → Needs immediate resuscitation

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🔷 Complete Newborn Physical Assessment

After initial stabilization, conduct a head-to-toe assessment:

Area	What to Check
Head and fontanelles	Shape, molding, swelling, caput/moulding
Eyes and nose	Discharge, symmetry
Mouth and palate	Cleft palate, suck reflex
Chest and lungs	Breathing rate (40–60/min), symmetry
Heart	Rate (120–160 bpm), murmurs
Abdomen	Soft, umbilical cord—3 vessels
Genitalia	Normal structure, ambiguous features
Anus and spine	Patency of anus, any spinal defects
Limbs and tone	Active movement, normal tone
Weight	Measure and record in grams/kilograms
Length and head circumference	Routine newborn measurements

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🔷 Essential Newborn Care (Immediately After Birth)

Refer to the 5 pillars of ENBC:

1. Warmth – Skin-to-skin contact, cap, warm room
2. Breathing – Ensure spontaneous breathing
3. Cord care – Delay clamping (1–3 mins), clean and dry stump
4. Early initiation of breastfeeding – Within 1 hour
5. Infection prevention – Hand hygiene, eye care (if applicable)

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🔷 Additional Care Measures

• Vitamin K injection – 1 mg IM (prevents bleeding disorders)
• Birth dose immunizations:
  • BCG
  • Hepatitis B
  • OPV-0 (Oral polio vaccine)
• Monitor for danger signs:
  • Grunting or chest indrawing
  • Poor feeding
  • Jaundice in first 24 hours
  • Convulsions
  • Lethargy or temperature instability

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🔷 Documentation

What to Record	Details
Time of birth	In hours and minutes
Sex and weight of baby	In grams/kilograms
Apgar score (1 & 5 min)	Numerical value
Cord status, time of clamping	Immediate or delayed
Vitamin K and immunizations given	Yes/No with timing
Condition of baby and mother	Stable or any interventions
Breastfeeding initiation	Time started and acceptance
Any abnormalities or resuscitation	Details of action taken

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🔷 Nurse/Midwife’s Responsibilities

Phase	Role
At birth	Dry, warm, assess breathing, suction if needed
First minute	Apgar scoring, cord care, stimulation
First hour	Encourage breastfeeding, skin-to-skin contact
Assessment	Head-to-toe examination, record weight and signs
Educate the mother	On cord care, danger signs, and feeding
Prepare for referral	If baby shows signs of distress or abnormality

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✅ Summary: Immediate Newborn Care Steps

Task	Time Frame
Dry and warm the baby	Immediately at birth
Skin-to-skin contact with mother	Within 1 minute
Delayed cord clamping	After 1–3 minutes
Apgar score assessment	At 1 and 5 minutes
Breastfeeding initiation	Within first hour
Vitamin K and immunizations	Within 1 hour of birth
Document all findings and actions	As soon as care is completed

🌼 APGAR Assessment.

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🔷 Definition

The APGAR Score is a quick clinical tool used to assess the overall health and vitality of a newborn baby immediately after birth. It helps determine whether the baby needs resuscitation or extra medical care.

🧠 Developed by Dr. Virginia Apgar in 1952.

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🔷 Full Form of APGAR

Letter	Meaning
A	Appearance (Skin Color)
P	Pulse (Heart Rate)
G	Grimace (Reflex Irritability)
A	Activity (Muscle Tone)
R	Respiration (Breathing Effort)

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🔷 Timing of APGAR Score Assessment

• First assessment: At 1 minute after birth
• Second assessment: At 5 minutes after birth
• A third assessment at 10 minutes may be done if the 5-minute score is ≤7

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🔷 APGAR Scoring Chart (0 to 2 for each sign)

Sign	0	1	2
Appearance (Color)	Blue or pale all over	Body pink, extremities blue	Completely pink
Pulse (Heart Rate)	Absent	Less than 100 beats per minute	100 beats per minute or more
Grimace (Reflex)	No response	Grimace or weak cry	Cough, sneeze, or strong cry
Activity (Muscle Tone)	Limp	Some flexion of arms and legs	Active movement
Respiration (Breathing)	Not breathing	Slow or irregular breathing	Good, strong cry

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🔷 Total APGAR Score Interpretation

Score Range	Interpretation	Action Needed
7 to 10	Normal; baby is in good condition	Routine newborn care
4 to 6	Moderate distress	May need gentle stimulation or oxygen
0 to 3	Severe distress (asphyxia)	Immediate resuscitation required

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🔷 Significance of Each Component

Component	Assesses…
Appearance	Peripheral circulation and oxygenation
Pulse	Cardiovascular function
Grimace	Neurological reflexes
Activity	Muscle tone and neuromuscular function
Respiration	Lung maturity and breathing effort

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🔷 Nurse/Midwife’s Role in APGAR Assessment

Task	Responsibility
Observe and assess	Start at 1 minute after birth
Score and record each component	Use Apgar scoring sheet or delivery record
Perform quick interventions if needed	Drying, stimulation, suction, oxygen
Start resuscitation if score is low	Follow Helping Babies Breathe (HBB) protocol
Monitor changes	Repeat score at 5 minutes
Document findings	In labour/delivery register and newborn care notes
Communicate with pediatrician	If 5-min score is ≤7 or baby needs extra care

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✅ Quick Example: APGAR at 1 Minute

Parameter	Score
Appearance	1 (body pink, limbs blue)
Pulse	2 (HR >100 bpm)
Grimace	2 (crying, sneezing)
Activity	1 (some flexion)
Respiration	2 (good cry)

🟢 Total = 8/10 → No immediate concern

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❗ REMEMBER:

• APGAR score is not used to predict long-term outcomes
• It is a guide to immediate care needs only
• Always prepare for neonatal resuscitation even if the pregnancy was normal

🌼 Role of Doula / ASHA During the Second Stage of Labour.

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🔷 SECOND STAGE OF LABOUR: QUICK RECAP

• Begins from full cervical dilatation (10 cm)
• Ends with the birth of the baby
• Characterized by strong expulsive uterine contractions and maternal bearing down efforts

🔔 It is a critical and intense stage, both physically and emotionally, requiring focused support from caregivers and birth companions.

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🔷 Role of a DOULA in Second Stage of Labour

A doula is a trained, non-clinical birth companion who provides continuous physical, emotional, and informational support to the labouring woman.

✅ Emotional Support

• Offers constant reassurance, calming words, and encouragement:
  “You’re doing beautifully,” “Your baby is almost here.”
• Reduces fear and anxiety by staying by the woman’s side
• Validates her pain and progress

✅ Physical Comfort Measures

• Supports mother’s preferred birth position (squatting, side-lying, kneeling)
• Applies cold compress or massage on lower back/perineum
• Wipes sweat, provides sips of water, adjusts pillows
• Guides breathing and relaxation during contractions and pushing

✅ Empowerment and Advocacy

• Reminds the mother of her birth plan preferences
• Helps her express needs to healthcare staff
• Encourages her to listen to her body and push when ready

✅ Companionship and Presence

• Provides non-stop support, unlike staff who may be busy
• Holds her hand, looks into her eyes, keeps her grounded
• Helps reduce the perception of pain and improves maternal satisfaction

🎯 Outcome: Women supported by doulas during second stage often have shorter labour, fewer interventions, and a more positive birth experience.

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🔷 Role of an ASHA in Second Stage of Labour

An ASHA is a community health activist trained to facilitate safe motherhood in rural and underserved areas. While not a clinical provider, her role during labour includes supportive and logistic functions.

✅ Supportive Presence

• Accompanies the woman to the health facility
• Provides emotional reassurance during pushing efforts
• Assists in positioning the woman for delivery if trained

✅ Comfort and Hygiene Assistance

• Brings water, helps with wiping sweat, holding hand, or reassuring touch
• Ensures mother is covered and feels dignified during birth

✅ Communication Link

• Informs nurses/midwives if the woman is in distress or ready to push
• Translates or explains medical instructions if needed
• Assists in communicating with family or husband outside

✅ Promotes Positive Behaviour

• Reminds mother to breathe and relax
• Encourages normal delivery and discourages fear
• Prepares for baby’s arrival – cloth, baby wrap, etc.

✅ Immediate Support After Birth

• Assists in covering baby and mother with clean cloths
• Encourages early breastfeeding if trained and allowed
• Observes for any immediate danger signs and reports

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🔷 Limitations of Role

Doula	ASHA
Cannot perform clinical tasks (e.g., vaginal exams, episiotomy)	Not trained for delivery conduction
Must defer to healthcare staff for medical decisions	Primarily for non-clinical support
Should maintain boundaries	Should follow facility rules and hygiene protocols

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✅ Midwife/Nurse Collaboration Tips

• Allow presence of doula/ASHA in the labour room (as per facility policy)
• Explain their role and limits clearly
• Encourage them to offer emotional and physical comfort
• Ensure infection control and privacy
• Thank and involve them as part of the support team

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💡 Conclusion

Doula’s Contribution	ASHA’s Contribution
Emotional support & comfort	Emotional support & logistics
Breathing guidance & massage	Hygiene help and motivation
Advocacy for birth preferences	Communication with health staff
Reduces stress and panic	Encourages trust and calmness

Both play complementary roles in providing woman-centered, respectful maternity care during the most intense and emotional phase of labour.

🌼 Third Stage of Labour – Physiology.

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🔷 Definition

The third stage of labour is the period from the birth of the baby to the expulsion of the placenta and membranes. It is a crucial phase for both maternal safety and uterine recovery and involves important physiological changes to ensure completion of childbirth.

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🔷 Duration

• Normally lasts 5–30 minutes
• If it exceeds 30 minutes → prolonged third stage
• Longer duration increases the risk of postpartum hemorrhage (PPH)

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🔷 Key Objectives of the Third Stage

• Detach the placenta from the uterine wall
• Expel placenta and membranes completely
• Ensure uterine contraction and retraction to control bleeding
• Prepare uterus for postpartum involution

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🔷 Physiological Changes in the Third Stage

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✅ 1. Uterine Contraction and Retraction

• After baby is delivered, the uterus contracts strongly and rhythmically.
• Retraction refers to the permanent shortening of uterine muscle fibers, which reduces uterine size and prevents hemorrhage.
• This causes the placenta to shear off from the uterine wall.

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✅ 2. Placental Separation

The placenta separates from the uterine wall through a natural shearing process due to:

• Sudden decrease in uterine size after baby is delivered
• Continued uterine contraction and retraction
• Formation of a retroplacental hematoma (collection of blood) behind the placenta, which helps push it away from the wall

There are two types of placental separation:

Type	Description
Schultze mechanism	Central separation first; fetal side (shiny) appears at vulva; minimal bleeding
Matthews Duncan mechanism	Separation starts from margins; maternal side (dull, red) appears first; more bleeding

🔔 Both are normal, but Schultze is more common and neater.

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✅ 3. Descent of Placenta into Lower Uterine Segment and Vagina

• After separation, placenta slides down into the lower uterine segment and vagina, guided by contractions and gravity.
• The mother may feel an urge to push again, and the placenta is expelled naturally or with gentle controlled cord traction.

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✅ 4. Expulsion of Placenta and Membranes

• Usually expelled with a gentle push or by controlled cord traction.
• The placenta is followed by the membranes, which peel off and are delivered as a continuous sheet.

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✅ 5. Uterine Involution Begins

• Once placenta is out, the uterus firmly contracts and retracts.
• This compresses the open maternal blood vessels at the placental site and helps prevent postpartum hemorrhage.
• The uterine fundus should feel firm, round, and central below the umbilicus.

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🔷 Signs of Placental Separation (Clinical Signs)

These indicate the placenta is ready to be delivered:

1. Lengthening of the umbilical cord
2. Gush of blood from the vagina
3. Uterus becomes firm, round, and rises in abdomen
4. Mother may feel urge to push

🔔 Do not pull the cord until signs of separation are clearly visible!

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🔷 Hormonal Influence in Third Stage

Hormone	Role
Oxytocin	Stimulates uterine contractions → placental separation and bleeding control
Prostaglandins	Help maintain contraction
Endorphins	Reduce maternal stress and enhance bonding

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🔷 Clinical Importance of Understanding Third Stage Physiology

• To prevent and manage postpartum hemorrhage (PPH)
• To ensure complete expulsion of placenta and avoid retained placenta
• To safely perform Active Management of Third Stage of Labour (AMTSL)

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✅ Summary: Physiological Steps in the Third Stage

Step	Event
Uterine contraction	Uterus reduces in size
Placental separation	Due to shearing force and retroplacental clot
Descent into lower segment	Placenta moves into vagina
Expulsion of placenta	Spontaneous or assisted
Uterine contraction post-expulsion	Prevents bleeding

🌼 Placental Separation and Expulsion.

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🔷 Definition

Placental separation and expulsion refers to the detachment of the placenta from the uterine wall and its delivery through the birth canal after the baby is born. This occurs during the third stage of labour and is vital for completing the childbirth process and preventing complications like postpartum hemorrhage.

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🔷 Normal Duration

• Usually occurs within 5–30 minutes after the baby is born
• If it takes more than 30 minutes, it is called a retained placenta

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🔷 Physiology of Placental Separation

After the baby is born, the uterus:

1. Contracts and retracts strongly, decreasing its size.
2. This shrinks the placental bed, causing the placenta to shear off from the uterine wall.
3. A small amount of blood collects behind the placenta (retroplacental clot), helping to push it away.
4. The placenta detaches and slides into the lower uterine segment and vagina.

These actions are largely controlled by the hormone oxytocin, which promotes strong uterine contractions.

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🔷 Mechanisms of Placental Separation

✅ 1. Schultze Mechanism (Most Common – ~80% of cases)

Feature	Description
Separation starts	From the center of placenta
Fetal side (shiny)	Presents at vulva first
Bleeding	Concealed until placenta is delivered
Appearance	Clean and neater delivery

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✅ 2. Matthews Duncan Mechanism

Feature	Description
Separation starts	From the margins of placenta
Maternal side (dull, red)	Appears first
Bleeding	More external bleeding before expulsion
Appearance	Less neat, common in partial separation

🔔 Both mechanisms are normal, but Schultze is cleaner and preferred.

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🔷 Signs of Placental Separation

These clinical signs indicate the placenta has detached and is ready to be expelled:

Sign	Observation
Gush of blood	Sudden flow from the vagina
Lengthening of cord	Umbilical cord protrudes further out
Uterus rises	Fundus becomes higher and firm
Change in uterine shape	From flat to globular
Urge to push again	May be felt by the mother

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🔷 Placental Expulsion Methods

Once separation is complete, expulsion occurs either:

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✅ 1. Spontaneous Expulsion (Physiological Method)

• Mother pushes the placenta out naturally with or without help
• Usually occurs with minimal handling
• Often used in natural or home births

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✅ 2. Assisted Expulsion (Controlled Cord Traction – CCT)

Used in Active Management of Third Stage of Labour (AMTSL):

1. After signs of separation, the uterus is guarded with one hand above the pubic bone.
2. The other hand applies gentle downward traction on the clamped umbilical cord.
3. Placenta is delivered slowly with controlled force.
4. Membranes are twisted during expulsion to avoid tearing.

⚠️ Never pull on the cord before separation signs appear to avoid uterine inversion.

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🔷 Inspection After Expulsion

It is vital to inspect the placenta and membranes:

Check For	Why It Matters
Completeness of placenta	To rule out retained fragments
Three vessels in the cord	Normal anatomy: 2 arteries, 1 vein
No missing cotyledons	Missing lobes can cause bleeding
Complete membranes	Prevents infection and retained tissue

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🔷 Midwife/Nurse’s Responsibilities

Step	Action
Monitor for separation signs	Observe closely after baby is born
Assist with CCT (if skilled)	Perform only when uterus is contracted and signs are present
Inspect placenta thoroughly	To ensure no retained parts
Check uterine tone	Fundus should be firm to prevent hemorrhage
Record time of placenta delivery	Document in delivery notes
Monitor for bleeding	Observe for signs of PPH (Postpartum Hemorrhage)
Educate the mother	Encourage breastfeeding (helps contraction)

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🔷 Complications to Watch For

Problem	Risk
Retained placenta	Can lead to PPH and infection
Uterine inversion	May occur due to premature or forceful traction
Uterine atony	Poor contraction leads to heavy bleeding
Torn membranes	May lead to infection or retained parts

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✅ Summary: Steps of Placental Separation and Expulsion

1. Uterus contracts and retracts
2. Placenta separates (Schultze or Duncan method)
3. Signs of separation appear
4. Placenta descends into vagina
5. Expelled spontaneously or with CCT
6. Membranes delivered
7. Placenta is inspected for completeness
8. Uterus is massaged and monitored

🌼 Homeostasis.

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🔷 Definition

Homeostasis is the process by which the body maintains a stable internal environment despite external changes. It ensures that vital conditions like temperature, blood pressure, pH, blood glucose, fluid levels, and oxygen supply remain within narrow, healthy limits for the body to function properly.

🔁 Homeostasis = Balance or Equilibrium in the body

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🔷 Why is Homeostasis Important?

Homeostasis is essential to:

• Keep cells functioning properly
• Maintain life and health
• Respond to stress, infections, or injuries
• Adapt to changes during pregnancy, labour, or illness

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🔷 Examples of Homeostasis in the Human Body

System	What It Maintains	Example
Thermoregulation	Body temperature (36.5–37.5°C)	Sweating when hot; shivering when cold
Respiratory system	Oxygen and CO₂ levels	Increased breathing during exercise
Cardiovascular system	Blood pressure	Vasoconstriction when BP drops
Renal system	Fluid and electrolyte balance	Kidneys excreting more water when overhydrated
Endocrine system	Blood sugar levels	Insulin lowers blood glucose after a meal

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🔷 Basic Components of Homeostatic Control

1. Receptor – Detects change (e.g., temperature sensors in skin)
2. Control Center – Brain or hormone center interprets the signal
3. Effector – Carries out the response (e.g., muscles, glands)

Example:

• Receptor: Thermoreceptors sense heat
• Control center: Hypothalamus
• Effector: Sweat glands cool the body

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🔷 Homeostasis in Pregnancy and Labour

Condition	How Homeostasis Works
Increased blood volume	Kidneys regulate fluid & electrolyte balance
Fetal oxygenation	Respiratory rate increases to meet O₂ needs
Labour contractions	Hormonal balance (oxytocin & prostaglandins) controls timing
Blood loss during birth	Blood clotting and uterine contraction prevent hemorrhage
Thermoregulation in newborn	Skin-to-skin contact supports baby’s temperature

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🔷 Disruption of Homeostasis (Imbalance)

When homeostasis is disturbed, the body may develop conditions like:

• Fever (temp imbalance)
• Hypotension or shock (circulatory imbalance)
• Hypoglycemia or hyperglycemia (glucose imbalance)
• Dehydration or edema (fluid imbalance)

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🔷 Nursing Implications in Maintaining Homeostasis

Nurse’s Role	How to Support Homeostasis
Monitor vital signs	Detect early signs of imbalance
Hydration and nutrition	Maintain fluid and electrolyte levels
Oxygen therapy	Ensure tissue oxygenation if needed
Infection control	Prevent fever and sepsis
Pain management	Reduce stress response
Thermal care in newborns	Prevent hypothermia/hyperthermia

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✅ Key Summary

Feature	Description
Meaning	Body’s way of keeping balance
Systems involved	Nervous, endocrine, cardiovascular, renal
Vital parameters	Temp, BP, glucose, fluid, pH, oxygen
Nurse’s job	Observe, detect changes, intervene early

🌼 Physiological (Expectant) Management of the Third Stage of Labour.

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🔷 Definition

Physiological management of the third stage of labour refers to allowing the placenta to separate and be expelled naturally, without the routine use of uterotonic drugs, cord traction, or early cord clamping.

🧠 It relies on the mother’s natural oxytocin release, effective uterine contractions, and gravity to complete the third stage of labour.

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🔷 Stages of Labour Recap

• First stage: Cervical dilation (0–10 cm)
• Second stage: Birth of the baby
• Third stage: Birth of placenta and membranes
• Fourth stage: First 1–2 hours postpartum (monitoring phase)

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🔷 Goal of Physiological Management

• Support the natural processes of placental separation and expulsion
• Minimize interference and allow the woman’s body to complete the process on its own
• Promote bonding and breastfeeding, which help trigger oxytocin naturally

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🔷 Steps of Physiological Management

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✅ 1. Skin-to-Skin Contact and Early Breastfeeding

• Immediately after birth, the baby is placed on the mother’s chest
• This stimulates natural oxytocin release, aiding uterine contraction
• Enhances bonding, temperature regulation, and emotional connection

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✅ 2. Wait for Signs of Placental Separation

Let the uterus contract naturally and observe for signs such as:

Sign of Separation	What You Observe
Gush of blood	Vaginal bleeding without trauma
Lengthening of umbilical cord	Cord becomes longer at the vulva
Rising of the uterine fundus	Uterus rises in the abdomen
Change in uterine shape	From flat to globular
Maternal urge to push again	Reflex to expel placenta

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✅ 3. Mother Pushes Out the Placenta

• Ask the mother to push gently when she feels the urge
• Placenta usually slides out by gravity and effort
• No uterotonic injection or cord traction is used routinely

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✅ 4. Expulsion of Membranes

• Membranes usually follow the placenta
• Midwife may gently help if membranes trail behind (using sterile gloves)
• Ensure membranes are expelled intact to prevent infection or retention

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✅ 5. Uterus Contracts and Retraction Begins

• Natural uterine contractions and retraction compress blood vessels
• This prevents excessive bleeding and supports natural hemostasis

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🔷 What is NOT Done in Physiological Management?

❌ Not Done	Reason
No routine uterotonics (e.g., oxytocin)	Let body produce natural oxytocin
No controlled cord traction	Avoid disrupting natural separation
No early cord clamping	Allows more blood transfer to baby

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🔷 Duration

• Usually takes 5–30 minutes
• If placenta is not expelled after 30 minutes → investigate for retained placenta

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🔷 Benefits of Physiological Management

Benefits to Mother	Benefits to Baby
Encourages natural hormonal flow	Gets more blood volume via delayed cord clamping
Promotes normal uterine contraction	Reduces risk of anemia (due to more iron)
Minimizes intervention and trauma	Supports early bonding
Encourages autonomy and satisfaction	Promotes successful breastfeeding

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🔷 Who is Suitable for Physiological Management?

✅ Low-risk women
✅ No history of postpartum hemorrhage
✅ Normal labour and delivery
✅ Woman prefers natural, minimal-intervention birth

⚠️ Not suitable in high-risk cases (e.g., multiple gestation, prolonged labour, bleeding disorders, previous PPH)

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🔷 Midwife/Nurse’s Role in Physiological Management

Task	Action
Support skin-to-skin contact	Place baby on chest, encourage early feeding
Observe for separation signs	Wait and monitor patiently
Guide gentle maternal effort	Assist when mother feels urge to push
Do not apply traction or uterotonics	Unless medically required
Inspect placenta and membranes	Ensure completeness post-expulsion
Monitor bleeding and uterine tone	Watch closely for signs of PPH
Document clearly	Record time of placenta expulsion, blood loss, observations

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🔷 When to Switch to Active Management

Switch to active management if:

• Placenta not delivered within 30 minutes
• Excessive bleeding
• Signs of uterine atony (poor contraction)
• Maternal distress or complications

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✅ Summary Table: Physiological vs Active Management

Feature	Physiological Management	Active Management
Use of uterotonics	❌ No	✅ Yes (Oxytocin)
Cord traction	❌ No	✅ Yes (Controlled Cord Traction)
Cord clamping	✅ Delayed (after pulsation stops)	❌ Early (immediately after birth)
Suitable for	Low-risk, natural birth	High-risk or hospital-managed birth
Midwife’s role	Observe and support	Perform interventions and manage steps

🌼 Active Management of the Third Stage of Labour (AMTSL).

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🔷 Definition

Active Management of the Third Stage of Labour (AMTSL) is a prophylactic intervention used immediately after the birth of the baby to facilitate placental expulsion, promote uterine contraction, and prevent postpartum hemorrhage (PPH) — one of the leading causes of maternal mortality.

✅ AMTSL involves uterotonics, controlled cord traction, and uterine massage to ensure safe delivery of the placenta.

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🔷 Objectives of AMTSL

• Prevent postpartum hemorrhage (PPH)
• Facilitate quick and complete delivery of placenta
• Ensure uterine contraction and retraction
• Reduce maternal morbidity and mortality
• Minimize need for manual removal of placenta

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🔷 Timing

• AMTSL is started immediately after the birth of the baby (within 1 minute), before the placenta is expelled.

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🔷 Three Main Components of AMTSL

✅ 1. Administration of Uterotonic Drug

• The first and most important step.
• Drug of choice: Oxytocin 10 IU IM
• Given within 1 minute of baby’s birth
• Alternative: Misoprostol (600 mcg oral or 800 mcg rectal) — if oxytocin is unavailable

Drug	Route	Effect
Oxytocin	IM/IV	Causes strong uterine contractions
Misoprostol	Oral/Rectal	Stimulates uterine tone

❗ Never give uterotonic before delivery of the second baby in twin pregnancies.

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✅ 2. Controlled Cord Traction (CCT)

Performed after signs of placental separation (e.g., lengthening cord, gush of blood):

🔹 Steps:

• Guard the uterus with one hand (above pubic symphysis)
• Hold clamped cord and apply gentle downward traction
• Assist placenta to come out slowly
• Do not pull if uterus is not contracted or signs of separation are absent

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✅ 3. Uterine Massage After Placenta Delivery

• After placenta is expelled, massage the fundus through the abdomen
• Stimulates continued contraction of uterus
• Ensures the uterus is firm and central
• Reduces risk of uterine atony and bleeding

🔁 Repeat massage every 15 minutes for the first 1–2 hours postpartum or as needed

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🔷 WHO-Recommended Sequence for AMTSL

1. Oxytocin administration (within 1 minute of baby’s birth)
2. Wait for signs of placental separation
3. Apply controlled cord traction
4. Perform uterine massage
5. Inspect placenta for completeness
6. Monitor maternal vitals and blood loss

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🔷 Benefits of Active Management

Benefit	Outcome
Reduces risk of PPH	Prevents excessive blood loss
Shortens third stage duration	Faster delivery of placenta
Decreases need for blood transfusion	Safer for mother
Prevents retained placenta	Avoids surgical/manual removal

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🔷 Contraindications / When to Modify

Condition	Caution/Action
Twin pregnancy (before 2nd baby)	Delay uterotonic
Cord prolapse or short cord	Avoid traction
Uterus not contracted	Don’t perform CCT yet
Suspected uterine rupture	Do not massage until evaluated

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🔷 Midwife/Nurse’s Responsibilities in AMTSL

Role	Responsibility
Prepare uterotonic	Before baby is born
Give injection	Immediately after birth
Observe for separation signs	Gush of blood, cord lengthening
Apply controlled traction	With uterine support
Massage uterus	After placenta is delivered
Inspect placenta/membranes	Ensure complete expulsion
Monitor vitals and bleeding	Every 15 minutes
Document all steps	Time, dose, findings, complications

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✅ Summary of AMTSL Steps

Step	Action
1. Administer Oxytocin	10 IU IM within 1 minute
2. Controlled Cord Traction	After signs of separation
3. Uterine Massage	After placenta delivery
4. Monitor and document	Vitals, bleeding, placenta status

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🔷 Difference Between Active and Physiological Management

Feature	Active Management	Physiological Management
Uterotonic used?	✅ Yes (Oxytocin)	❌ No (relies on natural oxytocin)
Cord traction?	✅ Yes	❌ No
Cord clamping	Early or delayed	Delayed
Suitable for	Most institutional deliveries	Low-risk home births
Risk of PPH	Significantly reduced	Slightly higher risk

🌼 Examination of the Placenta, Membranes, and Vessels.

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🔷 Purpose of Placental Examination

• To ensure the complete expulsion of the placenta and membranes
• To detect any retained parts which could lead to postpartum hemorrhage (PPH) or infection
• To assess for congenital anomalies or signs of intrauterine problems
• To evaluate the umbilical cord and vessels

🔔 Every placenta must be examined immediately after delivery, regardless of whether the birth was normal or complicated.

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🔷 Timing

• Examination is done immediately after the delivery of the placenta, before discarding it.
• Always done on a clean, flat surface with adequate lighting.

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🔷 Steps in Examination of the Placenta, Membranes, and Vessels

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✅ 1. Wash hands and wear gloves

Ensure aseptic precautions.

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✅ 2. Examine the Maternal Surface (Rough, Dull Side)

Feature	Normal Findings
Shape	Round or oval
Color	Dark reddish-purple
Cotyledons	15–20 lobes (cotyledons) present
Surface	Should be complete and intact
No gaps or missing parts	Indicates complete separation

🔍 Missing cotyledons suggest retained placental tissue – a cause of PPH or infection.

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✅ 3. Examine the Fetal Surface (Shiny Side)

Feature	Normal Findings
Color	Shiny, greyish
Amnion and Chorion	Should be intact and complete
Vessels	Radiate from cord insertion site
Wharton’s jelly	Present around vessels for protection

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✅ 4. Examine the Umbilical Cord

Feature	Normal Findings
Length	Average 50–60 cm
Insertion site	Central or slightly eccentric
Vessels	Three vessels: 2 arteries, 1 vein
Knots/twists	False knots or normal coiling may be present
True knots	Rare but can affect fetal circulation
Wharton’s jelly	Present and protective

🔎 Check for cord abnormalities like short cord, single artery, true knots, or velamentous insertion.

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✅ 5. Examine the Membranes

Check For	Significance
Completeness of sac	Prevent retained membranes
Color or staining	Greenish = meconium; Yellow = infection
Site of rupture	Spontaneous or artificial rupture location
Two layers visible	Amnion (inner) and chorion (outer)

🔔 Incomplete membranes can cause infection or delayed bleeding.

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✅ 6. Document Findings

• Placenta: Complete/incomplete
• Membranes: Intact/incomplete
• Cord: Length, insertion site, number of vessels
• Any abnormalities or missing parts

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🔷 Midwife/Nurse’s Responsibilities

Task	Role
Perform examination	Check placenta, membranes, and cord thoroughly
Detect abnormalities	Report missing lobes, cord issues, or infection signs
Prevent complications	Ensure no retained tissue remains
Document findings	Accurately in birth register/case notes
Educate mother (if needed)	Reassure or explain if placenta is sent for histopathology

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🔷 Common Abnormal Findings

Abnormality	Risk/Concern
Missing cotyledons	Retained placenta → PPH, infection
Single umbilical artery	May indicate fetal anomalies
Velamentous insertion	Risk of cord rupture, fetal death
Meconium-stained membranes	Fetal distress during labour
Succenturiate lobe	Accessory lobe may remain inside uterus

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✅ Quick Checklist for Placenta Examination

Item	✓ Checked
Maternal surface complete (no gaps)
Cotyledons all present
Fetal surface smooth and shiny
Vessels visible and normal
Cord: 2 arteries + 1 vein
Membranes complete and intact
No signs of infection or staining

🌼 Assessment of Perineal/Vaginal Tears and Suturing.

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🔷 Definition

Perineal and vaginal tears are spontaneous lacerations or surgical incisions (e.g., episiotomy) that occur during the second stage of labour due to stretching or tearing of the perineal body, vaginal mucosa, or anal sphincter as the baby is delivered.

🔔 Prompt assessment, classification, and repair are essential to prevent infection, bleeding, incontinence, and long-term complications.

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🔷 When to Assess for Tears

• Immediately after delivery of the placenta
• Before applying perineal pads or allowing ambulation
• Under adequate lighting and aseptic conditions
• With patient properly positioned (lithotomy or dorsal)

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🔷 Steps in Assessment of Perineal/Vaginal Tears

✅ 1. Explain the Procedure

• Reassure the mother and obtain informed consent
• Ensure privacy and dignity

✅ 2. Position the Woman

• Use dorsal or lithotomy position
• Provide good light source and draping

✅ 3. Clean the Area

• Use sterile normal saline and gauze
• Gently clean blood and clots

✅ 4. Inspect for Injuries

• Observe vaginal wall, perineum, and anal area
• Identify the type and depth of tear or laceration

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🔷 Classification of Perineal Tears (Degrees)

Degree	Structures Involved
1st degree	Involves only vaginal mucosa and skin of perineum
2nd degree	Extends into perineal muscles but not anal sphincter
3rd degree	Involves partial or complete rupture of anal sphincter
4th degree	Extends through anal sphincter into rectal mucosa

⚠️ 3rd and 4th-degree tears are considered obstetric emergencies and require repair by experienced obstetricians/surgeons under anesthesia.

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🔷 Other Types of Injuries to Check

Injury Type	Location
Vaginal tear	Inside the vaginal walls
Labial tear	In the labia minora or majora
Clitoral injury	Sensitive and prone to bleeding
Cervical tear	May occur even without perineal tear; check if bleeding persists after delivery

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🔷 Indications for Suturing

• Tear is more than 1st degree
• Persistent bleeding
• Gaping wound or risk of infection
• To promote healing and restore anatomy

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🔷 Preparation for Suturing

Requirement	Details
Consent	Always obtain
Aseptic technique	Sterile gloves, gown, mask
Instruments	Perineal repair set: needle holder, scissors, toothed forceps, sponge holding forceps
Suture material	Chromic catgut 1-0 or Vicryl Rapide 2-0 (absorbable)
Local anesthesia	1% Lignocaine (unless epidural is in place)
Good lighting	Essential for visibility

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🔷 Suturing Technique (For 1st and 2nd Degree Tears)

Step-by-Step for 2nd Degree Tear:

1. Infiltrate local anesthesia into perineal and vaginal tissues.
2. Start suturing vaginal mucosa first, using continuous non-locking technique.
3. Approximate perineal muscles with interrupted absorbable sutures.
4. Close skin of perineum using subcuticular or interrupted sutures.
5. Check for hemostasis and ensure no gaps.

🔔 Check rectal tone after repair to rule out unnoticed sphincter injury.

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🔷 Post-Repair Care

Care Type	Action
Monitor bleeding	Check pad hourly for 2–4 hours
Pain relief	Prescribe analgesics if needed
Perineal hygiene	Clean with warm water; encourage proper wiping
Stool softeners	To prevent constipation and straining
Advise sitz baths	Warm saltwater baths after 24 hours
Observe for infection	Redness, pus, swelling, fever
Educate woman	On healing time (2–3 weeks), when to seek help

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🔷 Documentation

• Degree and type of tear
• Location of tear
• Type of suture used
• Amount of local anesthesia
• Patient’s tolerance of procedure
• Time, name, and signature of the person who performed the repair

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✅ Quick Summary: Nurse/Midwife’s Role

Step	Responsibility
Assess for tears	Immediately after birth
Classify degree	1st–4th
Prepare for suturing	Set up sterile tray, local anesthetic
Assist or perform repair	If trained and allowed (1st–2nd degree only)
Educate mother	Perineal care, hygiene, signs of infection
Monitor post-repair	Vitals, bleeding, healing
Document all findings	Accurately and timely

🌼 Insertion of Postpartum Intrauterine Contraceptive Device (PPIUCD).

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🔷 Definition

A Postpartum IUCD (PPIUCD) is a long-acting reversible contraceptive inserted within 48 hours of childbirth (vaginal or cesarean) to prevent unintended pregnancies during the postpartum period. It is a safe, effective, hormone-free method of contraception.

🧷 Common type used: Copper T 380A
📆 Duration of protection: Up to 10 years

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🔷 Timing of PPIUCD Insertion

Type of Insertion	Timing
Postplacental	Within 10 minutes after placental expulsion (vaginal birth or cesarean)
Intracesarean	During cesarean section, after removal of placenta
Early postpartum	Within 48 hours of childbirth
Interval IUCD	After 6 weeks postpartum (if not inserted earlier)

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🔷 Eligibility Criteria (MEC Guidelines)

✅ Eligible:

• Woman has delivered a live baby
• Uterus is well-contracted
• No PPH or uterine abnormalities
• No signs of infection
• Woman has received counseling and consented antenatally or before insertion

🚫 Not Eligible (Contraindications):

• PPH or uterine atony
• Ruptured membranes for >24 hrs before delivery (↑ infection risk)
• Sepsis or chorioamnionitis
• Uterine malformations
• Unresolved anemia or bleeding disorders
• Active STIs or pelvic infection

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🔷 Counseling for PPIUCD

Counsel during antenatal visits, early labour, or postpartum, covering:

Topic	Details
Effectiveness	>99%
Duration of protection	10 years (removable anytime)
Fertility return	Immediate after removal
Side effects	Cramping, spotting in early months
No effect on breastfeeding	Safe during lactation
Can be used discreetly	Good for women who want spacing silently

🔔 Informed written consent is essential before insertion.

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🔷 Preparation for Insertion

✅ Supplies/Tray for PPIUCD Insertion:

• Sterile gloves
• Cusco’s or Sim’s speculum
• PPIUCD forceps (long, curved) – special instrument
• Uterine sound (optional)
• Antiseptic solution (e.g., Betadine)
• Copper T 380A IUCD (loaded in sterile package)
• Sterile gauze, kidney tray
• Towel/pad

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🔷 Steps of PPIUCD Insertion (Postplacental Vaginal)

Step-by-Step Technique:

1. Explain procedure and gain consent
2. Wash hands and wear sterile gloves
3. Ensure uterus is well contracted
4. Position woman in dorsal lithotomy
5. Visualize cervix using speculum
6. Clean cervix and vagina with antiseptic
7. Using PPIUCD forceps, grasp the IUCD string, keeping arms folded
8. Gently pass the IUCD through the cervical os into uterine fundus
9. Ensure placement at fundus (important to reduce expulsion)
10. Withdraw forceps gently without dislodging device
11. Do NOT cut the threads in postpartum insertions – they retract into uterus and may descend later
12. Remove speculum and check for bleeding
13. Record date, batch number, and patient details

🧷 For intracesarean insertion, the device is placed at the uterine fundus with fingers after placental removal.

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🔷 Post-Insertion Instructions and Follow-up

• Monitor for bleeding, cramping, or discomfort
• Provide discharge advice:
  • Come back if pain, fever, foul discharge, or expulsion
  • Come for follow-up at 6 weeks
  • No restriction on sex or activity after healing

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🔷 Advantages of PPIUCD

Benefit	Explanation
Highly effective	>99% success rate
Long-term protection	Up to 10 years
Hormone-free	Safe for breastfeeding
Reversible	Can be removed anytime
No daily action needed	Convenient and private
Cost-effective	One-time insertion

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🔷 Possible Side Effects/Complications

Side Effect	Notes
Mild abdominal cramping	Common in first few days
Irregular bleeding or spotting	Often resolves in a few weeks
String not felt	May be retracted; confirm position by ultrasound
Expulsion (partial/complete)	Occurs in ~5–10% cases
Pelvic infection (rare)	Especially if sepsis present at time of insertion

⚠️ PPIUCD does not protect against STIs or HIV – dual protection advised if at risk.

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🔷 Nurse/Midwife’s Responsibilities

Stage	Responsibility
Antenatal	Educate, counsel, and screen for eligibility
Intrapartum	Confirm consent, ensure sterile technique
Insertion	Use correct technique and instruments
Postpartum	Monitor for complications, counsel for follow-up
Documentation	Record type, date, batch number, and woman’s understanding

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✅ Summary: PPIUCD Insertion in 10 Key Points

1. Safe, long-acting contraceptive for postpartum women
2. Inserted within 10 mins (postplacental) or up to 48 hrs (early postpartum)
3. Requires counseling and consent
4. Use long forceps for high fundal placement
5. Do not cut threads after insertion
6. Watch for signs of expulsion or infection
7. No hormonal effects – safe for breastfeeding
8. Can be removed anytime by trained provider
9. Follow-up visit at 6 weeks postpartum
10. Midwives play a central role in education, insertion, and follow-up

🌼 Immediate Perineal Care.

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🔷 Definition

Immediate perineal care refers to the cleaning, assessment, and care of the perineal area immediately after childbirth, especially if there is bleeding, episiotomy, tear, or suturing involved.

🧼 It is a part of post-delivery care to promote healing, comfort, and infection prevention.

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🔷 Objectives of Immediate Perineal Care

• To maintain hygiene and prevent infection
• To assess for bleeding, swelling, hematoma, or lacerations
• To promote comfort and healing
• To reduce the risk of perineal trauma complications
• To provide an opportunity for early detection of complications

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🔷 Indications for Perineal Care

• After episiotomy or perineal tear
• Following suturing or repair
• After normal vaginal delivery (especially with bleeding or edema)
• For women with excessive lochia or soiling
• Routine postpartum care

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🔷 Articles Required (Perineal Tray)

Item	Purpose
Sterile gloves	Infection control
Perineal pad	Absorb blood/lochia
Kidney tray	Waste collection
Sterile gauze/swabs	Cleaning perineum
Antiseptic solution (e.g., Betadine, Savlon diluted)	Disinfection
Forceps	Handling gauze/swabs
Jug/bowl with warm water	Comfort and cleansing
Clean linen or underpad	For comfort and hygiene
Torch/light source	Clear visibility
Methylated spirit (optional)	Final swab if required
Analgesic cream (if prescribed)	Pain relief (e.g., lidocaine gel)

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🔷 Preparation Before the Procedure

1. Explain the procedure to the mother
2. Ensure privacy and consent
3. Place the woman in a dorsal position with knees bent and thighs apart
4. Drape appropriately
5. Wash hands and wear sterile gloves

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🔷 Step-by-Step Procedure of Immediate Perineal Care

✅ 1. Inspect the Perineal Area

• Look for:
  • Bleeding
  • Swelling or bruising
  • Episiotomy wound or suture line
  • Signs of infection or hematoma

✅ 2. Cleanse the Perineum

• Use clean swabs soaked in warm antiseptic solution
• Clean from front to back (vulva to anus) to prevent contamination
• Use a new swab each time
• Clean:
  1. Labia majora (one side at a time)
  2. Labia minora
  3. Perineum
  4. Around suture line (if present)
  5. Anus last

⚠️ Always clean front to back to avoid transferring fecal bacteria to the vagina.

✅ 3. Dry the Area Gently

• Use a sterile dry gauze to pat the area dry gently
• Avoid rubbing

✅ 4. Apply Medication (If Needed)

• Apply antiseptic or analgesic cream if prescribed
• Avoid using talcum powder or home remedies

✅ 5. Place Clean Pad and Linen

• Place a fresh, sterile maternity pad under the perineum
• Change soiled underpads or linen
• Ensure comfort and dryness

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🔷 Post-Procedure Care

• Dispose of soiled materials safely (as per biomedical waste protocols)
• Wash hands thoroughly after glove removal
• Document the:
  • Condition of perineum
  • Any signs of infection or hematoma
  • Medications applied
  • Patient’s response to care
• Educate the woman on self-perineal hygiene, pad change, and signs of infection

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🔷 Assessment Points During Perineal Care

Assessment Area	What to Look For
Episiotomy site	Redness, discharge, dehiscence
Lochia	Amount, color, odor
Swelling/Bruising	Hematoma or edema
Pain level	Report severe pain
Perineal tone	Muscle firmness

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🔷 Health Teaching for the Mother

• Always wipe or clean from front to back
• Change perineal pad every 4–6 hours or when soaked
• Avoid using perfumed soaps or powders
• Take sitz baths after 24 hours (if advised)
• Report:
  • Foul-smelling lochia
  • Pus or discharge from wound
  • Severe pain or swelling
  • Fever or chills

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🔷 Nurse/Midwife’s Responsibilities

Responsibility	Description
Hygienic care	Maintain asepsis during procedure
Observation	Detect any abnormality or complications
Documentation	Record findings and care given
Emotional support	Reassure and maintain dignity
Education	Teach mother about perineal hygiene

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✅ Quick Summary: Procedure at a Glance

Step	Key Action
Prepare woman and articles	Explain, position, drape
Inspect perineum	Assess for injury or infection
Clean with antiseptic solution	Use front-to-back technique
Dry and apply medication	Only if prescribed
Place fresh pad and linen	Ensure comfort
Dispose waste and document	Maintain records
Teach self-care	Hygiene and warning signs

🌼 Initiation of Breastfeeding.

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🔷 Definition

Initiation of breastfeeding refers to the process of starting the baby on the mother’s breast for the first feed, ideally within the first hour of birth. This is a critical step in promoting bonding, nutrition, and newborn survival.

🍼 Early initiation is part of Essential Newborn Care (ENBC) and is strongly recommended by the WHO and Government of India.

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🔷 Ideal Time for Initiation

• Within the first hour of birth (golden hour)
• Once the baby is:
  • Breathing well
  • Skin-to-skin on mother’s chest
  • Clinically stable

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🔷 Importance of Early Initiation

Benefit for Baby	Benefit for Mother
Receives colostrum – rich in antibodies	Stimulates uterine contraction (reduces PPH)
Boosts immunity and prevents infection	Helps in bonding and emotional connection
Promotes gut maturation	Supports breast milk production (prolactin and oxytocin release)
Reduces neonatal mortality	Natural form of contraception (Lactational Amenorrhea)
Regulates blood sugar & temperature	Enhances confidence and satisfaction

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🔷 Physiology of Breastfeeding

• Oxytocin (from posterior pituitary): causes milk ejection (“let-down reflex”)
• Prolactin (from anterior pituitary): promotes milk production
• Baby’s suckling triggers these hormones
• Colostrum is the first milk—thick, yellow, nutrient-rich, and full of immunoglobulins (IgA)

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🔷 Steps for Initiating Breastfeeding – Step-by-Step Guide

✅ 1. Ensure Skin-to-Skin Contact

• Place the naked baby on the mother’s bare chest
• Cover both with a warm cloth
• Supports thermal regulation and suckling instinct

✅ 2. Position the Baby Properly

Good Positioning Signs
Baby’s head and body in straight line
Baby’s nose level with the nipple
Baby’s body turned toward mother
Mother supports baby’s neck and back

✅ 3. Help with Latching-On

Good Latch Signs
Baby’s mouth wide open
Lower lip turned outward
More areola visible above than below nipple
No clicking sound or pain

⚠️ Poor latch can cause nipple pain, cracked nipples, and poor milk transfer.

✅ 4. Observe and Encourage

• Observe the baby’s suckling (slow, deep sucks followed by swallowing)
• Encourage the mother to relax and continue feeding for at least 20–30 minutes

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🔷 What is Colostrum and Why is It Important?

Feature	Description
First milk	Thick, yellowish, available from birth to day 3–5
High in antibodies	Especially IgA, protects against infections
Nutrient-rich	Proteins, fat-soluble vitamins, growth factors
Acts as a laxative	Helps pass meconium, prevents jaundice

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🔷 Common Challenges in Initiation

Challenge	Nursing Intervention
Baby not latching	Help with positioning, stimulate rooting reflex
Mother afraid or unsure	Reassure, teach, and stay with her
Cesarean birth	Assist with comfortable position (side-lying or football hold)
Preterm baby or NICU stay	Express colostrum and give via spoon/cup
Flat or inverted nipples	Use manual techniques or breast pump temporarily

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🔷 Nurse/Midwife’s Role in Initiating Breastfeeding

Stage	Role
Immediately after birth	Place baby skin-to-skin, delay weighing/bathing
Assist with first latch	Guide baby’s mouth, support mother
Assess feeding	Check latch, duration, baby’s suck/swallow
Provide encouragement	Reassure and empower the mother
Educate on benefits	Importance of colostrum and exclusive breastfeeding
Monitor	Baby’s feeding cues and mother’s comfort
Document	Time of first breastfeeding, any difficulties, mother’s response

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🔷 Key Health Education for the Mother

• Feed on demand (8–12 times/day)
• Do not give prelacteal feeds (e.g., honey, water, glucose)
• No bottles or pacifiers in early weeks
• Signs baby is getting enough milk:
  • Active feeding
  • Passing urine ≥6 times/day
  • Baby appears satisfied and gains weight

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✅ Summary: Initiation of Breastfeeding – Golden Hour Checklist

Task	Done? ✅
Skin-to-skin contact started
Colostrum offered
Baby latched well
Mother supported and reassured
Feeding continued for 20–30 mins
Documented time and response

🌼 Skin-to-Skin Contact (SSC).

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🔷 Definition

Skin-to-skin contact (SSC) is the practice of placing the naked newborn baby directly on the mother’s bare chest or abdomen, immediately after birth, with both covered in a warm blanket. The baby’s skin touches the mother’s skin without any barriers.

👶 This is also called Kangaroo Mother Care (KMC) in low birth weight or preterm babies.

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🔷 Timing of Skin-to-Skin Contact

• Begin immediately after birth (within the first minute), ideally before cutting the cord
• Continue for at least 1 hour, or until after the first breastfeeding

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🔷 Objectives of Skin-to-Skin Contact

• Promote early bonding and attachment
• Regulate the baby’s temperature, heart rate, and breathing
• Support early initiation of breastfeeding
• Reduce stress, crying, and pain in the baby
• Stimulate maternal oxytocin release, aiding uterine contraction

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🔷 Procedure: Step-by-Step

✅ Before Initiating

1. Dry the baby thoroughly with a clean warm towel
2. Ensure the baby is breathing and stable
3. Place a cap on the baby’s head to prevent heat loss

✅ Skin-to-Skin Positioning

1. Place the naked baby prone (on their stomach) on the mother’s bare chest or upper abdomen
2. The baby’s head is turned to one side, neck slightly extended
3. Keep the arms and legs flexed, in a fetal position
4. Cover both mother and baby with a warm cloth or blanket
5. Ensure the baby’s nose and mouth are not obstructed

🕒 Continue uninterrupted SSC for at least 1 hour

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🔷 Benefits of Skin-to-Skin Contact

For the Baby	For the Mother
Regulates temperature (thermoregulation)	Enhances oxytocin release – promotes bonding
Stabilizes heart rate and respiration	Encourages uterine contraction – reduces bleeding
Improves blood sugar levels	Increases breast milk production
Reduces crying and stress	Builds maternal confidence and satisfaction
Promotes early breastfeeding	Strengthens mother-infant bond
Improves immunity through early colostrum	Encourages calm and relaxation

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🔷 Skin-to-Skin Contact in Special Situations

Situation	Consideration
Cesarean section	Baby can be placed on chest in OR with support
Low birth weight/preterm	Use Kangaroo Mother Care with close monitoring
NICU/Separation required	Encourage father or relative to provide SSC if mother is unavailable

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🔷 Safety Measures During SSC

• Keep baby’s airway clear (face turned to the side)
• Monitor breathing and color
• Ensure warm environment (room temp ≥25°C)
• Do not leave baby unattended
• Avoid tight swaddling or slumping of baby

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🔷 Nurse/Midwife’s Role

Action	Responsibility
Initiate SSC immediately after birth	Place baby on mother’s chest
Educate mother and family	Explain benefits and technique
Monitor baby’s breathing and warmth	Observe continuously
Support early breastfeeding	Encourage latch during SSC
Document time and duration	Record in delivery notes and newborn record
Assist in SSC during Cesarean or complications	If mother cannot, assist partner/guardian

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🔷 Duration of SSC

• Minimum 1 hour immediately after birth
• Can continue as often as possible in first few days
• In case of low birth weight or preterm, longer SSC (KMC) improves survival

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✅ Quick Summary: Skin-to-Skin Contact Checklist

Task	Done? ✅
Baby dried and placed on mother’s chest
Skin-to-skin initiated within 1 minute
Baby’s head turned to one side
Baby covered with warm cloth
Breastfeeding started during SSC
Baby monitored for color and breathing
Duration documented

🌼 Vitamin K Prophylaxis in Newborns.

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🔷 What is Vitamin K Prophylaxis?

Vitamin K prophylaxis refers to the preventive administration of Vitamin K to newborns soon after birth to reduce the risk of Vitamin K Deficiency Bleeding (VKDB), also known as Hemorrhagic Disease of the Newborn.

💉 Given intramuscularly (IM) shortly after birth—one of the first life-saving injections a baby receives.

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🔷 Why Do Newborns Need Vitamin K?

• At birth, newborns have low stores of Vitamin K.
• Gut bacteria (which help make Vitamin K) are not yet established.
• Breast milk contains only small amounts of Vitamin K.
• Without Vitamin K, the baby is at risk of spontaneous bleeding in the brain, intestines, skin, or umbilicus.

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🔷 Mechanism of Action (How Vitamin K Works)

• Vitamin K is essential for the synthesis of clotting factors II, VII, IX, and X in the liver.
• It helps prevent prolonged bleeding by supporting normal blood clotting.

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🔷 Types of VKDB (Vitamin K Deficiency Bleeding)

Type	Timing	Features
Early VKDB	Within 24 hrs	Seen in babies of mothers on anti-seizure drugs
Classic VKDB	Day 2–7	Most common, bleeding from umbilicus, skin, GI
Late VKDB	After 2 weeks – 6 months	May cause intracranial hemorrhage; often fatal if not prevented

✅ Vitamin K injection at birth prevents all 3 forms, especially late VKDB.

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🔷 Recommended Dose of Vitamin K

Category	Dose	Route	Time
Term baby (≥2.5 kg)	1 mg	IM injection	Within 1 hour after birth
Preterm or LBW (<2.5 kg)	0.5 mg	IM injection	Within 1 hour after birth
Babies not given IM dose	2 mg oral weekly (but less effective than IM)	Oral	For 3 months (not preferred in India)

⚠️ IM route is preferred over oral due to better absorption and longer protection.

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🔷 Preparation and Administration

• Use Vitamin K1 (Phytonadione) injection
• Use a 1 mL syringe with 26/27G needle
• Site: Anterolateral thigh (vastus lateralis muscle)
• Use aseptic technique
• Administer within first hour after birth

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🔷 Indications for Vitamin K

• All live newborns, regardless of delivery mode
• Especially important for:
  • Preterm or LBW infants
  • Babies born to mothers on anticonvulsants, anti-tubercular, or anticoagulant therapy
  • Delayed breastfeeding
  • Babies with liver immaturity or family history of bleeding disorders

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🔷 Side Effects (Rare)

Possible Reaction	Management
Mild pain at injection site	Cold compress
Local redness/swelling	Monitor
Anaphylactic reaction (very rare)	Emergency management

Vitamin K is generally very safe and well tolerated.

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🔷 Nurse/Midwife Responsibilities

Task	Role
Check correct dose	1 mg (term) / 0.5 mg (preterm/LBW)
Ensure proper timing	Within first hour of life
Maintain asepsis	During IM injection
Document	Dose, time, batch number, and site of injection
Educate parents	Explain the importance and safety
Monitor	For side effects or bleeding signs
Coordinate with immunization	Keep record updated with birth vaccines (BCG, OPV, Hep B)

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✅ Summary Table: Vitamin K Prophylaxis at Birth

Baby Type	Dose	Route	Timing
Normal Term Baby	1 mg	IM	Within 1 hour
Preterm or LBW Baby	0.5 mg	IM	Within 1 hour
No IM Available	2 mg orally/week × 3 months (less preferred)	Oral	First dose ASAP

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🔷 Documentation Example

• Date/Time: 28 March 2025, 09:10 AM
• Vitamin K1 (Phytonadione) 1 mg IM
• Batch No.: VK12345
• Injection Site: Right thigh (vastus lateralis)
• Given by: Nurse/ANM Signature

🌼 Newborn Resuscitation.

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🔷 Definition

Newborn resuscitation is the immediate emergency care given to a newborn who is not breathing or breathing inadequately after birth, to establish normal breathing and heart rate.

⚠️ Approximately 10% of newborns need some help to breathe at birth.
Around 1–2% require extensive resuscitation.

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🔷 Objectives of Newborn Resuscitation

• Establish effective breathing
• Ensure adequate oxygenation
• Prevent brain damage and death
• Improve Apgar score and neonatal survival
• Transition the newborn from intrauterine to extrauterine life

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🔷 Golden Minute Concept

• The first 60 seconds after birth is called the Golden Minute.
• In this time, you should:
  1. Dry and stimulate the baby
  2. Assess breathing
  3. If not breathing → start bag and mask ventilation

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🔷 Indications for Resuscitation

Newborn showing any of the following after birth:

Sign	Action
Not crying or breathing	Start resuscitation immediately
Weak/irregular breathing	Stimulate or ventilate
Poor muscle tone or limp	Assess and stimulate
Low heart rate (<100 bpm)	Begin positive pressure ventilation (PPV)

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🔷 Apgar Score & Resuscitation

• Scored at 1 and 5 minutes post-delivery
• Based on: Appearance, Pulse, Grimace, Activity, Respiration

Score Range	Action Needed
7–10	Normal; no resuscitation
4–6	Moderate depression; stimulation + oxygen
0–3	Severe distress; full resuscitation required

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🔷 Essential Equipment for Newborn Resuscitation

Resuscitation Corner Must Have:

Equipment	Purpose
Radiant warmer or heat source	Maintain warmth
Suction device (bulb/suction machine)	Clear airway
Bag and mask (self-inflating)	Provide breaths
Oxygen supply	Supplement oxygen
Clock or timer	Track Golden Minute
Towel, clean linen	Drying and wrapping
Mucus extractor	Clear mouth and nose
Stethoscope and gloves	Assessment and infection control

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🔷 Step-by-Step Procedure: Neonatal Resuscitation Algorithm (WHO/HBB Protocol)

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✅ Step 1: Preparation Before Birth

• Check equipment and supplies
• Ensure clean, warm, safe environment
• Inform team and assign roles
• Wash hands and wear gloves

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✅ Step 2: Immediate Care at Birth (Within 30 Seconds)

Task	Action
Dry the baby	Use warm towel
Provide warmth	Place under warmer or skin-to-skin
Position the airway	Slight neck extension (sniffing position)
Clear airway if needed	Suction mouth, then nose
Stimulate the baby	Rub back or flick feet
Assess breathing	Is the baby crying or breathing?

If baby is breathing well → no resuscitation needed
If not breathing → move to Step 3

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✅ Step 3: Ventilation (Start Within Golden Minute)

Criteria	Action
Not breathing/gasping	Start bag and mask ventilation
Heart rate <100 bpm	Continue PPV (Positive Pressure Ventilation)
Use room air (21%) if no oxygen available
Position mask over nose & mouth, form seal
Give 40–60 breaths per minute (1 breath every 1–1.5 seconds)
Observe for chest rise

💡 Reassess every 30 seconds

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✅ Step 4: Reassess After 30 Seconds of Ventilation

Heart Rate (via stethoscope)	Action
>100 bpm and breathing	Stop ventilation, monitor
<100 bpm, not breathing	Continue PPV
<60 bpm despite 30 sec PPV	Start Chest Compressions (Step 5) and call for help

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✅ Step 5: Chest Compressions (If HR <60 bpm)

Task	Method
Use 2-thumb technique	Both thumbs on sternum, fingers around chest
Compress depth: 1/3 of chest
Compression to ventilation ratio: 3:1
Give 90 compressions + 30 breaths = 120 events/min

Continue for 1 minute, then reassess heart rate

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✅ Step 6: Medications (Only if Needed)

• Rare in delivery room
• If HR <60 bpm after 1 min of CPR, consider:
  • Epinephrine (0.01–0.03 mg/kg IV)
  • Normal saline bolus (if shock suspected)

To be given by trained personnel in neonatal units

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🔷 Post-Resuscitation Care

• Continue monitoring HR, breathing, temperature
• Maintain warmth and oxygenation
• Encourage early breastfeeding if stable
• Watch for seizures, poor feeding, lethargy
• Document procedure details
• Transfer to NICU if baby had severe distress

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🔷 Midwife/Nurse’s Responsibilities in Resuscitation

Stage	Responsibility
Before birth	Prepare equipment and corner
At birth	Dry, assess, stimulate
If needed	Initiate ventilation and monitor
Post-resuscitation	Observe, support breastfeeding, educate parents
Documentation	Record time, Apgar scores, interventions given, outcome

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✅ Quick Summary Table: Actions Based on Newborn’s Condition

Condition	Action
Breathing/crying, good tone	Routine care
Not breathing, poor tone	Dry + Stimulate + Clear airway
Still no breathing after 30s	Start bag and mask ventilation
HR <60 bpm	Start chest compressions
No improvement	Continue CPR + call for advanced help

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🔷 Documentation Example

• Time of birth: 8:40 AM
• Condition: Not breathing, HR <100 bpm
• Intervention: PPV started at 8:41 AM, good chest rise
• HR after 30 seconds: >100 bpm
• Breathing resumed at: 8:43 AM
• Outcome: Stable, transferred to mother
• Apgar: 3 at 1 min, 8 at 5 min

🌼 Fourth Stage of Labour – Care and Monitoring.

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🔷 Definition

The fourth stage of labour is the initial postpartum period immediately after the delivery of the placenta. It typically lasts for the first 1 to 2 hours after birth and is a critical time for observation, as the mother is at risk for postpartum hemorrhage, shock, and complications.

It is often called the “Recovery Stage” – when the woman begins to stabilize physically and emotionally after childbirth.

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🔷 Duration

• First 1–2 hours after expulsion of placenta
• May be extended based on facility protocols or complications

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🔷 Goals of Care During the Fourth Stage

• Prevent postpartum hemorrhage (PPH)
• Ensure uterine contraction and involution
• Monitor for vital sign stability
• Promote bonding and breastfeeding
• Ensure comfort, hygiene, and emotional support

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🔷 Physiological Events in the Fourth Stage

• Uterus begins to firmly contract and retract
• Placental site seals with clot formation
• Lochia rubra (bloody discharge) begins
• Vital signs return towards baseline
• The woman may feel fatigue, chills, thirst, hunger, or excitement

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🔷 Nursing Care During the Fourth Stage of Labour

✅ 1. Uterine Assessment

Task	Observation
Palpate fundus every 15 minutes	Should be firm, round, and below the umbilicus
If soft or boggy → Massage gently	May indicate uterine atony (risk of PPH)
Document fundal height and tone	“Fundus firm, at umbilicus”

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✅ 2. Vaginal Bleeding and Lochia

What to Monitor	Signs of Concern
Amount and nature of bleeding	Heavy, continuous, or large clots
Type of lochia	Rubra: dark red, moderate in amount
Pad count and saturation	Soaking >1 pad in 15 mins = abnormal
Presence of clots	Large clots or continuous passage is abnormal

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✅ 3. Vital Signs Monitoring

Parameter	Frequency
Blood Pressure	Every 15 minutes x 1 hour, then hourly
Pulse	Same as BP
Respiratory rate	Every 15–30 mins
Temperature	Once in first hour or if indicated

🛑 Watch for signs of shock: ↓ BP, ↑ pulse, pale skin, sweating, confusion.

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✅ 4. Perineum and Episiotomy/Tear Inspection

• Check for:
  • Redness, swelling, hematoma
  • Sutures intact
  • Bleeding from wound site
• Apply cold compress if swollen (first 24 hours)
• Teach mother perineal hygiene and pain relief

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✅ 5. Bladder Care

• Check if bladder is distended
• Encourage the woman to void within 6 hours
• Full bladder can interfere with uterine contraction
• May need catheterization if not passing urine

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✅ 6. Breastfeeding Support

• Encourage initiation of breastfeeding within the first hour
• Help with:
  • Positioning
  • Latching-on
  • Confidence building
• Explain importance of colostrum and early suckling
• Observe for effective feeding signs

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✅ 7. Emotional and Physical Support

• Reassure and comfort the mother
• Address feelings of anxiety, fear, or happiness
• Offer warm fluids, blankets, and physical support
• Respect privacy and dignity

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✅ 8. Promote Bonding and Skin-to-Skin Contact

• Continue skin-to-skin contact for at least one hour
• Encourages:
  • Thermal regulation
  • Oxytocin release
  • Successful breastfeeding
  • Maternal-infant bonding

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✅ 9. Hygiene and Comfort Measures

• Change soiled linens and pads
• Help mother clean perineum and wear clean clothes
• Offer food or fluids if allowed
• Position mother comfortably

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✅ 10. Documentation

What to Record	Example
Time of placenta delivery	10:15 AM
Fundal tone and position	Firm, 1 cm below umbilicus
Amount/type of lochia	Moderate rubra
Vital signs charted	BP: 110/70 mmHg, Pulse: 82 bpm
Breastfeeding initiation	Yes, at 10:45 AM
Perineal condition	Episiotomy intact, no swelling
Urination	Voided 200 ml at 11:00 AM
Any medications or interventions	Oxytocin 10 IU IM given

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🔷 Midwife/Nurse’s Responsibilities

Role	Tasks
Observation	Fundus, bleeding, vital signs
Support	Comfort, reassurance, emotional care
Health Education	Breastfeeding, hygiene, warning signs
Documentation	Accurate, timely recording
Emergency Preparedness	Be alert for PPH or shock signs

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✅ Signs That Require Immediate Attention

Danger Sign	Possible Cause
Heavy vaginal bleeding	Uterine atony or retained tissue
Soft or boggy uterus	Inadequate uterine contraction
Severe perineal pain/swelling	Hematoma
Pallor, dizziness, fainting	Hypovolemia/shock
High temperature or foul lochia	Infection

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🔷 Discharge Education for the Mother

• How to monitor lochia and uterine tone at home
• Perineal care and hygiene
• Importance of rest and nutrition
• Danger signs to report:
  • Excessive bleeding
  • Fever or foul-smelling discharge
  • Pain or swelling in legs
  • Breast pain or cracked nipples

🌼 Observation, Critical Analysis, and Management of the Mother During the Fourth Stage of Labour.

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🔷 Definition of Fourth Stage of Labour

The fourth stage of labour is the first 1–2 hours after delivery of the placenta, also known as the “recovery phase.” It is a critical period for the mother, as complications like postpartum hemorrhage (PPH), shock, uterine atony, or perineal hematoma can occur.

The nurse/midwife must closely observe and critically analyze the mother’s condition to prevent or manage life-threatening complications.

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🔷 Goals of Observation and Management

• Prevent postpartum hemorrhage
• Ensure uterine contraction
• Monitor vital stability
• Promote early breastfeeding and bonding
• Provide comfort, hygiene, and psychological support

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🔷 Observation: What to Monitor During 4th Stage

✅ 1. Uterine Fundus

What to Observe	Normal Finding	Danger Sign
Fundal height and tone	Firm, central, at or just below umbilicus	Soft/boggy = uterine atony (risk of PPH)
Position	Midline	Deviated = full bladder

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✅ 2. Vaginal Bleeding (Lochia)

What to Observe	Normal	Abnormal
Amount	Moderate flow	Heavy bleeding, >1 pad in 15 mins
Type	Lochia rubra (dark red)	Bright red, large clots, foul-smelling
Clots	Small, occasional	Large clots or continuous clots

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✅ 3. Vital Signs

Parameter	Normal	Critical Signs
BP	110–140/70–90 mmHg	↓ BP (<90/60 mmHg) = shock
Pulse	70–90 bpm	↑ Pulse (>100 bpm) = blood loss
Resp. rate	16–20/min	Rapid, shallow = anxiety or shock
Temp	<38°C	>38°C = infection (puerperal sepsis)

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✅ 4. Perineum/Episiotomy Site

• Check for:
  • Bleeding from sutured area
  • Swelling or hematoma formation
  • Integrity of suture line
  • Signs of infection (redness, warmth, discharge)

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✅ 5. Bladder Status

• Ask if the woman has voided
• A full bladder can:
  • Displace the uterus
  • Cause uterine atony and increased bleeding

If no urine passed within 6 hours → may require catheterization

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✅ 6. General Condition and Consciousness

• Level of alertness
• Pallor, dizziness, restlessness
• Observe emotional response to birth

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🔷 Critical Analysis: Interpret the Observations

Observation	Interpretation	Risk
Soft uterus + heavy bleeding	Uterine atony	PPH
Firm uterus but bleeding continues	Possible retained placental fragments	PPH
Swollen, painful perineum	Possible perineal hematoma	Concealed bleeding
Pale, weak, low BP	Hypovolemic shock	Life-threatening
High temperature	Postpartum infection	Sepsis

⚠️ Immediate action required if any danger sign is noted.

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🔷 Management and Interventions

✅ 1. Uterine Atony or PPH

Action	Details
Fundal massage	Perform gently until uterus becomes firm
Empty bladder	Encourage voiding or catheterize
Administer uterotonics	Oxytocin 10 IU IM or IV, Misoprostol 600 mcg orally
Monitor vitals continuously	Every 5–15 minutes
Prepare for referral (if bleeding continues)	Call for medical team, IV fluids, blood if needed

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✅ 2. Perineal Pain or Hematoma

Action	Details
Inspect site	Look for swelling or bluish discoloration
Apply cold compress	Within first 24 hours
If large or expanding hematoma	Inform obstetrician/surgeon immediately

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✅ 3. Infection Signs

Action	Details
Check temperature, lochia	Foul smell, fever, uterine tenderness
Start antibiotics (if prescribed)	As per protocol
Maintain hygiene	Change pads, encourage cleanliness

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✅ 4. Bladder Care

Action	Details
Encourage early ambulation	Promotes bladder emptying
Support privacy for urination	Emotional comfort helps
Catheterize if no urine passed	After 6 hours post-delivery

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✅ 5. Emotional Support and Bonding

Action	Details
Encourage skin-to-skin and breastfeeding	Reduces stress, supports lactation
Allow rest, nutrition, fluids	Promote recovery
Reassure, listen to her feelings	Emotional well-being matters

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🔷 Documentation of Fourth Stage

Parameter	Documentation Example
Fundal tone and height	Firm, 1 cm below umbilicus
Lochia	Moderate rubra, no clots
Vitals	BP 120/80, P 84 bpm, Temp 37°C
Perineal status	Episiotomy intact, no swelling
Voiding	Passed 200 ml at 10:30 AM
Breastfeeding initiated	Yes, at 10:45 AM
Medications given	Oxytocin 10 IU IM, Tab Paracetamol

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✅ Key Summary: Observation & Management in 4th Stage

Aspect	Key Points
Time Frame	First 1–2 hours post placenta
Main Risks	PPH, shock, infection, hematoma
Monitor	Uterus, lochia, vitals, perineum
Manage	Fundal massage, bladder care, drugs
Support	Emotional care, hygiene, breastfeeding
Document	All findings and actions

🌼 Observation, Critical Analysis, and Management of the Newborn During the Fourth Stage of Labour.

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🔷 Definition

The fourth stage of labour (0–2 hours after birth) is a vital monitoring period for the newborn. During this time, the newborn is transitioning from intrauterine to extrauterine life, and careful observation is required to detect and manage any signs of distress, hypothermia, breathing difficulty, or poor feeding.

It is part of Essential Newborn Care (ENBC) and includes thermal care, breastfeeding, assessment, and danger sign identification.

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🔷 Objectives of Newborn Monitoring During the Fourth Stage

• Ensure the baby is breathing adequately
• Prevent hypothermia and hypoglycemia
• Monitor for signs of distress, sepsis, or congenital issues
• Support early breastfeeding
• Promote bonding and maternal involvement
• Identify any newborn needing resuscitation or referral

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🔷 Observation: What to Monitor in the First 1–2 Hours

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✅ 1. Breathing and Respiratory Effort

What to Monitor	Normal	Danger Sign
Chest movement	Regular, quiet	Grunting, chest indrawing, apnea
Respiratory rate	40–60 breaths/min	<30 or >60 breaths/min
Sounds	No noisy breathing	Stridor, gasping

🔔 If baby is gasping, grunting, or not breathing: initiate resuscitation

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✅ 2. Heart Rate and Color

Parameter	Normal	Danger Sign
Heart rate	120–160 bpm	<100 bpm (bradycardia)
Skin color	Pink all over	Bluish (cyanosis), pale, mottled

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✅ 3. Thermoregulation (Body Temperature)

What to Observe	Normal	Danger Sign
Body warmth (axilla)	36.5°C–37.5°C	<36.5°C (hypothermia), >37.5°C (fever)
Extremities	Warm, pink	Cold hands/feet, shivering

Maintain warmth through skin-to-skin contact or radiant warmer.

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✅ 4. Activity and Muscle Tone

Observation	Normal	Danger Sign
Movements	Active, spontaneous	Floppy, no movement
Tone	Flexed limbs	Limp, poor tone
Response to stimuli	Cries or moves	No response

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✅ 5. Feeding Behavior

Behavior	Normal	Danger Sign
Rooting/suckling	Baby searches and latches	Weak or no suck
Colostrum intake	Yes	Unable to feed

Support initiation of breastfeeding within 1 hour.

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✅ 6. Urine and Meconium Output

Observation	Normal	Action
Urine	At least once in first 24 hrs	Record time
Meconium	Sticky black passed in 24 hrs	Monitor and record

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🔷 Critical Analysis: Interpreting Danger Signs

Danger Sign	Possible Cause	Action
Grunting, fast breathing, retractions	Respiratory distress	Immediate evaluation, oxygen or NICU referral
Cyanosis (blue lips, tongue)	Hypoxia	Start oxygen, check circulation
Poor tone, lethargy, no cry	Birth asphyxia, sepsis	Monitor, refer for evaluation
No suckling or feeding	Neurological issues, sepsis	Support feeding or refer
Hypothermia (<36.5°C)	Cold environment	Warm baby, initiate KMC or warmer
Seizures, twitching	Asphyxia, metabolic issue	Urgent referral
Delayed urine or meconium	GI or renal anomalies	Observe and report

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🔷 Management: What the Nurse/Midwife Should Do

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✅ 1. Thermal Protection

• Start skin-to-skin contact or use a radiant warmer
• Cover baby’s head with a cap
• Avoid bathing in the first 24 hours
• Monitor axillary temperature every 30 minutes for 2 hours

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✅ 2. Airway and Breathing Support

• Ensure clear airway (suction if needed)
• Position baby with neck slightly extended
• If not breathing or gasping → start bag and mask ventilation
• Refer for oxygen or NICU if respiratory distress persists

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✅ 3. Support Breastfeeding

• Help mother with positioning and latching
• Observe for effective suckling
• Encourage frequent feeding to prevent hypoglycemia
• Do not give prelacteal feeds (e.g., honey, sugar water)

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✅ 4. Monitor and Document Vitals

Parameter	Frequency
Temperature	Every 30 mins for 2 hours
Respiratory rate	Every 30 mins
Heart rate	Every 30 mins
Activity and tone	Every 30 mins

Use Newborn Monitoring Chart or NICU observation sheet.

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✅ 5. Prevent Infection

• Maintain hand hygiene
• Use clean linens and equipment
• Do not apply anything to the cord
• Educate mother on hygiene and hand washing

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✅ 6. Cord and Eye Care

• Keep cord dry and clean
• Apply Tetracycline eye ointment if protocol requires (for ophthalmia prevention)
• Observe for bleeding or discharge

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✅ 7. Educate the Mother

• Recognize danger signs in baby
• Importance of exclusive breastfeeding
• How to keep the baby warm
• When to seek help (e.g., no cry, no feed, fever)

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🔷 Documentation: What to Record

• Time of birth
• APGAR scores at 1 and 5 minutes
• First breath/cry status
• Temperature, heart rate, respiration
• Breastfeeding initiated and time
• Cord and eye care done
• Any interventions or abnormal findings
• Name and signature of nurse/midwife

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✅ Summary Table: Newborn Care During 4th Stage

Aspect	Action
Breathing	Monitor, start resuscitation if needed
Temperature	Skin-to-skin, cap, monitor every 30 mins
Heart rate	Auscultate or palpate, monitor
Feeding	Breastfeeding within 1 hour
Color and tone	Pink, active, alert
Danger signs	Identify and refer early
Documentation	Complete all records

🌼 Maternal Assessment During the Fourth Stage of Labour.

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🔷 Definition

Maternal assessment during the fourth stage of labour refers to the systematic observation and evaluation of the mother during the first 1–2 hours after the delivery of the placenta. This is a critical recovery period, where the mother is most at risk for postpartum hemorrhage (PPH), shock, infection, or injury complications.

🔔 This period is also known as the early postpartum period or immediate puerperium.

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🔷 Goals of Maternal Assessment

• Detect early signs of complications (e.g., hemorrhage, shock, perineal trauma, infection)
• Promote stabilization of vital signs
• Ensure uterine contraction and control of bleeding
• Support emotional and physical recovery
• Facilitate early breastfeeding and bonding

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🔷 Frequency of Assessment

Time Interval	Frequency
First hour post-delivery	Every 15 minutes
Second hour	Every 30 minutes
Thereafter	Hourly until transferred or stable

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🔷 Key Areas of Maternal Assessment

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✅ 1. Uterine Fundus

What to Check	Normal Finding	Abnormality
Fundal tone	Firm to touch	Soft, boggy (→ uterine atony)
Fundal height	At or slightly below the umbilicus, midline	High or deviated (→ full bladder)

🛑 A soft uterus is a sign of ineffective contraction, increasing the risk of PPH.

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✅ 2. Vaginal Bleeding (Lochia)

What to Observe	Normal	Abnormal
Amount	Moderate lochia rubra	Heavy bleeding, large clots
Color	Dark red	Bright red, foul-smelling
Pad saturation	One pad in 2–3 hours	Soaking >1 pad in 15 minutes = PPH

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✅ 3. Vital Signs

Parameter	Normal	Danger Sign
Blood Pressure	110–140/70–90 mmHg	↓ BP (<90/60 mmHg) = shock
Pulse	70–90 bpm	↑ Pulse (>100 bpm) = hemorrhage
Resp. rate	16–20/min	Rapid or labored breathing
Temperature	<38°C	>38°C = possible infection

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✅ 4. Perineum/Episiotomy Site

Assessment	Normal	Danger Sign
Sutures	Intact, no bleeding	Gaping, bleeding, infection
Swelling	Mild, localized	Large, painful swelling = hematoma
Pain	Mild, controlled	Severe or increasing pain = complication

Use REEDA scale (Redness, Edema, Ecchymosis, Discharge, Approximation) to assess healing.

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✅ 5. Bladder Status

Parameter	Observation
Voiding ability	Should pass urine within 6 hours
Bladder distension	If uterus is high or deviated
Intervention	Encourage urination or catheterize if unable

A full bladder can interfere with uterine contraction and increase bleeding.

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✅ 6. General Appearance and Behavior

• Consciousness level (alert or drowsy)
• Skin color and moisture (pale, cold, clammy = shock)
• Complaints (e.g., dizziness, weakness, headache, pain)
• Emotional state (anxiety, crying, excitement, relief)

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✅ 7. Breast and Feeding Status

• Inspect breasts for fullness, nipple condition
• Observe baby’s latch and sucking
• Ask mother about pain or discomfort
• Support early breastfeeding within the first hour

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✅ 8. Legs and Mobility

• Check legs for:
  • Swelling
  • Pain
  • Redness
  • Signs of deep vein thrombosis (DVT)
• Encourage early mobilization once stable

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🔷 Nurse/Midwife Responsibilities

Task	Actions
Perform assessments on time	As per protocol (Q15 mins first hour)
Record all findings	In maternal monitoring chart
Massage uterus if soft	Until firm
Check bleeding and pad count	Measure and report heavy loss
Support breastfeeding	Assist latching, comfort mother
Monitor emotional status	Provide reassurance and support
Educate mother	On perineal care, danger signs, voiding
Call for help if danger signs	Activate emergency protocol

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🔷 Warning Signs That Require Immediate Action

Danger Sign	Possible Cause	Immediate Action
Heavy vaginal bleeding	Uterine atony, PPH	Fundal massage, Oxytocin, alert doctor
Soft, boggy uterus	Uterine atony	Massage and administer uterotonic
Rapid pulse + low BP	Hypovolemic shock	IV fluids, monitor, call for help
Painful perineal swelling	Hematoma	Notify doctor for surgical evaluation
Fever (>38°C)	Infection	Start antibiotics if prescribed
Fainting, dizziness	Blood loss or hypotension	Keep flat, monitor vitals, report

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🔷 Documentation Example

• Time: 30 mins post-delivery
• Fundus: Firm, at umbilicus
• Lochia: Moderate rubra, no clots
• BP/Pulse: 118/76 mmHg, 84 bpm
• Perineum: Episiotomy clean, sutures intact
• Voided: 200 ml clear urine
• Breastfeeding: Started at 10:15 AM, baby latched well
• Mother’s behavior: Calm, cooperative

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✅ Summary Table: Maternal Assessment Checklist – Fourth Stage

Parameter	Normal Finding
Uterus	Firm, midline, below umbilicus
Bleeding (Lochia)	Moderate, dark red
Vitals	Stable (BP, pulse, temp)
Perineum	Intact, mild pain/swelling
Bladder	Voiding within 6 hours
Breastfeeding	Initiated within 1 hour
General condition	Alert, oriented, no distress

🌼 Observation of Fundal Height.

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🔷 What is Fundal Height?

Fundal height refers to the level or position of the top of the uterus (fundus) as palpated through the abdominal wall. It is assessed to evaluate uterine contraction, tone, and involution, especially after the delivery of the placenta.

🩺 During the fourth stage of labour (first 1–2 hours postpartum), frequent monitoring of the fundal height and tone is essential to prevent postpartum hemorrhage (PPH).

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🔷 Why Monitor Fundal Height in the Fourth Stage?

• To ensure the uterus is firm and contracted
• To detect uterine atony (leading cause of PPH)
• To assess if bladder is full, causing displacement
• To monitor progress of uterine involution
• To ensure effective action of uterotonics like oxytocin

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🔷 When to Assess Fundal Height

Time Frame	Frequency
First hour after placenta delivery	Every 15 minutes
Second hour	Every 30 minutes
Thereafter	Hourly until stable

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🔷 How to Assess Fundal Height – Step-by-Step

✅ Preparation:

• Ensure privacy
• Ask the woman to empty her bladder before assessment
• Lay the woman in supine position with knees slightly flexed
• Wash hands and use clean gloves

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✅ Palpation Technique:

1. Stand at the right side of the woman
2. Place your dominant hand on the lower abdomen (above symphysis pubis)
3. Use the other hand to gently palpate the top of the uterus (fundus) with a rolling motion
4. Assess for:
   • Height: in relation to the umbilicus
   • Tone: whether the uterus feels firm or soft
   • Position: central or deviated to one side

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🔷 Normal Fundal Findings During Fourth Stage

Parameter	Normal Finding
Fundal height	At or 1 fingerbreadth (1 cm) below the umbilicus
Tone	Firm and well contracted
Position	Midline (not deviated)

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🔷 Abnormal Findings & Interpretation

Abnormality	Possible Cause	Action Required
Soft/Boggy uterus	Uterine atony → risk of PPH	Massage uterus, administer uterotonics
High fundus	Full bladder displacing uterus	Encourage urination or catheterize
Deviated uterus	Bladder distension	Same as above
Rising fundus + bleeding	Internal bleeding or retained placenta	Immediate doctor alert, manage PPH

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🔷 Uterine Involution Reference (For Postpartum Days)

Time Postpartum	Expected Fundal Height
Immediately after placenta	At or just below umbilicus
After 12 hours	May rise slightly (to umbilicus)
Day 1 onward	Decreases 1 cm/day (1 fingerbreadth per day)
By day 10–14	Not palpable abdominally (within pelvis)

Note: These values apply if uterus contracts normally and no complications arise.

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🔷 Documentation Example

Time	Fundal Height	Tone	Position	Action Taken
10:15 AM	At umbilicus	Firm	Midline	No action
10:30 AM	Slightly above	Soft	Central	Fundal massage given
10:45 AM	1 cm below	Firm	Midline	Oxytocin effective

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🔷 Nurse/Midwife’s Responsibilities

Task	Description
Perform regular assessments	As per protocol
Ensure bladder is emptied	Before palpation
Observe for signs of atony or PPH	Act immediately if present
Perform fundal massage if soft	Until firm
Administer uterotonics if needed	As prescribed
Document findings accurately	Every 15–30 minutes
Educate mother	On uterine contraction and reporting heavy bleeding

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✅ Quick Summary: Fundal Height Monitoring – Fourth Stage

What to Check	Normal Value
Height	At or just below umbilicus
Tone	Firm, not boggy
Position	Midline
Frequency	Every 15 mins × 1 hr, then 30 mins × 1 hr
Immediate action if abnormal	Massage, medication, call for help

🌼 Uterine Consistency.

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🔷 Definition

Uterine consistency refers to the feel or firmness of the uterus when palpated through the abdominal wall. It is assessed to determine whether the uterus is contracted and firm, or relaxed and soft (also called boggy), especially during the fourth stage of labour—the first 1–2 hours after placenta delivery.

The tone and consistency of the uterus are key indicators of effective uterine contraction and help in the prevention of postpartum hemorrhage (PPH).

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🔷 Purpose of Assessing Uterine Consistency

• Ensure that the uterus is firmly contracted
• Detect early uterine atony, the most common cause of primary PPH
• Monitor the effectiveness of uterotonic drugs (e.g., oxytocin)
• Evaluate the need for intervention (massage, medication, referral)

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🔷 When to Assess Uterine Consistency

Time Frame	Frequency
First hour after birth	Every 15 minutes
Second hour post-delivery	Every 30 minutes
After 2 hours or stable	Hourly or as needed

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🔷 How to Assess Uterine Consistency – Step-by-Step

✅ Procedure

1. Wash hands and wear gloves
2. Ask the mother to empty her bladder (a full bladder can affect consistency)
3. Position the mother supine with knees slightly flexed
4. Place one hand just above the pubic bone to support the lower uterus
5. Use the other hand to palpate the top of the uterus (fundus) using gentle circular pressure
6. Assess whether the uterus feels:
   • Firm
   • Soft/Boggy
   • Contracting intermittently

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🔷 Normal Uterine Consistency

Finding	Description
Firm	Uterus feels hard and well-contracted, like a clenched fist
Consistent	No fluctuation in tone, maintains firmness between checks
Midline	Uterus is centrally located and not deviated

✅ A firm uterus helps compress blood vessels at the placental site, preventing bleeding.

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🔷 Abnormal Uterine Consistency

Finding	Possible Cause	Nursing Action
Soft/Boggy	Uterine atony (risk of PPH)	Massage the uterus, give uterotonics
Inconsistently firm	Ineffective contraction or retained products	Continue monitoring, alert medical officer
Feels displaced	Full bladder displacing uterus	Encourage urination or catheterization

⚠️ A boggy uterus does not compress blood vessels → leads to continued bleeding → postpartum hemorrhage.

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🔷 Nursing Management Based on Uterine Consistency

Situation	Intervention
Uterus is firm	Continue regular monitoring
Uterus is soft	Perform fundal massage until it becomes firm
No improvement after massage	Administer uterotonic drug (e.g., oxytocin 10 IU IM)
Still boggy or excessive bleeding	Call doctor, prepare for PPH protocol
Uterus deviated to side	Empty bladder and reassess

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🔷 Documentation of Uterine Consistency

Parameter	Sample Documentation
Fundal height	“At umbilicus” or “1 cm below”
Uterine tone	“Firm and midline” or “Soft and deviated to right”
Action taken	“Fundal massage performed, oxytocin 10 IU given IM”
Response	“Uterus became firm, bleeding decreased”

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✅ Quick Summary: Uterine Consistency Assessment

What to Check	Normal Finding	Abnormal Finding
Tone	Firm, hard	Soft, boggy
Position	Central, midline	Deviated (→ full bladder)
Response to massage	Becomes firm quickly	Remains soft → uterotonic needed
Associated bleeding	Minimal	Heavy or ongoing

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🔷 Nurse/Midwife’s Role

• Palpate uterus regularly during the 4th stage
• Act immediately if soft/boggy
• Provide fundal massage if needed
• Administer prescribed uterotonics
• Monitor for bleeding and vital signs
• Document findings and actions clearly
• Educate the mother about uterine contraction and danger signs (e.g., heavy bleeding, dizziness)

🌼 Urine Output.

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🔷 Why Assess Urine Output During the 4th Stage?

During the fourth stage of labour (the first 1–2 hours after delivery of the placenta), monitoring the mother’s urine output is essential for:

• Evaluating renal perfusion and hydration status
• Ensuring bladder is not full, which could:
  • Displace the uterus
  • Interfere with uterine contraction
  • Increase the risk of postpartum hemorrhage (PPH)
• Detecting early signs of complications like:
  • Shock (low urine output)
  • Bladder injury
  • Urinary retention

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🔷 Normal Urine Output

Parameter	Normal Range
Initial postpartum void	Within 6 hours of delivery
Volume per void	≥150–200 ml
Minimum hourly output	≥30 ml/hour (if monitored via catheter)

✅ A mother should void within 6 hours after delivery (sooner if on IV fluids or catheterized during labour).

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🔷 Assessment of Urine Output – Step-by-Step

✅ 1. Ask the Mother

• When was the last time she passed urine?
• Does she feel the urge to urinate?
• Is she comfortable while voiding?

✅ 2. Observe for Signs of Bladder Distension

Sign	Indication
Fundus deviated to one side	Full bladder
High-rising uterus	May be displaced by bladder
Visible or palpable bladder	Over-distended
No urge to void	May indicate retention (due to trauma or epidural anesthesia)

✅ 3. Encourage Voiding

• Provide privacy
• Help her into a comfortable position
• Offer warm water trickling sounds or pour over perineum (if needed)
• Allow time and reassure

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🔷 What to Observe in Urine Output

Characteristic	Normal	Abnormal
Color	Clear, pale yellow	Dark, concentrated, bloody
Volume	≥150 ml	<100 ml or absent
Odor	Mild or no odor	Foul-smelling (→ infection)
Flow	Smooth stream	Dribbling, retention, painful micturition
Frequency	Every 2–4 hours	No urine in 6 hours = concern

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🔷 Abnormal Findings and Causes

Observation	Possible Cause	Action
No urine in 6 hours	Retention, trauma, pain, fear, anesthesia	Encourage voiding or catheterize
Scanty urine output	Hypovolemia, dehydration, shock	Check vitals, start IV fluids, monitor
Hematuria (blood in urine)	Bladder injury or trauma	Notify doctor immediately
Burning/pain	UTI or catheter trauma	Send urine sample for analysis

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🔷 Management of Urinary Issues

Issue	Nursing Action
Unable to void naturally	Assist with perineal care, privacy
Still unable to void	Perform bladder catheterization under aseptic technique
Full bladder (palpable)	Catheterize immediately to prevent uterine displacement
Signs of infection or bleeding	Collect urine sample, notify physician
Ongoing monitoring needed	Insert Foley catheter for hourly urine output (especially in PPH or cesarean cases)

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🔷 Documentation

Parameter	Example Entry
Voided amount	“Voided 250 ml at 11:00 AM”
Time of first urination	Within 2 hours of birth
Catheterization (if done)	“Catheterized at 12:15 PM; 450 ml drained”
Any issues	“Complains of burning micturition; sample sent for analysis”

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✅ Quick Summary: Urine Output in Fourth Stage

What to Assess	Normal Finding
First urination	Within 6 hours of birth
Volume	≥150 ml
Color and clarity	Pale yellow, clear
Signs of distension	None; uterus midline
Nursing action	Assist, observe, catheterize if necessary

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🔷 Nurse/Midwife Responsibilities

• Encourage and assist the mother to void
• Observe for urinary retention, distension, or infection
• Perform catheterization if the mother cannot void naturally
• Monitor uterine height and tone, as a full bladder can affect fundal position
• Record and report any abnormal findings promptly

🌼 Blood Loss.

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🔷 Why Assess Blood Loss in the Fourth Stage?

The fourth stage of labour (first 1–2 hours after placenta delivery) is the most critical period for detecting and managing postpartum hemorrhage (PPH)—a leading cause of maternal mortality.

⚠️ Most cases of PPH occur within 2 hours of delivery. Early identification and response can save lives.

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🔷 Normal Blood Loss After Vaginal Delivery

Type of Delivery	Normal Estimated Blood Loss
Vaginal delivery	Up to 500 ml
Cesarean section	Up to 1000 ml

Blood loss more than these limits = Postpartum Hemorrhage (PPH)

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🔷 Methods of Blood Loss Assessment

✅ 1. Visual Estimation (Routine Method)

Observation	Approximate Blood Loss
Fully soaked maternity pad	~100 ml
Blood trickling but not soaking pads	<250 ml
Constant flow/soaking multiple pads quickly	>500 ml
Presence of clots > fist-size	Suggests heavy bleeding

🔔 Visual estimation may underestimate actual blood loss—frequent checks are essential.

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✅ 2. Gravimetric Method (If Available)

• Weigh used pads and linen using a weighing scale
• Subtract the dry weight
• 1 gram = 1 ml of blood

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✅ 3. Observation of Clinical Signs

Even before visible heavy bleeding, watch for early signs of hypovolemia:

Sign	Suggestive of Blood Loss
↑ Pulse (>100 bpm)	Early hypovolemia
↓ BP (<90/60 mmHg)	Compensated shock
Pallor, restlessness	Moderate to severe loss
Cold, clammy skin	Severe blood loss
Dizziness or fainting	Danger – possible shock

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🔷 Types of Postpartum Hemorrhage (PPH)

Type	Definition
Primary PPH	Blood loss >500 ml within 24 hours of delivery
Secondary PPH	Bleeding occurring after 24 hours to 6 weeks postpartum

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🔷 Common Causes of Excessive Blood Loss (The 4 T’s)

Cause	Description
Tone	Uterine atony (most common cause)
Tissue	Retained placenta or clots
Trauma	Cervical, vaginal, or perineal tears
Thrombin	Coagulation disorders

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🔷 Signs That Blood Loss is Abnormal

• Soaking more than one pad in 15–30 minutes
• Passing large clots (>golf ball or fist-sized)
• Bleeding continues despite firm uterus
• Mother appears restless, pale, or dizzy
• Uterus is soft or boggy on palpation

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🔷 Immediate Nursing Actions for Excessive Blood Loss

If PPH is suspected:

1. Call for help immediately
2. Fundal massage – if uterus is soft
3. Check for tears – notify doctor
4. Administer uterotonics (as per order):
   • Oxytocin 10 IU IM or IV
   • Misoprostol 600–800 mcg oral/rectal
   • Ergometrine if not hypertensive
5. Insert IV line, start normal saline or Ringer’s lactate
6. Monitor vital signs every 5–15 minutes
7. Keep mother warm and calm
8. Prepare for referral or blood transfusion if needed

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🔷 Documentation of Blood Loss

Parameter	Example
Pad change frequency	“Soaked 1 pad in 10 mins”
Clots	“Passed 2 large clots (fist-size)”
Fundal tone and height	“Soft, 1 cm above umbilicus, shifted right”
Action taken	“Massage done, 10 IU Oxytocin given IM”
Vitals	“BP 90/60, Pulse 112 bpm”
Estimated blood loss	“Approx. 600 ml”
Response to intervention	“Uterus firm, bleeding reduced”

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🔷 Nurse/Midwife’s Responsibilities

Role	Actions
Frequent observation	Every 15 minutes for 1st hour, then 30 minutes
Fundal and lochia checks	Tone, height, amount/type of bleeding
Early identification of PPH	Act on danger signs promptly
Administer medications	Uterotonics as per standing orders
Initiate emergency care	Oxygen, fluids, prepare for referral
Educate and reassure mother	Keep her calm and informed
Accurate documentation	Time, quantity, signs, actions, outcome

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✅ Quick Summary: Blood Loss Assessment in Fourth Stage

Parameter	Normal Range	Abnormal
Blood loss	≤500 ml (vaginal)	>500 ml (PPH)
Pad saturation	1 pad in 2–3 hours	1 pad in <15–30 mins
Clots	Small, occasional	Large, frequent
Uterine tone	Firm and midline	Soft, boggy
Vital signs	Stable	Tachycardia, hypotension

🌼 Documentation and Record of Birth.

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🔷 Definition

Documentation and record of birth refers to the systematic recording of all relevant details of the labour and delivery process, the condition of the mother and newborn, and interventions provided, in official records/registers at the time of and immediately after childbirth.

✅ It is a legal, ethical, and clinical responsibility of the nurse or midwife conducting or assisting in the delivery.

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🔷 Purpose of Birth Documentation

• Serve as a legal record of birth
• Ensure continuity of care for mother and newborn
• Provide evidence-based clinical history
• Facilitate data collection for hospital statistics, audits, and public health reporting
• Enable accountability and quality assurance

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🔷 When to Document

• Immediately after birth (no delays)
• During each stage of labour (1st, 2nd, 3rd, 4th stages)
• At the time of interventions (e.g., medication, resuscitation)
• When significant changes are observed in the mother or baby
• After handover of care

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🔷 What to Document – Key Components

✅ 1. Mother’s Identification and Admission Details

Item	Details
Name, Age, Address	Full identification
Registration/Hospital No.	Unique patient ID
Gravida/Para	Obstetric history
Date & Time of Admission	For reference
Reason for admission	Labour onset, complication, etc.

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✅ 2. Labour Progress Record

Item	Example
Onset of labour (date/time)	28 March, 01:15 PM
Cervical dilation & effacement	4 cm dilated, 50% effaced
Membrane status	Intact or ruptured (SROM/AROM)
Use of partograph	Ongoing hourly record of progress
Fetal heart rate monitoring	Every 30 minutes or as per protocol

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✅ 3. Delivery Record (Birth Note)

Section	What to Record
Date and time of birth	Exact time in 24-hour format
Gender of baby	Male/Female
Mode of delivery	Normal vaginal, assisted, C-section
Presentation and position	Cephalic, breech, LOA, etc.
Condition of baby	Cried well, required resuscitation
APGAR scores	At 1 min and 5 mins
Cord details	Around neck (yes/no), number of loops
Placenta delivery	Time, type (Schultze/Duncan), completeness
Estimated blood loss	In ml
Perineal status	Intact, tear (degree), episiotomy
Medications given	Oxytocin, Vitamin K, etc.
Any complications	PPH, retained placenta, etc.

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✅ 4. Newborn Care and Assessment

Parameter	Record
Weight	In grams/kgs
Length and head circumference	In cm
Vitamin K administered	Dose and time
First urination/pass of meconium	Yes/No
Breastfeeding initiated	Yes/No and time
Any resuscitation done	Details of intervention
Birth defects or observations	If any, document and inform parents

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✅ 5. Fourth Stage Monitoring

Maternal Parameter	Frequency
Uterine fundus	Every 15–30 mins
Vaginal bleeding	Check pad, lochia
Vital signs	BP, pulse, temp
Urination	Passed urine or catheterized
Breastfeeding support	Initiated, duration
Emotional state	Calm, pain, crying, etc.

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🔷 Registers and Forms to Be Filled

Record/Register	Description
Birth Register	Official government record of all births
Labour Room Register	Includes all stages of labour and delivery outcomes
Mother’s Case Sheet	Individual detailed documentation
Newborn Care Record	For early care and condition of baby
Partograph	For tracking progress of labour
Immunization Record	For Hepatitis B, BCG, OPV administration
Maternal Outcome Form	Complications, interventions, referral
Consent Forms (if applicable)	For episiotomy, instrumental delivery, C-section

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🔷 Legal Importance of Documentation

• Serves as medico-legal evidence in case of disputes
• Proof of timely interventions
• Ensures accountability in maternal and neonatal care
• Required for birth certificate issuance

🖋 All entries should be clear, dated, timed, legible, and signed by the attending nurse/midwife/doctor.

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🔷 Nurse/Midwife Responsibilities

Task	Description
Maintain accurate, timely records	Immediately after each event
Use standard formats and registers	As per hospital/NRHM guidelines
Sign and stamp records properly	Include name and designation
Ensure confidentiality	Do not share records publicly
Communicate any abnormalities	To medical officer promptly
Educate mother	About the care provided and baby’s condition

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✅ Quick Documentation Checklist After Birth

✔ Time of birth
✔ Mode of delivery
✔ Sex and condition of baby
✔ APGAR score
✔ Placenta expelled: complete or incomplete
✔ Blood loss estimation
✔ Perineum: intact, episiotomy, tear
✔ Oxytocin/Vitamin K given
✔ Breastfeeding initiated
✔ Maternal and newborn vitals
✔ Signature of responsible staff

🌼 Breastfeeding and Latching.

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🔷 Definition

Breastfeeding is the process of feeding a newborn with milk directly from the mother’s breast.
Latching refers to how the baby attaches their mouth to the mother’s nipple and areola during breastfeeding.

🔔 A proper latch is critical for effective milk transfer, preventing nipple pain, and ensuring adequate nutrition for the newborn.

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🔷 Importance of Breastfeeding

For Baby	For Mother
Provides complete nutrition	Promotes uterine contraction and reduces PPH
Rich in antibodies (IgA)	Helps return to pre-pregnancy weight
Reduces risk of infections, allergies	Delays return of menstruation (LAM method)
Promotes bonding and comfort	Reduces risk of breast and ovarian cancer
Supports brain and emotional development	Enhances mother-baby bonding

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🔷 Initiation of Breastfeeding

• Should begin within the first hour after birth
• Promote skin-to-skin contact to stimulate natural reflexes
• Offer the breast when the baby shows early hunger cues:
  • Rooting (turning head to side)
  • Sucking motions
  • Hand-to-mouth movements
  • Crying is a late sign of hunger

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🔷 Steps to Achieve a Good Latch

✅ 1. Positioning the Mother

• Ensure mother is comfortable and relaxed
• Use supportive pillows if needed
• Hold baby close, tummy to tummy, with head, neck, and body aligned

✅ 2. Positioning the Baby

• Nose level with the nipple
• Baby’s head slightly tilted back
• Mouth wide open, tongue forward

✅ 3. Encouraging a Deep Latch

• Gently touch the baby’s lips with the nipple
• Wait for the baby to open mouth wide (like a yawn)
• Quickly bring baby to the breast (not breast to baby)
• Ensure more areola is inside baby’s mouth (especially from below)

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🔷 Signs of a Good Latch

Feature	Observation
Baby’s mouth	Wide open, lips flanged outwards
Baby’s chin	Touching the breast
Areola visibility	More visible above the mouth than below
No clicking/smacking sound	Indicates proper seal
Mother feels	Pulling sensation but no pain
Suck pattern	Slow, rhythmic sucking with audible swallowing
Baby’s response	Calm, satisfied, feeding well

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🔷 Common Breastfeeding Positions

Position	Description
Cradle hold	Most common; baby lies across mother’s body
Cross-cradle	Baby held with opposite arm; good for learning latch
Football hold	Baby tucked under arm; ideal after cesarean
Side-lying	Mother and baby lie on their sides; good for nighttime feeding or rest

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🔷 Common Latching Problems and Corrections

Problem	Cause	Solution
Nipple pain or cracks	Poor latch	Reposition baby, ensure deep latch
Baby sucking only nipple	Shallow latch	Encourage baby to take more areola
Clicking sound	Air leaking; poor seal	Break suction, reposition
Baby sleepy at breast	Ineffective feeding	Stimulate gently (tickle feet, undress slightly)
Flat/inverted nipples	Difficult latch	Use breast pump or nipple shield temporarily

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🔷 How to Break the Latch Safely

• Insert a clean finger gently into the corner of the baby’s mouth
• Release the suction before removing the baby from the breast
• Avoid pulling the baby off the breast without breaking suction → prevents nipple trauma

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🔷 Duration and Frequency of Breastfeeding

• Feed on demand, usually 8–12 times/day
• Let baby nurse from one breast until satisfied, then offer the other
• Feeding may last 15–40 minutes per session

Newborns typically feed every 2–3 hours

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🔷 Mother’s Diet and Self-Care During Breastfeeding

• Stay hydrated (8–10 glasses of water/day)
• Eat a balanced, nutritious diet rich in calcium, protein, and iron
• Avoid smoking, alcohol, and strong medications (consult doctor)
• Maintain breast hygiene (clean with plain water only)

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🔷 Nurse/Midwife’s Role in Breastfeeding Support

Task	Action
Initiate breastfeeding	Within first hour of birth
Observe first latch	Check for good attachment
Correct positioning	Teach and guide mother
Identify and manage problems	Address sore nipples, poor latch
Reassure and encourage	Build mother’s confidence
Document	Time, success of first feed, any issues

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🔷 When to Refer or Seek Help

• Baby not feeding well or losing weight
• Mother has severe breast pain, mastitis, or engorgement
• Baby has tongue-tie or cleft palate
• Mother taking medications contraindicated in breastfeeding

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✅ Quick Summary: Breastfeeding & Latching Checklist

Step	Done? ✅
Initiated within 1 hour
Baby alert, mouth wide open
More areola visible above
Chin touches breast
No nipple pain
Audible sucking/swallowing
Baby appears satisfied

🌼 Managing Uterine Cramps (Afterbirth Pains).

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🔷 What Are Uterine Cramps (Afterbirth Pains)?

Uterine cramps, also called afterbirth pains, are rhythmic, cramping sensations caused by uterine contractions after childbirth. These contractions help the uterus return to its pre-pregnancy size (involution) and control postpartum bleeding.

These cramps are normal but can be uncomfortable, especially during breastfeeding.

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🔷 Causes of Uterine Cramps

Cause	Explanation
Uterine involution	Natural shrinking of uterus to pre-pregnancy size
Oxytocin release during breastfeeding	Stimulates stronger contractions
Multigravida uterus	Less uterine tone = stronger cramps in multiparas
Uterotonics (e.g., oxytocin)	Increase contraction intensity
Bladder distension	May worsen uterine discomfort

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🔷 Characteristics of Uterine Cramps

• Intermittent lower abdominal cramping
• Increases during or just after breastfeeding
• Felt more intensely by multiparas (second or third-time mothers)
• Usually lasts 2–4 days postpartum

⚠️ If pain is severe, constant, or increasing beyond a few days → evaluate for infection, retained products, or complications

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🔷 Assessment Before Management

Parameter	What to Observe
Pain intensity	Mild, moderate, severe
Timing	Associated with breastfeeding or constant
Fundal height and tone	Uterus firm or boggy
Bleeding status	Normal lochia or heavy/clots
Bladder status	Full bladder increases discomfort
Other symptoms	Fever, foul-smelling lochia (suggest infection)

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🔷 Non-Pharmacological Management

Method	How It Helps
✅ Reassurance and explanation	Reduces anxiety and helps mother cope
✅ Warm compress/heating pad	Relieves muscle tension and pain
✅ Breathing and relaxation techniques	Lowers perception of pain
✅ Positioning (e.g., lying prone with pillow under abdomen)	Promotes uterine drainage and comfort
✅ Bladder emptying	A full bladder worsens cramping; encourage voiding
✅ Gentle abdominal massage	Can stimulate involution and reduce cramping

✳️ Avoid cold packs, as they may increase cramping and slow involution.

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🔷 Pharmacological Management (If Pain Persists)

Medication	Dose & Route	Purpose
Paracetamol	500–650 mg oral, 6–8 hourly	Mild pain relief
Ibuprofen	400 mg oral every 6–8 hours	Reduces pain and inflammation
Drotaverine (if prescribed)	40–80 mg oral or IM	Antispasmodic for stronger cramps
Mefenamic acid	250–500 mg oral, 8 hourly	Used in some cases (avoid if GI upset)

🍼 Choose medications safe for breastfeeding mothers

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🔷 When to Report or Refer

Danger Sign	Possible Cause
Severe, continuous pain	Uterine subinvolution, retained placenta
Heavy bleeding/clots	Postpartum hemorrhage
Foul-smelling lochia + fever	Infection (endometritis)
Pain with rising fundal height	Full bladder or retained tissue

🛑 These require medical evaluation and intervention.

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🔷 Nurse/Midwife’s Role

Responsibility	Action
Educate mother about normal cramps	Reassure, explain cause
Monitor uterine tone and fundal height	Palpate regularly
Encourage early breastfeeding	Despite cramps, promotes recovery
Provide warm packs or positioning tips	For comfort
Assess pain regularly	Use visual analog scale (VAS)
Administer prescribed pain relief	As per protocol
Record and document interventions	With response to treatment

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✅ Quick Tips for Mothers: Managing Afterbirth Cramps

• Cramps are normal and temporary
• Breastfeeding increases cramping, but helps the uterus shrink
• Use a warm cloth or hot water bottle on your lower abdomen
• Keep your bladder empty
• Rest and use relaxation techniques
• Ask for pain relief if needed
• Call for help if cramps are severe, constant, or accompanied by heavy bleeding

🌿 Alternative & Complementary Therapies for Managing Uterine Cramps (Afterbirth Pains)

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🔷 What Are Uterine Cramps?

• Uterine cramps are normal postnatal contractions that occur as the uterus returns to its pre-pregnancy size (uterine involution).
• They are often stronger in multiparous women, and can be triggered by breastfeeding, uterotonics, or bladder distension.

🧘 Complementary therapies help reduce discomfort, support natural healing, and promote maternal well-being without relying solely on medications.

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🔷 Safe Alternative/Complementary Therapies for Uterine Cramps

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✅ 1. Warm Compress / Hot Water Bag

How it Helps	Application
Relaxes uterine muscles and improves circulation	Apply to lower abdomen for 15–20 minutes every 3–4 hours
Reduces muscle spasm and perceived pain	Ensure safe temperature to prevent burns

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✅ 2. Herbal Teas (Postpartum Uterine Soothers)

Herbal Remedy	Effect
🌿 Ginger tea	Anti-inflammatory, warming, pain-relieving
🌿 Chamomile tea	Calms the nervous system and soothes cramping
🌿 Fennel tea	Natural antispasmodic, aids digestion and uterus
🌿 Motherwort tea	Traditional uterine tonic (with caution under supervision)

⚠️ Use only approved herbs and consult a healthcare provider if on medications or breastfeeding.

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✅ 3. Aromatherapy

Essential Oil	Application & Effect
🌸 Lavender	Calming, reduces pain perception – use in diffuser or diluted in carrier oil
🌿 Clary sage	Promotes uterine tone and relaxation – massage diluted oil on abdomen
🌺 Rose or geranium	Uplifts mood, relieves tension

⚠️ Use only safe, diluted oils in postpartum women and never ingest essential oils.

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✅ 4. Abdominal Massage with Natural Oils

Oil Used	Effect
Coconut oil, almond oil	Gentle lubrication for massage
Castor oil (small amount)	Traditional uterine soother
Massage technique	Use circular, clockwise motion over lower abdomen for 10–15 mins, 2–3 times/day

Massage improves blood flow, relaxes uterine muscles, and reduces spasm.

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✅ 5. Acupressure and Reflexology

Method	Application
Acupressure points such as SP6 (Sanyinjiao) – inside of lower leg, 3 fingers above ankle bone	Press gently for 2–3 minutes each side to reduce uterine cramping
Foot reflexology for uterus and pelvic area	Done by trained personnel only

Encourages natural energy flow, balances hormones, and supports uterine function.

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✅ 6. Yoga & Deep Breathing Exercises

Technique	Benefit
Postnatal yoga stretches (e.g., child’s pose, gentle pelvic tilts)	Releases pelvic tension and reduces cramps
Deep belly breathing	Activates parasympathetic nervous system, reduces pain perception
Guided relaxation/meditation	Reduces stress and enhances healing hormones like oxytocin

Start only when medically cleared, and avoid strenuous poses postpartum.

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✅ 7. Homeopathic Remedies (Optional, Under Supervision)

Remedy	Used For
Belladonna	Sudden, sharp cramping pains
Chamomilla	Irritable cramping with emotional stress
Magnesium Phos.	Cramping relieved by warmth

Only to be used under qualified homeopath guidance.

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🔷 Nurse/Midwife’s Role in Complementary Therapy Use

Task	Action
Educate mothers	On safe and effective natural methods
Provide warm compress or massage	In hospital setting if permitted
Observe for improvement or complications	Monitor pain level and bleeding
Refer to trained professionals	For acupressure, reflexology, herbal advice
Encourage hydration and rest	Support overall recovery and wellness
Document alternative therapies used	Note timing, response, and any adverse effects

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✅ Summary Table: Alternative Therapies for Uterine Cramps

Method	Action	Safety Note
Warm compress	Relaxes uterine muscles	Safe with caution
Herbal teas	Natural pain relief	Use known herbs
Aromatherapy	Pain relief, stress relief	Dilute oils
Abdominal massage	Improves circulation	Use light pressure
Acupressure/Reflexology	Hormonal balance & pain	Seek trained provider
Yoga/Breathing	Stress & pain reduction	Gentle only
Homeopathy	Holistic approach	Under expert care

🌼 Role of Doula / ASHA.

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🔷 Definition of the Fourth Stage of Labour

The fourth stage of labour refers to the first 1–2 hours after the delivery of the placenta, when the mother and baby are transitioning to postpartum recovery. This period is critical for preventing complications and establishing maternal-newborn bonding.

During this time, doulas and ASHAs offer vital physical, emotional, and informational support, especially in institutional and community-based deliveries.

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🔷 Who Are Doulas and ASHAs?

Role	Description
Doula	A trained non-medical professional who provides continuous physical, emotional, and informational support to a woman before, during, and just after childbirth
ASHA	A community health worker appointed under India’s National Rural Health Mission (NRHM), who promotes maternal and child health, connects families to services, and provides basic postnatal care and education

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🔷 Roles and Responsibilities in the Fourth Stage of Labour

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✅ 1. Emotional and Physical Support to the Mother

Doula’s Role	ASHA’s Role
Comforts the mother with calming words, reassurance	Offers emotional support and encourages rest
Helps the mother relax, relieves stress or anxiety	Observes for discomfort, anxiety, or signs of distress
Advocates for the mother’s needs (positioning, privacy)	Ensures the mother is comfortably placed and monitored

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✅ 2. Encouraging Breastfeeding

Doula	ASHA
Assists in early initiation of breastfeeding (within 1 hour)	Encourages breastfeeding and explains colostrum benefits
Guides on correct latching techniques	Reinforces exclusive breastfeeding education
Provides non-judgmental reassurance during first feed	Refers to nurse or ANM if feeding problems are observed

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✅ 3. Promoting Skin-to-Skin Contact

Doula	ASHA
Places baby on mother’s chest and ensures skin-to-skin bonding	Educates on the importance of Kangaroo Care (especially for LBW)
Helps cover both with a warm cloth	Ensures the baby is warm and secure

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✅ 4. Monitoring Basic Wellbeing (Support Role)

Task	Doula / ASHA Contribution
Fundus and lochia observation	Can report any excessive bleeding or discomfort to the nurse
Mother’s alertness and comfort	Can alert staff if mother seems dizzy, pale, or unwell
Encourage hydration and nutrition	Offer water, help initiate fluid intake if allowed

⚠️ While Doulas and ASHAs do not perform clinical procedures, they are trained to observe, report, and support.

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✅ 5. Facilitating Cleanliness and Hygiene

• Help the mother change pads or clothing if allowed
• Maintain a clean environment
• Encourage the mother to void urine or report discomfort
• Remind about perineal hygiene

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✅ 6. Birth Registration & Record Follow-up (ASHAs)

• Help collect and provide details for birth certificate
• Link mother to Janani Suraksha Yojana (JSY) benefits
• Ensure immunization card is updated
• Remind family about postnatal check-ups

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✅ 7. Identifying Danger Signs and Prompt Reporting

Maternal Danger Signs	Newborn Danger Signs
Heavy bleeding (soaking pad quickly)	Baby not crying or breathing normally
Dizziness, fainting, paleness	Baby not feeding or has weak suck
Fever, foul-smelling lochia	Cold, limp, or excessively sleepy baby

ASHAs and Doulas are trained to identify danger signs and report them promptly to the nurse, ANM, or doctor.

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🔷 Doula and ASHA: Working Alongside Clinical Staff

Support Function	Task
Communication bridge	Help mother express her needs
Cultural sensitivity	Respect family beliefs and language
Advocacy	Ensure mother’s comfort and informed choices
Continuity of care	ASHA follows up at home after discharge

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✅ Quick Summary Table: Role of Doula/ASHA in Fourth Stage

Area of Support	Role
Emotional care	Reassure, comfort, stay with mother
Early breastfeeding	Encourage, assist, support latching
Maternal hygiene	Help with cleanliness and pad change
Observation/reporting	Identify and report danger signs
Bonding and warmth	Promote skin-to-skin contact
Health education	Explain perineal care, breastfeeding, newborn care
Community linkage (ASHA)	Help register birth, promote check-ups, immunization

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📝 Documentation (ASHAs)

• Mother’s name, delivery date, place of birth
• Condition of mother and baby during initial postnatal period
• Whether colostrum was given
• Any referrals made
• Date of next visit or check-up reminder

🌼 Various Childbirth Practices.

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🔷 Definition

Childbirth practices refer to the methods, procedures, customs, and support strategies used during labour and delivery, aiming to ensure the safe and respectful birth of a child, while respecting the physiological, emotional, and cultural needs of the mother and family.

🩺 These practices may vary based on medical protocols, cultural beliefs, maternal preference, and evidence-based guidelines.

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🔷 Categories of Childbirth Practices

Type	Examples
Physiological practices	Natural labour progression, upright positions
Supportive practices	Birth companion, pain relief options
Medical interventions	Induction, augmentation, C-section
Cultural practices	Rituals, birthing positions, foods used
Institutional practices	Hospital protocols, continuous monitoring

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🔷 Common and Recommended Childbirth Practices

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✅ 1. Encouraging Mobility and Upright Positions

Practice	Purpose
Walking, squatting, kneeling	Uses gravity to aid descent of baby
Sitting on a birthing ball	Opens pelvis, relieves back pain
Avoiding supine/lithotomy for long	Prevents blood flow restriction and back pain

WHO supports active movement in labour for improved outcomes.

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✅ 2. Presence of a Birth Companion

Role	Benefit
Husband, mother, doula, ASHA	Emotional support, reduced anxiety, shorter labour
Continuous presence	Enhances confidence and satisfaction

Recommended by WHO and Government of India (LaQshya guidelines).

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✅ 3. Skin-to-Skin Contact and Early Breastfeeding

Practice	Benefit
Baby placed on mother’s chest	Maintains warmth, improves bonding
Breastfeeding within 1 hour	Provides colostrum, initiates milk production

Immediate skin-to-skin is now a standard of essential newborn care.

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✅ 4. Perineal Support and Delayed Cord Clamping

Practice	Purpose
Perineal support	Reduces risk of tear during birth
Delayed cord clamping (1–3 minutes)	Increases iron stores in the baby

Delayed cord clamping is a WHO-recommended practice.

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✅ 5. Minimal Routine Interventions

Routine to Avoid Unless Needed	Why
Routine episiotomy	Can cause unnecessary trauma
Routine artificial rupture of membranes	Should be done only when indicated
Unnecessary induction or C-section	May increase risk without benefit

Birth should be respected as a natural process unless complications arise.

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✅ 6. Pain Relief Options

Type	Examples
Non-pharmacological	Breathing techniques, massage, warm baths, music
Pharmacological	Epidural, IV analgesia, inhaled nitrous oxide

Women should be informed of all pain relief choices and allowed to choose.

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✅ 7. Monitoring Labour Progress (Partograph Use)

• Tracks cervical dilation, contractions, fetal heart rate, maternal vitals
• Helps identify slow progress or complications

An essential tool in institutional childbirth care.

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✅ 8. Respectful Maternity Care (RMC)

Practice	Explanation
Obtaining informed consent	Before procedures
Privacy and dignity	Use of curtains, appropriate communication
No verbal/physical abuse	Encourage respectful dialogue
Involving woman in decisions	Promotes autonomy and satisfaction

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✅ 9. Use of Birth Plans

What It Includes	Why It Matters
Preferred birth position, pain relief, companion	Gives woman control and preparation
Emergency preferences	Reduces anxiety and ensures informed care

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🔷 Cultural Childbirth Practices (May Vary by Region)

Cultural Practice	Midwifery Consideration
Use of traditional herbs/oils	Evaluate for safety
Preference for home birth	Counsel on safe delivery options
Fasting or restricted diet	Educate on nutritional needs
Specific rituals for placenta	Respect within safe boundaries

Nurses must be culturally sensitive and respect beliefs, while ensuring safety.

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🔷 Discouraged or Outdated Practices

Practice	Reason
Routine enemas or shaving	Uncomfortable, not evidence-based
Binding abdomen immediately post-delivery	May cause discomfort, hinder healing
Keeping baby away from mother after birth	Affects bonding and thermal care

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✅ Summary Table: Key Childbirth Practices

Practice	Recommended? ✅ / ❌
Early breastfeeding	✅
Routine episiotomy	❌
Birth companion allowed	✅
Supine position only	❌
Continuous labour support	✅
Delayed cord clamping	✅
Routine enemas/shaving	❌
Immediate skin-to-skin	✅

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🔷 Nurse/Midwife’s Role in Promoting Safe Childbirth Practices

• Educate and prepare the woman antenatally
• Support her choices and comfort
• Monitor labour progress and fetal well-being
• Respect birth plans and cultural values
• Promote informed, evidence-based care
• Ensure privacy, dignity, and support

🌼 Safe Environment for Mother and Newborn to Promote Bonding.

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🔷 Definition

A safe environment for mother and newborn refers to a clean, comfortable, respectful, and supportive setting that ensures the physical and emotional well-being of both, while encouraging early skin-to-skin contact, breastfeeding, and parent-infant bonding.

🌸 The first few hours after birth are a critical window for bonding, which lays the foundation for emotional development, maternal confidence, and successful breastfeeding.

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🔷 Why Bonding Matters

For the Baby	For the Mother
Promotes emotional security	Builds confidence as a caregiver
Enhances brain development	Reduces risk of postpartum depression
Stabilizes temperature & heart rate	Encourages milk let-down
Improves breastfeeding success	Strengthens maternal instincts

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🔷 Elements of a Safe and Bonding-Promoting Environment

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✅ 1. Clean, Warm, and Hygienic Physical Space

Feature	Why It Matters
Clean bed, sterile linen	Prevents infection
Warm room (≥25°C)	Prevents newborn hypothermia
Dim or soft lighting	Reduces stress for mother and baby
Quiet, low-noise area	Encourages calm and focus on bonding

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✅ 2. Immediate Skin-to-Skin Contact

• Place the naked baby on the mother’s bare chest within 1 minute after birth
• Cover both with a warm cloth or blanket
• Supports:
  • Temperature regulation
  • Breastfeeding initiation
  • Mother-infant recognition
  • Release of oxytocin (bonding hormone)

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✅ 3. Early and Exclusive Breastfeeding

• Encourage first feed within the first hour
• Provide lactation support and privacy
• Promote rooming-in – baby stays with mother 24×7

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✅ 4. Presence of a Birth Companion

• Allow a supportive person (husband, mother, friend, doula, ASHA)
• Provides:
  • Comfort and reassurance
  • Help with positioning, baby care
  • Emotional support for bonding

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✅ 5. Emotional Support and Respectful Care

Practice	Impact
Using the mother’s name	Builds trust
Encouraging questions	Reduces fear
Active listening	Promotes maternal confidence
Respecting privacy	Allows mother to relax and focus on baby

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✅ 6. No Separation Unless Medically Necessary

• Avoid:
  • Taking baby away for routine procedures unless essential
  • Unnecessary NICU separation
• Delay:
  • Bathing (for 24 hours)
  • Weighing or measuring until after first feed

Keeping the mother and baby together continuously enhances attachment and breastfeeding success.

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✅ 7. Safe Sleeping Environment

Safe Practice	Why Important
Baby sleeps in same room, different surface (co-sleeping precautions)	Reduces risk of SIDS (Sudden Infant Death Syndrome)
No soft toys or pillows	Prevents suffocation
Baby placed on back	Safer sleep position

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🔷 Nurse/Midwife’s Role in Promoting Bonding in a Safe Environment

Role	Action
Prepare clean, calm delivery area	Infection control and comfort
Encourage early skin-to-skin contact	Immediate after birth
Assist with first breastfeeding	Support latching and positioning
Provide emotional support	Reassure, educate, involve companion
Keep mother and baby together	Rooming-in practice
Monitor for danger signs	Maintain safety without interrupting bonding
Advocate respectful maternity care (RMC)	Dignity, choice, involvement

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🔷 Key Policies That Support Safe Bonding

• Baby-Friendly Hospital Initiative (BFHI)
• Essential Newborn Care (ENBC)
• Respectful Maternity Care Guidelines (LaQshya, India)

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✅ Quick Checklist: Creating a Bonding-Friendly Safe Environment

Item	Done? ✅
Clean, warm delivery and postnatal area
Skin-to-skin started within 1 minute
Breastfeeding started within 1 hour
No unnecessary separation
Companion allowed and supportive
Nurse/midwife offered reassurance
Rooming-in initiated

🌼 Maintaining Records and Reports.

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🔷 Definition

Maintaining labour records and reports refers to the accurate, timely, and systematic documentation of all information related to the labour, delivery, and immediate postpartum period of the mother and newborn. These records are essential for clinical care, communication, legal purposes, and public health monitoring.

📑 “If it’s not documented, it’s not done” – in healthcare, documentation is care.

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🔷 Purpose of Labour Records and Reports

Purpose	Description
Clinical continuity	Supports team coordination and ongoing care
Legal documentation	Protects healthcare providers and institutions
Statistical and audit use	Supports hospital management and public health
Maternal and newborn tracking	Enables follow-up, registration, and benefit delivery
Quality improvement	Helps monitor standards and outcomes

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🔷 Types of Labour Records and Reports

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✅ 1. Partograph (Labour Progress Chart)

| Purpose | Monitors labour progress, maternal and fetal well-being | | Sections | Cervical dilation, contractions, fetal HR, BP, pulse, urine output | | Usage | Started at 4 cm dilation and updated hourly |

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✅ 2. Labour Room Register

| Contains | Basic demographic details, gravida/parity, delivery type, outcome, complications | | Maintained by | Labour room nurse/midwife | | Entry time | At delivery or immediately post-delivery |

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✅ 3. Mother’s Case Sheet / Delivery Record

| Includes |

• Admission history
• Vaginal examinations
• Monitoring findings
• Medication given
• Mode of delivery
• APGAR scores
• Condition of mother & baby

| Importance | Individual detailed clinical record used throughout labour and postpartum care |

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✅ 4. Birth Record / Birth Notification Form

| Content |

• Date & time of birth
• Sex and weight of the baby
• Place of birth
• Name of mother
• Name of attendant (doctor/nurse)

| Use | For birth certificate registration and health department notification |

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✅ 5. Newborn Record

| Information |

• Resuscitation steps
• APGAR scores
• Breastfeeding initiation
• Vitamin K injection
• Congenital anomalies (if any)
• Immunizations given (BCG, OPV, Hep B)

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✅ 6. Medication and Intervention Records

| Includes | Oxytocin administration, antibiotics, pain relief, IV fluids, episiotomy | | Purpose | Ensures correct medication management and legal accountability |

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✅ 7. Fourth Stage Monitoring Chart

| Includes |

• Fundal height and tone
• Lochia amount/type
• Maternal vitals (BP, pulse, temp)
• Voiding
• Breastfeeding status
• Any complications

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✅ 8. Referral / Transfer Records (if applicable)

| Used When | Mother or baby is referred to higher centre or NICU | | Must Contain | Reason for referral, interventions done, vital signs, escort details |

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🔷 Best Practices for Labour Documentation

Practice	Explanation
Timely documentation	Record events as they occur, not after hours
Legibility and clarity	Use clear handwriting or electronic records
Standard abbreviations only	Avoid personal short forms
Sign and date every entry	Include time and name/designation of staff
Maintain confidentiality	Never disclose information publicly
Correct errors properly	Use single line strike-through, write “error,” correct it, and sign

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🔷 Legal and Ethical Considerations

• All labour records are legal documents
• Can be used in court as evidence in case of disputes or negligence claims
• Must be stored securely and confidentially
• Tampering, falsifying, or failing to document is a punishable offense under medical ethics and law

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✅ Quick Checklist: Essential Records to Maintain in Labour Room

Record Type	Maintained? ✅
Partograph
Labour Room Register
Delivery Notes / Case Sheet
APGAR Score Chart
Medication Sheet
Newborn Care Record
Birth Notification Form
Fourth Stage Monitoring Chart
Referral Form (if needed)

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🔷 Nurse/Midwife Responsibilities

Task	Role
Record all assessments & procedures	Vaginal exams, vitals, medications
Use correct formats/registers	As per hospital/NHM guidelines
Communicate clearly in documentation	Avoid ambiguity
Document promptly	Do not delay record-keeping
Review records before handover	Ensure continuity of care
Report and record any complications	Clearly and completely