Normal labour and delivery

NORMAL LABOUR
AND DELIVERY
MR. JONES H.M-MBA
8/27/2019JONES H.M-MBA 1

NORMAL LABOUR
• NORMAL LABOUR REFERS TO LABOUR THAT OCCURS AT
TERM AND IS SPONTANEOUS IN ONSET WITH THE FETUS
PRESENTING BY VERTEX, IN WHICH THERE IS REGULAR
UTERINE CONTRACTIONS ASSOCIATED WITH EFFACEMENT
AND DILATATION OF THE CERVIX.

ONSET OF LABOR
• THERE ARE THREE CLASSICAL SIGNS BY WHICH THE ONSET
OF LABOR IS DIAGNOSED.
• ANY ONE OF THE SIGNS IS ENOUGH TO DIAGNOSE THE
ONSET OF LABOR - IT IS NOT NECESSARY TO GET ALL
THREE SIGNS.

1.PAINFUL UTERINE CONTRACTIONS: THE ONSET OF LABOUR
IS CHARACTERIZED BY PAINFUL, INTERMITTENT,
INVOLUNTARY AND CO-ORDINATED UTERINE
CONTRACTIONS WHICH CANNOT BE RELIEVED BY
MEDICINES OR REST.

• SOME WOMEN GET UTERINE CONTRACTIONS IN LATE
PREGNANCY WHICH THEY OFTEN MISTAKE FOR ONSET OF
LABOR.
• BUT THE CONTRACTIONS ARE USUALLY NOT REGULAR,
DOES NOT INCREASE GRADUALLY IN INTENSITY AND ARE
RELIEVED BY MEDICINES OR REST.
• THESE ARE 'FALSE LABOR PAINS‘.

• BRAXTON HICKS CONTRACTIONS OCCUR THROUGHOUT
PREGNANCY AND ARE NOT RELATED TO LABOR PAINS.
2.EXPULSION OF SHOW OR MUCUS PLUG: DURING
PREGNANCY, THE CERVIX WHICH IS THE MOUTH OF THE
UTERUS IS FILLED WITH DENSE MUCUS THAT SEALS IT TO
SOME EXTENT.

• AS THE CERVIX BEGINS TO THIN OUT AND OPEN TO ALLOW
THE BABY TO BE BORN, THIS MUCUS IS EXPELLED THROUGH
THE VAGINA.
• THERE IS ALSO SOME AMOUNT OF BLEEDING FROM BLOOD
VESSELS THAT RUPTURE WHEN THE CERVIX DILATES.
• THESE PRESENT AT THE VAGINAL OPENING AS BLOOD
STAINED MUCUS.

• THIS BLOOD STAINED MUCUS IS CALLED 'SHOW'OR 'MUCUS
PLUG'. THE MUCUS PLUG MAY CONSIST OF THIN OR THICK
MUCUS.
• IT MAY BE JUST BLOODSTAINED IN SOME WOMEN,
RESULTING IN BROWNISH VAGINAL DISCHARGE. BUT IN
OTHERS , THERE MAY BE FRANK BLEEDING AT THE TIME OF
EXPULSION OF THE MUCUS PLUG.

3.RUPTURE OF MEMBRANES: IN MANY WOMEN, THE ONSET OF
LABOR IS SIGNIFIED BY THE RUPTURE OF THE BAG OF WATERS
(RUPTURE OF MEMBRANES) WITHOUT ANY PRIOR ABDOMINAL
PAIN.
• THE RUPTURE OF THE MEMBRANES MAY OCCUR WITH A
SUDDEN GUSH OF WATERS, OR WITH ONLY A THIN TRICKLE
THAT IS BARELY ENOUGH TO SOAK THE UNDERWEARS.

• USUALLY, LEAKAGE OF WATER IS MORE IN THE LYING
DOWN POSITION.
• STANDING OR SITTING UP CAUSES THE HEAD OF THE FETUS
TO PLUG THE MOUTH OF THE UTERUS AND PREVENTS
OUTFLOW OF THE AMNIOTIC FLUIDS (WATERS).

TRUE LABOR
• CONTRACTIONS BECOME STRONGER, LONGER AND CLOSER
TOGETHER
• BAG OF WATERS MAY BREAK (SHORTENS); CALL YOUR
HEALTH CARE PROVIDER

• CERVIX PROGRESSIVELY EFFACES (SHORTENS) AND DILATES
(OPENS)
• INCREASE IN MUCUS AND BLOODY SHOW MAY BE PRESENT

• WALKING INCREASES INTENSITY
• DISCOMFORT IN BACK AND ABDOMEN
• CONTRACTIONS DON'T GO AWAY AFTER REST OR ACTIVITY

FALSE LABOR
• CONTRACTIONS MAY BE UNCOMFORTABLE
• CONTRACTIONS USUALLY DON'T GET CLOSER TOGETHER OR
LAST LONGER
• CONTRACTIONS ARE USUALLY NOT REGULAR
• CERVIX SHOWS LITTLE OR NO DILATION OR EFFACEMENT
• CHANGE IN ACTIVITY, EITHER RESTING OR MOVING AROUND,
MAY STOP CONTRACTIONS

• POSITION CHANGE MAY STOP CONTRACTIONS
• DISCOMFORT USUALLY ONLY IN ABDOMEN

STAGES OF NORMAL LABOUR
• LABOR IS DIVIDED INTO THREE STAGES, THOUGH A
FOURTH STAGE HAS ALSO BEEN INSTITUTED RECENTLY
AND IS DISCUSSED UNDER IMMEDIATE CARE OF WOMAN
AFTER DELIVERY OF PLACENTA:
• STAGE I : STAGE I LASTS FROM THE ONSET OF LABOR TO
FULL DILATION OF THE CERVIX. IN A PRIMIGRAVIDA, THIS
STAGE LASTS FOR ABOUT 10 TO 12 HOURS.

• IN A WOMAN WHO HAS DELIVERED EARLIER, IT LASTS FROM
6 TO 8 HOURS.

THE FIRST STAGE IS AGAIN DIVIDED INTO THREE PHASES:
• PHASE I: THIS IS THE LONGEST AND LEAST PAINFUL PHASE
OF THE ENTIRE DURATION OF LABOR.
• IT STARTS FROM THE TIME WHEN THE CERVIX FIRST
STARTS TO DILATE TO THE TIME WHEN THE CERVIX IS 4 CM
DILATED.

• IT IS ALSO CALLED THE 'LATENT PHASE' OF LABOR OR THE
'EARLY PHASE' OF LABOR.
• IT CAN LAST FOR DAYS AND CAN OCCUR WITH ONLY THE
MILDEST DISCOMFORT TO THE PREGNANT WOMAN.

• PHASE II: THIS IS A MORE ACTIVE PHASE OF LABOR. THE
CERVIX DILATES FROM 4 CM TO 8 CM DURING THIS PHASE.
• THE CONTRACTIONS ARE MORE PAINFUL , OF LONGER
DURATION AND COME MORE REGULARLY.
• IT IS ALSO CALLED THE 'MIDDLE PHASE ' OF LABOR.

• PHASE III: DURING THIS PHASE, THE CERVIX DILATES FROM
8 CM TO 10 CM .
• AT 10 CM, THE CERVIX IS FULLY DILATED AND THE BABY'S
HEAD CAN COME OUT OF THE UTERUS SAFELY AND EASILY.
• THIS PHASE IS ALSO CALLED THE 'TRANSITION PHASE' OF
LABOR SINCE IT MARKS THE TRANSITION OF THE FIRST
STAGE OF LABOR TO THE SECOND STAGE.

• STAGE II : STAGE II LASTS FROM THE FULL DILATATION OF
THE CERVIX TO THE EXPULSION OF THE BABY. IN A FIRST
PREGNANCY, IT LASTS FOR ABOUT 1 HOUR, IN
SUBSEQUENT PREGNANCIES, IT LASTS FOR ABOUT ½ HOUR.
• THIS STAGE (SECOND STAGE) IS A STAGE WHEN THE BABY'S
HEAD IS TRAVELLING DOWN THE VAGINAL CANAL TO BE
DELIVERED.

• THE CONTRACTIONS ARE VERY PAINFUL AND RUN INTO
EACH OTHER, APPEARING TO PRODUCE ALMOST
CONTINUOUS PAIN.

• STAGE III : STAGE III LASTS FROM THE BIRTH OF THE BABY
TO THE EXPULSION OF THE PLACENTA AND THE
MEMBRANES.
• IT LASTS FOR ABOUT 15 - 20 MINUTES IN BOTH FIRST AND
LATER PREGNANCIES.

• THE THIRD STAGE IS COMPARATIVELY LESS PAINFUL AND IS
CHARACTERIZED BY A GUSH OF BLEEDING AT THE TIME
THE PLACENTA SEPARATES FROM THE UTERUS.

MANAGEMENT OF NORMAL
LABOUR
ADMISSION OF A WOMAN IN LABOUR
OBJECTIVES:
• TO CONFIRM IF PATIENT IS IN LABOUR
• REASSURE THE PATIENT AND ALLAY ANXIETY.
• DETECT ANY ABNORMALITY AND TAKE APPROPRIATE
ACTION.

REQUIREMENTS
• TROLLEY SHOULD BE PREPARED AS FOLLOWS.
TOP SHELF
• VAGINAL DELIVERY PACK CONTAINING 2 GALLIPOTS, WITH
COTTON WOOL SWABS, EPISIOTOMY SCISSOR, UMBILICAL
CORD SCISSOR, VAGINAL PAD, PAIR OF STERILE GLOVES.

• BOTTOM SHELF
• CLEAN SHEETS
• MACKINGTOSH WITH DRAW SHEETS
• RECEIVER FOR USED SWABS
• SPHYGMOMANOTER AND STETHOSCOPE

• BOTTLE OF SAVLON 1:2000 FOR SWABBING
• THERMOMETER
• FETAL STETHOSCOPE
• MULTISTIC REAGENTS

• GALLIPOT WITH CLEAN COTTON WOOL
• GALLIPOT WITH CLEAN WATER
• SOAP AND TOWEL.

PROCEDURE
• GREET THE WOMAN AND WELCOME HER INTO THE WARD.
• INTRODUCE YOURSELF IN A FRIENDLY MANNER AND
REASSURE THE WOMAN.
• QUICKLY ASSESS THE GENERAL CONDITION OF THE
WOMAN AND STABLE GO AHEAD WITH THE ADMISSION
PROCEDURE.

• REVIEW THE ANTENATAL CARD NOTING THE PAST
OBSTETRIC HISTORY, MEDICAL HISTORY, ANY THING
UNUSUAL ABOUT THE PRESENT PREGNANCY AND
RELEVANT DATA.
• IF PATIENT IS UNBOOKED, A FULL HISTORY SHOULD BE
TAKEN
• LABOUR HISTORY - OBTAIN DETAILS CONCERNING THE
PRESENT LABOUR

INQUIRE ABOUT THE FOLLOWING:
• TIME AND ONSET OF REGULAR UTERINE CONTRACTIONS.
• HISTORY OF ANY SHOW.
• ANY VAGINAL BLEEDING OBSERVED.
• ANY DANGER SIGNALS SUCH AS SEVERE HEADACHE, BLURRED
VISION, DIZZINESS, FEVER.
• IF THE MEMBRANES HAVE RUPTURE AND AT WHAT TIME DID
THE THEY RUPTURE.

• NOTE THE COLOR OF LIQUOR
VITAL SIGNS
• CHECK THE TEMPERATURE, PULSE, RESPIRATION AND
BLOOD PRESSURE.

• URINALYSIS - OBTAIN URINE FOR URINALYSIS AND TEST
ESPECIALLY LOOKING FOR PRESENCE OF ALBUMIN, SUGAR
OR ACETONE, MEASURE THE AMOUNT AND RECORD

• HEAD TO TOE EXAMINATION - CARRY OUT THE HEAD TO
TOE EXAMINATION AS PREVIOUSLY DESCRIBED TAKING
NOTE ABNORMALITIES SUCH AS ANAEMIA, OEDEMA,
VARICOSE VEINS, LYMPHADENOPATHY AND ANY VAGINAL
DISCHARGE OR VULVAL SORES.

ABDOMINAL EXAMINATION
• INSPECTION
• SIZE OF ABDOMEN IN RELATION TO CALCULATED
GESTATIONAL AGE.
• SHAPE AND CONTOUR OF THE ABDOMEN
• ANY SCARS OR SKIN CHANGES
• UTERINE CONTRACTIONS-TYPE, FREQUENCY AND
DURATION.
• FETAL MOVEMENTS AND ACTIVITY

• PALPATION
• ESTIMATE THE HEIGHT OF THE UTERINE FUNDUS
• LEOPARD PALPATION
• PELVIC PALPATION

AUSCULTATION
• CHECK THE FOETAL HEART RATE NOTING THE VOLUME,
RHYTHM, ETC.
• AFTER PHYSICAL EXAMINATION, THEN PERFORM VAGINAL
EXAMINATION

VAGINAL EXAMINATION
• THIS IS A STERILE PROCEDURE
OBJECTIVES
• TO CONFIRM THAT THE WOMAN IS IN LABOUR.
• TO FORM BASELINE DATA FOR SUBSEQUENT
EXAMINATIONS.
• TO DETECT ANY ABNORMALITIES AND TO MAKE
APPROPRIATE INTERVENTIONS.

• TO RULE OUT CORD PROLAPSE WHEN THE MEMBRANES
RUPTURE.
• TO CONFIRM THE PRESENTATION
• TO ASSESS THE LABOUR BEFORE GIVING ANALGESICS SUCH
AS PETHIDINE.

DURING VAGINAL EXAMINATION NOTE THE FOLLOWING;
• VAGINA-SHOULD FEEL WARM AND MOIST.
• HOT OR DRY VAGINA MAY BE A SIGN OF OBSTRUCTED
LABOUR.

• CERVIX-IS IT EFFACED OR NOT. IS IT THICK OR THIN, IS IT
WELL APPLIED TO THE PRESENTING PART. IS IT
OEDEMATOUS AND THEN ESTIMATE CERVICAL DILATATION
IN CM.

• MEMBRANES- ARE THEY INTACT OR RUPTURED, DO THEY
BULGE WITH A CONTRACTION, IF RUPTURED, NOTE THE
COLOR OF LIQUOR, ANY MECONIUM IN LIQUOR.
• IF MECONIUM PRESENT IN LIQUOR NOTE IF FRESH OR DRY.
• NOTE IF THE LIQUOR IS OFFENSIVE AND TAKE NOTE OF THE
TIME OF RUPTURE OF MEMBRANES.

• UMBILICAL CORD-FEEL FOR THE UMBILICAL CORD AND IF
ABSENT THAT INDICATES THAT THERE IS NO CORD
PRESENTATION OR PROLAPSE.
• IF THE CORD IS FELT AND THE MEMBRANES ARE INTACT, IT
IS CALLED CORD PRESENTATION OR FUNIC PRESENTATION

• IF CORD IS FELT AND MEMBRANES ARE RUPTURED, IT IS
CALLED CORD PROLAPSE.
• DURING VAGINAL EXAMINATION, CONFIRM THE;
• THE PRESENTATION AND DEGREE OF FLEXION.

THE PRESENTING PART
• PRESENCE OF CAPUT SUCCEDANEUM AND DEGREE.
• NOTE IF MOULDING IS PRESENT AND ASSESS THE DEGREE
OF MOULDING SUCH AS O, +1, +2, +3

• ASSESS FOR STATION OF THE PRESENTING PART.
• FINALLY CARRY OUT PELVIC EXAMINATION TO RULE CPD.
• IF THE WOMAN IS IN ACTIVE LABOUR-OS 4CM AND ABOVE,
OPEN THE PARTOGRAM

MANAGEMENT OF FIRST STAGE
OF LABOUR
MEDICAL MANAGEMENT
LAB WORK
• LAB WORK MAINLY DONE IF IT WAS NOT DONE
ANTENATALLY AND CLIENT HAS COMPLAINTS.

THE FOLLOWING LAB WORK IS USUALLY DONE;
BLOOD SLIDE FOR MPS TO DETECT ANY MALARIA.
HB/HCT TO DETECT ANY ANAEMIA WHICH IS COMMON IN
PREGNANCY.
• GROUPING AND CROSS MATCH IN CASE OF NEED FOR
BLOOD TRANSFUSION.
• RHESUS FACTOR IN CASE OF RHESUS INCOMPATIBILITY.

• URINALYSIS IS DONE MAINLY TO EXCLUDE ABNORMALITIES
SUCH AS PRESENCE OF PROTEINS IN URINE WHICH CAN BE
AN INDICATION OF PRE-ECLAMPSIA.
DRUGS ARE GIVEN ONLY IF ORDERED AND ONLY IN SPECIAL
CONDITIONS SUCH AS HIV/
AIDS, HYPERTENSIVE PATIENT.

NURSING MANAGEMENT
AIM
TO ENSURE THAT THE WOMAN GIVES BIRTH NORMALLY BY
MONITORING THE MATERNAL WELL-BEING, FOETAL
WELLBEING AND PROGRESS OF LABOUR AND THAT THE
MATERNAL-FETAL STATUS IS WITHIN NORMAL LIMITS.

MATERNAL WELL BEING
ROOM
CLEAN ROOM TO REDUCE CHANCES OF INFECTION.
• WARM TO PROMOTE COMFORT TO THE MOTHER AND
PREVENT HYPOTHERMIA TO THE NEW BORN BABY.
QUIET TO PROMOTE REST.
WELL VENTILATED TO PROMOTE FREE CIRCULATION OF
AIR.

THE FOLLOWING EQUIPMENT SHOULD BE IN THE ROOM:
• THE TPR TRAY, BLOOD PRESSURE MACHINE
• STETHOSCOPE, ELECTRONIC FOETAL MONITOR OR
FOETOSCOPE, FLASHLIGHT OR PENLIGHT, OXYGEN
MACHINE, IV POLE.

POSITION
LATERAL POSITION IS PREFERABLE IF WOMAN WISHES TO
LIE DOWN.
• LATERAL POSITION IS PREFERABLE AS IT PREVENTS
COMPRESSION OF THE INFERIOR VENA CAVA WHICH MAY
CAUSE SUPINE HYPOTENSION.

THE WOMAN SHOULD BE ENCOURAGED TO ADOPT
LATERAL POSITION.
UPRIGHT POSITION SHOULD BE ENCOURAGED AS WELL AS
THIS POSITION FACILITATES UTERINE CONTRACTIONS AND
PROMOTE GOOD PROGRESS OF LABOUR.

• THE CLIENT SHOULD NEVER LIE IN RECUMBENT POSITION
AS THIS CAN LEAD TO SUPINE HYPOTENSION.
• WITH SUPINE HYPOTENSION, THE WOMAN WILL USUALLY
COMPLAIN OF VERTIGO, DIZZINESS AND FINALLY SHE CAN
FAINT.
• RECUMBENT POSITION WILL ALSO RESULT INTO
REDUCTION OF PLACENTAL BLOOD FLOW AND THIS WILL
COMPROMISE THE WELL BEING OF THE FETUS.

OBSERVATIONS
BLOOD PRESSURE
THIS IS DONE TO RULE OUT PREECLAMPSIA/ECLAMPSIA
• THE NORMAL LEVELS OF BLOOD PRESSURE DURING LABOUR
SHOULD RANGE AS FOLLOWS: 90/60-140/90 MMHG.

• MEASURES REFLECTING AN INCREASE BY 30MMHG IN
SYSTOLIC AND 15MMHG IN DIASTOLIC ABOVE THE
ANTEPATURM BASE LINE DATA ARE AN ABNORMAL AND
SHOULD BE INVESTIGATED.

ASSESS AND RECORD BLOOD PRESSURE ON ADMISSION
AND AT LEAST HOURLY DURING THE ACTIVE PHASE AND
MORE FREQUENTLY IF BLOOD PRESSURE ELEVATED.
THE BLOOD PRESSURE SHOULD NOT BE TAKEN WHEN
PATIENT IS IN SUPINE POSITION BECAUSE OF THE RISK OF
SUPINE HYPOTENSIVE SYNDROME AND THIS MAY GIVE
FALSE READING.

• BLOOD PRESSURE SHOULD NOT BE ASSESSED DURING
CONTRACTIONS AS THIS MAY CAUSE A FALSE ELEVATION.

TEMPERATURE:
THE TEMPERATURE SHOULD BE ASSESSED INITIALLY AS
BASE LINE DATA AND EVERY 4 HOURS THEREAFTER.
IF THE MEMBRANES ARE RUPTURED AND THE TEMPERATURE
IS ELEVATED, IT SHOULD BE OBSERVED 1 TO 2 HOURLY.
TEMPERATURE IS MAINLY DONE TO RULE OUT INFECTION
SUCH AS MALARIA, UTI, URTI, GITI, OBSTRUCTED LABOUR
ETC.

PULSE AND RESPIRATIONS
• THE PULSE AND RESPIRATIONS ARE ASSESSED INITIALLY AS
BASELINE DATA AND EVERY 4HOURS.
• THE PULSE IS ASSESSED TO DETECT ANY DEVIATION FROM
NORMAL SUCH AS TACHYCARDIA AND BRADYCARDIA.

• NORMAL RANGE OF PULSE IS 60-90 BEATS/MINUTE AND
RESPIRATIONS 16-24 BREATHS/MINUTE.
INCREASED RESPIRATION AND PULSE MAY BE ATTRIBUTED
TO ANXIETY, EXCITEMENT AND PAIN.
WHEN TACHYCARDIA IS ASSOCIATED WITH ELEVATED
TEMPERATURE, IT IS A GOOD INDICATION OF INFECTION.

• OTHER OBSERVATIONS INCLUDE THE GENERAL CONDITION
OF THE CLIENT, HOW THE CLIENT IS RESPONDING TO
LABOUR.

NUTRITION AND HYDRATION
THE CLIENT IS ENCOURAGED TO TAKE ENOUGH CALORIES
FLUIDS TO REPLENISH ENERGY EXPENDITURE AND
PROMOTE EFFICIENT UTERINE CONTRACTIONS AND
GENERAL WELL BEING OF THE WOMAN.

• THE CLIENT IS ENCOURAGED TO TAKE FOODS AND FLUIDS
ORALLY AND OR COMMENCING HER ON INTRAVENOUS
FLUIDS SUCH AS 5% DEXTROSE.
• THIS WILL HELP PREVENT MATERNAL DISTRESS ATONIC
UTERUS.
• THE CLIENT SHOULD BE ENCOURAGED TO EAT LIGHT FOOD
THAT CAN NOT CAUSE CONSTIPATION AND MAKE RECTUM
FULL AS THESE CAN DELAY THE PROGRESS OF LABOUR.

• ENSURE THAT THE WOMAN HAS ENOUGH TO EAT WHEN
ABLE TO AS THIS WILL GENERALLY PROMOTE THE
WELLBEING OF THE WOMAN IN LABOUR.

EMOTIONAL SUPPORT (PSYCHOLOGICAL CARE)
• EMOTIONAL SUPPORT ENCOMPASSES SUCH FACTORS AS
ACCEPTANCE, UNDERSTANDING, AND CONTINUOUS
UNINTERRUPTED PHYSICAL PRESENCE OF THE NURSE,
ENCOURAGEMENT AND PRAISE.
• ALL THE ABOVE COMPONENTS OF SUPPORTIVE ROLE HAVE
A MAJOR IMPACT ON THE OUTCOME OF LABOUR.

• MAKE THE CLIENT AND HER FAMILY WELCOME,
COMFORTABLE AND ACCEPTABLE TO ALLAY ANXIETY.
CREATE GOOD CLIENT- NURSE RELATIONSHIP AS THIS
TENDS TO RELIEVE THE TENSION AND STRESS THE WOMAN
MAY BE FEELING.

• WORK IN A CALM AND FRIENDLY MANNER TO AVOID
ALARMING THE WOMAN AS COLD, ABRUPT OR IRRITABLE
NURSE WILL MAKE WOMAN FEEL DEFENSIVE AND MORE
APPREHENSIVE ESPECIALLY THAT THIS WOMAN IS FROM
MUSELEPETE.
• THE NURSE SHOULD SPEND AS MUCH TIME AS POSSIBLE
WITH THE CLIENT TO ESTABLISH A POSITIVE RELATIONSHIP.

• THE NURSE SHOULD IDENTIFY WHAT THE CLIENT NEEDS TO
KNOW AND SHARE INFORMATION WITH THE CLIENT.
• THE NURSE SHOULD TEACH THE WOMAN ON WHAT IS
EXPECTED SUCH AS WHEN TO START PUSHING,
CONTRACTION PATTERNS, TIMING THE CONTRACTIONS
AND CHANGES THROUGH OUT LABOUR THAT INDICATE
THE PROGRESS SUCH AS CERVICAL DILATATION, DECENT,
EFFACEMENT AND STATION.

• DIVERTIONAL THERAPY MAY BE ENCOURAGED IN THE
EARLY PHASE OF LABOUR SUCH AS PLAYING CARDS,
LISTENING TO MUSIC OR WATCHING TELEVISION.
EXPLAIN EVERY PROCEDURE DONE TO THE WOMAN SUCH
AS VAGINAL EXAMINATION, FETAL HEART RATE TO ALLAY
ANXIETY.
TELL THE WOMAN THE PROGRESS OF LABOUR, HER
WELLBEING AND WELLBEING OF THE FETUS EVERY AFTER
EACH EXAMINATION.
THIS WILL ALLAY APPREHENSION THE WOMAN MAY HAVE.

HYGIENE
BASIC HYGIENE SHOULD NOT BE OVERLOOKED IN THE
EXCITEMENT FOR LABOUR.
KEEP THE WOMAN CLEAN AND DRY
IF PERSPIRING, CHANGE HER GOWN FREQUENTLY TO KEEP
HER DRY AND COMFORTABLE.
COLD MOIST WASH CLOTH CAN BE PLACED ON HER
FOREHEAD OR USED TO WIPE HER FACE AND HANDS TO
REFLESHEN THE CLIENT.

KEEP THE BED DRY ESPECIALLY IF THE WOMAN IS HAVING
LARGE AMOUNTS OF BLOOD SHOW OR MEMBRANES HAVE
RUPTURED AND SHE IS LEAKING AMNIOTIC FLUID.
ORAL HYGIENE IN THE FORM OF MOUTH WASH SHOULD BE
ENCOURAGED TO HELP HER FEEL REFRESHED.
ICE CHIPS CAN BE GIVEN TO KEEP HER MOUTH MOIST.

PAIN MANAGEMENT
 IF THE WOMAN IS TENSE AND IN PAIN, A SOOTHING
BACKRUB WILL BE DONE AS THIS MAY HELP TO RELAX THE
WOMAN.
ENCOURAGE WOMAN TO USE ICE PACKS OR HOT PACKS AS
THIS MAY RELIEVE PAIN.
ENCOURAGE WOMAN TO RELAX HER MUSCLES DURING
CONTRACTIONS BY TAKING SLOW-PACED BREATHING.
PAIN KILLERS SUCH AS PETHIDINE IN CASE OF SEVERE
BACKACHE CAN BE GIVEN.

• HOWEVER CARE SHOULD BE TAKEN AS PETHIDINE CAN
CAUSE FETAL DISTRESS.
• IT IS RECOMMENDED TO GIVE PETHIDINE ONLY WHEN THE
CERVICAL DILATATION IS LESS THAN 6CM.

ELIMINATION/BLADDER CARE
• ENCOURAGE WOMAN TO VOID EVERY AFTER 2 HOURS TO
AVOID RETENTION OF URINE AS A DISTENDED BLADDER
CAN CAUSE DISCOMFORT TO THE CLIENT AND MAY DELAY
THE PROGRESS OF LABOUR.
• IF MEMBRANES ARE INTACT OR RUPTURED AND THE
PRESENTING PART IS WELL ENGAGED INTO THE PELVIS, THE
WOMAN CAN BE ENCOURAGED TO GET UP TO GO TO THE
BATHROOM TO VOID ON THE TOILET AS THE CHANCES OF
CORD PROLAPSE IN THIS CASE ARE SLIM.

• IF MEMBRANES ARE RUPTURED AND HEAD IS NOT
ENGAGED, WOMAN SHOULD REMAIN IN BED AND BEDPAN
SHOULD BE GIVEN TO HER FOR USE AS CHANCES OF CORD
PROLAPSE IN THIS CASE ARE INCREASED.
• IF THE WOMAN IS UNABLE TO VOID AND IT IS OBVIOUS BY
OBSERVATION OR PALPATION THAT THE
• BLADDER IS FULL, IN AND OUT CATHETERIZATION MAY BE
NECESSARY.

ACTIVITIES/REST
IF THE MEMBRANES ARE INTACT AND THE HEAD IS WELL
ENGAGED, SHE CAN BE ALLOWED TO WALK UP AND DOWN
AS THIS PROMOTES THE PROGRESS OF LABOUR.
ALLOW WOMAN TO REST IF SHE WISHES BY PROMOTING A
QUIET ROOM AND DRY BED TO MAKE HER COMFORTABLE.

FOETAL WELBEING
• FETAL WELL BEING DURING LABOUR IS VERY IMPORTANT
AND THE FOLLOWING NURSING INTERVENTION SHOULD BE
CARRIED OUT;
 FOETAL HEART RATE SHOULD BE DONE EVERY 30 MINUTES.
 THIS IS MAINLY DONE TO RULE OUT ANY DEVIATION FROM
NORMAL SUCH AS FOETAL DISTRESS.

• THE FETAL HEART RATE SHOULD BE WITHIN A NORMAL
RANGE OF 120-160BEATS/MINUTE.
 THE HEART RATE SHOULD BE REGULAR.
• WHEN TAKING THE FETAL HEART NOTE THE RHYTHM IN
WHICH THE HEART BEAT SHOULD BE COUPLED AND
STEADY.

 HEART BEAT VOLUME SHOULD BE STRONG AS WEAK HEART
BEAT VOLUME MAY INDICATE FETAL DISTRESS.
 THE HEART RATE SHOULD REMAIN STEAD OR ACCELERATE
DURING CONTRACTIONS.
 AVOID TAKING HEART RATE DURING CONTRACTIONS AS
THIS CAN GIVE A MISLEADING HEART RATE.

• NOTE IF THERE IS ANY DIMINISHED OR CEASATION OF
FOETAL MOVEMENT TO RULE OUT INTRA UTERINE
• FOETAL DEATH OR EXCESSIVE FOETAL MOVEMENT TO RULE
OUT FOETAL DISTRESS.
• CHECK FOR ANY PASSAGE OF FRESH MECONIUM AS THIS
CAN BE AN INDICATION OF FOETAL DISTRESS.

• CHECK THE DEGREE OF MOULDING AS THIS MAY
ENDANGER THE LIFE OF THE FOETAL AND CAUSE HEAD
INJURY.
• CARRY OUT ABDOMINAL PALPATION EVERY 4 HOURS TO
DETERMINE THE LIE, POSITION, PRESENTATION OF THE
FETUS AS ABNORMAL LIE, POSITION AND PRESENTATION
PUT A FETUS AT HIGH RISK OF FOETAL DEATH OR INJURIES.

• WATCH FOR THE SIGNS OF DISTRESS SUCH FETAL HEART
RATE ABOVE OR BELOW THE NORMAL RANGE OF 120-
160B/M.
• PASSAGE OF FRESH MECONIUM AND EXCESSIVE FETAL
MOVEMENT.

PROGRESS OF LABOUR
ABDOMINAL PALPATION
 THIS IS DONE EVERY AFTER 4HOURS TO DETERMINE THE
POSITION, LIE , DESCENT AND PRESENTATION OF THE
FETUS.

UTERINE CONTRACTIONS
•THE FREQUENCY, DURATION
AND INTENSITY OF UTERINE
CONTRACTIONS HAVE TO BE DONE EVERY 15-30 MINUTES.

VAGINAL EXAMINATION
• DONE EVERY 4 HOURS TO ASSESS FOR THE FOLLOWING:
CERVICAL DILATATION, CERVICAL POSITION, CERVICAL
EFFACEMENT, CERVICAL CONSISTENCY, FOETAL STATION,
PRESENTING PART AND NOTING IF MEMBRANES INTACT OR
NOT.
• THESE ASSESSMENTS ARE THE BASIS FOR DETERMINING
LABOUR PROGRESS.

PARTOGRAPH
• THIS WILL BE USED WHEN THE WOMAN IS IN AN ACTIVE
LABOUR WITH A CERVICAL DILATATION OF 4CM AND
ABOVE AND ALL THE NECESSARY INFORMATION WILL BE
ENTERED.

SECOND STAGE OF LABOUR
• THE SECOND STAGE OF LABOR STARTS AT THE END OF THE
FIRST STAGE WHEN THE CERVIX IS FULLY DILATED TO 10
CM.
• THIS STAGE IS CHARACTERIZED BY SOME SPECIFIC
DYNAMICS IN BOTH THE MOTHER AND THE BABY.

MECHANISM OF LABOUR
• THESE ARE SERIES OF ADAPTATIONS THAT THE FETUS
MAKES AS IT MOVES THROUGH THE MATERNAL BONY
PELVIS DURING THE PROCESS OF LABOUR AND BIRTH.
• MECHANISM OF LABOUR IS INFLUENCED BY SIZE AND
POSITION OF THE FETUS, THE POWERS OF LABOUR, THE
SIZE AND SHAPE OF THE MATERNAL PELVIS AND THE
MOTHER’S POSITION AND THESE CAN BE SUMMARISED AS
THE 4PS.

• STUDENT4PS STAND FOR:
• ………………………..
• ………………………..
• ………………………..
• ……………………….
• S TO COMPLETE THE 4PS

MANAGEMENT OF SECOND STAGE
OF LABOUR• TOWARD THE END OF THE FIRST STAGE OF LABOUR, THE
MIDWIFE SHOULD MAKE PREPARATION FOR THE CONDUCT OF
THE SECOND STAGE OF LABOUR.

REQUIREMENT:
• ROOM WHICH IS CLEAN AND WARM {26DEGREE CELSIUS}
• PRIVACY
• RESUSCITAIRE
• TROLLEY-TOP SHELF {SHOULD BE STERILE}
A STERILE DELIVERY PACK CONTAINING:
• 1 BOWL WITH COTTON WOOL AND GAUZE SWABS
• 1 GALLIPOT FOR PUTTING 1:200 HIBITANE OR SAVLON

• 1 CORD CLAMP
• 2 RECEIVERS
• 2 ARTERY FORCEPS
• 1 CORD SCISSORS
• 2 MATERNITY PADS
• 1 EPISIOTOMY SCISSORS
• 15CC OR 10CC SYRINGE WITH GREEN TOP NEEDLES G21.
• 1 URINARY GATHETER
• 2 STERILE DRESSING TOWELS

TROLLEY-BOTTOM SHELF
• INJECTION OF SYNTOMETRINE 1ML, OR OXYTOCIN 10
UNITS
• SYRINGES 2CC, 5CC, 10CC. AND NEEDLES.
• LIGNOCAINE PLAIN 1% OR 2%
• WATER FOR INJECTION

• RECEIVER FOR USED SWABS ETC.
• STERILE GROVES
• FETAL STETHOSCOPE
• PACKET OF MATERNITY PADS
• EXTRA LINEN
• BOTTLE OF HIBITANE OR SAVLON 1:200

• BABY WRAPPER, LABEL, NEONATAL FORM
• RESUSCITAIRE MUST ALWAYS BE READY AT ALL TIMES TO
RESUSCITATE THE BABY
PROCEDURE {2 MIDWIVES SHOULD BE IN ATTENDANCE}

• ASK THE PATIENT TO PASS URINE OR PASS A CATHETER IF
SHE FAILS TO PASS URINE IN ORDER TO PREVENT DELAY IN
2ND AND 3RD STAGE OF LABOUR.
• THE PATIENT SHOULD BE GIVEN INSTRUCTION ON HOW TO
PUSH.
• THE MIDWIFE CONDUCTING THE DELIVERY NOW WASHES
AND DRIES HER HANDS, OPENS THE OUTER PART OF THE
DELIVERY PACK.
8/27/2019JONES H.M-MBA 100

• S/HE NOW PUTS ON {GOWN IF AVAILABLE} STERILE GLOVES
AND COMPLETES THE PREPARATION OF THE STERILE PART
OF THE TROLLEY.
• THE SECOND MIDWIFE IS RESPONSIBLE FOR MONITORING
FETAL AND MATERNAL WELL-BEING, AS WELL AS THE
EFFICIENCY OF THE UTERINE CONTRACTION.
8/27/2019JONES H.M-MBA 101

• OBSERVATION IN SECOND STAGE SHOULD BE DONE EVERY
FIVE MINUTES.
• S/HE IS ALSO RESPONSIBLE TO SEE THAT THE MOTHER
MAINTAINS A GOOD POSITION AND GIVES CLEAR HELPFUL
INSTRUCTIONS.
8/27/2019JONES H.M-MBA 102

• THE ATTENDING MIDWIFE STANDS ON THE PATIENT’S
RIGHT SIDE.
• THE PERINEUM IS SWABBED WITH ANTISEPTIC SOLUTION.
• THE ADVANCE OF THE FETAL HEAD SHOULD BE CAREFULLY
WATCHED AND CONTROLLED IN A DOWNWARD DIRECTION
WITH THE LEFT HAND.
• MEANWHILE USING THE RIGHT HAND THE PERINEUM AND
ANUS ARE COVERED WITH THE STERILE PAD.
• AT THIS TIME, THE DECISION AS TO WHETHER OR NOT TO
PERFORM AN EPISIOTOMY IS MADE.
8/27/2019JONES H.M-MBA 103

• THE PATIENT SHOULD ONLY PUSH WHEN SHE HAS A
CONTRACTION.
• THE FETAL HEAD IS DELIVERED SLOWLY TO PREVENT
TRAUMA OF THE HEAD AND PERINEAL TEARS.
• THE HEAD IS CROWNED AND THE BROW, FACE AND CHIN
ARE BORN BY A MOVEMENT OF EXTENSION.
8/27/2019JONES H.M-MBA 104

• DURING THIS PHASE THE MOTHER IS ASKED TO ‘PANT’.
• NOW FOLLOWS A SHORT RESTING PHASE DURING WHICH
THE MIDWIFE CHECKS TO SEE IF THE CORD IS AROUND THE
BABY’S NECK.
8/27/2019JONES H.M-MBA 105

• IF IT IS LOOSE, IT CAN BE SLIPPED OVER THE SHOULDERS.
• IF TIGHT, THEN APPLY 2 ARTERY FORCEPS ABOUT 3CMS
APART, HOLD A SWAB OVER THE CORD, CUT AND UNWIND.
• CLEAN THE BABY’S EYES WITH STERILE SWABS, AND CLEAR
BABY’S AIRWAY.
8/27/2019JONES H.M-MBA 106

DELIVERY OF THE SHOULDERS
• ALLOW THE SHOULDER TO ROTATE INTO THE ANTERIOR
POSTERIOR DIAMETER OF THE PELVIC OUTLET.
• IF SPONTANEOUS ROTATION FAILS TO OCCUR THEN ASSIST
THE SHOULDERS TO ROTATE.
• PLACE ONE HAND ON EACH SIDE OF THE BABY’S HEAD AND
APPLY GENTLE DOWNWARD TRACTION.
8/27/2019JONES H.M-MBA 107

• THE ANTERIOR SHOULDER SHOULD SLIP UNDER THE
SYMPHYSIS PUBIS, ONCE THE ANTERIOR SHOULDER IS FREE
CARRY THE BABY UPWARD TOWARD THE MOTHER’S
ABDOMEN.
• DURING THIS MANOEUVRE THE POSTERIOR SHOULDER CAN
ESCAPE OVER THE PERINEUM.
• WITH THE SAME MANOEUVRE THE REST OF THE BABY’S
BODY IS BORN BY LATERAL FLEXION.
8/27/2019JONES H.M-MBA 108

• DRY THE BABY AND PUT IT ON THE MOTHER’S ABDOMEN.
• CLAMP THE CORD BY APPLYING 2 ARTERY FORCEPS ABOUT
3CMS APART, HOLD A SWAB OVER THE CORD, AND CUT
THE UMBILICAL CORD.
• NOTE THE TIME OF THE BABY’S BIRTH. ASSESS THE BABY’S
CONDITION ESPECIALLY HIS RESPIRATIONS. GIVE AN APGAR
SCORE AT ONE MINUTE AND AGAIN AT FIVE MINUTES.
8/27/2019JONES H.M-MBA 109

• SHOW THE BABY TO THE MOTHER FOR IDENTIFICATION
{ESPECIALLY THE SEX}.
• LEAVE THE BABY IN SKIN TO SKIN CONTACT ON THE
MOTHER’S ABDOMEN OR CHEST COVERED BY A CLEAN,
DRY TOWEL/CLOTH OR WRAP THE BABY WARMLY TO
PREVENT HYPOTHERMIA.
8/27/2019JONES H.M-MBA 110

• PALPATE THE MOTHER’S ABDOMEN TO EXCLUDE A
SECOND BABY.
• THE ASSISTANT MIDWIFE GIVES I/M SYNTOMETRINE 1ML OR
10 UNITS OXYTOCIN WITHIN 1 MINUTE OF THE DELIVERY
OF THE BABY.
8/27/2019JONES H.M-MBA 111

• PLACE THE IDENTITY BAND ON THE BABY’S WRIST.
• THE FOLLOWING INFORMATION SHOULD BE PUT IDENTITY
BAND-NAME, FILE NO. DATE AND TIME OF BIRTH, APGAR
SCORE, SEX.
• INITIATE BREASTFEEDING AS SOON AS POSSIBLE {THIS
PROMOTES MOTHER/BABY BONDING ALSO STIMULATES
THE PRODUCTION OF OXYTOCIN FROM THE POSTERIOR
PITUITARY GLAND WHICH IN TURN CAUSES CONTRACTION
OF THE UTERINE MUSCLE.}
8/27/2019JONES H.M-MBA 112

• WRAP THE BABY IN A TOWEL TO REDUCE HEAT LOSS, THEN
GIVE HIM TO HIS MOTHER AND ENCOURAGE HER TO
SUCKLE HIM IMMEDIATELY; OR GIVE HIM TO THE MOTHER
WITHOUT WRAPPING HIM AND COVER THEM BOTH UP
TOGETHER.
8/27/2019JONES H.M-MBA 113

THIRD STAGE OF LABOUR
• PERIOD FROM DELIVERY OF THE BABY UP TO DELIVERY OF
THE PLACENTA
8/27/2019JONES H.M-MBA 114

MANAGEMENT OF THIRD STAGE OF
LABOUR
• THE MOTHER MUST NEVER BE LEFT ALONE DURING THIRD
STAGE OF LABOUR.
• TELL THE WOMAN AND HER SUPPORT PERSON WHAT IS
GOING TO BE DONE.
8/27/2019JONES H.M-MBA 115

ACTIVE MANAGEMENT OF THIRD
STAGE
• AS NOTED ABOVE: GIVE 10 UNITS OF OXYTOCIN E.G
SYTOMETRINE 1ML OR ERGOMETRINE 0.5MG
INTRAMUSCULARY WITHIN 1 MINUTE OF THE BABY’S BIRTH.
• THE MOTHER SHOULD BE IN THE DORSAL POSITION WITH
THE STERILE RECEIVER UNDER THE VULVA.
• EMPTY THE BLADDER IF NOT ALREADY DONE.
• CLAMP THE CORD NEAR THE VULVA WITH AN ARTERY
FORCEPS
8/27/2019JONES H.M-MBA 116

• THE RIGHT HAND GRASPS THE FORCEPS AND CORD
• WAIT FOR THE UTERUS TO CONTRACT.
• PLACE THE OTHER HAND {LEFT HAND} ABOVE THE LEVEL OF
THE SYMPHYSIS PUBIS, WITH THE PALM FACING TOWARD THE
MOTHER’S UMBILICUS AND GENTLY APPLY PRESSURE TO THE
UTERUS IN AN UPWARD AN BACKWARD DIRECTION.
8/27/2019JONES H.M-MBA 117

• AT THE SAME TIME, FIRMLY APPLY TRACTION TO THE
CORD, IN A DOWN WARD DIRECTION, USING THE HAND
THAT IS GRASPING THE FORCEPS.
8/27/2019JONES H.M-MBA 118

• APPLY STEADY TENSION BY PULLING THE CORD FIRMLY
AND MAINTAINING UPWARD PRESSURE ON THE UTERUS.
• JERKY MOVEMENT AND FORCE MUST BE AVOIDED} IF THE
MANOEUVRE IS NOT IMMEDIATELY SUCCESSFUL, STOP
PULLING AND WAIT FOR THE NEXT CONTRACTION AND
REPEAT.
8/27/2019JONES H.M-MBA 119

• WHEN THE PLACENTA APPEARS AT THE VULVA GRASP IT
WITH BOTH HANDS AND ROTATE IT IN ORDER TO ‘ROPE’
THE MEMBRANES-THIS ASSISTS THE COMPLETE DELIVERY
OF THE MEMBRANES.
• IF THE PLACENTA DOES NOT ADVANCE, IT CAN BE
DELIVERED WITH GENTLE UPWARD AND DOWNWARD
MOTION.
8/27/2019JONES H.M-MBA 120

• ONCE THE PLACENTA AND MEMBRANES ARE DELIVERED,
THEN MASSAGE THE UTERUS IN ORDER TO ‘RUB UP’ A
CONTRACTION AND EXPEL ANY BLOOD CLOTS.
• MAKE SURE THE UTERUS IS WELL CONTRACTED.
• REMOVE THE PLACENTA, MEMBRANES AND CLOTS IN THE
RECEIVER.
8/27/2019JONES H.M-MBA 121

• THE UTERINE FUNDUS RISES UP TO THE LEVEL OF THE
UMBILICUS, BECOMES HARD, ROUND AND BALLOTABLE
• THE CORD ELONGATES IN THE RECEIVER AND DOES NOT
RECEDES ON SUPRA-PUBLIC PRESSURE
• A SMALL GUSH OF BLOOD
8/27/2019JONES H.M-MBA 122

DELIVERY OF THE PLACENTA
• ONCE THE PLACENTA HAS SEPARATED IT IS DELIVERED BY
MATERNAL EFFORTS.
• AN ARTERY FORCEPS IS CLAMPED ON THE CORD NEAR THE
VULVA.
8/27/2019JONES H.M-MBA 123

• WHEN THE PLACENTA APPEARS AT THE VULVA GRASP IT
WITH BOTH HANDS AND ROTATE IT IN ORDER TO ‘ROPE’
THE MEMBRANES-THIS ASSIST THE COMPLETE DELIVERY OF
THE MEMBRANES.
• IF THE PLACENTA DOES NOT ADVANCE IT CAN BE
DELIVERED WITH GENTLE UPWARD AND DOWNWARD
MOTION.
8/27/2019JONES H.M-MBA 124

• ONCE THE PLACENTA AND MEMBRANES ARE DELIVERED
THEN MASSAGE THE UTERUS IN ORDER TO ‘RUB UP’ A
CONTRACTION AND EXPEL ANY BLOOD CLOTS.
MAKE SURE THE UTERUS IS WELL CONTRACTED.
• REMOVE THE PLACENTA, MEMBRANES AND CLOTS IN THE
RECEIVER.
8/27/2019JONES H.M-MBA 125

IMMEDIATE CARE AFTER DELIVERY
OF PLACENTA
• THIS CARE IS GIVEN IN THE FIRST HOUR AFTER DELIVERY
AND IS MAINLY REFERRED AS THE FOUR STAGE.
• CLEAN AND DRY THE BUTTOCKS, REMOVE THE WET LINEN
AND SECURE THE PERINEAL PAD.
• CHANGE THE LINEN, LEAVE THE PATIENT CLEAN, WARM
AND COMFORTABLE.
• GIVE A WARM DRINK, AND IF NECESSARY SOME ANALGESIC
FOR RELIEF OF ‘AFTER PAINS’
8/27/2019JONES H.M-MBA 126

• TAKE THE FOLLOWING VITALS IMMEDIATELY AND THESE
SHOULD RETURN TO PRELABOUR VALUES WITHIN ONE
HOUR.
• VITAL SIGNS ARE USUALLY ASSESSED EVERY 15 MINUTES
DURING THE IMMEDIATE POST PARTUM PERIOD.
8/27/2019JONES H.M-MBA 127

• MASSAGE THE UTERINE FUNDUS TO PREVENT
HAEMORRHAGE.
• MAINTAIN FLUID BALANCE AND NUTRITION BY GIVING
PATIENT WARM DURING OR LIGHT DIET IF WOMAN IS IN
STABLE CONDITION.
8/27/2019JONES H.M-MBA 128

• ENCOURAGE WOMAN TO VOID TO PROMOTE
CONTRACTION OF THE UTERUS AND PREVENT
HAEMORRHAGE.
• THE WOMAN CAN BE GIVEN ANALGESICS FOR AFTER PAIN
SUCH AS PANADOL.
8/27/2019JONES H.M-MBA 129

• OBSERVE THE TYPE OF LOCHIA TO DETECT ANY ACTIVE
BLEEDING.
• CHANGE ANY SOILED LINEN/CLOTHS
• KEEP THE WOMAN CLEAN ESPECIALLY PERINEAL HYGIENE.
8/27/2019JONES H.M-MBA 130

• GIVE PSYCHOLOGICAL CARE TO THE WOMAN TO ALLAY
ANXIETY.
• ALLOW THE WOMAN TO VERBALIZE ABOUT HER DELIVERY
AND BABY.
• ALLOW THE WOMAN TO BE WITH THE BABY IF BOTH THE
BABY AND THE MOTHER ARE IN GOOD CONDITION.
• KEEP PATIENT WARM AND KEEP ROOM QUITE TO PROMOTE
REST AS WOMAN MAY BE TIRED DURING LABOUR PROCESS
SHE UNDERWENT. 8/27/2019JONES H.M-MBA 131

THE END!
8/27/2019JONES H.M-MBA 132

Normal labour and delivery

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