Republic of the Philippines

Bulacan State University

City of Malolos

NCM 107B RLE

Care of the Mother, Child and Adolescent

UNIT 4 MATERNAL CONCEPTS

Prepared by:

MART JUARESA C. YAMBAO, MAN, RN

EDWIN MENDOZA, MAN, RN

JOSEPH RAINIER ARRIOLA, RN

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 Table of Contents

Lesson 1: Introduction to Maternal Concepts .................................................................. 104

Lesson 2: Fundic Height ..................................................................................................... 112
Lesson 3: Leopold’s Maneuver .......................................................................................... 115
Lesson 4: The Labor Process ............................................................................................ 121
Lesson 5: Perineal Care and Straight Catheterization.................................................... 123
Lesson 6 The Performance Checklist .............................................................................. 128

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Introduction

This section of the module discusses the concepts and skills needed in caring
for the pregnant woman. It will allow you to review important competencies and
concepts learned in the lecture component of this course. Reviewing these learned
concepts helps you bridge the gap between theory and how it is applied in the
nursing practice. Unit 4 consists of six lessons on maternal concepts.

In this module, you will be working as a group. Given a chosen pregnant

client, you are expected to obtain a comprehensive nursing health history, perform
physical assessment, develop nursing care plans, devise a health teaching plan and
pamphlet, and implement the health teaching to your client. Forms and checklists will
be provided to help you with this task.

This particular module is divided into 6 lessons:

 Lesson 1 Introduction to Maternal Concepts

 Lesson 2 Fundic Height
 Lesson 3 Leopold’s Maneuver
 Lesson 4 Perineal Care
 Lesson 5 Straight Catheterization
 Lesson 6 The Performance Checklist

Objectives/Competencies

Upon completion of this module, you are expected to:

1. competently perform the skills demonstration on a selected client

2. compare normal from above normal parameters after a thorough
assessment of a pregnant client.
3. select a pregnant client within the members of the family and be able to
develop a mini case study.

Pre-test

Encircle the letter of the correct answer.

1. A woman asks the nurse, "My period is a week late. Is it too early for
pregnancy test?” Which of the following responses would be the most
appropriate?
a. A pregnancy test would be accurate at this time
b. For accuracy, you should be at least 2 weeks late
c. Have you been sexually active?
d. Would you be upset if you were pregnant?

2. What is a positive sign of pregnancy?

a. Fatigue
b. Fetal heart rate
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 c. Amennorrhea
d. Enlargement of abdomen

3. Mrs. Antonio has had three deliveries at term, one preterm delivery, and two
abortions. She has four living children.
a. G6 P4 3124
b. G6 P4 3214
c. G6 P3 2224
d. G6 P3 1324

4. The ____ has to dilate ____ before a woman can deliver the baby.
a. Placenta, 20 cm
b. Cervix, 10 cm
c. Umbilical cord, 5 cm
d. Vagina, 8 cm

5. Which of these hormones is responsible for the stretching of the cervix?

a. Prolactin
b. Relaxin
c. Oxytocin
d. Estrogen

6. A post-mature baby is one who is not born by his or her due date.
a. True
b. False

7. The most important factor in achieving a vaginal birth is the size of the baby.
a. True
b. False

8. Frequent urination in late pregnancy is normal because the uterus pushes

down on the bladder.
a. True
b. False

9. Heart rate, stroke volume and cardiac output all increase during pregnancy.
a. True
b. False

10. A woman can be in labor even if the bag of water hasn't broken.
a. True
b. False

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Lesson 1: Introduction to Maternal Concepts
Duration: 3 hours

Pregnancy is a blessing and a gift from God. The experience is so complex

and hard but is very rewarding in nature. Every pair of parent has different stories to
tell regarding each pregnancy that they experience. To introduce this concept, watch
the movie “What to Expect When You Are Expecting” (2012). Be able to answer the
following guide questions on your own.

Self Check 19
Answer briefly the following guide questions.

1. Identify the three A.

main characters in
the movie and
describe their
experience on
pregnancy. B.

C.

D.

E.

2. Identify different A.
physiologic
changes in
pregnancy and
which character
experienced such B.
change.

C.

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 D.

E.

3. Identify different A.
psychological
changes in
pregnancy and
which character
was able to B.
experience it.

C.

D.

E.

Upon watching the movie, you were able to see that every pregnancy is
unique and special. This is the wonder of learning the process of conception.

Common Terminologies
Presented below are common obstetrical and gynecological terms that you
need to be even more familiar with a discussed in your maternal lecture.

1. Antepartum is the time between conception & onset of labor, usually used to
describe the period during which a woman is pregnant. It i used
interchangeably with prenatal

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 2. Intrapartum is the time from onset of labor until the birth of the infant and
placenta
3. Postpartum is the time from birth until the woman’s body returns to an
essentially pre-pregnant condition
4. Gestation refers to the number of weeks since the first day of the last
menstrual period (LMP)
5. Abortion is a birth that occurs before 20 weeks gestation or the birth of a
fetus-neonate who weighs less than 500g
6. Term is the normal duration of pregnancy (38 to 42 weeks gestation)
7. Preterm or premature labor is labor that occurs after 20 weeks but before
the completion of 37 weeks of gestation
8. Postterm Labor is labor that occurs after 42 weeks of gestation
9. Gravida refers to any pregnancy, regardless of duration, including present
pregnancy
10. Nulligravida refers to a woman who has never been pregnant
11. Primigravida is a woman who is pregnant for the first time
12. Multigravida is a woman who is on her second or any subsequent pregnancy
13. Para refers to birth after 20 weeks gestation, regardless of whether the infant
is born alive or dead
14. Nullipara is a woman who has not given birth at more than 20 weeks
gestation
15. Primipara is a woman who has had one birth at more than 20 weeks’
gestation, regardless of whether the infant is born alive or dead
16. Multipara is a woman who has had two or more births at more than 20 weeks
gestation
17. Stillbirth is a fetus born dead after 20 weeks of gestation

PRENATAL CARE

Also known as Antenatal care refers to the health care given to a woman and
her family before and during the course of pregnancy. Its primary goal is to provide
maximum health to expectant mothers and their babies.

Recommended Frequency of Prenatal Visit

 Every 4 weeks for the first 28 weeks of gestation
 Every 2 weeks until 36 weeks gestation
 After 36 weeks, every week until child birth

Components of Prenatal Care

a. History Taking

 OB Scoring. Initial client history includes the obstetrical history. This is

essential during the first visit as this will be used for coming up with the
obstetrical scoring (OB Score) and coding of the results of previous
pregnancies. This method of coding the results of the previous
pregnancies involves the use of 6 consecutive digits to represent 6 items:

G P (T P A L)

o G (Gravida) – refers to the total number of past and present

pregnancies regardless of its outcome
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o P (Para) – refers to the total number of deliveries that reached the age
of viability (20 weeks gestation)
o T (Term) – number of term infants born at the completion of 37 weeks’
gestation or beyond, whether living or still born
o P (Preterm) – number of preterm infants born after 20 weeks but
before the completion of 37 weeks gestation, whether living or stillborn
o A (Abortion) – number of pregnancies ending in either spontaneous or
therapeutic abortion before reaching 20 weeks of gestation
o L (Living) – number of currently living children to whom the woman
has given birth

Nurse Marty Memory Tip 10: OB Scoring

G P (T P A L)

o G for Gravida
o P for Para
o T for Term
o P for Preterm
o A for Abortion
o L for Living

Example:

A pregnant client comes to the wellness clinic today and tells the
receptionist that her last menstrual period was February 22, 2020. She also
mentioned that she has three children at home 1 boy and 2 girls with ages 15, 11,
and 5 respectively. Her baby book shows records of her deliveries at 38 3/7
weeks, 36 1/7 weeks and 39 2/7 weeks respectively. And in addition to that, she
also mentioned that she had a miscarriage before the present pregnancy at 12
4/7 weeks gestation. What is her OB Score?

o G (Gravida) o T (Term)
pregnant at present 1 Boy at 38 3/7 weeks 1
boy at 15 years old 1 Girl at 39 2/7 weeks 1
girl at 11 years old 1 2
girl at 5 years old 1 o P (Preterm)
miscarriage 1 Girl at 36 1/7 weeks 1
5 o A (Abortion)
o P (Para) At 12 4/7 weeks 1
boy at 38 3/7 weeks 1 o L (Living)
girl at 36 1/7 weeks 1 boy at 15 years old 1
girl at 39 2/7 weeks 1 girl at 11 years old 1
3 girl at 5 years old 1
3

Considering the following data, the OB Score of the client is:

G5 P3 (2113)

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 Nurse Marty Memory Tip 11: OB Scoring Reminders

 The number of pregnancies is counted and not the

number of fetuses.
 To check for correctness of Para, it should be the sum
of T (Term) and P (Preterm)
 Even if the baby is born dead after the age of viability, it
will still be counted to Gravida, Para, and Term or
Preterm depending on the age of gestation.

Self-Check 20

Identify the OB Score of Mrs. Go

Case Scenario What is the OB of Mrs. Go?

th
Mrs. Go is pregnant for the 5 time. She
has a 7 year old child born at 39 weeks, a
toddler born at 36 weeks. She lost one
pregnancy at 10 weeks gestation and gave
birth to another infant stillborn at term. What is
the obstetrical history of Mrs. Nieto?

o Age of Gestation (AOG). Another necessary data from the client is her Age
of Gestation (AOG). This refers to the age of the fetus or the uterus. To put
it simply, it is the length of time the client has been pregnant from the time
of her Last Menstrual Period (LMP).Use the following steps to determine
the AOG:

o Step 1. Determine the client’s Last Menstrual Period (LMP). Consider

the day in the LMP as the first entry for that particular month.

For Example:
February 22, 2020 (LMP)

Subtract the day of the LMP to the total number days of that
particular month. So we have:
Total days of February 29
- The date of the LMP 22
07

o Step 2. Get all the days in the months following the month of the LMP
until the month of the client’s consultation in the clinic. Then add all the
days.

For Example:
Date of Consultation is September 18, 2020.

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 You will identify all the days in the months starting from
February to September like this:

February 7 (from Step 1)

March 31
April 30
May 31
June 30
July 31
August 31
September 18 (the Date of Consultation)
209 days

o Step 3. Divide the total number of day by 7. Seven because there are 7
days in a week. Use manual method of division because this will guide
you as to only dividing by the whole number and let the remainder as it
is. Use 209 as dividend and 7 as the divisor.

For Example:
_29
7 / 209
-14
69
-63
6 (as remainder)

o Step 4. Translate the quotient and remainder as the AOG.

For Example:
The quotient (29) is the number of whole weeks and the
remainder (6) is the numerator for the fraction of the days not
completing an entire week (7 days).

Age of Gestation: 29 weeks and 6/7 days

Self-Check 21
Use the space on the right side to compute for the AOG.

Case Scenario What is the AOG of Mrs. Go?

Mrs. Go went
to the clinic last
October 8, 2020.
Upon interview
she said that her
last menstrual
period was March
29, 2020.

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 Apart from the Ob Scoring, her Last Menstrual Period (LMP), Age of
Gestation (AOG) and Expected Date of Confinement (EDC) were also
recorded. These will be discussed in Lesson 2. The pre-pregnancy health of
the woman, presence of concurrent disease and even emotional status of the
pregnant woman is noted here. Gynecologic history is also determined at this
point. Pap smear test, age at menarche, menstruation details and use of
contraceptives are determined.

The form for OB Nursing Health History can be found on our Google
Classroom.

b. Physical Examination

A thorough head to assessment is necessary to establish baseline data

of your client. It will be helpful if we review the different physiologic changes of
pregnancy which we expect a pregnant mother to experience at a particular
time in her pregnancy.
Remembering the signs and symptoms experienced by a mother, they
are classified into three:
o Presumptive Signs of Pregnancy ~ those that are least indicative of
pregnancy includes:
 Breast changes  Uterine enlargement
 Nausea, vomiting  Quickening
 Amenorrhea  Linea Nigra
 Frequent Urination  Melasma
 Fatigue  Striae gravidarum
o Probable Signs of Pregnancy ~ Can be documented by the examiner,
though they are more reliable than presumptive signs, they are not positive
or true diagnostic findings
 Chadwick’s sign  Braxton Hick’s Contraction
 Goodell’s sign  Ballotment
 Hegar’s sign  Uterine soufflé
 Abdominal enlargement  Fetal outline
 Pregnancy Test ~ detecting for the presence of human chorionic
gonadotrophin (hCG), a hormone created by the chorionic villi of the
placenta
o Positive Signs of Pregnancy
 Demonstration of fetal heart tone (FHT) separate from the mother
 Fetal movements felt by the examiner
 Visualization of fetus by ultrasound

The form for Pregnant Physical Assessment Checklist can be found on

our Google Classroom.

c. Nursing Care Plan

Every pregnant woman has unique experiences of the pregnancy and

requires an individualized plan of care depending on their chief complaints.
The template for Individualized Nursing Care Plan can be found on our
Google Classroom.

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d. Health Teaching

A specialize plan for teaching the pregnant woman has to be prepared

alongside the problems identified in the nursing care plan. This may include
but not limited to the following:
 Normal signs and symptoms of pregnancy
 Minor discomforts, prevention and management
 Danger signs and symptoms
 Nutrition and diet
 Rest, exercise and relaxation measures
 Avoidance of drugs, alcohol, cigarette and too much caffeine
 Clothing
 Sexual relations
 Employment
 Travel
 Preparation for labor, delivery and puerperium

The template for Health Teaching Plan can be found on our Google
Classroom. Samples of the accompanying pamphlets for health teaching are
also posted there.

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Lesson 2: Fundic Height
Duration: 1 hour

All pregnant women would naturally want to know when is the baby coming or
the “due date.” This competency is highly needed among student nurses most
especially in dealing with maternity clients. There are several ways on how we can
estimate this date.

Naegele’s Rule

The Naegele’s rule is the most common method of determining the Expected
Date of Delivery (EDD). Naegele’s Rule may be a fairly accurate determiner of EDD
if a woman has a history of menses every 28 days. Use the following steps to
determine EDD:

 Step 1. Determine the client’s Last Menstrual Period (LMP). This is the first
day of the client’s last menstruation.

For Example:
February 22, 2020

 Step 2. Write the LMP in numerical form

For Example:
02 22 2020

 Step 3. Determine which rule on Naegele’s Formula you will need to use
following the Month of the LMP as basis for choosing.

Rule 1: If the LMP falls on January to March, add 9 to the month and 7 to the
days.

For Example:

02 22 2020
+ 09 07
11 29 2020

Rule 2: if LMP falls on April to December, subtract 3 to the month and add 7
to the days and 1 to the year.

For Example:

05 22 2020
- 03 + 07 +1
02 29 2021

Since February 2021 only has 28 days, we subtract 28 with 29 and will
get 1. This means that the EDD of the client will be on March 1, 2021.

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 Nurse Marty Memory Tip 13: EDD

 January to March use +9 +7

 April to December use -3 +7 +1

Self-Check 22
Compute for the EDD of the following LMP.

Last Menstrual Period What is the EDD?

1. April 14, 2020

2. January 30, 2020

3. May 26, 2020

McDonald’s Method

The McDonald’s Method is used to determine the Fundic Height. This is the
measurement of the height of the abdomen of a pregnant woman to estimate her
AOG, fetal growth and eventually the EDD. The age of gestation according to fundic
height is presented in figure 20. It may be used as an indicator of uterine size,
although cannot be used in late pregnancy.

Figure 20. Fundal Height Chart

*Image from Cherian (2017)

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Assessing the Fundic Height
This procedure involves the use of a centimeter tape measure. The tape
measure is used to measure the distance from the top of the symphisis pubis over
the curve of the abdomen to the top of the uterine fundus (McDonald’s Method).

Purpose of Assessing the Fundic Height

1. To estimate the Age of Gestation, fetal growth and EDD

Equipment for Assessing the Fundic Height

a. Centimeter tape measure
b. Note pad and pen

Procedure for Assessing the Fundic Height

Step Rationale
1. Close the room door or curtains.  In order to provide privacy as
the client will expose her entire
abdominal area.
2. Ask the patient to empty her bladder  A full bladder displaces the
uterus causing inaccurate
measurement.
3. Position the patient in dorsal  For maternal comfort and better
recumbent. results.
4. Drape the client.  Cover the client with a blanket
from waist to the lower
extremities to provide further
privacy.
5. Warm hands by rubbing one against  Cold hands may stimulate
the other before placing on the uterine contractions, making it
abdomen. hard to perform assessment.
6. Measure the distance abdominally from  To determine the height of the
the top of the symphysis pubis over the pregnant abdomen and estimate
curve of the abdomen to the top of the the age of gestation (AOG).
uterine fundus. See figure 21.

Figure 21. Fundal Height Measurement

*Image from Cherian (2017)

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Lesson 3: Leopold’s Maneuver
Duration: 1 hour

There are five components of labor (5 P’s) that was discussed in the lecture
component of this course. These include:
 The Passenger or the fetus
 The Passageway or the mother’s pelvis and its structure
 The Power or the uterine contractions and bearing-down efforts
 The Placental Position and Function
 The Psychological Response of the mother during labor and delivery

The next skill for demonstration is called Leopold’s Maneuver. This an

assessment technique used to determine the presentation, position, engagement
and station of the first component of labor, the Passenger (fetus).

Let us first review the above mentioned integral assessment characteristic of the
Passenger (fetus).

e. Fetal Skull. From an Ob point of view, the fetal skull is the most important
part of the fetus because:
 it is the largest part of the body
 it is the most frequent presenting part
 it is the least compressible of all part

The fetal skull consists of cranial bones called frontal, occipital and
parietal bones. Membrane spaces between suture lines of these bones are
important because they allow the bones to move and overlap changing the
shape of the fetal head in order to fit through the birth canal in a process
called Molding.

At the junction of the main suture lines are structures called

Fontanelle. In a newborn, there are 2 types of fontanelles.
 Anterior fontanelle that is larger, diamond shaped, and closes
between 12-18 months in infants.
 Posterior fontanelle is the smaller, triangular shaped, closes between
2-3 months in infants.

f. Fetal Presentation denotes the part that will first contact the cervix or deliver
first. This is determined by:

 Fetal Lie is the relationship between the long (cephalocaudal) axis of

the fetal body & the long (cephalocaudal) axis of the woman’s body. In
short, whether the fetus is lying in a horizontal (transverse) or vertical
(longitudinal) position

 Fetal Attitude is the term used to describe the degree of flexion the
fetus assumes or in relation of the fetal parts to each other:
o Full flexion (vertex)
o Moderate flexion (sinciput)
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 o Full extension (face)
o Poor flexion (brow)

Fetal presentation has three types.

 Cephalic Presentation denotes that the head is the body part that first
contacts the cervix. This is the most frequent (95%) type. During labor,
the area of the fetal skull that contacts the cervix often becomes
edematous from the continued pressure against it. (Caput
succedaneum).

o Types of Cephalic Presentation:

 Vertex (A)
 Sinciput (B)
 Brow (C)
 Face (D)

Figure 23.. Types of Cephalic Presentation

*Image from Cunnigham (2010)

 Breech Presentation means that either the buttocks or feet are the first
body parts to contact the cervix. This type of presentation occurs
approximately 3% of births and are affected by fetal attitude

o Types of Breech Presentation

 Frank (Extended)
 Complete (Flexed)
 Footling

Figure 24. Types of Breech Presentation

*Image from Nowlan (2015)

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  Shoulder Presentation. In a transverse lie, the fetus is lying horizontally
in the pelvis so that the long axis is perpendicular to that of the mother.
The presenting part usually becomes one of the shoulders, an iliac
crest, a hand or an elbow. This type occurs fewer than 1 %

Figure 25. Shoulder Presentation

*Image from Cunnigham (2010)

g. Fetal Position is the relationship of the presenting part to a specific quadrant

of the woman’s pelvis. There are four (4) quadrants according to the mother’s
right & left side of the pelvic outlet: (1) right anterior, (2) right posterior, (3) left
anterior, and (4) left posterior. Fetal position is abbreviated in 3 letters:
 First letter defines whether the landmark is pointing to the mother’s right
(R) or left (L).
 Middle letter denotes fetal landmark; O for occiput, M for mentum or chin,
Sa for sacrum and A for acromion process.
 Last letter defines whether the land mark points anteriorly (A),
posteriorly (P), or transversely (T)

The following are the possible fetal positions grouped according to the
presenting part.

 Vertex Presentation (Occiput)  Face Presentation (Mentum)

o LOA, left occipitoanterior o LMA, left mentoanterior
o LOP, left occipitoposterior o LMP, left mentoposterior
o LOT, left occipitotransverse o LMT, left mentotransverse
o ROA, right occipitoanterior o RMA, right mentoanterior
o ROP, right occipitoposterior o RMP, right mentoposterior
o ROT, right occipito- o RMT, right mentotransverse
transverse
 Shoulder Presentation
 Breech Presentation (Sacrum) o LAA, left scapuloanterior
o LSaA, left sacroanterior o LAP, left scapuloposterior
o LSaP, Left sacroposterior o RAA, right scapuloanterior
o LSaT, left sacrotransverse o RAP, right scapuloposterior
o RSaA, right sacroanterior
o RSaP, right sacroposterior
o RSaT, right sacrotransverse

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 h. Fetal Station. The station refers to the relationship of the presenting part of
the fetus to the level of the ischial spine.

i. Fetal Engagement. This term means that the presenting part of the fetus is
said to be engaged when it has settled far enough into the pelvis to be at the
level of the ischial spine. This is also refers to the zero (0) station. If the
presenting part is not yet engaged is termed as floating.

Figure 26. Fetal Station and Engagement

*Image from Cunnigham (2010)

Performing Leopold’s Manuever

This is a systematic abdominal palpation done at around twenty-four (24)
weeks age of gestation onwards to determine the presentation, position,
engagement and station of the first component of labor, the Passenger (fetus).

Purpose of Assessing the Fundic Height

a. To determine fetal presentation, position, engagement and station.
b. To locate and assess the fetal heart tone.
c. To monitor fetal growth and movement during pregnancy

Equipment for Assessing the Fundic Height

1. Stethoscope
2. Note pad and pen
3. Drape

Procedure for Assessing the Fundic Height

Step Rationale
1. Close the room door or curtains.  In order to provide privacy as
the client will expose her entire
abdominal area.
2. Ask the patient to empty her bladder  A full bladder displaces the
uterus causing inaccurate
measurement.
118
3. Position the patient in dorsal  To relax the abdominal muscles.
recumbent.
4. Drape the client.  Cover the client with a blanket
from waist to the lower
extremities to provide further
privacy.
5. Warm hands by rubbing one against  Cold hands may stimulate
the other before placing on the uterine contractions, making it
abdomen. hard to perform assessment.
6. Observe the woman’s abdomen as to  The longest diameter (axis) is
which is the longest diameter and the length of the fetus. The
where fetal movement is apparent locations of activity will most
likely reflects the position of the
feet.
7. 1st Maneuver. (Fundal Palpation)  This maneuver determines
o Facing the client’s head part, FETAL PRESENTATION.
palpate the fundus with both hands  Head – hard, firm and round and
and observe for shape, moves independently with the
consistency and mobility. body (breech position)
 Buttocks – soft, globular, and
moves only in conjunction with
the body (cephalic
presentation)
8. 2nd Maneuver. (Lateral Palpation)  This maneuver locates the back
o Still facing client’s head part, place of the fetus.
the left hand stationary on the right  Back - smooth, hard, and
side of the uterus to immobilize it. resistant surface. Take note of
Palpate the left side of the uterus this location as this is the best
from top to bottom with the right site for the Fetal Heart Tone
hand. (FHT)
o Apply gentle but deep pressure to  Extremities - angular bumps or
be able to determine what lies on nodules
either side of the uterus.
o Repeat the procedure on either
side of the uterus.
rd
9. 3 Maneuver (Pawlik’s Grip)  This maneuver determines
o Still facing client’s head part, grasp engagement of the presenting
the lower abdomen above the part.
symphysis pubis with the hand  Engaged – if the presenting part
nearer the mother’s legs using is no longer movable.
thumbs and fingers.  Floating – if the presenting part
moves upward so your fingers
and thumb can be pressed
together.
10. 4th Maneuver (Pelvic Palpation)  This maneuver determines fetal
o Facing the client’s foot part, place attitude and degree of fetal
tips of the first 3 fingers on both extension if the presentation is
sides of the lower uterus about 2 cephalic.
inches above the inguinal region.  Flexed – if the brow is on the
o Press downward and inward in the same side as the extremities
direction of the birth canal. Note  Extended – if the brow is on the
that the fingers on one hand meet same side as the back.
no obstruction and glide over the
nape of the baby’s neck. The
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 other hand meets an obstruction,
this is a brow of the baby
11. Auscultate the Fetal Heart Tone  Counting for a full minute is
o Remember the fetal back from the necessary to observe the rate
2nd Maneuver. and rhythm of the pulse.
o Place the bell of the stethoscope at  The bell is used to hear low
the area of the fetal back. frequency sounds like the heart
o Count for 1 full minute while sounds.
comparing with the mother’s pulse.  Observe proper technique of
placing fingers in the
stethoscope learned in Vital
Signs.

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Lesson 4: The Labor Process
Duration: 1 hour

Your exposure in the delivery room requires review of the most important
concept in labor and delivery. This is the labor process. Labor refers to the series
of events involving uterine contractions and abdominal pressure leading to the
expulsion of the fetus and placenta from the uterus.

There are preliminary signs of labor that can give signal to the mother that the
long awaited delivery of her baby is about to happen.

1. Lightening refers to the descent of the fetal presenting part into the pelvis,
occurs approximately 10 to 14 days before labor begins. This process causes
changes in the woman’s abdominal contour as the uterus becomes lower &
more anterior. It gives woman relief from the diaphragmatic pressure &
shortness of breath she has been experiencing and thus “lightens” her load.
However the abdominal pressure increases, and this may result in reports of:
 Shooting leg pains from the pressure on the sciatic nerve,
 Increased amounts of vaginal discharge, and
 Urinary frequency from pressure on the bladder

2. An increase in the woman’s level of activity. A woman wakes up on the

morning of labor full of energy due to increase in epinephrine release it is
initiated by a decrease in progesterone produced by the placenta. Additional
epinephrine prepares the woman’s body for work of labor ahead

2. Braxton Hicks Contractions. In the last week or days before labor begins,
the woman usually notices extremely strong Braxton Hicks Contraction, which
may be interpreted as true labor.

3. Ripening of the cervix is an internal sign seen only on pelvic examination.

Throughout pregnancy, feels softer than normal like the earlobe. At term, the
cervix becomes still softer & described as “butter-soft”

As nurses, it is imperative that you know how to identify the different signs of
true labor.
1. Uterine Contractions. Once uterine contractions are evident, this is the
surest sign that labor has begun. This refers to the initiation of effective,
productive, involuntary uterine contractions. The experience may be
frightening in early labor because contractions are involuntary and can come
without any warning. Instructions on proper breathing exercises can offer the
woman a sense of control\
2. Cervical Effacement and Dilatation. The myometrial activity at the onset of
labor leads to full cervical effacement and dilatation. Cervical effacement
refers to the progressive shortening of the vaginal portion of the cervix and
thinning of its walls as it is stretched by the fetus during labor. Dilatation
pertains to the progressive enlargement of the cervical OS from less than 1
cm to about 10 cm (full dilatation) to allow passage of the fetus from the
uterus to the vagina.
3. Rupture of Membrane. Labor may begin with rupture of membranes. This is
membranes often refers to the bag of water. Its rupture is experienced either
as a sudden gush or scanty, slow seeping of clear fluid from the vagina. It you

121
 can remember, the amniotic fluid continues to be produced until delivery of
the membranes after the birth of the fetus; thus no labor is ever “dry.”

Early rupture can help the fetal head to settle snugly into the pelvis.
This process can actually shorten labor. However, there are possible risks
associated with ruptured membrane
 Intrauterine infection
 Prolapse of the umbilical cord, which can cut off the oxygen supply to
the fetus

If labor has not spontaneously occurred within twenty-four (24) hours

after rupture of membrane and the pregnancy is at term, labor will be induced
to help reduce the risks.

The following cues can guide you in identifying whether the labor experience
by the woman is considered a True or False Labor:

1. False Labor
 Begin and remain irregular
 Felt first abdominally and remain confined to the abdomen and groin
 Often disappears with ambulation and sleep
 Do not increase in duration, frequency or intensity
 Do not achieve cervical dilatation

2. True Labor
 Begin irregularly but become regular and predictable
 Felt first in lower back and sweeps around to the abdomen in a wave
 Continue no matter what the woman’s level of activity
 Increase in duration, frequency an intensity
 Achieve cervical dilatation

Normal labor usually lasts for about 14 hours in primipara and around 8
hours among multipara. The table below shows the usual length of time spent in
each stages of labor when compared among primi and multiparas.

Table 7. Hours in Labor

Stage Primipara Multipara

1st Stage of Labor 12 hours 30 minutes 7 hours 20 minutes
2nd Stage of Labor 1 hour 20 minutes 30 minutes
3rd Stage of Labor 10 minutes 10 minutes
TOTAL 14 hours 8 hours

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Lesson 5: Perineal Care and Straight Catheterization
Duration 1 hour

Perineal care is routinely performed in the labor room as well as in the normal
spontaneous delivery (NSD) ward. Straight catheterization is part of the nursing
responsibilities before NSD takes place as this facilitates delivery of the newborn.

Performing Perineal Care

Performing perineal care is a procedure that involves bathing the genitalia and
surrounding area. This facilitates proper assessment and care of the perineal area.
While performing this procedure, pay particular attention to condition of the perineum
and its surrounding. Take note of assessment findings on your nurse’s notes.

Purpose of Perineal Care

1. To maintain cleanliness and prevent from infection in perineal area
2. To promote client comfort

Equipment for Performing Perineal Care

1. Clean gloves
2. Washcloth
3. Pitcher with lukewarm water
4. Waterproof pad
5. Bedpan
6. Cotton balls with soap suds in a small basin
7. Bath towel

Procedure for Performing Perineal Care

Step Rationale
1. Perform hand hygiene  To minimize the spread of
infection.
2. Position the patient to dorsal  This position facilitates proper
recumbent. exposure of the perineal area.
3. Close the curtains and drape the  To provide client privacy.
client’s abdomen and thighs.

4. Put on clean gloves  A clean procedure requires the

use of clean gloves to avoid
direct contact with body fluids.
5. Place a bath towel over a waterproof  To protect the bed sheet from
pad under your client’s hips. water splashes.
6. Slide in a bedpan directly under her  This will collect all the water for
hips. the entire procedure.
7. Pour water over the perineum and the  Cleaning the inner thighs
inner thighs. Clean the left and right promotes client comfort.
inner thighs and mons pubis by using
cotton balls with soap suds in a single
zigzag stroke from proximal to distal
perineum. (See strokes 1, 2 and 3 on
figure 27.) Rinse and then dry using
washcloth.
8. Clean the labia majora using figure of 7  Clean from the vagina outwards

123
 on the left labia and a reverse figure of so that microogranisms move
seven on the right labia using a single away from the vagina not
stroke with each cotton. (See strokes 4 towards it.
and 5 on figure 27_).
9. Clean the labia minora by spreading  Secretions that tend to collect
them with your non-dominant hand. around this area facilitate growth
Use the same manner for cleansing as of microorganisms.
the labia majora. (See strokes 6 and 7
on figure 27.)
10. Apply a last single downward stroke  A single downward stroke is
from the urinary orifice to the anus. applied to prevent contamination
(See stroke 8 on figure 27). of the vaginal inlet.
11. Rinse the area thoroughly by pouring  Moisture supports growth of
lukewarm water and pat dry the many microorganisms
perineum using the other side of the
washcloth.
12. Assess the surrounding skin and  This will be your baseline data in
perineum for: developing your plan of care
o Intactness of the perineal orifice
o Skin redness, excoriation,
breakdown, discharge or drainage
o Areas of tenderness

Figure 27. Recommended Strokes for Perineal Care

6 7
5 4
3
2 8

*Image from Cunnigham (2010)

In this course, we will not be performing routine perineal care. Instead, we will
modify the use of soap suds and replace it with cotton balls soaked in betadine
solution as the medium for sterilizing the perineal area in preparation for straight
catheterization. On page 117 presents the performance checklist on perineal care
and straight catheterization. The initial demonstration on the Google Classroom is
patterned on this checklist.

124
Performing Straight Catheterization

Catheterization is the insertion of a straight urethral catheter into the bladder

through the urinary orifice in order to drain the urine and eventually empty the
bladder. This procedure is routinely done in the delivery room as part of the
preparation for the delivery of the infant. The specimen obtained here is sent to the
laboratory for urine analysis and will guide the physician in the course of the
treatment after labor and delivery. The checklist was created with the delivery room
set-up in mind.

Purpose of Straight Catheterization

1. To relieve urinary retention
2. To promote urinary drainage prior to a diagnostic procedure, surgery or
delivery.
3. To collect urine specimen

Equipment for Straight Catheterization

1. Sterile gloves
2. Waterproof pad (kellypad)
3. Pitcher with lukewarm water
4. Cotton balls with betadine solution
5. Water soluble lubricant
6. Straight catheter of appropriate size
7. Urine specimen container
8. Pail
9. Waste receptacle

Procedure for Performing Straight Catheterization

Step Rationale
1. Perform hand hygiene  To minimize the spread of
infection.
2. Place the patient to lithotomy position.  This position facilitates proper
Place kellypad under the client’s exposure of the perineal area
buttocks. and eventually leading to the
delivery of the newborn. Placing
Kellypad will facilitate drainage
of all body secretion towards the
pail on the floor.
3. Drape the client’s abdomen and thighs.  To provide client privacy.

4. Ensure adequate lighting in the  To facilitate proper viewing of

perineal area. the urinary orifice

5. Wash hands  Washing hands will prepare you

for the gloving technique.
6. Place the sterile tray within reach  Preparing necessary materials
containing the following: following this technique will help
o Open sterile gloves and make a save time and effort and will
sterile field. Ensure following the minimize chances of needing
sterile technique while doing so. extra help while doing the

125
 o Away from your gloves, place 8 procedure.
pieces of cotton balls with
betadine solution.
o Put an ample amount of water
soluble lubricant on any vacant
spot in your sterile field.
o Open straight catheter and place
on the sterile field using sterile
technique.
7. Test temperature of water and pour  Testing temperature avoids
ample amount over the perineum and discomfort.
the inner thighs.
8. Put on sterile gloves  Sterile procedure requires the
use of sterile materials
9. Clean the perineal area using your  This procedure is part of the skin
dominant hand by: preparation prior to delivery of
o Clean the inner thighs and mons the newborn.
pubis by using cotton balls with
betadine solution in a single zigzag
stroke from proximal to distal
perineum. (See strokes 1, 2 and 3
on figure 27.) Let it dry.
o Clean the labia majora using figure
of 7 on the left labia and a reverse
figure of seven on the right labia
using a single stroke with each
cotton. (See strokes 4 and 5 on
figure 27).
o Clean the labia minora by spreading
them with your non-dominant hand.
Use the same manner for cleansing
as the labia majora. (See strokes 6
and 7 on figure 27)
o Apply a last single downward stroke
from the urinary orifice to the anus.
(See stroke 8 on figure 27).
10. Pick the cathether using your dominant  Lubricants facilitate ease in
hand and apply ample amount of water insertion.
soluble lubricant at the insertion tip of
the catheter about 5-7 centimeters (2-3
inches) using strict aseptic technique.
11. Place the drainage end of the catheter  To fully drain urine
towards the Kellypad using your non-
dominant hand.
12. Gently insert the catheter into the  Muscles are relaxed during
urinary meatus until urine flows. If there exhalation.
is resistance, do not force the catheter.
Ask the client to take deep breaths and
advance catheter as client exhales.
13. Allow some urine to flow then collect  Allowing urine to flow rinses the
specimen for urinalysis. passageway for any
microorganisms. This technique
is called mid-stream urine
collection. Allow 20 to 30 ml of
126
 urine to flow in the specimen
bottle without touching the
catheter to the rim of the bottle
to prevent contamination
14. Fully empty the bladder and then  Remove catheter when urine
remove the catheter by pinching and flow stops.
withdrawing it smoothly

127
Lesson 6 The Performance Checklist
Duration 8 hours

The first six hours of this lesson is attributed to practicing the skill through
online and offline method. Presented below are the two performance checklists for
the skills discussed in the previous lessons. Take time to review the procedure,
watch the initial demonstration on our Google Classroom and practice the skill on
your own at home. Initial return demonstration schedule will be on next meeting. To
perform grand return demonstration of the skills, see Final Requirement part of this
module.

Performing Fundic Height Measurement and Leopold’ Maneuver

Materials Needed:
 Centimeter tape measure  Watch with a second hand
 Note pad and pen  Drape
 Stethoscope

Procedures Not
Done Remarks
Done
ASSESMENT
1. Review the client’s record of last menstrual
period and pre-natal visits.
2. Gather the necessary materials.
PLANNING
1. Identify the patient. Explain the procedure to the
patient.
2. Perform hand hygiene.
3. Close the room door or curtains. Place the bed
at an appropriate and comfortable working
height.
4. Ask the patient to empty her bladder
IMPLEMENTATION
1. Position the patient in dorsal recumbent.
2. Drape the client.
3. Warm hands by rubbing one against the other
before placing on the abdomen.
4. Observe the woman’s abdomen as to which the
longest diameter is and where fetal movement is
apparent.
5. Measure the distance abdominally from the top
of the symphysis pubis over the curve of the
abdomen to the top of the uterine fundus.
6. First Maneuver
o Facing the client’s head part, palpate the
fundus with both hands and observe for
shape, consistency and mobility.
7. Second Maneuver
o Still facing client’s head part, place the left
hand stationary on the right side of the uterus
to immobilize it. Palpate the left side of the

128
 uterus from top to bottom with the right hand.
o Apply gentle but deep pressure to be able to
determine what lies on either side of the
uterus.
o Repeat the procedure on either side of the
uterus.
8. Third Maneuver
o Still facing client’s head part, grasp the lower
abdomen above the symphysis pubis with
the hand nearer the mother’s legs using
thumbs and fingers.
9. Fourth Maneuver
o Facing the client’s foot part, place tips of the
first 3 fingers on both sides of the lower
uterus about 2 inches above the inguinal
region.
o Press downward and inward in the direction
of the birth canal. Note that the fingers on
one hand meet no obstruction and glide over
the nape of the baby’s neck. The other hand
meets an obstruction, this is a brow of the
baby
10. Auscultate the Fetal Heart Tone
o Remember the fetal back from the second
maneuver.
o Place the bell of the stethoscope at the area
of the fetal back.
o Count for 1 full minute while comparing with
the mother’s pulse.
11. Place the patient on comfortable position.
EVALUATION
1. Evaluate client comfort and patient’s response to
the procedure
DOCUMENTATION
1. Record the findings correctly, interpret and relay
findings to the mother.

___________________ ____________________________ -----------------

Student's Signature Clinical Instructor’s Date
Printed Name & Signature

Self Check 23

Practice the procedure at home after watching the initial demonstration. Your
clinical instructor will schedule a practice return demonstration online. For remote
learning, your clinical instructor will contact you personally for a practice return
demonstration of the procedure.

129
 Performing Straight Catheterization

Materials Needed
 Sterile gloves  Straight catheter of appropriate
 Waterproof pad (kellypad) size
 Pitcher with lukewarm water  Urine specimen container
 Cotton balls with betadine  Pail
solution  Waste receptacle
 Water soluble lubricant

Procedures Done Not Remarks

Done
ASSESMENT
1. Review the need for performing perineal care
and check order for catheterization.
2. Assess the genital of your client and determine
the perineal-genital hygiene practices, self-
care abilities, etc.
PLANNING
1. Gather all the materials needed.
2. Identify the patient. Explain to the client what
you are going to do, why it is necessary and
how she can cooperate.
3. Perform hand hygiene.
IMPLEMENTATION
1. Place the patient to lithotomy position. Place
kellypad under the client’s buttocks.
2. Drape the client’s abdomen and thighs.
3. Ensure adequate lighting in the perineal area
4. Wash hands.
5. Place the sterile tray within reach containing
the following:
o Open sterile gloves and make a sterile
field. Ensure following the sterile technique
while doing so.
o Away from your gloves, place 8 pieces of
cotton balls with betadine solution.
o Put an ample amount of water soluble
lubricant on any vacant spot in your sterile
field.
o Open straight catheter and place on the
sterile field using sterile technique.
6. Test the temperature of water and pour a small
amount of water over the perineum and the
inner thighs
7. Put on sterile gloves.
8. Clean the perineal area using your dominant
hand.
o Clean mons pubis and the left and right
inner thighs by using cotton balls with
130
 betadine solution in a single zigzag stroke
starting at the proximal to the distal area of
the perineum.
o Clean the labia majora using figure of 7 on
the left labia and a reverse figure of seven
on the right labia using a single stroke with
each cotton.
o Clean the labia minora by spreading them
with your non-dominant hand. Use the
same manner for cleansing as the labia
majora.
o Apply a last single downward stroke from
the urinary orifice to the anus.
9. Pick the catheter using your dominant hand
and apply ample amount of water soluble
lubricant at the insertion tip of the catheter
about 5-7 cm (2-3 inches) using strict aseptic
technique.
10. Place the drainage end of the catheter in the
urine receptacle using your non-dominant
hand.
11. Gently insert the catheter into the urinary
meatus until urine flows. If there is resistance,
do not force the catheter. Ask the client to take
deep breaths.
12. Allow some urine to flow then collect
specimen for urinalysis.
13. Fully empty the bladder and then remove the
catheter by pinching and withdrawing it
smoothly
EVALUATION
1. Perform reassessment of the genitals and note
for any signs of abnormality.
2. Note for any untoward client’s response
DOCUMENTATION
1. Record the procedure and any untoward
patient’s response.
2. Assessment before and after the procedure
3. Type and size of catheter used
4. Characteristics and amount of urine obtained
5. Whether specimen was sent for examination.

___________________ ____________________________ -----------------

Student's Signature Clinical Instructor’s Date
Printed Name & Signature

131
Self Check 24

Watch the initial demonstration on our Google Classroom. Since this

procedure requires the use of female perineal models in the laboratory, return
demonstration is postponed until further notice. Hopefully by the next semester, we
can all go back in the school’s premises and be able to perform grand return
demonstration of this skill.

Post-test

Encircle the correct answer.

1. When assessing fundic height for a 27 weeks pregnant patient, the nurse
expect for fundic height would be?
a. 25 centimeters
b. 26 centimeters
c. 27 centimeters
d. 28 centimeters

2. What is the fourth maneuver in performing leopold’s maneuver?

a. Pawlik's grip
b. fundal grip
c. pelvic grip
d. umbilical grip

3. You’re providing discharge teaching to a new mother who is going home after
a vaginal delivery. The woman asks when the uterus will return to its pre-
pregnancy size. Your response is?
a. At about 14 days
b. At about 7 days
c. At about 6 months
d. At about 6 weeks

4. You’re assessing a patient’s chart and find that the patient is 36 weeks
pregnant. Where should you find the fundus during your assessment of fundal
height?
a. About 4cm below the xiphoid process
b. 5cm above the umbilicus
c. At the xiphoid process
d. Midway between the umbilicus and xiphoid process

5. A patient is 40 weeks pregnant, and you find the fundal height to be 4 cm

below the xiphoid process. Your next nursing action is to:
a. Chart this as a normal finding
b. Notify the physician immediately
c. Assess the baby’s heart rate with a doppler
d. Place the patient on continuous fetal monitoring
222
 6. Which finding while measuring fundic height of a patient who is 36 weeks
pregnant would require immediate action?
a. The patient states she cannot sleep at night
b. the patient complains of feeling lightened and dizzy
c. the fundic height measure at 38cm
d. the fundus of the uterus is at the xiphoid process

7. One hour after delivery where do you expect to find the fundus of the uterus?
a. At the umbilicus
b. 4cm below the xiphoid process
c. Right above the symphysis pubis
d. 2cm below the umbilicus
e.
8. When auscultating for the fetal heart tone, the first step is?
a. Place the stethoscope at the back of the fetal back
b. Count for 1 full minute while comparing with the mother’s pulse
c. Locate the fetal back
d. Place your 2 fingers on to locate the fetal back

9. During a prenatal visit, you are assessing the fundic height. You find the
fundus of the uterus to be right above the symphysis pubis. Based on this
finding the patient is about how far long in her pregnancy?
a. 20 weeks
b. 16 weeks
c. 24 weeks
d. 12 weeks

10. It is common and systematic way to determine the position of a fetus inside
the woman's uterus. And also used to estimate term fetal weight.
a. pelvic ultrasound
b. leopold’s maneuver
c. fundic height
d. catheterization

Final Requirement

1. Select a pregnant women among your group’s family members. Be able to

come up with a mini case study with the following components:
a. Nursing Health History
b. Physical Assessment
c. 3 Nursing Care Plan
d. 1 Health Teaching Plan for the priority nursing problem
e. Pamphlet for Health Teaching
f. A Video of you/your group member delivering the health teaching to the
pregnant client.

Requirements A to E has a template which can be found on the Google

Classroom as discussed in Lesson 1.
223
 2. Improvise a pregnant abdomen on an adult family member and ask for their
consent to act as your client. Prepare a short video of yourself performing return
demonstration of the procedure:
a. Performing Fundic Height and Leopold’s Maneuver
3. Quiz via Google Forms on Google Classroom

Suggested Readings and Websites

1. Pillitteri A. (2014) Chapter 15: Nursing Care of a Family During Labor and
Birth. Maternal and Child Health Nursing 7th Edition. Care of the Childbearing
and Childrearing Family. Lippincott Williams and Wilkins. Philadelphia United
States of America.
2. Berman A, Snyder S, Frandsen G. (2016). Perineal-Genital Care. Kozier &
Erb's Fundamentals of Nursing. 10th Edition. (pages 707-709). Pearson
Education, Inc. United States of America.
3. Berman A, Snyder S, Frandsen G. (2016). Urinary Catheterization. Kozier &
Erb's Fundamentals of Nursing. 10th Edition. (pages 1217-1223). Pearson
Education, Inc. United States of America.

References

Berman A, Snyder S, Frandsen G. (2016). Kozier and Erb’s Fundamentals of

Nursing. 10th Edition. Pearson Education, Inc. United States of America.

Cherian AG. Diagnosis of intrauterine growth restriction. Curr Med Issues Retrieved
from: http://www.cmijournal.org/text.asp?2017/15/4/267/218644

Cunnigham FG, Leveno KJ, Bloom SL, (2010). Williams Obstetrics, 23rd Edition.
McGraw-Hill Companies. New York

Nowlan N, (2015). Biomechanics of foetal movement. European cells & materials

Retrieved from
https://www.researchgate.net/publication/270289098_Biomechanics_of_foetal
_movement

Pillitteri A. (2014) Chapter 15: Nursing Care of a Family During Labor and Birth.
Maternal and Child Health Nursing 7th Edition. Care of the Childbearing and
Childrearing Family. Lippincott Williams and Wilkins. Philadelphia United
States of America.

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