Page 62 - 2023 Elctronic Book (3) Normal Labor_Neat

• Membranes rupture.

• Perineum starts to bulge and the anal orifice starts to dilate.
• Woman starts involuntary bearing down and feels the desire to defecate.
• She may be eager to sleep.

• She is apprehensive, irritable, unwilling to be touched, and may cry if
disturbed.

• She is frustrated, and unable to manage labor alone.
Nursing Diagnosis
• Pain related to descent of the fetus and stretching of vagina

and perineum.
• Fatigue related to inability to rest and pushing efforts.

• Anxiety related to unknown outcome of labor process.
• High risk of infection

Planning and Implementation

 Transfer to delivery room:
o Primigravida is transferred to the delivery room when the cervix is fully
dilated and the presenting part is seen.
o Multipara is transferred when the cervix is 7-8 cm (3-4 fingers).

 Posture of woman in labor:
The woman lies on the delivery table in one of the following positions:

 Dorsal or lithotomy position:
T

Woman lies on her back and puts her legs up into the stirrups or leg hold. he
advantages of this position are:
 Change of position is not needed to check FHS and to conduct the 3 stage of
rd
labor.
 Draping woman and preserving aseptic techniques are easy.
 Left lateral position:

Woman lies on left side, her thighs are partly flexed and another person holds
her knees apart. The advantages of this position are

:
 Decrease liability for perineal laceration.
 Easy removal of feces
.
 Easy manipulation of shoulders.
 Preparations:

o Preparation of the delivery room:

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