LABOR

Labor is a series of rhythmic, progressive

contractions of the uterus that gradually move
the fetus through the lower part of the uterus
(cervix) and birth canal (vagina) to the outside
world.
 The Physiology of Labor
POSSIBLE CAUSES OF LABOR ONSET

• Progesterone Withdrawal Hypothesis

• Prostaglandin Hypothesis
• Corticotropin-Releasing Hormone
 Premonitory Signs of Labor
• 1. LIGHTENING – describes the effects that
occur when the fetus begins to settle into the
pelvic inlet (engagement)
• -With fetal descent the uterus moves
downward, and the fundus no longer presses
on the diaphragm which allows breathing to
become easier.
2. BRAXTON HICK’S CONTRACTIONS – (the
irregular, intermittent that have been
occuring throughout the pregnancy) may
become uncomfortable. Pain is focused on
the abdomen and groin
3. CERVICAL CHANGES – weakening and
softening of the cervix brought about by
breaking down of collagen fibers by certain
enzymes; ability to bind together
decreases; water content of the cervix
increases
4. BLOODY SHOW – pink-tinged secretions,
small amount of blood loss from the exposed
cervical capillaries after a mucous plug is
expelled
– Bloody show is considered a sign that labor will
begin within 24 to 48 hours
5. RUPTURE OF MEMBRANES – amniotic
membranes rupture and the woman
experiences labor within 24 hours.
6. SUDDEN BURST OF ENERGY- 24 -48 hours
before labor
• Induction of Labor
 
• Induction of labor is the deliberate starting of
uterine contractions before they begin on their
own.
• Augmentation is the administration of  synthetic
oxytocin to enhance existing labor.

Methods
• Cervical ripening
• Amniotomy
• Oxytocin
Monitoring Techniques
During Labor
FHR auscultation
Fetoscope
Doppler
EFM
 Factors Affecting Labor(5 Ps)
• 1.Passenger = the size, presentation,and position
of the fetus.
• 2. Passageway = shape and measurement of
maternal pelvis.
• 3. Powers = forces of labor, acting in concert, to
expel the fetus and placenta.
• 4. Placenta = position of placenta
• 5. Psyche or Psychologic Response = A woman
who is relaxed, aware, and participating in the
birth usually has a shorter, less intense labor.
1. PASSENGER
• Attitude: This refers to the posturing of
the joints and relation of fetal parts to
one another. The normal fetal attitude
when labor begins is with all joints in
flexion.

• Lie: relationship of cephalocaudal axis

(fetal spine) of the fetus to the
cephalocaudal axis of the mother
(maternal spine) i.e., transverse, oblique,
or longitudinal (parallel).

• Presentation: This describes the part on

the fetus lying over the inlet of the pelvic
or at the cervical os.
 Types of Presentation
1. CEPHALIC = the fetal head presents itself to the passage, occurs in 97% of births
Classified as:
1. Vertex – most common; fetal head is completely flexed; smallest
diameter of the fetal head (suboccipitobregmatic ) presents to the maternal
pelvis
2. Military – fetal head is neither flexed nor extended; top of the head is
the presenting part
3. Brow – fetal head is partially extended; sinciput is the presenting part
4. Face – fetal head completely extended; face is the presenting part
2. BREECH (buttocks) or (lower extremities)
a.Frank: thighs flexed, legs extended on
anterior surface, buttocks presenting
b.Full or complete: thighs and legs flexed,
buttocks and feet presenting(squatting)
c. Footling: one or both feet are presenting
3. SHOULDER (Scapula).CS
Position: relationship of reference point on fetal presenting part to
maternal bony pelvis. Maternal bony pelvis divided into 4 quadrants
(R and L anterior, R and L posterior)
 2. PASSAGEWAY
= shape and measurement of maternal pelvis and
distensibility of birth canal.
False Pelvis
• Shallow upper basin of
the pelvis
• Supports the enlarging
uterus
True Pelvis
• Consists of the pelvic
inlet, pelvic cavity, and
pelvic outlet.
• Influence the conduct
and progress of labor
and delivery
•Engagement: This occurs when the largest diameter
of the presenting part reaches or passes through the
inlet of the true pelvis.
•Station: refers to the relationship of the presenting
part to an imaginary line drawn between the ischial
spines of the maternal pelvis measured in + or -
centimeters.
 3. POWER
• Major forces: Involuntary and voluntary
• Involuntary: includes frequency, regularity,
intensity and duration.
• Voluntary: bearing-down efforts. The
contraction of levator ani muscles.
Uterine contraction
 3 phases of labor contraction
1. INCREMENT – building up of the contraction
(longest phase)
2. ACME – peak of the contraction
3. DECREMENT – letting up of the contraction
 Terms to describe uterine contractions
during labor
• DURATION - measured from the beginning of a
contraction to the completion of the same
contraction
• FREQUENCY- refers to the time between the
beginning of one contraction and the beginning of
the next contraction
• INTERVAL- refers to the time between the end of
one contraction to the beginning of the next
contraction
• INTENSITY – refers to the strength of the contraction
during acme.
 4. POSITION
• Maternal positioning during labor
• Influence pelvic size and contours
• Affects pelvic joints, facilitate descent and rotation
• E.g. squatting – enlarges the pelvic outlet by
approximately 25%
• Kneeling removes pressure on the maternal vena
cava and assists to rotate the fetus in the posterior
position (Breslin and Lucas, 2003)
 Supine/ Lithotomy

• Non-moving, back lying positions are not

healthy ( Simkin, 2002)
• To conserve energy and not to tire themselves
• To keep track of ambulating women
• Facilitate vaginal examination
 Upright/ lateral position
• Reduce duration of 2nd stage of labor
• Reduce number of assisted deliveries (vacuum,
forceps)
• Reduce episiotomies and perineal tears
• Reduces abnormal fetal heart patterns
• Increase comfort/reduce request for pain
medications
• Enhance a sense of control
• Alters shape, size of pelvis; facilitates descent
• Reduce length of labor (Gupta & Hofmeyr,2003)
 5. PSYCHE
The woman feels confident in her ability to cope
and find ways to work with the contractions, the
labor process is enhanced.

 If the laboring woman becomes fearful or has

intense pain, she may become tense and fight the
contractions.

 This situation often becomes a cycle of fear,

tension, and pain that interferes with the progress of
labor.
 Difference between true and false labor
TRUE LABOR FALSE LABOR
Contraction Regular, increasing Irregular, no
frequency and change in
intensity, shortening of frequency,
interval duration and
intensity
Discomfort Radiates from back Pain at abdomen
around the abdomen
Rest/ Contraction does not Contraction may
decrease with rest or lessen with activity
Activity activity or rest.
Cervix Progressive Cervical changes
effacement and do not occur yet
dilatation of cervix
• Four Stages of Labor:

1. First Stage: Dilation

a. Early Labor (latent phase)
b. Active Labor (active phase)
c. Transition (Transition phase)
2. Second Stage: Birth
3. Third Stage: Delivery of Placenta
4. Fourth Stage: Recovery
FIRST STAGE =From the beginning of labor
to the full opening (dilation)of the cervix—to about
4inches(10centimeters).
Initial (Latent) Phase
•  Contractions begin which are
usually mild lasting from 15-20 sec.;
frequency every 10-20 mins.
•  Discomfort is minimal.
•  The cervix thins and opens to
about 11/2 inches (4 centimeters).
• This phase lasts an average of 12
hours in a first pregnancy and 5
hours in subsequent pregnancies.
Active Phase
  The cervix opens from
about 4 centimeters to 8
centimeters.
  The presenting part of the
baby, usually the head,
begins to descend into the
woman's pelvis.
Transition Phase
Cervix (8- full dilatation
10cm)
    The woman begins to feel
the urge to push as the baby
descends.
Comfort Measures for the Laboring Woman

 Do not leave alone in active labor.

 Change soiled and damp linen promptly.
 Provide mouth care.
 Ice chips, lubricate lips.
 Keep room cool, uncluttered, quiet and privacy.
 Promote participation of coach.
 When to position your patient
• S – udden gush of blood
• U – rge to defecate
• B – loody show
• I – ncrease in contractions
• R – upture of Membranes
• B – earing down
• A – nal dilatation
 SECOND STAGE
From the complete opening of the cervix to delivery of
the baby. This stage averages about 45 to 60 minutes in
a first pregnancy and 15 to 30 minutes in subsequent
pregnancies.
CROWNING occurs when the fetal head is encircled by
the external opening of the vagina (introitus), and it
means birth is imminent
 Mechanism of a spontaneous
vaginal delivery/ Cardinal
movements

• Definition: A mechanism of labor is a series

of passive, adaptive movements of the fetal
head and shoulders through the birth canal.
Mechanisms of Labor
• Descent
• Engagement
• Flexion
• Internal Rotation
• Extension
• Restitution
• External Rotation
• Expulsion
 THIRD STAGE (Placental stage)
From delivery of the baby to delivery of the placenta. This
stage usually lasts only a few minutes but may last up to
30 minutes.
• Made up of 15-20 lobes
called cotyledons
• 2 mechanisms of placental
separation
• 1. SCHULTZE – separates
from the inside to the
outer margin; expelled
with the fetal side ;
“Shiny”
• 2. DUNCAN- separates
from the outer margins
inward, rolls up and
presents sideways with the
maternal surface; “Dirty”
 Fourth stage
• Recovery: The woman is observed frequently for
signs of hemorrhage or other complications; 1-4
hours after birth
• Hemodynamic changes occur
• Blood loss ranges from 250-500ml
• Uterus remains contracted in the midline
Possible complications for the mother
include:
• rupture (tearing) of the uterus
• hemorrhage (heavy bleeding) after the
delivery
• bruising or tearing of the cervix or vagina
• tearing of the rectum
• bruising or irritation of the bladder.
 Maternal Adaptation during the
Postpartum Period
• Normal uterine involution occurs at a predictable
rate. One hour after chilbirth, the fundus is at the
level of the umbilicus.
• On the 1st postpartum day, the fundus is
approximately 1 fingerbreadth or 1 cm below the
level of the umbilicus.
• Thereafter, it descends downward at the rate of 1 cm
per day until it becomes a pelvic organ again on the
10th day postpartum.
• Lochia rubra, serosa and alba.
• Normal blood loss during
NSVD 300 to 500 ml.

• CS: 500 to 1,000 mL.

 Maternal Role Development
• Taking In Phase
Mother is dependent, has difficult making decisions and
needs assistance with self-care. Can last several hours to
days.
• Taking Hold Phase
After she has rested and recovered from stress of delivery,
the new mother has energy for the infant. Lasts 2 days to
several weeks.
• Letting Go Phase
Family relationships are adjusted to accommodate the
infant. Give up the fantasy child and gets to know the
real child.
• “Postpartum blues” = a temporary depression that
usually begins on the 3rd day and lasts for 2-3 days.
S/S: tearful, difficulty sleeping and eating, and feel generally
down.
Psychological adjustment, plus fatigue, disturbed sleep
patterns, and discomfort may contribute.

Focus of early postpartum period:

1. Preventing and detecting hemorrhage
2. Treating pain
3. Preventing infection
4. Detecting and treating urinary retention
5. Promoting sleep
6. Promoting healthy parental-newborn attachment.
 POSTPARTUM COMPLICATIONS
1. HEMORRHAGE - 1-4 hrs postpartum is the most critical stage
Causes:
• a. Laceration
• b. Placental retention
• c. Uterine rupture
• d. Uterine inversion
• e. Uterine atony
2. INFECTIONS
• a. Endometritis – Endometriosis is the growth of endometrial
tissue outside the uterus. When infected, it is called
endometritis.
• Clinical manifestations:
• foul smelling vaginal discharge
• fever & chills
• profuse bleeding
• b. Episiotomy Infection
Operative Obstetrical
Procedures
 Forceps Delivery

Forceps Delivery – method of delivering infants through

the use of forceps extraction
- 2 double-crossed, spoonlike articulated blades that
are used to assist in delivery of fetal head
- may cause damage on the facial nerve of the baby
Vacuum Delivery – method of delivering an
infant using a vacuum applied over the scalp of
the baby
- may cause caput succedaneum
 Cesarean Section
In the case of severe obstetric emergencies, the
time from decision to delivery is ideally within 30
minutes .
3 types
a. Low Segment CS –
method os choice since
lower segment is thinner,
fewer bld vessels,
passive during labor
b. Classical CS –
indicated for transverse
lie, placenta previa,
adhesion of tissues
c. Pfannenstiel or bikini