Theories of Labor Onset

Labor is a coordinated sequence of involuntary, intermittent uterine contractions. It is the series of events
that expels the fetus and placenta out of the mothers body. This is made possible by the presence of
uterine contractions and abdominal pressure that push the fetus out during the expulsion period of
delivery. Regular contractions result to gradual cervical effacement and dilatation. Adequate pressure
from abdominal muscles allows the baby to be pushed outside the mothers womb.

Labor and delivery require a woman to utilize her coping methods psychologically and physiologically.
Normally, labor begins when the fetus reaches a mature age (38-42 weeks age of gestation). This is to
ensure survival of the fetus with the extrauterine life. The mechanism that converts Braxton Hicks
Contractions (painless contractions) to strong and coordinated uterine contractions is unknown. In some
cases, labor occurs before the fetus reaches the mature age (preterm birth) while in others it is delayed
(postterm birth).

Although the exact mechanism that initiates labor is unknown. Theories have been proposed to explain
how and why labor occurs.

Uterine Stretch theory
The idea is based on the concept that any hollow body organ when stretched to its capacity will inevitably
contract to expel its contents. The uterus, which is a hollow muscular organ, becomes stretched due to
the growing fetal structures. In return, the pressure increases causing physiologic changes (uterine
contractions) that initiate labor.

Oxytocin theory
Pressure on the cervix stimulates the hypophysis to release oxytocin from the maternal posterior pituitary
gland. As pregnancy advances, the uterus becomes more sensitive to oxytocin. Presence of this hormone
causes the initiation of contraction of the smooth muscles of the body (uterus is composed of smooth
muscles).

Progesterone deprivation theory
Progesterone is the hormone designed to promote pregnancy. It is believed that presence of this
hormone inhibits uterine motility. As pregnancy advances, changes in the relative effects estrogen and
progesterone encourage the onset of labor. A marked increase in estrogen level is noted in relation to
progesterone, making the latter hormone less effective in controlling rhythmic uterine contractions. Also,
in later pregnancy, rising fetal cortisol levels inhibit progesterone production from the placenta. Reduce
progesterone formation initiates labor.

Prostaglandin theory
In the latter part of pregnancy, fetal membranes and uterine decidua increase prostaglandin levels. This
hormone is secreted from the lower area of the fetal membrane (forebag). A decrease in progesterone
amount also elevates the prostaglandin level. Synthesis of prostaglandin, in return, causes uterine
contraction thus, labor is initiated.

Theory of Aging Placenta
Advance placental age decreases blood supply to the uterus. This event triggers uterine contractions,
thereby, starting the labor.





SIGNS of LABOR

Preliminary/Prodromal Signs of Labor

1. Ligthening setting of fetal head into pelvic brim
occurs approximately 10-14 days before labor begins
gives the woman relief from diaphragmatic pressure and shortness of breath
occurs early in primiparas
mother may experience: shooting leg pains from the increased pressure on the sciatic
nerve, increased amounts of vaginal discharge and urinary frequency from pressure on
the bladder
2. Increased in Level of Activity related to an increase in epinephrine release that is initiated by a
decrease in progesterone produced by the placenta
3. Braxton Hicks Contractions painless irregular contractions, sometimes strong that may cause
discomfort
4. Ripening of the cervix Goodells sign: the cervix feels softer than normal similar to earlobe
throughout pregnancy; at term cervix is described butter-soft

Signs of TRUE LABOR:

1. Uterine Contractions surest sign that labor has begun
2. Show the blood mixed with mucus, takes on a pink tinge. It is when mucus plug is expelled and
capillaries are exposed.
3. Rupture of the membranes experienced either as a sudden gush or as a scanty, slow seeping
of clear fluid from the vagina.

False Labor:
Irregular contractions
Pain is confined to the abdominal
No increase in duration, frequency, and intensity.
Pain disappears with ambulating
No cervical change
Sedation stops contractions

True Labor:
Regular contractions
Pain on the lower back to the abdomen
Increase in duration, frequency and intensity
Pain not relieved upon ambulating
Accompanied with effacement and dilatation
Sedation does not stop contraction

CHARACTERISTICS of CONTRACTIONS
1. Mild uterine muscle are somewhat tense but can be indented by a gentle pressure
2. Moderate uterus is moderately firm and a firmer pressure is needed to indent
3. Strong the uterus becomes very firm that at the height of contraction cannot be indented.

COMPONENTS of LABOR
1. Passage refers to the shape and measurement of maternal pelvis and distensibility of birth canal
refers to the route a fetus must travel from the uterus through the cervix and vagina to the
external perineum.
Elastic to expand and accommodate

4 Basic Classification of Pelvis:
a. Gynecoid best pelvis; half of the population
b. Android common in men, 20% in women; heart shape and difficult for vaginal delivery
c. Anthropoid common in men; 20-30%, pelvic inlet oval
d. Platypelloid flat pelvis; least common; 5% of the population, long sacrum

2. Passenger refers to the fetus, its size, presentation, and position.

3. Power forces acting together to expel fetus from the uterus
2 TYPES of POWER
a. Primary Powers involuntary contractions of the uterus
b. Secondary Powers- voluntary bearing down efforts of the mother

4. Psyche reflects the womans frame of mind in dealing with the labor experience

Structure of the fetal skull
Cranium uppermost portion of the skull, comprises eight bones.
- the four bones: the frontal (actually 2 fused bones), 2 parietal and occipital.
- The other four: sphenoid, ethmoid, and 2 temporal bones

The Suture Lines:
Sagittal suture- joins the 2 parietal bones of the skull
Coronal suture the line of juncture of the frontal bones and the 2 parietal bones
Lambdoid suture the line of juncture of the occipital bone and 2 parietal bones.

Fontanelles:
- significant membrane-covered spaces that are found at the junction of the main suture lines

Anterior Fontanelle referred to as bregma; lies at the junction of the coronal and sagittal sutures
- diamond-shape
- anteroposterior diameter is 3-4cm
- transverse diameter is 2-3cm

Posterior Fontanelle lies at the junction of the lambdoidal and sagittal sutures.
- triangular
- smaller than the anterior Fontanelle
- only 2cm across its widest part

Vertex the space between two fontanelles
Sinciput the area over the frontal bone
Occiput the area over the occipital bone

Suboccipitobregmatic narrowest diameter 9.5cm; from the inferior aspect of the occiput to the center of
the anterior fontanelle

Occipitofrontal measured from the bridge of the nose to the occipital prominence is 12cm

Occipitomental the widest which is 13.5cm; measured from the chin to the posterior fontanelle

Molding the change in shape of the fetal skull produced by the force of uterine contractions pressing the
vertex of the head against the not-yet-dilated cervix.

FETAL PRESENTATION and POSITION

Attitude describes the degree of flexion a fetus assumes during labor or the relation of fetal parts to
each other

1) Good Attitude (complete flexion) the spinal column is bowed forward that the chin touches the
sternum, the arms are flexed and folded on chest, the thighs are flexed onto the abdomen and
the calves are pressed against the posterior aspect of the thighs.
2) Moderate flexion the chin is not touching the chest but is in an alert or military position
3) Poor flexion the back is arched, the neck in extended and a fetus is in complete extension,
presenting the occipitomental diameter of the head to the birth canal (face presentation)

Engagement refers to the settling of the presenting part of a fetus far enough into the pelvis to be at the
level of the ischial spines.

Floating a presenting part that is not engaged
Dipping one that is descending but has not yet reached the ischial spines

Station refers to the relationship of the presenting part of a fetus to the level of ischial spines

0 station presenting part of a fetus is at the level of the ischial spines
-4 station head is at outlet
+4 station head is floating

FETAL LIE the relationship between the long axis of the body and the long axis of a womans body

2 Primary Lie
1. Longitudinal
2. Transverse

FETAL PRESENTATIONS denote the body part that will first contact the cervix of be born first.
- this is determined by a combination of fetal lie and the degree of flexion


3 Main Presentations

a. Cephalic the fetal head is the body part that will first contact the cervix
- the four types of cephalic presentation: vertex, brow, face and mentum

b. Breech either the buttocks or the feet are the first body part that will contact the cervix
- the 3 type of breech presentation: complete, frank, and footling)

c. Shoulder the presenting part is usually one of the shoulders (acromion process, an iliac crest, a hand,
or an elbow

POSITION the relationship of the presenting part to a specific quadrant of a womans pelvis

UTERINE CONTRACTIONS:

Origins
Labor contractions begin a pacemaker point located in the myometrium near one of the
uterotubal junctions
In some women, contractions appear to originate in the lower uterine segment rather than in the
fundus.

Phases
3 Phases: increment, acme, decrement
Increment- when the intensity of the contraction increases
Acme- when the contraction is at its strongest
Decrement- when the intensity decreases
As labor progresses the relaxation intervals decrease from 10 minutes to 2 3 minutes
The duration also changes from 20-30 sec to a range of 60-90 sec



Contour Changes
Upper segment becomes thicker and active, preparing it to be able to exert the strength
necessary to expel the fetus when the expulsion phase of labor is reached
The lower segment becomes thin-walled, supple, and passive so that the fetus can be pushed out
of the uterus easily
Physiologic retraction ring a ridge on the inner uterine surface that marks the boundary between
the 2 portions
Pathologic retraction ring (Bandls ring) it is a danger sign that signifies impending rupture of the
lower uterine segment if the obstruction to labor is not relieved

Cervical Changes

Effacement
Shortening and thinning of the cervical canal
Normally the canal is 1-2cm
With effacement the canal virtually disappears because of longitudinal traction from the contracting
uterine fundus


Dilation
Refers to the enlargement or widening of the cervical canal from an opening of few millimeters
wide to one large enough (10cm).
First reason why dilation occurs is uterine contractions gradually increase the diameter of the
cervical canal lumen by pulling the cervix up over the presenting part of the fetus
Second, the fluid-filled membranes press against the cervix
As dilation begins there is large amount of vaginal secretions (show) because the last of the
operculum or mucus plug in the cervix is dislodged and capillaries in the cervix rupture