• Theories of Labor Onset
fetal parts to one another
1. Uterine stretch theory –
any hallowed organ when stretched
to its maximum capacity will
contrast and empty.
2. Oxytocin theory – Oxytocin,
which causes contractions of the
smooth muscles of the posterior
pituitary gland as a result of stressful
event in labor.
3. Progesterone Deprivation
Theory – Progesterone, secreted by
the corpus Luteum and then by the
placenta, is essential in maintaining
pregnancy. However, the decrease
in the level of progesterone
circulating in the body will initiate
body pains.
4. Prostaglandin Theory –
Prostaglandins, formed by the
uterine deciduas under level of
concentration in the amniotic fluid
and blood of women increases
during labor. Research has shown
prostaglandin to be very effective in
inducing uterine contraction at any
stage of gestation. Initiation of labor
is said to be the result of the release
of arachidonic acid is believed to
increase prostaglandin synthesis
contractions.
5. Theory of Aging Placenta
– as the placenta matures, blood
supply decreases resulting in uterine
contractions.
Related Terms:
 Labor – is the process of moving
the fetus, placenta and membranes
out of the uterus and through the
birth canal. Synonymous with
childbirth and parturition.
 Delivery – is the actual birth of
baby
 Crowning – encircling of the largest
diameter of the baby’s head by the
vulvar ring
 Effacement – shortening and
thinning of the cervical canal. It is
expressed in percentage (%).
 Dilatation – is the enlargement of
the cervical os from an orifice a few
millimeters in size to an aperture
large enough to permit the passage of
the fetus.
 Show – is a mucoid discharge from
the cervix that is present after the
mucous plug has been discharged.
 Attitude – the relationship of the
 Lie – relationship of the fetal spine
to the spine of the mother.
 Presentation – portion of the fetus
that enters the pelvis first.
 Position – relationship of the
assigned area of the presenting part
of the landmark of the material pelvis.
 Station – measurement of the
progress of descent of the presenting
part in relation to the ischial spine.
 Frequency – from the beginning of
one contraction to the beginning of
the next contraction
 Duration – from the beginning of
contraction to its completion
 Intensity – the strength of
contraction to its completion
 Effacement – progressive thinning
and shortening of the cervix
 Dilatation – opening of the cervix
os during 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 – Goodell’s
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 woman’s
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 woman’s 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 woman’s 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 (Bandl’s
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
STAGES OF LABOR
1. Stage 1 (stage of dilatation) – begins
with the true labor pains and ends when
the cervix has reached full dilatation
Nursing Care:
 Stay with woman; provide constant
support
 Reminds, reassures and encourages
woman to reestablish breathing
patterns and concentration as needed
 Prompts partial respirations if
woman begins to push prematurely
accepts woman inability to comply
with instructions
 Keeps woman aware of progress
4 Phases:
• Latent Phase
 Begins at the regularly
perceived uterine contractions
and ends when rapid cervical
dilatation begins
 Contractions are mild and short
lasting 20-40 seconds
 Cervix dilates from 0-3cm
 6 hours in nullipara
 4.5 hours in multipara
Nursing Care:
- Assists woman to cope with
contraction
- Helps to concentrate in
breathing techniques
- Assists into comfortable
position
- Informs woman of the
progress of labor
- Explains procedure and
routines
- Offer fluids, ice chips, food
as ordered
• Active Phase
 Dilatation increases from 4 – 7
cm
  Contraction lasts 40-60 sec and
occur every 3-5 minutes
 3 hours in nullipara
 2 hours in multipara
 Show and spontaneous rupture
of membranes may occur
Nursing Care:
- Finds assessment
techniques between
contractions
- Assists with frequent
position change
- Applies counter pressure to
sacrococcygeal area
- Encourages and praises
- Keeps woman aware of
progress
- Check bladder and
encourages voiding
- Gives oral care
• Transition Phase
 Contractions reached their peak
of intensity occurring every 2-3
minutes with duration of 60-
90sec
 Maximum dilatation 8-10cm
 Complete cervical effacement
 Woman experiences intense
discomfort accompanied by
nausea and vomiting
 Woman may also experience a
feeling of loss of control,
anxiety, panic or irritability
2. Stage 2 (Stage of Expulsion) – the
period from full dilatation to birth of the
infant
 Contractions change from the
characteristic crescendo-
decrescendo pattern to
overwhelming uncontrollable urge
to push or bear down with each
contraction as if to move her
bowels
 Woman perspire and the blood
vessels in her neck may become
distended
 Crowning takes place
 The need to push become
intense and the woman cannot
stop herself
6 Cardinal Movements of the
Mechanism of labor
o Descent – downward movement
of the biparietal diameter of the
fetal head to within the pelvic inlet
- full descent occurs and the
fetal head extrudes beyond
the dilated cervix and
touches the posterior
vaginal floor
o Flexion – the head bends
forward onto the chest, making the
smallest anteroposterior diameter
o Internal rotation – the occiput
rotates until it is superior, or just
below the symphysis pubis,
bringing the head into the best
relationship to the outlet of the
pelvis
o Extension – as the occiput is
born, the back of the neck stops
beneath the pubic arch and acts as
a pivot for the rest of the head. The
head extends, and the foremost
parts of the head, the face and chin
are born.
o External Rotation – almost
immediately after the head of the
infant is born, the head rotates
(from the anteroposterior position
it assumed to enter the outlet)
back to the diagonal or transverse
position of the early part of labor
o Expulsion – the rest of the baby
is born easily and smoothly
because of its smaller part size.
The end of the pelvic division of
labor.
Nursing Care:
 Put both legs at the same
time when positioning to the
lithotomy position
 Instruct mother to push as
fetal head crowns. If
hyperventilation occurs, let patient
breathe into a brown paper or a
cupped hand.
3. Stage 3 (Placental Stage) – begins
from the delivery of the baby up to
the delivery of the placenta
2 Phases:
a. Placental Separation
Signs:
- Lengthening of the cord
- Sudden gush of blood
- Change of shape of the
uterus
b. Placental Expulsion
- Brandt Andrew’s Maneuver – tract
the cord slowly, winding it around the
clamp until placenta spontaneously
comes out rotating it slowly so that no
membranes are left
Nursing Care:
 Don’t hurry the expulsion of the
placenta, just watch for the signs of
placental separation
 Take note of the time of
placental delivery
 Inspect for the completeness of
the placenta
 Palpate the uterus to determine
degree of contraction. If relaxed,
massage gently and apply ice cap
 Inspect for lacerations
Types of Placental Presentation
 Schultze’s –
appearing shiny and glittering
from the fetal membranes
 Duncan – it looks raw,
dirty, meaty, red and irregular
4. Stage 4 (Puerperium Stage) – first 4
hours after delivery of placenta
Degrees of Perineal Lacerations:
1. First Degree – skin and superficial to
muscle
2. Second Degree – muscles of the
perineum
3. Third Degree – continues to anal
sphincter
4. Fourth Degree – involves the anterior
anal wall
Episiotomy – incision made to the
perineum to enlarge the vaginal opening
for easy delivery
Types:
a. Midline/Median
b. Mediolateral
c. Lateral
Advantages:
1. Enlarging of the vaginal opening
2. Shortening of the second stage of
labor
3. Minimizing the stretching of the
perineal muscle
4. Preventing perineal tearing
Fetal Monitoring – periodic change or
fluctuation in FHR occur in response to
contractions and the fetal movements
are described in terms of accelerations or
decelerations
- done through intermittent
auscultation
- electronic monitoring
1. External – transabdominal,
noninvasive, monitors uterine contraction
and FHR; client needs to decrease extra-
abdominal movements
2. Internal – membranes must be
ruptured, cervix sufficiently dilated and
presenting part; invasive procedure;
continuous monitoring
- results of monitoring: normal FHR
120-160; must obtain a baseline
Acceleration – 15 bpm rise above
baseline followed by return; usually in
response to fetal movement or
contractions; indicates fetal well-being
Deceleration – fall below baseline lasting
15 seconds or more, followed by a
return:
a. Early Deceleration – are periodic
decreases in the FHR resulting from
pressure on the fetal head during
contraction (head compression)
b. Late Deceleration – indicative of
fetal hypoxia because of deficient
placental perfusion (uteroplacental
insufficiency)
c. Variable Deceleration – occurs at
unpredictable times during contractions
and indicates cord compression
Anesthesia – encompasses analgesia
amnesia, relaxation and reflex activity. It
abolishes pain perception by interrupting
the nerve impulses to the brain. The loss
of sensation may be partial incomplete,
sometimes with loss of consciousness.
Analgesia – refers to the alleviation of the
sensation of pain or in the raising of the
threshold for pain perception without loss
of consciousness