Chapter 18

Caring for a Woman During Vaginal Birth

Theories of Labor Onset

LABOR – series of processes by w/c the mature, or almost mature, products of conception are expelled from the mother’s body

 The trigger that converts the random, painless Braxton Hicks contractions into strong, coordinated, productive labor
contractions is unknown

 Although a number of theories have been proposed to explain why labor begins, it is believed that labor is influenced by a
combination of factors originating from the mother and the fetus

 These factors include the following:

 Uterine muscle stretching, w/c results in release of prostaglandins (Uterine Stretch Theory)
 Pressure on the cervix – w/c stimulates the release of oxytocin from the posterior pituitary (Oxytocin Theory)
 Oxytocin stimulation – w/c works together w/ prostaglandins to initiate contractions
 Change in the ratio of estrogen (stimulating effect) to progesterone (relaxing effect)– stimulates uterine
contraction
 Placental age – w/c triggers contractions @ a set point (Placental Degeneration Theory)
 At the end of 8th month, thrombosis formed on the venous sinus of the placenta – will impair circulation
to the placenta = causing it to age or senile = causing it to be incapable in providing hormone and
nutrient to the fetus = termination of pregnancy
 Rising fetal cortisol levels w/c reduce progesterone formation and  prostaglandin formation (Progesterone
Deprivation Theory)
 Fetal membrane production of prostaglandin – w/c stimulates contractions

Signs of Labor
Preliminary Signs of Labor
 Before labor, a woman often experiences subtle signs that signal onset of labor
 All pregnant women should be taught these signs so that they can recognize when labor is beginning

1. Lightening
 Primiparas: lightening or descent of the fetal presenting part in to the pelvis – occurs approximately 10 – 14 days
before labor begins
 Changes a woman’s abdominal contour – uterus becomes lower and more anterior
 Gives woman relief from the diaphragmatic pressure and SOB that she has been experiencing
 Multiparas: not as dramatic as in primiparas – usually on the day of labor or even after labor has begun
 As fetus sinks lower into the pelvis, mother may experience:
 shooting leg pains – from the ed pressure on sciatic nerve
 increased amounts of vaginal discharge, and
 urinary frequency from pressure on the bladder

2. Increase in Level of Activity

 woman may awaken on the morning of labor full of energy – in contrast to her feelings of chronic fatigue
 related to  in epinephrine release initiated by a  in progesterone produced by the placenta
 additional epinephrine prepares a woman’s body for the work of labor ahead

3. Braxton Hicks Contractions

 Last week or days before labor begins – extremely strong Braxton Hicks contractions, w/c she may interpret as
true labor contractions
 Primiparas may have difficulty distinguishing the 2 forms of contractions
 DIFFERENCE BETWEEN TRUE AND FALSE LABOR CONTRACTIONS (TABLE 18.1, P. 490)

FALSE CONTRACTIONS TRUE CONTRACTIONS

 Begin and remain irregular  Begin irregularly but become regular and predictable
 Felt 1st abdominally and remain confined to the abdomen  Felt 1st in lower back and sweep around to the abdomen in
and groin a wave
 Often disappear w/ ambulation and sleep  Continue no matter what the woman’s level of activity
 Do not increase in duration, frequency, or intensity  Increase in duration, frequency, and intensity
 Do not achieve cervical dilatation  Achieve cervical dilatation
4. Ripening of the Cervix
 An internal sign seen only on pelvic examination
 Throughout pregnancy – “Goodell’s sign”
 At term – “butter – soft,” and tips forward
 Ripening is an internal announcement that labor is very close @ hand

Signs of True Labor

 Involve uterine and cervical changes
 Knowledge about true labor signs may be helpful to:
o Prevent preterm birth, and
o Feel secure knowing what is happening during labor

1. Uterine Contractions
 Productive uterine contractions – surest sign that labor has begun
 Contractions are involuntary and come w/o warning –their intensity can be frightening in early labor
 Breathing exercises offers her a sense of control to the discomfort due to contractions

2. Show
 As cervix softens and ripens, mucus plug that filled the cervical canal during pregnancy (operculum) is expelled
 Exposed cervical capillaries seep blood as a result of pressure exerted by the fetus
 Blood mixed w/ mucus, takes on a pink tinge = “show” or “bloody show”

3. Rupture of the Membranes

 Experienced either as a sudden gush or as scanty, slow seeping of clear fluid from the vagina
 amniotic fluid continues to be produced until delivery of the membranes after the birth of the fetus – no labor is
ever “dry”
 early rupture may be advantageous if it causes the fetal head to settle snugly into the pelvis – this can actually
shorten labor
 2 Risks w/ ruptured membranes:
 Intrauterine infection
 Prolapse of the umbilical cord – can cut off the O2 supply to the fetus
 If labor has not spontaneously occurred by 24 hours after membrane rupture and pregnancy is @ term – labor is
induced to help these risks

Components of Labor
 A successful labor depends on 4 integrated concepts (4 P’s):

1. The woman’s pelvis is of adequate size & contour (THE PASSAGE)

2. The fetus of appropriate size and in an advantageous position and presentation (THE PASSENGER)
3. Uterine factors are adequate (THE POWERS OF LABOR)
4. A woman’s PSYCHE is preserved, so that afterward labor can be viewed as a positive experience

PASSAGE
 Refers to the route a fetus must travel from the uterus through the cervix and vagina to the external perineum
 Since the cervix and vagina are contained inside the pelvis, a fetus must also pass through the bony pelvic ring
 For a fetus to pass thru the pelvis – pelvis must be of adequate size
 2 pelvic measurements that are important to determine adequacy of the pelvic size:
 Diagonal conjugate (anterior – posterior diameter of the inlet) – the narrowest diameter @ the pelvic inlet
 Transverse diameter of the outlet – the narrowest @ the outlet

PASSENGER
 The passenger is the fetus
 The body part of the fetus that has the widest diameter is the head – this is the part least likely to be able to pass thru the
pelvic ring
 Whether a fetal skull can pass or not depends on both its structure (bones, fontanelles, and suture lines) and its alignment
w/ the pelvis

 Structure of the Fetal Skull

 Cranium – uppermost portion of the skull; comprises 8 bones:
 4 superior bones: frontal (actually 2 fused bones), 2 parietal, the occipital – bones important in childbirth
 Other 4 bones of the skull: sphenoid, ethmoid, and 2 temporal bones – lie @ the base of the cranium; they are
of little significance in childbirth; never presenting parts
 Chin – referred to by its Latin name mentum – can be a presenting part

 Bones of the skull meet @ the suture lines:

 Sagittal suture – joins the 2 parietal bones of the skull
 Coronal suture – line of juncture of the frontal bones and the 2 parietal bones
 Lambdoid suture – line of juncture of the occipital bone and the 2 parietal bones
 Suture lines are important in birth because as membranous interspaces, they allow the cranial bones to move and
overlap, molding or diminishing the size of the skull so that it can pass thru the birth canal more readily

 Fontanelles – membrane-covered spaces found @ the junction of the main suture lines
 Anterior fontanelle (bregma) – lies @ the junction of the coronal and sagittal sutures; diamond-shaped – 4
bones are involved @ this junction (frontal and 2 parietal bones); anteroposterior diameter measures
approximately 3 – 4 cm; transverse diameter, 2 – 3 cm
 Posterior fontanelle – lies @ the junction of the lambdoidal and sagittal sutures; triangular shape – 2 parietal
bones and occipital bone are involved @ this junction; smaller than the anterior fontanelle, measuring
approximately 2 cm across its widest part
  Fontanelle spaces compress during birth to aid in molding of the fetal head
 Their presence can be assessed manually thru the cervix after it has dilatated during labor
 This helps to establish the position of the fetal head and whether it is in a favorable position for birth
 The space between the 2 fontanelles is referred to as vertex
 The area over the frontal bone is referred to as the sinciput
 The area over the occipital bone – occiput

 Diameters of the Fetal Skull

 The shape of the fetal skull causes it to be wider in its anteroposterior diameter than in its transverse diameter
 To fit thru the birth canal best, fetus must present the smaller diameter (transverse diameter) to the smaller diameter of
the maternal pelvis – otherwise progress can be halted and birth may not be accomplished
 The diameter of the anteroposterior fetal skull depends on where the measurement is taken:
 Narrowest diameter (approximately 9.5 cm) – is from the inferior aspect of the occiput to the center of the
anterior fontanelle = suboccipitobregmatic diameter
 Occipitofrontal diameter – measured from the bridge of the nose to the occipital prominence; approximately
12 cm
 Occipitomental diameter – widest anteroposterior diameter; approximately 13.5 cm; measured from the chin
to the posterior fontanelle

 The anteroposterior diameter that will be presented to the birth canal is determined by the degree of flexion of the fetal
head:
• Full flexion – fetal head flexes so sharply the chin rests on the thorax, and the smallest anteroposterior
diameter, the suboccipitobregmatic, is presented to the birth canal
• Moderate flexion – occipitofrontal diameter is presented
• Poor flexion – head hyperextended; largest diameter (occipitomental) will present

 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-dilatated cervix
 Pressure causes bones of the fetal skull to overlap (not yet completely ossified) and cause the head to become narrower
and longer – a shape that facilitates passage through the rigid pelvis
 Only lasts a day or two and is not permanent
 Little molding – brow as presenting part because frontal bones are fused
 No skull molding – breech presentation, because the buttocks, not the head are presented 1st

 Fetal Presentation and Position

 Attitude – describes the degree of flexion a fetus assumes during labor or the relation of the fetal parts to each other
• Good attitude – is in complete flexion; spinal column is bowed forward, the head is flexed forward so much
that the chin touches the sternum, arms are flexed and folded on the chest, thighs flexed onto the abdomen, and
calve pressed against posterior aspect of the thighs
 This normal “fetal position” – advantageous for birth – helps a fetus present the smallest
anteroposterior diameter of the skull to the pelvis, and puts the whole body into an ovoid shape,
occupying the smallest space possible
• Moderate flexion – chin is not touching the chest but is in an alert or “military position”
 Occipitofrontal diameter (2nd widest anteroposterior diameter) as presenting
 Does not usually interfere w/ labor – later mechanisms of labor (descent and flexion), fetus is forced
to flex the head fully
• Poor flexion – back is arched, neck is extended; fetus is in complete extension = occipitomental diameter to the
birth canal (face presentation)
 Less than normal amount of amniotic fluid present (oligohydramnios) – does not allow a fetus
adequate movement
 May reflect a neurologic abnormality causing spasticity
• Partial extension – presents the “brow” of the head to the birth canal

 Engagement – refers to the settling of the presenting part of a fetus far enough into the pelvis to be @ the level of the
ischial spines, a midpoint of the pelvis
• Primipara – nonengagement of the head @ the beginning of labor indicates possible complication, such as
abnormal presentation or position, abnormality of the fetal head, or cephalo-pelvic disproportion
• Multipara – engagement may or may not be present @ the beginning of labor
• Degree of engagement is assessed by vaginal and cervical examination
• Presenting part that is not engaged = “floating”
• Presenting part that is descending but has not yet reached the ischial spine = “dipping”

 Station – refers to the relationship of the presenting part of a fetus to the level of the ischial spines
 • Presenting part @ the level of the ischial spines = 0 station (synonymous w/ engagement)
• Above the ischial spines = distance is measured and described as minus stations, w/c range from -1 to – 4 cm
 - 4 station = head is floating
• Below the ischial spines = stated as plus stations (+1 to +4 cm)
• @ a +3 or +4 station= presenting part is @ the perineum and can be seen if vulva is separated (i.e., it is
crowning)

 Fetal Lie – relationship between the long (cephalocaudal) axis of the fetal body and the long (cephalocaudal) axis of a
woman’s body; whether the fetus is lying in a horizontal (transverse) or a vertical (longitudinal) position
• 99% of fetuses assume a longitudinal lie (their long axis is parallel to the long axis of the woman)
• Longitudinal lie further classified as:
 Cephalic – head will be the 1st part to contact the cervix
 Breech – breech or buttocks as the 1st to contact the cervix

Types of Fetal Presentation

Fetal presentation denotes the body part that will first contact the cervix or be born 1st

This is determined by a combination of fetal lie and the degree of fetal flexion (attitude)

Cephalic Presentation
 Most frequent type of presentation – occurring as often as 95% of the time
 Fetal head is the body part that will 1st contact the cervix
 4 Types of Cephalic Presentation:

TYPE LIE ATTITUDE DESCRIPTION

Vertex Longitudinal Good (Full flexion)  The head is sharply flexed, making parietal bones
or the space bet. fontanelles (vertex) the
presenting part
 Most common presentation and allows the
suboccipitobregmatic diameter to present to the
cervix
Brow Longitudinal Moderate (military)  Because head is only moderately flexed, the brow
or sinciput becomes the presenting part
Face Longitudinal Poor  Head of fetus is extended = face is the presenting
part
 From this position, extreme edema and distortion
of the face may occur
 Presenting diameter (occipitomental) is so wide
that birth may be impossible
Mentum Longitudinal Very Poor  Head hyperextended – chin presentation
 Widest diameter (occipitomental) is presenting
 As a rule, the fetus cannot enter the pelvis in this
presentation

 During labor, the area of the fetal skull that contacts the cervix often becomes edematous from the continued
pressure against it = caput succedanum

 Breech Presentation
 Either the buttocks or the feet are the 1st body parts that will contact the cervix
 Occur in approx. 3% of birth and are affected by fetal attitude
 Good attitude – brings fetal knees up against the umbilicus
 Poor attitude – means that knees are extended
 Can be difficult births – w/ the presenting point influencing the degree of difficulty
 3 Types of Breech Presentation:
1. Complete – fetus has thighs tightly flexed on the abdomen; both buttocks and the tightly flexed feet
present to the cervix
2. Frank – Attitude is moderate because hips are flexed but knees are extended to rest on the chest;
buttocks alone present to the cervix
3. Footling – neither thighs nor lower legs are flexed; if 1 foot presents = single footling; both legs =
double footling breech

 Shoulder Presentation
 In a transverse lie - fetus lies horizontally in the pelvis so that the longest fetal axis is perpendicular to that of the
mother
 Presenting part – usually one of the shoulders (acromion process), an iliac crest, a hand, or an elbow
 Fewer than 1% of fetuses lie transversely
 May be caused by:
 Relaxed abdominal walls from grand multiparity – w/c allow the unsupported uterus to fall forward
 Pelvic contraction – w/c the horizontal space is greater than the vertical space
  Placenta previa (placenta located low in the uterus, obscuring some of the vertical space) – may limit
a fetus’ ability to turn, resulting

 Types of Fetal Position

 Position – the relationship of the presenting part to a specific quadrant of a woman’s pelvis

 4 Pelvic Quadrants accdng. to mother’s right and left:

1. right anterior 3. right posterior
2. left anterior 4. left posterior

 4 parts of a fetus have been chosen as landmarks to describe the relationship of the presenting part to one of the pelvic
quadrants:
 Vertex presentation – occiput (O) is the chosen point
 Face presentation – chin (mentum) (M)
 Breech presentation – sacrum (Sa)
 Shoulder presentation – scapula or the acromion process (A)

 Position is indicated by an abbreviation of 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 – mentum, Sa – sacrum, and A – acromion process)
 Last letter – defines whether the landmark points anteriorly (A), posteriorly (P), or transversely (T)

 LOA – most common fetal position Fetus born fastest in

 ROA – 2nd most frequent these 2 positions

 ROP / LOP – labor is considerably extended; posterior positions may also be more painful for the mother – rotation of
fetal head puts pressure on the sacral nerves, causing sharp back pain