LABOR AND DELIVERY pelvis, the pressure of the fetus is removed so the

MR. ANDRE CARLO C. DE VEYRA lungs could expand better.

- This occurs early in primipara because of the tight
THEORIES OF LABOR ONSET abdominal muscle but may also occur after the onset
1. Uterine stretching reaching its peak of labor in some multiparous woman.
- When the uterus stretches and reaches its peak for - When this happens, abdominal pressure increases
distention it releases prostaglandins which then and this may result to reports of shooting leg pains
stimulates labor contractions. When there is from the pressure on the sciatic nerves. There may
contraction, you can expect labor and delivery also be increased vaginal discharges, and increased
2. Pressure on the cervix stimulates release of oxytocin urinary frequency because of the pressure on the
- When the pressure of the cervix stimulates release of bladder.
oxytocin from the posterior pituitary gland. The 2. Increased level of activity
function of oxytocin is to stimulate contractions and - A woman sometimes experiences a feeling of being
when there are contractions, there is no way for the very energetic and this is normal.
fetus but to go out. - This happens due to a decreased production of
3. Changes in ratio of estrogen to progesterone progesterone which then results to an increased
- Progesterone is increased during pregnancy and it epinephrine (catecholamine) which is responsible for
helps in preventing and halting uterine contraction the fight and flight response of the body.
para hindi mailabas ang product of conception. This is - Epinephrine levels increase because it prepares the
why it is elevated during pregnancy. body for labor and delivery.
- According to the theory, during labor onset, the 3. Braxton Hicks contraction
estrogen is increased and progesterone decreases so - “rehearsal contractions” in preparation for the true
there is no hormone that would halt uterine labor
contraction. 4. Ripening of cervix
- Progesterone decreases and prostaglandin increases - Also known as Goodell’s sign
in order to stimulate uterine contraction. - Pre-pregnant, the consistency of the cervix is like the
4. Placental age, triggers contractions tip of the nose, during pregnancy it is like an earlobe,
- If the placenta is already old or if it reaches a certain and if the woman is about to give birth, the
number of weeks, it triggers contractions at a set consistency becomes butter-soft.
point.
5. Increase in fetal cortisol level which decrease FLASE CONTRACTIONS TRUE CONTRACTIONS
progesterone formation and increase prostaglandin Irregular Regular & predictable
- At a certain point of pregnancy, when the fetus is Felt first abdominally & Felt first in the lower back
ideally ready term, the fetal cortisol level would remain confined to the & sweep around the
increase and would result to decreased progesterone abdomen and groin abdomen
and an increase of prostaglandin in order to stimulate Disappear with sleep & Continuous
and initiate uterine contraction. ambulation
6. Fetal membrane production of prostaglandin Do not increase in Increase in duration,
duration, frequency, frequency, intensity
- The fetal membrane at a certain point or after a
intensity
certain number of weeks would produce prostaglandin
No cervical dilatation With cervical dilatation
which would help in initiating and stimulating uterine
contraction.
Note: nurses would perform IE or internal examination to
7. Seasonal & time influences
check the cervical dilatation and it could dilate as much as
- Other causes of labor onset may be seasonal and
10cm
time influences.
- Example is if there are problems in the woman, the
SIGNS OF TRUE LABOR
woman has been so stressed, or there was so much
1. Uterine contractions
physical activity and exertion then it may trigger labor
- Considered as the surest sign that labor has already
onset.
begun
2. Show
SIGNS OF TRUE LABOR
- During labor or before delivery, the mucus plug or
A. Preliminary signs
operculum is removed and sometimes tinged with
1. Lightening
blood. This is called as show
- 10 to 14 days prior to labor
- Sometimes colored pink or has tinge of blood which is
- Lightening is the descent of the fetal presenting part
called bloody show
into the pelvis and this usually happens 10 to 14 days
3. Rupture of membranes
prior to labor.
- Nagbuto na an panubigan
- It is called lightening because the woman gets a
- There is a sudden gush or scanty slow seeping of
lightened feeling in the sense that when the
clear fluid from the vagina
presenting part of the fetus starts to descent into the
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 - Nitrizine paper test is used to differentiate amniotic
fluid from urine. Amniotic fluid is slightly alkaline in
nature.
- Risk of rupture of membranes
 Intrauterine infections
 Prolapse of umbilical cord
 because of sudden change of pressure, the
umbilical cord may go out or peep on the - Four superior bones: frontal, 2 parietal, occipital
vaginal opening. When this happens, never - The area over the frontal base is called sinciput
put back the cord because there is a - Opposite to sinciput is occiput
tendency that the cord will be compressed. If - The chin is referred to as mentum
the cord is compressed, the blood supply to - Anterior fontanelle is called bregma
the fetus will be compromised. You should - Anteroposterior diameter is 3-4cm
instead get a sterile gauze wet it with sterile - Transverse diameter 2-3cm
water and put it on the cord. This is done in - Posterior fontanelle is 2cm across the widest part
order to prevent drying of the cord because if - Vertex is the space between two fontanelles
it is exposed in open air, there is a high - The posterior fontanelle usually closes by age 1 or 2
possibility that it would atrophy and will months. It may already be closed at birth. The anterior
become dry and the blood supply will be fontanelle usually closes sometime between 9 months
compromised. and 18 months.
 Upon rupture of the membranes, assess and - It is not sealed completely so that during childbirth, it
monitor the FHT from time to time to check if will just slide against each other and can be
the blood supply to the fetus is adequate. accommodated on the birth canal.
Monitor the temperature of the mother,
because elevation of temp may be
associated with infection.
 If labor has not occurred by 24hrs after the
rupture of the membrane and the fetus is at
term, labor will be induced to help decreased
the risk. The mother will be given oxytocin to
stimulate contraction of uterus. - Suboccipitobregmatic diameter
 The narrowest diameter 9.5cm
COMPONENTS OF LABOR
 From the interior aspect of the occiput to the
1. Passage (the woman’s pelvis)
center of the anterior fontanelle
- Refers to the route the fetus must travel from the
 This is most ideal for childbirth because it will fit
uterus through the cervix, to the vagina, to the
the pelvic.
external perineum.
- Occipitofrontal diameter
- 2 pelvic measurements important to determine
 11 to 12 cm from the bridge of the nose to the
adequacy of pelvic size:
occipital prominence
- Occipitomental diameter
 13.5 cm
 The widest
 From the chin to the posterior fontanelle
 The woman will have the problem in deliver the
baby normally.
 Diagonal conjugate
 Anterior posterior diameter of the inlet
 Transverse diameter
- We measure it through pelvimetry. It is important to
measure this to check whether the pelvis of the
woman is ideal for childbirth.
- If the pelvis is not ideal for childbirth or the baby’s
head will not fit the pelvis, it is called CPD or
cephalopelvic disproportion. We will not advise - Anteroposterior diameter that is presented to the birth
women with CPD to deliver normally and would canal is determined by the degree of flexion (attitude).
suggest cesarean section instead. - Engagement refers to settlement of the fetal head into
- Most ideal pelvis for childbirth is gynecoid the pelvis at the level of the ischial spine
2. Passenger (the fetus) - Full flexion

2
  head flexes so sharply and the chin rested on the Molding – change of shape of the fetal skull produced by the
thorax, force of the uterine contractions pressing against the vertex of
 the suboccipitobregmatic diameter (9.5cm) is the a not yet dilated cervix. Would usually last a day or two and
one that is presented in the birth canal. would go back to its normal shape. Only present in cephalic
 Ideal for childbirth presentation.
- Moderate flexion CAPUT SUCCEDANEUM
 Occipitofrontal (11 cm)
- Poor flexion
 Occipitomental diameter (13.5) is presented
 There may be difficulty in terms of child birth
 Anteroposterior diameter must fit into the
transverse diameter of the pelvis to see if it can Caput succedaneum – there is collection of blood and fluid.
fit. This would disappear after a day or two. This is only present in
 Causes of brow presentation oligohydramnios, cephalic presentation.
may reflect neurologic abnormality causing BREECH PRESENTATION
spasticity.
 In primipara, non-engagement may indicate
abnormal presentation and position, abnormality
of the fetal head and CPD. In this case, CS is
recommended.
STATION – refers to the relationship of the presenting part of
the fetus to the ischial spine.
Floating – on -1,-2,-3 means not yet engaged Extended/Frank Breech
Crowning – on +1,+2,+3 (pronounced as 1 positive) - Most frank breech is front breech
- This is what we call “suhi”
Flexed Breech
- The baby looks like in an Indian position
Shoulder presentation
- They are in a transverse lie
- Causes:
 Relaxed abdominal wall
TYPES OF FETAL PRESENTATION & FETAL LIE  Grand multiparity (gave birth for more than 5
times due to relaxed abdominal muscles)
 Pelvic contraction in which the horizontal space is
greater than the vertical space
 May be found in placenta previa or low-lying
placenta

FETAL POSITION – the relationship of the presenting part to a

specific quadrant of the woman’s pelvi
Fetal lie – relationship of the long axis of the woman’s body to
the long axis of the fetus’ body. 4 Divisions of the Maternal Pelvis
Longitudinal lie – either be breech or cephalic 1. Right Anterior (RA)
Transverse lie – shoulder presentation; difficult to give birth to 2. Left Anterior (LA)
Note: it is important that the baby receives adequate oxygen 3. Right Posterior (RP)
supply to prevent asphyxia, anoxia and will result to brain 4. Left Posterior (LP)
damage and is irreversible. This is one of the possible causes 4 Parts of the Fetus chosen as landmarks to describe the
of cerebral palsy. relationship of the presenting part to the pelvic quadrants:
MOLDING 1. Vertex- occiput (O)
2. Face- mentum (M)
3. Breech- sacrum (S)
4. Shoulder- acromion/scapula (A)
A-anterior
P-posterior
T-transverse

LOA – most common, 80%

ROA – second most common

3
LOP & ROP – difficult to deliver and painful to the mother
because the rotation of the fetal head puts pressure on the
sacral nerve causing sharp back pain
4 Methods to determine fetal position and fetal lie:
1. Combined abdominal inspection and palpation
2. Vaginal examination
3. Auscultation of the fetal heart tone
4. Sonography (i.e. ultrasound)
MECHANISM (Cardinal Movements) OF LABOR
1. Descent – downward movement of the biparietal
diameter of the fetal head within the pelvic inlet
2. Full Descent – when the fetal head protrudes beyond
the dilated cervix and touches the posterior vaginal
floor.
3. Flexion – fetal head bend forward to the chest due to
the pressure of the pelvic floor
4. Internal rotation – occiput would rotate until it is
superior or just below the symphysis pubis bringing
the head into the best diameter of the outlet of the
pelvis
5. Extension – as the occiput is born, the back of the
neck stops beneath the pubic arc and acts as the
pivot for the rest of the head
4
6. External rotation – the shoulders and anterior position
which is best for entering the outlet
7. Expulsion – once the shoulders are born, the rest of
the baby is born easily and smoothly
3. Power (contractions)
Power of labor – is supplied by the fundus of the uterus
and implemented by uterine contractions, which causes
cervical dilation and then expulsion of the fetus from the
uterus.
1. Uterine contraction – begins at a pacemaker located
at the myometrium near one of the uterotubular
junctions.
Note: Nurses job is to monitor uterine contractions.
Note: as labor progresses, contraction becomes more
frequent and the interval becomes smaller
2. Phases
a) Increment – increasing (contraction starting to
increase)
b) Acme – at its peak (the contraction is at its
strongest)
c) Decrement – slowly disappearing (contraction start
to decrease in intensity)
3. Contour changes – the upper portion of the uterus
becomes thick and the lower uterine segment
becomes thin and becomes soft in preparation for
childbirth.
- During labor and delivery the upper portion becomes
thick and the lower uterine softens to accommodate
the passage of the baby.
- Lower uterine segment (Hegar’s sign) would relax and
soften to accommodate the fetus for it to go out.
- Watch out during difficult labor, the round ligaments of
the uterus becomes too tensed during dilatation and
expulsion and may cause palpable pathologic
retraction ring/Bandl’s ring. Do not apply pressure on
it. This is an emergency situation because this
pathologic retraction ring should be handled with
outmost care because this is a sign of an impending
rupture of uterus.
Note: If the membranes are ruptured do not let the woman
walk because this might cause cord prolapse.
 3rd stage – birth of neonate to delivery of placenta
- 2 separate process:
a. Placental separation – placenta separates from
endometrium
b. Placental expulsion – placenta is expelled

Signs of Placental Separation:

1. Lengthening of the cord
2. Sudden gush of vaginal blood
3. Change of shape of the uterus (Calkin’s sign)
- Normally, the cervical canal is 1-2cm but with 4. Appearance of the placenta at the vaginal orrifice
effacement, the cervix diameter would virtually
disappear.
- In true labor, the cervical dilatation is more than 7cm
(4-7cm).

PRIED – primipara the effacement is first then the dilation

MUDE – multipara the dilation is first then effacement
Fetal side – mahamis (Schultze presentation), Schultze = shiny
2 reasons why there is effacement and dilatation: Maternal side – bagan karne, maraksot (Duncan) Duncan =
1. Uterine contractions dirty
2. Fluid filled membrane pressing against the cervix ADDITIONAL NOTES:
- make sure that the placenta is complete
4. Psyche (the woman’s psychological state) - Normal blood loss in normal delivery 300-500ml
- Strong sense of self-esteem meaningful support - Never apply pressure on the non-contracted uterus
system thereby promoting better labor and delivery because it may lead to eversion and result to massive
experience. bleeding
- Do not get bp if the uterus is contracting
STAGES OF LABOR - Upon delivery of the placenta, check the bp and heart
1st stage – true labor contractions to full cervical dilatation rate of the mother
1. Latent phase Credé maneuver – supporting the uterus so that it will not
- Contraction is 20-40 sec make sama with the placenta
- Cervical effacement 4th stage – 1 to 4 hours after birth
- Dilatation of 0-3cm
- 6hrs for nullipara MATERNAL & FETAL RESPONSES TO LABOR:
- 4.5hrs for multipara A. Cardiovascular
- No analgesia because this will prolong the latent - During pushing cardiac output increases by 40-50%
phase and bb will not be delivered immediately. The above pre-labor level and after delivery, blood may
longer the baby is not delivered the higher the risk flood into the pelvic vasculature and momentarily
would be because blood circulation is compromised. dropping the pressure on the vena cava
- This phase is prolonged in CPD - 1st hour after birth cardiac output will decrease by
- Woman may continue to walk and do light activities 50%
2. Active phase Note: do not make the client stand up immediately after birth.
- Dilatation of 4-7cm Elevate the head of the bed to wait for the blood to cool down
- 40-60 sec of contractions every 3-5 min and let the mother dangle the legs and after 5-10 mins, slowly
- 3hrs in nullipara assist the mother to the wheelchair or stretcher. You also have
- 2hrs in multipara to monitor the bp
- Show & rupture of membranes may occur Note again: the bp will increase during contractions with an
- Woman is told to lay on the bed average of 15mmHg with each contraction. The higher the
3. Transition phase increase, it could be a sign of pathologic supine position.
- Dilatation of 8-10cm
- Contractions at its highest peak of intensity B. Hematopoietic System
- Every 2-3 min lasting 60-90 sec Leukocytosis 25,000-30,000/mm3 due to stress
- Intense discomfort may be accompanied with nausea, Normal pre-pregnant 5,000-10,00/mm3
vomiting, feeling of loss of control, anxiety, panic, Note: do not interpret this immediately as infection
irritability C. Respiratory system – increase RR and possible
2 stage – full cervical dilatation to birth of the neonate
nd
hyperventilation of the mother (give brown paper bag if
- Anus may appear everted hyperventilating to prevent alkalosis)
- Stool may be expelled - Teach the mother proper breathing techniques
- Vaginal introitus opens
5
D. Temperature regulation increase by 1C this is brought
about by increased muscle activity and diaphoresis
(excessive sweating)
E. Fluid Balance – should be monitored and maintained
properly
F. Urinary system
- Concentrated urine
- Specific gravity of 1.020-1.030
- Not unusual for (trace 1+) protein from breakdown of
protein because there is an increase breakdown of
protein brought about by increased muscle activity
- Decrease bladder tone – there is sense of feeling
from the pressure of the fetal head upon its descent
G. Musculoskeletal System
- Cartilage may become soft during delivery as an
effect due to release of relaxin
H. Gastrointestinal System
- Becomes inactive during labor because there is
shunting of blood to more life sustaining organs and
because of the pressure on the stomach and the
intestine from the contracting uterus
- The digestive emptying time is slowed because of the
pressure brought about by the contracting uterus
I. Neuro & Sensory – pain is registered at the uterine and
cervical nerve plexuses at the level of T11 & T12
- Perineal pain is registered at S2 & S4 nerves
Causes of pain:
1. Uterine anoxia – lack of blood supply to uterus
2. Compression of nerve ganglia
3. Stretching of the cervix
4. Traction & displacement of perineum
5. Pressure of the ureter and the bladder
6. Distention of the lower uterine segment
7. Stretching of the uterine ligament
Management of pain:
1. Narcotic analgesia
- Side effects on neonate: there is depressive effect or
respiratory distress. Decreased FHT and decreased
apgar scoring.
- Side effects on mother: Can cause nausea and
vomiting, respiratory depression and transient mental
impairment.
Note: If the patient experience side effect antidote is given
which is naloxone or Narcan
2. Barbiturates
- Side effects on mother: nausea and vomiting,
hypotension, restlessness and vertifo
- Side effects on neonate: CNS depression, drowsiness
and poor sucking
3. Tranquilizer
- Side effects on mother: decreased anxiety,
hypotension, drowsiness, and dizziness
- Side effects on neonate: hypotonia (decreased
muscle tone) & hyperthermia
Psychological responses of the woman in labor:
1. Fatigue (physical and mental)
2. Fear
6
3. Cultural influences
Fetal responses to labor:
A. Neuro – with each uterine contraction there is
increased ICP (intracranial pressure)
B. Cardio – decreased heart rate by 5bpm during
contraction
C. Integumentary – pressure creates petechiae or
ecchymotic areas or even edema at the presenting
D. Musculoskeletal system – the fetus will be ideally in
full flexion during delivery
E. Respiratory system – labor process aids in the
maturation of the surfactant. Neonates through NSVD
(normal spontaneous vaginal delivery) are most likely
to have lesser incidence of respiratory distress
syndrome as compared to CS. This is because they
will go through a narrow birth canal and the chest is
compressed which helps expelling the excess fluid in
the airway and from the lungs.
The danger signs of labor:
Fetal
A. High or low FHR
- More than 160 bpm (fetal tachycardia)
- Less than 110 bpm (fetal bradycardia
- This is not good because it is indicative of fetal
distress
B. Meconium Staining
- Clear = clear
- MS = meconium stained
- TMS = thickly meconium stained
- VTMS = very thickly meconium stained
- It is indicative of fetal distress
- Babies born with this are given antibiotic prophylaxis
- If breech presentation, it is not indicative of fetal
distress
C. Hyperactivity – the fetus is becoming restless brought
about by hypoxia
D. Fetal acidosis – use of scalp capillary technique
- The pH is decreased by 7.2
Maternal
A. Rising or falling of BP, more than 140/90 mmHg
- An increase more than 30mmHg or diastolic pressure
more than 15mmHg (basic criteria for PIH/Pregnancy
Induced Hypertension)
- Decreased BP, early sign of hemorrhage
B. Abnormal pulse – more than 100bpm should be reported
this can be an indication of hemorrhage
C. Inadequate or prolonged contraction
- less intense and less frequent, uterine
exhaustion/uterine inertia
- Uterine contractions lasting longer than 70 seconds
should be reported because this may compromise the
fetal well-being
D. Pathologic retraction ring/Bandl’s ring
- Indication of impending uterine rupture which is an
emergency situation
- Opposite is the physiologic ring
E. Abnormal lower contour
 - A full bladder may be felt on the lower anterior
abdomen
- Before labor and delivery, we make sure the mother
has peed or we insert a straight catheter to excrete
urine because a full bladder impedes the effective and
full descent of the fetus and also affect uterine
contraction
F. Increased apprehension – the mother is becoming
restless
- A sign of oxygen deprivation, hemorrhage, embolism

NOTE:
Memorize Cardinal Movements of Labor, Differentiate from
True and False Contractions
Memorize Stages of Labor, Signs of Placental Expulsion And
Danger Signs