4 P’s of Labor

and Birth
Presented by:
Ana Laurice R. Nastor &
Nerissa N. Natata
RLE II-7.2
 "Hope has two beautiful "Women's strongest feelings [in
daughters. Their names are terms of their birthings],
anger and courage; anger at positive and negative, focus on
the way things are, and the way they were treated by
courage to see that they do not their caregivers." - Annie
remain the way they are." - Kennedy & Penny Simkin
Augustine
"There is power that comes to women when
they give birth. They don't ask for it, it
simply invades them. Accumulates like
clouds on the horizon and passes through,
carrying the child with it." Sheryl Feldman
 Labor is defined as the onset of rhythmic
contractions and the relaxation of the uterine
smooth muscles which results in effacement
or progressive thinning of the cervix, and
dilation or widening of the cervix (see figure 2-
1). This process culminates with the expulsion
of the fetus and expulsion of the other
products of conception (placenta and
membranes) from the uterus.
1. Passageway
a) Size of the maternal pelvis (diameters of the
pelvic inlet, midpelvis, and outlet)
b) Type of maternal pelvis (gynecoid, android,
anthropoid, platypelloid, or a combination)
c) Ability of the cervix to dilate and efface and
ability of the vaginal canal and the external
opening of the vagina to distend.
Size of the maternal pelvis
• Major pelvic bones include the two innominate
bones (formed by the fusion of the ilium, ischium,
and pubis around the acetabulum), the sacrum, and
the coccyx.
• Division:
Pelvis is arbitrarily divided into halves –
the false and the true pelvis.
False pelvis – serves to support the
weight of the enlarged pregnant uterus and
direct the presenting fetal part into the true
pelvis.
The size and the shape of the true pelvis
must be adequate for normal fetal passage
during labor and at birth. It consists of the
inlet, pelvic cavity, and the outlet.
1. Pelvic inlet – size and shape are determined
by assessing 3 anterposterior diameters:

a. Diagonal conjugate - from subpubic

angle to the middle of the sacral promontory
(12.5 cm)
b. Obstetric
conjugate - from
middle of the
sacral promontory
to an area approx.
1 cm below the
pubic crest. (DC –
1.5 cm = OC)
c. True
conjugate -
from middle of
the sacral
promontory to
the middle of
the pubic crest
(superior
surface of the
symphysis,
approx. 10.5 –
11 cm)
2. Pelvic cavity – a
curved canal with
a longer posterior
that anterior wall.
A change in the
lumbar curve can
icrease or
decrease the tilt
of the pelvis and
can influence the
progress of labor.
3. Pelvic outlet – at the lower border of true
pelvis. Its size can be determined by
assessing the transvers diameter or bi-
ishial/intertuberous diameter.
Transverse diameter – helps determine the
shape of the inlet; largest diamter and is
measured by using the linea terminalis as
the point of reference.
Four Classic Types of Pelvis
Implications for birth
Gynecoid Favorable for vaginal birth
Android Not favorable; descent into pelvis
is slow; fetal head enters pelvis in
transvers or posterior position with
arrest of labours frequent

Anthropoid Favorable for vaginal birth

Platypelloid Not favorable; fetal head engages
in transvers position; difficult
descent through midpelvis;
frequent delay of progress at
outlet of pelvis
Soft passage through maternal soft
tissue structures
• Soft tissues of the cervix, vagina and
perineum must stretch to allow passage of the
fetus through the axis of the birth canal.
• Progesterone and relaxin help facilitate the
softening & increase the elasticity of muscles
and ligaments.
Engagement
• Fetal presenting part reaches or passes
through the pelvic inlet.
• Confirms the adequacy of the pelvic inlet.
• Determined by vaginal examination.
• In primigravidas - 2 weeks before term.
• In multiparas – several weeks before the
onset of labor or during the process of labor.
Engagement
Station
• Measurement of how far the presenting part
has descended into the pelvis.
• Referrant is ischial spine.
• At ischial spines, station is“0”
• Above ischial spines, station is negative
number
• Below ischial spines, station is positive
number
• “High” or “floating” terms used to denote
unengaged presenting part.
Station
2. Passenger
 Fetal head
 Fetal attitude
 Fetal lie
 Fetal presentation
 Fetal position
Fetal Head: Bones
Measurement of the Head:
Anteroposterior diameter
Measurement of the Head:
Transverse diameter

9.5 cm

8 cm
Fetal Head: Sutures
Fetal Head: Molding
Fetal Head: Molding
• It is the overlapping of sutures of
the skull
Fetal Head: Fontanelles
 Fetal Attitude The fetus is in the
- The relation of the fetal normal attitude of
parts to one another flexion:
 moderate flexion
of the head
 flexion of the arms
onto the chest
 flexion of the legs
onto the abdomen
Fetal Attitude The fetus is in an
- The relation of the fetal abnormal attitude
parts to one another of flexion:
 extended head
 extended right arm
 a face
presentation is
illustrated
 Fetal Lie
- Relationship of the cephalo -
caudal axis of the fetus to the
cephalocaudal axis of the mother

Longitudinal lie
- occurs when the
cephalocaudal axis of
the fetus is
PARALLEL to the
woman’s spine.
 Fetal Lie
- Relationship of the cephalo -caudal axis of
the fetus to the cephalocaudal axis of the
mother

Transverse lie
- occurs when the
cephalocaudal axis of
the fetus is at a RIGHT
ANGLE to the woman’s
spine.
- the woman has a wide
short, appearance
Fetal Presentations
• Determined by fetal lie and by the
body part of the fetus that enters the
pelvic passage first (presenting part)
• There are three presentations.
• Most common: Cephalic
• Malpresentations: Breech and
Shoulder
Fetal Presentation: Cephalic
 Fetal Presentation: Cephalic
Vertex
§ Most common
§ Head completely flexed
§ Smallest dm presents
§ Occiput: presenting part
Brow
§ Partially extended
§ Largest dm presents
§ Sinciput: presenting part
Face
§ Hyperextended
§ Small dm presents
§ Face: presenting part
Military
§ Neither flexed/extended
§ Larger dm presents
§ Top of head: presenting
part
 Fetal Presentation: Breech

Fetal hips flexed; Fetal knees and hips are Fetal hips and legs are
knees extended; flexed; thighs on extended; FEET of the
BUTTOCKS of the fetus abdomen; fetus present to maternal
present to maternal BUTTOCKS and FEET pelvis
pelvis present to maternal pelvis
Fetal Presentation:
Shoulder
 A transverse lie
 Most frequently, the
shoulder is the presenting part
 The arm, back, and
abdomen may also present
 The acromion process of
the scapula is the landmark to
be noted
 Fetal Position
- The relationship of a site of the presenting
part to the location on maternal pelvis

1. Right (R) or left (L) side of the maternal

pelvis
2. Landmark of the presenting part: occiput
(O), mentum (M), sacrum (S), or acromion
process (A)
3. Anterior (A), posterior (P), or transverse (T),
depending on whether the landmark is front,
back or side of the pelvis
 Fetal Position

• LOA
- most
common
fetal
position
Fetal Engagement
• Floating: If presenting part directed towards
pelvis but can easily be moved out of inlet
• Dipping: The fetal head dips into the inlet but
can be moved away by exerting pressure on
the fetus.
• Engagement occurs biparietal diameter of
presenting part is in the pelvic inlet. In most
instances, the presenting part will be at the
level of the spine.
Station
• Engagement
– “lightening”
– 0 = At the level of ischial spines =
• Above ischial spines
- 1 to - 5
- 5 = unengaged
- 4 = pelvic inlet
• Below ischial spines
- +1 to +5
- +5 = crowning
Maternal Position

o Affects: circulation, fatigue, comfort

o Upright position
(walking, sitting. kneeling, squatting)
• Promotes descent of fetus
• Improves blood flow
• Relieves backache
• Straightens axis of birth canal
• Increases pelvic outlet
Lithotomy Position
During a woman's labor,
a birth doula offers  Facilitates physiologic
continuous care. positions for labor
 Allows for pelvic rocking
and body movements
 Encourages pelvic mobility
 Allows freedom to shift
weight for comfort
 May speed labor
 Helps contractions to be
less painful and more
productive
- creates more space
in the pelvis
- helps lessen back
labor
- help them slip out
more easily.
 This lifts up one
side of the pelvis
and creates extra
space for poorly-
positioned babies
to reposition and
rotate more easily.
3. Power
• Forces acting to expel fetus.
a. Primary force – involuntary uterine
muscular contractions causing complete
effacement and dilatation of cervix (during
first stage of labor)
b. Secondary force – use of abdominal
muscles to push during the second stage of
labor (voluntary bearing down).
Contractions
• Rhythmic but intermittent during labor
• Period of relaxation between contractions.
• Allows uterine muscles to rest.
• Restores uteroplacental circulation.
• Each contraction has 3 phases:
a. Increment – building up of contraction
b. Acme – peak of the contraction
c. Decrement – letting up of contraction.
Phases of Contractions
 Describing contractions during labor
• Frequency – time between the beginning of one
contraction and the beginning of the next
contraction.
• Duration – from the beginning of the contraction to
the completion of that same contraction.
• Intensity – strength of the contraction during acme.
a. Mild – the uterine wall can be indented easily
b. Strong – uterine wall cannot be indented.
c. Moderate – falls between the said 2 ranges.
Bearing Down
• Maternal abdominal muscles contract as the
woman pushes.
• This pushing action aids in the expulsion of
the fetus and placenta.
• Cervix is not completely dilated – cervical
edema, tearing and bruising of the cervix,
and maternal exhaustion.
4. Psychologic Response
• The progress of labor and birth can be
adversely affected maternal fear and tension
• Norepinephrine and epineprhine may
stimulate both alpha and beta receptors of
the myometrium and interfere with the
rhythmic nature of labor.
• Anxiety can also increase pain perception
and lead to an increased need for analgesia
and anesthesia.
4. Psychologic Response
• A woman who is relax, aware and
participating in the birth process usually
has a shorter, less intense labor.

• A woman who is fearful has high levels of

adrenaline which shows uterine contractions.
 Speak tenderly to them. Let
there be kindness in your
face, in your eyes, in your
smile, in the warmth of our
greeting. Always have a
cheerful smile. Don't only give
your care, but give your heart
as well.
- Mother Teresa