Onset of Labor

Maternal factors:

• Stretching of uterine muscle.

• Pressure on the cervix.
• Oxytocin stimulation (oxytocin and prostaglandin work together to produce uterine muscle
contractions).
• Change in estrogen/progestin ratio (estrogen increases uterine muscle response/progestin
relaxes the uterine musculature).

Fetal factors:

Placental aging.

• Fetal cortisol concentration (cortisol is produced by the fetal adrenal glands and serves to
increase placental production of progestin and prostaglandin).
• Prostaglandin (originating from the fetal membranes).

Preparation for Labor

Lightening:

• A unique process in a primigravida (a woman having her first baby).

• Occurs over a 10- to 14-day period.
• Does not typically occur in multigravida (a woman who has been pregnant one or more times).

Lightening is perceived by the woman as:

• Relief from shortness of breath.

• Less diaphragmatic pressure.
• Increased pelvic pressure.

Preparation for Labor:

• Lightening
 Braxton Hicks contractions ("false labor")
 False vs. True labor

Preparation for Labor

• Lightening
• Braxton Hicks contractions
• Ripening of cervix
• Effacement (thinning)
• Primigravida: Effacement precedes dilation.
• Multipara: Effacement and dilation are simultaneous.

Preparation for Labor:

• Lightening
 • Braxton Hicks contractions
• Ripening of cervix
• Bishop score

Bishop score considers:

• Effacement
• Consistency
• Position

Dilation

Fetal station (relationship of the presenting part to the level of the ischial spines)

For women at term, a Bishop score of 6 or higher is a useful predictor of the onset of labor within 7 days.

Preparation for Labor:

• Lightening

• Braxton Hicks contractions

• Ripening of cervix

• Bishop score

• Mucus plug/bloody show

Mucus Plug:

• Occludes the cervical canal during pregnancy • Inhibits ascension of bacteria into gravid uterus

Show:

• Indicative of capillary rupture.

Notation Technique

• Gravida: Number of pregnancies

Parity: Pregnancy outcome

Notation of Parity

• Gestation

• Number of living children

Information is documented in this order:

• Full Term: >37 weeks

• Preterm: 20 to 36 weeks

• Abortion: <20 weeks

• Living Children

(Some professionals use the mnemonic "Florida Power And Light" to remember the sequence of parity.)

Example: A woman who has been pregnant 4 times, within 2 term children, 1 preterm child, and 1
miscarriage. Her gravida and parity is written as G4P2113.

Determining the "Due date"

Gestational age: Based on last menstrual period (LMP). • Conceptional age: Based on when ovum was
fertilized.

A full-term pregnancy is 40 weeks gestational age, or 280 days from the first day of the last menstrual
period.

Due date is based on gestational age:

• Estimated date of confinement (EDC), or

• Estimated date of delivery (EDD)

Due date is based on gestational age:

• Estimated date of confinement (EDC). or

• Estimated date of delivery (EDD)

Nägele rule:

• Determine LMP (month/day).

• Subtract 3 calendar months from the LMP month.

• Add 7 days from the LMP day.

• Result of steps 2 and 3 are the month and day of the due date, respectively.

Example:

• LMP = July 13 (7/13)

• Subtract 3 calendar months (7-3 = 4, which is April)

• Add 7 days to the date: 13+ 7 = 20

• EDC = 4/20 or April 20

Passage or Birth Canal

Hormones and soft tissue changes influence the birth canal.

Four Primary Maternal Pelvic Shapes

Android: "Male" Pelvis

• Acute angle at arch

• Narrow outlet

Anthropoid: "Apelike" Pelvis

• Narrow transverse diameter

Gynecoid: "Normal" female pelvis

• Rounded inlet

• Wide pubic arch

Platypelloid: "Flattened" pelvis

• Short anterior-posterior diameter

Android Pelvis:

• Occurs in approximately 20% of women.

• Typically described as a heart shaped pelvis. • Carries a poor prognosis for vaginal delivery.

Anthropoid Pelvis:

• Occurs in approximately 25% of women.

• Carries a good prognosis for vaginal birth.

Platypelloid Pelvis:

• Present in only 5% of women.

• Carries a poor prognosis for vaginal birth.

• Fetal presenting part is unable to engage.

• Cesarean section is very common for women with this type of pelvis.

Gynecoid Pelvis:

• Ideal for vaginal birth

• Present in approximately 50% of women

Passenger (Fetus)

Head or Vertex:

• Largest body part.

• Most common presenting part (first into the birth canal) in childbirth.
• The smallest head diameter fits into the smaller pelvic opening, and the widest fetal head diameter fits
into the widest area of the pelvis.

Fetal head comprised of 8 bones that are incompletely joined.

• Bones are separated by fontanelles.

• Molding: Bones conform to shape of maternal pelvis during descent.

When vertex enters the birth canal at an irregular angle, the fetal head may sustain: • Caput
succedaneum: Asymmetrical pressure causes swelling. • Cephalhematoma: Pressure causes collection of
blood from broken blood vessels under the scalp.

Variations in Presentation

Cephalic presentations:

• Vertex

• Brow

• Face

• Mentum (chin)

Breech presentation:

• Buttocks

• Feet

Shoulder presentation:

• Fetus lies across the maternal abdomen.

Fetal position:

• Presenting part is used to describe position in relation to the maternal pelvis.

• The maternal pelvis is divided into quadrants:

• Right and left anterior

• Right and left posterior

Fetal anatomy is used to describe the relationship of the presenting part to the maternal pelvis:

• Vertex presentation: Occiput (posterior skull bone) is the landmark.

• Face presentation: Mentum (chin) is the landmark.

• Breech presentation: The sacrum is the point of reference.

Fetal attitude:

• Describes the degree of fetal flexion.

Complete flexion:

• Fetus presents the smallest skull diameter into the pelvis. • The body assumes an oval shape,
occupying the smallest possible space.

Incomplete flexion:

• Wider head diameters enter the pelvis first.

• Possibly inhibits descent into the birth canal.

Leopold maneuvers:

• Method to determine fetal position and presentation.

Engagement: The settling of the presenting part into pelvic inlet.

Station: The relationship of the presenting part to the level of the ischial spines.

When the head reaches +4, the vertex is visible at the introitus and is said to be crowning.

Passenger

• Fetus is an active participant in the birth process.

• Navigates through the birth canal by keeping the smallest diameter of the head presenting to the
smallest diameter of the birth canal.

Cardinal movements of labor:

• Descent: Fetus passes through the fully dilated cervix.

• Flexion: Head flexes so the chin rests on the fetal chest.

• Internal Rotation: Head rotates, occiput moves to the superior position just under the pubic
symphysis.

• Extension: Occiput slides under the symphysis.

• External rotation (restitution): Head turns after completely emerged from the birth canal.

Passenger

• Fetus is an active participant in the birth process.

• Navigates through the birth canal by keeping the smallest diameter of the head presenting to the
smallest diameter of the birth canal.

Cardinal movements of labor:

• Descent: Fetus passes through the fully dilated cervix.

• Flexion: Head flexes so the chin rests on the fetal chest.

• Internal Rotation: Head rotates, occiput moves to the superior position just under the pubic
symphysis.

• Extension: Occiput slides under the symphysis.

• External rotation (restitution): Head turns after completely emerged from the birth canal.

Power Source for Labor:

• Uterine musculature

• Uterine contraction originates at the fundus

Maternal Psyche

Factors that may influence birth experience:

• Anxiety

• Uncertainty

• Loss of control

• Past experiences

• Attachment to support systems

• Cultural expectations

Maternal history of abuse presents special challenges to health care providers.

Sensations of labor may precipitate flashback of the abuse.

Strategies for care givers:

• Help maintain focus on reality.

• Minimize anxiety.

• Work with the woman and her partner to identify ways for her to have maximum control and power
during the labor and birth.

• Be sensitive to woman's anxiety level.

Stages of Labor and Birth

• Stage I: Labor to full cervical dilatation

• Stage II: Full cervical dilatation to birth

• Stage III: Birth until delivery of placenta

• Stage IV: First hour postpartum

Stage I: Labor to full cervical dilatation

Three phases of Stage I

• Latent
• Active
 Transition

Assessments for risk/complications:

• Blood pressure, pulse, respiration, and temperature

• Uterine contraction pattern

• Fetal heart rate

Other vital information:

• Urinary protein and glucose

• Cervical exam findings (presentation, station, effacement, dilatation)

• Membrane status (intact, ruptured and if so, description)

• Fetal movement

In absence of risk factors, assess and document...

Maternal vital signs:

• q4h or less

and...

Fetal heart rate:

• q 30 min during active labor

• q 15 min during second stage

Assessment (continued):

Maternal pulse or uterine souffle.

Rupture of Membranes

• May occur prior to or during labor.

• Signs: gush of fluid from vagina or steady leaking of amniotic fluid. • Risk for infection and cord
prolapse after membrane rupture.

Characteristics:

Normally clear.

• May contain flecks of vernix.

• May be green, reddish, or combination.

• Green suggests meconium stain.

• Red suggests hemorrhage (eg, placental abruption).

Assess:

Obtain sample of fluid perineum.

• Nitrazine paper confirms the pH is greater than 6.5 (appears blue-green).

Stage I: Latent Phase

• Cervical dilatation: 0 to 3 cm

• Duration

• Primigravida: 8.5 h

• Multipara: 5 h

• Contractions

• Mild

• Regular or irregular

• Short duration, yet persistent

Most women will continue with their daily activities even though they are aware the time for labor has
arrived.

Stage I, Active Phase: "Phase of Maximum Slope"

• Cervical dilatation: 4 to 7 cm

• Duration

• Primigravida: 4.5 h

• Multipara: 2.5 h

• Contractions

• Moderate to strong

• Regular, q 2 to 5 min

• Last 1 min

• Rate of cervical dilatation

• Primigravida: 3.5 cm/h

• Multipara: 9 cm/h
Stage I Nonpharmacologic Pain Relief

• Emotional and physical support from partner, family members, and birth attendants.

• Relaxation techniques including imagery, music, self-hypnosis, and patterned breathing.

• Cutaneous techniques:

• Massage, effleurage, counterpressure, acupuncture, heat/cold, and hydrotherapy.

• Physical activity, such as walking, squatting, and use of a birthing ball.

• Intradermal injections of sterile water. (Four intradermal injections of 0.1 mL of sterile water are
placed over the sacrum, leaving a fluid-filled wheal similar to a tuberculosis test.)

Stage I Pharmacologic Pain Management

Analgesics:

• Sedatives.

• Hypnotics may be used as a sleep agent during prolonged latent phase.

Parenteral opioids are most commonly used during active labor.

Regional anesthesia:

• Local infiltration administered prior to episiotomy.

• Pudendal block is usually limited to second stage.

• Epidural analgesia

Stage I, Transition Phase

• Cervical dilatation: 8 to 10 cm

• Duration

• Primigravida: 3.5 h

• Multipara: minutes to hours

• Contractions

• Strong

• Regular, q 1.5 to 2 min

• Last 60 to 90 seconds

Friedman Curve: Used to summarize progress of labor.

Stage I

Factors that may affect labor progress:

• Pharmacological intervention

• Timing of rupture of membranes

• Maternal psyche

• Maternal activity

• Maternal position

• Fetal size

• Fetal position

• Parity

Stage I Assessment

Electronic fetal monitoring evaluates:

• Labor progress

• Fetal well being

Monitors:

• Uterine contractions

• Fetal heart rate

• Continuous

• Intermittent

• External

• Internal

Stage I Assessment

External monitoring:

• Uterine contractions

• Fetal heart rate

Information printed on graph paper

Stage I Assessment

External monitoring:
• Normal tracing

Limitation of monitoring:

• Amplitude of tracing does not indicate the strength or intensity of contraction.

Assess contractions with fingertips:

Mild: Perceived, but fundus can be indented.

• Moderate: Fundus can be slightly indented.

• Firm: Fundus cannot be indented.

Stage I Assessment

Internal monitoring:

More exact measurement of fetal heart rate and contraction with electronic fetal monitor.

• Accurate assessment of contraction frequency, duration, intensity.

• Documents uterine resting tone.

• Documents fetal heart rate and fetal heart rate variability.

Fetal heart rate variability reflects variation in the beats per minute over time. Normally this variation is
between 5 and 25 beats per minute and is considered a reliable indicator of fetal well being.

Normal Tracing

Characteristics:

• Fetal heart rate: 120 to 160/min

• Excellent variability

• Contractions: q 2.5 to 3 min

⚫ Duration: 60 sec

• Intensity: 60 mm Hg (>50 mm Hg is considered moderate to strong)

• Uterine resting tone: 10 to 20 mm Hg (within normal limits)

Stage I

Factors that may affect labor progress:

• Pharmacological intervention

• Timing of rupture of membranes

• Maternal psyche

• Maternal activity
• Maternal position

• Fetal size

• Fetal position

• Parity

Stage I Assessment

Electronic fetal monitoring evaluates:

• Labor progress

• Fetal well being

Monitors:

• Uterine contractions

• Fetal heart rate

• Continuous

• Intermittent

• External

• Internal

Stage I Assessment (continued)

Auscultation vs. Electronic Monitoring:

• Patient history

• Fetal condition

• Risk classification

• Hospital policies and procedures

• Standard of practice

Stage I Assessment

Vaginal examination:

• Use systematic approach.

• Avoid unnecessary exposure

• Position for comfort and to avoid compression of vena cava.

Avoid using antiseptics, such as povidone-iodine and hexachlorophene:

• Do not decrease infection.

• Are likely to cause local irritation.

• Possible systemic absorption.

Stage I Assessment

Vaginal examination:

• Identify the cervix and assess:

• Consistency

• Dilatation

• Effacement

• Identify the ischial spines and determine station.

• Identify anterior or posterior fontanelle to determine fetal position (vertex presentation).

Stage II: Full cervical dilatation to birth

Two phases of Stage II:

• Phase 1: From full cervical dilatation to spontaneous bearing down.

• Phase 2: Onset of vigorous and spontaneous bearing down efforts until birth.

Stage II: Full cervical dilatation to birth

• Cervix is fully dilated.

• Fetus begins descent through birth canal.

• Associated sensations:

• Urge to vomit (due to vagal reflex).

• Involuntary urge to push.

Coaching during Stage II

Closed glottis pushing:

• Traditional approach.

• Woman coached to hold deep breath for 10 seconds while bearing down.

• No sound is uttered with pushing efforts.

• Knees are drawn up toward abdomen.

• Associated with risks to mother and fetus.

Open glottis pushing:

• Un-coached technique. • May occur involuntarily.

• Less impact on uteroplacental blood flow.

• Better tolerated by mother and fetus.

• Physiologic.

• Results in shorter second stage.

Positioning during Stage II

Upright position shortens second stage.

Laboring Down

Used in situations when a woman does not perceive an urge to push (such as regional analgesia).

• Fetus descends passively.

• Useful when urge to push is absent.

• Active pushing is delayed.

• Lateral position until mother perceives the urge to push (Ferguson reflex).

• Improves success rate for vaginal birth.

• Reduces maternal fatigue.

• Second stage is not significantly prolonged.

• Fewer complications.

Positioning during Stage II

• Allow woman to select position.

• Positions that lessen tension on the perineum:

• Lateral

• Sims position

• Semi-sitting

• All fours position

• Squatting

Stage II: Birth

When baby's head is visible at the introitus.

Birth attendant:

• Supports the head.

• Provides gentle pressure on presenting part.

• Supports perineum to reduce risk of tearing.

Stage II: Birth

Birth attendant:

• Suctions infant's nose and mouth.

• Checks for presence of nuchal cord (umbilical cord around neck).

After the head is delivered, external rotation (restitution) occurs.

Birth attendant:

• Lowers the head to facilitate of anterior shoulder.

• Raises head and neck to allow birth of posterior shoulder.

• Supports infant as rest of body is born quickly.

• Clamps cord.

Stage III: Birth until delivery of placenta

Two phases of Stage III:

• Phase 1: Separation of the placenta.

• Phase 2: Expulsion of the placenta.

Phase 1: Separation of the placenta.

• As separation begins the maternal surface begins to bleed.

• Gentle tension may facilitate separation.

• AVOID strong traction.

Signs of placental separation:

• Lengthening of the umbilical cord

• Sudden gush of vaginal blood.

• Change in the shape of the postpartum uterus.

Stage III: Birth until delivery of placenta

Phase 2: Expulsion of the placenta.

Schultze placenta

• Placenta folds on itself showing shiny fetal surface during expulsion.

• "Shiny Schultze"

Duncan placenta
• Placenta slides along uterine wall and maternal side exposed during expulsion.

• "Dirty Duncan"

Involution of the uterus begins. Normal blood loss is approximately 500 mL.

Stage IV: First hour postpartum

Postpartum stage:

• Stabilization

• Transition

Physical assessment:

Assess maternal vital signs, including blood pressure and pulse, q 15 min.

• Evaluate uterine fundus for tone and position.

• Bleeding from placental site increases with uterine atony.

• Reduce risk of uterine atony by fundal assessment and massage as necessary.

Postpartum stage:

Stabilization

• Transition

Physical assessment:

• Assess maternal vital signs, including blood pressure and pulse, q 15 min.

• Evaluate uterine fundus for tone and position.

• Bleeding from placental site increases with uterine atony. • Reduce risk of uterine atony by fundal
assessment and massage as necessary.

BUBBLE

Breast

Uterus

Bowel

Bladder

Lochia

Episiotomy/Laceration/ C-Section

Stage IV Pain Management

Postpartum Pain:
• Episiotomy

• Lacerations

• Perineal trauma

• Incisions

• Uterine contractions - "afterbirth pains"

• Hemorrhoids

• Breast engorgement

• Nipple tenderness

Stage IV Psychosocial Assessment

• Ongoing

• Maternal-infant relationship

Family dynamics

Nursing outcomes based on:

• Dependent function

• Interdependent functions

• Independent functions

Independent nursing functions:

• Supportive care during labor

• Patient knowledge of labor and birth

• Postpartum care

• Newborn care

• Pain management during the perinatal period

Quality of care is measured by:

• Patient outcomes

• Quality improvement

• Clinical indicators

Quality of service is measure by:

• Patient Satisfaction

Contraction frequency:
• Time from beginning of one contraction to the beginning of the next, or from contraction peak to
peak, so long as the method is consistent.

• Expressed in terms of minutes (ie "every 3 minutes").

Contraction intensity:

• Expressed as mild, moderate, or firm.

• Mild: The fundus can be easily indented during the contraction.

Moderate: The fundus can be slightly indented during the contraction.

Contraction duration:

• Time from the beginning of a contraction to the end of the contraction.

Expressed in terms of seconds.

Resting tone:

• Tone of the uterus in the absence of contractions or between contractions.

• Expressed in terms of soft or firm.

Intermittent Auscultation of Fetal Heart Tones

Hand-held Doppler is the most common.

Auscultate before, during, and after a contraction for the most reliable means of ensuring fetal well
being.

• Normal fetal heart baseline rate is between 110 and 160 beats per minute.

• Normal for the rate to vary from 5 to 25 beats per minute.

• Fetal movement may increase rate between 15 and 20 beats before returning to baseline (a reassuring
sign).

• In absence of risk factors assess fetal heart rate every 30 minutes during active labor and every 15
minutes in the second stage of labor.

• If risk factor are present assess every 15 minutes during active labor and every 5 minutes in the second
stage.

• If primary method of fetal surveillance during labor requires 1:1 nurse-patient ratio.

Summary

Key Points

• Although there are common theories, the true impetus for labor onset is yet unknown.
There are four key factors that play a vital role in normal labor and birth: passenger, power, passage,
and psyche. Nurses play a key role in facilitating a normal birth and providing support to the mother and
her family during the process.

• There are four stages of labor and birth, each with a specific milestone, characteristic duration,
contraction pattern, maternal behavior, and physical sensation.

• A nurse's recognition of normal labor provides a foundation for maternal support, anticipatory
guidance of the family, and recognition of the events that may require intervention to improve
maternal-fetal outcome.