Labor
 regular contractions to gradual cervical effacement 3. Ripening of cervix
and dilatation.
 adequate pressure from abdominal muscles allows
the baby to be pushed outside the mother’s womb
 thinning of the cervix
THEORIES OF LABOR:
1. Fetal Adrenal response theory (contraction)
 the theory suggests that when a pregnant woman
experiences stress or encounters stressors, her body
may release stress hormones such as cortisol. These
stress hormones can cross the placenta and reach
the fetus, potentially affecting the developing fetal
adrenal glands.
 The fetal adrenal glands are responsible for
producing hormones, including cortisol.
2. Oxytocin Stimulation Theory
 Pressure on the cervix stimulates the hypophysis to
release oxytocin from the maternal posterior
pituitary gland. As pregnancy advances, the uterus
becomes more sensitive to oxytocin: presence of this
hormone causes the initiation of contraction of the
smooth muscles of the body ( uterus is composed of
smooth muscles)
 Oxytocin - pituitary gland of mother (posterior
pituitary glands)
 helps in contractions
 Oxytoxinase - the one lowered and control oxytocin
3. Uterine Stretch Theory
 any hollow body organ when stretched to its
capacity will inevitably contract to expel its contents
4. Theory of Aging Placenta
 placental function is up to 40 weeks
 Advance placental age decreases blood supply to the
uterus. This even triggers uterine contraction,
thereby, starting the labor
5. Progesterone Deprivation Theory
 when placenta is matured it will lowered production
of progesterone where oxytocin to act on the uterus
then contraction will begin
 Reduced progesterone inhibits labor
6. Prostaglandin Theory
 in the latter part or pregnancy, fetal membranes and
uterine decidua increase prostaglandin levels. This
hormone is secreted from the lower area of the fetal
membrane (forebag). A decrease in progesterone
amount also elevates the prostaglandin level.
Synthesis of prostaglandin, in return, causes uterine
contraction thus, labor is initiated.
CERVICAL CHANGES:
1. Effacement
 the shortening and thinning of the cervical canal
2. Dilatation
 the enlargement or widening of the cervical canal
from
SIGNS OF LABOR:
1. Increase Braxton Hicks Contraction
 sporadic contraction and relaxation of the uterine
muscle
 Irregular painless of pregnancy
2. Lightening of baby dropped
 occur 2 weeks onset, muscle cramps, frequent
urination
 in terms of effacement (%) and dilatation (cm)
 ripen the cervix pag dilated
 1 (tip of pointing finger)
 1.25- 1.5 (tip of middle finger)
 Primipara (10cm) - una effacement bago dilatation
 Multipara (7-8cm) - sabay effacement at dilatation
Measure degree of effacement:
 3/4 - 25%
 1/2 - 50%
 1/4 - 75%
 Paper thin - 100%
4. Increased level of activity
 2 weeks before onset of labor, lowering amount of
progesterone where adrenaline start to produce
epinephrine that results to hype the mother, but
that energy should be conserve.
5. Weight loss
 2 weeks before labor sudden weight loss, 2-3 lb,
because lowering level of progesterone, edema
subsides
6. Show
 because contraction pressing and pressure against
capillaries where mucus plug will be sloughed off
7. Rupture of membranes
 delivery must go within 24 hrs after rupture
membranes, frequent IE is not advisable (can cause
contractions)
TYPES OF CONTRACTIONS:
1. False contractions
 begin and remain irregular
 Felt first abdominally and remain confined to the
abdomen and groin
 Often disappear with ambulation or sleep
 Do not increase in duration, frequency, or intensity
 Do not achieve cervical dilatation
2. True contractions
 begin irregularly but become regular and predictable
 Felt first in lower back and sweep around to the
abdomen in a wave
 Continue no matter what the woman’s level of
activity
 Increase in duration, frequency, and intensity
 Achieve cervical dilatation
STAGES OF LABOR:
1. First stage (stage of dilatation)
 Begins with the initiation of true labor contractions
and ends when the cervix is fully dilated
Phases:
a. Latent phase
 begins at the onset of regularly perceived uterine
contraction and ends when rapid cervical dilatation
begins
 cervical dilatation – 0 to 3cm
 minutes of contractions – 20 to 40 secs occur every 5 to
20 min
 phase duration – 6 hours (nullipara), 4.5 hours (multipara)
b. Active phase
 cervical dilatation: 4 to 7cm
 minutes of contractions: 40 to 60 secs occur every 3
to 5 mins
  phase duration: 3 hours (nullipara), 2 hours
(multipara)
 Show (increased vaginal secretions) and perhaps
spontaneous rupture of the membranes may occur
during this time
c. Transition Phase
 cervical dilatation : 8 to 10 cm
 minutes of contractions : 60 to 70 secs occur every 2
to 3 minutes
 phase duration: 1 hour (nullipara), 30 mins
(multipara)
 By the end of this phase, both full dilatation (10cm)
2. Second stage (stage of delivery)
 time span from full dilatation and cervical
effacement to birth of the infant
 A woman typically feels contractions change from
the characteristic crescendo-decrescendo pattern to
an uncontrollable urge to push or bear down with
each contraction as if to move her bowels
3. Third stage (the placental stage)
 begins with the delivery ends with the delivery of
placenta
Placental Separation
 as the uterus contracts down on an almost empty
interior, there is such a disproportion between the
placenta and the contracting wall of the uterus, that
folding and separation of the placenta occur
(If there’s no contractions meaning naaa pay placenta present)
SIGNS OF DELIVERY OF PLACENTA:
1. There is lengthening of the umbilical cord
2. A sudden gush of vaginal blood occurs
3. The placenta is visible at the vaginal opening
4. The uterus contracts and feels firm again
TYPES OF PLACENTA:
1. Schultze
 the fetal part of the placenta. Usually shiny in nature
due to fetal membrane
 dark side
2. Duncan
 the side that attaches to the mother or maternal
side. Usually considered the dirty part due to the
presence of raw, red and irregular with the ridges or
cotyledons (15 to 20 normal) that separates blood
collection spaces evident.
PLACENTAL EXPULSION
 natural bearing effort of the mother or by gentle
pressure on the contracted uterine fundus by the
primary health care provider (a Crede’s maneuver)
 If the placenta does not delivery spontaneously, it
can remove manually
4 P’s OF LABOR
1. Passage
2. Passenger
3. Powers
4. Psychological outlook (psyche)
1. Passage (pelvis)
 Refers to the route a fetus must travel from the
uterus through the cervix and vagina
 At the pelvic inlet, the anteroposterior diameter is
the narrowest diameter
2. Passenger (the fetus)
 Head is the part of fetus that has widest diameter
 the cranium, the uppermost portion of the skull, is
composed of 8 bones:
 the four superior bones - the frontal (actually 2
fused bones), two parietal and the occipital
 sphenoid, ethmoid, and two temporal bones
Diameters of the fetal skull:
To fit through the inlet of the birth canal best, a fetus must
present the smallest diameter (the transverse diameter) of the
head to the smallest diameter of the maternal pelvis (the
diagonal conjugate)
Molding
 the overlapping of skull bones along the suture lines,
which causes a change in the shape of the fetal skull
to one long and narrow, a shape that facilitates
passage through the rigid pelvis
Fetal Presentation and Position:
1. Fetal attitude
 attitude describes the degree of flexion a fetus
assumes during labor or the relation of the fetal
parts to each other
 a fetus in good attitude is in complete flexion: the
spinal column is bowed forward, the head id flexed
forward so much that the chin touches the sternum
2. fetal position
 the relationship of the presenting part to a specific
quadrant and side of a woman’s pelvis. For
convenience, the maternal pelvis is divided into four
quadrants according to the mother’s right and left:
A) right anterior
B) left anterior
C) right posterior
D) left posterior
3. Fetal lie
 lie is the relationship between the long
(cephalocaudal) axis of the fetal body and long
(cephalocaudal)
4. Fetal presentation
 denotes the body part that will first contact the
cervix or be born first
 the fetal head is the body part that first contact the
cervix
TYPES OF FETAL PRESENTATION:
1. Cephalic Presentation
 the fetal head first contact the cervix
2. Breech Presentation
 either the buttocks or the feet are the first body part
that contact the cervix
3. Shoulder Presentation
 fetus lies horizontally in the pelvis and the
presenting part is usually one of the shoulders
(acromion process), an iliac crest, a hand, or an
elbow
Station
 refers to the relationship of the presenting part of
the fetus to the level of the ischial spines
 when the presenting part is at the level of the ischial
spines, it is at a 0 station (synonymous with
engagement)
MECHANISM OF LABOR (cardinal movements)
 effective passage of fetus through fetal canal
  the position changes to keep the smallest diameter
of the fetal head
Cardinal movements: 5. Fluid balance
 descent  insensible water loss increases during labor due to
 the downward movement of the biparietal diameter diaphoresis
of the fetal head within the pelvic inlet. Occurs due 6. Urinary system
to pressure  ask a woman to void approximately every 2 hours
during labor to avoid over-filing can decrease
 flexion postpartal bladder tone
 the head bend forwards onto the chest, causing the  pressure on the fetal head as it descends in the birth
smallest anteroposterior diameter. canal against the anterior bladder reduces bladder
 flexion is also aided by abdominal muscle tone or the ability of bladder to sense filling.
contraction during pushing floor 7. The musculoskeletal system
 throughout the pregnancy, relaxin is secreted from
 internal rotation the ovaries, a hormone released from the ovary
 bring the shoulders, coming next into the optimal causing the cartilage between joints to be more
position to enter the inlet flexible
8. Gastrointestinal system
 extension  becomes fairly inactive during labor
 the head extends, the foremost parts of the head, 9. Neurologic and sensory responses
the face and chin are born  occur during labor are those which typically occur
with pain
 external rotation  increased respiratory rate
 the fetal head rotates, this brings the after coming 10. Psychological Response
shoulders into an anteroposterior position, which is  labor can lead to emotional distress
best for entering the outlet
MATERNAL PHYSIOLOGIC EFFECTS AND PSYCHOLOGICAL
 expulsion RESPONSES:
 once the shoulder are born, the rest of the baby is
born easily Response to pain
 women are encouraged to help plan their care. in
Engagement addition, every woman responds to cultural cues in
 refers to the settling of the presenting part of a fetus some way. This makes her response to pain, her
far enough into the pelvis choice of nourishment, her preferred birthing
position, the proximity and involvement of a support
3. Power (uterine factors) person, and customs related to the immediate
 The force supplied by the fundus of the uterus and postpartal period highly individualized.
implemented by uterine contractions which cause Response to fatigue
cervical dilatation and the expulsion of fetus from  a woman is generally tired from the burden of
the uterus carrying so much extra weight and has not slept well
for the past month
PHASES OF CONTRACTION: Response to fear
1. The increment  this sense or lack or control combined with pain may
 When the intensity of the contraction increase cause her to begin to worry for her infant and make
2. The acme her afraid she will not meet her own behavioral
 When the contraction is at its strongest expectations
3. The decrement
 When the intensity decreases FETAL RESPONSES TO LABOR:
The Neurologic system
4. Psyche  increased in intracranial pressure
 a woman’s psychological outlook  decrease in fetal heart rate 5 bpm during
 Refers to the psychological state or feelings a woman contractions
brings into labor  the decrease in FHR appears on a fetal heart monitor
as a normal or early deceleration pattern
MATERNAL AND FETAL RESPONSES TO LABOR: The Cardiovascular system
 the increase in blood pressure caused by increased
Physiologic Changes: intracranial pressure raises blood pressure and keeps
1. The cardiovascular system circulation from falling below normal for the
 each uterine contraction greatly decreases blood duration of a contraction
flow to the uterus because the contracting uterine Integumentary system
wall puts pressure on the uterine arteries  the pressure involved in the birth process is often
 Blood loss will happen around 300 to 500ml reflected in minimal petechiae or ecchymotic areas
2. The hematopoietic system on a fetus (particularly the presenting part). There
 the major change in the blood-forming may also be edema of the presenting part (caput
3. Respiratory system succedaneum) from this pressure
 whenever there is an increase in a cardiovascular Musculoskeletal system
parameter, the body responds by increasing the  the force of uterine contractions tends to push a
respiratory rate to supply additional oxygen. fetus into a position of full flexion or with the head
4. Temperature regulation bent forward, which is the most advantageous
 increase muscular activity position for birth
 increase body temperature Respiratory system
  the process of labor appears to aid in the maturation
of surfactant production by alveoli in the fetal lung.
 the pressure applied to the chest from contractions
and passage through the birth canal can help to
clear the respiratory tract of lung fluid.
MATERNAL DANGER SIGNS OF LABOR:
Blood pressure
 a BP of 140/90 mmHG (sign for gestational
hypertension)
 Decreasing blood pressure because it may be the
first sign of intrauterine hemorrhage
 Hypovolemic shock
 Rises slightly in the second (pelvic) stage of labor
because of their pushing effort
Abnormal pulse
 Normal pulse rate during pregnancy: 70 to 80 bpm
 Greater than 100 bpm: indication of hemorrhage
Inadequate or prolonged contractions
 as a rule, the uterine contractions lasting longer than
70 seconds are becoming long enough to
compromise fetal well-being because it interferes
with adequate uterine artery filling
 less frequent or shorter in duration: indicate uterine
exhaustion (inertia)
Abnormal lower abdominal contour
 ask patient to void every 2 hrs
 if a woman has full bladder during labor, a round
bulge appears on her lower anterior abdomen. This
is a danger signal for two reasons:
1. the bladder may be injured by the pressure if fetal head
pressing against it
2. the pressure of full bladder may not allow the head to
descend
Increasing apprehension
 apprehension - anxiety or fear that something bad
or unpleasant will happen
 cause they might have some concern that has not
been met
FETAL DANGER SIGNS OF LABOR:
High or low fetal hear rate
 normal rate : 120 - 160bpm
 160 bpm (fetal tachycardia) or 110 bpm (fetal
bradycardia) is a sign of possible fetal distress
 Frequent monitoring by a fetoscope, doppler and
monitor is necessary to detect these changes as they
first occur
Meconium staining
 a green color in the amniotic fluid, reveals the fetus
has had a loss of rectal sphincter control allowing
meconium to pass into amniotic fluid
 It may indicate a fetus has or is experiencing
hypoxia, which stimulates the vagal reflex and leads
to increased bowel motility
Hyperactivity
 Ordinarily fetus remains quiet and barely moves
during labor
 Fetal hyperactivity may be sign of hypoxia because
frantic motion is common reaction to the need for
oxygen
Low oxygen saturation
 oxygen saturation in a fetus is normally 40 o 70%
 if fetal blood is obtained by scalp puncture, the
finding of acidosis (blood pH lower than 7.2) need
to report.
FOUR METHODS USED TO DETERMINE IF FETUS IS IN AN
OPTIMAL PISITION FOR BIRTH:
1. Determining the place on the patient’s abdomen where fetal
heart tones are heard strongest
2. Abdominal inspection and palpation: Leopold’s Maneuver
3. Vaginal Examination
4. Sonography
Leopold’s Maneuver
 systematic method of observation and palpation to
determine fetal presentation and position.
Vaginal Examination
 necessary to determine the extent of cervical
softening, effacement, and dilatation to confirm the
fetal presentation, position and degree of descent.
 Don’t perform if there is presence of fresh bleeding
because it indicates that placenta previa
(implantation of the placenta so low in the uterus is
encroaching on the cervical os) is present.
Sonography
 Used to determine the diameters of the fetal skull
and to determine the presentation ,position ,flexion
and degree of descent of fetus
 Usually done by a portable unit
VITAL SIGNS:
Temperature
 Usually obtained every 4 hours during labor
 After rupture of membranes, the temperature
should be taken every 2 hours
 99F (37.2C) report because it may indicate infection
Pulse
 Normal rate during labor: 70 to 80 bpm
 More than 100 bpm may indicate tachycardia
because of dehydration or hemorrhage
Respiration
 Normal rate during labor: 18 to 20 bpm
 Don’t count during contractions
 Observe for hyperventilation (rapid, deep
respiration) because it can cause a “blowing off” of
carbon dioxide and accompanying of symptoms such
as dizziness, and tingling of the hands and feet.
ASSESSMENT OF UTERINE CONTRACTIONS:
Length of contractions (duration)
 to determine the beginning of a contraction without
a monitor, rest a hand on a woman’s abdomen at
the fundus of the uterus very gently until sense the
gradual testing and upward rising of the fundus that
accompanies a contraction.
 To determine with a monitor, observe the rhythm
strip and using the time line, count the number of
seconds the contraction lasted
Intensity of contractions (strength)
-if assessing manually, rate a contraction according to:
 Mild - the uterus does not feel more than minimally
tense
 Moderate - if the uterus feels firm
 Strong - if the uterus feels as hard as a wooden
board or you are unable to indent the uterus with
your fingertips at the peak of the contraction
Frequency of contractions
 frequency- is timed from the beginning of one
contraction to the beginning of the next
LABORATORY ANALYSIS
Blood
  drawn for hemoglobin and hematocrit, blood typing  Duration: 15 seconds or more but less
to determine whether a blood incompatibility is than 2 minutes
likely to exist in the newborn and what type of blood  Before 32 weeks of gestation:
need to be supplied  Peak: 10 bpm
 Duration: 10 seconds or more but less
than 2 minutes

Urine  Prolonged acceleration

 obtain a clean-catch urine specimen and test it at  Lasts 2 minutes or more but less than 10
the point of care of protein and glucose and send it minutes in duration
to the laboratory for urinalysis.  If an acceleration lasts 10 mins or longer:
 A base line change or a new baseline is
AUSCULTATION OF FETAL HEART SOUNDS established
2. Decelerations
FHR are transmitted best through the convex portion of a fetus  Visually apparent, usually symmetrical, periodic
because it is the part that lies in closer contact with the uterine decreases in FHR resulting from pressure on the fetal
wall head during contractions

 Vertex presentation= fetal back  Late decelerations

 Face presentation = convex thorax  An ominous pattern in labor because it
 Breech presentation = uterus at a patient’s suggests uteroplacental insufficiency or
umbilicus or above decreased blood flow through the
 Cephalic presentation = low in a patient’s abdomen intervillous spaces of the uterus during
 ROA position = right lower quadrant uterine contractions
 LOA position = left lower quadrant  Prolonged Decelerations
 Posterior position (LOP or ROP) = at a patient’s side  Decrease from the FHR baseline of 15
bpm or more and last longer than 2 to 3
When to get the FHR during labor? mins but less than 10 mins
q 30 mins = beginning latent labor  May signify a significant event:
q 15 mins = active first-stage  Cord compressions
q 5 mins = second stage  Maternal hypotension

FETAL HEART RATE PARAMETERS  Variable Decelerations

FHR patterns involves evaluating 3 parameters:  Refers to decelerations that occur at
1. The baseline fetal heart rate unpredictable times in relation to
2. Variability contractions
3. Periodic changes (acceleration and deceleration)
The Sinusoidal Pattern
1. The baseline fetal heart rate  In a fetus that is severely anemic or
 Determine by analyzing the pace of fetal heartbeats hypoxic, central nervous system control
recorded in a minimum of 2 minutes obtained of heart pacing may be so impaired that
between contractions the FHR pattern resembles a smooth,
2. Variability frequently undulating wave.
 The difference between the highest and lowest heart
rates shown on a strip
 One of the most reliable indicators of fetal well-
being
 Reflected on FHR tracing as a slight irregularity or
“jitter” to the wave

Variability should be record as:

 Absent: no amplitude range is detectable
 Minimal: amplitude range is detectable but is 5 bpm
of fewer
 Moderate (normal): amplitude range is 6 to 25 bpm
 Marked: amplitude range is greater than 25 bpm

3. Periodic Changes
 Fluctuation in FHR occur in response to contractions
and fetal movement
 Are short term changes in rate other than baseline;
they last from a few seconds to 1 or 2 mins.

Periodic changes can be described in terms of:

1. Acceleration
 Nonperiodic accelerations are temporary normal
increase in FHR caused by fetal movement.
 An acceleration is visually apparent abrupt increase
(onset to peak in less than 30 seconds) in the FHR
 At 32 weeks of gestation:
 Peak: 15 bpm