Maternal 1 Side-notes: Labor and Delivery
⁃ Operculum/ mucus plug expelled
Labor
⁃ mature fetus to cope with
extrauterine life
Progesterone Withdrawal
⁃ Prostaglandins = muscle stretching
⁃ Oxytocin = cervical pressure
⁃ Oxytocin + prostaglandin = uterine
contraction
⁃ Placental age = contraction
⁃ Fetal cortisol = prostaglandin
formation
⁃ Fetal membrane = prostaglandin =
contraction
Signs of Labor
1. Preliminary Signs
Lightening (Descent)
⁃ change abdominal contour
⁃ Relief diaphragmatic pressure and
SOB
⁃ “Lightens woman’s load”
Increase Level Activity
⁃ increase epinephrine (prepares body
for labor)
Slight loss of weight
⁃ Progesterone drops= body fluid
excreted
⁃ Urine= loss 1-3 pounds
Braxston Hicks Contraction
⁃ strong contraction
Ripening of Cervix
⁃ “butter soft”
⁃ Goodell sign
2. True Labor Signs
⁃ uterine and cervical changes
Uterine Contraction
⁃ surest sign
⁃ Productive, involuntary and without
warning
⁃ Increase intensity
⁃ Breathing exercise (discomfort)
Show (Bloody Show)
⁃ bloody discharge
⁃ Blood with mucus
Rupture of Membranes (ROM)
⁃ Sudden gush or scanty show
⁃ Seeping clear fluid
⁃ Early rupture = shortens labor and
fetus to fit into pelvis
Risk ROM:
⁃ intrauterine infection
⁃ Umbilical cord prolapse (cut-off O2)
Induced Labor
⁃ labor NOT spontaneous within 24hrs
after rupture of membranes
Components of Labor (5P’s)
1. Passage (Pelvis)
⁃ pelvis size and contour
⁃ Route of fetus
⁃ 2 measurements: diagonal
conjugate and transverse diameter
Diagonal Conjugate (INLET)
⁃ anteroposterior diameter inlet
⁃ Narrowest diameter inlet
Transverse Diameter (OUTLET)
⁃ pelvic outlet
⁃ Narrowest diameter outlet
2. Passenger (Fetus)
⁃ size, position, presentation
⁃ Head= widest diameter
Head
⁃ difficult to pass pelvic ring
⁃ Passing rate depends structure and
alignment
Molding
⁃ change shape fetal skull
⁃ Due to force of contraction
⁃ Vertex against NOT dilated cervix
Engagement
⁃ presenting part into pelvis
⁃ Level of ISCHIAL SPINES (pelvis
midpoint)
Fetal Attitude 2. Moderate Flexion
⁃ Degree of flexion ⁃ Alert/ Military Position
⁃ Relationship of fetal parts with each ⁃ Chin NOT touching chest
other
3. Partial Extension
Descent ⁃ Poor flexion
⁃ widest part passed pelvic inlet/ outlet ⁃ BROW presents into birth canal

Fetal Lie Descent

⁃ Fetal and maternal spine alignment ⁃ widest part into pelvic ring
⁃ Relationship long of axis of fetus to
long axis of mother 1. Biparietal Diameter
⁃ cephalic presentation
Fetal Presentation
⁃ body parts to be born 1st 2. Intertrochanteric Diameter
⁃ Determined by fetal lie and fetal ⁃ Breech presentation
attitude
Fetal Lie
Fetal Position ⁃ Alignment of long axis of mother and
⁃ Relationship presenting part to baby
quadrant of pelvis
Long axis- cephalocaudal
3. Powers of Labor (Uterine Factor)
⁃ Labor position Fetal Station
⁃ Force by fundus of uterus 1. 0 station
⁃ Uterine contraction ⁃ presenting part at level of ischial
spine
4. Psyche (Psychological Outlook) ⁃ ENGAGEMENT
⁃ Psychological state or feeling
⁃ Apprehension or fright 2. - 1 to - 4 station
⁃ Above spine (NOT ENGAGED)
5. Placental Factor
⁃ site and timing of separation 3. + 1 to + 4 station
⁃ Below spine
Fetal Attitude
⁃ degree of flexion 4. + 3 to + 4 station
⁃ Perineum level
1. Good attitude ⁃ CROWNING
⁃ Complete flexion
⁃ Spinal bowed forward Types Fetal Presentation
⁃ Chin touches sternum ⁃ Body part 1st contact with cervix
⁃ Arms folded on chest ⁃ Fetal Attitude + Fetal Lie
⁃ Thighs towards abdomen
⁃ Calves onto posterior aspect of 1. Cephalic Presentation
thighs ⁃ frequent type
⁃ Head 1st to be born
Normal Fetal Position ⁃ 4 Types: vertex, brow, face, mentum
⁃ Smallest anteroposterior diameter
skull to pelvis 2. Breech Presentation
⁃ Whole body = OVOID SHAPE ⁃ Buttocks or feet
⁃ occupies smallest space as possible ⁃ Presenting part influence labor
difficulty
 ⁃ 3 Types: comple, frank, footing ⁃ effacement and dilatation

Good attitude Effacement

⁃ Knees against abdomen ⁃ shortening and thinning of cervical
canal
Poor attitude ⁃ Canal 1-2cm long
⁃ knees extended ⁃ Disappears virtually

3. Shoulder Presentation Dilatation

⁃ Acromion process ⁃ Enlargement or widening of cervical
⁃ Iliac crest, hand or elbow canal
⁃ Fully: 10cm
Fetal Position
⁃ Relationship presenting part to 511 Rule of Labor
quadrant of pelvis 5 - 5mins apart
1. Right Anterior 1 - 1min last
2. Left Anterior 1 - 1 pattern lasted 1 hour
3. Right Posterior
4. Left Posterior False Contraction VS True Contraction:
1. FALSE
Mechanism of Labor (Cardinal Movement) ⁃ Remain irregular
⁃ Keeps smallest diameter of head ⁃ 1st abdomen
always presenting to smallest diameter of pelvis ⁃ confined abdomen and groin
1. Descent ⁃ Disappear with ambulation/ sleep
2. Flexion ⁃ NO increase: duration, frequency,
3. Internal Rotation intensity
4. Extension ⁃ NO CERVICAL DILATATION
5. External Rotation
6. Expulsion 2. TRUE
⁃ Regularly and predictable
Powers of Labor ⁃ 1st lower back
⁃ Force fundus of uterus ⁃ Sweep around abdomen
⁃ Continuous
Primary Power or Force ⁃ INCREASE: duration, frequency,
⁃ after full dilatation intensity
⁃ Abdominal muscles ⁃ (+) CERVICAL DILATATION
⁃ DONT BEAR DOWN WITH
ABDOMINAL MUSCLES UNTIL FULL DILATION Types of Pelvis
OF CERVIX (impedes primary force and damages 1. Gynecoid
both fetus and cervix) ⁃ Female Pelvis
⁃ Favorable vaginal birth
1. Uterine Contraction
⁃ Effective: rhythm, lengthening and 2. Android
intensity ⁃ Male Pelvis
⁃ 3 Phases: increment, acme, ⁃ Funnel shaped
decrement ⁃ Caesarean Section NEEDED

Increment- intensity increases 3. Anthropoid

Acme- strongest contraction (PEAK) ⁃ long, narrow and oval shaped
Decrement- intensity decreases ⁃ Possible vaginal birth BUT high risk

2. Cervical Changes 4. Platypelloid

 ⁃ Wide and flat pelvis ⁃ from beginning of one contraction to
⁃ Caesarean Section NEEDED beginning of next contraction

Fetal Variables (affects LABOR) 2. Duration

1. Fetal Size ⁃ From beginning of one contraction to
2. Fetal Lie end of same contraction
⁃ Longitudinal, transverse, oblique
3. Fetal Presentation Note:
⁃ Vertex (head) ⁃ labor progresses relaxation intervals
⁃ Breech shortens (from 10mins to 2-3mins)
⁃ Shoulder ⁃ Duration (from 20-30sec to 60-
⁃ Compound (vertex and hand) 90sec)
⁃ Funic (umbilical cord)
4. Fetal Attitude Leopold’s Maneuver
5. Fetal Station 1. 1st Maneuver- presentation/lie
6. Number of Fetuses 2. 2nd Maneuver- back/ FHR
7. Fetal Anomalies 3. 3rd Maneuver- engagement
⁃ hydrocephalus 4. 4th Maneuver- attitude
⁃ Sacrococcygeal teratoma (tumor
coccyx) Psychological Task Pregnancy
1. 1st Trimester
Structure Fetal Skull ⁃ ambivalence/ confusion
Cranium 2. 2nd Trimester
⁃ uppermost ⁃ Acceptance
⁃ 8 bones ⁃ Day dreaming/ role playing
3. 3rd Trimester
1. Frontal (1x) ⁃ Nest building activities
2. Parietal (2x) ⁃ Parenthood
3. Occipital (1x)
4. Sphenoid (1x) Positive Signs Pregnancy
5. Ethmoid (1x) 1. Fetal Outline
6. Temporal (2x) 2. Fetal Movement
Total: 8 BONES 3. FHR audible

3 Types Breech Presentation Estriol

1. Frank Breech ⁃ to evaluate neural tube defects and
⁃ hip joints flexed structural abnormalities
⁃ Knee joints extended
OB Scoring
2. Complete Breech 1. Term- 37 weeks
⁃ hip and knee flexed 2. Pre-Term- 20 to 36 weeks
3. Abortion- less than 20 weeks
3. Incomplete Breech 4. Living- currently living
Footling 5. Multiple- Twins
⁃ hip and knee extended
Stages of Labor
Kneeling 1. 1st stage (DILATATION)
⁃ hip extended ⁃ cervical dilatation
⁃ Knee flexed
Latent (preparatory phase)
Uterine Contraction ⁃ 0-3 cm
1. Frequency ⁃ Rapid dilatation
 ⁃ Mild and short contraction
⁃ Cervical effacement
⁃ Early analgesia= prolongs labor
⁃ Still ambulates
⁃ Cephalopelvic disproportion =
Caesarean section
⁃ Excitement and still communicates
Active (difficult phase)
⁃ 4-6 cm
⁃ More Rapid dilatation (maximum
slope)
⁃ Contraction q 3-5mins
⁃ Bloody show and ROM
⁃ Irritable but still comprehend
⁃ Encourage to remain active in labor
by assuming comfortable position
⁃ Acceleration: 4-5cm
Transition
⁃ peak of contraction q 2-3mins
⁃ 8-10 cm
⁃ Loss of control (URGE TO PUSH)
⁃ Bearing down techniques
⁃ Full dilatation and complete
effacement
⁃ Intense discomfort (N&V)
⁃ Peak: slight slowing rate of dilatation
(DECELERATION)
⁃ Deceleration: 9cm reached
2. 2nd stage (BABY)
⁃ 10cm to Baby
⁃ Uncomplicated: 1hr
⁃ N and V momentarily
⁃ Neck vessels distended
⁃ Contraction: crescendo to
decrescendo pattern
⁃ (+) Feces
⁃ Anus everted
⁃ Perineal bulging
⁃ Pushes abdominal muscle
⁃ Legs simultaneously lithotomy
position
⁃ CROWNING
⁃ Modified Ritgen’s Maneuver (to
deliver head, prevents damage to anal sphincter,
prevents episiotomy)
Oxytocin- After birth of BABY
Methergine- After PLACENTA EXPULSION
3. 3rd stage (PLACENTA)
⁃ Baby to Placenta
⁃ Placental expulsion
⁃ Brandt-Andrew Maneuver
(suprapubic pressure and cord traction)
⁃ Complete cotyledons
⁃ Oxytocin/ methergine after placental
expulsion
⁃ Uterus shape: DISCOID to OVOID
⁃ Perineum laceration
⁃ 2 Phase: Separation and Expulsion
Placental Separation
⁃ Folding and separation
⁃ Active bleeding helps detachment
⁃ Bleeding: 300-500mL
Signs Placental Delivery:
⁃ lengthening of cord
⁃ Sudden gush of blood
⁃ Calkins sign: change shape of
uterus (from discoid to ovoid)
⁃ Firm contraction of uterus
⁃ Placenta at vaginal openning
Umbrella Separation
⁃ begins at CENTER
⁃ Fetal surface evident
Edges Separation
⁃ Slides uterine surface
⁃ Maternal surface evident
Schultze Presentation
⁃ shiny and glistening
⁃ Shiny fetal membrane surface
Duncan Presentation
⁃ Raw, red and irregular
⁃ (+) Ridges/ cotyledons
⁃ DIRTY PRESENTATION
⁃ Irregular maternal surface
Placental Expulsion
⁃ Natural bearing down or CREDE’S
MANEUVER
Crede’s Maneuver
⁃ Gentle pressure contracted uterine
⁃ NEVER in NON-CONTRACTED due
to hemorrhage and eversion
 ⁃ Pressure over bladder (similar with
emptying bladder or voiding of urine)

4. 4th stage (RECOVERY)

⁃ 1st 4hrs after placental expulsion
⁃ “Bonding Time”
⁃ Recovery