WHAT IS LABOR?

Labor is the series of events by which uterine contractions expel a fetus and placenta from a woman’s body.

- EARLY TERM: 37-38 weeks

- FULL TERM: 39-40 weeks
- LATE TERM: 41 weeks
- POST TERM: 42 weeks and beyond

WHY LABOR BEGINS

- uterine muscle stretching, results in release of prostaglandins
- pressure on the cervix, stimulates the release of oxytocin from the posterior pituitary
- oxytocin stimulation, works together with prostaglandins to initiate contractions
- change in the ratio of estrogen to progesterone (increases estrogen in relation to progesterone, interpreted as
progesterone withdrawal)
- placental age, triggers contractions at a set point
- rising fetal cortisol levels, reduces progesterone formation and increases prostaglandin formation
- fetal membrane production of prostaglandin, which stimulates contractions

Preliminary Signs of Labor Signs of True Labor

 Lightening  Uterine Contractions/True Contractions
- fetal descent, occurs 10-14 days before - Begin irregularly but become regular and
labor begins predictable
 Increase in Level of Activity - felt first in lower back and sweep around
- prepares her body for labor ahead to the abdomen in a wave
- due to increase in epinephrine release - continue no matter what the woman’s
initiated by a decrease in progesterone level of activity
 Slight Loss of Weight - increase in duration, frequency, and
- low level of progesterone increases intensity
fluid excretion which leads to weight - achieve cervical dilatation.
loss  Bloody Show
 Braxton Hicks Contraction - mucus plug is expelled as cervix softens
- begin and remain irregular and ripens
- felt first abdominally and remain - exposed cervical capillaries seep blood
confined to the abdomen and groin and mixes with mucus
- often disappear with ambulation or  Rupture of Membranes
sleep - sudden gush or as scanty, slow seeping
- do not increase in duration, frequency, of clear fluid from the vagina
or intensity - risks associated: intrauterine infection
- do not achieve cervical dilatation. and prolapse of the umbilical cord
 Ripening of Cervix
- cervix is soft (Goodell’s Sign)

COMPONENTS OF LABOR
1. PASSSAGE
- a woman’s pelvis, the route a fetus must travel from the uterus through the cervix and vagina to
the external perineum.
- Two important pelvic measurements to determine the adequacy of the pelvic size: the diagonal
conjugate (the anteroposterior diameter of the inlet) and the transverse diameter of the outlet.
- At the pelvic inlet, the anteroposterior diameter is the narrowest diameter; at the outlet, the transverse
diameter is the narrowest

2. PASSENGER
 - the fetus
- the best presentation for birth is when the fetus presents a biparietal diameter of the fetal skull (the
narrowest fetal head diameter) to the anteroposterior diameter of the inlet so that engagement, or the
settling of the fetal head into the pelvis will occur.

Molding – overlapping of skull bones along the suture lines, causes a change in the shape of the fetal skull
– produced by the force of uterine contractions pressing the vertex of the head against the not-yet-dilated
cervix

Engagement – the settling of the presenting part of a fetus far enough into the pelvis to be at the level of the
ischial spines a midpoint of the pelvis
– degree is assessed y vaginal and cervical examination

® presenting part that is not engaged is said to be “floating.” One that is descending but has not yet reached
the ischial spines is said to be “dipping.”

Descent – the widest part of the fetus (the biparietal diameter in a cephalic presentation; the intertrochanteric
diameter in a breech presentation) has passed through the pelvis inlet or the pelvic inlet has been proved
adequate for birth

Station – the relationship of the presenting part of a fetus to the level of the ischial spines
– 0 station: engaged
– -4 station: floating
– +4 station: at outlet (crowning)

Fetal Attitude
– degree of flexion a fetus assumes during labor or the relation of the fetal parts to each other
– good attitude is in complete flexion: spinal column is bowed forward, the head is flexed forward
where the chin touches the sternum, arms are flexed and folded on the chest, thighs are flexed onto the
abdomen, and calves are pressed against the posterior aspect of the thigh
– moderate flexion: alert or military position, chin is not touching the chest, causes the next widest
anteroposterior diameter
– partial extension: presents the brow
– complete extension: back is arched, the neck is extended, presenting the occipitomental
diameter of the head to the birth canal; occur if there is less than the normal amount of amniotic
fluid present (oligohydramnios)

Fetal Lie
– the relationship between the long (cephalocaudal) axis of the fetal body and the long (cephalocaudal)
axis of a woman’s body
– Longitudinal lie: parallel to long axis of mother, vertical
– Transverse lie: horizontal

Fetal Presentation
– denotes the body part that will first contact the cervix; combination of fetal lie and attitude
– Cephalic Presentation: fetal head
 Vertex - suboccipitobregmatic diameter to present to the cervix
 Brow - brow or sinciput becomes the presenting part
 Face - face is the presenting part
 Mentum - chin presents to cervix
– Breech Presentation: buttocks or the feet
 Complete - thighs tightly flexed on the abdomen, buttocks and flexed feet present to cervix
  Frank - knees are extended to rest on the chest; buttocks present to cervix
 Footling – one foot or both present to cervix
– Shoulder Presentation: shoulders (acromion process), an iliac crest, a hand, or an elbow

Fetal Position
– relationship of the presenting part to a specific quadrant of a woman’s pelvis
– indicated by an abbreviation of three letters
– 1st letter: if landmark is pointing to mother’s L or R
– 2nd letter: landmark (Sacrum, Occiput, Mentum, Acromion)
– 3rd letter: if landmark points anteriorly (A), posteriorly (P), transversely (T)

METHODS TO DETERMINE FETAL POSITION, LIE, AND PRESENTATION

® Leopold’s maneuvers
® vaginal examination
® auscultation of fetal heart tones
® ultrasound

IMPORTANCE OF DETERMINING FETAL POSITION AND PRESENTATION!!!

® helps predict if the presentation of a body part puts the fetus at risk
® labor may be longer if vertex is not the part present to the cervix due to ineffective descent of the fetus,
ineffective dilatation of the cervix, or irregular and weak uterine contractions
® may lead to early rupture of membranes
® to determine if labor is ineffective

MECHANISMS (CARDINAL MOVEMENTS) OF LABOR

– different position changes to keep the smallest diameter of the fetal head (in cephalic presentations)
always presenting to the smallest diameter of the pelvis

Descent – downward movement of the biparietal diameter of the fetal head within the pelvic inlet; occurs
due to pressure on the fetus by the uterine fundus.

Flexion – the head bends forward onto the chest as it reaches the pelvic floor, making the smallest
anteroposterior diameter (the suboccipitobregmatic diameter) present to the birth canal

Internal Rotation – as the head flexes when it touches the pelvic floor, the occiput rotates to bring the head
into the best relationship to the outlet of the pelvis. This puts the widest diameter of the shoulders in
line with the wide transverse diameter of the inlet.

Extension – as the occiput is born, the back of the neck stops beneath the pubic arch and acts as a pivot for
the rest of the head

External Rotation/restitution – after the head of the infant is born, the head rotates back to the diagonal or
transverse position of the early part of labor where the shoulders are in anteroposterior position

Expulsion – the rest of the baby is born easily and smoothly

3. POWERS OF LABOR
 Uterine Contractions
Phases of Contraction
Increment when the intensity of the contraction increases
 Acme when the contraction is at its strongest
Decrement when the intensity of the contraction decreases
Duration of Contraction: From increment to decrement
Period of Relaxation: after decrement and before another set of contraction
Frequency: from the beginning of one contraction to the beginning of the next contraction

Contour Changes
Upper part of uterus: becomes thicker and active, preparing it to be able to exert the strength
necessary to expel the fetus when the expulsion phase of labor is reached
Lower part of uterus: becomes thin walled, supple, and passive, so that the fetus can be easily
pushed out of the uterus
Physiologic Retraction Ring: boundary between two portions
Pathologic Retraction Ring (Bandl’s Ring): abnormal indentation between the two portions due to
abnormal contraction during difficult labor; signifies impending rupture of the lower uterine
segment if the obstruction to labor is not relieved

Nursing Responsibility: evaluating the rate, intensity, and pattern of uterine contractions (uncoordinated
contractions may slow labor and can lead to failure to progress and fetal distress as they may not allow
for adequate placental filling)

 Cervical Changes
Effacement – shortening and thinning of the cervical canal
Dilatation – enlargement or widening of the cervical canal; occur due to uterine contractions and
the fluid-filled membranes pressing against the cervix

4. PSYCHE
– the psychological state or feelings that a woman brings into labor
– the feeling of apprehension or fright, or sense of excitement or awe
Strong self-esteem with support person: can manage best in labor
Without adequate support, stressed, frightened: may develop post-traumatic stress syndrome

Nursing Responsibility: encourage women to ask questions at prenatal visits and to attend preparation for
childbirth classes helps prepare them for labor, share their experience after labor serves as “debriefing
time”

STAGES OF LABOR
First Stage
Latent Phase - starts during the onset of true labor contractions until cervical dilatation
- contractions: mild and short, 20-40 sec
- effacement occurs, cervix dilates 0-3 cm
- lasts 6hrs in nullipara, 4.5hrs in multipara, “nonripe” cervix = longer latent
phase

Nursing Responsibilities: Encourage woman to continue to be active such as

walking, and encourage her to begin relaxation techniques along with alternative
methods of pain relief such as aromatherapy or distraction
Active Phase - occurs when cervical dilatation is at 4 to 7 cm
- contractions: 40 to 60 sec with 3-5 mins interval
- lasts 3hrs in nullipara, 2hrs in multipara
- show and rupture of membranes occur
 - contractions grow strong, last longer, and begin to cause true discomfort

Nursing Responsibilities:
® Inform patient on the progress of her labor to lessen her anxiety and obtain
her trust and cooperation.
® Start monitoring progress of labor with the use of WHO partograph
® Encourage patient to be continually active to maximize the effect of uterine
contractions. Upright maternal positions are recommended if tolerated.
® Assist patient in assuming her position of comfort. If upright position is a
hassle, left-side lying is recommended to avoid disruption in fetal
oxygenation.
® Monitor maternal vital signs and fetal heart rate every 2 hours, or
depending on the doctor’s order.
® Anticipate patient needs (e.g. keeping bed clean and dry, sponging face with
cool cloth, providing ice chips or lip balm) to promote comfort.
® Promote voiding and provide bladder care. A full bladder can impede
descent of a fetus
® Establish non-pharmacological pain measures (e.g. distraction method,
breathing exercises, imagery, music therapy, etc.)
Transition - occurs when contractions reach their peak of intensity
Phase - contractions: 2-3 mins, duration of 60-90sec
- dilatation of 8 to 10 cm
- intense discomfort
- irresistible urge to push occurs at the ed of this stage, at 10cm dilation

Nursing Responsibilities:
® Assist patient with pant-blow breathing
® Respect and promote the support person
® When perineal bulging is noticeable, prepare for delivery
Lamaze method
All fours
“Amniotomy” – artificial rupturing of membranes using amniohook; allows a fetal head to contact the cervix more
directly

Second Stage
 this stage starts at full cervical dilatation until the birth of the infant
 the woman may experience an uncontrollable urge to push and bear down with every contraction
 crowning or the appearance of the fetal head on the vaginal opening occurs

Nursing Responsibility:
- Assess fetal heart sounds at the beginning of the second stage of labor to be certain that the start of the
baby’s passage into the birth canal is not occluding the cord and interfering with fetal circulation.
- the place of delivery of the woman must be prepared
- the position of birth wherein the woman is most comfortable must be determined
- promote effective second-stage pushing, urge her to breathe out while pushing if possible
- do perineal cleaning to remove vaginal or rectal secretions and prepare the cleanest environment for the
birth of the baby

“Episiotomy” - surgical incision of the perineum that is made both to prevent tearing of the perineum and to
release pressure on the fetal head with birth
“Ritgen Maneuver” - placing a sterile towel over the rectum and press forward on the fetal chin while the other
hand is pressed downward on the occiput; to help achieve extension

“Nuchal Cord” - a loop of umbilical cord is encircling the neck

“Time of Birth” – when the whole body is born

Involution – pregnant to pre pregnant state (palpate the fundus 1 hr after, fundus is at level of embolitus for 24
hrs. after 1day, baba uterus at 1cm

Lochia rubra
Alba
Serosa – may leukocytes, distinct smell

uterus not contracted; if there is bleeding

lochia not absent in first three weeks

there is lochia in cs

Third Stage
 the third stage begins with the birth of the infant until the delivery of the placenta; up to 25-30mins
 300-500ml bloodloss normal

Placental Separation – occur due to disproportion between the placenta and the contracting wall of the uterus as
uterus contracts; bleeding helps to separate the placenta; sinks to upper vagina as separation is
completed
Schultze presentation: “shiny” and glistening from fetal membranes
Duncan presentation: “dirty”, raw, red, and irregular, with cotyledons that separate blood collection spaces

 signs indicate that the placenta has loosened and is ready to deliver:
- lengthening of the umbilical cord
- sudden gush of vaginal blood
- changes in the shape of the uterus and its firm contraction (bulging of fundus)
- the appearance of the placenta at the vaginal opening

Placental Expulsion – delivered either by the natural bearing-down effort of the mother or by gentle pressure on
the contracted uterine fundus (Crede’s Maneuver)
– pressure must never be applied to a uterus in a noncontracted state, because doing so may cause the
uterus to evert and hemorrhage

Nursing Responsibility:
- Ask parents whether saving the placenta is important to them before it is destroyed
- administer oxytocin as ordered to promote uterine contractions and minimize uterine bleeding
- assess for vaginal bleeding and vital signs to rule out hemorrhage due to dislodged placenta

MATERNAL AND FETAL RESPONSES TO LABOR

Physiologic Effects of Labor
MOTHER FETUS
Cardiovascular System - increased cardiac output due to - mature enough that the fetus is
contractions unaffected by the continual variations of
- systolic BP rises 15mmHg/contraction heart rate
Respiratory System - total oxygen consumption in- creases - maturation of surfactant production by
 by about 100% during the second alveoli in the fetal lung
stage of labor
Neurologic System - neurologic responses that occur - response that is involved with any
during labor are responses related to instance of increased intracranial
pain pressure occurs (FHR <5bpm during
contraction)
Musculoskeletal System - relaxin softens cartilage to increase - force of uterine contractions tends to
the size of the pelvic ring push a fetus into a position of full flexion
Integumentary System - minimal petechiae or ecchymotic areas
due to pressure; edema of the
presenting part (caput succedaneum)
Gastrointestinal System - fairly inactive during labor because of
the shunting of blood to more life-
sustaining organs and due to pressure
on the stomach and intestines from
the contracting uterus
Hemopoietic System - increase in WBC count (leukocytosis)
due to stress and heavy exertion
Temperature Regulation - slight elevation of temperature (1° F)
Fluid Balance - due to the increase in rate and depth
of respirations (which causes moisture
to be lost with each breath) and
diaphoresis, insensible water loss
increases during labor

DANGER SIGNS OF LABOR

Maternal Danger Signs Fetal Danger Signs
 High or Low BP  High or Low FHR
- >140/90mmHg; increase in more than - >160bpm (tachycardia)
30mmHg and 15mmHg for systolic and - <110bpm (bradycardia)
diastolic respectively (hypertension);  Meconium Staining
falling BP (sign of intrauterine - fetus has had loss of rectal sphincter
hemorrhage) control; indicates hypoxia, stimulates
 Abnormal Pulse vagal reflex and leads to increased bowel
- >100bpm in second stage (hemorrhage) motility
 Inadequate or Prolonged Contractions  Hyperactivity
- less frequent, less intense, or shorter in - sign that hypoxia is occurring, because
duration (uterine exhaustion/inertria) frantic motion is a common reaction to
- contractions >70sec (may compromise the need for oxygen
fetal well-being)  Oxygen Saturation
 Pathologic Retraction Ring - low o2 sat suggests that fetal well-being
- sign of extreme uterine stress and is becoming compromised (normal: 40%-
possible impending uterine rupture 70%)
 Abnormal Lower Abdominal Contour
- round bulge on her lower anterior
abdomen due to full bladder
- bladder may be injured by the pressure
of a fetal head; pressure of the full
bladder may not allow the fetal head to
descend
 Increasing Apprehension
- it can be a sign of oxygen deprivation or
 internal hemorrhage

ASSESSMENT
® Assess vital signs q4h (between contractions), contractions (frequency, duration and intensity), and her
preparedness and readiness for labor
® Obtain full history such as current pregnancy history, past pregnancy history, past health history, and family
medical history.
® Conduct physical examination
® Assess for Ruptured Membranes = must be clear as water
Yellow stained - blood incompatibility between mother and fetus; Green stained - meconium staining
® Vaginal Examination - to determine the extent of cervical effacement and dilatation; to confirm the fetal
presentation, position, and degree of descent
DO NOT: conduct vaginal examinations in the presence of fresh bleeding (indicates placenta previa =
implantation of the placenta so low in the uterus)
® Assess Pelvic Adequacy – to determine if cephalopelvic disproportion could occur

Abdominal Assessment - to estimate fetal size by fundal height, to detect a full bladder
Leopold’s Maneuver - observation and palpation to determine fetal presentation and position
First Maneuver: determines whether fetal head or breech is in the fundus
Second Maneuver: locates the back of the fetus
Third Maneuver: determines the part of the fetus at the inlet and its mobility
Fourth Maneuver: determines fetal attitude and degree of fetal extension into the pelvis (cephalic only)

INITIAL FETAL ASSESSMENT

® Auscultate FHS - every 30mins during beginning labor, every 15mins during active labor, and every 5 mins
during the second stage of labor.
® External electronic monitoring - useful for monitoring both uterine contractions and FHR continuously or
intermittently
® Internal electronic monitoring - most precise method for assessing FHR and uterine contractions
® Telemetry – monitors both FHR and uterine contractions to be carried out free of connecting wires that could
hamper the woman’s movements in labor
® Monitor fetal oxygen saturation level