NORMAL LABOR AND
NURSING RESPONSIBILITY
GUIDED BY – LT COL JAMALA BANO
PRESENTED BY – MAJ JEYALAKSHMI
CONTENTS
• Definition of Normal Labor
• Causes of onset of Labor
• Prelabor
• False labor
• True labor
• Stages of labor –Physiology and clinical course of (I, II ,III &IV
stage) labor
LABOR
• Series of events that take place in the genital organs in an effort to
expel the viable products of conception (fetus, placenta and the
membranes) out of the womb through the vagina into the outer
world is called ‘labor’.
NORMAL LABOR (EUTOCIA )
1. Spontaneous in onset and at term
2. With vertex presentation
3. Without undue prolongation
4. Natural termination with minimal aids
5. Without any complications affecting the health of the mother
and /or the baby
ABNORMAL LABOR (DYSTOCIA )
• Any deviation from the definition of normal labor is called
abnormal labor
CAUSES OF ONSET OF LABOR
Uterine
distension
Neurological Fetoplacental
factors contribution
Oxytocin and
myometrial oxytocin Estrogen
receptors
Prostaglandins Progesterone
CAUSES OF ONSET OF LABOR
• Fetoplacental contribution
Fetal hypothalamic pituitary adrenal axis
Increased CRH
Increased ACTH
Contd…
• Fetoplacental contribution (continued..)
Fetal adrenals
Increased cortisol secretion
Accelerated production of estrogen and
prostaglandins from placenta
Contd…
• ESTROGEN
• Increases release of oxytocin from maternal pituitary
• Promotes synthesis of myometrial receptors for oxytocin and
prostaglandins
• Stimulates the synthesis of myometrial contractile protein
• Increases excitability of myometrial cells.
Contd…
• PROGESTERONE
• Alteration in estrogen and progesterone ratio is associated with
PG synthesis .
Contd…
• PROSTAGLANDINS
• Major site of production :- Amnion , Chorion ,Decidual cells and
myometrium
• Triggered by rise in estrogen level ,glucocorticoids , mechanical
stretching in late pregnancy , increase in cytokines , infection ,
vaginal examination and separation or rupture of the membranes
Contd…
• OXYTOCIN AND MYOMETRIAL OXYTOCIN RECEPTORS
• ACTIONS
• Stimulates uterine contractions
• Stimulates synthesis and release of PGs from amnion and
decidua.
• Ferguson reflex .
PRELABOR (Premonitory stage )
Primigravida
2-3 weeks before Multigravida
the onset of labor Few days before
delivery
PRELABOR (continued..)
LIGHTENING
Before lightening After lightening
CERVICAL CHANGES
• Cervix becomes ripe
• Soft
• Effaced
• Admits one finger easily
• Cervical canal is dilatable
FALSE LABOR PAIN
1. Dull in nature
2. Confined to lower abdomen and groin
3. May be associated with hardening of uterus
4. Have no other features of true labor pain and
5. Usually relived by analgesics .
TRUE LABOR PAIN
1. Painful uterine contractions at regular intervals
2. Frequency of contractions increases gradually
3. Intensity and duration of contractions increases progressively
4. Associated with show
5. Progressive effacement and dilatation of the cervix
6. Descent of the presenting part
7. Formation of bag of waters and
8. Not relived by enema or sedatives
SHOW
• Profuse cervical mucoid discharge .
• Expulsion of cervical mucus plug mixed with blood is called
‘show’.
STAGES OF LABOR
STAGES OF LABOR
• FOUR STAGES :-
• FIRST STAGE : ”Cervical stage”
• From onset of true labor pain and ends with full dilatation of the
cervix .
• Primi – 12 - 16 hrs
• Multi – 6 - 8hrs
CONTD…
• SECOND STAGE :- From full dilatation of cervix and ends with expulsion of
fetus
Two phases :- 1. Propulsive phase
2. Expulsive phase
• THIRD STAGE :-
• Begins after expulsion of the fetus and ends with expulsion of the placenta
and membranes
• 15 min – both in Primigravida and Multigravida
CONTD…
• FOURTH STAGE :-
• Stage of observation for at least 1 hour
• To monitor :- Vitals of mother, uterine retraction and vaginal
bleeding .
• Baby is examined
PHYSIOLOGY OF NORMAL LABOR
• There is marked hypertrophy and hyperplasia of uterine muscle
• Length of uterus +cervix = 35 cm at term
• Uterus assumes pyriform /ovoid shape
• Cervical canal occluded by thick , tenacious mucus plug
PHYSIOLOGY CONTD…
• UTERINE CONTRACTION IN LABOR
• PATTERN OF CONTRACTION
• Good synchronization of contraction waves form one cornual
end of the uterus
• Fundal dominance
• Waves of contraction follow a regular pattern
FUNDAL DOMINANCE
PHYSIOLOGY CONTD…
• Upper segment of uterus contracts more strongly and for a
longer time than the lower part
• Intra amniotic pressure rises beyond 20 mm hg during uterine
contraction
• Good relaxation occurs in between contraction.
PHYSIOLOGY CONTD…
• RETRACTION
• Phenomenon of uterus in labor in which muscle fibers are
permanently shortened
Relaxed Progressive retraction
CONTD...
• EFFECTS OF RETRACTION
• Formation of lower uterine segment and dilatation and
effacement of cervix
• Descent of presenting part and expulsion of fetus
• Reduce surface area and favors the separation of placenta
• Effective hemostasis after separation of placenta
FIRST STAGE OF LABOR
• Concerned with formation of birth canal
• Main events :-
[Link] of the cervix and effacement of the cervix
[Link] uterine segment formation
FACTORS RESPONSIBLE IN DILATATION
• UTERINE CONTRACTION AND RETRACTION
FACTORS CONTD…
• BAG OF MEMBRANES
EFFACEMENT OF CERVIX
• Muscular fibers of cervix pulled upward and merge with fibers
of lower uterine segments
• Primigravidae:- effacement precedes dilation of cervix
• Multigravida:- effacement and dilatation occur at same time
FIRST STAGE OF LABOR :
• There are two phases in first stage of labor :-
• Latent phase
• Active phase
• LATENT PHASE • ACTIVE PHASE
• Time b/w onset of true labor • Time b/w end of latent phase (3-
pain and 3-4 cm dilatation and 4 cm dilatation) and full
cervix become fully effaced. dilatation (10cm)
• Lasts for 3-8 hrs • Lasts for 2-6 hrs
EVENTS IN FIRST STAGE OF LABOR
Pain
Dilatation
and
Fetal system
effacement
First of cervix
stage
Maternal Status of
system membrane
EVENTS CONTD…
• STATUS OF THE MEMBRANE
• Remains intact until the full dilatation of the cervix
• Best felt with fingers during contractions when it becomes tense
and bulges out through the cervical opening.
• When membranes get relaxed it lies in contact with head .
• With ROM , liquor escapes from vagina .
EVENTS CONTD…
• MATERNAL SYSTEM
• Transient fatigue
• PR- increased by 10 -15 beats/min during contraction
• SBP- raised by 10 mm Hg during contraction.
• Temperature remain unchanged
EVENTS CONTD…
• FETAL EFFECT
• Slowing of FHR during
contraction by 10-20
beats/min
NURSING RESPONSIBILITY IN FIRST STAGE
• Explain the process of labour & counsel the mother
• Preparation of the unit
• Record Maternal Pulse, BP, Respiratory rate, Urine output every 1-2hrs
• Monitor FHS every 30mts
• Adequate hydration by oral fluids / IV fluids
• Monitor Uterine Contractions every 30mts for frequency, intensity and
duration
• Maintain Partogram to record the process
PARTOGRAM PICTURE
SECOND STAGE OF LABOR
• Concerned with the descent and delivery of the
fetus through the birth canal
• Second stage has two phases :-
[Link] – from full dilatation until head
touches the pelvic floor
[Link] – since the time mother has
irresistible desire to bear down and push until the
baby is delivered .
EVENTS IN SECOND STAGE OF LABOR
Pain
Bearing down
Fetal effects
efforts
Second
stage Membrane
Maternal signs
status
Vaginal signs Descent of the
fetus
EVENTS CONTD…
• PAIN – 2-3 minutes interval and lasts for about 1- 2 min.
• BEARING DOWN EFFORTS – It is the additional voluntary
expulsive efforts that appear during 2nd stage of labor.
• MEMBRANE STATUS – Rupture with a gush of liquor per vagina
EVENTS CONTD…
• DESCENT OF THE FETUS –
Evident by the abdominal and vaginal examination
• VAGINAL SIGNS –
The vulval opening looks like a slit through which scalp hair is
visible. The maximum diameter of the head stretches the vulval
tract called “Crowning of the head .”
EVENTS CONTD…
• MATERNAL SIGNS – Exhaustion , Slow respiration with
increased perspiration. Face become congested and neck veins
prominent during bearing down efforts.
• After expulsion of the fetus ,mother heaves a sigh of relief.
• FETAL EFFECTS – slowing of FHR during contractions and
comes to normal before next contraction
NURSING RESPONSIBILITY IN SECOND STAGE
• Monitor FHS every 5mts / after every contraction
• Encourage the mother to hold her breath and bearing down in each
contraction
• Vaginal examination every 30mts
• Position the mother for the delivery
• 10ml of 1% [Link] is given as a local anaesthesia before
episiotomy.
THIRD STAGE OF LABOR
Placental Separation of Expulsion of
Separation the Membranes Placenta
EVENTS CONTD…
• PAIN – For a short time ,no pain
• Intermittent discomfort in the lower abdomen, corresponding
with uterine contractions
TYPES OF PLACENTAL SEPARATION
SCHULTZE METHOD MATHEWS –DUNCAN METHOD
EVENTS IN THIRD STAGE OF LABOR
• SEPARATION OF MEMBRANES
• FACILITATED BY-
• Uterine contraction
• By weight of placenta as it descends down
NURSING RESPONSIBILITY IN THIRD STAGE
• After delivery the baby placed on the mother’s abdomen
• Early cord clamping
• ‘Milking’ before cord cutting
• [Link] 5U in 10ml saline over 1 minute slow IV
• Wait for the signs of placental separation
SIGNS OF PLACENTAL SEPARATION
• A fresh show of blood from the vagina
• The umbilical cord lengthen outside the vagina naturally
• The fundus of the uterus rises up
• The uterus becomes firm and globular
FOURTH STAGE OF LABOR
• Stage of recovery
• Examination of placenta , membranes and umbilical cord should
be done for completeness and for anomalies.
• Fundus – firm ,contracted and midline and at the level of
umbilicus
EVENTS CONTD…
• Laceration of birth canal (vagina and perineum ).
• First degree – perineal skin , vaginal mucus membrane but not
underlying fascia and muscle
• Second degree – Involve in addition , the fascia and muscle of
perineal body but not anal sphincter
• Third degree – Extend further to involve the anal sphincter
• Fourth degree- Rectum’s mucosa to its lumen .
NURSES RESPONSIBILITY IN FOURTH STAGE
To monitor
•Pulse
•Blood pressure
•Tone of uterus
•Abnormal vaginal bleeding