Labor and Delivery

April Grace E. Ochon

What is Labor?
• Series of events by which uterine contractions
and abdominal pressure expel the fetus and
placenta from the woman’s body

• Regular contractions cause progressive

dilatation of the cervix and sufficient muscular
force to allow the baby to be pushed to the
outside.
• Normally begins when a fetus is sufficiently
mature to cope with extrauterine life, yet not
too large to cause mechanical difficulties with
birth.

• In some instances, it begins before the fetus is

mature (preterm birth) or delayed until the
fetus and the placenta have both passed
beyond the optimal point for birth (postterm
birth).
Theories of Labor Onset
• Uterine muscle stretching, which results in
prostaglandin release

• Pressure on the cervix, which stimulates the

release of oxytocin from the posterior pituitary

• Oxytocin stimulation, which works together with

prostaglandin to initiate contractions

• Change in the ratio of estrogen to progesterone

(increasing estrogen in relation to progesterone
stimulates uterine contractions)
• Placental age, which triggers contractions at a
set point

• Rising fetal cortisol levels, which reduce

progesterone formation and increase
prostaglandin formation

• Fetal membrane production of prostaglandin,

which stimulates contractions

• Seasonal and time influences

 Preliminary
Signs of Labor
1. Lightening

2. Increase in Level of Activity

3. Braxton Hicks Contractions

4. Ripening of the Cervix

 Lightening
• Also called descent of the fetal presenting
part into pelvis
• Occurs 10-14 days before labor begins
• Changes the woman’s abdominal contour as
the uterus becomes lower and more anterior
• Abdominal pressure increases, result to
shooting leg pains from pressure on sciatic
nerve, increased amounts of vaginal
discharge, urinary frequency
 Increase in Level of Activity
• Woman wakes in the morning full of energy
due to an increase in epinephrine release
that is initiated by a decrease in
progesterone produced by the placenta.

• Additional epinephrine prepares the

woman’s body for the work of labor ahead.
 Braxton Hicks Contractions
Muscles of your uterus (womb) tightening, for anywhere
from 30 to 60 seconds. This may happen to you several times
an hour, several times a day starting the 28th week AOG.
False Contractions True Contractions
Begin and remain irregular. Begin irregularly but become regular
and predictable.
Felt first abdominally and remain Felt first in the lower back and
confined to the abdomen and groin. sweep around to the abdomen in a
wave.
Often disappear with ambulation Continue no matter what the
and sleep. woman’s level of activity.
Do not increase in duration, Increase in duration, frequency, and
frequency, or intensity. intensity.
Do not achieve cervical dilatation. Achieve cervical dilatation.
 Ripening of the Cervix

• Internal sign seen only on pelvic examination

• Cervix becomes softer and it tips forward.

• Internal announcement that labor is close at

hand.
Signs of True Labor
[Link] Contractions

[Link]

[Link] of Membranes
 Uterine Contractions

• Surest way that labor has begun

• Effective, productive, involuntary initiation

 Show
• As the cervix ripens, the mucus plug that
filled the cervical canal during pregnancy is
expelled.

• The exposed cervical capillaries seep blood

as a result of pressure exerted by the fetus.

• The blood, mixed with mucus takes on a pink

tinge and is referred to as “show” or “bloody
show”
 Rupture of the Membranes

• Sudden gush or scanty, show seeping of clear

fluid from the vagina

• Early rupture can be advantageous if it

causes the fetal head to settle snuggly into
the pelvis, this can actually shorten labor.
• Two risks are intrauterine infection and
prolapse of the umbilical cord, which can cut
off the oxygen supply to the fetus.

• If labor has not spontaneously occurred by

24 hours after membrane rupture and the
pregnancy is at term, labor will be induced to
help reduce risks.
Components of Labor
1. Passage

2. Passenger

3. Powers

4. Psyche
 Passage
• Route the fetus must
travel from the uterus
through the cervix and
vagina to the external
perineum. The fetus must
also pass the pelvic ring.

• The woman’s pelvis must

be of adequate size and
contour.
 Pelvic Inlet Pelvic Outlet

•Two pelvic measurements are important to determine adequacy

of the pelvic size: the diagonal conjugate (anterior-posterior
diameter of the inlet) and the transverse diameter of the outlet.
•At the pelvic inlet, the antero-posterior diameter is the
narrowest; at the outlet, the transverse diameter is the narrowest.
•If disproportion between the fetus and the pelvis occurs, the
pelvis is the structure at fault.
 Passenger
• Refers to the fetus.

• Head has the widest

diameter.

• Whether a fetal skull

can pass depends on
both its structure and
its alignment.
• Molding
– Change in shape of the
fetal skull produced by
the force of uterine
contractions pressing
the vertex against the
not-yet-dilated cervix.
– Lasts only for a day or
two and is not a
permanent condition
Fetal Presentation and Position

[Link] Flexion B. Moderate Flexion C. Poor Flexion D. Hyperextension

• Attitude
– Describes the degree of flexion the fetus assumes during
labor or the relation of the fetal parts to each other
• Engagement
– Settling of the presenting
part of the fetus far
enough into the pelvis to
be at the level of the
ischial spines, a midpoint
of the pelvis
• Floating
- presenting part that is
not engaged
• Dipping
- Descending but has not
yet reached the iliac
psines
• Station
– Relationship of the presenting part of
the fetus to the level of the ischial
spines
• 0 station – presenting part is at the level of the
ischial spines (engagement)
• Minus stations – presenting part is above the spines
which range form -1 cm to -4cm
• Plus stations – presenting part is below the spines
which range from +1cm to +4cm
• Crowning – presenting part is at the perineum and
can be seen id the vulva is separated (+3 or +4
station)
• Fetal Lie
– Relationship between the long (cephalocaudal) axis of the
fetal body and the long (cephalocaudal) axis of the
woman’s body.
– Whether the fetus is lying in a horizontal (transverse) or a
vertical (longitudinal) position
Types of Fetal Presentation – denotes the body part that will first
contact the cervix or deliver first

• Cephalic – head is the first part which contacts the

cervix
• Breech – either the buttocks or feet first contacts the
cervix
• Shoulder – fetus is lying horizontally in the pelvis so
that its long axis is perpendicular to that of the
mother
Types of Fetal Position – relationship of the
presenting part to a specific quadrant of the woman’s pelvis

• Four quadrants of the maternal pelvis:

– Right anterior
– Left anterior
– Right posterior
– Left posterior
• Four parts of the fetus as landmarks to
describe relationship of the presenting part to
one of the pelvic quadrants:

 Vertex presentation- occiput

 Face presentation- chin (mentum)
 Breech presentation- sacrum
 Shoulder presentation- scapula (acromion
process)
• Middle letter- fetal
landmark

• First letter – if landmark

point either to left or
right of mother

• Last letter – whether

landmark points to
anteriorly, posteriorly,
or transversely.
• LOA (Left occiput anterior) – most common
fetal position
• ROA -2nd most frequent position
• Position – most important because it
influences the process and efficiency of labor
• ROA/LOA – fetus delivers fastest
• ROP/LOP – labor is extended
• Posterior positions – more painful for mother
because rotation of fetal head puts pressure
on sacral nerves, causing sharp back pains.
Methods to determine fetal position

1. Combined abdominal inspection and palpation

2. Vaginal examination

3. Auscultation of fetal heart tones

4. Sonography
 Powers of Labor
• Supplied by the fundus of the uterus

• Implemented by uterine contractions

• Process that causes cervical dilatation and

then expulsion of the fetus from the uterus
• Uterine contractions
 Phases:
[Link]- intensity of contraction increases
[Link] – when the contraction is at its strongest
[Link]- when the intensity decreases

 Contour Changes
• Upper portion – becomes thicker and active preparing
it to exert the strength necessary to expel the fetus
when the expulsion phase of labor is reached
• Lower segment- thin-walled, supple, and passive so
the fetus can be pushed out of the uterus easily
Cervical Changes
Effacement
• Shortening and thinning
of the cervical canal
• 1-2 cm canal virtually
disappears
• Occurs because of
longitudinal traction
from the contracting
uterine fundus
Dilatation
• Enlargement of the cervical
canal from an opening a few
millimeters wide to one large
enough to permit the passage
of the fetus
• Occurs as uterine contractions
gradually increase the diameter
of the cervical canal of the
lumen by pulling the cervix up
over the presenting part of the
fetus
• Fluid-filled membranes press
against the cervix.
Psyche
• Psychological
state or feelings
that women bring
into labor with
them.
Stages of
 First Stage of Labor
1. Latent Phase
• begins at the onset of regularly perceived
uterine contractions and ends when rapid
cervical dilatation begins
• Mild and short, lasting 20 to 40 seconds
• Cervix dilates from 0 to 3 cm.
• Lasts 6 hours in nullipara and 4.5 hours in
multipara
2. Active Phase
• Cervical dilatation occurs more rapidly, going
form 4 cm to 7 cm
• Contractions are stronger, lasting 40 to 60
seconds and occurring approximately 3 to 5
minutes
• Lasts 3 hours in nullipara and 2 hours in
multipara
3. Transition Phase

• Maximum dilatation of 8 to 10 cm occurs and

contractions reach their peak of intensity,
occurring every 2 to 3 minutes with a duration
of 60 to 90 seconds
 Second Stage of Labor
• Period from full dilatation and cervical
effacement to birth of the infant
 Third Stage of Labor

• Placental Stage
• Begins with the birth of the infant and ends
with the delivery of the placenta
1. Placental Separation – occurs automatically
as the uterus resumes contractions
Placenta is ready to deliver when:
 Umbilical cord is lengthened
 Sudden gush of vaginal blood
 Change in the shape of the uterus
• Schultz placenta – shiny and glistening from the
fetal membranes
• Duncan placenta – raw, red, irregular, presents at
the vagina with the maternal surface evident
• 300-500 mL – normal blood loss
2. Placental Expulsion
• Placenta is delivered either by the natural
bearing down effort of the mother or by
gentle pressure on the contracted fundus by
the physician (Crede’s maneuver)
 Mechanisms of Labor:
Cardinal Movements of Labor
 1. Descent
• Downward movement of the parietal diameter if
the fetal head to within the pelvic inlet.
• Full descent occurs when the fetal head extrudes
beyond the dilated cervix and touches the
posterior vaginal wall.
• Occurs because of pressure on the fetus by the
uterine fundus.
• Full descent may be aided by abdominal muscle
contraction.
 2. Flexion
• As descent occurs, pressure from the pelvic
floor causes the fetla head to bend forward
onto the chest.

• Aided by abdomina, muscle contraction

during pushing.
 3. Internal Rotation
• Head enters pelvis with the fetal anteroposterior
head diameter in a diagonal or transverse position.
• The head flexes as it touches the pelvic floor, and the
occiput rotates until it is superior, or just below the
symphysis pubis, bringing the head into the best
diameter for the outlet of the pelvis.
• Brings the shoulders, coming next, into the optimal
position to enter the inlet of puts the widest
diameter of the shoulders in line with the wide
transverse diameter of the inlet.
 4. Extension
• As the occiput is born, the back of the neck
stops beneath the oubic arch and acts as a
pivot for the rest of the head.

• The head thus extends, and the foremost

parts of the head, the face and chin, are born.
 5. External Rotation
• Almost immediately after the head of the
infant is born, the head rotates back to the
diagonal or transverse position of the early
part of labor.
• The aftercoming shoulders are thus brought
into an anteroposterior position, which is best
for entering the outlet.
• The anterior shoulder is born first, assisted
perhaps by downward flexion of the infant’s
head.
 6. Expulsion
• Once the shoulder is born, the rest of the
baby is born easily and smoothly because of
its smaller size.

• This is expulsion and is the end of the pelvic

division of labor.
Maternal and Fetal Responses
to Labor
 Physiologic Effects on Mother
1. Increase in cardiac output
2. Increase in white blood cell count
3. Increase in respiratory rate/Hyperventilation
4. Slight elevation in temperature
5. Increase in insensible water loss
6. Decrease in bladder tone
7. Increased back pain
8. Perineal pain
 Psychological Responses of the
Woman in Labor

1. Fatigue

2. Fear

3. Cultural Influences
 Fetal Responses to Labor
1. Fetal heart rate decreases by as much as 5
bpm
2. Slight, unconsequential fetal hypoxia
3. Minimal petechiae, ecchymotic areas on
fetus, capput succedaneum
4. Fuul flexion
5. Establishment of respiration
 Fetal Danger Signs

1. High or Low Fetal Heart Rate – more than

160/less than 110 bpm
2. Meconium Staining
3. Hyperactivity
4. Fetal Acidosis
 Maternal Danger Signs
1. Rising or falling of blood pressure
2. Abnormal pulse
3. Inadequate or prolonged contractions
4. Pathologic retraction ring
5. Abnormal lower abdominal contour
6. Increasing apprehension
Nursing Interventions
 For the Mother
1. Admitting client to birthing area after
determining that client is in labor
2. Determining if client’s membranes have
ruptured
3. Encouraging family participation as
appropriate with the labor process
4. Performing Leopold’s maneuver and vaginal
exams as appropriate
5. Monitoring maternal vital signs and fetal heart
rate and patterns, reporting deviations and
abnormalities
6. Assessing pain level, instituting positioning,
breathing, relaxation, and other methods for pain
control; administering analgesics as ordered
7. Providing ice chips, wet washcloth, or hand candy
8. Encouraging voiding atleast every 2 hours
9. Cleansing perineum and assisting with pad changes
10. Monitoring vaginal discharge, cervical dilation and
effacement, posititon and fetal descent
11. Encourage bearing down
12. Evaluate pushing efforts and length of time in 2nd
stage
13. Preparing supplies and equipment for surgery/
 For the Baby

1. Verifying maternal and fetal heart rate

response to uterine contractions during
intrapartal care
2. Applying tocotransducer after determining
fetal position via Leopold maneuver
3. Palpating to determine contraction intensity
with tocotransducer use
 First Stage of Labor
1. Maternal and Health History review
2. Physical examination
3. Leopold’s maneuver
4. Assessing rupture of membranes
5. Assessing pelvic adequacy
6. Sonography
7. Vital signs
8. Laboratory Analysis
9. Auscultation of fetal heat sounds
[Link] of Uterine Contractions

• Duration - Length of Contraction

– Timed from the moment the uterus first tenses
until it has relaxed again

• Intensity – mild/moderate/strong

• Frequency – timed from the beginning of one

contraction to the beginning of the next
[Link] contraction time.

[Link] change of positions.

[Link] voiding and provide bladder care.

[Link] support.
 Second Stage of Labor
1. Preparing the place for birth
2. Positioning for Birth
3. Promoting effective second-stage pushing
4. Perineal cleaning
5. Episiotomy
6. Birth
7. Cutting and clamping the cord
8. Introducing the infant
 Third Stage of Labor
1. Oxytocin
2. Placenta Delivery
3. Perineal repair
Thank you!