• Theories of Labor Onset  Presentation – portion of the fetus that enters
the pelvis first.
1. Uterine stretc h theory – any hallowed
organ when stretched to its maximum
capacity will contrast and empty.
2. Oxy tocin th eory – Oxytocin, which
causes contractions of the smooth muscles of
the posterior pituitary gland as a result of
stressful event in labor.
3. Progesterone Deprivation Theory –
Progesterone, secreted by the corpus
Luteum and then by the placenta, is
essential in maintaining pregnancy.
However, the decrease in the level of
progesterone circulating in the body will
initiate body pains.
4. Prostaglandin Theory – Prostaglandins,
formed by the uterine deciduas under level
of concentration in the amniotic fluid and
blood of women increases during labor.
Research has shown prostaglandin to be
very effective in inducing uterine
contraction at any stage of gestation.
Initiation of labor is said to be the result of
the release of arachidonic acid is believed to
increase prostaglandin synthesis
contractions.
5. Theory of Aging Placen ta – as the
placenta matures, blood supply decreases
resulting in uterine contractions.
Related Terms:
 Labor – is the process of moving the fetus,
placenta and membranes out of the uterus and
through the birth canal. Synonymous with
childbirth and parturition.
 Delivery – is the actual birth of baby
 Crowning – encircling of the largest diameter
of the baby’s head by the vulvar ring
 Effacement – shortening and thinning of the
cervical canal. It is expressed in percentage
(%).
 Dilatation – is the enlargement of the cervical
os from an orifice a few millimeters in size to
an aperture large enough to permit the
passage of the fetus.
 Show – is a mucoid discharge from the cervix
that is present after the mucous plug has been
discharged.
 Attitude – the relationship of the fetal parts to
one another
 Lie – relationship of the fetal spine to the
spine of the mother.
 Position – relationship of the assigned area of
the presenting part of the landmark of the
material pelvis.
 Station – measurement of the progress of
descent of the presenting part in relation to
the ischial spine.
 Frequency – from the beginning of one
contraction to the beginning of the next
contraction
 Duration – from the beginning of contraction
to its completion
 Intensity – the strength of contraction to its
completion
 Effacement – progressive thinning and
shortening of the cervix
 Dilatation – opening of the cervix os during
labor
SIGNS of LABOR
Preliminary/Prodromal Signs of Labor
1. Ligthening – setting of fetal head into
pelvic brim
 occurs approximately 10-14 days
before labor begins
 gives the woman relief from
diaphragmatic pressure and
shortness of breath
 occurs early in primiparas
 mother may experience: shooting
leg pains from the increased
pressure on the sciatic nerve,
increased amounts of vaginal
discharge and urinary frequency
from pressure on the bladder
2. Increased in Level of Activity – related to
an increase in epinephrine release that is
initiated by a decrease in progesterone
produced by the placenta
3. Braxton Hicks Contractions – painless
irregular contractions, sometimes strong
that may cause discomfort
4. Ripening of the cervix – Goodell’s sign: the
cervix feels softer than normal similar to
earlobe throughout pregnancy; at term
cervix is described butter-soft
Signs of TRUE LABOR:
1. Uterine Contractions – surest sign that
labor has begun
 2. Show – the blood mixed with mucus, takes
on a pink tinge. It is when mucus plug is
expelled and capillaries are exposed.
3. Rupture of the membranes – experienced
either as a sudden gush or as a scanty, slow
seeping of clear fluid from the vagina.
False Labor:
 Irregular contractions
 Pain is confined to the abdominal
 No increase in duration, frequency, and
intensity.
 Pain disappears with ambulating
 No cervical change
 Sedation stops contractions
True Labor:
 Regular contractions
 Pain on the lower back to the abdomen
 Increase in duration, frequency and intensity
 Pain not relieved upon ambulating
 Accompanied with effacement and dilatation
 Sedation does not stop contraction
The Suture Lines:
CHARACTERISTICS of CONTRACTIONS
1. Mild – uterine muscle are somewhat tense
but can be indented by a gentle pressure
2. Moderate – uterus is moderately firm and a
firmer pressure is needed to indent
3. Strong – the uterus becomes very firm that
at the height of contraction cannot be
indented.
COMPONENTS of LABOR
1. Passage – refers to the shape and
measurement of maternal pelvis and
distensibility of birth canal
– refers to the route a fetus must
travel from the uterus through the
cervix and vagina to the external
perineum.
– Elastic to expand and accommodate
4 Basic Classification of Pelvis:
a. Gynecoid – best pelvis; half of the
population
b. Android – common in men, 20% in
women; heart shape and difficult for vaginal
delivery
c. Anthropoid – common in men; 20-30%,
pelvic inlet oval
d. Platypelloid – flat pelvis; least common;
5% of the population, long sacrum
2. Passenger – refers to the fetus, its size,
presentation, and position.
3. Power – forces acting together to expel
fetus from the uterus
2 TYPES of POWER
a. Primary Powers – involuntary contractions of
the uterus
b. Secondary Powers- voluntary bearing down
efforts of the mother
4. Psyche – reflects the woman’s frame of
mind in dealing with the labor experience
Structure of the fetal skull
 Cranium – uppermost portion of the
skull, comprises eight bones.
- the four bones: the frontal
(actually 2 fused bones), 2 parietal
and occipital.
- The other four: sphenoid,
ethmoid, and 2 temporal bones
 Sagittal suture- joins the 2 parietal bones
of the skull
 Coronal suture – the line of juncture of the
frontal bones and the 2 parietal bones
 Lambdoid suture – the line of juncture of
the occipital bone and 2 parietal bones.
Fontanelles:
- significant membrane-covered spaces that
are found at the junction of the main suture
lines
Anterior Fontanelle – referred to as bregma;
lies at the junction of the coronal and sagittal
sutures
- diamond-shape
- anteroposterior diameter is 3-4cm
- transverse diameter is 2-3cm
Posterior Fontanelle – lies at the junction of
the lambdoidal and sagittal sutures.
- triangular
- smaller than the anterior
Fontanelle
- only 2cm across its widest part
Vertex – the space between two fontanelles
Sinciput – the area over the frontal bone
Occiput – the area over the occipital bone
Suboccipitobregmatic – narrowest diameter
9.5cm; from the inferior aspect of the occiput to
the center of the anterior fontanelle
Occipitofrontal – measured from the bridge of the
nose to the occipital prominence is 12cm
Occipitomental – the widest which is 13.5cm;
measured from the chin to the posterior
fontanelle
Molding – the change in shape of the fetal skull
produced by the force of uterine contractions
pressing the vertex of the head against the not-
yet-dilated cervix.
FETAL PRESENTATION and POSITION
Attitude – describes the degree of flexion a fetus
assumes during labor or the relation of fetal parts
to each other
1) Good Attitude (complete flexion) – the
spinal column is bowed forward that the
chin touches the sternum, the arms are
flexed and folded on chest, the thighs are
flexed onto the abdomen and the calves
are pressed against the posterior aspect of
the thighs.
2) Moderate flexion – the chin is not
touching the chest but is in an alert or
military position
3) Poor flexion – the back is arched, the neck
in extended and a fetus is in complete
extension, presenting the occipitomental
diameter of the head to the birth canal
(face presentation)
Engagement – refers to the settling of the
presenting part of a fetus far enough into the
pelvis to be at the level of the ischial spines.
Floating – a presenting part that is not
engaged
Dipping – one that is descending but has not
yet reached the ischial spines
Station – refers to the relationship of the
presenting part of a fetus to the
level of ischial spines
0 station – presenting part of a fetus is at the
level of the ischial spines
-4 station – head is at outlet
+4 station – head is floating
FETAL LIE – the relationship between the long
axis of the body and the long axis of
a woman’s body
2 Primary Lie
1. Longitudinal 2. Transverse
FETAL PRESENTATIONS – denote the body part
that will first contact the cervix of
be born first.
- this is determined by a
combination of fetal lie and the
degree of flexion
3 Main Presentations
a. Cephalic – the fetal head is the body part that
will first contact the cervix
- the four types of cephalic presentation:
vertex, brow, face and mentum
b. Breech – either the buttocks or the feet are the
first body part that will contact the
cervix
- the 3 type of breech presentation: complete,
frank, and footling)
c. Shoulder – the presenting part is usually one of
the shoulders (acromion process, an
iliac crest, a hand, or an elbow
POSITION – the relationship of the presenting
part to a specific quadrant of a
woman’s pelvis
UTERINE CONTRACTIONS:
Origins
 Labor contractions begin a “pacemaker”
point located in the myometrium near one
of the uterotubal junctions
 In some women, contractions appear to
originate in the lower uterine segment
rather than in the fundus.
Phases
 3 Phases: increment, acme, decrement
 Increment- when the intensity of the
contraction increases
 Acme- when the contraction is at its
strongest
  Decrement- when the intensity decreases
 As labor progresses the relaxation intervals
decrease from 10 minutes to 2 – 3 minutes
 The duration also changes from 20-30 sec
to a range of 60-90 sec
Contour Changes
 Upper segment 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
 The lower segment becomes thin-walled,
supple, and passive so that the fetus can be
pushed out of the uterus easily
 Physiologic retraction ring – a ridge on the
inner uterine surface that marks the
boundary between the 2 portions
 Pathologic retraction ring (Bandl’s ring) –
it is a danger sign that signifies impending
rupture of the lower uterine segment if the
obstruction to labor is not relieved
Cervical Changes
Effacement
 Shortening and thinning of the cervical
canal
 Normally the canal is 1-2cm
 With effacement the canal virtually
disappears because of longitudinal traction
from the contracting uterine fundus
Dilation
 Refers to the enlargement or widening of
the cervical canal from an opening of few
millimeters wide to one large enough
(10cm).
 First reason why dilation occurs is uterine
contractions gradually increase the
diameter of the cervical canal lumen by
pulling the cervix up over the presenting
part of the fetus
 Second, the fluid-filled membranes press
against the cervix
 As dilation begins there is large amount of
vaginal secretions (show) because the last
of the operculum or mucus plug in the
cervix is dislodged and capillaries in the
cervix rupture
STAGES OF LABOR
1. Stage 1 (stage of dilatation) – begins with the
true labor pains and ends when the cervix has
reached full dilatation
Nursing Care:
Stay with woman; provide constant support
Reminds, reassures and encourages woman
to reestablish breathing patterns and
concentration as needed
Prompts partial respirations if woman begins
to push prematurely accepts woman
inability to comply with instructions
Keeps woman aware of progress
4 Phases:
• Latent Phase
Begins at the regularly perceived
uterine contractions and ends when
rapid cervical dilatation begins
Contractions are mild and short lasting
20-40 seconds
Cervix dilates from 0-3cm
6 hours in nullipara
4.5 hours in multipara
Nursing Care:
- Assists woman to cope with
contraction
- Helps to concentrate in breathing
techniques
- Assists into comfortable position
- Informs woman of the progress of
labor
- Explains procedure and routines
- Offer fluids, ice chips, food as
ordered
• Active Phase
Dilatation increases from 4 – 7 cm
Contraction lasts 40-60 sec and occur
every 3-5 minutes
3 hours in nullipara
2 hours in multipara
Show and spontaneous rupture of
membranes may occur
Nursing Care:
- Finds assessment techniques
between contractions
- Assists with frequent position
change
- Applies counter pressure to
sacrococcygeal area
- Encourages and praises
- Keeps woman aware of progress
 - Check bladder and encourages
voiding
- Gives oral care
• Transition Phase
Contractions reached their peak of
intensity occurring every 2-3 minutes
with duration of 60-90sec
Maximum dilatation 8-10cm
Complete cervical effacement
Woman experiences intense
discomfort accompanied by nausea and
vomiting
Woman may also experience a feeling
of loss of control, anxiety, panic or
irritability
2. Stage 2 (Stage of Expulsion) – the period from
full dilatation to birth of the infant
Contractions change from the
characteristic crescendo-decrescendo
pattern to overwhelming uncontrollable
urge to push or bear down with each
contraction as if to move her bowels
Woman perspire and the blood vessels in
her neck may become distended
Crowning takes place
The need to push become intense and the
woman cannot stop herself
6 Cardinal Movements of the Mechanism of
labor
o Descent – downward movement of the
biparietal diameter of the fetal head to
within the pelvic inlet
- full descent occurs and the fetal
head extrudes beyond the dilated
cervix and touches the posterior
vaginal floor
o Flexion – the head bends forward onto the
chest, making the smallest anteroposterior
diameter
o Internal rotation – the occiput rotates until
it is superior, or just below the symphysis
pubis, bringing the head into the best
relationship to the outlet of the pelvis
o 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. The head extends, and the foremost
parts of the head, the face and chin are
born.
o External Rotation – almost immediately
after the head of the infant is born, the
head rotates (from the anteroposterior
position it assumed to enter the outlet)
back to the diagonal or transverse position
of the early part of labor
o Expulsion – the rest of the baby is born
easily and smoothly because of its smaller
part size. The end of the pelvic division of
labor.
Nursing Care:
Put both legs at the same time when
positioning to the lithotomy position
Instruct mother to push as fetal head
crowns. If hyperventilation occurs, let
patient breathe into a brown paper or a
cupped hand.
3. Stage 3 (Placental Stage) – begins from the
delivery of the baby up to the delivery of the
placenta
2 Phases:
a. Placental Separation
Signs:
- Lengthening of the cord
- Sudden gush of blood
- Change of shape of the uterus
b. Placental Expulsion
- Brandt Andrew’s Maneuver – tract the
cord slowly, winding it around the clamp until
placenta spontaneously comes out rotating it
slowly so that no membranes are left
Nursing Care:
Don’t hurry the expulsion of the placenta,
just watch for the signs of placental
separation
Take note of the time of placental delivery
Inspect for the completeness of the
placenta
Palpate the uterus to determine degree of
contraction. If relaxed, massage gently and
apply ice cap
Inspect for lacerations
Types of Placental Presentation
 Schultze’s – appearing shiny and
glittering from the fetal membranes
  Duncan – it looks raw, dirty, meaty,
red and irregular
4. Stage 4 (Puerperium Stage) – first 4 hours after
delivery of placenta
Degrees of Perineal Lacerations:
a. Early Deceleration – are periodic decreases
in the FHR resulting from pressure on the fetal
head during contraction (head compression)
b. Late Deceleration – indicative of fetal
hypoxia because of deficient placental perfusion
(uteroplacental insufficiency)

1. First Degree – skin and superficial to muscle c. Variable Deceleration – occurs at

2. Second Degree – muscles of the perineum unpredictable times during contractions and
3. Third Degree – continues to anal sphincter indicates cord compression
4. Fourth Degree – involves the anterior anal wall
Anesthesia – encompasses analgesia amnesia,
Episiotomy – incision made to the perineum to relaxation and reflex activity. It abolishes pain
enlarge the vaginal opening for easy delivery perception by interrupting the nerve impulses to
the brain. The loss of sensation may be partial
Types: incomplete, sometimes with loss of consciousness.
a. Midline/Median
b. Mediolateral Analgesia – refers to the alleviation of the
c. Lateral sensation of pain or in the raising of the threshold
for pain perception without loss of consciousness
Advantages:
1. Enlarging of the vaginal opening
2. Shortening of the second stage of labor
3. Minimizing the stretching of the perineal
muscle
4. Preventing perineal tearing

Fetal Monitoring – periodic change or fluctuation

in FHR occur in response to contractions and the
fetal movements are described in terms of
accelerations or decelerations
- done through intermittent
auscultation
- electronic monitoring

1. External – transabdominal, noninvasive,

monitors uterine contraction and FHR; client
needs to decrease extra-abdominal movements

2. Internal – membranes must be ruptured, cervix

sufficiently dilated and presenting part; invasive
procedure; continuous monitoring
- results of monitoring: normal FHR 120-
160; must obtain a baseline

Acceleration – 15 bpm rise above baseline

followed by return; usually in response to fetal
movement or contractions; indicates fetal well-
being

Deceleration – fall below baseline lasting 15

seconds or more, followed by a return: