Stages of Labor (Dilatation, Expulsion, Placental)

Onset Onset of Contractions to Full Cervical dilatation

Second Full cervical dilatation to Fetal Expulsion

Third Fetal expulsion to Placental Expulsion

True Labor False Labor (Braxton Hicks)

Contractions regular Contractions Irregular

Pain, starting in back, moving to front Pain in lower abd and groin

Increases in intensity, duration, & frequency Does NOT increase in

intensity, duration, or freq.

Cervix dilates and effaces Cervix does NOT dilate or efface

Walking increases intensity Walking relieves intensity

Labor begins 270 days after conception. It is an involuntary process over which the
mother has no control. Several theories have been proposed concerning the onset
of labor, which begins with the rhythmic contractions of uterine muscles. One
theory maintains that the decrease levels of progesterone and estrogen just before
the onset of labor, initiates spontaneous contractions. (Due to the placenta being
‘elderly’ and not functioning as efficiently as an endocrine gland). A second theory
is based on 3 facts: one-emotional and physical stresses cause oxytocin to be
released, into the blood stream, 2-the uterus becomes more sensitive to oxytocin in
late pregnancy, and 3-oxytocin augments myometrial contractions. A third theory is
the uterine stretch theory. Any hollow organ that becomes significantly stretched by
its contents will tend to empty itself. Thus, when the uterus reaches its maximum
capacity, it begins to contract. This theory may explain premature labor in multiple
pregnancies.

Signs of labor

Lightening- the decent of the presenting part of the fetus into the pelvic inlet; where
it becomes engaged or fixed. *moms can breathe easier due to less impingement
on diaphragm **mom will have new pelvic pains

Bloody Show- loss of mucous plug into cervical canal *labor is approaching

Labor usually begins after bloody show within a few hours to a few days.
Contractions

Contractions propagate from uterine pacemakers in the fundus.

3 Phases of Uterine Contractions

Increment Acme Decrement

(Ranges 30-90 seconds; Averages 1 minute)

The strength of a contraction increases during its Increment phase, is at its height
at its acme phase, and decreases during its decrement phase. The increment phase
is longer than the other 2 phases combined. The duration of a contraction is
measured from the moment the uterus begins to tighten until it relaxes once again.
The frequency of contractions is measured from the beginning of one contraction to
the beginning of another. The intensity is measured by the depress ability of the
fundus: Mild-fundus is depressible; Moderate-fundus becoming harder; Strong-
fundus at its hardest.

-Period of- -----Duration------

Relaxation

---------- Frequency--------------

The periods of relaxation provide rest for uterine muscles, and allow circulation to
be restored. Uterine relaxation is also necessary for the fetus, since constant
contractions could interfere with fetal circulation enough to cause fetal hypoxia and
distress.

Early Stages of Labor

• Frequency: every 5-10 min

 • Duration: 30-35 sec

• Intensity: Mild

Mid Stage of Labor

• Frequency: every 4-5 min

• Duration: 40-45 sec

• Intensity: Mild to Hard

Transitional Stage

• Frequency: every 2-3 min

• Duration: 55-60 sec

• Intensity: Strong

**Precipitous deliver- when head ‘pops’ out**

-can cause perineal tear; potential for placental rupture or umbilical tear;
epidural hematoma

Mechanism of Labor

Engagement-head enters pelvic inlet

Descent- movement of fetus as it passes through birth canal

Flexion

Internal Rotation

Extension

Restitution

External Rotation

Expulsion

Fetal/Pelvic Relationships

Attitude- (habitus) fetal posture within the uterus

Flexion-must include all parts Extension-one or more parts

extended

Lie-fetal axis (spine) in relationship to maternal axis (spine)

 Longitudinal: axi are parallel (99%) Transverse: axi are
perpendicular

Presenting Part-names the part nearest to the uterine os

***Cephalic (majority) ***vertex **Brow *Face

Presentation-

Breech-butt/legs first

Frank Breech-one or more legs extended to head

Double/single foot- one or more legs extended downward

Kneeling breech-knee presents

Shoulder presentation-**must be changed**

Compound-hands over head

Frequency of Presentations

Vertex 95%

Breech 3.5%

Face 0.5%

Shoulder 0.5%

Position-dominator (specific point on presenting part)

i.e.: Vertex presentation=occiput

Mentum-tip on mandible/chin (face presentation)

Breech-Sacrum

LOA (left occiput anterior) most common***

Station-how far into the pelvis has the fetus progressed. *vaginal exam

Primigravida Multigravida
1st Stage 10 hours 5 ½ hours
2nd Stage 50 min 20 min
3rd Stage 5-10 min 5-10 min
Total 11 hours 6 hours
Leopold’s Maneuvers: systematic palpation of abdomen

Pt lays flat on back, knees up, bladder empty

1-palpate fundus to feel for head or breech

2-palpate ‘sides’ to feel for back/extremities

3-palpate/press on fundus and C-cup presenting end to see if it moves

Moves? Yes-floating No-fixed/engaged

4-If engaged, push down in direction of birth canal

-prominence on side opposite of back- vertex presentation

-prominence on same side as back- face presentation

Position preferred after birth= lateral recumbent (on side with head down and butt
in air)

Suction oropharynx first and nasopharynx second

With a meconium stain, if baby is vigorous, routine care; if listless, intubate/suction

Signs of Placental Separation:

-cord lengthening

-gush of blood

(Post partum hemorrhage: >500mL within 24 hours)

Uterine Atoni: uterus without tone. *Most common cause for post partum
hemorrhage*

Stop Labor: FLUID BOLUS (Osmoreceptors in hypothalamus respond to osmolarity

changes in blood, which tells posterior pituitary gland to stop secreting ADH:
Oxytocin also comes from here, so suppressing the secretion of ADH, also
suppresses the secretion of oxytocin=stops labor)

Placental Delivery

Shiny Shultze-placenta encased in amniotic sac

Dirty Duncan-placenta expelled with sac trailing behind