Intrapartum

(Process of Labor 
and Delivery)
LABOR
• The process by which 
the fetus and 
products of 
conception are 
expelled as the result 
  of regular, progressive,  
  frequent, and strong 
  uterine contractions.
 An involuntary 
physiologic process 
whereby the contents 
of the gravid uterus 
are expelled through 
the birth canal into 
the external 
environment  
• Preterm delivery   occurring 
after 24 weeks and before 37 
completed weeks of gestation. 
Term delivery   occurring after 
37 weeks and before 42 
completed weeks of gestation.
• Postterm delivery   occurring 
after 42 completed weeks of 
gestation.
Theories of labor Onset
• Uterine Stretch Theory – a 
hollow organ such as the uterus 
when full, will empty

•  Oxytocin Theory – oxytocin 
released by the posterior 
pituitary gland initiates labor.
 
Theories of labor Onset
• Progesterone Deprivation Theory 
– contractions are initiated when 
progesterone levels are decreased as 
such at the end of pregnancy
• Prostaglandin Cascade Theory – 
labor is initiated due to the 
production of prostaglandin as a 
result of the interplay between 
adrenal, fetus, and uterus.
Preliminary signs of Labor
1. LIGHTENING 
    ­ the descent of the fetus and 
      uterus into the pelvic cavity 
      2 to 3 weeks before the onset 
      of labor
Preliminary signs of Labor
Preliminary signs of Labor
2. BRAXTON HICKS contraction 
    are irregular, intermittent    
    contraction that have occurred 
    throughout the pregnancy, 
    becomes uncomfortable, and 
    produce a drawing pain in the 
    abdomen and groin
Preliminary signs of Labor
3. CERVICAL CHANGES include 
    softening, “ripening” and effacement 
    of the cervix that will cause 
    expulsion of the mucus plug 
    (bloody show) and increase vaginal 
    discharge
  
Preliminary signs of Labor
Cervical effacement 
refers to a thinning of the cervix. 
It can be expressed as a 
percentage. 
Prior to effacement, the cervix is 
like a long bottleneck, usually 
about four centimeters in length.
Preliminary signs of Labor
    Cervical Dilatation 
   – process of the cervix opening 
    in preparation for childbirth.
   ­ measured in centimeters or 
   in fingers” during an internal 
   (manual ) pelvic exam. 
Preliminary signs of Labor
4. RUPTURE of amniotic 
membrane may occur before the 
onset of labor, if suspect that her 
membranes have ruptured, she have 
to contact health care provider, 
should be examined for prolapsed 
cord (a life threatening condition of 
the fetus)
Preliminary signs of Labor
5. Burst of energy ­“nesting 
    Instinct”  and fatigue may 
    occur right before the onset 
    of labor
 due to an increase in 
epinephrine that is initiated by 
decrease in progesterone 
produced by the placenta.
Preliminary signs of Labor
6. Weight loss of about 1 to 3 
    lbs. may occur 2 to 3 days 
    before the onset f labor
7. Urinary frequency returns
8. Cramps and Backache 
     ­ muscles and joints are 
       stretching in preparation 
       for childbirth.  
 Difference between True Labor & 
False labor contractions
True labor False labor
 
Begin irregular but become  Begin and remain 
regular and predictable irregular 
Radiates from the back to the  Pain localized in the 
abdomen in a wave abdomen
Pain does not diminish with  Pain decreases with 
ambulation activity
Results to progressive effacement  No cervical changes
and dilatation of cervix
Increase in frequency, duration  consistent in interval, 
and intensity duration and frequency
 Difference between True Labor & 
False labor contractions
 
True labor False labor
Shorter intervals between  Longer intervals between 
contractions contractions
Contractions continue while  Contractions disappear 
sleeping while sleeping
Bloody show usually present Bloody show usually not 
present
Sedation does not stop  Sedation decreases or stops 
contraction contractions
Components of Labor

5 P’s of Labor
  1. Passenger
  2. Passageway
  3. Power
4. Position
  4. Psyche
 
1. Passenger ­ Fetus
• The way the passenger or fetus moves 
through the birth canal is 
determined by:
 Size of the fetal head
 Fetal presentation
 Fetal lie
 Fetal attitude
 Fetal position
Passenger – Fetal size
• Fetal head – is the largest presenting 
part
• Cranium – uppermost portion of the 
skull; comprises 6 bones
    2 Frontal
    2 parietal
    1 occipital
   sphenoid
   ethmoid
   2 temporal 
• Suture lines 
­membranous 
interspaces that allow 
the cranial bones to 
move and overlap to 
pass the birth canal 
readily
• Sutures allow the 
bones to move during 
the birth process. 
• Lambdoid suture. This extends across the 
back of the head. Each parietal bone meets 
the occipital bone at the lambdoid suture.
• Sagittal suture. This extends from the front 
of the head to the back, down the middle of 
the top of the head. The 2 parietal bone plates 
meet at the sagittal suture.
• Metopic suture (Frontal). This extends 
from the top of the head down the middle of 
the forehead, toward the nose. The 2 frontal 
bone plates meet at the metopic suture
• Coronal suture. This extends from ear to 
ear. Each frontal bone plate meets with a 
parietal bone plate at the coronal suture.
 Anterior
Fontanelles ­ larger;  2 by 3cm, lies at 
frontal, coronal and 
sagittal sutures.
­It closes by 12­18 months 
after birth.
Posterior
1cm­2cm, lies at the 
junction of the sutures of 2 
parietal bones and the 
occipital bone, is 
triangular. It closes 6­8 
weeks after birth.
Diameter of the fetal head
should be small enough to
allow the head to travel
through the bony maternal
pelvis.
Molding – a process that
reduces the diameter of the
head; .elongation of the
fetal skull. Molding can be
extensive but the heads of
most newborns assume
their normal shape within 3
days after birth
Fetal Lie
• relationship of fetal spine to
maternal spine.

• Longitudinal/ vertical –is

when fetus is parallel to
mother's spine, It is either
cephalic or breech
presentation, depending on
the fetal structure that first
enters the mother’s pelvis
Transverse/horizontal/oblique – is at right angle
to mother's spine. The long axis of the fetus is at a
right angle diagonal to the long axis of the mother.
 Fetal Presentation
• The presenting part is that portion of
the fetal body that is either foremost
within the birth canal or in closest
proximity to it.
• Presentation - portion of fetus that
enters pelvis first:
 Cephalic- head
 Breech- feet or buttocks (frank, footling)
 Shoulder- shoulder
 Fetal Position
• relationship of the presenting part to a
specific quadrant of a woman’s pelvis.
MATERNAL PELVIS:
- Right anterior
- Left anterior
- Right posterior
- Left posterior
Maternal side in which reference
point is found
•A- Anterior ( front of pelvis)
•P- Posterior ( back)
•T- transverse (side)
•Ex. ROA (right occiput anterior) -
Vertex presentation, facing the right
anterior quadrant of the pelvis.
FETUS:
•Vertex- occiput
•Face- chin (mentum)
•Breech – sacrum
•Shoulder – scapula or acromiom
•Sinciput - forehead
To document fetal position:
•The side of the maternal pelvis in which the
presenting part is found : Right (R), Left (L)
•Reference point on the presenting part
(Fetal Landmark)
•O- occiput
•M- Mentum or chin
•Sa- Sacrum
•A- acromiom process
• Fetus is born
fastest from an
ROA or LOA
position
• Labor is extended if
position is ROP or
LOP – more painful
because rotation of
the fetal head puts
pressure on sacral
nerves causing sharp
back pain
 Fetal Attitude
- relationship of fetal body parts to each other,
normal uterine posture is completely flexed
– Good/ Well flexed Attitude- General flexion
that is advantageous during birth
– The fetus assumes a characteristic posture in
utero partly because the way the fetus
conforms to the shape of the uterine cavity.
•The fetus becomes folded/bent upon itself in such
a manner that the back becomes markedly convex
•The head is sharply flexed so that the chin is
almost in contact with the chest.
• Normally, the back of the fetus is
rounded so that the chin is flexed on
the chest, the thighs are flexed on
the abdomen, and the legs are flexed
on the knees.
• The arms are crossed over the
thorax, and the umbilical cord lies
between the arms and legs.
Fetal Attitude
Good attitude – is in
complete flexion; the spinal
column is bowed forward;
head is flexed forward; chin
touches the sternum; arms
are flexed and folded on the
chest, the thighs are flexed
onto the abdomen; the calves
are pressed against the
posterior aspect of the thighs.
Fetal Attitude

Moderate flexion – the

chin is not touching the
chest but is in an alert
or “military position”
Fetal Attitude

Partial extension
-presents the “brow” of
the head to the birth
canal
Fetal Attitude

Poor Flexion
- the back is arched;
the neck is extended;
In complete extension,
presenting the occipito-
mental diameter of the
head to the birth canal
(face presentation).
 2. Power
• The involuntary and voluntary
powers combine to expel the fetus
and the placenta from the uterus.
• Involuntary contractions
originate at a “pacemaker” point
located in the myometrium;
• contractions move downward over
the uterus in waves separated by
short rest periods.
 2. Power
• Primary power - supplied by
involuntary muscle contractions of
the fundus of the uterus causing
DILATION AND EFFACEMENT
(shortening and thinning of the
cervix during the first stage of
labor.)
• Secondary power - voluntary
muscle contractions of the
maternal abdomen during the
second stage of labor; the bearing-
down efforts to aid in the expulsion
of the fetus as she contracts her
diaphragm and abdominal muscles
and pushes.
• Valsalva maneuver – closed
glottis & prolonged bearing down
Phases of uterine contractions:
a.Increment / crescendo-longest; intensity of contraction
increases
b. acme – contraction at its strongest; peak
c. Decrement / decrescendo– letting –up phase; intensity
decreases
• Between contractions, the uterus relaxes
• As labor progresses, relaxation intervals
decreases from10 minutes early in labor to 2 to
3 minutes
 Descriptors of Contractions:
a. Frequency- number of contractions, the time from the
beginning of one contraction to the beginning of the next
contraction.
b. Duration – interval from the beginning to end; length of
contraction
c. Intensity - strength of the contraction; mild, moderate or
strong
d. Interval – resting time b/n contractions allows for placental
perfusion

e
 Descriptors of Contractions:
a. Frequency-
b. Duration – interval from the beginning to end; length of
contraction
c. Intensity - strength of the contraction; mild, moderate or
strong
d. Interval – resting time b/n contractions allows for placental
perfusion

e
Terms used to describe what is felt on
palpation: • a. Mild – feels slightly tensed
fundus that is easy to indent with
fingertips. Feels like touching
finger to tip of nose.
• b. Moderate – the fundus is firm
that is difficult to indent with
fingertips. Feels like touching a
finger to chin.
• c. Strong – there is rigid, boardlike
fundus that is almost impossible to
indent with fingertips. Feels like
touching finger to forehead.
• Do not bear down with the abdominal 
muscles until the cervix is fully dilated. 
Doing so impedes the primary force and 
could cause fetal and cervical damage.
 3. PASSAGEWAY 
• Includes the bony pelvis, the soft 
tissues of the cervix, and the 
vagina.
• refers to the adequacy of the pelvis 
and birth canal in allowing fetal 
descent. 
• The maternal pelvis  is the greatest 
determinant in the vaginal 
delivery of the fetus.
 PASSAGEWAY 

• During the first stage of labor, the 
cervix opens (dilates) and 
thins out (effaces) to allow the 
baby to move into the birth canal.
• The cervix must be 100 percent 
effaced and 10 centimeters dilated 
before a vaginal delivery. 
 Female bony pelvis
• The woman’s pelvis is adapted for child bearing, and is a
wider and flatter shape than the male pelvis.
• The size and shape can affect the ease or difficulty of
labour and delivery; a broad pelvis gives less difficulty than
a narrow one, which may obstruct the descent of the baby
down the birth canal.
Bones of the Pelvis • are composed of
three sets of bones
that fuse together as
we grow older.
• Ilium: largest part of
the hip bone. The
crests of the iliac are
what people typically
consider their hips as
they typically can be
felt at the waist.
Bones of the Pelvis • Pubis: This is at the front
of the hip bone closest to
the genitals. There is a
joint between the two
pubes bones called the
pubic symphysis. In
women, this becomes
more flexible in late
pregnancy to allow the
baby’s head to pass
through during delivery.
Bones of the Pelvis

• Ischium: Below the

ilium and next to the
pubis, this circular bone
creates the lowest
portion of the hip bone.
This is where the femur
meets the pelvis to
create the hip joint.
Pelvic shape
Gynecoid (sometimes called a
“true female pelvis”
- round, wide, deeper, most
suitable for vaginal delivery
 Android
- heart shape resembling a “ male pelvis”
- brim is heart-shaped with
straight sacrum which
prevent fetal rotation.
- Larger babies have difficulty traversing this
pelvis as the normal areas for fetal rotation and
extension are blocked by boney prominences.
- Smaller babies still
squeeze through.
 Anthropoid
• like the gynecoid pelvis,
Oval “ape like pelvis basically oval at the inlet, with
short transverse diameter which
lead to fetal malposition
• Subpubic arch may be slightly
narrowed.
• This pelvis favors occiput
posterior presentations.
• Assisted vaginal birth usually
forceps; 20-25%
 Platypelloid
• Is kidney shaped, flattened at the inlet
and has a prominent sacrum. The
subpubic arch is generally wide but the
ischial spines are prominent. This pelvis
favors transverse presentations.
presentations
• Vaginal delivery is difficult
 Divisions
• Pelvis is a two-storied, bony basin divided into:
• False Pelvis- upper part; wide broad area between the
iliac crests & has no major clinical significance for Labor
& Delivery (support pelvic organ)
• True Pelvis- the actual bony canal that the fetus must
pass during labor and birth. Shape is a curved axis, not
a straight passage; contains the pelvic organs*
 Divisions
True Pelvis- divided into:
- Pelvic inlet or brim is the space where the baby's
head enters the pelvis; it is larger than the pelvic outlet,
where the baby's head emerges from the pelvis.
The dimensions in centimeters (cm) in both directions (12
cm top to bottom; and 13 cm (on average) transverse or
side to side).
 • Pelvic outlet - is formed
Top to bottom: 11cm by the lower border of the
Transverse: 12.5 cm pubic bones at the front,
and the lower border of
the sacrum at the back.
The ischial spines point
into this space on both
sides.
• Figure shows the
dimensions of the space
that the fetus must pass
through as it emerges
from the mother’s pelvis.
 Pelvic dimensions
Diagonal Conjugate
•The diagonal conjugate is the alternative,
measuring from the inferior border of the
pubic symphysis to the sacral promontory and
can be measured manually via the vagina.

•(To do this you use the tip of your middle

finger to measure the sacral promontory and
then using the other hand to mark the level of
the inferior
 Pelvic dimensions
Obstetric conjugate (or true conjugate)
•This distance is between the sacral
promontory and the midpoint of the pubic
symphysis (where the pubic bone is
thickest) .
• Pelvimetry is the
measurement of the
female pelvis.[1] It can
theoretically identify
cephalo-pelvic
disproportion, which
is when the capacity of
the pelvis is inadequate
to allow the fetus to
negotiate the birth
canal.
• However, clinical evidence indicate
that all pregnant women should be
allowed a trial of labor regardless
of pelvimetry results
• Clinical pelvimetry attempts to
assess the pelvis by clinical
examination.
• can also be done by radiography
and MRI.
 4. POSITION OF THE WOMAN
> Frequent changes in position relieves fatigue, increase
comfort and improve circulation.
> Upright position like walking, sitting, kneeling, and squatting
are preferred
 Upright Position
• Gravity promotes descent of the
fetus. It is beneficial to to the
mother’s cardiac output, that
improves blood flow to the
uteroplacental unit and maternal
kidneys.
• More efficient uterine contractions
• Improved fetal alignment.
 Upright Position
• Larger anterior-posterior and
transverse diameters of pelvic outlet
→ enhances fetal movement
through the maternal pelvis in
descent for birth.
• Faster delivery
• Leads to less interventions: less
episiotomies
• lateral position is suggested if the woman 
wants to lie down, to prevent compression of 
the major blood vessels (ascending vena cava 
and descending aorta) that results in supine 
hypotension that decreases placental 
perfusion.
 5. PSYCHE
• psychological state or feelings 
that the woman brings into labor 
and her response.
• A feeling of apprehension or 
fright.
• The progress of labor and birth 
can be adversely affected 
maternal fear and tension.
 5. PSYCHE
• Anxiety can also increase pain 
perception and lead to an increased 
need for analgesia & anesthesia. 

• Factors: current and previous 
pregnancy experience, expectations, 
preparation for birth, support 
system & culture. 
 
Mechanisms (Cardinal 
movements) of Labor
• A series of adaptations the fetus 
makes as it moves through the 
maternal bony pelvis during the 
process of labor & birth.
• Passage of Fetus through the 
birth canal involves position 
changes called Cardinal 
movements of Labor.
Mechanisms (Cardinal 
movements) of Labor
• E – Engagement
• D – Descent
• F ­ Flexion
• IR – Internal rotation
• E ­ Extension
• ER – External rotation
• E ­ Expulsion
Engagement
• Largest diameter of the fetal head passes through
the pelvic inlet
• Fetal head reached the level of the ischial spine ,
known as zero station
Engagement
• Settling of the presenting
part of a fetus far enough
into the pelvis to be at the
level of the ischial spine
• Floating – presenting part
not engaged
• It often occurs few weeks
just before labor begins in
nulliparas; and may occur
during labor in multiparas.
Engagement
• Leopold’s maneuvers: the head is more difficult
to move and less of the head is able to be
palpated abdominally after engagement
• For a primipara, often occurs approx. 2 weeks
before labor begins. Woman may report that it’s
easier to breathe, since the pressure on the
diaphragm and the lungs is decreased. May
complain of increased need to urinate or an
increased pelvic heaviness.
• For a multiparous woman, engagement may
not occur until labor begins.
Descent
• Downward movement through the pelvic 
inlet through dilated cervix, reaches 
posterior vaginal wall .
 Descent
• Occurs because of pressure on the 
fetus by the contracting uterus
• Full descent occurs when the fetal 
head extrudes the dilated cervix and 
touches the posterior vaginal floor.
• Descent is continuous from the time 
of engagement until birth.
Descent
• Assessed by measurements 
called stations.
• Ranges from –3 to +3 station.
• STATIONS = based on an 
imaginary scale that uses the 
ischial spines of the 
maternal pelvis as its 
reference point.
• Ischial spines are located at 
the narrowest diameter of 
the pelvis.
Descent
• Halfway through the 
pelvic passage is zero 
station.
• If the presenting part is 
above zero station, it is 
assigned a negative 
number.
• If it is below zero station, 
a positive number is 
assigned.
• Use the “RULE OF 
THIRDS” to calculate 
station
Descent
• The space above and below 
the ischial spines is divided 
into 3 levels.
• The presenting part is 
designated –3 if unengaged 
and +3 if fully crowning.
• Crowning = a term used to 
describe the visualization of 
the biparietal diameter of 
the fetal head at the 
vaginal introitus.
Flexion • The head bends 
forward onto the 
chest, making the 
smallest 
anteroposterior 
diameter 
presented to the 
birth canal.
• Also aided by 
abdominal muscle 
contraction during 
pushing.
Internal rotation
• Rotation of the fetal head until the longest
diameter of the fetal head match the longest
diameter of the maternal pelvis.
• The head flexes as it touches the pelvic floor, and
the occiput rotates until it is superior toward the
symphysis pubis.
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 part of the head, the face and chin
were born.
 External rotation (Restitution)
• After the head has delivered, the
shoulders rotate internally to fit the pelvis
 Expulsion
• The shoulder and the remainder of the
body are delivered