Objectives:

•Theories of the onset of labour

•Four P’s of labour
•Psychological response to labour
•4 stages of labour
•Maternal & fetal response to labour
•Danger signs in labour
Onset of Labor
How does labor start? Rupture of membranes, complain
of backache, pressure,
What are the triggers that says that it is time for baby to
be born?
 Uterine muscle stretching
 Cervical pressure (dilate)
 Oxytocin stimulation
 Change in ratio of estrogen to progesterone
 Placental age 38-40 weeks
 Rising fetal cortisol levels
 Fetal membrane production of prostaglandin
L & D: The Components of Labor
The 4 “P’s” of normal birth
The Passenger: baby and placeanta
The Passageway: birth canal
The Powers: the contraction and pushing
The Psyche: Emotional and mental
preparedness
position of mother
The Passenger – The Fetus and
PLACENTA
FETAL PRESENTATION

This refers to the part of the baby that enters the pelvis
first.
Several factors determine this such as size of fetal head,
fetal presentation, fetal lie, fetal attitude and fetal
position]
- Cephalic presentation is most common
- Breech presentation is the buttock or feet
- Shoulder is the scapula
The Passenger
Fetal presentation

F
The Passenger
Fetal Lie:
Relation of the fetal spine to the spine of the mother
Longitudinal lies are either cephalic or breech presentations
Transverse lie cannot be delivered vaginally
Fetal Attitude:
Relation of fetal body parts to one another
Assume a characteristic posture or attitude
General flexion
Generally back rounded, chin flexed on the chest, thighs are
flexed on abdomen and legs flexed at knees and arms cross over
thorax. Deviations from this can put mom at risk for prolonged
labor, vacuum, c section
The Passenger
FETAL POSITION
Position refers to the relation of presenting part to
the 4 quadrants of the mother’s pelvis.
Position is denoted by a 3 letter abbreviation
first: denotes the location of the presenting part in
either R of L side of mom’s pelvis
second: specific presenting part of fetus
third: stands for the location of the presenting part in
relation to mom’s pelvis
The Passenger
Fetal position

F
The Passenger
Station of the Presenting Part:
This is where the lowest part of the presenting part (head) is in
relation to the ischial spines which are in the cavity of the
maternal pelvis
Placement is measured in cm above or below ischial spines
 Is presenting part is above spines - measured as minus station
 If presenting part is below spines – measured as plus station

Engagement:
 Term used to indicate the largest diameter of presenting part
passed thru mom’s pelvic inlet
 Corresponds to a 0 station
The Passenger and Passageway

F
The Passageway
Passage
Route from uterus to external perineum
Passageway is the birth canal
Cervix has to efface (thins,100%) and dilates (opens, 10)
Boney pelvis, cervix, pelvic floor, vagina, external
opening to vagina
The Passageway
The Powers
Primary Powers: Contractions
Should be rhythmic and progressive
We use frequency, duration and intensity to describe
contractions
Secondary powers: bearing down efforts by woman
augment contractions (urge to push)
Effacement-shortening and thinning of the cervix in
first stage labour (expressed as percentage)
Dilation-enlargement of cervical opening (expressed
in cm)
The Powers of Labour
Cervical effacement &dilation

F
The Powers of Labour
Contraction Cycle
The Psyche
Psychological Outlook:

What they bring into labour

Some women feel apprehension
Most feel excitement
Good support systems are needed
 if good support system are in place they tend to feel more in
control and can adapt easier
Process of Labour
First stage – Onset of Labour to full dilation
The first stage of labour is divided into 3 phases
 Latent stage: early
 Active: rapid dilation

 transition :full dilation

1-18 hours
Second stage- Full dilation of the cervix until baby is born
Third stage – From delivery of the baby until the delivery of
the placenta
Fourth stage – 24 hours following birth
First Stage – longest
First Stage of Labour:
Averages = 12 hrs for first baby, 6-8 hrs for second
Cervix 0 – 3

The first stage of labour is divided into 3 phases

Early/Latent Phase of Labour
0 – 3 cm diliation
Contractions last 30 – 45 seconds
5 – 30 minutes apart
Mild to moderate intensity
Medication can be given during this phase but can
slow down or arrest the process of the labour
Women: alert, happy, mild anxiety
Active phase of Labour
4 – 7 cm of dilation
Contractions last 40 – 70 seconds
3 – 5 minutes apart
Moderate to strong intensity
Ideal time for medication as the early phase has
passed and is far enough from delivery not to cause
complications for baby after delivery
Women: seriously labour oriented, concentration is
need with contractions, is more demanding
Transition phase of Labour
8 – 10 cm dilated
Contractions last 45 – 90 seconds
2 – 3 minutes apart
Strong in intensity
Poor time for meds… to close to delivery and can
cause difficulty for baby after delivery… can take the
urge to push away
Urge to push
Women: more irritable, intense concentration,
nausea. vomiting
Second Stage
Second Stage of Labour:
From full dilation of the cervix until the baby is born
Strong urge to push is seen as the presenting part puts
pressure on the pelvic floor – this will not be felt by
moms that have had an epidural
Stool may be expelled during this stage – keep
perineum clean
Check V/S for mom and FHR – fetal heart (110-160)
Can take just a few minutes with a multipara or hours
with a nulliparous
Process of labor
Cardinal movements of
labor
Descent
Flexion
Internal rotation
Extension
External rotation
expulsion
Third Stage
3rd Stage of Labour
From delivery of the baby until the placenta (afterbirth)
is delivered
Contractions begin again during this stage
As the uterus contracts it shrinks in size the anchor villi
will break and cause the placenta to separate
If a uterus is not contracting this can not happen!
Oxytocin is usually given to increase contractions and
minimize uterine bleeding
Fourth Stage
Fourth Stage of Labour – first 24 hours

 Recovering from the physical process of birth

 Bonding is occurring

 Period of high risk for PPH

Maternal Response to Labor
Affects almost all body systems
CVS –BP may go up slightly during contractions
WBC’s – increase
Respiratory – 02 needs increase (like strenuous
exercise)
Temperature – perspiring, feels warm/cold
Maternal Response
Fluid Balance – increase in resps = insensible water
loss + not eating = may need IV
Urinary system – Concentrates urine to preserve
electrolytes/fluid. Empty bladder frequently unless
there is a problem (posterior baby)
Musculoskeletal – relaxin causes softening of cartilage
in pelvis
Maternal Response
GI System – slows down, blood shunted to other
organs. Stomach does not empty fast. May have
bowel movements in early labour due to action of
Prostaglandins.

Neurological/Sensory – increased pulse/respiratory

rate in response to pain
Psychological Response in Labor
Emotional distress
Pain reduces ability to cope
Needs to be in a quiet environment so she can
concentrate, breathe, relax, develop coping strategies
Fatigue
Fear
Culture can play a big role in how she copes
Fetal Physiological Response to
labor
Neurological System – contractions push baby’s head
on to the cervix - can decrease heart rate by a few
beats that show clearly on the fetal monitor as an
“early” deceleration pattern
Often interpreted as a positive sign that the head is
descending
As long as heart rate comes back to normal range at
end of contraction
Fetal Response to Labor
CVS – Baby responds well to the rhythm of the
contractions UNLESS there is a problem with the
contractions
E.g. oxytocin being used for induction and
contractions are strong, with no relaxation between
them for baby to recoup before the next contraction.
NEED to monitor inductions one on one so this DOES
NOT happen
Fetal Response to Labor
E.g. Cord around the neck happens in 40% of births –
usually no problem
HOWEVER – if cord is short or wrapped unusually
around the baby e.g. X3 around the neck then IF there
is a problem it will show up in the fetal heart rate
pattern. There will be huge, erratic,
deceleration/acceleration patterns that are typically a
“CORD PATTERN”
Fetal Response to Labor
Integumentary – edema of presenting part, petechiae.
Bruising of some areas
Musculoskeletal – Baby forced into full flexion
Respiratory - chest compression in birth canal clears
lung fluid
Easier to breath if vaginally born
Danger Signs in Labor-woman
BP – increase or decrease.
Increase-could be due to effort of pushing = short term
Decrease – losing blood(shock), side effect of epidural
Abnormal Pulse – If consistently over 100 bpm then
need to assess carefully (dehydration, shock, CPD)
Danger Signs in Labor-woman
Inadequate contractions
Prolonged contractions
Pathologic retraction ring
Danger Signs in Labor-Fetus
Worrisome fetal heart rate pattern
Meconium in amniotic fluid (thick and like pea soup
can be a major problem)
Hyperactivity