Student Handout

Childbirth
Introduction
Why an understanding of pregnancy, labor and childbirth is
important in Nursing
In some countries, including the United Kingdom, New Zealand and Australia, Nurses and
Midwives are trained separately. In other countries such as the United States, Nurses may
specialize in midwifery at the end of their Nursing training. In this case, they are referred to
as Nurse-midwives, such as the Nurse-midwife introducing many of the videos in the
Childbirth class.
After a nine month gestation period, the full-term human fetus has a disproportionately large
head so, as a species, we have particular difficulty delivering babies and have developed a
number of technologies to assist in childbirth. These technologies, such as delivery by
caesarean section, will not be covered here. The aim of this Childbirth class is to introduce
the nursing student to how things should happen physiologically (naturally). There is
historical video footage of an uncomplicated, vaginal delivery. This class should provide a
good introduction for midwifery students and also be of general interest to nursing students.

The Onset of Labor

The exact triggers for the onset of labor are as yet unknown, but hormonal, mechanical and
fetal factors all play a role. Estrogen levels peak in the last few weeks of pregnancy, causing
receptors for oxytocin to appear on uterine smooth muscle cells, and opposing the calming
actions of progesterone. Uterine contractions are initiated by a combination of:

the increase in prostaglandins released from the placenta and fetal membranes,
high levels of oxytocin (released from the posterior pituitary, see Figure 1 of the
Ferguson reflex), and
several hormones released from the fetus.

The Ferguson reflex is the neuroendocrine feedback loop causing oxytocin synthesis and
release from the brain.
1. Pressure on the cervix from the baby's head activates sensory neurons.
2. Messages are carried to the hypothalamus in the brain.
3. Increased activity in hormone-producing neurons after cervical stimulation causes
increased oxytocin secretion, which is released into the blood stream.
4. Increased oxytocin levels cause uterine contractions.
5. These, in turn, apply more pressure on the cervix.

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Figure 1. The initiation of labor by the Ferguson reflex.

Uterine Contractions
Fundal dominance describes how each contraction starts at the fundus (the top of the uterus)
and spreads downwards, with the force of the contraction being the greatest at the fundus
and weaker elsewhere. Following each contraction, retraction occurs. Retraction is a unique
property of uterine smooth muscle cells, whereby they do not fully return to a relaxed state.
Instead the muscle fibers shorten slightly, and the smooth muscle cells are said to be

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retracted. This allows the thick muscular wall of the upper uterus to become thicker and
shorter. Hence the dimensions of the uterus decrease, expelling the fetus. The lower uterine
segment, by contrast, has a much thinner wall, which is designed for stretching and widening
to allow passage of the uterine head.

Figure 2: Dimensions of the non-pregnant uterus. The outer muscle layers are arranged
longitudinally, whereas inner muscle fibers have circular and spiral orientations.

Cervical Effacement and Dilatation

Cervical effacement is the process by which the cervix thins, allowing the cervical canal to
become continuous with the lower uterine segment, forming the birth canal. In a primagravid
woman, the cervix will not dilate until effacement has occurred. In multigravida, effacement
and dilatation often occur concurrently. Cervical dilatation occurs as a result of pressure
applied by the fetal head and membranes, due to uterine contractions. In turn, pressure on
the presenting part of the cervix triggers further oxytocin release due to the Ferguson reflex
(Figure 1). This helps to maintain labor as it becomes established and enters the first stage.

Latent Phase
Often the latent phase is included in first stage of labor but this stage can be very prolonged
(up to ~72 hours) in primagravida (first time mothers). Therefore, it is useful to consider it

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separately. During the latent phase, prostaglandins cause the cervix to soften or ripen. Early
contractions, often called 'Braxton Hicks' contractions, help to move the baby into a favorable
position, putting pressure on the cervix, and also cause bowel emptying. During this phase,
the mucus plug may be passed, which normally contains a little blood.

First Stage of Labor

The first stage of labor starts at 3 cm cervical dilatation. It is characterized by rapid cervical
dilatation and three strong contractions in every ten minutes. Cervical dilatation occurs at
0.51.0 cm per hour in primagravida and ~1.5cm per hour in multigravida. During this time it
is useful to monitor the well-being of the fetus using cardiotocography (CTG).

Five things to look out for in a CTG:

Baseline fetal heart rate (FHR):
FHR should lie between 120160 beats per minute (bpm).

Baseline bradycardia = less than 120 bpm, although some fetuses may have a
normal rate of 110120 bpm.
Baseline tachycardia = greater than 160 bpm.
Fetal bradycardia or tachycardia becomes a concern if it persists for 20 minutes or
more. Prolonged, severe bradycardia may indicate compression of the umbilical cord.

Baseline variability:
FHR should vary by more than 5 bpm over 1 minute.
A sustained decrease of variability of less than 5 bpm for 10 minutes or more may
indicate fetal hypoxia.
Baseline variability is considered abnormal if varies less than 5 bpm for more than 90
minutes.
Baseline reactivity:
A healthy FHR should react to external changes, such as a change of maternal
position or palpation of the stomach.
The response of FHR to uterine contractions:
It is normal for the FHR to remain unchanged or accelerate during a contraction.
Accelerations should recover quickly and not reach a tachycardic rate.
Decelerations in FHR:
It is reassuring if none are present as these can indicate fetal hypoxia.
If present, they should recover quickly the greater the bradycardia the greater the
concern.

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These are grouped into early decelerations and late decelerations if these appear,
an obstetrician should be consulted immediately.

Figure 3: A CTG recording showing a

healthy 'reactive' acceleration the fetal
heart rate accelerates during a contraction
and then rapidly recovers.
This is a physiological response the
FHR increases to raise the fetal blood
pressure, which helps to maintain the
blood supply to the baby's brain during
each contraction, in which the intracranial
pressure increases.

Maternal care and monitoring during the first stage of labor

If the CTG record is normal, the focus should be on care of the woman during first stage. She
should be kept hydrated with regular fluids, encouraged to urinate every hour, and
encouraged to be as active as possible to help keep the labor progressing.
Her temperature should be taken every four hours, heart rate every hour and blood pressure
every two hours (unless indicated). Urinalysis may be carried out to check for
ketoacidosis. Note the color of her waters if they break if they are green, an
obstetrician should be consulted as there meconium in the amniotic fluid, which is
an early indication of fetal distress.

Pain Relief during Labor

As the contractions become steadily more intense, many women require pain relief to help
them through labor. Natural approaches such as using warm water, in baths or birthing pools,
can be a great help in soothing and supporting the woman. Another non-pharmacological
approach known as TENS (transcutaneous electrical nerve stimulation) uses small electrical
shocks to stimulate nerves, which some women find can help to detract from the pain in early
labor.
In most parts of the world, the following pharmacological agents are available for pain
relief during labor:

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1. Gas and air, also known as Entonox or Nitronox, is 50% oxygen (O 2) and
50% nitrous oxide (N2O) or 'laughing gas' this is widely used in the developed
world and the U.K. but rarely used in the US. The woman inhales the gas, either
using a face mask or a mouth piece, from a gas cylinder. Many maternity wards have
it piped to every room. The advantage is that the woman is in control of the amount
she inhales and it is excreted quickly. Infants are born alert and unsedated. Any
undesirable effects such as nausea and "giddiness" rapidly reverse when she
exhales the gas.
2. Pethidine is an opioid analgesic drug, similar to morphine. It is very powerful and
effective for pain relief and is generally administered as an intramuscular injection.
The disadvantage of this drug is that it can cause cardiac and respiratory depression
in the fetus, so it should not be given if delivery is imminent (within 12 hours).
However, it takes up to 4 hours to allow clearance of the drug from the woman's
bloodstream. If an infant is born soon after administration of pethidine, an antidote
called naloxone can be given to the newborn to reverse the effects of pethidine.
3. Epidural this involves an anesthetist inserting a cannula into the epidural
space in the woman's spine, around the level of T10 for labor and T4 for
caesarean section. Tiny amounts of local anesthetic drugs, like bupivacaine or
lignocaine, can then be given by the health practitioner. The local anesthetic drug
then surrounds the specific spinal nerves that carry pain impulses to the brain and
can provide very effective pain relief. However, motor and autonomic nerves in this
region can also become blocked, causing hypotension due to relaxation of smooth
muscle in the blood vessels of the legs, loss of bladder function, and sometimes
partial or complete immobility. The health practitioner needs to monitor the woman's
blood pressure closely following an epidural. A rare complication is known as 'dural
tap' in which the anesthetist accidentally punctures the dura, allowing some
cerebrospinal fluid (CSF) to escape. This can lead to a drop in intracranial pressure,
often resulting in a debilitating headache that can last for a week.

Second Stage of Labor: The Delivery

The second stage starts when cervix is fully dilated and ends with the baby's birth. Usually,
after a long first stage lasting several hours, the second stage is relatively quick taking 12
hours in primagravida and often considerably less time in multigravida. The skill of the
midwife or health practitioner is required to recognize the signs of the onset of the second
stage, when the woman is encouraged to start pushing. Pushing before the cervix is fully
dilated is discouraged to prevent soft tissue damage and to conserve the energy of the
woman.
The five presentations
The term presentation refers to the part of the fetus that lies at the lower pole of the uterus or
at the pelvic inlet. These are listed below with the relative frequency of their occurrence
shown. Vertex, face and brow are known as cephalic (head) presentations.

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Vertex ~96.8 %
Shoulder 0.4 % (1 in 250)
Face 0.2 % (1 in 500)
Brow 0.1 % (1 in 1000)
Breech 2.5 % (1 in 40)

Two forms of breech presentations are commonly described:

1. In a footling breech presentation, the feet pass through the cervix first, which is
generally not fully dilated, and delivery by cesarean (C-section) is definitely required.
2. In a frank breech presentation (bottom first, see diagram above) it is possible, in
theory, to proceed with a vaginal delivery. However, internationally most breech
babies are delivered by C-section. In a frank breech presentation the baby descends
into the pelvis bottom first with its sacrum as the presenting part (see Figure 4 below).
In theory, it is possible to proceed with a vaginal delivery. However, internationally
most breech babies are delivered by C-section. The two most commonly described
frank breech positions are:
Complete or flexed breech baby has its thighs and knees flexed and feet
crossed, close to the buttocks
Extended breech baby has its knees extended and legs lie alongside the trunk,
with feet near its head

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Figure 4. This diagram illustrates commonly used terms to describe the 'lie', 'presentation'
and 'attitude' of the fetus.
For the most favorable fetal position for a vaginal delivery, the lie should be longitudinal, the
presentation should be vertex, and the baby's head should be fully flexed and facing the
mother's bottom (referred to as an occipitoanterior position). In this position, the fetal head
can progress through the female pelvis and pelvic floor muscles using a turning action,
shown in Figure 5.

Figure 5a: Fetal head in a left occipitoanterior

position.

Figure 5b: Fetal head turns to take advantage of

the widest diameter at the pelvic outlet, which is
anteroposterior.

The turning of the fetal head as it transits allows the widest transverse diameter of the fetal
head known as the biparietal diameter to encounter the widest diameters of the maternal
pelvis.

Anatomy of the Fetal Skull

During labor, the midwife or obstetrician perform vaginal examinations in which they assess
cervical dilatation and can also feel for landmarks like sutures and fontanelles on the fetal
skull to assess the position of the fetal head. Feeling the sagittal suture, for example,
confirms a vertex presentation.
Routinely measured in antenatal ultrasound scans, the biparietal diameter is the distance
between the two parietal eminences on each side of the fetal skull. In practice, this is the

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widest transverse diameter when the fetal head engages with the maternal pelvis in an
occipitoanterior position. As shown in Figure 5, an occipitoanterior position is the most
favorable presentation for a vaginal delivery. This is because, when the fetal head is well
flexed, the biparietal and the suboccipitobregmatic (SOB) diameters present. These two
diameters are the same length (approx. 9.5 cm), which makes the presenting area circular
the most efficient shape for dilating the cervix.

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Figure 6. The major landmarks and transverse diameters of the fetal skull (top) and the
major anteroposterior diameters (bottom left). The presenting area of a well flexed fetal head
is almost circular (bottom right), which is ideal for dilating the cervix.

Third Stage of Labor: Delivery of the Placenta

Skin-to-skin contact between the mother and newborn immediately after birth is very
important as it increases maternal oxytocin levels. Oxytocin is released from the posterior
pituitary gland in the brain and acts on a number of levels:
1. Oxytocin, which is a neuromodulator, increases feelings of love and trust and plays
an important role in early maternal-infant bonding.
2. Oxytocin stimulates the letdown reflex by acting on the mammary glands, causing
milk to move from the subareolar sinuses to the nipples, from where it can be
suckled. Nipple stimulation further increases oxytocin production, another advantage
of skin-to-skin contact and plays a major role in establishing successful breast
feeding.
3. Oxytocin release helps the uterus to contract down, which shuts off the placental
blood supply. A retroplacental blood clot forms and the placenta comes away.
In a physiological third stage, no drugs are given to assist placental separation. A
retroplacental clot forms and the placenta detaches from the uterine wall, generally 1020
minutes after the delivery of the baby. Encouraging the woman to move around or take an
upright position often causes the placenta to slide down and out through the birth canal
unassisted.

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Figure 7. After the baby has vacated the uterus, a large, strong contraction causes the
fundus to round up and move above the umbilicus. This can be seen and palpated by the
health practitioner. Placental separation occurs as the placental blood vessels are shut off by
the contracting uterine muscle fibers. The placenta then slips down into the lower pole of the
uterus, and out.
In a managed third stage, a drug called Syntometrine in given by intramuscular injection.
Then the midwife or obstetrician delivers the placenta by applying controlled cord traction.
The advantages and disadvantages of each type of third stage are discussed in Exercise 4.
Ideally, in a managed third stage the umbilical cord should be clamped before any
Syntometrine is given. This is to prevent a rush of cord blood to the newborn, which can
cause jaundice. However, with active management, Syntometrine is often given with the birth
of the anterior shoulder while the baby's head is on the perineum.

The umbilical cord and cord blood

During the third stage, the umbilical cord must be clamped and then cut. The cord generally
stops pulsing at birth, indicating constriction of the umbilical artery. The cord can then be
clamped. However, the umbilical vein remains dilated and studies have shown that if
allowed to transfuse by gravity the baby can receive up to 85 mL of umbilical blood. This
transfusion results in an initial increase in iron levels, which may be advantageous. However,
this increase is not detectable three days postnatally. In recent years it has become
fashionable to collect the cord blood, which is then frozen down, providing a source of stem
cells for the child's use in the future.
Note: Cord blood sampling is also important at this point if the mothers blood group is
Rhesus positive, or is unknown, or if any abnormal antibodies have been detected during her
pregnancy.

Examination of the Placenta

A careful examination of the placenta and membranes should be carried out as soon after
delivery as possible. It is important to ensure that no part of the placenta or membranes has
been left behind. The membranes are the most difficult to check because they are torn by the
baby's exit during delivery. By holding the placenta up by the cord, it is possible to insert a
gloved hand into the hole in the membranes made by the baby's delivery, allowing a
thorough examination. They often become raggedy so every attempt should be made to
piece them together.
The size and weight of the placenta are often recorded. It is also examined for completeness
it is important to seek medical aid if it is suspected that the placenta is incomplete. The
cord should also be checked to ensure it has three vessels: one umbilical vein and two
umbilical arteries. Absence of an artery often indicates a congenital abnormality and a
pediatrician should be alerted.

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Postnatal Care of the Infant
After birth, the immediate needs of the infant are warmth, food and close contact with the
mother. Therefore, placing the newborn 'skin-to-skin' on the mother's chest often initiates
breast feeding and quickly soothes any signs of distress. The health practitioner should
assess the infant's well-being by observation (skin color should be pink, indicating adequate
oxygen supply) and monitor the baby for signs of respiratory problems respiratory rates
greater than 60 breaths per minute indicate respiratory distress. Signs of increased work of
breathing include:

any forcible pulling-in of the chest wall or ribs on inspiration,

flaring of the nostrils as the baby uses its accessory muscles to inhale as much air as
possible, or
grunting sounds as the baby exhales against a partially closed glottis, trying to retain
as much air as possible in the lungs.

Close monitoring of a baby with signs of respiratory problems is vital. Interventions include:
suctioning to clear the infants nasal passages and airways to remove any meconium or
secretions, holding oxygen to the babys nose with a nasal cannula, keeping the infant warm
(although not too warm hot temperatures increase the respiratory rate), and if necessary
placing an unwell baby in an incubator in which the temperature and oxygen levels can be
controlled. Some infants may require additional help with their breathing, such as intubation
or continuous positive airway pressure (CPAP) ventilation.

What you will do in this class

This class has been divided into five exercises, interspersed with a case study:

1. The first stage of labor you will learn how to examine a CTG.
2. The second stage of labor (otherwise known as Delivery) you will learn why the
fetal head should turn as it passes through the maternal pelvis.

3. CTG in the second stage of labor you will look for early warning signs in a CTG.
4. Client Management you will be introduced to physiological versus managed third
stages and then asked to describe what actions you would take to assist a client in
the third stage of labor (the delivery of the Placenta).
5. Managed Third Stage of Labor you will be introduced to the timing of events
occurring in a managed third stage, following the administration of the drug
Syntometrine.
Case Study: As you work through this class, you will watch historical video footage of a
woman in labor and the delivery of her first child. Video interviews with a Nurse-Midwife will
explain important concepts and events at each stage. Finally, in the client follow-up, you will
be asked to think about the care of a woman in the puerperium, the 6-week period following
labor and delivery.

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At the end of this class you will be asked to review your answers to the questions and submit
a report. This may be done during or after the class, using LabTutor Online.

References:
Bennett, V.R. and Brown, L.K. Myles Textbook for Midwives 13th edition, (Churchill
Livingstone, 1999)
Stables, D. Physiology in Childbearing with Anatomy and Related Biosciences, (Balliere
Tindall, Harcourt Publishers Ltd., 1999)
Findlay, A.L.R. Reproduction and the Fetus (Physiological Principles in medicine Series,
Edward Arnold Publishers Ltd., 1988)

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