The four stages of labor

There are four stages of labor.

First stage of labor
Thinning (effacement) and opening (dilation) of the cervix
During the first stage of labor, contractions help your cervix to thin and begin to open.
This is called effacement and dilation. As your cervix dilates, your health care provider
will measure the opening in centimeters. One centimeter is a little less than half an inch.
During this stage, your cervix will widen to about 10 centimeters. This first stage of labor
usually lasts about 12 to 13 hours for a first baby, and 7 to 8 hours for a second child.
The first stage of labor has three parts:
1. Early labor
Your cervix opens to 4 centimeters. You will probably spend most of early
labor at home. Try to keep doing your usual activities. Relax, rest, drink clear
fluids, eat light meals if you want to, and keep track of your contractions.
Contractions may go away if you change activity, but over time they'll get
stronger. When you notice a clear change in how frequent, how strong, and
how long your contractions are, and when you can no longer talk during a
contraction, you are probably moving into active labor.
2. Active labor
Your cervix opens from 4 to 7 centimeters. This is when you should head to
the hospital. When you have contractions every 3 to 4 minutes and they
each last about 60 seconds, it often means that your cervix is opening faster
(about 1 centimeter per hour). You may not want to talk as you become
more involved in dealing with your contractions. As your labor progresses,
your bag of waters may break, causing a gush of fluid. After the bag of
waters breaks, you can expect your contractions to speed up.
Slow, easy breathing is usually helpful at this time. Focusing on positive, relaxing
images or music may also be helpful. Changing positions, massage, and hot or cold
compresses can help you feel better. Walking, standing, or sitting upright will help labor
progress. Relaxing during and between contractions saves your energy and helps the
cervix to open. Many hospitals have whirlpool or soaking tubs that may help you relax
and ease discomfort.
3. Transition to second stage
Your cervix opens from 7 to 10 centimeters. For most women, this is the
hardest or most painful part of labor. This is when your cervix opens to its
fullest. Contractions last about 60 to 90 seconds and come every 2 to 3
minutes.
There is very little time to rest and you may feel overwhelmed by the
strength of the contractions. You may feel tired, frustrated, or irritated, and
may not want to be touched. You may feel sweaty, sick to your stomach, shaky, hot, or
cold. Although you may find slow, easy breathing to be most effective throughout labor,
you may also find an uneven breathing pattern most helpful at this time.
Second stage of labor
Your baby moves through the birth canal
The second stage of labor begins when the cervix is completely dilated (open), and
ends with the birth of your baby. Contractions push the baby down the birth canal, and
you may feel intense pressure, similar to an urge to have a bowel movement.
Your health care provider may ask you to push with each contraction. The contractions
continue to be strong, but they may spread out a bit and give you time to rest. The
length of the second stage depends on whether or not you've given birth before and
how many times, and the position and size of the baby.
The intensity at the end of the first stage of labor will continue in this pushing phase.
You may be irritable during a contraction and alternate between wanting to be touched
and talked to, and wanting to be left alone. It isn't unusual for a woman to grunt or moan
when the contractions reach their peak.
Third stage of labor
Afterbirth
After the birth of your baby, your uterus continues to contract to push out the placenta
(afterbirth). The placenta usually delivers about 5 to 15 minutes after the baby arrives.
Fourth stage of labor
Recovery
Your baby is born, the placenta has delivered, and you and your partner will probably
feel joy, relief, and fatigue. Most babies are ready to nurse within a short period after
birth. Others wait a little longer. If you are planning to breastfeed, we strongly
encourage you to try to nurse as soon as possible after your baby is born. Nursing right
after birth will help your uterus to contract and will decrease the amount of bleeding.
From the "Birth Day News" series.

Clinical review by James Greene, MD

Kaiser Permanente
Reviewed 01/03/2019
O62 Abnormalities of forces of labour

O62.0 Primary inadequate contractions

Failure of cervical dilatation

Primary hypotonic uterine dysfunction

O62.1 Secondary uterine inertia

Arrested active phase of labour

Secondary hypotonic uterine dysfunction

O62.2 Other uterine inertia

Atony of uterus
Desultory labour
Hypotonic uterine dysfunction NOS
Irregular labour
Poor contractions
Uterine inertia NOS

O62.3 Precipitate labour

O62.4 Hypertonic, incoordinate, and prolonged uterine contractions

Contraction ring dystocia

Dyscoordinate labour
Hour-glass contraction of uterus
Hypertonic uterine dysfunction
Incoordinate uterine action
Tetanic contractions
Uterine dystocia NOS

Excludes: dystocia (fetal)(maternal) NOS ( O66.9 )

O62.8 Other abnormalities of forces of labour

O62.9 Abnormality of forces of labour, unspecified

O63 Long labour

O63.0 Prolonged first stage (of labour)

O63.1 Prolonged second stage (of labour)

O63.2 Delayed delivery of second twin, triplet, etc.

O63.9 Long labour, unspecified

Prolonged labour NOS

https://apps.who.int/classifications/apps/icd/icd10online2007/index.htm?go60.htm+

What are the 3 classifications for abnormal uterine action

Over-efficient uterus
*Precipitate delivery
*Excessive contraction and retraction
Inefficient uterine action
* Hypotonic inertia
* Hypertonic inertia
* Constriction (contraction) ring
Cervical dystocia

Abnormal Uterine Action

Classification

 Over-efficient uterine action

o Precipitate labour: in absence of obstruction
o Excessive contraction and retraction: in presence of obstruction
 Inefficient uterine action
o Hypotonic inertia
o Hypertonic inertia
 Colicky uterus
 Hyperactive lower uterine segment
o Constriction (contraction) ring
 Cervical dystocia

PRECIPITATE LABOUR

Definition

A labour lasting less than 3 hours.

Aetiology
It is more common in multiparas when there are;

 strong uterine contractions,

 small sized baby,
 roomy pelvis,
 minimal soft tissue resistance.

Complications

 Maternal:
o Lacerations of the cervix, vagina and perineum.
o Shock.
o Inversion of the uterus.
o Postpartum haemorrhage:
 no time for retraction,
 lacerations.
o Sepsis due to:
 lacerations,
 inappropriate surroundings.
 Foetal:
o Intracranial haemorrhage due to sudden compression and decompression of the head.
o Foetal asphyxia due to:
 strong frequent uterine contractions reducing placental perfusion,
 lack of immediate resuscitation.
o Avulsion of the umbilical cord.
o Foetal injury due to falling down.

Management

Before delivery

Patient who had previous precipitate labour should be hospitalized before expected date of delivery as she is more
prone to repeated precipitate labour.

During delivery

 Inhalation anaesthesia: as nitrous oxide and oxygen is given to slow the course of labour.
 Tocolytic agents: as ritodrine (Yutopar) may be effective.
 Episiotomy: to avoid perineal lacerations and intracranial haemorrhage.

After delivery

Examine the mother and foetus for injuries.

EXCESSIVE UTERINE CONTRACTION AND RETRACTION

Physiological Retraction Ring

It is a line of demarcation between the upper and lower uterine segment present during normal labour and cannot
usually be felt abdominally.

Pathological Retraction Ring (Bandl’s ring)

  It is the rising up retraction ring during obstructed labour due to marked retraction and thickening of the
upper uterine segment while the relatively passive lower segment is markedly stretched and thinned to
accommodate the foetus.
 The Bandl’s ring is seen and felt abdominally as a transverse groove that may rise to or above the umbilicus.
 Clinical picture: is that of obstructed labour with impending rupture uterus (see later).
 Obstructed labour should be properly treated otherwise the thinned lower uterine segment will rupture.

HYPOTONIC UTERINE INERTIA

Definition

The uterine contractions are infrequent, weak and of short duration.

Aetiology

Unknown but the following factors may be incriminated:

 General factors:
o Primigravida particularly elderly.
o Anaemia and asthenia.
o Nervous and emotional as anxiety and fear.
o Hormonal due to deficient prostaglandins or oxytocin as in induced labour.
o Improper use of analgesics.
 Local factors:
o Overdistension of the uterus.
o Developmental anomalies of the uterus e.g. hypoplasia.
o Myomas of the uterus interfering mechanically with contractions.
o Malpresentations, malpositions and cephalopelvic disproportion. The presenting part is not fitting in
the lower uterine segment leading to absence of reflex uterine contractions.
o Full bladder and rectum.

Types

 Primary inertia: weak uterine contractions from the start.

 Secondary inertia: inertia developed after a period of good uterine contractions when it failed to overcome
an obstruction so the uterus is exhausted.

Clinical Picture

 Labour is prolonged.
 Uterine contractions are infrequent, weak and of short duration.
 Slow cervical dilatation.
 Membranes are usually intact.
 The foetus and mother are usually not affected apart from maternal anxiety due to prolonged labour.
 More susceptibility for retained placenta and postpartum haemorrhage due to persistent inertia.
 Tocography: shows infrequent waves of contractions with low amplitude.

Management

 General measures:
o Examination to detect disproportion, malpresentation or malposition and manage according to the
case.
o Proper management of the first stage (see normal labour).
o Prophylactic antibiotics in prolonged labour particularly if the membranes are ruptured.
 Amniotomy:
 o Providing that;
 vaginal delivery is amenable,
 the cervix is more than 3 cm dilatation and
 the presenting part occupying well the lower uterine segment.
o Artificial rupture of membranes augments the uterine contractions by:
 release of prostaglandins.
 reflex stimulation of uterine contractions when the presenting part is brought closer to the
lower uterine segment.
 Oxytocin:
o Providing that there is no contraindication for it, 5 units of oxytocin (syntocinon) in 500 c.c glucose
5% is given by IV infusion starting with 10 drops per minute and increasing gradually to get a
uterine contraction rate of 3 per 10 minutes.
 Operative delivery:
o Vaginal delivery: by forceps, vacuum or breech extraction according to the presenting part and its
level providing that,
 cervix is fully dilated.
 vaginal delivery is amenable.
o Caesarean section is indicated in:
 failure of the previous methods.
 contraindications to oxytocin infusion including disproportion.
 foetal distress before full cervical dilatation.

HYPERTONIC UTERINE INERTIA (Uncoordinated Uterine Action)

Types

 Colicky uterus: incoordination of the different parts of the uterus in contractions.

 Hyperactive lower uterine segment: so the dominance of the upper segment is lost.

Clinical Picture

The condition is more common in primigravidae and characterised by:

 Labour is prolonged.
 Uterine contractions are irregular and more painful. The pain is felt before and throughout the contractions
with marked low backache often in occipito-posterior position.
 High resting intrauterine pressure in between uterine contractions detected by tocography (normal value is
5-10 mmHg).
 Slow cervical dilatation .
 Premature rupture of membranes.
 Foetal and maternal distress.

Management

 General measures: as hypotonic inertia.

 Medical measures:
o Analgesic and antispasmodic as pethidine.
o Epidural analgesia may be of good benefit.
 Caesarean section is indicated in:
o Failure of the previous methods.
o Disproportion.
o Foetal distress before full cervical dilatation.

CONSTRICTION (CONTRACTION) RING

Definition
  It is a persistent localised annular spasm of the circular uterine muscles.
 It occurs at any part of the uterus but usually at junction of the upper and lower uterine segments.
 It can occur at the 1st, 2nd or 3 rd stage of labour.

Aetiology

Unknown but the predisposing factors are:

 Malpresentations and malpositions.

 Clumsy intrauterine manipulations under light anaesthesia.
 Improper use of oxytocin e.g.
o use of oxytocin in hypertonic inertia.
o IM injection of oxytocin.

Diagnosis

 The condition is more common in primigravidae and frequently preceded by colicky uterus.
 The exact diagnosis is achieved only by feeling the ring with a hand introduced into the uterine cavity.

Complications

 Prolonged 1st stage: if the ring occurs at the level of the internal os.
 Prolonged 2nd stage: if the ring occurs around the foetal neck.
 Retained placenta and postpartum haemorrhage: if the ring occurs in the 3rd stage (hour- glass contraction).

Pathological Retraction Ring Constriction Ring

Occurs in prolonged 2nd stage. Occurs in the 1st, 2nd or 3rd stage.

Always between upper and lower uterine segments. At any level of the uterus.

Rises up. Does not change its position.

Felt and seen abdominally. Felt only vaginally.

The uterus is tonically retracted, tender and the foetal The uterus is not tonically retracted and the foetal parts
parts cannot be felt. can be felt.

Maternal distress and foetal distress or death. Maternal and foetal distress may not be present.

Relieved only by delivery of the foetus. May be relieved by anaesthetics or antispasmodics.

Management

 Exclude malpresentations, malposition and disproportion.

 In the 1st stage: Pethidine may be of benefit.
 In the 2nd stage: Deep general anaesthesia and amyl nitrite inhalation are given to relax the constriction
ring:
o If the ring is relaxed, the foetus is delivered immediately by forceps.
o If the ring does not relax, caesarean section is carried out with lower segment vertical incision to
divide the ring.
 In the 3rd stage: Deep general anaesthesia and amyl nitrite inhalation are given followed by manual removal
of the placenta.

CERVICAL DYSTOCIA
Definition

Failure of the cervix to dilate within a reasonable time in spite of good regular uterine contractions.

Varieties

 Organic (secondary) due to:

o Cervical stances as a sequel to previous amputation, cone biopsy, extensive cauterisation or
obstetric trauma.
o Organic lesions as cervical myoma or carcinoma.
 Functional (primary):
o In spite of the absence of any organic lesion and the well effacement of the cervix, the external os
fails to dilate.
o This may be due to lack of softening of the cervix during pregnancy or cervical spasm resulted from
overactive sympathetic tone.

Complications

 Annular detachment of the cervix: surprisingly the bleeding from the cervix is minimal because of fibrosis
and avascular pressure necrosis leading to thrombosis of the vessels before detachment.
 Rupture uterus.
 Postpartum haemorrhage: particularly if cervical laceration extends upwards tearing the main uterine
vessels.

Management

 Organic dystocia:
o Caesarean section is the management of choice.
 (II) Functional dystocia:
o Pethidine and antispasmodics: may be effective.
o Caesarean section: if
 medical treatment fails or
 foetal distress developed.

https://www.gfmer.ch/Obstetrics_simplified/abnormal_uterine_action.htm

normal uterine action and abnormal uterine action

Prolonged Labor: Failure To

Progress
Prolonged Labor: Causes and Solutions
Prolonged labor, also known as failure to progress, occurs
when labor lasts for approximately 20 hours or more if you are a first-
time mother, and 14 hours or more if you have previously given birth.
A prolonged latent phase happens during the first stage of labor. It can
be exhausting and emotionally draining, but rarely leads to
complications.
However, prolonged labor during the active phase of giving birth can
be cause for concern. If you experience a failure to progress, your
healthcare provider will begin running tests to determine the cause.
What causes prolonged labor?
There are a number of possible causes of prolonged labor. During the
latent phase, slow effacement of the cervix can cause labor time to
increase. During the active phase, if the baby is too large, the birthing
canal is too small, or the woman’s pelvis is too small, delivery can take
longer or fail to progress.
Carrying multiples may also lead to prolonged labor, as might weak
uterine contractions, or an incorrect position of the baby. Research
has also linked prolonged labor or failure to progress to psychological
factors, such as worry, stress, or fear. Additionally, certain pain
medications can slow or weaken your contractions.
What are some solutions?
Although some causes of prolonged labor may require medical
intervention, there are some steps you can take to ease your way. If
you are failing to progress during the latent phase, the best thing to do
is relax and wait while the cervix ripens.
Take a walk, sleep, or take a warm bath. If drugs are slowing your
contractions, you may need to simply wait until they are flushed from
your body. Sometimes changing positions may help the process
along; lay on your other side, stand, walk, or squat.
Prolonged Labor and Cesarean Sections
Also called a C-section, the Cesarean section may be the answer to
several of the issues that cause prolonged labor. Nearly a third of C-
sections are performed due to failure to progress. If your baby is
turned the wrong way, the head is too large to fit through the pelvis, or
the baby’s head is in the wrong position, a Cesarean birth might be
the best choice to avoid further complications.
C-sections are also very common for births of multiples. Nearly half of
twin births are done through C-section, while approximately 90% of
triplets are born using C-sections. Although C-sections are major
surgery, and there are risks associated with the procedure, it is
considered fairly safe.
This procedure is most often employed to prevent more serious birth
complications, and it is generally considered worth the risk to avoid
further critical labor issues.
Last updated: October 12, 2019 at 20:58 pm

Compiled using information from the following sources:

1. Erickson, M. (1976). The relationship between psychological
variables and specific complications of pregnancy, labor, and delivery.
Journal of Psychosomatic Research, 20(3), 207-210.
2. Harms, R. (2004). Mayo Clinic guide to a healthy pregnancy. New
York: HarperResource.
3. Kapp, F., Hornstein, S., & Graham, V. (1963). Some psychologic
factors in prolonged labor due to inefficient uterine action.
Comprehensive Psychiatry, 4(1), 9-18.
4. Prolonged Labor: Causes and Treatment.
https://www.webmd.com/baby/guide/prolonged-labor-causes-
treatments
5. Simkin, P. (1991). Pregnancy, childbirth, and the newborn: The
complete guide (Revised/Expanded ed.). Minnetonka, Minn.:
Meadowbrook Press
https://americanpregnancy.org/labor-and-birth/prolonged-labor-failure-progress/

https://nurseslabs.com/wp-content/uploads/2016/06/Featured-Care-of-the-Woman-with-
Complications-during-Labor.png

https://www.slideshare.net/EmmanuelUmoh/uterine-inertia?from_action=save
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https://www.slideshare.net/MnSavita/ppt-prolonged-labour

https://www.slideshare.net/MnSavita/essential-newborn-care-with-nursing-management