CERVICAL

RIPENING AND
STAGES OF
LABOR
Presented By Group 3
 MEMBERS

DE LEON, ELIZA DELA CRUZ, LARA DESQUITADO,

ANGEL GRACE ANGELA LEIGH

DIMAANO, MERSHEN DUENAS, FERNANDEZ, ANDREA

MAY TENNIEXEL NICOLE
 MEMBERS

FERRER, QUEENIE FURIGAY, JOHN GALVAN, CRISTEL

MARIE FIESTER JANE

GARGARITA, KIMMY GOJIT, PATRIQUE

LEIN ANNE
 CERVICAL RIPENING
What is Cervical
Ripening?
This is the process where
the cervix of a pregnant
women softens and opens
up before labor starts.
Cervical Ripening is also
known as Cervical
Effacement.
WHAT IS CERVICAL
RIPENING ?
The cervix stays tight and firm
throughout pregnancy in order to
keep the baby secure inside the
uterus. But the cervix gradually
widens as labor approaches to make
it easier for the infant to enter
through the birth canal. Cervical
ripening is a natural process that can
occasionally be aided by drugs, tools,
or techniques to get the cervix ready
for labor.
 CERVICAL RIPENING
WHO NEEDS CERVICAL RIPENING?
You might need labor induction and/or cervical ripening
if you:
1. Have an overdue pregnancy (pregnancy that lasts longer than 41
weeks).
2. Have health risks that threaten your health or the health of the
fetus. These may include preeclampsia, gestational diabetes or growth
restriction.
3. Live far from a hospital and need to plan your labor at a closer
location.
 CERVICAL RIPENING
AT WHAT STAGE
OF LABOR DOES
CERVICAL Cervical ripening usually begins before
RIPENING labor starts. During the first stage of labor
HAPPEN? your cervix will both thin and dilate. The
second stage usually begins when your
cervix is fully dilated and will allow your
baby's head to pass by, which usually is
10 centimeters.
WAYS OF PERFORMING
CERVICAL RIPENING
 WAYS OF PERFORMING
CERVICAL RIPENING

1. Nonpharmacologic Methods
Natural Methods
Special Devices
1. Nonpharmacologic Methods
Surgical Methods

2. Pharmacologic Methods
NONPHARMACOLOGIC
METHODS
 NONPHARMACOLOGIC
METHODS

Nonpharmacological ripening methods may

work by stimulating the release of hormone-like
chemicals in your body through a natural
approach for cervical ripening which are not
primarily based on medications.
 NONPHARMACOLOGIC
METHODS
According to Adair (2000), Nonpharmacological methods are
used for cervical ripening for the following purposes:
Highly efficacious and safe (less invasive)
Cost-efficient
Allows women to have greater control over the
induction process
However, the overall usefulness and clinical efficiency of these
methods are yet to be determined as there are only limited
research efforts to determine their activity.
 A. NATURAL METHODS
1.
Some herbal remedies have been known to help soften the cervix and
prepare the body for labor:
a.) Red Raspberry Leaf Tea - used to enhance uterine contractions
once labor is initiated
b.) Evening Primrose Oil - contains linoleic acid that triggers
prostaglandin to ripen the cervix
c.) Black Cohosh - has uterine toning effect, as well as softening
cervix
d.) Blue Cohosh - stimulates uterine contraction
 A. NATURAL METHODS
1.

Red Raspberry
Black Cohosh
Leaf

Evening
Blue Cohosh
Primrose Oil
 A. NATURAL METHODS

a.) Castor Oil - promotes release of prostaglandins

b.) Hot Baths - relaxes the body and leads to release
oxytocin
c.) Enema - stimulates the bowel which releases
prostaglandins
 A. NATURAL METHODS

Due to physical trigger or penetration, the lower uterine

segment is stimulated
Female orgasm also stimulates contraction due to the
endogenous release of oxytocin
Ejaculation of semen ripens the cervix and helps labor to
start as it contains high amounts of prostaglandin
A. NATURAL METHODS

Breast massage or nipple stimulation

increases the release of oxytocin,
which helps in stimulating
contractions
 A. NATURAL METHODS

This approach leverages the body's ability to

produce its own natural hormones (oxytocin) to
stimulate cervical ripening
Having the correct choice of acupuncture points
supports cervical ripening
A. NATURAL METHODS

Uses electrical current to activate

nerves to decrease pain and
stimulates release of prostaglandin
and oxytocin to induce labor.
 B. SPECIAL DEVICES
1.

Hygroscopic dilator is a tool that

absorbs fluid from the cervical cells,
leading to cell membrane dehydration,
and softening and opening of the
cervix
 B. SPECIAL DEVICES

A Foley bulb induction is a balloon

dilator that induces labor during
pregnancy by inserting catheter in the
cervix and filling it with saline to
cause cervix to dilate
 C. SURGICAL METHODS
1.

Membrane stripping or membrane

sweep helps the body release
prostaglandins which will soften the
cervix and prepare the body for labor.
 C. SURGICAL METHODS

Amniotomy is the process of breaking

the waters or rupturing the amniotic
sac to induce labor contractions and
ripening of cervix through release of
prostaglandins
PHARMACOLOGIC
METHODS
 PHARMACOLOGIC
METHODS

Pharmacological methods are the use of

medications to cause cervical ripening that
targets the separation of collagen fibers in the
cervix, thus making them soft and ready for
labor.
 PHARMACOLOGIC
METHODS
Synthetic and natural prostaglandins work
to soften the cervix and relax cervical
muscles, which helps with dilation.
These medications are proven and tested
through evidence-based research thus its
efficacy has been approved.
PHARMACOLOGIC METHOD

Prostaglandins are naturally occurring

chemicals in your body (uterine cells) that have
hormone-like properties which helps dilating
cervix and causing uterine contractions.
Patient may receive prostaglandins as a gel or
as a pessary (vaginal insert)
 PHARMACOLOGIC METHOD

DINOPROSTONE - PGE2
This gel is administered to the
cervix through a syringe placed in
the vagina.
The drug helps the cervix dilate.
The contractions should begin
slowly; given 20mg every 3-5
hours.
 PHARMACOLOGIC METHOD

A tablet attached to a ribbon

which is placed inside the vagina
just behind the cervix
Releases prostaglandin hormone
over 24 hours, and prepares cervix
for labor
More effective than prostaglandin
gel
 PHARMACOLOGIC METHOD

Misoprostol (synthetic PGE1 analog) is a pill to

be ingested either via oral, buccal, or vaginal
(most common).
Induces cervical ripening and uterine
contractions to assist in delivery by
stimulating the endometrium
Starts to work within 30 mins to 6 hours
(25mcg)
It is also used as an induction of abortion
(400-800mcg, following intake of
mifepristone)
 PHARMACOLOGIC METHOD

Mifepristone is an antiprogesterone that

causes softening and dilation of cervix
(for unripe cervix), and increases uterine
activity.
Recommended regimen: 200mg orally
Acts with 48-96 hours and shows more
favorable cervix
It is also used for induction of abortion,
when used simultaneously with
misoprostol
 PHARMACOLOGIC METHOD

Oxytocin is the most common used

induction agent.
Pitocin - synthetic oxytocin
It is a natural hormone from
hypothalamus and secreted to
bloodstream through pituitary gland to
induce uterine contractions
Oxytocin are infused intravenously;
1-4mU/min
HOW DO DEVICES
RIPEN THE
CERVIX
HOW DO DEVICES RIPEN THE CERVIX?

1. Insert a “dilator” to widen the

cervix in order to stimulate the
release of natural prostaglandins.
2. An inflatable balloon may be
inserted into your cervix through a
catheter. Then, they fill the balloon
with saline or sterile water.
CERVICAL DILATORS
PROCEDURES TO
RIPEN THE
CERVIX
 PROCEDURES TO RIPEN THE CERVIX
Amniotomy
Also decsribe as “Breaking the water”. It uses a small hook to
rupture the membranes around the amniotic sac. Breaking the
sac can help release prostaglandins to enable cervical ripening.
 PROCEDURES TO RIPEN THE CERVIX
Stripping the membranes
Doctor inserts a gloved finger into your cervix. Then, they rub or
separate the membranes connecting your uterus and amniotic
sac. This technique releases prostaglandins and helps ripen the
cervix.
RISKS OF
CERVICAL
RIPENING
 RISKS OF MEDICATION

It is typically mild, but may include:

Diarrhea
Fever
Nausea and vomiting
Too many contractions (hyperstimulation)
>Uterine Hyperstimulation - it is a rare but serious side effect of
some labor-inducing medications. They can cause prolonged or
too frequent contractions and can threaten the health of the
fetus.
 RISKS OF PROCEDURES

It may include:
Bleeding
Drops in fetal heart rate
Fetal Injury or death
Infections in the mother or fetus
Umbilical cord prolapse (cord drops into the cervix) or
compression ( cord stretches or get pressed, so it doesn’t
deliver enough blood to the fetus)
 BENEFITS OF CERVICAL
RIPENING
Cervical ripening helps Cervical ripening helps
01 shorten the length of 03 for natural labor.
labor.
Cervical ripening can Cervical ripening can
02 also help in 04 also be done as an
medication, like outpatient procedure.
oxytocin to be
successful.
FETAL HEART
MONITORING
WHAT IS FHR? NORMAL
VALUE
FHR or Fetal heart rate refers 120 to 160
to the number of times a beats per
fetus's heart beats per minute minute
(bpm) while in the womb. It is
typically monitored during It can vary from
pregnancy to assess the well- 5 to 25 beats
being and health of the fetus. per minutes
2 WAYS OF FHR MONITORING
EXTERNAL FETAL HEART MONITORING
External fetal heart monitoring is typically
used at prenatal checkups to monitor the
fetal heart rate and measure fetal well-
being, it can also be used during labor to
detect any signs of distress. This process
involves the use of Doppler ultrasound, an
ultrasonic transducer, and a
tocodymamometer.
Handheld
Doppler Device
2 WAYS OF FHR MONITORING
EXTERNAL FETAL HEART MONITORING

Ultrasonic Transducer and

Tocodymamometer
2 WAYS OF FHR MONITORING
INTERNAL FETAL HEART MONITORING
Internal fetal heart monitoring, also known
as fetal scalp electrode (FSE) monitoring, is
a procedure that directly measures the fetal
heart rate and uterine contractions during
labor. Unlike external fetal monitoring,
which involves placing sensors on the
mother's abdomen, internal fetal monitoring
involves inserting a small electrode directly
into the baby's scalp via the cervix.
FETAL HEART MONITORING
is especially helpful if you have a high-risk pregnancy.

What is the purpose of Fetal heart rate monitoring?

To check how preterm labor medicines are affecting your
baby
To detect changes in the normal fetal heart rate pattern
during labor
To prevent treatments that are not needed.
OTHER TEST THAT USES FHM
Nonstress test.
Contraction stress test.
A biophysical profile (BPP).

Five parameters of BPP:

Nonstress test
Body movement
Muscle Tone
Breathing movements
Amniotic fluid volume
FETAL HEART MONITORING
Things that may affect the fetal heart rate during labor:
Uterine contractions
Pain medicines or anesthesia given to you during labor
Tests done during labor
Pushing during the second stage of labor
FETAL HEART MONITORING
What are the risks of internal fetal heart monitoring?
Infection
Bruising of the patient's baby's scalp or other body part
Transmission of HIV or genital herpes from mom to
baby

Note: patients should not have internal fetal heart rate monitoring
if you are HIV positive.
FETAL HEART MONITORING
Certain things may make the results of fetal heart rate
monitoring less accurate. These include:
Obesity of the mother
Position of the baby or mother
Too much amniotic fluid (polyhydramnios)
Cervix is not dilated or the amniotic sac is not
broken. Both of these need to happen to do internal
monitoring
 MEDICAL AND
NURSING CARE
DURING
INTRAPARTUM
PERIOD
STAGE 1 OF LABOR:
CERVICAL DILATATION
Dilatation refers to the
widening of the external cervix
up to 10cm.
Expressed in cm
Described as the opening,
widening, enlarging, or
increase in diameter
Divided into three phases
 LATENT PHASE
Irregular and mild to uncomfortable contractions
occurring every 5-10 mins
0-3cm dilatation
Lasts for less than 20s
Mother may be apprehensive excited but can
communicate
Nurse encourages the client to walk to shorten the
labor period
Nurse encourages the client to void because full
bladder inhibits uterine contraction
Nurse encourages the client to do chest breathing
 ACTIVE PHASE
Moderate contractions occur every 3-5mins
4-7cm dilatation
Lasts for less than 20-40s
Mother may feel fear of losing control of herself
Nurse prepares medication
Nurse assesses VS, progress of dilatation, fetal
monitoring
Nurse encourages the client to do abdominal
breathing
 TRANSITION PHASE
Strong contractions occurring every 2-3 mins
8-10cm dilatation
Lasts for more than 40-90s
Mother may have sudden behavioral mood
changes usually accompanied by hyperesthesia of
the skin
Nurse encourages the client to do controlled chest
breathing
Nurse encourages and praise the client
Nurse applies sacral pressure to suppress pain
transmission on the brain for discomfort
EFFACEMENT
It refers to the softening
and thinning of the cervical
canal and denoted in
percentage (%)
Mucus plug is loosened and
passed through the vagina
SIGNS OF EFFACEMENT
Braxton Hicks contractions
Loss of mucus plug
Feeling the fetus drop
More vaginal discharge
 COMPLICATIONS TO
EFFACEMENT
For slow effacement:
Weak contractions
Cephalopelvic disproportion
Breech presentation
Transverse lie presentation
 COMPLICATIONS TO
EFFACEMENT
For quick effacement:
Incompetent cervix
Short cervix
Injury to your cervix
Prior surgery to your cervix
EFFACEMENT PERCENTAGE
0%: the cervix is at 2-2.5cm length; not
effaced
25%: cervix is thick and at 3/4 of its
original size
50%: cervical canal is at 1/2 of its
original size
75%: cervix is at 1/4 of its original size
and very thin already
100%: cervix is fully effaced; no longer
present
FETAL STATION
describes how far down your
baby’s head has descended into
your pelvis.
It is determined by examining a
pregnant woman's cervix and
locating where the lowest part of
her baby is in relation to her
pelvis.It will then assign a number
from -5 to +5 to describe where
the baby’s presenting part (usually
the head) is located.
FETAL STATION CHART
FETAL STATION CHART
The number
differences from -5 to
-4, and so on, are
equivalent to length in
centimeters. When the
baby moves from zero
station to +1 station,
they have moved
about 1 centimeter.
FETAL STATION MNEMONIC
 WHY IS IT IMPORTANT?
It helps the doctor evaluate how labor is
progressing.
Note: If a baby isn’t progressing through the
cervix, a doctor may need to consider child
birth by cesarean delivery or with the help of
instruments like forceps or vacuum.
 PROS
Cervical examination to determine fetal
station can be a fast and painless.
This method is used to determine how a
baby is progressing through the birth
canal.
This measurement is usually one of
many that a doctor may use to
determine labor progression.
 CONS
It’s a subjective measurement.
Two doctors could both conduct a cervical exam
to try to determine fetal station and come up with
two different numbers.
The appearance of the pelvis can vary from
woman to woman.
Too many vaginal exams done while a woman is
in labor may increase the chance of infection.
The baby could be in a position known as the
“face” presentation.
 BISHOP SCORE
A system used by medical professionals to
decide how likely a pregnant woman will go
into labor soon. They use it to determine
whether they should recommend induction,
and how likely it is that an induction will
result in a vaginal birth.
 BISHOP SCORE
The five components of a Bishop score are:
Dilation. Measured in centimeters, dilation describes how
widened the cervix has become.
Effacement. Measured in percentage, effacement is a
measurement of how thin and elongated the cervix is.
Station. Station is the measurement of the baby relative
to the ischial spines.
Consistency. Ranging from firm to soft, this describes the
consistency of the cervix. The softer the cervix, the closer
to delivering the baby.
Position. This describes the position of the baby.
 BISHOP SCORE

Score legends:
8 or above- good indication that spontaneous labor would start soon. If an induction becomes necessary,
it’s likely to be successful.
6 and 7- it’s unlikely that labor will be starting soon. An induction may or may not be successful.
5 or below- labor is even less likely to start spontaneously soon and an induction is unlikely to be
successful.
POP QUIZ
POP QUIZ
 UTERINE CONTRACTION
The tightening and shortening of the uterine muscles.
During labor, contractions
accomplish two things:

(1) they cause the cervix to thin

and dilate (open); and

(2) they help the baby to

descend into the birth canal.
 3 PHASES OF UC
1. Increment (crescendo) the phase of↑
“building up” of contraction; the 1st
or
phase, the longest phase.
2. Acme (Apex);the height/peak of uterine
contractions.
3. Decrement (decrescendo) the phase of ↓
contraction; “letting up” ,the last/end
phase
3 PHASES OF UC
 TYPES OF UC
1. Braxton Hicks contractions
known as prodromal or false contractions as they
usually occur during the second or third
trimester.
These contractions are usually
a. concentrated in the abdomen
b. uncomfortable
c. usually get better upon lying down or emptying
the bladder
d. make the belly feel tight
 TYPES OF UC
2. Preterm Labor Contractions
Preterm labor contractions occur before 37 weeks,
and these may be a sign of premature labor.
Preterm labor contractions may feel like
a. hardness of the abdomen and regular uterine
contractions
b. painful menstrual cramp-like feeling
c. backache accompanied by vaginal discharge
d. pelvic pressure
 TYPES OF UC
3. Early Labor Contractions
The cervix begins to dilate and the contractions
last anywhere from 30 to 90 seconds.
They come at regular intervals of time and include
a. pain radiating from the back to the abdomen
b. severe cramps
c. difficulty breathing
 TYPES OF UC
4. Active Labor Contractions
This type of pregnancy contraction is increasingly painful
and indicates that delivery is approaching. The cervix
dilates further. The contractions are closer, about 4-5
minutes apart, and last anywhere from 30 seconds to a
minute.
These contractions may include
a. an urge to push
b. contractions that get closer and last until a minute
c. nausea, hot flashes, gas, and vomiting
d. pain that radiates as the baby descends down the birth canal
 TYPES OF UC
5. Transition Labor Contractions
This is the final phase where the pressure is on the rectum,
back and vagina. Only when the cervix is fully dilated will
the doctor advise the pregnant woman to push.
The contractions, in this case, last 60-90 seconds and
occur every 3-5 minutes. These pregnancy contractions
are the most intense part of the labor and are associated
with extreme pressure. They affect the vagina, pelvis, and
back.
MONITORING THE CONTRACTIONS
MONITORING THE CONTRACTIONS
STAGE 2 OF LABOR:
EXPULSION OF THE BABY
The second stage of labor is
the time from full cervical
dilatation to birth of the
newborn. Duration of 30
minutes to 3 hours for
primigravidas, and 5 to 30
minutes for multigravidas;
begins with full dilation and
ends with delivery of the
baby.
 INTERVENTION
Provide ice chips and ointment for dry lips
Provide encouragement and emotional
support
Monitor uterine contractions
Monitor both the mother and baby's vital
signs
Maintain privacy and encourage breathing
patterns and rest between contractions
Monitor for signs of birth (perineal bulging
or visualization of fetal head)
CARDINAL MOVEMENTS
OF LABOR:
For the fetus to pass
through the birth canal, the
fetal head and body must
adjust to the maternal
pelvis by certain positional
changes. These changes,
called cardinal movements
or mechanisms of labor, are
described in the order in
which they occur.
CARDINAL MOVEMENTS
OF LABOR
MNEMONICS – ED FIRE
ERE
E - ngagement
D - escent
F - lexion
I - nternal R - otation
E - xtension
E - xternal R - otation
E - xpulsion
 SPONTANEOUS VAGINAL
DELIVERY
Spontaneous vaginal delivery ( SVD ) is one
which occurs when a pregnant woman goes
into labor without the use of drugs or other
techniques to induce labor and she delivers
her baby through the vagina (birth canal)
without forceps, vacuum extraction or a
cesarean section.
STAGE 3 OF LABOR:
PLACENTAL STAGE
The third stage of labor is defined as
the period of time from the birth of the
infant until the completed delivery of
the placenta.
Third stage includes separation,
descent, and expulsion of the placenta.
Delivery of the placenta usually takes
less than 30 minutes. The placenta is
normally delivered on its own by
uterine contractions.
 SIGNS OF PLACENTAL DELIVERY

Lengthening umbilical cord

Gush of blood
Rise of the fundus in the abdomen
Uterus changes from oval to globular shape
 DELIVERY MECHANISM OF THE PLACENTA

“Shiny Schultz” Side of baby delivered first

“Dirty Duncan” Side of mother delivered first

SHINY SCHULTZ
It is expelled with the fetal
(shiny) side presenting.
DIRTY DUNCAN
If the placenta separates
from the outer margins
inward, it will roll up and
present sideways with the
maternal surface
delivering first.
 COMPLICATIONS
Hemorrhage- It is the excessive bleeding that can be caused by the failure of the
uterus to contract adequately after the placenta is delivered. PPH can be life-
threatening and can cause anemia that requires immediate medical attention.

Retained Placenta- The placenta may not be expelled completely from the uterus

Hematoma Formation- It is due to venous occlusion and vascular rupture in the

placental bed caused by uterine contractions.

Inversion of uterus- This is a rare but very serious complication in which the uterus is
turned inside out and comes out through the vulval orifice wholly or partly.
 INTERVENTION
Assessing mother vital signs
Uterine status (fundal rubs every 15
minutes)
Provide warmth to the mother
Promote parental-neonatal attachment
Examine placenta & verify it’s intact -
Should have 2 arteries and 1 vein
 STAGE 4 OF LABOR:
POSTPARTUM STAGE
The postpartum period begins soon after the delivery
of the baby and usually lasts six to eight weeks and
ends when the mother's body has nearly returned to
its pre-pregnant state.
 INTERVENTION
Assessing the fundus
Continue to monitor vital signs & temperature for
infection
Administer Iv fluids
Monitor lochia discharge (lochia may be moderate
in amount & red)
Monitor for respiratory depression, vomiting &
aspiration if general anesthesia was used
Monitor complications such as bleeding
(postpartum hemorrhage).
THANK YOU
FELLOW
FUTURE
NURSES!