NORMAL LABOR & DELIVERY

The World Health Organization (WHO) defines

normal birth as follows:

-The birth is spontaneous in onset and low risk at

the start of labor and remains so throughout labor
and delivery.

-The infant is born spontaneously in the vertex

position between 37 and 42 weeks of pregnancy.
LABOR

A series of events by which uterine contractions

and abdominal pressure expel a fetus and placenta
from the uterus.

Regular contractions cause progressive dilatation of

the cervix and create sufficient muscular uterine
force to allow baby to be pushed out into the
extrauterine world.
LABOR

Normally labor begins between 37 and 42 weeks of

pregnancy when the fetus is sufficiently matured to
adapt to extrauterine life.

- Labor begins before a fetus is mature (preterm)

- Labor is delayed until the fetus and the placenta

have both passed beyond the optimal point for
birth ( post-term).
 THEORIES OF LABOR ONSET

Uterine Stretch Theory

Uterine muscle stretches from the increasing size of
the fetus, which results in the release of
prostaglandins.

Oxytocin Stimulation Theory

The fetus presses on the cervix which stimulates the
release of oxytocin from the posterior pituitary
gland.
 Oxytocin (PPG) – increased
 Oxytocinase (Placenta) – decreased
Progesterone Deprivation Theory
Changes in the ratio of estrogen to progesterone
increasing estrogen in relation to progesterone which
is interpreted as progesterone withdrawal.

Theory of Aging Placenta

The placenta reaches a set age, which triggers
contraction

Fetal- adrenal Response Theory

Rising fetal cortisol levels reduce progesterone
formation and increase prostaglandin formation.
Prostaglandin Theory
Does coitus help induce labor?

Semen does contain prostaglandins, which can be

helpful in softening, a.ka. “ripening” of the cervix.
If the cervix is ready to ripen, the semen
prostaglandins could possibly stimulate the beginning
of contraction.
SIGNS OF LABOR
 Weight Loss – 2-3 pounds (decreased progesterone)
 Ripening of the Cervix – “softening” and effacing
 Increased Braxton Hicks – “irregular, painless”
 Show – “ruptured capillaries + operculum = pinkish color”
 Lightening – “the baby dropped”
- 2 weeks (primi) and before or during (multi)
Relief of respiratory discomfort
Increased frequency of urination
Leg pains
Muscle spasms
Increased vaginal discharge
Decreased fundal height
 Increased Level of Activity – large amount of epinephrine
 Rupture of Membranes – gush or steady trickle of clear fluid
SIGNS OF LABOR
 FALSE LABOR TRUE LABOR
• Contraction • Contraction persists when
disappear with sedated
ambulation
• Uterine contraction
• Absence of cervical
dilation • Progressive cervical
dilation
• Discomfort @
abdomen • Presence of show

• Absence of show • Ambulation increase

contractions
• Contraction stops • Discomfort radiates to
when sedated lumbosacral area
LENGTH OF LABOR
COMPONENTS OF LABOR 4 Ps

Passage (pelvis) – adequate size and contour

Hard – bony pelvis
Soft – lower uterine segment, cervix,
vagina, pelvic floor and perineum
Passenger (the fetus) – is of appropriate size and in an
advantageous position, presentation and
attitude
Powers – the uterine factors are adequate
Primary – involuntary uterine contraction
Secondary – mother “ bears down”
Psyche – or the psychological state, which may either
encourage or inhibit labor.
 THE PASSAGE
FUNCTIONS
• Serves as birthcanal
• It provides attachment to muscles, fascia and ligaments
• Supports uterus during pregnancy
• It provides protection to the organs found within the pelvic cavity
TYPES
Gynecoid – normal female type of pelvis
- most ideal for childbirth
- round shape, found in 50% of women
Android – male pelvis
- presents the most difficulty during childbirth
- found in 20% of women
Platypelloid – flat pelvis, rarest, occurs to 5% of women
Anthropoid – apelike pelvis, deepest type of pelvis found in 25% of
women
DIVISION OF PELVIS
False Pelvis- is superior and is surrounded by iliac fossa
portions of the coxal bones and the upper portion of the sacrum

True Pelvis- is inferior and is surrounded by the pubis and

ischium portions of the coxal bones, in addition to the lower
sections of the ilium and the sacrum.
the true pelvis defines the space babies must squeeze through
during childbirth.
THE PASSENGER
- The body part of the fetus that has the widest diameter is the
head.

Structure of the Fetal Skull

• Cranium- the uppermost portion of the skull

4 superior bones
frontal- 2 fused bones (1)
parietal- 2
occipital- 1
Other 4 bones
sphenoid, ethmoid, temporal bones (2)
• Fontanel – spaces compress during birth to aid in molding of
the fetal head.
 Lateral View

Vertex View
Diameters of the Fetal Skull

- The shape of a fetal skull causes it to be wider in its

anteroposterior diameter than its transverse diameter.

• Biparietal diameter/ transverse diameter- smallest ( 9.25 cm)

• Suboccipitobregmatic – smallest AP diameter ( 9.5 cm)
-from the inferior aspect of the occiput to the center
of the anterior fontanel
• Occipitofrontal diameter- measured fronm the occipital
prominence to the bridge of the nose (12 cm)
• Occipitomental diameter- the widest AP diameter (13.5 cm)
- measured from the posterior fontanel to the chin
Degree of Flexion

Full Flexion
-fetal head flexes so
sharply that the chin rests on
the chest

Moderate Flexion
- occipitofrontal diameter
presents

Poor flexion
-head is hyperextended
-the largest diameter the
occipitomental will
present
 Molding
- Is the overlapping of skull bones along the suture lines, which
causes a change in the shape of the fetal skull
- It is caused by the force of uterine contractions as the vertex of
the head is pressed against the not-yet-dilated cervix.
• SUTURE LINES – allow skull bones to overlap (molding) and for
further brain development (SFC La)
Sagittal Suture – between 2 parietal bones
Frontal Suture – between 2 frontal bones
Coronal Suture – between frontal and parietal
Lamdiodal Suture – between parietal and occipital

• FONTANELS – intersection of suture lines

Anterior Fontanel or Bregma – intersection of SFC
- diamond shaped, closes b/n 12 – 18 months
- 3 x 4 cm
Posterior Fontanel or Lambda – intersection of Sla -
-triangular shaped, closes b/n 2 – 3 months
Fetal Presentation and Position

 Fetal Attitude- describes the degree of flexion

 Optimal/full flexion – complete flexion; the spinal column

is bowed forward, the head ifs flexed forward that the
chin touches the sternum.

 Moderate/ military flexion- sinciput; the chin is not

touching the chest but is in alert position.

 Partial extension- presents the “brow” of the head to the

birth canal

 Poor flexion/complete extension- the back is arched and

the neck is extended, presenting the occ
 Fetal Lie
- is the relationship between long axis of the fetal body and
the long axis of female’s body (cephalocaudal)
• Horizontal – transverse
• Vertical – longitudinal

 Fetal Presentation
- denotes the body part that will first contact the cervix or be
born first and is determined by the combination of fetal lie and the
degree of fetal flexion ( attitude)
• Cephalic Presentation
- the fetal head is the body part that first
contacts the cervix.
Caput Succedaneum- edema formed in the skull of the baby
due to continued pressure against it during the labor.
Four types of Cephalic Presentation
Types Attitude Description

Vertex Good ( Full Flexion) Head is sharply flexed

Most common and allows the SOB diameter to
present to the cervix

Brow Moderate ( military) Head is moderately flexed

The brow or sinciput becomes the presenting
part

Face Poor Head of the fetus is extended making the face

the presenting part.
This position can cause edema and extreme
distortion of the face.

Mentum Very poor Head is hyperextended completely and making

the chin the presenting part.
Causing the presenting diamete
(occipitomental) to be so wide that vaginal birth
may not be possible.
 • Breech Presentation
- means its either the buttocks or the feet are the
first body parts that will contact the cervix.
 Good attitude- if the fetal knees brings up against the
fetal abdomen
 Poor attitude- means the legs and knees are extended
Types Attitude Description

Complete Good ( Full Flexion) The fetus has the thighs tightly flexed on the
abdomen; both the buttocks and the tightly
flexed feet present to the cervix.
Frank Moderate Attitude is moderate because the hips are
flexed, but the knees are extended to rest on
the chest.
The buttocks alone presents in the cervix.

Footling Poor Neither the thighs or the lower legs are flexed.
One foot - single-footling breech
Both – double-footling breech
Complete

Frank

Footling
• Shoulder Presentation ( < 1%)
- Transverse lie, fetus lies horizontally in the pelvis so
the longest fetal axis is perpendicular to that of the pregnant
mother.
Causes:
- pelvic contractions , in which the horizontal
space is greater than the vertical space
- Placenta Previa
- relaxed abdominal walls
from grand multiparity
-
 Fetal Position
- Is the relationship of the presenting part to a specific
quadrant and side of the pregnant person’s pelvis.

Four Quadrants ( Maternal pelvis)

a) Right anterior
b) Left anterior
c) Right posterior qr
d) Left posterior

Four Landmarks ( Parts of fetus )

 Vertex presentation- occiput (O)
 Face presentation- chin- mentum (M)
 Breech presentation- sacrum (Sa)
 Shoulder presentation- scapula or Acromion process (A)
Vertex Presentation
Engagement
- refers to the settling of the presenting part of a fetus far
enough into the pelvis that it rests at the level of the ischial
spines- the midpoint of the pelvis

 Floating- presenting part that is not engaged

 Dipping- one that is descending but has not yet reached the
ischial spine

 For Primipara – nonengagment of the fetal when labor starts

may indicates:
- abnormal position or presentation
- abnormality of the fetal head/
cephalopelvic disproportion
 For Multipara – engagement may or may not be present at the
beginning of labor.
Stations
- refers to the relationship of the presenting part of the
fetus to the level of the ischial spine.

-1 to -4 = presenting part is above the ischial spine

0 station= fetal part is at the level of ischial spine
+1 to +4 = presenting part is below the ischial spine

Crowning (+3-+4) – the presenting part is at the perenium and

can be seen if the vulva is separated.
Mechanisms of Labor ( Cardinal Movements)

- effective passage of a fetus through the birth canal involves

not only the position and presentation but also a number of
different position changes in order to keep the smallest diameter of
the fetal head always presenting to the smallest diameter of the
pelvis.
- these position changes is called the
Cardinal Movements of Labor

• Descent
• Flexion
• Internal rotation
• Extension
• External rotation
• Expulsion
Descent
- is the downward movement of the biparietal diameter of
the fetal head within the pelvic inlet.
- it occurs because of pressure on the fetus by the uterine
fundus.

Flexion
- the head bends forward onto the chest, causing the AP
diameter to present to the birth canal.
Internal Rotation

- the biparietal
diameter of the fetal skull was
aligned to fit through the AP
diameter of the pregnant
person’s pelvis

- the occiput rotates so the

head is brought into the best
relationship to the outlet of
the pelvis, or the AP diameter
Extension
- as the occiput of the fetal head 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 parts of the
head, the face and chin is born.
External Rotation

- almost immediately after

the head of the baby is born,
the head rotates a final time.

- from AP diameter back to

transverse position

- this brings the after coming

shoulders into an AP position
which is best for entering the
outlet
Expulsion

- once the shoulder is born, the rest of the baby is born

easily and smoothly because of it’s smaller size.
- the end of the pelvic division of labor.
THE POWERS of labor
- the third important requirements for a successful labor is
effective powers of labor.

- this is the force supplied by the fundus of the uterus and

implemented by uterine contractions, which causes cervical
dilatation and then expulsion of the fetus from the uterus.

 Patient should not bear down with her abdominal muscles to

push until the cervix is fully dilated.
Uterine Contractions

Braxton Hicks Contraction/ False Labor

- these contractions are usually mild but can be
strong enough to be mistaken for true labor
- the mark is that they are usually irregular and are
painful but do not cause cervical dilatation.

 Effective uterine contractions have rhythmicity, a progressive

increase in length and intensity and accompany dilatation of
the cervix.
 Contractions are assessed according to frequency, duration and
intensity
 False contractions True contractions

Begin and remain irregular Begin irregularly but become regular

and predictable

Felt first abdominally and remain Felt first in the lower back and sweep
confined to the abdomen and groin around to the abdomen in a wave

Often disappear with ambulation or Continue no matter what the patient’s

sleep level of activity

Do not increase in duration, frequency Increase in duration, frequency and

or intensity intensity

Do not achieve cervical dilatation Achieved cervical dilatation

Phases of Uterine Contraction
• Increment – when the intensity of contraction increases
• Acme – when the contraction is its strongest
• Decrement – when the intensity decreases

 INTENSITY - strength of uterine contraction

Mild – slightly tensed fundus
Moderate – firm fundus
Strong – rigid, board like fundus
 FREQUENCY – rate of uterine contraction
- measured from the beginning of a
contraction to the beginning of the next contraction
 DURATION – length of uterine contraction
- measured from the beginning of a
contraction to the end of the same contraction
 INTERVAL – measured from the end of contraction to the
beginning of the next contraction
Cervical Changes

• Effacement
- is the shortening and thinning of the cervical canal
• Dilatation
- refers to the enlargement or widening of the cervical
canal from an opening a few mm wide to one large enough, 10
cm to permit passage of a fetus
THE PSYCHE
- refers to the psychological state or feelings a pregnant
person brings into labor.
- feeling of apprehension or fright; sense of excitement or awe
FACTORS affecting labor
• Perception & meaning of childbirth
• Readiness & preparation for childbirth
• Coping skills
• Past experiences
• Cultural & social background
• Presence of significant others and support system
Nursing Implications:
 Encourage patients to ask questions at prenatal visits and to attend preparation
for childbirth classes so they are as well prepared for labor as possible.
 Encourage them after birth to talk about and share their experience because a
“debriefing time” can be an important way to help them appreciate everything
happened and integrate the experience into their total life.
 STAGES OF LABOR
STAGE 1 – DILATATION STAGE

Starts from first true uterine contraction until the cervix

is completely effaced and dilated.
Dilatation – widening of cervical os to 10 cm
Effacement – thinning to 1- 2 cm

 Maternal Assessment During Labor

1. Check V/S q 4hrs during the first stage
- temp q hour if membranes are already
ruptured ( risk of infection)
- BP b/n contractions, in left lateral pos,
q 15 – 20 mins after giving anesthesia
- a rapid pulse indicates hemorrhage &
dehydration
2. Uterine contraction
Manual: fingers over fundus, you feel it about 5 secs before the
client feels it
Techniques: 1. assess contraction
2. check contraction q 15 – 30 mins during
the first stage
3. refer immediately if:
- duration more than 90 secs
- interval less than 30 secs
- uterus not relaxing completely after
each contraction
3. Show – slightly blood-tinged mucus discharge
4. Internal Examination – to assess status of amniotic fluid,
consistency of cervix, effacement/dilatation, presentation,
station and pelvic measurement.
- do it during relaxation
- less IE done once membrane have ruptured
- start with middle finger then index finger
5. Status of Amniotic Fluid (if ruptured)

Danger of cord prolapse if fetal head is not yet engaged.

Danger of serious intrauterine infection if delivery does
not occur in 24 hours
Normal Color of AF – clear, colorless to straw colored
Green tinged – meconium stain (fetal distress in non –
breech presentation)
Yellow/Gold – hemolytic disease
Gray/Cloudy – infection
Pinkish/Red stained – bleeding
Brownish/Tea Colored/Coffee Colored – fetal death
FETAL ASSESSMENT DURING LABOR

 FHT Monitoring
Latent Phase – every hour
Active Phase – every 30 minutes
Second Stage of Labor – every 15 minutes
FHT is taken more frequently in high – risk cases

 Normal FHT Pattern

Baseline rate: 120 – 160 bpm
Early Deceleration – Increase FHT @ contraction, Normal
@ end of contraction (head
compression)
Acceleration - decrease FHT when fetus moves
 Abnormal FHT Pattern
Bradycardia – 100 – 119 bpm – moderate
- below 100 bpm – marked
CAUSES: 1. fetal hypoxia (analgesia &
anesthesia)
2. maternal hypotension
3. prolonged cord compression
MGT: 1. place mother on left side
2. assess for cord prolapse
3. administer oxygen

Tachycardia – 161 – 180 bpm – moderate

- above 180 bpm – marked
CAUSES: 1. maternal fever, dehydration
2. drugs (atrophine, terbutaline, ritodrine, etc.
MGT: 1. D/C oxytocin, position on LLP
2. give 02 at 8 – 10 lpm
3. prepare for birth if no improvement
 CARE OF THE PARTURIENT

1. LATENT PHASE
○ Cervical Dilation: 0 – 4 cm
○ Nature of Contraction: Duration: < 30 secs
Interval: 3 – 5 mins
○ Length of Latent Phase: Primis – 6 hours
Multis – 4 – 5 hours
○ Attitude of mother: feel comfortable, walking and sitting
at this time
○ Nsg Responsibilties:
1. Teach breathing techniques
2. Give instructions
3. Conversation is possible (cooperative
& focus mother)
2. ACTIVE PHASE
○ Cervical Dilation: 4 – 7 cm
○ Nature of contractions: Duration: 30 – 50 secs
Intensity: moderate to strong
○ Length of Active Phase: Primis – 3 hours
Multis – 2 hours
○ Attitude of mother: prefer to stay in bed, withdraws from
her environment and self – focused
○ Nsg Responsibilities:
1. Coach woman on breathing and relaxation
techniques
2. Prescribed analgesics given during active phase
3. Instruct woman to remain in bed, minimize
noise, raise side rails, NPO
4. Check BP 30 mins after giving analgesics
(hypotension)
3. TRANSITION PHASE
○ Cervical Dilatation: 8 – 10 cm
○ Nature of Contractions: Duration: 50 – 60 secs
Interval: 2 -3 mins
Intensity: moderate to strong
○ Length of Transition Phase:
Primis – 1 hour (baby delivered within 10 contractions or
20 mins)
Multis – 30 mins (baby delivered within 10 contractions
or 20 mins)
○ Attitude of mother: feel discouraged, ask midwife/nurse repeatedly
when labor will end, not in control of her emotions and sensations,
irritated, may not want to be touched
○ Nsg Responsibilities:
1. Reassure woman that labor is nearing end & baby will be
born soon
2. Reinforce breathing and relaxation techniques
3. Encourage fast-blow breathing to remove the urge to bear
down
• CARE OF THE BLADDER – encourage the woman to void q
2 hrs to:
○ Delay fetal descent
○ Increases the discomfort of labor
○ Predispose to UTI
○ Can be traumatized during labor

• FOODS & FLUIDS – NPO on active phase

○ Clear fluids on latent phase

• POSITIONING – LLP -
○ Relieves pressure – IVC
○ Improves urinary function
○ Prevent hypotensive syndrome
○ Encourage anterior rotation of the fetal head
○ Squatting is ideal position – directs presenting part
towards the cervix promoting dilatation
• AMBULATION – during the latent phase to shorten the
first stage, to decrease the need for analgesia, FHT
abnormalities & to promote comfort
NO WALKING IF BOW IS RUPTURED

• IV FLUIDS – reasons:
• Prevent dehydration/fluid & electrolyte imbalances
• Life – line for emergencies
• Usually required before administration of A/A
• Administration of oxytocin after delivery to prevent
atony

• PERINEAL PREP
• Clean & disinfect the external genitalia
• Provide better visualization of the perineum
ENEMA – emptying the colon of fecal matters to:
• Prevent infection
• Facilitate descent of fetus
• Stimulate uterine contractions

CONTRAINDICATIONS:
• Not given during active phase
• If premature labor bcoz of danger of cord prolapse
• Rupture of BOW
• Vaginal bleeding
• Abnormal fetal presentation & position
• Abnormal fetal heart rate pattern
SECOND STAGE – EXPULSIVE STAGE

MECHANISM OF LABOR:
Engagement
Descent – entrance of the greatest biparietal diameter of
the fetal head to the pelvic inlet
Flexion – the chin of the fetus touches his chest enabling
the smallest diameter (suboccipitobregmatic)
to be presented to the pelvis for delivery
Internal Rotation – when the head reach the level of the
ischial spine, it rotates from transverse
diameter to AP diameter so that its largest
diameter is presented to the largest
diameter of the outlet. This movement allows
the head to pass through the outlet.
Extension – the head of the fetus extend towards the
vaginal opening. As the head extend, the chin
is lifted up and then it is born.
External Rotation – when the head comes out, the shoulder
which enters the pelvis in transverse position turns to
anteroposterior position for it become in line with the
anteroposterior diameter of the outlet & pass through the
pelvis.

Expulsion – when the head is born, the shoulder & the rest
of the body follows without much difficulties.

 Duration of Second Stage: Primis – 50 mins

Multis – 20 mins
 Assessment: monitor FHT q 15 mins in normal case and
every 5 mins in high risk cases if not yet delivered

 Transfer to the DR: Primis – cervix fully dilated

Multis – cervix is 8 cm dilated
ASSISTING THE MOTHER IN THE DR

1. Coach the mother to push effectively

2. Instruct the woman to pant
3. Dorsiflex the affected foot and straighten the leg until the
cramps disappear
4. Perform ironing on vaginal orifice if the presenting part
moves towards the outlet
5. When the head is crowning, instruct the mother to pant.
6. Perform Ritgen’s Maneuver while delivering the fetal head
to:
1. Slows down delivery of the head
2. Lets the smallest diameter of the head to be born
3. Facilitates extension of the head
7. Just after delivery, immediately wipe the nose & mouth of
secretions then suction.
8. Take note of the exact time of baby’s birth
9. After the delivery of the baby, place the newborn in
dependent position to facilitate drainage of secretions.
10. Place the infant over the mother’s abdomen to help
contract the uterus.
11. Clamping the cord:
• After the pulsation stops
• Clamp the cord twice and cut in between 2– 5
inches from umbilicus
• After cutting the cord, look for 2 arteries & 1 vein
12. Wrap the infant & bring to the nursery.
THIRD STAGE – PLACENTAL DELIVERY

METHODS OF PLACENTAL SEPARATION:

1. Schultz Mechanism – separation of the placenta starts from the
center
- the shiny & smooth fetal side is delivered first
- 80% of placental separation
2. Duncan Mechanism – separation begins from the edges of placenta
- the dirty maternal side is delivered first
- 20% of placental separation
MANAGEMENT:
2. Watchful waiting.
1. Do not hurry placental delivery.
2. Rest a hand over the fundus to make sure the uterus remains
firm
3. Wait for signs of placental delivery
1. Calkin’s sign – uterus is firm, globular & rising to the level of
umbilicus
2. Sudden gush of blood from vagina
3. Lengthening of the cord
2. Manage the uterus to keep it contracted.
3. Administer methergin as prescribed.
4. Never leave the client unattended.
5. Oxygen & emergency equipment made available.
THE FOURT STAGE – PUERPERIUM

MANAGEMENT:
1. Repair of lacerations.
CLASSIFICATION OF PERINEAL LACERATIONS
First Degree – fourchette, vaginal mucous membrane,
perineal skin
Second Degree – fourchette, vaginal mucous membrane,
perineal skin, muscles of perineal
body
Third Degree – fourchette, vaginal mucous membrane,
perineal skin, muscles of perineal body &
anal sphincter
Fourth Degree - fourchette, vaginal mucous membrane,
perineal skin, muscles of perineal body, anal
sphincter & mucous
membrane of rectum
2. After repair of lacerations & episiotomy, perineum is cleansed, the legs
are lowered from stirrups at the same time.
3. Check V/S of the mother every 15 mins for the first hour & every 30
mins for the next 2 hours until stable.
THANK YOU !!