Childbirth

Normal Labor and

Delivery
 LABOR
Labor is a series of rhythmic, progressive
contractions of the uterus that gradually move the
fetus through the lower part of the uterus (cervix)
and birth canal (vagina) to the outside
world.
Childbirth
The labor consists of four stages beginning with
first, second, third and ending with fourth
(Recovery) stage
Terms
Term pregnancy: 38- 42 weeks from LMP
Pre-term delivery (labor): 28- <38 weeks of
gestational age
Post-term delivery: 42 weeks
* 85% of women spontaneous labor and
delivery between 37-42 weeks
Types of Delivery
1. Normal Vaginal Delivery
2. Normal Vaginal Delivery with
Episiotomy
3. Instrumental Delivery (Vaginal )
4. Cesarean Delivery
SIGNS OF LABOR
Preliminary:
1. Lightening: the descent of the fetus presenting part
into the pelvis. (10-14 days in the primigravida and
on the same day for a multi gravida).
2. Increase in the level of activity :
Increase in epinephrine release.
3. Braxton-Hicks contractions.
SIGNS OF LABOR

SIGNS OF TRUE LABOR:

1. Uterine contractions
2. Show
3. Rupture of the membranes
Four factors for labor (4 Ps)
1. Power: Force ( uterine
contraction)
2. Passage: birth canal (Pelvis)
3. Passenger: fetal skull (lie,
position , presentation,
weight)
4. Psychical factors
( Personality)
1. Power: Force ( uterine contraction)

Uterine contractions during active

labor have two major functions:
- To dilate the cervix
- To push the fetus through the
birth canal.
 Contractions
(onset, frequency, duration, intensity)
Increase in frequency and duration
Uterus can be felt to harden during contraction
lasting about 30-45 seconds
Interval between contractions to be 5 min’
Intensity (Mild, Moderate, Strong )
Power
Braxton-Hicks Contractions: These are painless,
intermittent, irregular uterine contractions that occur
throughout pregnancy. They help to make the uterus
more firm and well-defined.
In early pregnancy, the pregnant woman is usually
unaware of them, but in later pregnancy, when they
become more prominent, they may be mistaken for
the onset of labor. False labor pains
 True Contraction False contraction
Contractions often felt more Contractions felt more in the
in the back abdomen
Contractions become Contractions remain variable
progressively stronger, in interval, duration, and
longer, and closer intensity
together over time
Intensity increases with Intensity decreases with change
activity changes in activity
Bloody show often present No bloody show
Progressive effacement and No progressive effacement and
dilation of cervix dilation of cervix
Power
Mucus plug or Show: During pregnancy, the cervical
opening is filled up with thick mucus secreted by the
cervix.
This mucus serves as a barrier against infections
traveling up from the vagina. This is called the
mucus plug. When labor starts, there is profuse
cervical secretion.
At the same time, when the cervix begins to dilate,
small capillaries at the surface of the cervix ruptures
and bleeds.
Power
Dilation of the cervix: Dilation, mainly occurs due to the
pulling of the cervix by the contracting and retracting uterine
muscles.
Dilation is very useful for clinical diagnosis of the start of labor
as well as to measure the progress of labor.
Less than 4 cm dilation of the cervix means that the patient is in
the latent phase of labor.
When the cervix has dilated more than 4 cm, the patient is
deemed to have entered the active phase of labor.
At full dilation, the cervical opening measures 10 cm - large
enough for the widest diameter of a normally positioned fetal
head to pass through.
 Passage
Pelvis consists of :
1. 2 Innominate bones : Ilium, Ischium,
Pubis
2. Sacrum
3. Coccyx
Passage: birth canal (bony canal)
Pelvis include:
Inlet plane
Mid plane of pelvis (cavity)
Outlet plane
 Passenger: FETAL SKULL
Skull bones are :
1. 2 frontal bones
2. 2 parietal bones
3. 2 temporal bones
***The bones of the vault are not joined thus
changes in the shape of the fetal head during
labor can occur due to molding
Passenger
Molding of the head : There is usually some
alteration in the shape of the fetal head as well
as a reduction in its size to some extent due to
the resistance it encounters during its passage
in the birth canal.
Molding is physiological , harmless, and
disappears within a few hours after delivery of
the baby
 The "sutures" or
anatomical lines
where the bony
plates of the skull
join together can
be easily felt in
the newborn
infant. The
diamond-shaped
spaces on the top,
top back, and
sides of the skull
are often referred
to as the "soft
spot" in young
infants…correctly
known as
fontanelles
(fontanels).
 The fontanelles actually allow the skull to change to a new shape,
so it can emerge through the small cervical opening. This is called
“molding” of the head. This change in the shape of the skull will go
back to it’s original appearance in a few hours up to a few days.
Passenger
Caput Succedaneum : It is an area of localized
edema or collection of fluid on the fetal scalp
that develops during labor.
It results due to the pressure from the cervix
preventing the venous blood and lymphatic
fluid from flowing normally.
It usually disappears within twenty-four hours
after delivery.
 Passenger: Fetal relationship
1.Engagement: The fetal is engaged if the widest leading part (typically the widest
circumference of the head) is negotiating the inlet.

2.Station: Relationship of the leading bony part of the fetus to the maternal ischial spines. If
at the level of the spines it is at “0 (zero)” station, if it passed it by 2 cm it is at “+2”
station.

3.Attitude: Relationship of fetal head to spine: flexed, neutral (“military”), or extended

attitudes are possible.

4.Position: Relationship of presenting part to maternal pelvis, i.e. ROP=right occiput

posterior, or LOA=left occiput anterior.

5.Presentation: Relationship between the leading fetal part and the pelvic inlet: cephalic,
breech, or shoulder presentation.

6. Lie: Relationship between the longitudinal axis of fetus and mother: longitudinal, oblique,
and transverse.
.
Fetal presentation
Breech presentation.
Longitudinal lie. Vertex presentation. Right occiput anterior (RO
Longitudinal lie. Vertex presentation. A. Right occiput posterior (ROP)
LONGITUDINAL LIE VERTEX PRESENTATION

LOA LOP
Psychical-factors
it claims that the ability to have adequate 2nd stage can
be effected by:
- Fear and anxiety
- Mothers confidence in her ability
- Support she receives
- Response from health care workers
- labor environment
- Feeling overwhelmed, the psychological stress
added to the physical stress interferes with labor
progress
 FIRST STAGE OF NORMAL LABOR

Onset of Labor : There are three classical signs by

which the onset of labor is diagnosed.
Any one of the signs is enough to diagnose the
onset of labor - it is not necessary to get all three
signs.
FIRST STAGE OF NORMAL LABOR
1. Painful Uterine Contractions:
The onset of labor is characterized by painful,
intermittent, involuntary and co-ordinated uterine
contractions which cannot be relieved by medicines or
rest.
Frequency: beginning of 1st to beginning of 2nd contractions
Intensity: Mild, Moderate, Strong
Duration: 30,40,60 seconds
Interval: Ending of one contraction to next contraction
 FIRST STAGE OF NORMAL LABOR

2. Expulsion of Show or Mucus Plug:

During pregnancy, the cervix which is the mouth of the
uterus is filled with dense mucus that seals it to some
extent.
As the cervix begins to thin out and open to allow the
baby to be born, this mucus is expelled through the
vagina.
There is also some amount of bleeding from blood vessels
that rupture when the cervix dilates.
These present at the vaginal opening as blood-stained
mucus. This blood-stained mucus is called 'show' or
'mucus plug'.
 FIRST STAGE OF NORMAL LABOR
3. Rupture of Membranes:
In many women, the onset of labor is signified by the rupture of the
bag of waters (rupture of membranes) without any prior
abdominal pain.
The rupture of the membranes may occur with a sudden gush of
waters, or with only a thin trickle that is barely enough to soak
the underwear.
Usually, leakage of water is more in the lying down position.
Standing or sitting up causes the head of the fetus to plug the
mouth of the uterus and prevents outflow of the amniotic fluids
(waters).
Phases of the First Stage of Normal Labor
1. Latent Phase of Labor:
➢ Uterine contractions : very mild , irregular, and not forceful
enough to cause much pressure on the cervix.
➢ Cervix slowly becomes shorter and softer. This is known as
'Effacement'.
➢ Dilation of the cervix occurs from 0 cm to 3cm.
➢ The frequency of the uterine contractions at this stage is from 1
per 10 minutes in normal labor and each contraction lasts for less
than a minute.
➢ The uterus may become firm and more prominent with every
contraction.
➢ In some women, the labor pains start at the back. This is more
likely if the head of the fetus is more posteriorly placed and
presses on the mother's spine or ligaments.
`
Phases of the First Stage of Normal Labor
2. Active Phase of Labor:
 This is the phase where the uterus contracts more frequently
and the pain is maximum.
 Uterine contraction occurs after every 3-5 minutes and lasts
for more than a minute.
 The uterus becomes hard and more prominent as the pain
increases and softer as the uterus relaxes.
 The pains sometimes start at the back and radiates down to
the thighs. Later on, at the end of this stage, the pains come
even more frequently and appear to run into each other in
quick succession.
 The cervix dilates from 4 cm to 8 cm. Women whose waters
have not ruptured at the onset of labor, can experience a gush
of water flowing out of the vagina at this stage.
Phases of the First Stage of Normal Labor
3. Transitional Phase of Labor:
❖ transition from the first stage of labor to the second
stage of labor.
❖ The cervix dilates from 8 cm to 10 cm. At full
dilatation at the end of the first stage of labor, the
cervix is about 10 cm (4inches) in diameter.
❖ Since the maximum diameter of the fetal head is also
10 cm when it is in a normal position, the baby can
be born easily through the cervix.
 MANAGEMENT OF FIRST STAGE OF NORMAL
LABOUR

The principle of management of this stage is to

prepare the patient to have a safe vaginal
delivery and to carefully monitor the vital
signs for early detection of any deviation from
the normal.
 MANAGEMENT OF FIRST STAGE OF NORMAL
LABOUR
Thorough general and obstetrical examination is done as soon as labor pains start
to plan for an uncomplicated labor, to check for a normal fetal heart rate and to
exclude any cephalopelvic disproportion (where the diameter of the head is
larger than the mother's pelvis).
Antiseptic dressing of the external genitals, inner part of the thighs, and lower part
of the abdomen.
Bowel must be evacuated - with an enema, if necessary. A full bowel can hamper the
downward movement of the head.
Evacuation of the bladder with a catheter if the patient is unable to pass urine
herself.
Nourishment is provided by liquid food which can be easily suctioned out should
the need for anesthesia and operative delivery (cesarean section) arise.
During the active phase of labor when the pains are severe, the patient is
encouraged to lie down in bed to prevent injuring herself. Lying in the left lateral
position wil increase the blood flow to the contracting uterus and to the fetus.
When pain is less, she can walk around or sit up in any position she feels
comfortable.
 MANAGEMENT OF FIRST STAGE OF NORMAL
LABOUR
Labor monitoring :
Maternal vital signs like pulse, blood pressure, duration and frequency of
contractions are noted regularly.
Fetal Status is recorded by counting the fetal heart rate every two hours initially,
increasing the frequency in the later stages. Continuous electronic recording of
the heart rate and intrauterine pressure can be employed but this has the
disadvantage of restricting the movements of the patient. So it should ideally only
be used in high-risk pregnancies.
Uterine contractions – Frequency and duration are recorded at regular intervals.
Rupture of membranes : As soon as the bag of membranes ruptures / bursts, the
liquor amnii is checked for its color. Liquor stained brown or black signifies that
the fetus has passed meconium (fetal stool) in the uterus and is in danger.
Immediate delivery - whether vaginal or cesarean section - is a must.
Periodic vaginal examinations to determine the rate of dilation of the cervix.
When the cervix is fully dilated (10 cm) it signifies that the second stage has started and the
patient is shifted to the labor room from the observation room
Nursing Considerations:
If membranes have not previously ruptured or been ruptured by
amniotomy, they will rupture as a rule at full dilation.
Both full dilation and cervical effacement have occurred at this
stage
Woman may have intense discomfort and may be accompanied by
nausea and vomiting.
Woman may experience a feeling of loss of control, anxiety, panic
or irritability.
Her focus is on the entirety of delivering her baby.
This stage ends at 10 cm of dilatation and feels a new sensation (i.e.,
irresistible urge to push).
SECOND STAGE OF NORMAL LABOUR
The second stage of labor starts at the end of the
first stage when the cervix is fully dilated to
10 cm.
This stage is characterized by some specific
dynamics in both the mother and the baby.
SECOND STAGE OF NORMAL LABOUR
In the Mother:
Contraction and Retraction: Painful, involuntary
contractions as well retractions occur in the uterine
muscles.
Retractions mean that the uterine muscles become
somewhat shorter after every contraction as the baby
descends into the pelvic cavity of the mother. They
do not regain their original length even after the
contraction is over and the muscles relax.
SECOND STAGE OF NORMAL LABOUR
Contraction of the Accessory Muscles: As the second stage
starts, the abdominal muscles and the diaphragm, which are
the accessory muscles of labor, contract forcefully to expel
the fetus. The diaphragm is a tough muscle separating the
abdominal cavity from the chest.
The contractions of the diaphragm and the abdominal muscles are
clinically evident as 'bearing down pains'. The woman in
labor takes a deep inspiration and holds her breath, thereby
fixing the diaphragm in a lower position, and then contracts
the abdominal muscles. This action increases the intra-
abdominal pressure, compressing the uterus and helps in
increasing the expulsive force.
SECOND STAGE OF NORMAL LABOUR
In the beginning, this secondary power is
voluntary and the woman can withhold the
urge to push. But in the later part of the
second stage, the urge and the pressure
becomes involuntary and synchronizes with
the uterine contractions.
SECOND STAGE OF NORMAL LABOUR
Changes in the Surrounding Organs: As the fetus moves into
the vagina dilating the vaginal cavity, the structures in front
as well as those behind the uterus changes their position. The
structures in front - the bladder and the urethra - gets pushed
upwards and forwards. This results in ' inability to pass
urine' by the woman in labor.
The structures behind the uterus are the rectum, the anus and the
perineum (the area between the vagina and the anus). These
get displaced downwards and backwards. The result is that
the woman gets a desire to pass stool (as a result of pressure
upon the rectum), and the perineum becomes stretched and
thinned out. The anus opens up as the head descends.
SECOND STAGE OF NORMAL LABOUR
In the Baby: The baby undertakes a series of
movements and changes in position during its
passage through the vaginal canal to the
vaginal outlet.
In a normal labor, the baby faces the mothers
back at this time and delivers in this position
(with the face towards the mother's back).
SECOND STAGE OF NORMAL LABOUR
Crowning: Crowning of the head occurs in the late
second stage of labor. During this stage, the head
shows at the vaginal opening at every uterine
contraction.
Crowning is said to have occurred when the head
shows at the vagin continously, without retracting
into the vagina even when the uterus relaxes. It
indicates that delivery is going to occur within a few
minutes.
SECOND STAGE OF NORMAL LABOUR
Delivery by Extension: As the fetal head reaches the
maternal symphysis pubis (the bone just below the
mons pubis), it hitches under the bone.
The pressure from the uterine contractions causes the
neck of the baby to get extended and the baby is
born face first.
The forehead appears first, then the eyes and nose, and
lastly the mouth as the extends more and more.
The baby's nose and mouth needs to be suctioned out of
any secretions at this time to clear up the respiratory
tract and help the baby to breathe properly.
SECOND STAGE OF NORMAL LABOUR
Delivery of the Shoulders: Once the head is out, the
contractions may or may not decrease in intensity for
some time.
Then the contractions increase once again, the anterior
shoulder (the shoulder just under the symphysis
pubis) hitches under the pubic bone and the posterior
shoulder (the shoulder towards the rectum) is
delivered first.
The body of the baby now slides smoothly out of the
vaginal canal.
Steps of Management of the Second Stage of Labor

The principles of management of this stage are

(a) to ensure birth of a healthy baby.
(b) to prevent damage to the maternal tissues.
 Steps of Management of the Second Stage of
Labor
Labor monitoring – The maternal pulse and blood pressure are recorded. Fetal
heart rate is counted and recorded after every contraction. Uterine
contractions are checked.
Position during delivery – The standard position for the delivery of the baby is
the lithotomy position – the patient lies on her back, legs flexed on the hips,
knees flexed and spread wide apart.
However, many doctors prefer the patient to deliver in whatever position she
prefers – sometimes in the hands and knees position and sometimes
standing up.
Cleansing of the vulva and the surrounding parts with sterile solutions.
Catheterization of the bladder is done if the patient cannot pass urine herself.
The patient is encouraged to bear down with every pain, taking deep breaths
between pains to relax herself
Steps of Management of the Second Stage of
Labor
Relief of pain:
In the early part of labor, the patient may be allowed injectible
analgesics, but these may cause depression of the baby and is best
avoided if there are less than 3 hours before delivery.
Pethidine is a widely used drug for pain relief in labor. Pethidine is a
similar drug to morphine and heroin. (50mg to 100mg)
In later part of the first stage and early second stage, inhalation
anesthesia by mixing an equal part of oxygen and an anesthetic agent
can be used.
Epidural anesthesia (anesthetic through a needle in the spine) is used
when complete pain relief is needed. But the disadvantage is that the
patient cannot move about freely. There is also a risk of prolongation
of the second stage as the patient cannot bear down. The operative
delivery rate (Cesarean Section, vacuum extraction etc.) increases
Steps of Management of the Second Stage of
Labor
Episiotomy – Many doctors prefer to do an episiotomy when the head is
crowned to prevent injury to the perineum. An episiotomy is a controlled
surgical incision made on the perineum that increases the size of the
vaginal opening.
The head is delivered slowly, preventing sudden extension of the head at the
neck. A Sudden extension can cause injury and tear of the maternal
perineum.
The perineum is supported by the left palm of the doctor during delivery of
the head.
After the head is delivered, the eyes are swabbed with sterile cotton swabs,
the mouth and nostrils are aspirated, and a careful hand is passed over the
neck to check for the presence of the cord around the neck.
The baby is held in a head down position while the cord is clamped.
Steps of Management of the Second Stage of
Labor
Syntometrin: 5 units Oxytocin (Syntocinon) + 0.5 mg Ergometrin ()
per ml. Administered by deep I'm injection
An injection of a drug called Syntometrin is usually given
just after the baby is delivered to stimulate the uterus
to contract better. This helps to prevent any excess
bleeding.
Pushing: with the onset of each contraction, the mother
is encouraged to inhale, hold her breath, and push,
increase in intra-abdominal pressure aiding in fetal
descent through the birth canal.
 Immediate care of newborn
❑ Drying the baby with warm towels
or cloths, while being placed on the
mother's abdomen or in her arms.
This mother-child skin-to-skin
contact is important to maintain the
baby's temperature, encourage
bonding and expose the baby to the
mother's skin bacteria.
❑ Ensuring that the airway is clear,
removing mucus and other material
from the mouth, nose and throat
with a suction pump.
❑Clamping and cutting the umbilical cord with sterile
instruments, thoroughly decontaminated by sterilization.
This is of utmost importance for the prevention of
infections.
• A few drops of silver nitrate solution or an
antibiotic is usually placed into the eyes to prevent
infection from any harmful organisms that the baby
may have had contact with during delivery
• Vitamin K is also administered to
prevent hemorrhagic disease of the newborn .
• The baby's overall condition is recorded at 1 minute
and at 5 minutes after birth using the Apgar Scale .
❑Putting the baby to the breast as early as possible.
Early suckling/breast-feeding should be encouraged,
within the first hour after birth and of nipple
stimulation by the baby may influence uterine
contractions and postpartum blood loss but according
to the WHO, this should be investigated.
❑About 6 hours or so after birth, the baby is bathed,
but the vernix caseosa (whitish greasy material that
covers most of the newborn's skin) is tried to be
preserved, as it helps protect against infection.
 Apgar Score
The Apgar test is usually given to your baby twice: once at 1 minute after birth, and
again at 5 minutes after birth.
Apgar Scoring Apgar Sign (2 1 0 )
1. Heart Rate (pulse) Normal (above 100 beats per minute) Below 100 beats
per minute Absent (no pulse)
2. Breathing (rate and effort) Normal rate and effort, good cry Slow or irregular
breathing, weak cry Absent (no breathing)
3.Grimace (responsiveness or "reflex irritability") Pulls away, sneezes, or coughs
with stimulation Facial movement only (grimace) with stimulation Absent (no
response to stimulation)
4.Activity (muscle tone) Active, spontaneous movement Arms and legs flexed
with little movement No movement, "floppy" tone
5. Appearance (skin coloration) Normal color all over (hands and feet are pink)
Normal color (but hands and feet are bluish) Bluish-gray or pale all over
 THIRD STAGE OF NORMAL LABOUR
Delivery of the Placenta

Immediately after delivery of the baby, the

placenta is still attached inside the uterus.
Some time after delivery, the placenta will
detach from the uterus and then be expelled.
This process is called the "3rd stage of labor"
and may take just a few minutes or as long as
an hour.
Delivery of the Placenta
Uterine contractions start again
after about 5 - 10 minutes. The
contractions are strong and
powerful and show
characteristics similar to those
in the second stage - they
contract and relax alternately.
Pain is lesser than in the
second stage.
Delivery of the
Placenta
A simple way to encourage firm
uterine contraction is with uterine
massage. The fundus of the uterus
(top portion) is massaged to keep
it the consistency of a tightened
thigh muscle. If it is flabby, the
patient will likely continue to
bleed.
To encourage the uterus to firmly
contract, oxytocin 10 mIU IM can
be given after delivery.
 Signs that the placenta is beginning to separate
include

Lengthening of the umbilical cord

Sudden gush of vaginal blood
Change in the shape of the uterus
Firm contraction of the uterus
Appearance of the placenta at the vaginal opening
seems to enlarge and approach the umbilicus.
Examination of placenta
A one-minute examination of the placenta
performed in the delivery room provides
information that may be important to the
care of both mother and infant
Once the placenta is out , it is examined
carefully to see that all parts including the
membranes are completely out and there are
no bits left behind in the uterus. Retained
placental bits
Examination of placenta
The size, shape, consistency and completeness
of the placenta
The usual term placenta is about 22 cm in diameter and 2.0 to
2.5 cm thick. It generally weighs approximately 470 g
The maternal surface of the placenta should be dark maroon in
color and should be divided into lobules or cotyledons.
The structure should appear complete, with no missing
cotyledons.
The fetal surface of the placenta should be shiny, gray
Examination of placenta
At term, the typical umbilical cord is 55 to 60 cm
in length, with a diameter of 2.0 to 2.5 cm.
The structure should have abundant Wharton's
jelly, and no true knots or thromboses should
be present
The normal cord contains two arteries and one
vein
Delivery of the Placenta
Fourth Stage (Recovery)
1-2 hours after delivery
Check :
Vital signs
Bleeding
Urination
General condition of the mother

73
 NURSING CARE DURING THE FOURTH STAGE OF LABOR

a. Transfer the patient from the delivery table.

Remove the drapes and soiled linen.
Assist the patient to move from the table to the bed.
b. Provide care of the perineum.
An ice pack may be applied to the perineum to reduce
swelling
Apply a clean perineal pad.
c. Transfer the patient to the recovery room.
This will be done after you place a clean gown on the patient,
obtained a complete set of vital signs, evaluated the fundal
height and firmness, and evaluated the lochia.
d. Ensure emergency equipment is available in the
recovery room for possible complications.
(1) Suction and oxygen in case patient becomes
eclamptic.
(2) Pitocin is available in the event of hemorrhage.
(3) IV remains patent for possible use if complications
develop.
e. Check the fundus.
(1) Ensure the fundus remains firm.
(2) Massage the fundus until it is firm if the uterus
should relax
3) Massage the fundus every 15 minutes during
(

the first hour, every 30 minutes during the next

hour, and then, every hour until the patient is
ready for transfer.
(4) Chart fundal height. Evaluate from the
umbilicus using fingerbreadths. This is recorded
as two fingers below the umbilicus (U/2), one
finger above the umbilicus (1/U), and so forth.
The fundus should remain in the midline. If it
deviates from the middle, identify this and
evaluate for distended bladder.
(5) Inform the Charge Nurse or physician if the
fundus remains boggy after being massaged.
NOTE: A boggy uterus many indicate uterine atony
or retained placental fragments. Boggy refers to
being inadequately contracted and having a
spongy rather than firm feeling.
(6) Ask the woman to urinate Full bladders may
actually cause postpartum hemorrhage because it
prevents the uterus from contracting
appropriately.