Stages of labour and delivery

Definition of labour → Coordinate sequence of involuntary, intermittent uterine contractions & expel viable products of the conception uterus through the vagina into the outer world is called labour.

Delivery: Actual event of birth

Normal labor (Eutocia )

• Labor Spontaneous onset & at term. 
• With cephalic presentation. 
• Without prolongation. 
• Natural termination with minimum help.
• Without any complication to mother and fetus

Prolonged labor:-

• Abnormally slow progress of labor, > 18 hours duration of 1st + 2nd stage of labor.
  Rate of cervical dilation or descent of presenting part less than 1cm /hour during minimum 4 hours observation.
  Causes of prolonged labor are the fault of one or more “P”. 

Precipitate Labour : - 

• < 3 hours duration of 1st + 2nd stage of labor.
• Nulliparous - Dilatation & descente > 5cm/h
• multipara - Dilatation & descente > 5cm/h

Obstructed labor or dystocia (difficult labor) or abnormal labor

• Any deviation from normal labor called abnormal labor. 
• Arresting process of descend of presenting part or stopping progress of labor due to mechanical obstruction instead of good uterine contraction called obstructed labor. 
• It may be produced by either the big size of the fetus or the small size of the pelvic outlet. 

Causes of labor - following are some possible causes to start labor pain.

1. Uterine distension - Uterine distension due to growing fetus & amniotic fluid.

2. Activation of fetal hypothalamic pituitary adrenal - Increase secretion corticotropin releasing hormone

3. Estrogen

4. Progesterone

5. Oxytocin & myometrial oxytocin receptors - maximum during labour

5. Prostaglandins secretion - maximum 3rd stage of labour / delivery of placenta

6. ferguson reflex (foetal ejection reflex)- pressure at the cervix or vaginal walls examination.

Type of labor pain

Characteristic of false / True labor pain :-

factors related to child birth

4 major factors (four P’s) interact during normal childbirth, the four P’s are interrelated and depend on each other for a safe delivery

(A). Powers:- Uterine contractions → Forces acting to expel fetus

Effacement:→  Shortening and thinning of the cervix during first stage of labor

Dilation: → Enlargement of cervical os and cervical canal during first stage of labor

Pushing Efforts →  Mother During Second Stage

(B) Passage-way:→  mother’s rigid bony pelvis & soft tissues of cervix, pelvic floor, vagina, and introitus (external opening to vagina)

(C) Passenger:→ fetus, membranes, and placenta

(D) Psyche:→ A woman’s emotional structure that can determine her entire response to labor and influence physiological and psychological functioning, mother may experience anxiety or fear. 

OTHER:- factors

Lie, Attitude, Presentation, position

Pre-labor (Premonitory) Stage: -

→ It gives idea about true labor (Due to oxytocin receptors increase number and susceptibility in myometrium )

→ Onset 2-3 week before true labour in primigravida

 → often 24-48 hour before the labor mother feels a sudden burst of energy called "NESTING.

1. Lightening ( welcome sign )-

→ descent of the presenting part of the fetus into the pelvis, which ease breathing mother called lightening.

it often occurs 2 to 3 weeks before the first stage of labor begins. (36 - 38 week)

It may not occur in multipara until active labor begins.

2. cervical ripening → softening of the cervix than 1.5cm less in length, admits a finger easily and is dilatable

3. False labour pain. 

4. Show – Expulsion of cervical mucus plug mixed with blood is called "show"

5. Formation of "bag of waters" during uterine contraction.

After the contracten passes off the bulging may disappear completely. This is almost a certain sign of onset of labour. 

 

Labour:- divided in to 4 stages

First stage: - (1) First Stage Labor (stage of dilation, cervical stage) 

Starts → with onset of true labour pain


Ends → with full dilatation of cervix (10cm)


Duration → in primipara - 12 hrs,  / → in multipara - 6 hrs

Intrauterine pressure → 40-50 mmhg

Cervical dilation :-

Fried-man curve used to identify cervical dilatation.

It complete in three phase

Latent phase :-   

Cervical dilation    → 0 /1 to 4 cm.

Dilation rate   → 0.35cm/hour.

Uterine contraction (pain) -interval → 15 to 30 minute
                                            duration → 15 to 30 second.

Latent phase duration ↴

→ in primipara - 6 to 8 hrs (avg. 7.6 hr) if prolonged - > 20 hr

→ in multipara - 4 to 6 hrs (avg. 5.3 hr) if prolonged - > 14 hr

Active phase

Cervical dilation → 4 to 7 cm.


Dilation rate → 1 cm/hour in primigravida

                     → 1.5cm/hour in multigravida

Uterine contraction (pain)

interval → 3 to 5 minute

duration → 30 to 60 second.

good uterine contraction → 3 contraction / 10 min / duration 45 sec.

Transitional phase :-

Cervical dilatation → 8 to 10cm


Uterine contraction (pain)

interval → 2 to 3 minute


duration → 45 to 90 second

Abnormalities of active phase

1. Longer than active phase (cervical dilation or descent of head)


                                     


In primipara  cervical dilation   <1.2cm/ hrs,
Descent of head <1cm/hr


In multipara     cervical dilation   <1.5cm/ hrs,
Descent of head <2cm/hr


2. Arrest of dilatation –
Cessation (stoppage) of dilatation for 2 or more hours

3. Arrest of descent: -
cessation of descent for 1 or more hours

Mechanism of labour:-

(1) Engagement

- entry largest diameter of fetal presenting part into the pelvic inlet.

Q- MCC of non- Engagement fetal head in primi?

answer- Cephalo pelvic disproportion

(ii) Descent

- it is a continuous process, which is slow in 1" stage and rapid in 2nd stage.

In primigravida women it may start slowly before starting labor.

(iii) Flexion ( act of bending of head at neck)

Flexion occurs due to resistance applied by muscles of pelvic floor, bone pelvic walls and cervix against descending fetal head.

(iv) Internal rotation

- it is a very complex mechanism in which the fetal head comes under symphysis pubis.

(v) Crowning -

Visible presentation of the fetal head at the vaginal introitus.

Bi-parietal diameter of head stretches the vulvar outlet.

(vi) Extension

Delivery of head by forward forces.

Downward & upward forces are neutralized by uterine contraction & bearing down efforts.

(vii) Restitution

Passive movement & release the torsion of neck by rotation of head in 1/8 of circle in opposite direction of internal rotation.

(viii) External rotation

External rotation of head 1/8 of circle in direction of restitution due to internal rotation of shoulders.

Anterior shoulder comes toward symphysis pubis from oblique diameter.

Delivery of shoulders & trunk

Delivery of Anterior & Posterior shoulder by lateral flexion of spine & then rest of the trunk delivered by lateral flexion.

Management of First Stage

Bishop Score -

It is used to determine maternal readiness for labor and evaluates cervical status and fetal position.

It includes the following parameters / factor: - trick / mnemonic

1. Delhi – cervical dilatation

2 . Police - cervical position

3 . Employed - cervical effacement (or lengths )

4 . special - Head Station


5 . commando- - Cervical consistency

Each factor receives a score of 0, 1, 2, or 3. maximum predictive total score of 13.

Favorable score is 6 to 13 and unfavorable is less than 6.

Score 6 or more than 6 indicates maternal readiness for labor.

PARTOGRAPH

It is a composite graphical recording of key data (maternal and fetal) along with cervical dilatation & descent of head during labour.

• It is a vital tool to represent the progress of labour and to identify complications into the early stage.

Components of Partograph

• Mother information

• Fetal well-being

• Labor progress

• Medications

Maternal well-being In partograph fetal heart rate need to be recorded every 30 min

The condition of membrane and liquor need to be recorded as intact (I), clear (C), meconium stained (M)


Cervicogram indicates the cervical dilation and descent of the fetal head. Alert line starts at 3 cm dilation and ends at 10 cm dilation at a rate of 1cm/hr.

PARTOGRAPH 

Partograph consists of 3 zones.

I zone before the alert line (normal). normal progress

II zone between alert line and active line (may become abnormal).

III zone beyond active line (abnormal).

Other management -

1. Rupture of membranes :

- Usually membranes remain intact until full dilatation of the cervix or sometimes beyond, even in the second stage ( later)


Normaly Rupture of membrane    - After full dilatation of cervix

Early ruptureof membrane    - Any time after onset of labour but before full dilation cervix


Premature Rupture of membrane (PROM)   -Rupture of membranes before the onset of labour.

NOTE-If the membranes have ruptured, assess the fetal heart rate because of the risk of collapsed umbilical cord, and assess the color of the amniotic fluid because meconium-stained fluid can indicate fetal distress.


2. Encourage to maintain effective breathing pattern.

3. Provide a quiet environment.

4. Promote comfort with back rub, sacral pressure and position change.

5. Offer fluid and ice chips for dry mouth.

6. Encourage for voiding every 1-2 hours.

7. Monitor maternal vital signs (pulse every 30 minule, B.P every 4 hours and temperature.every 2 hours).

Monitor FHR every 1/2 hourly, during and after contraction (120 to 160 are normal).

Stage: - (2) Second Stage Labor (stage of expulsion)

Starts   → with full dilatation of cervix (10cm)


Ends   → with expulsion of fetus from birth canal


Duration   → in primipara - 2 hrs

                 → in multipara - 30 Minute

Intrauterine pressure    → 90-120 mmhg

Events in Second Stage:-

1. contraction
Interval → 2 to 3 minute
duration → 60 to 75 second

2. Crowning
→ When most of the head is visible and the vulvar ring encircles the head like a crown ( called crowning).

3. Bearing down effort
→ Combined force of uterus and abdomen muscle to expel the fetus in the outside world

Management of second stage of labour

1. assess mother condition and fetal heart rate every 5 minute.

2. Assist mother into lithotomy or semi sitting or side lying or squatting position.

3. Provide psychological support

4. Episiotomy done just prior to crowning (when visible 3 to 4 cm. scalp of fetus).

Episiotomy 

5. Assist in delivery of fetal head (maintain flexion of head, keep head 150 angle downward than body).

6. Use 3 “C” practices like clean hands, clean surface, clean cutting and ligation of cord.

Stage: - (3rd) Third stage of labour (placental stage)

Starts → after expulsion of fetus


Ends → with expulsion of placenta & membranes.


Duration
→ in primipara - 15 minute (5 minute in active management)

→ in multipara - 15 minute (5 minute in active management)

Intrauterine pressure → 100-120 mmhg

Events of third stage: - Separation of placenta

1.Shultz mechanism

Centre portion of placenta separate first.

Shiny fetal surface visible outside first.

2. Mathew Duncan mechanism

Margin of placenta separate first.

Dull, red rough maternal surface comes outside first.

Management of Third stage:-

1. Assess maternal vital sign and blood loss, normal loss is 100 to 500ml (average 200 ml).

2. massage the uterus.

3. Assess uterine status- firm (fundus will located 2 fingers below umbilicus).

4. Examine placenta for cotyledon and membrane intact.

5. Assess mother for shivering and provide warmth.

6. Promote mothers attachment with neonate (rooming in)

Stage: - (4th) Fourth Stage

Monitoring period of 1 to 4 hours after delivery.

Management:-

1. Check blood pressure (return to pre-labour stage). Pulse slight lower than labour period.
Fundus remain contracted in the midline 1 to 2 finger breadth below the umbilicus.

2. Perform maternal assessment every 15 minute in 1st hours, 30 minute in next hours, hourly in the next 2 hours

3. Massage uterus if needed in atonic condition

4. If the mother is Rh negative and if the Rh status of the fetus is unknown or positive, administer globulin to the mother within 72 hour of delivery.

5. Administer -300mcg Anti- D gamma globulin in full term delivery or abortion more than 12 wk of pregnancy

6. Administer -50mcg Rh immunoglobulin if abortions occur in first trimester.

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Nursing Officer

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