The Labor Process

Part I
LEARNING OBJECTIVES
Explain the five factors that affect the labor process.
Describe the anatomic structure of the bony pelvis.
Recognize the normal measurements of the diameters of the pelvic inlet, cavity,
and outlet.

LEARNING OBJECTIVES
Review the anatomy and the normal measurements of the fetal skull.
Explain the significance of molding of the fetal head during labor.
Describe the cardinal movements of the mechanism of labor.
Assess the maternal anatomic and physiologic adaptations to labor.
Describe fetal adaptations to labor.
Labor
is the process by which the fetus & placenta are expelled from the uterus.

It is accomplished by rhythmic contractions of the uterus, the fetus being an

inert passenger.
Labor
Five Factors are important in labor process:
a.passageway
b.passenger
c. power(physiologic force of labor)
d. placenta
e. psyche
PASSAGEWAY
Passageway
Shape and measurement of maternal pelvis and distensibility of birth canal
Refers to the route the fetus must travel from the uterus through the pelvis
Passages
Hard passages bony pelvis
Soft passages lower uterine segment, cervix, vagina, pelvic floor and perineum

PARTS OF PELVIS
Types of Pelvis
PELVIS
Measurement:
Pelvic Inlet
A. Diagonal conjugate distance between sacral promontory and inferior margin of
the symphisis pubis =12.5 cm 13 cm
B. true conjugate/conjugate vera- distance between the anterior surface of the
sacral promontory and the superior margin of the symphisis pubis = 10.5 11 cm
Pelvis
Bi-ischial diameter/ intertuberous diameter transverse diameter of the pelvic
outlet. Ave. = 11 cm
The examiner use closed fist to measure the outlet.

PASSAGEWAY
C. Soft tissue (cervix, vagina): stretches and dilates under the force of
contractions to accommodate the passage of the fetus.
The Passenger
The Passenger
Fetal Head
Bones of Fetal Skull:
a.Parietal (2)
b.Frontal (2)
c.Occipital (1)
d. Temporal (2)
Bones of skull are joined by membranous sutures, which allow for overlapping or
molding of cranial bones during birth.
The PASSENGER
Fetal Head

Molding

Is the change in shape of the fetal skull produced by the force of uterine
contractions pressing the vertex against the not yet dilated cervix
Fetal Head
Sutures of the fetal skull are membranous spaces between the cranial
bones.
 Fontanels is the intersection of cranial sutures & are used as landmarks
for internal examinations during labor to determine position of fetus.
Fetal Skull

1. Future Coronal Suture

2. Anterior Fontanel
3. Anterolateral Fontanel
4. Future Squamosal Suture
5. Posterolateral Fontanel
6. Future Lamdoidal Suture
7. External Acoustic Meatus
8. Future Sagittal Suture
9. Posterior Fontanel
Foetal skull

1. Bones: 2 parietals, 2 frontals,

2 temporals, occipital
2. Sutures: sagital, frontal,
lamboidal, coronal, temporal
3. Fontanelles: anterior,
posterior, 2 anterior
temporals, 2 posterior
temporals.
Fetal Skull
The PASSENGER
Fetal Head

Diameters of the Fetal Skull

Are measured between the various landmarks on the skull.

Landmarks of Fetal skull

Mentum fetal chin

Sinciput the brow

Vertex area between a & p fontanelles

Occiput occipital bone beneath posterior fontanelle

Bregma anterior fontanelle

Posterior fontanelle intersection bet. Posterior cranial suture

The PASSENGER
Measurements- the shape of the fetal skull causes it to be wider in its AP diameter
than in its transverse diameter.
Transverse diameter
A. biparietal diameter 9.25 cm
B bitemporal diameter 8 cm
The PASSENGER
Measurements
AP diameter
A. suboccipitobregmatic from below occipital area to anterior fontanelle 9.5 cm
B. occipitofrontal from occiput to midfrontal bone 12 cm
C. occipitomental from occiput to the chin 13.5 cm
D. submentobregmatic 9.5 cm
The PASSENGER

Fetal Attitude and Fetal Lie

 Attitude- refers to the degree of flexion the fetus assumes during labor or the
relation of the fetal parts to one another.

The normal attitude is the head is flexed forward, with chin almost resting on
the chest. The arms and legs are flexed.

Fetus positioned in the pelvis

The PASSENGER
Fetal presentation determined by fetal lie & the fetal part that is closest to the
cervix.
Presentation may be cephalic, breech or shoulder.
Shoulder & breech presentation are associated with difficulties during
labor,therefore called malpresentation.
The PASSENGER

Fetal Presentation

A. Vertex/occiput presentation- full flexion of the head presents smallest

anteroposterior diameter of skull to inlet, good attitude.

B. military presentation-head is neither flexed nor extended. Top of the head

is the presenting part.

The occipitofrontal diameter presents to the pelvis

The PASSENGER

Fetal Presentation and Position

C. Brow presentation- fetal head in partial extension.The occipitomental

diameter, largest AP diameter is presented to the maternal pelvis

D. Face Presentation- head is in complete extension. The submentobregmatic

diameter presents to the maternal pelvis.
The PASSENGER

Lie Presentation Attitude

A. Longitudinal Lie

1. Cephalic

vertex Complete flexion

sinciput Partial flexion

Brow Moderate flexion

Face Extension

chin Hyperextension

2. Breech

Complete Good flexion

Frank Moderate flexion

footling Very poor flexion

B. Transverse lie

shoulder flexion

Fetal Presentations
 A. Vertex (full flexion)
B. Sinciput (moderate flexion[military attitude])
C. Brow (partial extension)
D. Face (poor flexion,complete extension)

The PASSENGER

Fetal Presentation

Types of Fetal Presentation

1. Cephalic Presentation

Most frequent type, about 97%

2. Breech Presentation(3%)

the sacrum is the landmark to be noted.

3. Shoulder Presentation

Is also called a transverse lie

Types of Breech Presentation
ATTITUDE: Good
(full flexion)
The fetus has the thighs
tightly flexed on the
abdomen;both the
buttocks & the tightly
flexed feet present
to the cervix
ATTITUDE: Poor
Neither the thighs
nor lower legs are
flexed. If one foot
presents, it is a
Single-footling
Breech;
If both present, it
is a
Double-footling
breech
ATTITUDE: Moderate
Attitude is moderate
because the hips are
flexed but the knees
are extended to
rest on the chest.
The buttocks alone
present to the cervix
Types of Breech Presentation
Types of Breech Presentation
Footling Presentation

Position

Position- is the relationship of the presenting part to a specific quadrant of

the womans pelvis.

4 quadrants according to the mothers right & left(anterior /posterior)

Posterior position results in more backaches because of pressure of fetal

presenting part on the maternal sacrum.

Typically a fetus delivers fastest from ROA or LOA position.

Labor is considerably extended if the position is posterior (ROP or LOP)

because of pressure to sacral nerves
Position

Fetal Position

Types of Fetal Position

Four parts as landmarks:a.occiput for vertex presentation,

b.mentum for face presentation,

c.sacrum for breech presentation,

d. scapula or acromion for shoulder presentation

Position

Position is abbreviated in 3 letters:

First letter defines whether the landmark is pointing to the mothers right (R)
or left (L) side of pelvis.

Middle letter denotes fetal landmark;O for occiput, M for mentum or chin, S
for sacrum & A for acromion process.

Last letter defines whether the land mark points anteriorly (A), posteriorly (P),
or transversely (T)

Position
 Possible Fetal Position

Vertex Presentation (OCCIPUT)

LOA, left occipitoanterior

LOP, left occipitoposterior

LOT, left occipitotransverse

ROA, right occipitoanterior

ROP, right occipitoposterior

ROT, right occipitotransverse

Possible Fetal Positions

Breech Presentation (sacrum)
LSA, left sacroanterior

LSP, Left sacroposterior

LST, left sacrotransverse

RSA, right sacroanterior

RSP, right sacroposterior

RST, right sacrotransverse

Possible Fetal Positions

Face Presentation (mentum)
LMA, left mentoanterior

LMP, left mentoposterior

LMT, left mentotransverse

RMA, right mentoanterior

RMP, right mentoposterior

RMT, right mentotransverse

Possible Fetal Positions

Shoulder Presentation (acromion process)
LAA, left scapuloanterior

LAP, left scapuloposterior

 RAA, right scapuloanterior

RAP, right scapuloposterior

Assessment of fetal position can be made by:

A. Leopolds Maneuver: external palpitation of the maternal abdomen to locate fetal
parts, estimate fetal size & to determine fetal presentation, position & engagement.
Maternal obesity; excess amniotic fluid or uterine tumors may make palpation less
accurate.
Engagement

Occurs when the fetal presenting part enters true pelvis (inlet).

Is not an indication whether the midpelvis & outlet are adequate.

May occur two weeks before labor in primis; usually occurs at the beginning
of labor for multipara.
Station

Station 0=at the level of the ischial spine, synonymous with engagement

Station -1 to -4 =presenting part above the level of ischial spines

Station +1 to +4 cm =presenting part below the level of ischial spines

 Station +3 or +4 = (synonymous to Crowning)

Station
Powers of Labor
Primary & secondary forces work together to achieve birth of fetus, & placenta.
Primary force uterine muscular contractions causing complete effacement &
dilatation of the cervix.
Powers of Labor
Uterine contractions
Effacement- is the shortening & thinning of the cervical canal as
distinct from the uterus exists; It is expressed in percentage
Dilatation- refers to the enlargement of the cervical canal to 10cm
primarily as a result of uterine contractions & secondarily due to
pressure of the presenting part & BOW.
Effacement & Dilatation
Effacement & Dilatation
Uterine Contractions

Pain results from:

A. Contraction of uterine muscle when in ischemic state.

B.pressure on nerve ganglia in the cervix & lower uterine segment.

 C.stretching of ligaments adjacent to the uterus & in the pelvic joints

D. Stretching & displacement of the tissues of the vulva & perineum

Powers of Labor
Intensity strength of contraction. May be mild, moderate or strong.It is measured
by the consistency of the fundus at the acme of contraction.
Powers continue
Powers of Labor
Duration length of contraction.
Frequency-time from beginning of one contraction to the beginning of the next
contraction
Powers of Labor
Uterine Contractions
Uterus is gradually differentiated into distinct portions:
1. Upper uterine segment-becomes thick & active to expel out fetus
2.Lower uterine segment becomes thin walled, supple & passive so that fetus can
be pushed out easily.
Powers of Labor
Physiological retraction ring is formed at the boundary of upper & lower segment.In
difficult labor when fetus is larger than cervical canal, the round ligaments of the
uterus become tense during dilatation & expulsion, causing an abdominal
indentation called Bandls pathological retraction ring, a danger sign of labor
signifying impending rupture of the uterus if the obstruction is not relieved.
Powers of Labor
Secondary force is the use of abdominal muscles to push during second stage of
labor.
Placenta
As the placenta usually forms in the fundus of the uterus, it seldom interferes with
the progress of labor.
A low-lying, marginal, partial or complete placenta previa may require medical
intervention to complete the birth process.

Psyche

refers to the psychological state or feelings that women bring into labor with
them
 A woman who is relax, aware & participating in the birth process usually has
a shorter, less intense labor.

A woman who is fearful has high levels of adrenaline w/c slows uterine
contractions.

Encouraging woman to ask questions at prenatal visits & attend preparation

for childbirth classes helps prepare them for labor.

Encouraging them to share their experience after labor serves as debriefing

time & helps them integrate their experience into their total life.
PRELIMINARY/
PRODROMAL SIGNS OF LABOR
Lightening
the baby dropping into the pelvic cavity
In primis, it occur 2 weeks before EDC; in multis, on or before labor onset.
Lightening will result in:
Relief of respiratory discomfort
Increased frequency in urination
Leg pains sciatic nerve
Increased vaginal discharge
Decreased fundal height = fixation/floating
Increased Activity Level
Adrenal gland secretes large amounts of epinephrine or adrenalin about 2 weeks
before labor begins
Woman will be highly energetic and active(nesting behavior)
Advised not to use this increased energy for doing household chores.
Weight loss
About 1-3 lb
1-2 weeks before labor onset, probably due to decrease in progesterone production
leading to decrease in fluid retention.
Increased Braxton-Hicks Contractions
The irregular painless contraction of pregnancy become stronger, longer, more
frequent, enough to cause discomfort and alarm the mother
Described by pregnant mother as tightening of the uterus.
Ripening of the Cervix
From goodells sign the cervix becomes butter-soft
SHOW
Pressure of the presenting part result in rupture of minute capillaries.Blood mixes
with mucus when operculum is released.
Pinkish vaginal discharge
ROM
Rupture of membrane (BOW)
Gush or steady trickle of clear fluid from the vagina.
Once BOW have ruptured.Labor is inevitable. It will occur w/in 24 hours.
Infection can easily set in.aseptic techniques should be observed in all
procedures.doctors do less IE.
ROM
Cord prolapse can occur.Nursing action depends on the following situation:
a. A woman in labor seeking admission & say that her BOW has already ruptured
shld be put to bed & take FHT consequently.
b. In case of cord prolapse, the first action is to position her in T-position to reduce
pressure in the cord.(Remember: 5 min of cord compression can lead to irreversible
brain damage / even death.)In addition, apply a warm saline saturated OS on the
prolapse cord to prevent drying of cord.
Difference Between True and False Labor Contractions
Difference Between True and False Labor Contractions
Stages of Labor
1st cervical/dilatation stage
2nd expulsion stage
3rd placental stage
4th immediate postpartum period
TYPES OF DELIVERY
C-section
A small incision is made in the lower abdomen & uterus where the baby is delivered
C- SECTION
Why have a C-section?
Transverse position
Abruption placenta
breech presentation
Placenta previa
CPD

FORCEPS DELIVERY
FORCEPS
Are like metal tongs with two large spoon shaped edges that fit around the babys
head. They are inserted into the vagina to grip the babys head and speed up
delivery. This technique may be used if the babys heartbeat slows down during a
slow delivery of the head, or to ensure its safe delivery during a breech birth.
FORCEPS DELIVERY
VACUUM EXTRACTION
is a gentle alternative to forceps. A suction cup is placed over the top of babys
head and using an attached pump vacuum is created. This instrument then
becomes a handle which the doctor can use to rotate the head and pull while
pushing.

VACUUM EXTRACTION
VAGINAL BIRTH
The most common method of childbirth.
Women who give birth this way can breastfeed more easily, do not have to stay in
the hospital or clinic for very long and can avoid the risks involved with major
surgery, such as C-section.