ACTIVITY: DEFINE THE FOLLOWING TERMS

Lightening
Braxton Hicks
Dilatation
Effacement
Lie
Position
Station
Attitude

PRETEST:

1. Any hollow body organ when stretched to capacity will necessarily contract and empty
because of pressure on nerve endings and ↑increased irritability of the uterine musculature.
This is what theory in labor?
a. Uterine stretch

2. The decrease of ↓nutrients and ↓blood supply in the aging placenta causes uterine
contractions. This is what theory in labor?

a. Aging Placenta

3. The relative ↓progesterone deprivation and ↑estrogen predominance

[during late stage of pregnancy] set off production of cortical steroids which act on lipid
precursors to release arachidonic acid, and in turn, increase the synthesis of prostaglandins
which causes uterine contraction, this is an example of labor theory under:

a. Progesterone theory

4. This refers to the ROUTE the fetus must travel from the uterus through the cervix and
vagina to the external perineum; because these organs are contained inside the pelvis, the
fetus must also pass between the pelvic ring.
a. Passageway

5. This refers to GOOD EMOTIONAL STATE of the mother w/c helps her cope with the
pain effectively; helps her tune in to her body and helps guide her to her baby’s needs:

a. Psyche
6. This is supplied by the fundus of the uterus and implemented by uterine
contractions, a process that causes cervical dilatation and the expulsion of the fetus° from
the uterus.
 a. Power

7. Fetus° appropriate size and in an advantageous position and presentation.

a. Passenger

Put a check on the blank if the sign or symptom is for TRUE labor and (X) mark if false
labor.

FALSE____________ lightening
FALSE____________ Irregular contraction
TRUE____________ Regular Predictable contraction
TRUE____________ Pain is not relieve by ambulation
TRUE____________ With cervical dilatation
FALSE____________ Pain is confined in the abdomen and groin
TRUE ____________Pain sweep around the abdomen up to the back
FALSE____________ Pain disappears with ambulation and sleep

LABOR: a series of continuous,

progressive contractions of the uterus
which help the cervix to open (dilate) and
to thin (efface), allowing the fetus to move
through the birth canal
A. THEORIES OF LABOR ONSET
Labor normally begins when a fetus is sufficiently mature to cope with extrauterine life
yet not too large to cause mechanical difficulties in delivery. A
normal labor starts at [37 - 42 weeks AOG]. However, the trigger that converts the random,
painless Braxton Hicks contractions into strong, coordinated, productive labor contractions is
unknown.

A number of theories have been proposed to explain why labor begins. These include:

1. Uterine Stretch Theory. Any hollow body organ when stretched to capacity will
necessarily contract and empty bc of PRESSURE on nerve endings and ↑d irritability of
the uterine musculature.

2. Oxytocin Theory. Oxytocin is an effective stimulant of uterine contractions in late

pregnancy and is commonly used to induce or augment labor.

When the fetus presenting part presses the cervix, the nipples are stimulated that gives
impulse to the hypothalamus, this will stimulate the {posterior} pituitary gland to produce
oxytocin which causes uterine contraction.

3. Progesterone Deprivation Theory. Progesterone is believed to inhibit uterine motility.

The onset of labor in humans might result from withdrawal of ↓↓progesterone at a time of
relative ↑↑estrogen dominance.
4. Prostaglandin Theory. The relative ↓↓progesterone deprivation and ↑↑estrogen
predominance set off production of cortical steroids which act on lipid precursors to
release arachidonic acid, and in turn, increase the ↑synthesis of prostaglandins.
Prostaglandins,
like oxytocin are known to stimulate uterine contractions.

5. Theory of Aging Placenta. The decrease of ↓nutrients and ↓blood supply in the aging
placenta causes uterine contractions.

COMPONENTS OF LABOR

A successful labor depends on 4 integrated concepts:

1. Passageway. (PELVIS) This refers to the ROUTE the fetus must travel from the uterus
through the cervix and vagina to the external perineum; because these organs are contained
inside the pelvis, the fetus must also pass between the pelvic ring.
A favorable type of pelvis is the GYNECOID.

• The pelvic inlet - the top opening of the pelvis.

- part the baby’s head enters first.
The pelvic outlet - where the baby’s head and body exits. These dimensions need to
be sized sufficiently to allow baby to maneuver comfortably through the pelvis for birth.
• The tailbone (sacrum or coccyx) needs to be sufficiently mobile to be gently pressed
back out of the way when baby moves through. Your sacroiliac joint allows this nutation
or counter-nutation of the sacrum.

• The symphysis pubis is a cartilaginous joint in the front of the pelvis. It also needs to
be properly mobile to help the pelvis flex to allow baby to pass through. The relaxin
hormone in your body helps both the tailbone and the symphisis pubis become more
mobile to facilitate birth.

So, all of the physical components of the pelvis need to be working, moving, properly to
facilitate birth

INTERNAL PELVIC MEASUREMENT

a. Diagonal conjugate

distance b/w the anterior surface of the sacral prominence & anterior surface of the
inferior margin of the symphysis pubis.
- Most useful measurement for estimation of pelvic size
- It suggests anteroposterior diameter of the pelvic inlet
- Adequate for childbirth if the diameter is more than 12.5 cm
 b. True conjugate /conjugate vera

- Measurement between: anterior surface of the sacral prominence and

posterior surface of the inferior margin of the symphysis pubis
- Cannot be directly measured but it can be estimated
- Diagonal conjugate measurement minus 1.5 or 2 cm

- 12.5 – 1.5 or 2 cm (usual depth of the symphysis pubis) = 10.5 or 11 cm.

c. Ischial tuberosity
a. Distance between the ischial tuberosity or the transverse diameter of the
outlet.
b. Measured at the level of the anus
c. A pelvimeter is generally used. Can also use a ruler or compare it with a
known hand span or clenched fist measurement
d. A diameter of 11 cm is considered adequate because it will allow the widest
diameter of the fetal head, or 9 cm, to pass freely through the outlet.
 2. Passenger. (BABY)
• If the fetus is of appropriate SIZE and in an advantageous position and presentation.
• The baby needs to be positioned properly to make it through the pelvis. The optimal
position for birth is Occiput Anterior (OA). However, babies can be born vaginally in a
number of positions

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3. Power. (UTERINE CONTRACTION)

• This is supplied by the fundus of the uterus and implemented by uterine
contractions, a process that causes cervical dilatation and the expulsion of the fetus
from the uterus.
• The contractions needs to be strong enough to dilate the cervix and aid the baby in his
decent. They need to be at regular intervals, moving closer together and increasing in
strength throughout labor.
 • After dilatation of the cervix, the primary power is supplemented by the use of
abdominal muscles

4. Psyche. (EMOTIONAL STATE)

>The woman’s psyche is preserved so afterward labor can be viewed as a positive
experience.
> If mom is afraid, tense, stressed out, angry, feels unsafe or unsupported, she will not
likely do well during birth
> A good emotional state helps mom cope with the pain effectively; helps her tune
in to her body;
helps guide her to her baby’s needs and allows the other 3 P’s to sync up effectively. A
mom who’s psyche is healthy, strong and who has good support during labor, will have
a good birth. Regardless of the medical interventions she may need, she will ride her
labor to a birth experience she will remember with a strong heart and a peaceful mind .

PREMONITORY SIGNS OF LABOR

1. Lightening. This is the descent/settling of the presenting part into the pelvic inlet
which happens 10-14 days before labor in primigravida but at unpredictable times in
multiparas. And when the largest diameter of the presenting part passes the pelvic inlet,
the head is said to be "engaged."
However, lightening is heralded by the following signs:

a. Relief of dyspnea
b. Relief of abdominal tightness
c. Increased frequency of voiding
d. Increased amount of vaginal discharge
e. Increased lordosis as the fetus enters the pelvis and falls further forward
f. Increased varicosities
g. Shooting pains down the legs because of pressure on the sciatic nerve

2. Increased Braxton Hicks's contractions in the last week or days before labor.

These are false labor contractions, painless, irregular, abdominal and relieved by
walking, and are also known as practice contractions.

3. A sudden burst of maternal energy/activity because of hormone epinephrine. This is meant

to prepare the body for the “labor” ahead. “NESTING”
4. Slight decrease is maternal weight. Loss of weight is about 2-3 lbs. One to two days
before the onset of labor because of the decrease in progesterone level and probably loss
of appetite.

5. Softening /”ripening” of the cervix.

D. SIGNS OF TRUE LABOR

The more women know about true labor signs, the better, because they will be able to
recognize them. True labor is said to occur when the following signs are observed:

1. Uterine Contractions. The surest sign that labor has begun is the initiation of effective,
productive, involuntary uterine contractions.

There are 3 phases of uterine contractions:

a. Increment / Crescendo – intensity of the contraction increases.
b. Apex / Acme – the height or peak of the contraction.
c. Decrement / Decrescendo – intensity of the contraction decreases.
 Characteristics of Contractions:

1. Frequency of contraction – this is timed from the beginning of one contraction to

the beginning of the next.
2. Duration of contraction – this is time from moment the uterus first begins to tighten
until it relaxes again. 40-60 seconds duration.

3. Intensity of contraction – it may be mild moderate or strong at its acme.

a. Mild contraction – the uterine muscle becomes somewhat tense, but can
be indented with gentle pressure.
b. Moderate contraction – the uterus becomes moderately firm and a firmer
pressure is needed to indent.
c. Strong contraction – the uterus becomes so firm that it has the feel of
wood like hardness, and at the height of the contraction, the uterus cannot
be indented when pressure is applied by the examiner’s finger.

If true labour is progressing, there will be adequate uterine contraction, evaluated on

the basis of three features — the frequency, the duration and the intensity of the
contractions:

• The frequency of uterine contractions will be 3-5 times in every 10 minute period.
• Each contraction lasts 40–60 seconds; this is known as the duration of contractions.
• The woman tells you that her contractions feel strong; this is the intensity of contractions.

2. Uterine Changes. As labor contractions progress, the uterus is gradually

differentiated into two distinct portions. These are distinguished by a ridge formed in
the inner uterine surface, the physiologic retraction ring.

Upper uterine segment – this portion becomes thicker and active, preparing it to exert
the strength necessary to expel the fetus during the expulsion phase.
 Lower uterine segment – this portion becomes thin walled, supple, and passive so that
the fetus can push out of the uterus easily.
Contour of the uterus changes from a round ovoid to a structure markedly elongated
in a vertical diameter than horizontally. This serves to straighten the body of the
fetus and place it in better alignment to the cervix and pelvis.

3. Cervical changes. There are 2 changes that occur in the cervix.

a. Effacement. This is the shortening and thinning of the cervical canal to

paper-thin edges to primiparas, effacement is accomplished before
dilatation begins while with multiparas, dilatation may proceed before
effacement is complete.

b. Dilatation. This refers to the enlargement of the cervical canal from an

opening a few millimeters wide to one large enough (approximately 10 cm.)
to permit passage of the fetus. We approximate it using our fingers.

Dilatation occurs for two reasons. First, uterine contractions gradually increase
the diameter of the cervical canal lumen by pulling the cervix up over the
presenting part of the fetus. Second, the fluid-filled membranes press
against the cervix.
4. Show. This is the blood-tinged mucus discharged from the vagina because of
pressure of the descending fetal part on the cervical capillaries, causing their rupture.
Capillary blood mixes mucus when operculum is released.
5. Rupture of the membranes of bag of waters. This is a sudden gush or a scanty
slow seeping of amniotic fluid from the vagina. The color of the amniotic fluid should
always be noted. At term, this is clear, almost colorless and contains white specks of
vernix caseosa. Green staining means it has been contaminated with meconium, a
sign of fetal distress. Yellow staining may mean blood incompatibility while pink
staining may indicate bleeding.

Once membranes have rupture, labor is inevitable, meaning to say that uterine
contractions will occur within next 24 hours. The initial nursing action is for
patients with ruptured membranes are:

Notify physician.
Lie patient to bed to ensure that the fetus is not impinging on the cord.
Check the fetal heart rate to determine for fetal distress.
If the patient claims she can feel a loop of the cord coming out of her vagina
(umbilical cord prolapse), lower the head of the bed (Trendelenberg postion)
in order to release pressure on the cord. Also apply sterile saline-saturated
gauze to prevent drying of the cord, if needed.

If labor does not occur spontaneously at the end of 24 hours after

membrane rupture, it will be induced, provided the woman is estimated to be
at term.
Characteristics of true and false labor

FOR ADDITIONAL INFORMATION : You can watch this video that

differentiates TRUE from FALSE signs of Labor:
ASYNCRONOUS: CASE SCENARIO FOR TRUE AND FALSE SIGNS OF LABOR:

CASE SCENARIO #1: LABOR AND DELIVERY SITUATION: Mrs. M. is a 27-y/o

gravida 3, para 2, who was admitted at term at 6:30 p.m. She stated that she does not
know how to differentiate true from false labor because her 2 previous pregnancies were
delivered via CS delivery. Based from the assessment questions below, encircle the
signs that indicated that Mrs. M is already experiencing TRUE SIGNS of labor.
1. My Contractions are:
A. My contractions are not painful at all (less than 1 out of 10)
B. My contractions are somewhat painful (1-3 out of 10)
C. My contractions are moderately painful (4-6 out of 10)
D. My contractions are very painful (7-10 out of 10)

2. My Contractions last for:

A. 10-20 seconds
B. 20-30 seconds
C. 40-60 seconds
D. Over 60 seconds

3. I have this amount of contractions in 10 minutes:

A. Less than 1 per 10 minutes
B. 1-2 contractions per 10 minutes
C. 3-5 contractions per 10 minutes
D. 5 or more contractions in 10 minutes

4. My contractions have become more painful over the last 1-2 hours:
A. Yes, they have become more painful
B. No, they are now less painful

5. I have constant and severe uterine pain. It does not stop:

A. No, my uterine pain comes and goes. It stops in between.
B. Yes, my uterine pain is constant and stays the same.

6. I have vaginal bleeding:

A. No. There is no vaginal bleeding
 B. Yes, but my vaginal bleeding is only very little, like small drops
C. Yes, but my vaginal bleeding is heavy, more like a period or more

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7. I feel pressure in my vagina:

A. Not much
B. Somewhat
C. A lot of pressure
8. I have lost my mucus plug:
A. No, I have not lost my mucus plug
B. Yes, I passed my mucus plug
C. I do not know if I passed my mucus plug

VIDEO CONFERENCE: PHASES OF LABOR

Comparison of length of labor in Primigravida and Multigravida.

Stage of Labor Primigravida Multigravida

First stage 12 ½ hours 7 hrs. 20 minutes

Second stage 80 minutes 30 minutes
Third stage 10 minutes 10 minutes
Total 14 hours 8 hours

A. First stage of labor/dilatation stage.

This stage begins with the first symptoms of true labor and ends with the complete
dilatation of the cervix (10 cms.) The “force” or “power” at work during
this stage is the involuntary uterine contraction which is divided 3into
phases:

1. Latent phase – the phase begins with onset of regular contractions and ends
with complete effacement (100%) and cervical dilatation of about 3 cm. Mild
uterine contractions occur regularly 10-20 minutes apart and are of short
duration (20-40 seconds). The woman usually experiences low backaches,
and abdominal cramps and is general excited, alert talkative and in control.
This phase lasts approximately 6 hours in nullipara and 4.5 hours in multipara.
Analgesia given too early in labor will prolong this phase.

2. Active phase – this begins with complete effacement and cervical dilatation of
4-7 cms. Uterine contractions occur at 3-5 minutes apart and last 40-60
seconds. The contractions are stronger, last longer and begin to cause
discomfort. It is an exciting and frightening time because she realizes that
labor is truly progressing. This phase lasts approximately 3 hours in nullipara
and 2 hours in a multipara.

Two Periods of Active Phase:

a. Acceleration (4-5 cm)
b. Maximum slops (5-9 cm)

At its most rapid pace at an average rate of 3.5 cm. Per hour in nulliparas
and 5-9 cm. per hour in multiparas.
 3. Transition Phase – Maximum dilatation of 8 to 10 cm. occurs, and
contractions reaches their peak of intensity, occurring every 2-3 mins with a
duration of 6090 secs. May experience a feeling of loss of control, anxiety,
panic, and irritability. Her focus is entirely inward on the task of birthing her
baby. The peak of this phase can be identified by a slight slowing in the rate of
cervical dilatation when 9cm is reached. As the woman reaches 10 cm of
dilatation, an irresistible urge to push begins to occur.

SUMMARY OF THE 3 PHASES:

PHASE ONSET MINUTES OF Manifestations

CONTRACTIONS

LATENT onset of the Mild uterine Low backache,

Nulli = 6 hours regular contractions abdominal cramps,
Multi = 4.5 hours contractions and Interval: 10-20 mins excited, alert talkative
ends with Duration: 20-40 and in control
complete secs NR= aromatherapy,
effacement distraction,
(100%) accupressure;X
Cervical analgesics
dilation: = controlled breathing;
0-3 cm walk

ACTIVE complete Contractions are Begin to cause

Nulli = 3 hours effacement to stronger, last longer discomfort, exciting,
Multi = 2 hours Cervical dilatation: Interval = 3-5 mins frightening, labor is
4-7cms Duration = 40-60 progressing
*Show secs NR= active participant;
comfortable position
Transition Maximum dilatation Maximum dilatation Experience feeling of
(peak of this phase until of 8-10cm occurs loss of control, anxiety,
can be identified contractions and contractions panic, irritability
by a slight slowing reaches their peak reached their peak *intense discomfort
rate of cervical of Intensity of intensity (NV)
dilatation when *full dilatation Interval = 2-3 mins
9cm reached and *full effacement Duration = 60-70
10cm dilatation an secs
irresistible urge to
push begins to
occur
THE PARTOGRAPH: The partograph is a tool for monitoring maternal and fetal
wellbeing during the active phase of labor, and a decision-making aid when
abnormalities are detected. It is designed to be used at any level of care.
 A tool to help in management of labor.
 Guides birth attendant to identify women whose labor is delayed
and therefore decide appropriate action

OBJECTIVES:
> To understand the concept of the WHO partograph. To explain to the mother the significance of
the graph.
> To record the observations accurately on the graph
> To interpret the recoded findings, recognize deviation from normal and decide on timely
referral.

MONITOR DURING LABOR:

A. Progress of Labor
> Cervical dilatation
> Contraction Patterns

B. Maternal Well being

> Pulse, temperature, BP,
> Urine Voided

C. Fetal Well Being

 Fetal Heart Rate Pattern
  Color of Amniotic Fluid

PARTS OF THE PARTOGRAPH:

The [upper] colored portion is where you plot the progress of labor.
The [lower] portion is where you are supposed to write your other observations particularly
the findings of your monitoring of the maternal and fetal well-being.
Each horizontal gridline corresponds to the cervical dilatation in centimeter from 4 to
10.While the vertical gridlines indicate the time, in hours, the patient is in active labor.
The upper portion is also divided into 3 colors – green, yellow, and red. The boundary
between the green and yellow parts forms a diagonal line which is highlighted here. This
is designated as the alert line which starts at 4 cm. up to 10 cm.

CONDITIONS THAT DO NOT NEED THE USE OF PARTOGRAPH

The partograph need not be used in all pregnant or laboring patients especially those
who are for cesarean delivery like those with malpresenting babies (breech or
transverse lie), those with scarred uteri, those with antepartum hemorrhage (like
placenta previa). It is also not needed in those who have to be delivered immediately
because of fetal distress or those with severe uncontrolled pre-eclampsia and
eclampsia. Likewise it may not be appropriate for those with twins or very premature
baby.
• Antepartum hemorrhage
• Severe Pre-eclampsia and eclampsia
• Fetal distress
• Previous CS
• Multiple pregnancy
• Malpresentation
• Premature labor
• Obstructed labor.
Recording the findings in the partograph
Start by labeling the record with pertinent patient identifying information.

Plotting the progress of labor

Plot only the CERVICAL DILATATION using the symbol “X”Start when woman is in ACTIVE
LABOR (4 cm or more) and is contracting adequately (3-4 contractions in 10 minutes)
You do not always have to start the plotting in the 4 cm line since not all patients are first
seen at this cervical dilatation. If the patient arrives at 6 cm cervical dilatation start
plotting in the 6 cm line but still in the alert line. If she is first seen at 8 cm, then start at
the 8 cm line but still on the alert line.
If plotting passes alert line …
Reassess woman and consider referral if facilities are not available to deal with obstetric
emergencies, unless delivery is imminent. Alert transport services and Monitor
intensively

If plotting reaches the action line… the patient must be already in an EmOC facility, a
decision made about the cause of slow progress, and appropriate action taken EmOC facility
is a hospital with capability for Emergency Obstetric Care.
Status of membranes
Write“ I ” if intact
If RUPTURED, note color of amniotic fluid,

write“ C ” if clear“
“M ” if meconium stained“
A ” if absent“
B ” if bloody

Mother’s BP, PR, Temp and Urine voided (yes or No) must be monitored [every 4
hours]

Monitor more frequently and record the fndings

( # of contractions in 10 minute period, and fetal heart rate, FHR in [1 full minute])

NOTE:
If woman is admitted in LATENT PHASE of labor (less than 4 cm dilated)
= record only other findings (BP, FHT, Temp, PR)

If she remains in LATENT PHASE for the [next 8 hours]

(labor is prolonged, transfer her to the HOSPITAL)