Labor is defined as the process of expelling the fetus from the uterus through contractions of the uterus and cervix. It has four stages: 1) cervical dilation and effacement, 2) delivery of the fetus, 3) delivery of the placenta, 4) observation of the mother and baby. The first stage involves regular contractions that thin and open the cervix. The second stage involves pushing the baby through the birth canal in two phases. The third stage involves delivering the placenta, and the fourth involves post-delivery monitoring.

4. -Labor is defined as the process by which
a Viable fetus is expelled from the uterus. More
specifically, labor requires regular Contractions
that lead to dilation and effacement of the cervix.
-Labor is a physiologic process during which
the fetus, membranes, umbilical cord, and placenta
are expelled from the uterus.
-Normal labor describes the process of spontaneous expulsion of single, full
term, living fetus, presenting by the vertex, in occipito anterior position through normal
birth canal (Vagina), in not less than 3 hours and within 24 hours, without interference
rather than episiotomy and without any complications to the mother or the fetus.

5. -Precipitate deliveryrefers to childbirth after an
unusually rapid labor (combined 1st stage and second stage duration
is less than two hours) and culminates in the rapid, spontaneous
expulsion of the infant with a total time less than 3 hours. It can cause
maternal perineal laceration, PPH and intracranial fetal hemorrhage.
-Prolonged labor also known as failure to
progress, occurs when the (combined duration of the first
and second stage is more than the arbitrary time limit of
18 hours. It is not synonymous with inefficient uterine
contraction. As inefficient uterine contraction can be a
cause of prolonged labor, but labor may also be prolonged
due to pelvic or fetal factor.

6. Signs & symptoms of onset of labor:
*Lightening
Lightening is a term used to denote the descent of the
fetal head into the pelvis as labor approaches. It can occur
up to two weeks prior to the onset of labor, or it may not
occur at all. This diminishes the fundal height and hence minimizes the pressure on the
diaphragm. The mother experiences a sense of relief from the mechanical cardiorespiratory
embarrassment. Many women find it easier to breathe after lightening occurs because upward
pressure on the diaphragm diminishes but There may be frequency of micturition or
constipation due to mechanical factor—pressure by the engaged presenting part.
*Mucus plug
Release of the "mucus plug" can be another sign that labor is near. It is produced by
cervical glands normally blocks the entrance to the cervix and helps prevent infection. When
the fetal head impinges on the cervix, mucus plug stained with blood (Show) is expelled.

7. *Rupture of membranes
With the dilatation of the cervical canal, the lower pole of the fetal
membranes becomes unsupported and tends to bulge into the cervical
canal. As it contains liquor, which has passed below the presenting
part, it is called “bag of waters”. During uterine contraction with
consequent rise of intra-amniotic pressure, Spontaneous rupture of
the fetal membranes and clear amniotic fluid is often expelled from the vagina at that time.
Once this occurs, labor will generally ensue spontaneously. If it does not, induction of labor
may be necessary to avoid infection ascending upward through the vagina into the uterus.
*Contractions
Throughout pregnancy, painless Braxton Hicks contractions with simultaneous
hardening of the uterus occur. These contractions change their character, become more
powerful, intermittent and are associated with pain. Pain more often felt in front of the
abdomen or radiating toward the thighs. But these contractions are called false labor pain
which is significantly different from the true labor pain that is associated with labor.

9. True Labor Pain False Labor Pain
Regular Irregular
Increase progressively in frequency,
duration and intensity
Do not
Pain is felt in the abdomen and
radiating to the back
Pain is felt mainly in the abdomen
Progressive dilatation and effacement
of the cervix
No effect on the cervix
Membranes are bulging during
contractions
No bulging of the membranes
Not relieved by antispasmodics or
sedatives
Can be relieved by antispasmodics and
sedatives

10. Causes of onset of labor:
Estrogen theory:
Promotes the synthesis of myometrial receptors for oxytocin (by 100–200 folds),
prostaglandins, increase in gap junctions in myometrial cells and increase the
excitability of the myometrial cell membranes.
Progesterone withdrawal theory:
Before labor, there is a drop in progesterone synthesis, but there is alteration in estrogen :
progesterone ratio rather than the fall in the absolute concentration of progesterone.
Prostaglandins theory:
PGE2 and PGF2α in amnion & myometrium are powerful stimulators of uterine activity.
Oxytocin theory:
Oxytocin is a powerful stimulator of uterine contraction.
Fetal cortisol theory:
Increased cortisol production from the fetal adrenal gland before labor may influence its
onset by increasing estrogen production from the placenta.

12. Forces of labor
1-Uterine force:
It is the most important force of labor. It consists of contractions and retraction of the uterus
(Retraction means incomplete relaxation). The values of retraction are to: assist in dilatation
of the cervix, expulsion of the fetus and placenta also control of postpartum hemorrhage.
2-Auxiliary force:
It is the secondary force of labor. It consists of maternal voluntary bearing down through
strong repeated contractions of diaphragm and abdominal muscles, but these contractions
become involuntary when the fetal head stretch the pelvic floor.
3-Fetal axis pressure:
In labor with longitudinal lie and with flexed fetal head on the cervix, fetal vertebral column
is straightened by the contractions of the circular muscle fibers of the body of the uterus. This
causes mechanical stretching of the lower segment and dilatation of the cervical canal.

13. STAGES OF LABOR
-The First stage: It starts from the onset of true labor pain and ends with
full dilatation of the cervix. It is, in other words, the “cervical stage” of labor.
-The Second stage: It starts from the full dilatation of the cervix (not from the rupture of the
membranes) and ends with expulsion of the fetus from the birth canal. It has got two phases:
*Propulsive phase-from full dilatation up to descent of the presenting part to the pelvic floor.
*Expulsive phase-is distinguished by maternal bearing down efforts and ends with delivery
of the baby.
-The Third stage: It begins after expulsion of the fetus and ends with expulsion of the
placenta and membranes (afterbirths).
-The Fourth stage: It is the stage of observation for at least 1-2 hour after expulsion of the
after births. During this period maternal vitals and any vaginal bleeding are monitored.

14. The first stage (Cervical effacement and dilation)
-The first stage of labor and birth occurs with beginning of feeling
regular contractions, which cause the cervix to open (dilate) and
soften, shorten and thin (effacement). Initially, pains are not strong
enough to cause discomfort and come at varying intervals of
15–30 minutes with duration of about 30 seconds. But gradually
the interval becomes shortened with increasing intensity and
duration so that in late first stage the contraction comes at intervals
of 3–5 minutes and lasts for about 45 seconds.
-Effacement: is the process by which the muscular fibers of the cervix are pulled upward
and merges with the fibers of the lower uterine segment. The cervix becomes thin during
first stage of labor or even before that in primigravidae. In primigravidae, effacement
precedes dilatation of the cervix, whereas in multiparae, both occur simultaneously.

15. -LOWER UTERINE SEGMENT: Before the onset of labor, there is no complete
anatomical or functional division of the uterus. During labor, the demarcation of an
active upper segment and a relatively passive lower segment is more pronounced. The
wall of the upper segment becomes progressively thickened with progressive thinning of the
lower segment. This is pronounced in late first stage, especially after rupture of the
membranes and attains its maximum in second stage. A distinct ridge is produced at the
junction of the two, called physiological retraction ring.

16. -The first stage is the longest of the labor stages. It's divided into two phases of its own:
early labor (latent phase) and active phase.
*The latent phase → which is defined as period between the start of labor up until the
cervix is 4cm dilated. This latent phase tends to be slow, lasting an average of around 6
hours for primigravidae, and 4 to 5 hours for multiparous women.
*The active phase → is from 4cm of cervical dilation until the cervix is fully dilated
(10cm). During the active phase, it is expected that the cervix should dilate at least 1cm
an hour in women who are primigravidae. The cervix in multiparous women tends to
dilate more quickly (about 2cm/hr.).
-During the first stage of labor, the Midwife or Obstetrician will regularly do a vaginal
examination to assess how dilated the cervix is, how the baby is descending, and the
color of the amniotic fluid.

18. The Second Stage (Delivery of the fetus)
-The second stage begins with the complete dilatation of
the cervix and ends with the expulsion of the fetus. It can
last from 20 minutes to 2 hours in Primiparous while
less than 1 hour in multiparous women.
-With the full dilatation of the cervix, the membranes
usually rupture and there is escape of good amount of
liquor amni. The volume of the uterine cavity is thereby
reduced. Simultaneously, uterine contraction and retraction
become stronger. The uterus becomes elongated during
contraction, while the anteroposterior and transverse
diameters are reduced.

19. -The Second stage has two phases:
(1) Propulsive phase → from full dilatation until head touches the pelvic floor.
(2) Expulsive phase → since the time mother has irresistible desire to “bear down”
and push until the baby is delivered.
Cardinal Movements of Labor
Delivery of the head
*Descent:
It is continuous throughout labor particularly during the second stage and caused by:
-Uterine contractions and retractions.
-The auxiliary forces which is bearing down brought by contraction of the diaphragm and
abdominal muscles
-The unfolding of the fetus i.e., straightening of body especially after rupture of membranes.
*Engagement:
The head normally engages in the transverse diameter (70%) or oblique of the inlet.

20. *Flexion:
As the fetal chin is placed on the thorax & the occiput will meet the
pelvic floor. Flexion is essential for descent, since it reduces
the shape and size of the plane of the advancing diameter of the head.
*Internal rotation:
It is a movement of great importance without which there will be no further descent. Two
halves of levator ani form a gutter and viewed from above,
the direction of the fibers is backward and toward the midline.
-Thus, during each contraction, the head, occiput in particular,
in well-flexed position, stretches the levator ani, particularly
that half which is in relation to the occiput.
-After the contraction passes off, elastic recoil of the levator ani
occurs bringing the occiput forward toward the midline. The process
is repeated until the occiput is placed anteriorly. This is called rotation by law of pelvic floor.

21. Crowning → After internal rotation of the head, further descent occurs
until the subocciput lies underneath the pubic arch. At this stage, the
maximum diameter of the head (biparietal diameter) stretches the
vaginal orifice without any recession of the head (does not retract or
go back in) even after the contraction is over, This is called
“crowning of the head”, If the obstetrician decided to do episiotomy,
it should be done just before crowning.
*Extension:
The suboccipital region lies under the symphysis pubis then by head extension
the vertex, forehead and face come out successively.
The head is acted upon by 2 forces:
-The uterine contractions acting downwards and forwards.
-The pelvic floor resistance acting upwards and forwards,
so, the net result is forward direction i.e., extension of the head.

22. (Expulsion) Delivery of the shoulder and body
-The anterior shoulder hinges below the symphysis pubis and with further descent takes
place until the anterior shoulder escapes below the symphysis pubis first. By a movement
of lateral flexion of the spine, the posterior shoulder sweeps over the perineum.
Rest of the trunk is then expelled out by lateral flexion.
*Restitution:
After delivery, the head rotates 1/8 of a circle in the opposite
direction of internal rotation to undo the twist produced by it.
*External rotation:
The shoulders enter pelvis in opposite oblique diameter to that
previously passed by the head. When anterior shoulder meets
pelvic floor, it rotates anteriorly 1/8 of a circle. This movement is
transmitted to the head, so it rotates 1/8 of a circle in the same direction of restitution.

26. The third Stage (Delivery of the placenta)
-The third stage is the delivery of the placenta with its membranes.
-It is the shortest stage. The time it takes to deliver the
placenta can range from 5 to 30 minutes.
-It is composed of 3 phases: *Placental separation.
*Placental descent.
*Placental expulsion.
-The most reliable sign of Placental separation is the lengthening of the umbilical cord
as the placenta separates and is pushed into the lower uterine segment by uterine activity.
-The uterus takes on a more globular shape and becomes firmer.
-The uterus (fundal height) rises in the abdomen.
-A gush of blood occurs.

27. Management of the first stage of labor (in the hospital,
after admission)
*Monitoring of the fetal well-being (CTG, amnioscopy)
-Normal fetal heart rate ranges from 110 to 160 per minute
*Uterine contractions (by hand and/or by CTG)
as evaluation of the frequency, duration, and intensity
-Normal: 5 or fewer contractions in 10 minutes, averaged over a 30-minute window.

28. *Maternal vital signs (BP, Pulse, Temperature, Respiration)
*Subsequent vaginal examinations
*Oral intake but Food should be withheld
*Intravenous fluids (not necessary in all cases)
*Maternal position during labor
*Analgesia (intramuscular, TENS and/or epidural)
*Amniotomy
*Urinary bladder function

29. Management of the second stage of labor
*Spontaneous delivery
*Delivery of the head
*Crowning
*Episiotomy: If it is needed.
*Ritgen maneuver
*Controlled delivery of the head

30. *Delivery of the shoulders
*Gentle downward traction of the head
*The rest of the body almost always
follows the shoulder
*Clearing the nasopharynx
*Clamping and ligature of the umbilical cord
-Delay in clamping for 2–3 minutes or till
cessation of the cord pulsation facilitates
transfer of 80–100 mL blood from the
compressed placenta to the baby.

31. -Episiotomy, also known as
perineotomy.
*It is a surgical incision of the
perineum and the posterior vaginal
wall during childbirth generally done
by a midwife or obstetrician.
*Episiotomy is usually performed
during second stage of labor to
quickly enlarge the opening for the
baby to pass through.
*Its types: midline and mediolateral
approaches.

32. Management of the third stage of labor
*Spontaneous separation and descent of the placenta
*Gentle uterine massage during delivery of the placenta
*Manual removal of the placenta
*Controlled cord traction
*Active management of the third stage
*Oxytocin

33. Physical
Therapy
Role
During
Childbirth

34. Relaxation techniques:
*Relaxation techniques may relieve tension
and relax the involved muscle. These
techniques may also help relieve anxiety.
During labor it allows the body to function with
minimum energy and increases the pain
threshold.
*Diversion drill technique is one of the
best techniques that the mother actually
educated it during antenatal care is used during
the first stage to avoid bearing down to
prevent mother’s exhaustion.

35. Positions for first stage
Upright positions
-Standing: Leaning onto a bench top, ball or similar surface,
or the back of a chair, or leaning on a husband with hands
around their neck or waist for contractions may be helpful.
-Sitting: usually with the legs wide apart, leaning forward
with elbows on thighs. Alternatively, straddling a chair,
resting forward on pillows on the backrest, may be helpful,
especially to relieve back pain. Rocking chairs, or swaying
with the bottom on a large ball, may provide comfort.

36. -Kneeling: possibly with a pillow between the bottom and the feet and
leaning forwards onto a bed (hospital beds may have the head raised to lean
against) or chair seat.
-Walking around: it is helpful in-between uterine contractions although it
is important that the woman conserves her energy, so taking rests regularly
are encouraged and it is prevented if there is rupture of membranes.
Non-upright positions
-Four-point kneeling: in which the abdomen is hanging freely, and the
hips are over the shoulders. Weight may be taken alternately between the
hands and the forearms resting on a raised surface. This position has been
found to be appropriate for most women with epidural anesthesia.
-Side-lying: it is advised once the rupture of membranes is started
especially in hypertensive women, pillows between the legs for comfort.

37. Positions for second stage
Upright positions
-Partial sitting / half-lying: It is the most common position used during
childbirth; Trunk tilted backwards approximately thirty degrees to the vertical.
Pillows may be behind the knees, arms and back. During contractions, the
woman may brace by holding her knees and pulling up. The benefit of this
position is that the perineum can be easily visualized.
-Sitting: such as on a birth stool, with the legs wide apart and leaning forwards
with the arms supported on the thighs.
-Kneeling: on the bed or floor, leaning against a large pile of pillows, or
supported by the husband or catching the side rails of the hospital bed.

38. -Squatting: supported by the husband behind or a chair against the wall. The
woman should stand to rest between contractions. This may not be appropriate
for women who have had epidurals. This position helps the baby move into an
optimal position as gravity encourages movement, but it requires a strong and
elastic pelvic floor to decrease stress on the perineum from this position.
-Supported kneeling: It will open the pelvis wider than sitting or lying down,
and it may be a good position also through the 3rd stage to deliver the placenta.
Non-upright positions
-Side lying: also known as the lateral, or ‘Sims’ position, with an attendant
supporting the top leg. This is a good position for precipitate labor, as it is
gravity-neutral.
-Lithotomy position: Easy to check fetal heart rate and it makes assisted
delivery using forceps or vacuum extractor easier.

39. Breathing exercises
Benefits of breathing exercises:
*The mother remains in a more relaxed state and will respond more
positively to the onset of pain.
*The steady rhythm of breathing is calming during labor.
*Provides a sense of well being and control.
*Increased oxygen provides more strength and energy for both the mother and baby.
*Brings purpose to each contraction, making contractions more productive.
*Breathing exercises should be deep diaphragmatic breathing during the first stage
(during Uterine contractions) as a key for relaxation, deep intercostal breathing in the
Propulsive Phase of the second stage (Assisted with bearing down) to assist in expulsion of
fetus, then shifted to be shallow Painting sternal breathing at Crowning to prevent
bearing down to avoid perineal lacerations.

40. TENS
-When TENS is used for pain relief during labor, the electrodes are
applied to the lower back or to acupuncture points.
-It is an effective non-pharmacological, non-invasive adjuvant pain
relief modality for use in labor and delivery.
TENS application reduced the duration of the first stage of labor and
the amount of analgesic drug administered. There were no adverse
effects on mothers or newborns (Kaplan et al., 1998).
Kaplan et al., 1998: Transcutaneous electrical nerve stimulation
(TENS) for adjuvant pain-relief during labor and delivery. International
Journal of Gynecology and Obstetrics. 60(3):251-5.

41. APPLICATION of TENS during labor:
*During the first stage → the electrodes are frequently positioned on
the lower back on both sides of the spine at vertebral positions T10-L1
and S2-S4, corresponding to nerve pathways through which painful
impulses from contracting uterus are believed to enter the spinal cord.
The TENS apparatus emits low voltage impulses, frequency and
intensity of which can be controlled by woman in labor.
*During the 2nd stage → the distal electrodes (S2-S4) will be
transferred to anterior aspect of lower abdomen in a V-shaped
placement to relieve supra pubic pain.
*Frequency: 80-120 HZ
*Pulse width: 150 microseconds.
*Mechanism: Gate control theory

42. -Results from 17 studies show that there was little
difference in pain ratings between TENS and
control groups, although women receiving TENS
to acupuncture points were less likely to report
severe pain. There was some evidence (Low to
Moderate) that women using TENS were less
likely to rate their pain as severe.
(Dowswell et al., 2009): Transcutaneous electrical
nerve stimulation (TENS) for pain management in
labor. Cochrane Database Syst Rev.
-TENS produces a significant decrease in pain
during labor and postpones the need for
pharmacological analgesia for pain relief
(Santana et al., 2016).

43. Kinesio taping
-Kinesiotaping combined with deep breathing exercise is an effective
method in reducing labor pain and shortening the duration of the first
stage of labor (El-Refaye et al., 2016).
-Kinesio tape is a non‐pharmacological resource, significant
positive effects on pain sensation with no negative effects on perinatal
and neonatal variables would justify KT application during labor on
the vertebral regions corresponding to uterine dermatomes – from
T10 to L1 and from S2 to S4. Among the advantages of this technique
are its non‐invasiveness and its easy application; there is also no need
for constant monitoring, and it can be used concomitantly with other
alternative pain‐relief approaches (Miquelutti and Cecatti, 2017)

44. Heat and Cold therapy
-Intermittent local heat and cold therapy is a non- pharmacological,
safe and effective method to relief labor pain, The pain was significantly
lower in intervention group during the first and second phases of labor. Duration of the first &
third phases of labor was shorter in the intervention (heat & cold) group (Ganji et al., 2017).
-During the first stage, participants of intervention group received warm water pack with a
temperature of 38-40°C and covered with towel on their lower abdomen, and low back for 30
min. throughout contractions. Afterward, they received icepack covered with towel on the
same parts of the body for 10 m. Then, heat was used once more after 30 m, and this process
was repeated.
-During the second stage, these times were decreased to half, so warm water pack covered
with sterile towel was placed on patients’ perineum for 15 m. followed by icepack for 5 m.

45. -Localized heat and cold therapy are non-pharmacological, non-invasive, satisfactory
for the primiparous females, and effective methods to control and relieve pain during
labor without adverse effects on maternal and fetal outcomes (Yazdkhasti et al., 2018).
-Acupuncture may increase satisfaction with pain relief compared to
sham acupuncture (one trial, moderate-certainty evidence).
-It slightly reduced the use of pharmacological analgesia compared to
sham acupuncture (2 trials, 261 women, moderate-certainty evidence).
-Use of acupressure was associated with a reduction in pain intensity
in labor when compared to a combined control (2 trials, 322 women,
moderate-certainty evidence).
Smith et al., 2020: Acupuncture or acupressure for pain management
during labor. Cochrane Database of Systematic Reviews, Issue 2.
Acupuncture and Acupressure