Stages of normal labor- easy explanation for Nursing Students(B.Sc & GNM)... Introduction, definition of normal labor, definition of normal labor by WHO, Mechanism of labor, stages of labor, Intrapartum management of Labor, pain control.

1. STAGES OF NORMAL
LABOR
SWATILEKHA DAS
(RN,MSN)

2. INTRODUCTION
Labor is a physiologic process during which the
products of conception (i.e, the fetus, membranes,
umbilical cord, and placenta) are expelled outside of
the uterus. Labor is achieved with changes in the
biochemical connective tissue and with gradual
effacement and dilatation of the uterine cervix as a
result of rhythmic uterine contractions of sufficient
frequency, intensity, and duration.

3. DEFINITION OF NORMAL LABOR
The onset of labor is defined as regular, painful uterine
contractions resulting in progressive cervical effacement
and dilatation. Cervical dilatation in the absence of uterine
contraction suggests cervical insufficiency, whereas uterine
contraction without cervical change does not meet the
definition of labor.

4. DEFINITION OF LABOR BY WHO
The World Health Organization (WHO) defines
normal birth as "spontaneous in onset, low-risk
at the start of labor and remaining so
throughout labor and delivery. The infant is born
spontaneously in the vertex position between
37 and 42 completed weeks of pregnancy.

5. MECHANISM OF LABOR
• The mechanisms of labor, also known as the cardinal
movements, involve changes in the position of the
fetus’s head during its passage in labor. These are
described in relation to a vertex presentation. Although
labor and delivery occurs in a continuous fashion, the
cardinal movements are described as the following 7
discrete sequences :
• Engagement
• Descent
• Flexion
• Internal rotation
• Extension
• Restitution and external rotation
• Expulsion

7. STAGES OF LABOR

8. 1. FIRST STAGE OF LABOR
• Begins with regular uterine contractions and ends
with complete cervical dilatation at 10 cm
• Divided into a latent phase and an active phase
• The latent phase begins with mild, irregular uterine
contractions that soften and shorten the cervix
• Contractions become progressively more rhythmic
and stronger
• The active phase usually begins at about 3-4 cm of
cervical dilation and is characterized by rapid
cervical dilation and descent of the presenting fetal
part

10. 2. SECOND STAGE OF LABOR
• Begins with complete cervical dilatation and
ends with the delivery of the fetus
• In nulliparous women, the second stage should
be considered prolonged if it exceeds 3 hours if
regional anesthesia is administered or 2 hours in
the absence of regional anesthesia
• In multiparous women, the second stage should
be considered prolonged if it exceeds 2 hours
with regional anesthesia or 1 hour without it

12. 3. THIRD STAGE OF LABOR
• The period between the delivery of the fetus and the
delivery of the placenta and fetal membranes
• Delivery of the placenta often takes less than 10 minutes,
but the third stage may last as long as 30 minutes
• Expectant management involves spontaneous delivery of
the placenta
• The third stage of labor is considered prolonged after 30
minutes, and active intervention is commonly considered
Active management often involves prophylactic
administration of oxytocin or other uterotonics
(prostaglandins or ergot alkaloids), cord clamping/cutting,
and controlled traction of the umbilical cord

14. HISTORY TAKING
The initial assessment of labor should include :
• Frequency and time of onset of contractions
• Status of the amniotic membranes (whether
spontaneous rupture of the membranes has
occurred, and if so, whether the amniotic fluid is
clear or meconium stained)
• Fetal movements
• Presence or absence of vaginal bleeding.

15. POINTS TO REMEMBER WHILE HISTORY TAKING
Braxton-Hicks contractions must be differentiated from true
contractions. Typical features of Braxton-Hicks contractions are
as follows:
• Usually occur no more often than once or twice per hour, and
often just a few times per day
• Irregular and do not increase in frequency with increasing
intensity
• Resolve with ambulation or a change in activity
Contractions that lead to labor have the following
characteristics:
• May start as infrequently as every 10-15 minutes, but usually
accelerate over time, increasing to contractions that occur
every 2-3 minutes
• Tend to last longer and are more intense than Braxton-Hicks
contractions
• Lead to cervical change

16. PHYSICAL EXAMINATION
The physical examination should include :
• Maternal vital signs
• Fetal presentation
• Assessment of fetal well-being
• Frequency, duration, and intensity of uterine
contractions
• Abdominal examination with Leopold maneuvers
• Pelvic examination with sterile gloves

17. Digital examination
Digital examination allows the clinician to determine the
following aspects of the cervix:
• Degree of dilatation, which ranges from 0 cm (closed or
fingertip) to 10 cm (complete or fully dilated)
• Effacement (assessment of the cervical length, which can
be reported as a percentage of the normal 3- to 4-cm–long
cervix or described as the actual cervical length)
• Position (ie, anterior or posterior)
• Consistency (ie, soft or firm)
• Palpation of the presenting part of the fetus allows the
examiner to establish its station, by quantifying the
distance of the body (-5 to +5 cm) that is presenting
relative to the maternal ischial spines, where 0 station is in
line with the plane of the maternal ischial spines.

18. INTRAPARTUM MANAGEMENT
OF LABOR

19. 1. FIRST STAGE OF LABOR
On admission to the Labor and Delivery suite,
a woman having normal labor should be
encouraged to assume the position that she
finds most comfortable. Possibilities including
the following:
• Walking
• Lying supine
• Sitting
• Resting in a left lateral decubitus position

20. 1. FIRST STAGE OF LABOR
Management includes the following:
• Periodic assessment of the frequency and
strength of uterine contractions and changes
in cervix and in the fetus' station and position
• Monitoring the fetal heart rate at least every
15 minutes, particularly during and
immediately after uterine contractions; in
most obstetric units, the fetal heart rate is
assessed continuously

21. 2. SECOND STAGE OF LABOR
• With complete cervical dilatation, the fetal heart
rate should be monitored or auscultated at least
every 5 minutes and after each contraction.
• Prolonged duration of the second stage alone
does not mandate operative delivery if progress
is being made, but management options for
second-stage arrest include the following:

22. 2. SECOND STAGE OF LABOR
Continuing observation/expectant
management
• Operative vaginal delivery by forceps or
vacuum-assisted vaginal delivery, or cesarean
delivery.
Vacuum assisted delivery

23. DELIVERY OF THE FETUS
• Positioning of the mother for delivery can be any
of the following :
• Supine with her knees bent (i.e., dorsal lithotomy
position; the usual choice)
• Lateral (Sims) position
• Partial sitting or squatting position
• On her hands and knees
• Episiotomy used to be routinely performed at
this time, but current recommendations restrict
its use to maternal or fetal indications

24. DELIVERY MANEUVERS ARE AS FOLLOWS:
• The head is held in mid position until it is delivered,
followed by suctioning of the oropharynx and nares
• Check the fetus's neck for a wrapped umbilical cord, and
promptly reduce it if possible
• If the cord is wrapped too tightly to be removed, the cord
can be double clamped and cut
• The fetus's anterior shoulder is delivered with gentle
downward traction on its head and chin
• Subsequent upward pressure in the opposite direction
facilitates delivery of the posterior shoulder
• The rest of the fetus should now be easily delivered with
gentle traction away from the mother
• If not done previously, the cord is clamped and cut
• The baby is vigorously stimulated and dried and then
transferred to the care of the waiting attendants or placed
on the mother's abdomen

25. 3. THIRD STAGE OF LABOR
The following 3 classic signs indicate that the
placenta has separated from the uterus :
• The uterus contracts and rises
• The umbilical cord suddenly lengthens
• A gush of blood occurs
Delivery of the placenta usually happens within 5-
10 minutes after delivery of the fetus, but it is
considered normal up to 30 minutes after delivery
of the fetus.

26. 3. THIRD STAGE OF LABOR
Excessive blood loss during this period or immediately
thereafter can be prevented by giving oxytocin,
which is a drug that makes the womb contract to
close the blood vessels in the placenta and helps it
separate from the wall of the uterus.
Control Of Postpartum Uterine Bleeding
• Intravenous infusion (drip method). If the patient
has an intravenous infusion running, 10 to 40 units
of oxytocin may be added to the bottle, depending
on the amount of electrolyte or dextrose solution
remaining (maximum 40 units to 1000 mL)
• Intramuscular administration

27. 4. PAIN CONTROL
Agents given in intermittent doses for systemic
pain control include the following :
• Meperidine, 25-50 mg IV every 1-2 hours or 50-
100 mg IM every 2-4 hours
• Fentanyl, 50-100 mcg IV every hour
• Nalbuphine, 10 mg IV or IM every 3 hours
• Butorphanol, 1-2 mg IV or IM every 4 hours

28. 4. PAIN CONTROL
• Morphine, 2-5 mg IV or 10 mg IM every 4
hours
• As an alternative, regional anesthesia may be
given. Anesthesia options include the
following:
• Epidural
• Spinal
• Combined spinal-epidural