Physiology of Labor and Delivery

Rean Jean Tener Barrientos, 16 years old, had delivered to a baby boy last
November 25, 2009. She was admitted due to labor pain at 7:15 pm.

The fetus then was delivered ten minutes after at 7:25 pm, and the placenta was
at 7:30 pm.

Labor is defined as a series of events by which the product/s of conception is/are

expelled as the result of regular progressive, frequent and strong uterine contractions. It
includes the components—5 P’s.

The first P is the passenger or the fetus who came to be Baby Johan. He
weighed 2.53 kilograms and aged 37-38 weeks.

Passageway is the second P. It refers to the mother’s pelvis, cervix and vagina.
Since Rean did not undergo any prenatal check-up, there is no record of her pelvic
measurement which can assess cephalopelvic disproportion. Moreover, at this age, it is
expected that her pelvis is not fully mature and incapable of delivering a macrosomic
baby safely.

The powers is the third P. This is the mother’s ability to push. The length of
normal labor varies from Primi’s to Multi’s. Since Rean was a primigravida woman, the
usual dilatation stage occurred only for 12 ½ hours. Expulsion stage happens for 80
minutes and the placental stage for 10 minutes.

The fourth P is Psyche. This is the mother’s psychological condition during labor.
Rean had some degree of hesitation describing her feelings about the delivery process.
She only described it as ‘not painful. Also, she could not remember if she was given
general or epidural anaesthesia.
 The fifth and the last P is Position. Only fetuses at the position of occiput anterior
whether left or right are allowed to be expelled by means of NSVD.

Stages of Labor:

DILATATION / EFFACEMENT STAGE

Early or Latent Labor Phase

During phase 1 (latent phase) the cervix is at a dilation of around 1 – 4 cm.

Contractions occur every 5 – 20 minutes with duration of 15 – 30 seconds and are of
mild intensity. Amniotic membranes may be intact.In phase 1 the mother is very chatty
and excited to be in labor. She is cooperative and alert. She welcomes diversions. The
mother and father should be an active part of the care in this phase. Comfort is of the
utmost importance, mother should seek assistance with changes in position and
walking. Mother should also drink lots of fluids or ice chips. Voiding every 1 – 2 hours is
important at this point. This is because of the occurrence of urinary frequency and thirst.
Review breathing and relaxation techniques and assess fetal heart tone.

Active Labor Phase

In the active phase of stage 1 the cervix is dilated to 4 – 7 cm. Contractions take
place every 2 – 5 minutes with duration of 40 – 60 seconds and are of moderate
intensity. The mother becomes restless and anxious and because of this may have
feelings of helplessness. Mother is introverted and less social. She commonly perspires
and facial flushing is observed. She may need epidural anaesthesia at this time. For this
reason it is important to keep the mother’s breathing pattern effective, keep the room as
quiet as possible. Mother and father should be kept informed of the progress. Comfort
measures used in this phase include back rubs, sacral pressure, support with pillows,
and changes in position. Effleurage or Swedish massage should be done by the
husband; medical staff can show him what to do. Mother can use ointment for dry lips
and continue to drink fluids or ice chips and should void every 1 – 2 hours.

Transition Labor Phase

During the transition phase the cervix is dilated to 8 – 10 cm.

Contractions are occurring every 2 – 3 minutes with duration of 60 – 90 seconds and
are of strong intensity. At this point the mother has become exhausted, is edgy and
irritable, and feels out of control. The mother should rest between contractions to
conserve energy. Mother should be awakened at beginning of a contraction so she can
begin her breathing pattern. Continuing fluid intake or ice chips and voiding every 1 – 2
hours is important.
STAGE OF EXPULSION

Dilation of the cervix is complete—exactly 10 cm. The progress of this stage of

labor is measured by the changes in fetal station, which means the descent of the
baby’s head through the birth canal. Contractions occur every 2 – 3 minutes with
duration of 60 – 80 seconds and the intensity continues to be strong. The mother will
feel and urge to bear down and the medical staff will assist the mother in her efforts to
push. An increase in bloody show will occur. The vital signs of the mother are
important to monitor at this point. The baby’s heart rate will be monitored before,
during, and after a contraction or every 5 minutes. The normal heart rate of a baby is
120 – 160 beats a minute. Mother should be helped into positions of comfort and that
assist in her efforts to push such as side-lying, squatting, kneeling, or lithotomy. The
bulging of the mother’s perinea area or seeing the baby’s head are signs the birth is
about to occur. Episiotomy is done for the delivery of the fetus. Episiotomy is an incision
into the perineum and vagina to enlarge the vaginal opening for the delivery of the fetus
and to protect the surrounding muscle and fascia from tears.
EXPULSION OF PLACENTA

Prior to the third stage of labor, the baby had already been born. Stage 3 is the
delivery of the placenta. Mild to moderate intermittent contractions will continue until the
placenta is born. The placenta separates from the wall and natural removal occurs by
uterine contractions. The birth of the placenta takes place 5 – 30 minutes after the birth
of the baby. There are two different mechanisms of birth of the placenta that can
happen; they are “Dirty Duncan” or “Shiny Schulze’s”. For Duncan’s mechanism the
margin of the placenta separates, and the dull, red, and rough maternal surface
emerges from the vagina first. For Schulze’s mechanism the center portion of the
placenta separates first, and its shiny fetal surface emerges from the vagina. Signs of
placental separation are as follows: lengthening of the cord, uterine fundus rises and
becomes firm, fresh blood expelled from vagina and contraction of uterus to size of a
grapefruit. The mother has her vital signs and uterine fundus location checked. The
fundus, at this point, is located 2 fingerbreadths below the umbilicus. The placenta will
be checked for the presence of cotyledons, to make sure none of the placenta is
missing, including making sure that the placenta membranes are intact. Mother may
begin to shiver do to a decrease in body core temperature, provide blankets to warm up.
Medical staff should promote baby-mother attachment.
RECOVERY STAGE

The fourth stage of labor is the time from 1 to 4 hours after birth in which
physiologic readjustment of the mother’s body begins. With the birth hemodynamic
changes occur. Blood loss at birth ranges from 250 – 500 mL. With this blood loss, and
the weight of the pregnant uterus off the surrounding vessels, blood is redistributed into
venous beds. This results in a moderate drop in both systolic and diastolic blood
pressure, increases pulse pressure and moderate tachycardia.

The uterus remains contracted and is in the midline of the abdomen. The fundus
is usually midway between the symphysis pubis and umbilicus. Its contracted state
constricts the vessels at the site of the placental implantation. Immediately after birth of
the placenta the cervix is widely spread and thick. Nausea and vomiting the woman may
have experienced during transition usually cease. The woman may be thirsty or hungry.
She may experience a shaking chill, which is thought to be associated with the ending
of the physical exertion of labor or a thermoregulation response. Lochia rubra saturates
perineal pad. And the mother may have shaking chills that may be a thermoregulation
response. The bladder is often hypotonic due to trauma during the second stage and/or
the administration of anesthetics that may decrease sensations. Hypotonic bladder
leads to urinary retention. This stage is also the ‘get-acquainted period between woman,
partner and infant. Breastfeeding begins now.

Description of Rean Jean’s Delivery:

a.) Patient placed at dorsal lithotomy position

 ® The lithotomy position is the best and the easiest for performing obstetric
interventions, including maintaining sterility, monitoring fetal heart rate,
administering anesthetics, and performing and repairing episiotomies.

b.) Vaginal Preparation done and drapings applied

® In the delivery room, the perineum is washed and draped to maintain sterility.

c.) Infiltration of local anesthesia on the perineum

® Local anesthetics are commonly used. This drug pass through the placenta;
thus, during the hour before delivery, such drug should be given in small doses to
avoid toxicity in the neonate.

d.) Median episiotomy

® Episiotomy prevents excessive stretching and possible tearing of the perineal

tissues, including anterior tears. The incision is easier to repair than a tear.

e.) Delivered to a live full term baby boy in cephalic presentation via (spontaneous)
delivery, with clear and separate amount of amniotic fluid, cord coil.

® A vaginal examination is done to determine position and station of the fetal

head; the head is usually the presenting part. When effacement is complete and
the cervix is fully dilated, the woman is told to bear down and strain with each
contraction to move the head through the pelvis and progressively dilate the
vaginal introitus so that more and more of the head appears. When about 3 or 4
cm of the head is visible during a contraction in nulliparas (somewhat less in
multiparas), the following maneuvers can facilitate delivery and reduce risk of
perineal laceration.

f.) Repair of 2nd degree Median episiotomy with atrumic chronic 2.0/ viryl rapid with
continuous interlocking suture at vaginal wall. Simple, interrupted at the perineal
floor, skin-subcuticular.
 ® Inspection of the episiotomy is done and the extent of the wound is assessed.
Careful inspection includes matching up of land marks (such as the hymenal
tags). Assessment includes determination of damage. A second degree tear or
incision has damage beyond the fourchette, into the muscle tissue but not
involving the rectum or anal sphincter. Locating and finding the apex of the
incision and the matching sides. Repair of the episiotomy is achieved by closure
of the vaginal wall, interrupted sutures into the levatores ani, and interrupted
sutures to the skin. Care is taken to expose the apex of the incision in the vaginal
wall and a continuous absorbable suture is used to close the vaginal wall.
The wound is closed to the introitus. Care is taken to ensure that the introitus is
not constricted. Interrupted absorbable sutures are inserted into the levatores
ani. Interrupted mattress sutures are used to close the skin.

g.) Bleedings checked and ligated.

® For the first hour after delivery, the mother should be observed closely to make
sure the uterus is contracting (detected by palpation during abdominal
examination) and to check for bleeding, BP abnormalities, and general well-
being.

h.) Procedure terminated.