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NCBI Bookshelf. Labor is the process through which a fetus and placenta are delivered from the uterus through the vagina.
The first stage is further divided into two phases. Successful labor involves three factors, which include maternal efforts and uterine contractions, fetal characteristics, and pelvic anatomy. Serial cervical examinations are used to determine cervical dilation, effacement, and fetal position, also known as the station.
Fetal heart monitoring is employed nearly continuously to asses fetal well-being throughout labor. Cardiotocography is used to monitor the frequency and adequacy of contractions.
Medical professionals use the information they obtain from monitoring and cervical exams to determine the stage of labor of the patient and to monitor labor progression. Women will often self-present to obstetrical triage with concern for the onset of labor. The patient should be placed on continuous cardiotocographic monitoring to ensure fetal wellbeing. The patient's prenatal record, including obstetric history, surgical history, medical history, laboratory, and imaging data, should undergo review.
Finally, a history of present illness, review of systems, and physical exam, including a sterile speculum exam, will need to take place.
During the sterile speculum exam, clinicians will look for signs of rupture of membranes such as amniotic fluid pooling in the posterior vaginal canal. If the clinician is unsure about whether or not a rupture of membranes has occurred additional testing such as pH testing, microscopic exam looking for ferning of the fluid, or laboratory testing of the fluid can be the next step.
A sterile gloved exam should be done to determine the degree of cervical dilation and effacement. Effacement is measured by estimating the percentage remaining of the length of the thinned cervix compared to the uneffaced cervix. During the cervical exam, confirmation of the presenting fetal part is also necessary. Bedside ultrasound can be employed to confirm the presentation and position of the fetal presenting part. Particular mention should be noted in the case of breech presentation due to its increased risks regarding fetal morbidity and mortality compared with the cephalic presenting fetus.
Labor is a natural process, but it can suffer interruption by complicating factors, which at times necessitate clinical intervention. The management of low-risk labor is a delicate balance between allowing the natural process to proceed while limiting any potential complications. Clinicians monitor fetal heart tracings to evaluate for any signs of fetal distress that would warrant intervention as well as the adequacy or inadequacy of contractions.
Vital signs of the mother are taken at regular intervals and whenever there is a concern for change in clinical status. Laboratory testing often includes the hemoglobin, hematocrit, and platelet count and are sometimes repeated following delivery if significant blood loss occurs.
Cervical exams are usually performed every 2 to 3 hours unless concerns arise and warrant more frequent exams. Frequent cervical exams are associated with a higher risk of infection, especially if a rupture of membranes has occurred. Women should be allowed to ambulated freely and change positions if desired. Oral intake should not be withheld. If the patient remains without food or drink for a prolonged period of time intravenous fluids should be considered to help replace losses, but do not need to be used continuously on all laboring patients.
The first stage of labor begins when labor starts and ends with full cervical dilation to 10 centimeters. Thus, defining the onset of labor often relies on retrospective or subjective data. Friedman et al were some of the first to study labor progress and defined the beginning of labor as starting when women felt significant and regular contractions.
Based on the analysis from his labor graphs, he proposed that labor has three divisions. First, a preparatory stage marked by slow cervical dilation, with large biochemical and structural changes. This is also known as the latent phase of the first stage of labor. Second, a much shorter and rapid dilational phase, which is also known as the active phase of the first stage of labor. Third, a pelvic division phase, which takes place during the second stage of labor. The first stage of labor is further subdivides into two phases, which are defined by the degree of cervical dilation.
The latent phase is commonly defined as the 0 to 6 cm, while the active phase commences from 6 cm to full cervical dilation. The presenting fetal part also begins the process of engagement into the pelvis during the first stage.
Throughout the first stage of labor, serial cervical exams are done to determine the position of the fetus, cervical dilation, and cervical effacement. Cervical effacement refers to the cervical length in the anterior-posterior plane. When the cervix is completely thinned out and no length is left, this is referred to as percent effacement. When the bony fetal presenting part is aligned with the maternal ischial spine, the fetus is 0 station. During the latent phase, the cervix dilates slowly to approximately 6 centimeters.
The latent phase is generally considerably longer and less predictable with regard to the rate of cervical change than is observed in the active phase. A normal latent phase can last up to 20 hours and 14 hours in nulliparous and multiparous women respectively, without being considered prolonged. Active labor with more rapid cervical dilation generally starts around 6 centimeters of dilation.
During the active phase, the cervix typically dilates at a rate of 1. Multiparas, or women with a history of prior vaginal delivery, tend to demonstrate more rapid cervical dilation. The second stage of labor commences with complete cervical dilation to 10 centimeters and ends with the delivery of the neonate. This was also defined as the pelvic division phase by Friedman. After cervical dilation is complete, the fetus descends into the vaginal canal with or without maternal pushing efforts.
The fetus passes through the birth canal via 7 movements known as the cardinal movements. These include engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. In parturients without neuraxial anesthesia, the second stage of labor typically lasts less than three hours in nulliparous women and less than two hours in multiparous women.
In women who receive neuraxial anesthesia, the second stage of labor typically lasts less than four hours in nulliparous women and less than three hours in multiparous women.
Several elements may influence the duration of the second stage of labor including fetal factors such as fetal size and position, or maternal factors such as pelvis shape, the magnitude of expulsive efforts, comorbidities such as hypertension or diabetes, age, and history of previous deliveries. The third stage of labor commences when the fetus is delivered and concludes with the delivery of the placenta. The function of the stages of labor is to create a universal definition that can be used by medical professionals to communicate with each other about labor.
The stages of labor can be used to help determine where the patient is on the labor spectrum. Clarifying the stages of labor has helped create guidelines, which define normal and abnormal trends in labor. Clinical management also gears toward the various stages of labor. Complications may arise during any of the stages of labor to result in abnormal labor.
During the first stage, women may experience the arrest of parturition, necessitating cesarian delivery, which may carry greater maternal or fetal risk. Second stage complications include a variety of complications related to the trauma of the delivery process to either the fetus or the mother.
The fetus can suffer acidemia, shoulder dystocia, bony fractures, nerve palsies, scalp hematomas, and anoxic brain injuries. Similarly, the mother can develop a host of traumatic complications ranging from uterine rupture, vaginal laceration, cervical laceration, uterine hemorrhage, amniotic fluid embolism, and death.
The third stage of labor may encounter complications by hemorrhage, cord avulsion, retained placenta, or incomplete removal of the placenta. Defining the stages of labor with a specific beginning and end has allowed clinicians to study labor trends and to create labor curves.
For example, in the s, Dr. Friedman created a graphical representation of the rate of normal labor during latent and active labor using observed clinical data. Friedman observed that labor typically has a sigmoidal shape when measured by cervical dilation over time. During the active phase of labor, cervical dilation occurs at a rate of 1 centimeter or more per hour. If dilation occurs much slower, the patient may be at risk for abnormal labor or arrest of labor. The findings of Dr. Friedman have recently been challenged, and the current consensus is the normal latent phase of labor lasts longer than was previously observed.
Also, specific interventions are tailored to particular stages of labor to try to create better patient outcomes. For example, active management in the third stage of labor is carried out by placing immediate traction on the umbilical cord and administering intravenous oxytocin, which correlates with a lower risk of postpartum hemorrhage.
The stages of labor describe a complex physiologic process that starts when labor beings and ends with the delivery of the fetus and placenta.
Labor is usually monitored clinically with multiple modalities by an interprofessional team. The process of labor can proceed as typically expected with certain cardinal events and time parameters or can encounter complications and delays, which may require identification and medical intervention.
The role of the interprofessional team in monitoring and caring for women during labor is critically important in keeping women safe and improving outcomes during the labor process. Close communication is needed between these professionals to create an atmosphere of safety and patient-centered care.
Midwives often manage labor and delivery and work closely with physicians when complications arise that may require physician intervention such as Caesarian section or operative delivery. Pharmacists ensure that patients receive the proper analgesics, tocolytics, and other medications that may be needed during or following labor. Anesthesiologists and nurse anesthetists administer epidurals for analgesia and are available for general endotracheal anesthesia when necessary. Each labor is unique, but an interprofessional approach prenatally and during labor can be used to improve patient outcomes and provide patient-centered care, as each provider class works collaboratively to ensure communication lines remain open between different disciplines on the health care team [Level 5].
A Canadian retrospective cohort study of women found that an interprofessional team approach to obstetrical care was shown to provide better patient outcomes by decreasing the rate of cesarian sections and length of hospital stays for women. Nurses are intimately involved in monitoring and caring for laboring women. Nurses administer and titrate medications during labor such as oxytocin. Nurses monitor the vital signs, pain scores, and labor progression of women and fetuses closely and are responsible for recognizing and then notifying physicians and midwives when abnormalities arise.
This book is distributed under the terms of the Creative Commons Attribution 4. Turn recording back on. National Center for Biotechnology Information , U. StatPearls [Internet]. Search term. Affiliations 1 Kaiser Permanente School of Medicine. Introduction Labor is the process through which a fetus and placenta are delivered from the uterus through the vagina.
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