Stages of Labor & Leopold’s Maneuver

First Stage: Dilating Stage

― Begins with the onset of true labor contractions to full dilatation of the cervix.
― Divided into 3 phases:

1. Latent (preparatory) Phase – from the onset of true labor contractions to 3cm cervical
dilatation.
- contractions every 10-20 minutes progressing to every 5-7 minutes; duration of 15 to 30
seconds; 30-40 seconds.
- nulliparas: 6 hours; multiparas: 4.5 hours
2. Active Phase – starts from 4cm to 7cm cervical dilatation
- intensity is stronger, interval shortens (3-5 mins), and duration lengthens (50-60
seconds)
- patient is dependent and is focused on herself.
3. Transition Phase – starts from 8cm cervical dilatation to 10cm (full) cervical dilatation and
full cervical effacement.
- contractions every 2-3 mins, duration of 60 to 90 seconds, strong intensity.
Second Stage: Stage of Expulsion
• starts when cervical dilatation reaches 10 cm and ends when the baby is delivered.
• At this stage, the patient feels an uncontrollable urge to push.
• The patient may also experience temporary nausea together with increased restlessness and
shaking of extremities.
• EDFIREERE
Mechanisms (Cardinal movements) of Labor
E – Engagement
D – Descent
F - Flexion
IR – Internal rotation
E - Extension
ER – External rotation
E – Expulsion
Third Stage: Placental Stage
• starts from birth of infant to delivery of placenta.
 • It is divided into two separate phases: placental separation and placental expulsion.
• Five minutes after delivery of baby, the uterus begins to contract again, and placenta starts to
separate from the contracting wall.
• Blood loss of 300-500 mL occurs as a normal consequence of placental separation.
• Placenta sinks to the lower uterine segment or upper vagina. The placenta is then expelled using
gentle traction on the cord.
Signs of placental separation:
• Lengthening of umbilical cord
• Sudden gush of vaginal blood
• uterus – firm & globular in shape– Calkin’s sign
• Firm uterine contractions
• Appearance of placenta in vaginal opening
Mechanism of Placental separation
1. Mathew-Duncan Mechanism

― The leading edge of the placenta separates first and the placenta is delivered with its raw surface
exposed
―

2. Schultz mechanism
― If the placenta is inserted at the fundus and central area separates first, the placents inverts and
draws the memranes after it, covering the raw surface (inverted umbrella)
―

Fourth Stage: Recovery

• For immediate postpartum,
• the nurse checks the vital signs and monitors for excessive bleeding.
• The first four hours after birth is sometimes referred to as the Recovery stage of labor because
this is the most critical period for the mother.
 • The nurse is set to perform nursing interventions that would prevent the patient from infection
and hemorrhage. Also, they are being reminded of the importance of breastfeeding, ambulation,
and newborn care.

Leopold’s Maneuver
• Are a systematic method of observation and palpation to determine fetal position, presentation,
lie and attitude. It is preferably performed after 24 weeks gestation when fetal outline can be
palpated.
• CARDINAL RULE: instruct woman to empty bladder first.
THE 4 MANEUVERS
1. FIRST MANEUVER: Fundal grip – what fetal part occupies the fundus (cephalic or breech)
- head will be round and hard and groove of the neck may be felt. Breech has no groove
and feels more angular.
2. 2ND MANEUVER: Umbilical grip – which side is the fetal back
-small fetal pats like extremities feel nodular and fetal back feels smooth and firm.
3. 3RD MANEUVER: Pawlik’s grip – to determine if the presenting part is engaged (between
thumb and the 2 fingers of one hand)

4. 4TH MANEUVER: Pelvic grip – which side is the cephalic prominennce (flexion/extension)
- If cephalic prominence is on the same side as the small fetal parts, the head is flexed. If
cephalic prominence is on the same side as the fetal back, the head is extended.
LABOR
• The process by which the fetus and products of conception are expelled as the result
of regular, progressive,
frequent, and strong
uterine contractions.
 An involuntary physiologic process whereby the contents of the gravid uterus are expelled
through the birth canal into the external environment
Signs & Symptoms of Labor
1. LIGHTENING
- the descent of the fetus and
uterus into the pelvic cavity
2 to 3 weeks before the onset
of labor
2. BRAXTON HICKS contraction
are irregular, intermittent
contraction that have occurred
throughout the pregnancy,
becomes uncomfortable, and
produce a drawing pain in the
abdomen and groin
3. CERVICAL CHANGES include
softening, “ripening”, dilation and effacement
of the cervix that will cause
expulsion of the mucus plug
(bloody show) and increase vaginal
discharge
 4. RUPTURE of amniotic membrane may occur before the onset of labor, if suspect that her
membranes have ruptured, she have to contact health care provider, should be examined for
prolapsed cord (a life threatening condition of the fetus)
5. Burst of energy -“nesting
Instinct” and fatigue may
occur right before the onset
of labor
 due to an increase in epinephrine that is initiated by decrease in progesterone produced by the
placenta.
 6. Weight loss of about 1 to 3
 lbs. may occur 2 to 3 days
 before the onset f labor
 7. Urinary frequency returns
 8. Cramps and Backache
 - muscles and joints are
 stretching in preparation
 for childbirth.

Components of Labor/ Factors that affect the Labor and Birth

5 P’s of Labor
1. Passenger
2. Passageway
3. Power
4. Position
5. Psyche

1. Passenger – Fetus
• The way the passenger or fetus moves through the birth canal is determined by:
 Size of the fetal head
 Fetal presentation
 Fetal lie
 Fetal attitude
 Fetal position
2. Power
• The involuntary and voluntary powers combine to expel the fetus and the placenta from the
uterus.
• Involuntary contractions originate at a “pacemaker” point located in the myometrium;
• contractions move downward over the uterus in waves separated by short rest periods.

3. PASSAGEWAY
• Includes the bony pelvis, the soft tissues of the cervix, and the vagina.
• refers to the adequacy of the pelvis and birth canal in allowing fetal descent.
• The maternal pelvis is the greatest determinant in the vaginal delivery of the fetus.
4. POSITION OF THE WOMAN
> Frequent changes in position relieves fatigue, increase comfort and improve circulation.
 Upright position like walking, sitting, kneeling, and squatting are preferred.
  Gravity promotes descent of the fetus. It is beneficial to the mother’s cardiac output, that
improves blood flow to the uteroplacental unit and maternal kidneys.
5. PSYCHE
• psychological state or feelings that the woman brings into labor and her response.
• A feeling of apprehension or fright.
• The progress of labor and birth can be adversely affected maternal fear and tension.
Mechanisms (Cardinal movements) of Labor
• A series of adaptations the fetus makes as it moves through the maternal bony pelvis during the
process of labor & birth.
• Passage of Fetus through the birth canal involves position changes called Cardinal movements
of Labor.
• E – Engagement
• D – Descent
• F - Flexion
• IR – Internal rotation
• E - Extension
• ER – External rotation
• E - Expulsion

Engagement
• Largest diameter of the fetal head passes through the pelvic inlet
• Fetal head reached the level of the ischial spine , known as zero station

Descent
• Downward movement through the pelvic inlet through dilated cervix, reaches posterior vaginal
wall .
• Assessed by measurements called stations.
• Ranges from –3 to +3 station.
• STATIONS = based on an imaginary scale that uses the ischial spines of the maternal pelvis as
its reference point.
• Ischial spines are located at the narrowest diameter of the pelvis.
• The space above and below the ischial spines is divided into 3 levels.
• The presenting part is designated –3 if unengaged and +3 if fully crowning.
• Crowning = a term used to describe the visualization of the biparietal diameter of the fetal head
at the vaginal introitus.
Flexion
• The head bends forward onto the chest, making the smallest anteroposterior diameter presented
to the birth canal.
• Also aided by abdominal muscle contraction during pushing.
Internal rotation
• Rotation of the fetal head until the longest diameter of the fetal head match the longest diameter
of the maternal pelvis.
• The head flexes as it touches the pelvic floor, and the occiput rotates until it is superior toward
the symphysis pubis.
Extension
• As the occiput is born, the back of the neck stops beneath the pubic arch and acts as a pivot for
the rest of the head. The head extends and the foremost part of the head, the face and chin were
born.

Expulsion
• The shoulder and the remainder of the body are delivered