Stages of Labor and Normal Progression

Labor Kick-off - The Grand Opening

• Labor: Process; rhythmic uterine contractions cause progressive cervical effacement (thinning) & dilatation (opening), leading to fetal & placental expulsion.
• True Labor (📌 3 P's):
  • Painful, regular contractions: ↑ frequency, duration, intensity.
  • Progressive cervical changes: Effacement (0-100%), dilatation (0-10 cm).
  • Persistent: Not relieved by rest or simple analgesia.
  • Show (mucus plug, blood-tinged).
  • Rupture of Membranes (ROM).
• False Labor (Braxton Hicks): Irregular, short contractions; no cervical change; relieved by rest/hydration.
• Onset Theories:
  • Uterine stretch/distension.
  • Functional progesterone withdrawal.
  • ↑ Estrogen dominance (↑ oxytocin receptors, gap junctions).
  • ↑ Prostaglandins (PGE2, PGF2α): cervical ripening, myometrial contractility.
  • ↑ Oxytocin release & sensitivity.
  • Fetal HPA axis maturation (cortisol surge). oka

Stage One - Dilatation Station

• True labor pains → full dilatation (10 cm).
• Phases: Latent & Active.

Latent Phase (0 → <6 cm):

• Effacement & early dilatation.
• Contractions: Mild, irregular → stronger, frequent.
• Prolonged: P > 20 hrs, M > 14 hrs.

Active Phase (≥6 cm → 10 cm):

• Rapid dilatation.
• Rate: P ≥ 1.2 cm/hr; M ≥ 1.5 cm/hr.
• Contractions: Regular, strong (3-5/10 min, ≥45s).
• Descent starts.
• Protraction: Dilatation < P 1.2 cm/hr, M 1.5 cm/hr.
• Arrest: No change ≥ 4h (good ctx) or ≥ 6h (poor ctx).
• Monitoring: Partograph, FHR (Fetal Heart Rate).

Stage Two & Three - Delivery Double Bill

Stage Two: Fetal Expulsion

• Starts: Full cervical dilatation (10 cm). Ends: Complete fetal delivery.
• Duration (Max):
  • Primigravida: 2 hrs (extends to 3 hrs with epidural).
  • Multigravida: 1 hr (extends to 2 hrs with epidural).
• Cardinal Movements (📌 Every Darn Fool In Egypt Eats Raw Eggs): Engagement, Descent, Flexion, Internal Rotation, Extension, Restitution (External Rotation), Expulsion.

  ⭐ McRoberts maneuver (maternal thigh hyperflexion onto abdomen) is a primary intervention for shoulder dystocia.

• Episiotomy: Mediolateral common; consider for fetal distress, operative vaginal delivery, prior severe tear.

Stage Three: Placental Delivery

• Starts: After fetal delivery. Ends: Complete placental & membrane expulsion.
• Duration: Normally 5-15 min; prolonged if >30 min (risk of PPH).
• Signs of Placental Separation:
  • Sudden gush of blood.
  • Apparent lengthening of umbilical cord.
  • Uterus becomes globular, firm (Calkin's sign) & rises.
• Active Management (AMTSL) reduces PPH:
  • Oxytocic (e.g., Oxytocin 10 IU IM/IV) with anterior shoulder or post-delivery.
  • Controlled Cord Traction (CCT).
  • Uterine massage after placental delivery.

Stage Four & Partograph - Monitor & Map

• Stage Four (Immediate Postpartum): First 1-4 hours post-placental delivery.
  • Monitor: Uterine tone (firm at umbilicus), lochia (amount, color), vital signs (BP, pulse).
  • Assess perineum, bladder.
  • PPH risk: >500 mL (vaginal), >1000 mL (LSCS).
  • Promote bonding, breastfeeding.
• Partograph (WHO Modified): Graphical labor monitoring tool.
  • Aim: Early detection of dystocia & prolonged labor.
  • Components: 📌 Fetal condition, Labor progress, Maternal condition (FLM).
  • Labor Progress:
    • Cervical dilatation vs. time.
    • Alert Line: Vigilance.
    • Action Line: 4 hrs right of alert; intervention if crossed.
    • Active phase dilatation: ≥1 cm/hr (primi), ≥1.5 cm/hr (multi). ​

High‑Yield Points - ⚡ Biggest Takeaways

• First stage: Latent (0-6cm) & Active (6-10cm). Active phase: Primi ≥1.2cm/hr, Multi ≥1.5cm/hr dilatation.
• Second stage: Full dilatation to fetal expulsion. Duration: Primi up to 3hrs, Multi up to 2hrs (with epidural).
• Third stage: Placental expulsion, typically <30mins. Signs: cord lengthening, blood gush, fundal rise.
• Fourth stage: First hour postpartum; critical for PPH monitoring.
• Key Dystocias: Prolonged latent phase (>20h P, >14h M); Active phase arrest (no change ≥4h, adequate contractions).