Stages of Labor, Cervical Change & True vs False Labor Explained

Okay, first mini lecture for intrapartum content.  We are going to talk a little bit about different   um pieces of what we call labor and the different  stages and phases of labor and some of the   important assessments we do to determine what  stage andor phase patients are in. So to begin,  

what is labor? So how do we define when a  pregnant patient is in labor? So true labor   means that the patient is having contractions that  are occurring regularly, an increase in frequency,   so how often they occur, duration, how long  they last, and intensity, so how strong the  

contractions are. And not only do they have  to have contractions that are doing that,   the contractions have to cause cervical change in  the way of dilation or aacement. We're going to   talk about what each of those words mean, too. But  um if a patient is having contractions but their  

cervix is not changing then they are not truly  in labor yet. We can have pre-term contractions   that are not labor. Um we can also call that  false labor. So if they are having irregular   contractions um not to say that those contractions  can't be painful or uncomfortable um definitely  

noticeable but if they aren't truly changing the  cervix then uh true labor hasn't begun. And then   friendly reminder that rupture of membranes or  when the patient feels like their water breaks   um or lack of does not indicate whether the  patient is in labor or not. So just because  

their water has broken does not mean labor is  started. Um and just because their water has not   broken doesn't mean they can't be in labor. um  other important education points or how to tell   or how to explain to patients how to tell if they  are in labor or not because obviously they can't  

um and I guess some of them could but most of them  cannot check if their cervix is changing or would   not know how to. So true labor does not go away  when they go to sleep. Um if they were to drink a   lot of water and take a rest that the contractions  would not stop or go away or lessen in intensity.  

Um contractions can be caused by dehydration. Um,  but if if it goes away when they drink a lot of   fluids, then it wasn't true labor to begin with.  Um, or when they lay down to take a rest. So,   we we'd say those things because, you know, you  often hear like horror stories of women that are  

in labor for 20 hours and they're not progressing  or they're in labor for 5 days. Um, in many cases,   that is not an accurate representation. Um,  because yes, they may have been contracting,   but they weren't fully in labor, meaning making  cervical change. There are exceptions to the rule  

in which some women make progress very very  slowly and it can take an extensive amount of   time especially if they're being induced um early  for various reasons. Um but a lot of the time we   are just assuming that they are in labor in true  labor before they are. Uh so we want to be really  

careful when we start that labor clock we'll say.  So then we talk about what actually causes labor   to begin. Um and there's a lot of different uh  mechanisms and pathophysiological changes that   we know that um lead to the contraction piece.  Um oxytocin hormone very important um within the  

body and that also causes contractions to occur.  So when we talk about oxytocin as a medication,   we have natural oxytocin production within the  body and that stimulates uterine contractions.   Um we have a withdrawal of progesterone. um which  is like a drop in the levels of progesterone in  

the body that leads to an increase in estrogen and  sometimes that stimulates labor to begin. Uh there   is a pretty firm theory on uterine distension. So  once the uterus has been stretched to a certain   capacity that it will um contract as a reaction.  Uh this is the theory behind why women carrying  

multiples so twins, triplets etc tend to go into  labor sooner than women carrying a singleton   uh fetus just one. because with multiples the  uterus is distended in uh to an excessive more   amount than with just a singleton pregnancy and  that um is a theory as to why they often go into  

labor long before or at least weeks before uh  women who are carrying just one baby. There   is a prostaglandin um component as well that  is in the research meaning an increase um in   prostaglandins within the body or extra exposure  to prostaglandins um can cause labor to begin. So,  

with all of those theories in play and all of the  things that we know can kind of trigger different   pieces of labor, um the question always is, is it  something in mom or something in baby that leads   to which one, you know, chicken or the egg? Um  and we think really it's probably a combination  

of both. Um or for some patients, it might be  a combination of some factors and not all. Um   but it's really not an exact science as to oh,  this is the exact um change within the body that   leads to labor beginning. There are what we call  signs of approaching labor. So things that we tell  

patients to look for that when these things tend  to happen. Um usually labor is coming in the next   few weeks. It doesn't mean like within 24 hours  that they will start but within the next few weeks   labor is probably coming soon. Um so some of those  things they might have a burst of energy or what  

we call nesting. This is very common in the third  trimester, later in the third trimester. Um where   the pregnant woman feels like they have a lot  more energy than they have at baseline. They want   to clean and prep and pack and get things ready  um for the for the delivery of baby. Um primips,  

so first time pregnancies um will experience  something called lightning, which just means   that baby kind of drops in the pelvis um from  being held way up high where they feel like they   and usually the most um common report of this is  all of a sudden they feel like they can breathe  

easier. there's not as much pressure up on their  diaphragm um and because baby has dropped lower   into the pelvis and then they feel like they have  a little less pressure and can breathe better. So,   this is something commonly experienced by first  time pregnant women. This is not as frequently  

seen um in subsequent pregnancies. So, all that  means is after the body's done it once, they kind   of hold them up high until they go into labor  instead of letting them drop into the pelvis.   Um an increase in Braxton Hicks contractions. So,  we're going to talk um I have a demonstration in  

class that kind of uh helps you visualize what the  difference between true contraction and Braxton   Hicks contractions. Uh Braxton Hicks are what we  consider like practice contractions. So, they the   uterine muscle does tighten um and the patient can  usually feel them. They might be uncomfortable,  

but usually these are not typically what patients  uh report as uh painful. And they usually are um   sporadic, not rhythmic. They don't come every few  minutes like true contractions do. They're more   um they might have a couple and then they don't  have any more for a while or they feel them  

intermittently throughout the day. Uh we often see  what we call cervical ripening or softening of the   cervix. Um and this is noticeable by the examiner  when doing a cervical exam that they can tell that   that tissue is softening and preparing to open and  dilate. Um and patients might begin dilation. So  

it is completely possible for a patient to be 2  3 4 cm dilated and not actually be in labor. Um   especially with multi moms who have had vaginal  deliveries before. That is very common. Um so   remember for true labor we have to have both  things occurring at the same time. Dilation and  

um progressive contractions or well changes in the  cervix and pro progressive contractions. Um so if   all we have is dilation of facement alone and the  patient isn't actively contracting, we don't start   that labor clock for that either. just gives them  a better starting point for um when labor does  

occur or if they were induced. Um pregnant moms  often see like a 1 to three pound weight loss in   the weeks just prior to pregnancy. Um that is not  um always noticeable depending on how closely the   woman is tracking their weight. Um they might  see the loss of their mucus plug. Um this is  

the mucus is essentially within the in inner o  of the cervix um that builds up as a protective   barrier throughout pregnancy to keep everything  on the outside out. Um and as the cervix ripens   or softens or might begin to dilate they might  uh women will report that they they go to the  

bathroom and all of a sudden they see it on the  toilet paper or in the toilet um that there's just   this little clump of mucus um and that's their  mucous plug and sometimes that comes out. That   doesn't mean that everything is open. and there's  still an amniotic membrane holding in all the  

fluid and protecting baby. Um, as as long as their  membranes haven't ruptured. Um, so it doesn't mean   that like it's happening right now, but again,  it could still mean labor's a couple weeks away,   but many moms experience that prior to labor  beginning. Um, and then they can have spontaneous  

rupture of membranes. Again, it doesn't mean if  their water breaks that labor is automatically   going to start, but a lot of times if it does,  that is the that is the progression. Um, so they   might have their water break at home and that's  what brings them in. The biggest thing we tell  

patients to note um if they do have they feel like  their water breaks in their home or out wherever,   not with us in the hospital, is to know what time  their water breaks and what color the fluid is.   Um that's going to give us some information  that we use um used to predict any risk or  

best care for them. So what if you know it's not  labor? Because sometimes moms will come into the   hospital thinking they're in labor, they're  having contractions, they want to get checked   out. Um and sometimes it's not. Or sometimes they  feel like their water has broken and we check in.  

it wasn't it wasn't amniotic fluid, maybe they had  a little incontinence, it's urine, it's whatever.   Um it can be vaginal discharge, etc. Uh so if it's  not labor, we want to first validate the patient's   concerns cuz we never want them to not come seek  help if if they need it. We'd rather them show up  

and it be nothing than for them to ignore it and  it be something. Um so we validate those concerns   and then we we reinforce the education. If they  start having um contractions that progressively   get closer together, longer, stronger, come in to  be checked out. If they have ruptured membranes,  

we want them to come to the hospital. Um  regardless if they're experiencing contractions   or not, that's an automatic please come in and let  us check you. Um if they have vaginal bleeding,   um bright red, any amount is not to be assumed  normal. Um so we always tell them to come get  

checked out if they experience vaginal bleeding  while they're pregnant. Um and then any reports of   decreased fetal movement. This is a big red flag  warning sign um for patients who are pregnant,   especially past the 20we mark. Um we the only  person who subjectively knows how much the baby  

moves is the mom that's carrying baby. Um and if  they say that baby hasn't been moving or is moving   less than they feel like their normal baseline  is, we should take that assessment very seriously   and we want them to come get checked out. Um  decreased fetal movement can indicate hypoxia. Um,  

and we want to have them come in, let us get baby  on the monitor, check and make sure the baby looks   like they're doing okay. Um, because that can be  an indicator that something is not right and we   want to address that immediately. So, those are  the things that we tell patients to come back in  

for. Even if they come in and we turns out they're  not in labor and we have to send them home, um,   we still reiterate those points for when they need  to come in. So when we look at um the cervical   change piece. So we said we get a cervical change  for um to rule somebody into labor there are three  

assessments that we get when we do a sterile  vaginal exam or an SV cervical assessment. Um   and that is dilation easement and station. And  we always keep those assessment pieces in that   order. So we have three numbers and they're always  in the same order. We don't mix them up. So we all  

everybody always knows which ones we're talking  about. So dilation is how open the cervix is.   So it goes from completely closed, nothing can fit  inside to c 10 cm which we consider fully dilated.   So for reference 10 cm is roughly the size of like  a large fulls size bagel. Um easement is how thin  

the cervix is. So we we don't call it 0% but we  do measure easement in percentage. We say thick   is like it's not thinned at all. Um up to 100% or  completely aaced. And again, I have some visuals   that will help um help your brain understand  what this looks like um when we get to class.  

And then station is the reference of the fetal  presenting part. So, we hope that's the head,   but if it's their booty cuz they're breach or uh  shoulder or knee or whatever, if they're in a in a   non ideal position, whatever that presenting part  of baby is in the birth canal um in regards to the  

issial spines. So again, we always keep these  numbers in the same order. Dilation, easement,   station. Just to give kind of a representation  here. This is what we're talking about when we're   talking about fetal station or whatever baby's  presenting part is into the mother's pelvis. So  

when we do a vaginal um exam, a sterile vaginal  exam for a cervical assessment, we can feel on   mom's pelvis her isial spines of her pelvis. And  that's where we consider zero for once baby's   presenting part has made it to the isial spines.  We rank that as a zero for fetal station. And that  

tells us that baby is far enough down the birth  canal well enough engaged that nothing else is   going to fit out around baby except for leg fluid.  And that is important because we don't want the   umbilical cord for instance to come out before  baby's head or presenting part. So once we get  

to zero, we know that we're well engaged in  the pelvis. Um and that's a positive sign for   a vaginal delivery if baby can get that far down.  So um for example if uh the sterile vaginal exam   for a patient was 350 and minus 2 that would mean  mom's cervix is 3 cm dilated or open 50% thinned  

out or a faced and baby's presenting partly head  is at -2 station which for this one here would be   all the way up here which means they're not fully  engaged in the pelvis yet. Um, and those those are   what those numbers would mean. And we're going to  talk through that more um in class and kind of put  

some context to those numbers. For labor itself,  labor is divided into four stages. And then the   first two stages have different phases, but we're  going to start with just the stages. So the first   stage you can think of as the dilation piece. So  while mom is contracting, while mom is in labor,  

we are making our way through that dilation in  the basement. The latent phase is up to 5 cm and   then the active phase is 6 cm or more. Um so in  the latent phase, mom is probably experiencing   contractions but they are um either not regular,  they're coming at irregular increments um between  

as far as frequency or they're not super super  long in duration. Maybe they're 45 seconds,   maybe a little more, maybe a little less. Um, and  the intensity of those contractions is not what   they would consider, you know, really moderate  to severe super painful. They can notice they're  

having them. They're probably uncomfortable. They  can usually still talk um, converse through them.   They can breathe through them. They're comfortable  up moving around. Um, that's what we call the   latent phase of the first stage. Once they get  into that active phase, that active labor pattern,  

the contractions are um, closer together, last  a little bit longer, stronger, more painful. Um,   and that's when we have that 6 centimeters or  more, we're really working our way through um,   dilation in a facement. Moms are probably more  uncomfortable, more in pain, far less likely  

to be able to converse through while they're  having contractions. Um, and then we have this   transition phase is the 8 to 10 cm and that is  just kind of underneath the active phase itself.   Some moms don't experience fully the transition.  Not that they don't get to 8 to 10 centimeters.  

They don't experience subjectively what that  transition phase um encompasses. So um moms who do   not have an epidural or any type of anesthesia uh  usually experience transition pretty aggressively,   pretty intensely. Um moms with an epidural may or  may not exhibit those subjective signs at all. Um  

and we'll talk a little bit more about what that  looks like in class. So the first stage is all   of the labor portion the dilation getting to 10  cm which puts us to the second stage which is   the delivery of baby. So after we achieve full  dilation and a facement and um the patient is  

ready to start pushing delivering for baby. Um  so the second stage is from the time we get to   full dilation a facement until the birth of  baby. The third stage then is after delivery   of baby through when we deliver the placenta.  We need that placenta delivered and that should  

ideally take less than 30 minutes. Um usually it's  a little quicker. And then the fourth stage is the   postpartum recovery period. So that is like the 2  hours generally after the delivery of the placenta   where we are establishing that mom is stable  and recovering well from birth before they are  

considered like a normal postpartum patient.  So those are the four stages and those don't   change. They're all they're all those four stages  very clearly outlined. We know what starts one,   what ends one, how we move through. And then we  talk about I said we have different phases for the  

first and second stages. And we talked a little  bit about the first FA uh first stage phases.   The latent up to 5 cm and then that active is 6  cm or more. Contractions are stronger, longer,   closer together, more uncomfortable for mom. at  uh 8 to 10 centimeters, moms might experience what  

we call transition, especially if they don't have  any um epidural or anesthesia, anything on board.   Um and that looks really specific. And usually we  only note that because if a mom does not have an   epidural and they are experiencing those symptoms,  um that is our cue, our indication that like we  

need to make sure number one that we have all  of our team in place for delivery because it's   probably happening pretty quick uh soon after.  And then we want to make sure that by the time mom   starts pushing that she is fully dilated in a face  so that we're not going to cause any damage to the  

cervix. Um because sometimes they can feel the  urge to push right before they reach that 10 cm   and we don't want them to um cause any trauma to  the cervix by pushing too soon. So we want to make   sure she is fully dilated and that we have all um  team members in place that we need to um achieve a  

safe delivery. The second stage phases, the latent  phase means the patient is fully dilated. So   they've reached 10 centimeters, fully a faced um  but they haven't yet begun to push. Usually this   is only um able to be achieved with moms who have  an epidural in place. Um, and I say usually cuz  

there's exceptions to every rule, but for the most  part, if a mom does not have an epidural and can   feel fully um, her labor once she's 10 cm, it's  almost an involuntary urge to push that will occur   um, with the pain of contraction. So, the latent  phase, this is also um, often referred to as like  

letting a patient patient labor down. So, somebody  with an epidural and they're fully dilated,   but they're pretty comfortable still, and we sit  them up and help like use gravity to kind of get   baby down into the birth canal really engage. Let  the uterus do its job without mom exert exerting  

any extra um energy or effort to push. And then  the active phase is we we're fully dilated and   we are pushing. So again, we kind of have these  two two little caveats that like if a patient has   an epidural, they might not subjectively  feel the transition kind of phase. Um,  

and if they don't have an epidural, they might not  really get much of that latent phase of the second   stage because the pain of contractions um, and  the automatic reaction of their body um, usually   leads to pushing whether it's voluntary or not.  And so that is the end of the the mini lecture  

for our normal interpartum. Um and we'll pick up  looking at these various different um pieces and   a lot of hands-on examples and demonstrations in  class so you guys can really get some context for   what what all of these words and numbers mean.  Um and then we will go from there after that.