=First Stage.=—The first stage extends from the time of the labor
pains to the complete dilatation of the os uteri. It may come on very
slowly or act quickly. Slow dilatation occurs normally in a woman over
thirty years of age; and it may be due to inflammatory conditions or
appear in cases where the membranes lining the uterus are adherent. On
examining the vagina there is found a bulging (which is a main factor
in dilatation of the cervix) and a discharge of mucus tinged with
blood. The dilatation increases until it is 4 in. across, and the bag
of membranes bulges like a saucer. In abnormal cases it comes down into
the vagina in the shape of a tube. When the os is fully dilated the
membranes rupture, a rush of water escapes down the vagina, and the
first stage of labor is ended. Not all of the water comes away, for the
head comes down and acts as a plug. It is very important for the nurse
to recognize the true rupture and not mistake it for incontinence of
urine.
=Second Stage.=—This comprises the period from the time of complete
dilatation of the cervix to the end of the expulsion of the child. The
patient has some relief after the first stage, and when the second
stage comes on she holds her breath and contracts the abdominal muscles
as much as she can in making expulsive efforts. The pains become of
longer duration and more frequent; and upon examining the vagina the
head is found down, the tissues bulge, the rectum becomes stretched,
the majora and minora separate, and then, while the pain is on, there
is some change in the position of the head as it recedes and advances
again. Nature brings it slowly, for if the head plunged down it might
produce complete laceration of the perineum. If the head is delayed
too long there is swelling of the scalp. The most painful period is
when the head passes the perineum. Then there comes a marked change in
the position of the fetus, and it lies in that position for some time;
following, comes a rotation to one side, the shoulders turn, and birth
occurs. The cord is still in the vagina, and the third stage begins
with a flushing of amnii fluid. The placenta is still in place in the
uterus. The child may cry, and the pulsation may continue in the cord
for as long as fifteen minutes, but ordinarily for about five minutes,
while a new circulation is established in the infant and more blood is
drawn from the placenta.
=Third Stage.=—The patient has a rest for some minutes. Then the
contractions of the uterus continue until the membranes and placenta
are expelled. The pains begin again; the uterus is smaller, firm,
yet will recoil; it is rounded, and the fundus lies even with the
umbilicus. If the fundus is above the umbilicus something is wrong.
Painful contractions of the uterus follow and cause a squeezing off of
the placenta. There is a flow of blood, the placenta follows, passes
out of the vagina, dragging the membranes after it. The fundus sinks,
and the uterus, hard, contracted and firm, lies in the pelvis. In some
cases it becomes soft, rises up and then relaxes. If it becomes too
soft, the relaxation which follows may induce hemorrhage. The uterus
should be carefully massaged until it hardens.
=Period of Labor.=—Fourteen hours is a normal range. First stage
usually lasts about twelve hours; second stage about one hour, and the
third stage from fifteen to thirty minutes.
=Complications of Labor.=—Labor may be brought on by extreme mental
anxiety. The child may be born without any actual pain. It may be
expelled while the patient has an evacuation of the bowels, especially
if the bowel movement has been induced by enemata or a purgative.
Children may be born without the usual progression of labor, yet with
all normal conditions present. In cases where the mother dies during
labor the uterus continues to contract until the child is born about
fifteen minutes later. The child in such cases is sometimes saved by a
Cesarean section.