LABOR.
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.