Professor Razia Mustafa Abbasi

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Normal Labour

• Professor Razia Mustafa Abbasi

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Labour

• It is the process by which regular pain full
  uterine contraction bring about effacement and
  dilatation of cervix and decent of presenting
  part leading to explosion of the fetus and
  placenta from the mother

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Labour can occur at
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Normal labour

• Spontaneous expulsion, through the natural
  passages (birth canal) of a single, mature (37-42
  completed weeks of pregnancy) alive fetus,
  presenting by vertex, within a reasonable time,
  without fetal or maternal complications.

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• Physiology of labour
• Mechanical theories - uterine distension
• Hormonal theories
• Maternal
• progesterone withdrawal
• oxytocin stimulation
• prostaglandins
• serotonin
• fetal
• fetal cortisol
• fetal membranes
• Neuronal factors
• sympathetic- alpha receptor stimulation

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• STAGE OF LABOUR.

• STAGES OF LABOUR
• I-The First stage stage of cervical effacement
  and dilatation
• Definition the first stage of labour refers to
  the period from the onset of true uterine
  contractions to the fully dilation of the cervix,
  when the diameter of the cervical os measures
  10cm.

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• Duration
• primigravida 8-12 h
• multigravida 6-8 h
• Phases of the first stage
• Latent phase started when the cervix dilatated
  slowly and reached to about 3cm.
• in primigravida 8h
• in multigravida 4h
• - Active phase rapid dilatation of the cervix to
  reach 10cm
• in primigravda 4h
• in multigravida 2h

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• The active phase is divided into
• Accelerative phase
• Slopping phase
• Decelerative
• prolonged active phase
• primary dysfunction dilation in active phase
  oflt1cm/hr
• secondary arrest active phase dilation stops or
  slow significantly.
• N.B in primigravida the cervix dilates from
  above downwards, in multigravida dilatation of
  the internal os, taking up of the cervix and
  dilatation of the external os occurs
  simultaneously.

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• Factors affecting cervical dilatation
• Contraction and retraction of the uterus.
• The bag of fore-water.
• Absence of membranes.
• Fitting of the presenting part to the lower
  segment and the cervix.
• Pre-labour changes in the cervix (eg, softening)

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• II-The Second stage of labour
• stage of delivery of the fetus.
• Definition the second stage of labour refers to
  the period from complete cervical dilatation to
  the birth of the fetus.
• Duration
• in primigravida 1 h
• in multigravida ½ h
• however the timing of the second stage is very
  different to determine and controversial and can
  be extended as much as there is progress in
  descent and no harm to the mother or fetus

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• The second stage of labour had two phases
• Passive phase stage of descent of the
  presenting part and dilatation of the vagina
  due to contraction and retraction of the uterine
  muscle.
• Expulsive phase stage of bearing down due to
  contraction and retraction of the uterine muscle
  and voluntary efforts by diaphragm and abdominal
  muscles.

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A-Delivery of the fetal head
Enter the
pelvis by flexion

Engagement

Increased
flexion
Internal
rotation DESCENT
Crowning


Extension

Restitution

External rotation

Delivery of the fetal head B-Delivery of the
shoulder and body
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• Mechanism of labour in vertex presentation
• Definition The spontaneous adjustments of the
  fetal position and attitude to affect efficient
  passage of the fetus through the pelvis, marked
  by progressive descent until delivery of the
  fetus.
• Delivery of the fetal head
• A- Descent is a continuous movement throughout
  the process of delivery, however it becomes more
  rapid in the second stage of labour, it is caused
  by
• -Uterine contraction and retraction.
• -bearing down effort mainly in the second stage
  of labour

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• In normal pelvis, the fetal head enters with the
  sagittal suture in the transverse diameter (or
  occasionally oblique diameter of the brim). If
  the sagittal suture in between the symphysis
  pubis and sacral promontory both parietal bones
  are felt vaginally at the same level the head
  is said to be (synclitic). In such case the
  biparietal diameter (9.5cm) is the diameter of
  engagement. However some degree of lateral
  inclination of the head over the shoulder
  (Asynclitism) is present normally as the head
  enters the pelvic inlet.

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• If the sagittal suture lies close to the sacrum
  and the anterior patietal bone lies over the
  inlet (Anterior parietal bone presentation) -
  Anterior asynclitism.
• If the sagittal suture lies close to the
  symphysis pubis and the posterior parietal bone
  lies over the inlet (posterior parietal bone
  presentation) posterior asynclitism.

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• Increased flexion
• As the head descends, it meets resistance from
  the pelvic walls and floor and this leads to
  increased flexion of the head. As the head flexed
  it brings the shortest longitudinal diameter of
  the head (sub-occipito-bregmatic 9.5cm) to pass
  through the birth canal. Flexion is explained by
  the (two armed lever theory).

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• D-Internal rotation
• The internal rotation occurs as the head descends
  through the pelvic cavity. As the head enters the
  pelvic inlet in transverse diameter will rotate
  3/8 of the cycle to pass through the pelvic
  outlet in antero-posterior diameter.
• The rotation is favoured by the slopping shape of
  the pelvic floor, angling the leading point of
  the head (occiput) in downward and forward
  direction, by the effect of the contraction and
  retraction of the uterus.

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• E-Crowning, extension and delivery of the fetal
  head
• The combined effect of descent and internal
  rotation bring the presenting diameter to the
  plane of the pelvic outlet, with the occiput
  lying under the pubic arch and the sinciput at
  the lower border of the sacrum or coccyx.
• When the widest diameter of the fetal head is
  embraced by the distended vulva, it is said to be
  crowned.
• The occiput remains under the pubic arch but the
  sinciput sweeps forwards as the neck extends.

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• The head is acted upon by
• The downward and forward force of the uterine
  contraction and retraction.
• The upward and forward force offered by pelvic
  floor resistance so the head passes forwards i.e.
  extends vertex, forehead, and face come out
  successively.
• Frequently, especially in primigravida, the soft
  tissues are not able to distend equally so that
  tearing of the perineum and adjacent tissues may
  occur unless steps are taken to avoid it by
  making a formal incision (episiotomy).

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• F-Restitution and external rotation
• Following delivery of the head the occiput
  rotates to the lateral position, in the opposite
  direction of internal rotation to correct the
  twist of the head on the shoulders produced by
  internal rotation. The internal rotation of the
  shoulders inside the pelvis transmitted to the
  delivered head which in turn move one eight of a
  circle outside the pelvis, in the same direction
  as that of the restitution, so at the end the
  occiput is towards one thigh and the face is
  towards the other thigh.

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• Delivery of the shoulder and body
• The widest diameter of the shoulders,( the
  bi-acromial diameter), pass the pelvic brim at
  the time when the anterior rotation of the head
  is occurring. Thus the anterior rotation of the
  occiput is favourable for both the head and the
  shoulders. Similarly external rotation of the
  head is associated with rotation of the shoulders
  to bring them into the antero-posterior diameter
  of the outlet. With further descent, the anterior
  shoulder delivered first from under the pubic
  arch, followed by posterior shoulder, during
  which time lateral flexion of the trunk is
  occurring. The trunk and buttocks follow with the
  same or the next contraction.

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• Even in the course of normal delivery, there are
  many variations of the mechanisms, dependent on
  the variation in the size and shape of the pelvis
  and of the fetal head.
• III-The Third stage of labour the stage of
  expulsion of the placenta and membranes.

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• Duration up to 30 minutes, however the average
  length of the third stage of labour is 10
  minutes.
• Mechanism the third stage is made of two phases
• The first phase phase of placental separation
  occurs through the spongiosa layer of the decidua
  at the time of expulsion of the baby or very soon
  afterwards. The shearing force responsible for
  the separation is the contraction and retraction
  of the uterus, reducing the uterine volume and
  the area of the placental site, as the fetus is
  expelled.

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• The second phase phase of placental expulsion
  The separated placenta descends from the upper
  (active) segment into lower (passive) uterine
  segment, cervix, and vagina by two mechanisms
• -Schultze mechanism(80)
• The placenta delivered as an inverted umbrella
  with its fetal surface presenting first followed
  by the membranes with retro-placental haematoma.
• Mattews Duncan mechanism (20)
• The placenta delivered side way and it presents
  with its inferior surface first.

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Issues in the management of labour

• Review of antenatal record if available
• Diagnosis of labour
• Non engagement of presenting part
• Problems of first stage
• Problems of second stage
• Problem of third stage
• Contraception
• Breast feeding

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High risk pregnancy

• Agelt20 or gt35
• Parity Primigravida or Grand multipara
• Previous obstetric out come and mode of delivery
• Any medical disorder hypertension/ diabetes
• /epilepsy/autoimmune disorder
• Any obstetric problem in previous pregnancy
  difficult delivery/ instrument delivery
  /PPH/Perineal tears

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• Diagnosis
• symptoms
• True labour pains colicky pain in the abdomen
  and back are characterized by

False labour pain True labour pain character
Irregular regular contractions
Short duration, not progressive Progressive (increase in frequency and intensity) Interval between contractions and intensity
Not associated with effacement and dilation of the cervix Associated with effacement and dilation of the cervix Changes in the cervix
Not associated with bulging of membranes Associated with bulging of membranes Membranes
Relieved by sedation Not relieved by sedation Response to analgesia
Not followed by labour Followed by labour Labour
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• Causes of non-engagement
• Erroneous dates (primigravida)
• Extra-uterine
• full bladder or loaded rectum
• Pelvic tumours
• Pendulous abdomen and marked lumbar lordosis.
• High angle of inclination of the pelvis.
• Contracted pelvis.
• -Uterine
• Poor uterine tone.
• Congenital deformities.
• Fibromyomata.
• Placenta previa.

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• -Fetal
• polyhydramnios.
• Short umbilical cord(acutal or relative, due to
  entanglement)
• Large baby.
• Deflexion attitude, and malposition.
• Multiple pregnancy.
• Hydrocephalus.
• Engagement can be assessed by abdominal station
  in fifths during antenatal period, and by
  abdominal and vaginal stations during labour.

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Partogram - Maternal

• Name / DOA /Gestation
• Medical / Obstetrical issues
• HR / BP/ Temp
• Urinanalysis

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Partogram - Fetal

• Fetal heart rate
• Colour of liquor
• Moulding

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Moulding of the skull

• means obliteration of the suture line between the
  bones and overlapping of the un-united bones of
  the fetal skull, and is measured by degree.

Degree Clinical finding
Suture line closed, no overlap Overlap of suture line reducible Overlap of suture line irreducible
As the degree of moulding increase- means there
is CPD
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Partogram - Progress

• Uterine contractions
• Cervical dilatation
• Descent of presenting part
• Caput / Moulding
• Fetal position

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FRIEDMANS CURVE
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Problem of first stage
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Problem of first stage
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Problem of second stage
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What can go wrong?

• Powers
• Poor contractions/Maternal effort
• Passages
• Small pelvis/Pelvic shape
• Passenger
• Big baby/Presentation/Malposition

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Abnormal powers

• Artificial rupture of membranes
• Oxytocin infusion
• Change position
• Encouragement
• Review after four hours if no improvement refer
  for operative delivery.

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Problem in passenger/pelvis

• Refer for operative delivery if there is problem
  with passenger/ passage
• Passenger
• Good size baby
• Malpresentation
• Malposition
• Congenital abnormalities
• Multiple pregnancies

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Problem in passenger/pelvis

• Contracted pelvis
• CPD
• Congenital abnormalities of pelvis

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Problem of third stage

• Post partum haemorrhage
• Retained placenta
• Morbidly adherent placenta
• Uterine inversion
• Uterine rapture

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REFERRAL FORMS
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Management of labour The management of labour
should be commenced during the antenatal period,
and the women should be classified as high or low
risk pregnancy. The medical or surgical problems
should be corrected as in case of (anaemia,
hypertension, urinary tract infection),
vaccination should be given if necessary, and all
investigations should be performed and prepared
such as (HIV, HCV, Hbs Ag, blood grouping.etc).
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Also the patient should be advised to attend the
antenatal class (parenterful class) and visit the
hospital including the labour ward to be familiar
to the place and staff. Once labour is commenced
and the patient arrived to the admission room the
following to be done
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• -Taking history or reviewing the antenatal file.
• 1-Last menstrual period expected date of
  confinement.
• 2-Time of onset of labour.
• 3-Frequency and duration of contraction
  (3-4cm/10min).
• 4-Presence or absence of amniotic fluid
  leakage.
• 5-Presence or absence of show or vaginal
  bleeding.
• 6-Past obstetric history especially mode of
  previous delivery, presentation, mode of
  delivery, and weight of previous children.
• 7-Past medical or surgical history that may
  affect labour or delivery, especially diabetes,
  heart disease, respiratory disease allergies, and
  any medication.

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• B-Examination
• .General
• a-pallor, oedema, varicosities, height, and
  built.
• b-Vital signs (BP, P, T)
• c-Examination of heart, lungs, breast and other
  organs if necessary
• .Abdominal Examination
• a-To determine fundal height in cm using tape
  measure (to determine gestational age
  clinically), fetal lie, presentation, engagement
  in fifths, size of the fetus, amount of liquor,
  fetal heart rate.
• b-The frequency and duration of the contraction.

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• .Vaginal Examination to assess the following.
• a-Cervical dilatation in cm and effacement in .
• b-Length of the cervix.
• c-Consistency of the cervix
• d-Position of the cervix
• e-State of the membranes, amount and colour of
  liquor.
• f-fetal presentation, position and station.
• g-pelvic architecture.

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DO NOT DO VAGINAL EXAMINATION IN CASES OF VAGINAL
BLEEDING BEFORE THE PLACENTA PREVIA IS
EXCLUDED. DO STERIL SPECULUM EXAMINATION IF
SUSPECTED PLROM, IF THE WOMAN IS NOT IN
LABOUR. If the woman diagnosed as having active
labour to be admitted to labour ward. N.B-
active labour means regular strong and frequent
uterine contraction 3-4/10min lasting 45-50 sec,
and the cervix is fully effaced and 2.5-3cm
dilated.
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Arrival to the labour ward I-first stage of
labour 1-Ensure patients privacy by covering
her with sheaths or blankets. 2-Reassure and show
great sympathy and interest. 3-Record maternal
vital signs every hour (BP, P, T). 4-Take blood
for grouping and cross match for high risk
patients. 5-Monitor a-high risk patients should
have a continuous electronic fetal heart
monitoring.
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b-low risk patients should have brief electronic
fetal heart monitoring if NORMAL, to be followed
by intermittent auscultation -first stage every
15min -second stage every 5min 6-Limit oral
intake to small amount of clear fluid or frozen
pineapple. 7-Give all patients in active labour
Ranitidine (Zentac) 150mg orally /
6hourly. 8-Nurse the patient in a-left lateral
position for mediated patients. b-sitting or
semi-reclining for unmediated patients.
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9-Encourage spontaneous voiding, catheterization
may be necessary. 10-Test all urine specimen for
proteins, sugar, and acetone. 11-Give IV fluids
during labour to avoid dehydration a-0.9 Nacl
or hartmanns solution at 80-125ml/hr b-Supplement
ation with 5 dextrose to prevent ketosis and
hypoglycemia. 12-Give analgesia/anesthesia as
required. a-Pethidine (50-150mg)IM. b-Diamorphin
(5-10mg)IM. Every 3-4 hours. avoid giving it too
early in labour lt 3-4cm cervical dilation or too
late when the delivery is expected within
1-2hours.
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if given too late -inform the
pediatrician -give Naloxon (Narcon) 0.02mg IM to
the neonate. c-Use Entonox (NO2 50O2 50) by
mask if available. d-Use epidural analgesia in
selected cases if available such as Breech,
Twins, preterm delivery. e-Give anti-emetics such
as Metoclopromide (5-10mg)IM if necessary, but
should not be routine. 13-Do vaginal examination
to a-assess progress of labour every 2-4hr b-or
immediately after rupture of membranes c-FHR
abnormalities.
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14-Recall all the observations in labour in
Partogram. 15-Consider augmentation with
syntocinon if progress of labour is slow
(partogram). -1000 ml Hartmanns solution or
normal saline 10 units syntocinon (pitocin)
-Begin the infusion using a pump at 4 milliunits
per minute and double the dose every 20 minutes
to a maximum of 32 milliunits/min. -Or begin with
15 drops / min and increase the rate by 10 drops
every 30 minutes untill adequate contractions.
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• II-second stage of labour
• Once the patient reach the second stage of labour
  and have the desire to push down then
• 1-Put the patient in lithotomy position or other
  positions clean the vulva, and perineum with
  antiseptic solution.
• 2-Encourage organized pushing down which she is
  feeling to do so
• -Monitor the uterine contraction and fetal heart
  more frequent.
• -Use syntocinon if progress is slow and no
  contractions.
• -When the head appears at the vulva, the perineum
  is supported during uterine contraction by
  sterile pad to promote flexion and prevent
  premature extension of the head by pressing up on
  the sinciput until crowning occur.

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1. -After crowning the head is allowed to be
   delivered by extension slowly in between the
   contractions by sliding the perineum over the
   face.
2. -DO episiotomy if necessary under local
   anaesthetic ( 10-20 ml) of 1 lignocain, but
   should not be routine.
3. -Wait for the next contraction to deliver the
   shoulder and trunks.
4. -Clamp and deliver the cord and baby to be
   handled to pediatrician.

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III-Third stage of labour The management of
third stage is aimed at 1-Complete delivery of
the after birth (placenta and membranes). 2-Preven
tion of acute inversion of the uterus. 3-preventio
n of postpartum haemorrhage
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A-Delivery of the placenta and membranes a-Conser
vative method the left hand is placed over the
abdomen to detect any change in the level of the
fundus or sign of placental separation and decent
are detected, the patient is asked to bear down
to deliver the placenta spontaneously.
Ergometrine 0.5mg or Syntometrine(5 units
syntocinon 0.5mg Ergometrine) to be given
intravenouslly.
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• Signs of separation and decent of the placenta
• -The body of the uterus becomes smaller, harder,
  and globular.
• -The fundal level rises in the abdomen because
  the lower segment becomes distended by the
  placenta.
• -Suprapubic bulge may appear due to presence of
  the placenta in the lower segment.
• -Elongation of the cord out side the vulva.
• -Sudden gush of blood from the vagina.

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b-Active methods(prophylaxis against postpartum
haemorrhage) 1-Give Methargine 0.5 mg IM or
Syntometrine (5units oxytocin0.5mg Methargine),
at the time of the anterior shoulder is free from
symphysis pubis or as soon as possible
thereafter. 2-Deliver the placenta and membranes
by control cord traction by right hand, and the
left hand is placed on the suprapubic region,
pushing the uterus upwards. N.B. USE SYNTOCINON
RATHER THAN METHARGINE IN CARDIAC AND
HYPERTENSIVE CASES.
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IV-Post Delivery 1-examine the placenta for
their completeness, anomalies, length, and number
of vessels in the cord and record the placental
weight. 2-Suture the episiotomy or any
laceration. 3-Estimate blood loss, count swabs,
and take cord blood for Hb, blood group, Rh,
bilirubin, and coombs test for Rh negative
mother. 4-Check BP, P, T, Lochia and firmness of
the uterus before transferring the
patient. 5-Continue an infusion of syntocinon
through the first hour if necessary. 6-Allow no
food during the first hour, sips of water may be
taken, encourage nursing.
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• V-Care of the new born infant
• -Clearance of the new passages.
• -Determine the Apgar score one and five minutes
• heart rate
• respiratory rate
• muscle tone
• colour
• reflex irritability
• 3-Care of the umbilical cord stump
• 4-General assessment of the infant to exclude any
  congenital anomalies.
• 5-Identification of weight, estimate the
  gestational age, dress it and put a mask to
  identify it.
• 6-Protect the baby against cold.