Labor

District 1 ACOG Medical Student

Education Module 2008
Labor

 Labor is the physiologic process by which a

fetus is expelled form the uterus to the
outside world.
 It involves the sequential integrated
changes in the uterine decidua, and
myometrium.
 Changes in the uterine cervix tend to
precede uterine contractions
Labor - Mechanics

Uterine contractions have two major goals:

 To dilate cervix
 To push the fetus through the birth canal
 Success will depend on the three P’s:
 Powers
 Passenger
 Passage
Power

Uterine contractions
 Power refers to the force generated by the
contraction of the uterine myometrium
 Activity can be assessed by the simple
observation by the mother, palpation of the
fundus, or external tocodynamometry.
 Contraction force can also be measured by direct
measurement of intrauterine pressure using
internal manometry or pressure transducers.
Power

 There is no specific criteria for adequate

uterine activity
 Generally 3-5 contractions in a 10 minute
period is considered adequate labor
Passenger
Passenger =fetus
 Fetal variables that can affect labor:
 Fetal size
 Fetal Lie – longitudinal, transverse or oblique
 Fetal presentation – vertex, breech, shoulder, compound
(vertex and hand), and funic (umbilical cord).
 Attitude – degree of flexion or extension of the fetal
head
 Position
 Station – degree of descent of the presenting part of the
fetus, measured in centimeters from the ischial spines
 Number of fetuses
 Presence of fetal anomalies – hydrocephalus,
sacrococcygeal teratoma
Passage

Passage = Pelvis
 Consists of the bony pelvis and soft tissues of the
birth canal (cervix, pelvic floor musculature)
 Small pelvic outlet can result in cephalopelvic
disproportion
 Bony pelvis can be measured by pelvimetry but it
not accurate and thus has been replaced by a
clinical trial of labor
Passage

 www.uptodate.com
Passage - Pelvimetry

 www.uptodate.com
The Stages of Labor

First Stage
 Interval between the onset of labor and full
cervical dilation
 Two phases:
 Latent phase – onset o f labor with slow cervical
dilation to ~4 cm and variable duration
 Active phase – faster rate of cervical change, 1-
1.2 cm /hour, regular uterine contractions
The Labor Curve

 First stage - A: latent phase; B + C + D: active phase; B: acceleration; C:

maximum slope of dilation; D: deceleration; E: second stage.
Adapted from: Friedman. Labor: Clinical evaluation and management,
2nd ed, Appleton, New York 1978.
Labor
Labor NulliG MultiG
 Freidman’s curve
1st Stage Active phase
is a good
guideline for Duration 6-18 h 2-10 h
expected
progression in Dilation ~1 cm/h ~1.5 cm/h

labor and Arrested >2 h >2h

therefore helpful
to note abnormal 2nd Stage 0.5-3 h 5-30 min
labor patterns.
3rd Stage 0-30 min 0-30 min
Labor

 Variables associated with longer labors:

Electronic fetal monitoring

Narcotic use
Maternal age >30
Ambulation
Labor – Second Stage
 Interval between full cervical dilation to delivery
of the infant.
 Characterized by descent of the presenting part
through the maternal pelvis and expulsion of the
fetus.
 Indications of second stage:
 Increased maternal show
 Pelvic/rectal pressure
 Mother has active role of pushing to aid in fetal
descent.
Labor – Second Stage
 Examining the fetal head during the second
stage may become difficult due to molding
 Molding is the alteration of the fetal cranial
bones to each other as a result of compressive
forces of the maternal bony pelvis.
 Caput is the localized edematous area on the
fetal scalp caused by pressure on the scalp by the
cervix.
 PrimiG – 0.5-3 h; mulitG 0-30min
Labor – Third Stage
 The time from fetal delivery to delivery of
the placenta
 Three signs of placental separation:

Lengthening of umbilical cord

Gush of blood
Fundus becomes globular and more anteverted
against abdominal hand
Labor – Third Stage
 Placenta is delivered using one hand on
umbilical cord with gentle downward
traction. Other hand on abdomen
supporting the uterine fundus.
 Risk factor for aggressive traction is
uterine inversion.
 Obstetrical emergency!!
 Normal duration between 0-30 min for
both PrimiG and MultiG
Labor – Fourth Stage

 Refers to the time from delivery of the placenta

to 1 hour immediately postpartum
 Blood pressure, uterine blood loss and pulse
rate must be monitor closely ~ 15 minutes
 High risk for postpartum hemorrhage from:
 Uterine atony, retained placental fragments,
unrepaired lacerations of vagina, cervix or
perineum.
 Occult bleeding may occur – vaginal hematoma
 Be suspicious with increased heart rat, pelvic
pain or decreased BP
Cardinal Movements of Labor
 Refers to changes in the fetal head position
during its passage through the canal.
 Seven distinct movements:

 Engagement
 Descent
 Flexion
 Internal rotation
 Extension
 External rotation/restitution
 Expulsion
Cardinal Movements of Labor

Engagement
 Passage of the widest diameter fetal
presenting part below the plane of the
pelvic inlet
 The head is said to be engaged if the
leading edge is at the level of the ishial
spines.
Cardinal Movements of Labor

Descent
 Refers to the downward passage of the
presenting part through the bony pelvis
 Not steady process
 Greatest at deceleration phase of first
stage and during 2nd stage of labor
Cardinal Movements of Labor

Flexion
 Occurs passively as the head descends
due to the shape of the bony pelvis.
 Partial flexion occurs naturally but
complete flexion usually occurs only in
the labor process
 Complete flexion places the fetal head in
optimal smallest diameter to fit through
the pelvis
Cardinal Movements of Labor

Internal Rotation
 Rotation of the fetal head from occiput
transverse to occiput either in anterior or
posterior position
 Occurs passively due to the shape of the
bony pelvis
Cardinal Movements of Labor

Extension
 Occurs when the fetus has descended to
the level of the vaginal introitus
 When occiput is just past the level of the
symphysis, the angle of the birth canal
changes to upward position
Cardinal Movements of Labor

External Rotation/Restitution
 As the head is delivered, it rotates back to
its original position prior to internal
rotation
 It aligns anatomically with the fetal torso
 The release of the passive forces on the
fetal head allows it to return to
appropriate position
Cardinal Movements of Labor

Expulsion
 Delivery of the fetus
 After delivery of the fetal head, descent
and intraabdominal pressure by mother
brings shoulder to the level of the
symphysis
 Downward traction allows release of the
shoulder and the fetus is delivered.
Cardinal Movements of Labor
In Summary
 Know the different stages of labor
 Know the labor curve
 Know the cardinal movements of labor
 Know the causes of postpartum
hemorrhage
 The remaining talk regarding labor,
induction, augmentation, surveillance and
complications will be discussed in
following lectures…