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Normal Labour in Obstetric2
Normal Labour in Obstetric2
DEFINITION
A series of events that take place in female genital organs to expel the
product of conception that are fetus, placenta, membranes) out of womb through
the vagina into the outer world.
At the National Maternity Hospital in Dublin (O’Driscoll and colleagues,
1984). Criteria for onset of labour:
At term require painful uterine contractions accompanied by any one of
the following: (1) ruptured membranes,
(2) Bloody “show,” or
(3) complete cervical effacement.
Prostaglandin :
Major site of production: Amnion, chorion, decidua cells and
myometrium
Triggered by rise in estragon, glucocorticoids, mechanical stretching in
late pregnancy, separation or rupture of membrane
Enhances gap junction formation Oxytocin
Actions of Stimulate uterine contractions o Stimulate PG production from
amnion/decidua
RETRACTION
STAGES OF LABOR
1. First phase
2. Second phase
3. Third phase
4. Fourth phase
FIRST STAGE
Concerned with formation of birth canal
Main events:
Dilatation of cervix and effacement of cervix
Lower uterine segment formation
Active Phase
Cervical dilation of 3 to 5 cm in presence of uterine contractions: threshold
for active labor
Cervical dilatation: 1.2 to 6.8 cm/hour. Multiparas: minimum 1.5 cm/hr
Descent begins after 7 to 8 cm dilation, most rapid after 8 cm
SECOND STAGE OF LABOR
begins when cervical dilatation is complete and ends with fetal delivery.
Median duration
2 hr in primigravidae
30 minutes in multiparae
Uterine contractions and accompanying expulsive forces last:
60-90 seconds and
recur every 60 seconds
Events
Propulsive phase:
Period of full dilation until head touches pelvic floor
Expulsive phase:
Since the time mother has irresistible desire to ‘bear down’ and push
until the baby is delivered.
THIRD STAGE OF LABOR
Includes separation, descent and expulsion of placenta with its membrane.
• Ritgen maneuver:
• A towel-draped, gloved hand –used to exert forward pressure on the chin of
fetus through the perineum
• This maneuver allow delivery of head and also favors the neck extension so that
head is delivered with small diameter
Management of third stage labor
Expectant management
• Placental separation and its descent into the vagina are allowed to occur
spontaneously
• Constant watch
• Changed to dorsal position
• Hand placed over the fundus (signs of separation, state of uterine activity, detect
inversion of uterus)
• Expulsion of placenta
• Patient asked to bear down
• Placenta grasped by hands and twisted round and round with gentle traction
• Assisted expulsion
1. Controlled Cord Traction
2. Fundal Pressure
Examination of placenta
• Maternal surface: completeness, anomalies
• Membranes: completeness, abnormal vessels
• Cord: number of vessels
Active management
• To excite powerful uterine contractions within one minute of delivery of the
baby by giving parenteral oxytocic
• Injection Oxytocin 10 units IM
• Controlled Cord Traction
• Massaging the uterus
• To minimise blood loss in third stage to approx 1/5th
• To shorten the duration of third stage to half
• Disadvantage: increased incidence of retained placenta and consequent
increased incidence of manual removal
• Not to be used in cardiac failure, severe pre-eclampsia
Management of fourth stage labour
• Suture the episiotomy or any laceration
• Estimate blood loss, take cord blood for Hb, blood group, Rh, bilirubin, and
Coomb’s test for Rh negative mother
• Check BP, Pulse, Temperature, abnormal vaginal bleeding and firmness of the
uterus before transferring the patient
Cardinal Movements of Labour
1. Engagement
2. Descent
3. Flexion
4. Internal rotation
5. Extension
6. External rotation
7. Expulsion
Engagement
• The mechanism by which the Biparietal Diameter- the greatest transverse
diameter in occiput presentation crosses the pelvic inlet.
Fetal head enters the pelvic inlet either transversely or obliquely. 1. Head
floating before engagement 2. Engagement, descent and flexion
Asynclitism
The lateral deflection of the sagital suture anteriorly toward pubic symphysis
or posteriorly towards sacral promontory.
Anterior asynclitism:
Sagital suture approaches sacral promontory
Anterior parietal presentation
Posterior asynclitism:
Sagital suture approaches pubic symphysis
Posterior parietal presentation
Descent
• Downward passage of the presenting part through the pelvis
• Forces involved:-
Pressure of amniotic fluid
Pressure of fundus upon breech with contraction
Bearing down efforts of maternal abdominal muscles
Extension and straightening of fetal body
Flexion
• Occurs passively as the head descends
• Resistance from cervix, pelvic walls, pelvic floor
• Chin is brought into intimate contact with the fetal thorax
• Longer occipitofrontal diameter replaced by shorter suboccipito bregmatic
diameter
Internal Rotation
• Turning of head in such a manner that the occiput gradually moves towards the
symphysis pubis anteriorly from its original position.
Extension
• The sharply flexed head reaches the vulva and undergoes extension
• Driving force exerted by uterus
• Resistance offered by pelvic floor and symphysis
• Resultant vector: direction of vulvar opening causing head extension
• Occiput in direct contact with the inferior margin of symphysis pubis
External Rotation
•Movement of rotation of head visible externally due to the internal rotation of
the shoulders
•Anterior shoulder rotates towards symphysis pubis from oblique diameter
•Occiput points directly toward maternal thigh corresponding to the side to which
it originally directed at the time of engagement.
Expulsion
• Shoulders positioned in anteroposterior diameter
• Anterior shoulder escapes below pubic symphysis
• Lateral flexion of spine, the posterior shoulder sweeps over the perineum
• Rest of the trunk expelled out by lateral flexion 7. Delivery of anterior shoulder
Research article :
Abstract
In this column, the author summarizes research studies relevant to
normal birth. The studies summarized include a large trial evaluating
the effect of prior vaginal births after a cesarean on outcomes in
subsequent births; a study linking umbilical cord blood pH with
intellectual outcomes in childhood; and a prospective trial evaluating
the effect of routine antenatal nonstress testing on maternal anxiety.
The author also highlights four articles about normal birth in a recent
nursing journal series dedicated to the topic.
BIBLIOGRAPHY
1. Annama Jocab, text book of comprehensive text book of ‘MIDWIFY and
GYNECOLOGY nursing JAYPEE publication 3rd edition page no.285-
287.
2. D.C. DUTTA text book of obsterical including perinatary and
contraception central publication 7th edition page no. 583-585.
3. B.T.Basvanthppa “TEXT BOOK OF MIDWIFERY AND
REPRODUCTIVE,”2006
4. www.wikipedia.com
5. www.pubmad.com