The document discusses the physiology of labor, defining it as the process by which the fetus and associated products of conception are expelled from the uterus through rhythmic uterine contractions. It describes the stages of labor and factors that influence its progression, including uterine contractions, fetal positioning and size, and the mother's mental state. Normal labor is defined as spontaneous in onset, occurring at term with vertex presentation and resulting in delivery without undue prolongation or complications for the mother or baby.
The document discusses the physiology of labor, defining it as the process by which the fetus and associated products of conception are expelled from the uterus through rhythmic uterine contractions. It describes the stages of labor and factors that influence its progression, including uterine contractions, fetal positioning and size, and the mother's mental state. Normal labor is defined as spontaneous in onset, occurring at term with vertex presentation and resulting in delivery without undue prolongation or complications for the mother or baby.
The document discusses the physiology of labor, defining it as the process by which the fetus and associated products of conception are expelled from the uterus through rhythmic uterine contractions. It describes the stages of labor and factors that influence its progression, including uterine contractions, fetal positioning and size, and the mother's mental state. Normal labor is defined as spontaneous in onset, occurring at term with vertex presentation and resulting in delivery without undue prolongation or complications for the mother or baby.
The document discusses the physiology of labor, defining it as the process by which the fetus and associated products of conception are expelled from the uterus through rhythmic uterine contractions. It describes the stages of labor and factors that influence its progression, including uterine contractions, fetal positioning and size, and the mother's mental state. Normal labor is defined as spontaneous in onset, occurring at term with vertex presentation and resulting in delivery without undue prolongation or complications for the mother or baby.
MBBS, M.D Normal labor and delivery • Definition of labor • Causes of onset of labor • Changes before labor (premonitory symptoms) • True labor • Essential factors of labor • Stages of labor • Clinical course and management of stages Definition (1) Labor and delivery are the culmination of approximately 280days of preparation. Labor is the process by which the viable products of conception (fetus, placenta, cord and membrane ) are expelled from the uterus. (whole process, series of events ,viable fetus) It is defined as the progress effacement and dilation of the cervix, resulting from rhythmic contraction of the uterine musculature. preterm labor—prior to 37 completed weeks Definition (2) The term delivery refers only to the actual birth of the infant at the end of the second stage of labor. it is the expulsion or extraction of a viable fetus out of the womb. it is not synonymous with labor,delivery can take place without labor as in elective C.S. Delivery may be vaginal either spontaneous or aided or it may be abdominal. Definition (3) • Normal labor (eutocia) : labor is called normal if it fulfils the following criteria. 1) spontaneous in onset and at term. 2) with vertex presentation. 3) without undue prolongation. 4) natural termination with minimal aids. 5) without having any complications affecting the health of the mother and /or the baby. Definition (4) • Abnormal labor (dystocia): any deviation from the definition of normal labor.
• Date of onset of labor:it is very much
unpredictable to foretell precisely the exact date of onset of labor.it not only varies from case to case but even in different pregnancies of the same individual. • CALCULATE EDD Causes of onset of labor (1) • uterine distension: over-stretching of the uterus – • Stretching effect on the myometrium by the growing size of the fetus and amniotic liquor can explain the onset of labor at least in twins or hydramnios. • Feto-placental contribution: unknown factors stimulates fetal pituitary prior to onset of labor • increased release of ACTH stimulates fetal adrenals increased cortisol secretion acccelerated production of estrogen and prostaglandins from the placenta. • The alteration in the estrogen:progesterone ratio rather than the fall in the absolute concentration of progesterone which is linked with prostaglandin synthesis. Premonitory symptoms (1)
The premonitory stages may begin 2-3 weeks before the
onset of true labor in primigravidae and a few days before in multiparae. The symptoms are inconsistent and may consist of the following: false labor (false pain) lightening blood show cervical changes Premonitory symptoms (2) • False labor It usually appears prior to the onset of true labor pain, by one or two weeks in primigravidae and by a few days in multiparae.
The woman feels pain and discomfort in the abdomen
and these are mistaken for labor pain. Premonitory symptoms (3) Braxton-Hicks contractions cause the patient’s discomfort, it occur throughout pregnancy, late in pregnancy they become stronger and more frequent. But these contractions are not associated with progressive dilation of the cervix, and therefore do not fit the definition of labor. It is irregular and ineffective. It is not only a distressing feature to the woman but also annoying to the relatives. Premonitory symptoms (4) • False pain has the following features: 1.discomfort is characterized as over the lower abdomen and groin areas 2.without effect on dilation of the cervix (not associated with progressive dilation ) 3.typically shorter in duration 4.less intense 5.relieved by administration of a sedative, enema or ambulation Premonitory symptoms (5) • Lightening Few weeks prior to the onset of labor specially in primigravdae, the presenting part sinks into the pelvis. The patient reports the sensation that the baby has gotten less heavy, the result of the fetal head descending into the pelvis. The patient often notice that the lower abdomen is more prominent and the upper abdomen is flatter, and there may be more frequent urination as the bladder is compressed by the fetal head. Lower segment uptake into uterus Premonitory symptoms (6) This descending diminishes the fundal height and hence minimises the pressure on the diaphragm. This makes the woman more comfortable and has an easier time breathing.
It is a welcome sign, as it rules out cephalopelvic
disproportion and other conditions preventing the head from entering the pelvic inlet. Premonitory symptoms (7) • Blood show With the onset of labor, there is profuse cervical secretion. Simultaneously, there is slight oozing of blood from rupture of capillary vessels of the cervix and from the raw decidual surface caused by separation of the membranes due to stretching of the lower uterine segment. Expulsion of cervical mucus plug, mixed with blood is called show.
Patients often report the passage of blood-tinged mucus
late in pregnancy. Premonitory symptoms (8) Cervical changes: several days prior to the onset of labor the cervix becomes ripe. A ripe cervix is soft, less than 1.5cm in length, admits a finger easily and is dilatable. Cervical effacement is common before the onset of true labor. Ture labor or in labor • Painful uterine contractions • Increasingly intense and frequent • Is associated with progressive cervical effacement and dilation • Regular contraction occur every 5 minutes, duration lasts more than 30 seconds False labor and true labor 1.discomfort is characterized 1.over the uterine as over the lower abdomen fundus,with radiation of and groin areas discomfort to the low 2.without effect on dilation back and low abdomen. of the cervix (not associated with progressive dilation ) 2. Associated with 3.typically shorter in effacement and dilation duration 4.less intense 3. Increasingly intense and 5.relieved by administration frequent of a sedative or ambulation 4. Regular and effective Essential factors of labor(1) The progress and final outcome of labor are influenced by 4 factors: 1) the labor force 2) the passage (the bony and soft tissues of the maternal pelvis) 3) the passenger (fetus) 4) the psyche. Abnormalities of any of these components, singly or in combination, may result in dystocia. Essential factors of labor(2) Uterine contraction. Labor force Abdominal muscle. Levator ani muscle Bony canal (pelvis) (no change) Birth canal vulvar, vagina, cervix, Lower uterine segment Fetal position Fetus Fetal size Psychic factors. A high level of anxiety during pregnancy has been associated with decreased uterine activity and with longer and dysfunctional labor. Essential factors of labor(3) LABOR FORCE 1) Uterine contraction. It is the major force through the whole course of labor. It includes contraction and retraction. There are three effective features. Rhythmy and Intermittent Dominance and pacemaker Retraction. Essential factors of labor(4) LABOR FORCE-uterine contraction (1) Dominance and pacemaker Uterine contraction in labor (patterns of contraction) there is good synchronisation of the contraction waves of both halves of the uterus. The pacemaker of uterine contractions is probably situated in the region of the cornu from where waves of contraction spread downwards. Essential factors of labor(5) LABOR FORCE Essential factors of labor(6) LABOR FORCE Dominance : The upper segment contracts more strongly than the lower part, and the duration is longer than in the lower segment, this dominance of the upper segment leads to the stretching and thinning of the lower segment and to dilation of the cervix. Essential factors of labor(7) LABOR FORCE • (2) The contractions are regular and rhymic. • After contractions there is a intermittent period of relaxation Essential factors of labor(8) LABOR FORCE . As labor progress, the intensity increase, frequency increase, contractile duration prolonged and intermittent relaxation shortens gradually, by the end of the first stage of labor the contraction may come every 1 to 2 minutes and may last as long as a minute. Essential factors of labor(9) LABOR FORCE • Intermittent : The intermittent nature of the contractions is of great importance to both the fetus and the mother. During a contraction the circulation to the placental bed through the uterine wall is stopped; if the uterus contracted continuously the fetus would die from lack of oxygen. The intermittent relaxation allow the placental circulation to be re-established and give the mother time to recover from the fatigue effect of the contraction. Essential factors of labor LABOR FORCE
uterine contraction include three parts:
intensity duration frequency Essential factors of labor LABOR FORCE • Intensity of contraction: it describes the degree of uterine systole. The intensity gradually increases with advancement of labor until it becomes maximum in the second stage during delivery of the baby. During the first stage intrauterine cavity pressure is raised to 40-50mmHg and during second stage it is raised about to 100-120 mmHg. Frequency: in the early stage of labor, the contraction come at intervals of 10-15 min. The intervals gradually shorten with advancement of labor until in the second stage, when it comes every one or two minutes. Essential factors of labor LABOR FORCE
Duration: in the first stage, the contraction
lasts for about 30-40 seconds initially but gradually increases in duration with the progress of labor. Thus in the second stage, the contractions last longer than in the first stage. Essential factors of labor LABOR FORCE-- retraction • Retraction: retraction is a phenomenon of the uterus in labor in which the muscle fibres are permanently shortened, it is different from the contraction. Retraction is specially a property of upper uterine segment. Contraction is a temporary reduction in length of the fibres, which attain their full length after the contraction passes off. In contrast, retraction results in permanent shortening and the fibres are shortened once and for all. Essential factors of labor LABOR FORCE-- retraction Essential factors of labor LABOR FORCE-- retraction If contraction was followed by complete relaxation no progress would be made, in retraction some of the shortening of the fibres is maintained. So the uterine cavity becomes progressively smaller with each contraction. The net effect of retraction in normal labor are: -- essential property in the formation of lower segment and dilation and taking up of the cervix -- to maintain the advancement of the presenting part made by the uterine contraction and to help in ultimate expulsion of the fetus -- to reduce the surface area of the uterus favouring separation of placenta Essential factors of labor LABOR FORCE • Abdominal muscle and diaphragm . • In second stage,delivery of the fetus is accomplished by the downward thrust offered by uterine contractions supplemented by voluntary contraction of abdominal muscles against the resistance offered by bony and soft tissues of the birth canal. • Help fetus and placenta delivery in the second stage and third stage. Essential factors of labor LABOR FORCE • the expulsive force of uterine contraction is added by voluntary contraction of the abdominal muscles called “bearing down” efforts. • Pelvic floor (levator ani muscle.) Help fetus internal rotation Essential factors of labor birth canal The bony canal The bony canal means true pelvis, its size and shape is relation with delivery closely. There three plane. Pelvic inlet plane. The true conjugate describe the anteroposterior dimension of the inlet, it is average 11cm. The transverse diameter of the inlet is average 13cm. An oblique diameter is average 12.75cm. Essential factors of labor birth canal Pelvic midplane. it is the smallest plane of the pelvic canal. Its anteroposterior diameter is average 11.5cm. its transverse diameter between the ischial spines( interspinous diameter) is average 10cm The plane of least dimensions is an important obstetric plane because shortening of its diameters frequently is associated with obstructed labor. Essential factors of labor birth canal pelvic outlet plane. The plane of the pelvic outlet is actually two triangular planes at different inclinations that share the same base. The transverse diameter, between the inner margins of the ischial tuberosites, average 9cm. Essential factors of labor birth canal The soft birth canal The formation of lower segment. • Before labor begins, the uterine body appears to be a single unit. However, uterine contractions soon cause it to differentiate into visibly different upper and lower segments. • The upper segment is actively contractile, thick, and powerful. The lower segment is passive, thin, and distensible. • The physiologic retraction ring separates the two segments. Essential factors of labor birth canal Essential factors of labor birth canal This powerful segment draws the weaker, thinner and more passive lower segment up over its contents, and in so doing pulls up and then dilates the cervix. The wall of the upper segment becomes progressively thicker with progressive thinning of the lower segment. This is pronounced in late first stage, specially after rupture of the membranes and attains its maximum in second stage. A distinct ridge is produced at the junction of the two segments, called physiological retracting ring. Essential factors of labor birth canal • The change of cervix After cervical effacement ,dilation of cervix begins in primigravidae. But in multiparae the effacement and dilation occur together. Essential factors of labor birth canal Essential factors of labor birth canal Essential factors of labor birth canal During labor as the cervix dilated and the lower segment is drawn up, its shape changes from a hemisphere to a cylinder. The musculature of the lower segment stretches to permit more and more of the intrauterine contents to fit within it and to distend its walls. In labor the lower segment, cervix,vagina, pelvic floor and vulval outer are dilated until there is one continuous birth canal. Essential factors of labor birth canal
The forces which bring about this dilation and expel
the fetus are supplied mostly by the muscle of the upper uterine segment, with some assistance in the second stage from the abdominal muscles, including the diaphragm. Stages of labor (1)
Although labor is a continuous process, it
is divided into three functional stages: first stage ------ dilation of cervix second stage ----- fetus delivery third stage -------- placenta delivery fourth stage ------- within 2h after delivery Stages of labor(2)
• First stage: it starts from the onset of true labor pain
and ends with full dilation of the cervix. 8-12 hr The first stage is further divided into two phases, the latent phase and the active phase. In the latent phase, cervical dilation is under 4 cm, the contractions may be infrequent, are usually not more than moderately strong and the patient can tolerate, in active phase, more rapid cervical dilation occurs,usually beginning at approximately 4 cm . Stages of labor(3)
Second stage: (giving birth): it starts from the full
dilation of cervix and ends with expulsion of the fetus from the birth canal. Its duration is 1-2 h in primigravidae, 30 minutes in multiparae.
Third stage: it begins immediately after delivery of the
infant and ends with the delivery of the placenta. Its average duration is about 15 minutes in both primigravidae and multiparae. Stages of labor(4)
• Fourth stage: (after deliver of baby and placenta,
observing uterus and bleeding) it is defined as the immediate postpartum period of approximately 2 hr after delivery of the placenta. During this time the patient’s general condition and the behavior of the uterus are to be carefully watched. The midwife monitors the amount of blood as well as pulse and blood pressure in the first several hours after delivery to identify excessive blood loss. Clinical features and management of the stage (1) In the first stage 1. Events of the first stage (1) Cervical effacement and dilation Effacement of the cervix is a process of thinning out which is accomplished during first stage of labor or even before that in primigravidae. Taking up is effected by retraction. Expulsion of mucus and the compression effect also help in thinning of the cervix. In the first stage 1. Events of the first stage The degree of cervical effacement is expressed as percent effacement. i.e. A cervix that is thinned to one-half of its original 2cm length is termed 50%,whereas a cervix that is virtually totally thinned is described as 100% effaced. The dilation of cervix is described as centimeters of dilation. Fig . cervical effacement In the first stage 1. Events of the first stage • (2) formation of uterine segment In the first stage 2.Clinical features (1) (1) Pain---- come from the intermittent uterine contraction initially, the pain are not strong enough to cause discomfort and come at varying intervals of 15-30 min with duration of about 30 seconds. But gradually the interval becomes shortened with increasing intensity and duration so that in late first stage the contraction comes at intervals of 2-3min and last for about 50-60 seconds. In the first stage 2.Clinical features (3) • (3) Micturation--- during the course of labor, descent of the fetus causes the bladder to be elevated relative to the lower uterine segment and cervix. this often results in the patient having difficulty voiding. The patient, therefore, be encouraged to void frequently. Catheterization may become necessary if the bladder becomes distended In the first stage 2.Clinical features (4) (4) Diet --- during labor there is delay in the emptying time of the stomach and food or fluids may remain there for several hours. Solid food should be avoid intake. The diet should be liquid with sufficient food value and pleasant to take. In the first stage 2.Clinical features (5) (5) Dilation and taking up of the cervix --- by vaginal and rectum examination the dilation and taking up is found.
Cervical dilation is expressed in terms of centimeters. It is
usually measured with fingers but recorded in centimeters.
One finger equals to 1.5 cm and when the dilation is
more than 6 cm, it is easier to subtract twice the width of the remaining ‘rim’ from 10 cm to measure the actual dilation. In the first stage 2. Management (1) 1) admitted to hospital reasons: a. if their contractions occur approximately every 5~10 min for at least 1 hr b. If there is a sudden gush of fluid or a constant leakage of fluid c. if there is any significant bleeding d. If there is significant decrease in fetal movement In the first stage 2. Management (2) 2) evaluation for labor a. taking history in detail and review perinatal records (LMP, EDC,vaginal bleeding, infectious disease,...) b. A limited general physical examination is performed. Pay special attention to vital signs. In the first stage 2. Management (3) c. Abdominal examination: The initial examination of the gravid abdomen may be accomplished using Leopold maneuvers, a series of four palpations of the fetus through the abdominal wall that helps accurately determine fetal lie, fetal presentation, and fetal position. The fetal heart rate is checked and any abnormality of rate or rhythm is noted. In the first stage 2. Management (4) d. Vaginal examination: (dilation and station) • the vaginal examination should be performed using an aseptic technique, in the presence of significant bleeding , the vaginal examination should be done with extreme care. Before any digital examination a sterile speculum examination should be performed. The digital portion of the vaginal examination allows the examiner to determine the degree of cervical effacement. The cervix is also palpated for cervical dilation described as centimeters of dilation. The examiner uses one or two fingers to identify the diameter of the opening of the cervix. In the first stage 2. Management (5) • Fetal station is also determined by identifying the relative level of the foremost part of the fetal presenting part relative to the level of the ischial spines. If the presenting part has reached the level of the ischial spines, it is termed “0” station. In the first stage 2. Management (6) • Spines are the most prominent bony projections felt on internal examination and the bispinous diameter is the shortest diameter of the pelvis in transverse plane 10-10.5cm, the station is said to “0” if the presenting part is at the level of the spines. The station is stated in minus figures, if it is above the spines (-1,-2,-3 and floating ) and in plus figures if it is below the spines (+1,+2,+3 and on the perineum). In the first stage 2. Management (7) In the first stage 2. Management (8) The following information are to be noted and recorded carefully when performing vaginal examination: ( 1) degree of cervical dilation in centimeters ( 2) degree of effacement of cervix ( 3)status of membranes and if ruptured-color of the liquor ( 4) presenting part and its position by noting the fontanelles and sagittal suture in relation to the quadrants of the pelvis ( 5) station of the head in relation to ischial spines In the first stage 2. Management (10) 4) Fetal monitoring The fetal heart rate is counted with a stethoscope at half hourly intervals in early labor and at 10 min intervals in the active phase of labor. The normal rate 120 ~ 160 beats per minute and there is no change of rate, or only a very transient showing, with the uterine contractions. Most hospital have employed fetal monitoring during labor, the uterine contractions can be recorded . In the first stage 2. Management (12) 5) relief of pain Towards the end of the first stage the pains become more severe. The epidural analgesia should be employed. If it is not employed, drugs such as pethidine 100mg intramuscularly may be given if the woman is distressed In the first stage 2. Management (13) In the first stage the principle is: (1) non-interference with watchful expectancy so as to prepare the patient for a smooth delivery in the second stage. (2) to monitor carefully the progress of labor, maternal conditions and fetal behavior so as to detect any deviation from the normal at the earliest possible moment. In the second stage Events of the second stage • This stage is concerned with the descent and delivery of the fetus through the birth canal. In the second stage clinical features • Maternal signs: there are features of exhaustion. Respiration is slowed down with increased perspiration. During the bearing down efforts, the face becomes congested with neck veins prominent. Immediately following the expulsion of the fetus, the mother heaves a sigh of relief. • Fetal signs: bradycardia during contractions is very much prominent which often continues because of quick successive contractions. In the second stage clinical features • painful contraction is stronger and more frequent; • bearing birth efforts: voluntary contraction of the abdominal muscles . In majority, the pushing down efforts start just prior to full dilation of the cervix.
• descent of fetal head---features of descent of the fetus are
evident from abdominal and vaginal examination. In the second stage clinical features • Vaginal signs:as the head descends down, it distends the perineum, the vulval opening looks like a slit through which the scalp hairs are visible. During each contraction, the perineum is markedly distended with the overlying skin tense and glistening and the vulval opening becomes circular. In the second stage clinical features • Vaginal signs: the adjoining anal sphincter is stretched and stool comes out during contraction. The head recedes after the contraction passes off but is held up a little in advance because of retraction. Ultimately, the maximum diameter of the head stretches the vulval outlet and there is no recession even after the contraction passes off. This is called the crowning of the head. In the second stage clinical features • The perineum, including the anal sphincter, is very much stretched and the anterior rectal wall is visible. The head is born by extension. After a little pause, the mother experiences further pain and bearing down efforts to expel the shoulders and the trunk. In the second stage management • Principles: To assist in the natural expulsion of the fetus slowly and steadily To prevent perineal injuries • Preparation for delivery ( dorsal position, catheterise the bladder) • Conduction of delivery: delivery of the head, delivery of the shoulders, delivery of the trunk EPISIOTOMY In the second stage management Delivery of the head--- to maintain flexion of the head, to prevent its early extension and to regulate its slow escape out of the vulval outlet. • In order to prevent from perineal rupture, if is important that the head should be born slowly and in an interval between contractions. Episiotomy,or incision of the perineal body sometimes is necessary.
• The shoulders usually follow with the contraction following
the birth of the head, the anterior shoulder being delivered before the posterior. The shoulders can cause damage unless they are carefully delivered. In the second stage management • delivery of the shoulders, In the second stage management • Delivery of the trunk: after the delivery of the shoulders, the fore finger of each hand are inserted under the axillae and the trunk is delivered gently by lateral flexion. • The mouth and pharynx are sucked clear with a mucus extractor, a healthy baby breathes and cries very soon after it is born, if it fails to do so the baby needs active resuscitation. Normally the cord should not be clamped until the child has cried vigorously and pulsation in the cord has ceased.
So in the second stage the principle is (1) to assist in
the natural expulsion of the fetus slowly and steadily,(2) to prevent perineal injuries. In the third stage
• The third stage of labor comprises the phase of placental
separation, its descent to the lower segment and finally its expulsion with the membranes Placental separation : At the beginning of labor, the placental attachment roughly correspond to an area of 20 cm in diameter. During the second stage, there is slight but progressive diminution of the area following successive retractions, which attains its peak immediately following the birth of the baby. ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR: • Uterine fundal massage • Controlled cord traction • Oxytocics : Inj. Oxytocin 10 I.U given IM after delivery of baby • (Not in twins) In the third stage
• Mechanism of separation: marked retraction
reduces effectively the surface area at the placental site to about its half. But as the placenta is inelastic, it cannot keep pace with such an extent of diminution resulting in its buckling. A. Central separation B. margnal separation In the third stage events • Expulsion of placenta: after complete separation of the placenta, it is forced down into the flabby lower uterine segment or upper part of the vagina by effective contraction and retraction of the uterus. Thereafter, it is expelled out by either voluntary contraction of abdominal muscles or by manipulative procedure. In the third stage clinical features • Pains: for a short time, the patient experiences no pain. However, intermittent discomfort in the lower abdomen reappears, corresponding with the uterine contraction. • Before separation: per abdomen--- discoid, firm,funds below the umbilicus, per vagina--- slight trickling of blood,length of cord as visible from outside, remains static. In the third stage clinical features • After separation per abdomen--- uterus becomes globular,firm.the fundal height is slightly raised as the separated placenta comes down in the lower segment and the contracted uterus rests on top of it. per vagina--- there may be slight gush of vaginal bleeding. Permanent lengthening of the cord is established. FOURTH STAGE • Peroid of observation of the mother for 2 hours after delivery • Watch for pulse, BP, respiration • W/F Bleeding per vaginum, passage of urine. • Restart soft diet • Initiate breast feeding within 30 minutes Thanks!!