Normal Labour and Delivery

Labour
Diagnosis of labor: progressive effacement and dilatation of cervix in presence of uterine contractions
• Effacement: entire length of cervical canal is taken up into the lower segment of the uterus
• In a Primigravid patient, dilatation will not begin until full effacement is complete

‘Show:’ blood-stained mucous discharge or spontaneous rupture of membranes (SROM) provide further
evidence that a woman is in labor provided she is experiencing regular uterine contractions
• 3 stages:
1. First stage: from establishment of labour until full dilatation
2. Second stage: full dilatation to delivery of the fetus
3. Third stage: delivery of the placenta

Analgesia in Labour
• TENS machine
• Simple analgesia: Paracetamol
• Opiods:
1. IM Pethidine
2. Morphone PCA
3. Fentanyl PCA
4. Remifentanil PCA
• Epidural
• Combined spinal-epidural

Assessment
1. General examination  assessment of uterine contractions and fetal wellbeing
2. FBC, blood type and Rh status
3. Partogram
** Minimal vaginal examinations following initial assessment

Fetal Assessment
• Amniotic fluid (volume & colour)
• Fetal heart rate monitoring: continuous vs intermittent

Maternal Assessment
• BP / HR / temp charting
• Uterine contractions

First Stage of Labour

• Progress measured in terms of __ and recorded by partogram
1. Dilatation of the cervix
2. Descent of presenting part
• Average rate of cervical dilatation in primigravidae: 1cm/hr
• Descent of fetal head is measured in labour by:
1. Abdominal examination: if only 2-fifths or less of fetal head is palpable abdominally then
the head is engaged
2. Vaginal examination: ‘station’ of fetal head with respect to ischial spines is recorded.
 Ischial spines are designated station zero
 When head is above the spines, it is said to be at -1, -2, -3, -4 -5cm
 When head is below the spines it is +1, +2, +3, +4 and +5cm , with +5cm
representing crowning of the head

Second Stage of Labour

• Begins with full dilatation
 • Progress is measured:
1. Descent of the fetal head on vaginal exam
2. Rotation of the fetal head on vaginal exam
• 2 phases:
1. Passive phase: from full dilatation until head reaches pelvic floor.
2. Active phase: when fetal head reaches pelvic floor (usually a/w strong desire to push)

Mechanism of Labour
1. Engagement
2. Flexion
3. Descent
4. Internal rotation
a. Head rotated from a lateral(occipito-transverse)
position at the pelvic brim to an antero-posterior
position at the pelvic outlet)
b. Position of head as it traverses the canal is
described according to the position of the occiput
c. Head rotates from an occipitotransverse to an
occipitoanterior position
5. Extension  as the head delivers
6. External rotation  back to transverse position, allows
rotation of shoulders to anteroposterior position
7. Expulsion

Episiotomy + Perineal Tears

Episiotomy: surgical procedure where the perineum is cut with a scissors to widen the soft tissue
diameter of the introitus to prevent a severe perineal tear or accelerate delivery
• Indications: a rigid perineum, if it is felt that a perineal tear is imminent and shoulder dystocia

• First degree: injury to the vaginal epithelium & vulval skin only
• Second degree (equivalent to episiotomy): injury to perineal muscles, but not anal sphincter
• Third degree: injury to the perineum involving the anal sphincter
• Fourth degree: injury involving anal sphincter and rectal mucosa

Third Stage of Labour

• Signs of placental separation:
1. Lengthening of umbilical cord
2. Gush of blood per vaginam
3. ‘Rising up’ of the fundus
• Managed to minimize risk of postpartum haemorrhage, which involves administration of:
1. Syntocinon (oxytocin)
2. Syntometrine (oxytocin and ergometrine)
3. Delivery of placenta via controlled cord traction
• Uterine fundus is rubbed up to ensure that it is well contracted and placenta is examined to
ensure that it is complete