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2 Comparison DEFINITIONS:
between
normal and 1. NORMAL LABOR [EUTOCIA]:
abnormal labor Labor is said to be normal if:
 Spontaneous in nature and occurs at term.
 Fetus in vertex presentation.
 Completed in normal time period.
 Natural termination {minimal use of
instrumental aids}.
 No complications to mother and fetus.
2. ABNORMAL LABOR[DYSTOCIA]:
Any change in criteria of normal labor is
described in above definition is called abnormal
labor or dystocia.
Note:
 Labor pain that starts prior to 37 completed weeks
is called preterm labor.
 If labor pain occurs between 38-42 weeks it is
called termed labor.
 Post term labor occurs after completing 42 weeks.
3 Define Labor LABOR:
The process that that involves series of events that
take place in the genital organs in order to propel the
products of conception [fetus, placenta and membranes]
out of the uterus through the birth canal is called labor.
4 Enlist the STAGES OF LABOR:
stages of labor
There are four stages of labor,
Namely,
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FIRST STAGE

SECOND STAGE

THIRD STAGE

FOURTH STAGE

I. FIRST STAGE:
It starts from the onset of true labor pains and ends
till full dilatation of the cervix {cm}. Duration is
approximately 12 hours for primi and 6 hours for
multipara.

II. SECOND STAGE:

It starts with full dilatation of cervix and ends with
expulsion of fetus from birth canal. Duration is 2 hours in
primipara and 30 minutes in multipara.
1. PROPULSIVE PHASE:
 This starts from full dilatation up to the descent
of presenting part to the pelvic floor.
2. EXPULSIVE PHASE:
 It is characterized by maternal bearing down
effort and ends with delivery of the fetus.

III. THIRD STAGE:

It starts after the birth of baby and ends with
expulsion of placenta and membranes. Duration is about
15 minutes in both primi and multipara, however duration
is reduced to 5 minutes with active management.
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IV. FOURTH STAGE:
It is the stage of observation for at least 1 hour after the
expulsion of placenta and the membranes.during this
period; both mother and baby are observed carefully to
ensure that both are well.
5 Enlist and CAUSES OF ONSET OF LABOR:
explain the
The exact cause of onset is unknown. Some of the
causes of onset
of labor. hypotheses are as follows:
1. Uterine distension: The stretching effect on the
myometrium by growing fetus and liquor amnii
can initiate the labor pains.
2. Pressure of the presenting part: On the nerve
ending in the cervix may stimulate a nerve plexus
known as cervical ganglion can also initiate the
onset of labor.
3. Myometrial involvement: Estrogen increases
oxytocin receptors in myometrium and decidua.
4. Oxytocin stimulation theory: The uterus become
s increasingly sensitive to oxytocin as pregnancy
progresses and it is maximum at term {37 weeks}.
5. Progesterone withdrawal theory: In pregnancy
progesterone inhibits contractions, but at term
progesterone synthesis falls and estrogen
increases. There is change in estrogen;
progesterone ratio, which stimulate prostaglandin
synthesis
6. Prostaglandin stimulation theory: Prostaglandin
stimulates smoth muscles to contract, therefore it
initiates the labor.
7. Fetal cortisol theory: Estrogen level increases
due to the effects of cortisol in late pregnancy.
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8. Fetoplacental contribution: Due to unknown
factors fetal pituitary is stimulated that increases
the release of adrenocorticotropic hormone
[ACTH] and stimulates the fetal adrenal to secrete
cortisol that further accerates the production of
estrogen and prostaglandins from the placenta.

5 Enumerate the PRE-LABOR OR PREMONITORY

concept of pre-
labor or SIGNS OF LABOR:
premonitory Pre-labor may begin 2-3 weeks prior to the onset
signs of labor. of true labor in primipara and a few days before in
multipara. These signs are lightening, cervical changes,
taking up of cervix, increased frequency of macturition,
appearance of false labor pains, gastrointestinal upset,
premature rupture of membranes and energy spurt.
1. Lightening:
 A few days/weeks prior to the onset of labor,
presenting part sinks into the true pelvis.
 It is a welcome sign as it rules out cephalopelvic
disproportion and other conditions preventing the
head from entering the pelvic inlet.
2. Cervical ripening:
 The cervix becomes ripe, when cervix is soft, less
than 1.3 cm in length, admits one finger and is
dilatable.
3. Cervical effacement:
 It is a process by which muscular fibers of the
cervix are pulled upward and merge with the fibers
of the lower uterine segment.
 In primigravida, effacement precedes dilatation of
the cervix, whereas in multipara, both occur
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simultaneously.
4. Frequency of micturition:
 It means frequency of urination. It is due to
pressure by engaged presenting part.
5. Appearance of false labor pain:
 False labor pains consist of painful uterine
contractions that have no measurable progressive
effect on the cervix.
 It may be due to the stretching of cervix and lower
uterine segment with consequent irritation of the
neighboring ganglia.
 It may occur by 1-2 weeks prior to onset of true
labor pains in primipara and by a few days in
multipara.
6. Gastrointestinal upset:
 In the absence of any causative factors of
occurance of diarrhea, indigestion, nausea and
vomiting, it might be indicative of impending
labor.
 No explanation for this is known, but some women
do experience one to all of these signs.
7. Premature rupture of membranes {PROM}:
 Normally membranes rupture at the end of 1 st stage
of labor but in about 12 percent of women it may
rupture well before the onset of labor.
 Approximately, 80 percent of women with PROM
spontaneously experience onset of labor within 24
hours.
8. Energy spurt:
 Many women experience an energy spurt
approximately 24-48 hours before the onset of
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labor.
 There is no known explanation for this, other
than it is a nature’s way of giving the women the
energy she needs for the work of labor.
 Women should be informed about this and
advised her to conserve it for labor.
9. Late pregnancy feeling:
 Mood swings-both elation and depression in later
weeks occur just prior to onset of labor.

6. Explain about TRUE LABOR:

true labor pain The features of true labor pain are:
 Painful, rhythmic uterine contractions with
hardening of uterus.
 Progressive dilatation and effacement of cervix.
 Descent of the presenting part.

7. Differences DIFFERENCES BETWEEN TRUE

between true
labor and false AND FALSE LABOR PAINS
labor pain
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FEATURES TRUE LABOR PAIN FALSE LABOR
PAIN
Location of pain Lower abdomen and Lower abdomen only
back , radiating to
thighs
Characteristics of Intermittent in nature Pain is continous
pain with increased intensity, withput any
frequency and duration rhythmicity
Uterine changes Hardening of uterus due No hardening of
to relation of muscle uterus
fibers
Cervical changes Present Absent
{dilatation and
effacement}
Bag of waters Formed Not formed
Show Present Absent

8. Describe in ESSENTIAL FACTORS OF

detail about
essential
factors of LABOR
labor.

1.PASSAG
E

5.PSYCHO 2.PASSEN
LOGY GER

4.POSITIO
3.POWER
N
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I. PASSAGE {THE FEMALE
PELVIS}:
BONES OF PELVIS:
The pelvis is a skeletal ring often referred to as pelvic
girdle formed by two innominate [hip] bones, the sacrum
and the coccyx.
1. INNOMINATE [HIP] BONE:
 Each innominate [hip] bone is made up of three
bones:ilium, ischium and pubis.
i. ILIUM:
 It is large flared out part.The concave inner surface
is iliac fossa and curved upper border is the iliac
crest.
 At the front of iliac crest, there is bony prominence
known as anterior superior iliac spine and below is
anterior inferior iliac spine.
 On posterior side of iliac crest, similar bony
prominence called posterior superior and posterior
inferior iliac spine are located.
ii. ISCHIUM:
 Ischium forms parts of acetabulum above and the
thick lower part is the ischial tuberosity.
 The slight projection behind and just above the
tuberosity is called ischial spine.
 Ischial spine helps to assess the station of the head
during labor.
iii. PUBIS:
 It is a small bone that has a body and two
projections called superior ramus and the inferior
ramus.
 Two pubis bones meet at the symphysis pubis.
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 Two inferior rami form the apex of pubic arch.
2. SACRUM:
 The sacrum is a widge-shaped bone consisting
of five fused vertebrae and lies between the
two ilium on each side. The prominent upper
border is known as sacral promontory.
 The smooth concave anterior surface is
referred to as hallow of the sacrum and the
areas on either side are the alae or wings.
3. COCCYX:
 It is a small triangular bone which articulates
with the lower end of the sacrum.
 During labor the coccyx moves backward to
enlarge the pelvic outlet.

DIVISIONS OF PELVIS:
1. FALSE LABOR PAIN:
 It is the part of the pelvis situated above
the pelvic brim.
 It is formed by upper flared-out portion of
the iliac bones.
 Function of false pelvis is to support the
gravid uterus.
2. TRUE LABOR PAIN:
 It lies below the pelvic brim.
 The fetus passes through the bony canal
during labor.
 It is divided into three planes: brim, cavity and
outlet.
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a. Brim/inlet:
o It is the upper boundary of true pelvis.
It is bounded by upper margin of symphysis
pubis in front: linea terminalis on sides and
sacral promontory at back.
b. Cavity:
o It is circular in shape and it is the space
between the brim and that of outlet.
c. Outlet:
o It is diamond-shaped, bounded by lower
margin of symphysis pubis in front, ischial
tuberosities on sides and tip of sacrum
posteriorly.

PELVIC JOINTS:
 Sacroiliac joint-2
 Sacrococcygeal joint-1
 Symphysis pubis-1

PELVIC LIGAMENTS:
 Sacroiliac ligament
 Pubic ligament
 Sacrotuberous ligament
 Sacrospinous ligament
 Iliolumbar ligament

LANDMARKS OF PELVIS:
1) Symphysis pubis
2) Pubic crest
3) Pubic tubercle
4) Pectineal line
5) Iliopubic eminence
 6) Iliopectineal line
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7. Sacroiliac joint
8. Ala or wings of sacrum
9. Sacral promontory

TYPES OF PELVIS:
1. GYNECOID PELVIS:
 It is oval at the inlet, has a generous
capacity and wide subpubic arch.
 It is the typical female pelvis.
 Pelvic brim is a transverse ellipse and is
most favorable foe delivery.
2. ANDROID PELVIS:
 It is triangular in shape at the inlet with
narrow subpubic arch.
 It is a male-type pelvis.
 Pelvic brim is triangular.
3. ANTHROPOID PELVIS:
 It has an oval inlet but the long axis is
oriented vertically rather than side to side.
 It favors occiput posterior position.
 Pelvic brim is an anteroposterior ellipse.
4. PLATYPELLOID PELVIS:
 It is flattened at the inlet and has a
prominent sacrum.
 It favors transverse presentations.
 It is very short.
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DIAMETERS OF PELVIS:
1. BRIM OR INLET:
 Antero-posterior diameter:
 True conjugate/conjugate vera/anatomical
conjugate{11 cm}: It is the distance between
the midpoint of the sacral promontory to the
inner margin of the upper border of symphysis
pubis.
 Obstetric conjugate{10 cm}: Distance
between one sacroiliac joint to the opposite
iliopubic eminence. Right or left denotes the
sacroiliac joint from which it starts.
 Diagonal conjugate {12 cm}: Distance
between the lower border of symphysis pubis
to the mid-point on the sacral promontory.
 Oblique diameter {12 cm}: Distance between one
sacroiliac joint to the opposite iliopubic eminence.
Right or left denotes the sacroiliac joint from which
it starts.
 Transvers diameter {12 cm}: It is the distance
between the two farthest point on the pelvic brim
over the iliopectineal lines.
2. CAVITY;
 Anterio-posterior diameter {12 cm}: It measures
from the midpoint on the posterior surface of the
symphysis pubis to the junction of second and third
sacral vertebrae.
 Transverse diameter {12 cm}: It cannot be
measured as the points lie over the soft tissue
covering the sacrosciatic notches and obsturator
 formen.
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3. OUTLET:
 Anterio-posterior diameter {12 cm}: It extends
from the lower border of symphysis pubis to the tip
of coccyx.
 Transverse: There are two transverse diameters.
 A. Bispinous {10cm}: It is the distance between the
tips of two ischial spines.
 B. Intertuberous {11cm}:It is the distance between
the inner border of ischial tuberosities.

II. PASSENGER {THE FETAL

SKULL}:
The fetal skull is ovaid in shape. At term it is larger in
proportion to the other parts of the skeleton.

REGIONS OF FETAL SKULL:

 VERTEX: It is quadrilateral area bounded by the
anterior fontanel and coronal suture in front, the
posterior fontanel and lambdoidal suture behind
and longitudinal lines passing through the parietal
eminences laterally.
 BROW OR SINCIPUT: It is the area bounded
by the supraorbital ridges in front, the anterior
fontanel and coronal sutures behind and
longitudinal lines passing through the frontal
eminences laterally.
 FACE: It is area bounded by orbital ridges and
root of the nose to the junction of chin and neck.
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BONES OF FETAL SKULL:
 2 Frontal bones
 2 Parietal bones
 2 Temporal bones
 1 occipital bone

SUTURES OF FETAL SKULL:

Where two skull bones join is called sutures.
There are four sutures of obstetrical importance.
1) Frontal suture: Between two frontal bones.
2) Sagittal suture: Between two parietal bones.
3) Coronal suture: Between the frontal bone on one
side and the parietal bones on other side.
4) Lambdoidal suture: Between the parietal and
occipital bones.

FONTANELS:
Where two are more suture joins is called
fontanel. There are six fontanels on skull but only two are
of obstetrical importance:
1) Anterior fontanel: It is largest fontanel. It is the
junction of sagittal, frontal and coronal sutures. It is
diamond shaped with 2.5 cm length and 1.5 cm
width. Pulsations of cerebral vessels can be felt
through it. The fontanel closes by 18 months of age.
2) Posterior fontanel: This is located where the
sagittal suture meets the lambdoidal suture. It is
triangle shaped and measure about 1.2×1.2 cm and
smaller than anterior fontanel. It closes by 6 weeks
of age.
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DIAMETERS OF FETAL SKULL:
It has:
 Four transverse diameters
 Six anterioposterior diameters
1. TRANSVERSE DIAMETER: For memorizing
transverse diameters learn a mnemonic ‘Miss Tina
So Pretty’.
i. Biparital diameter [9.5cm]: Distance between
two parietal eminences.
ii. Super subparital diameter [8.5cm]: Extends
from a point placed below one parietal eminence
to a point placed above other parietal eminence of
the opposite side.
iii. Bitemporal diameter [8cm]: Distance between
anterioinferior ends of coronal suture.
iv. Bimastoid diameter [7.5cm]: Distance between
the tops of mastoid processes.

2. ANTERIO-POSTERIOR DIAMETER:
i. Suboccipit- bregmatic diameter [9.5cm]: It
extends from the nape of neck to enter of bregma.
ii. Submento-bregmatic diameter [9.5cm]: It
extends from junction of floor of mouth and neck
to the center of the bregma.
iii. Suboccipito-frontal diameter [10cm]: It starts
from nape of neck to the anterior end of anterior
fontanel or center of sinciput.
iv. Occipito-frontal diameter [11.5cm]: It extends
from the occipital eminence to the root of nose,
i.e. up to glabella.
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v. Sub-mento-vertical diameter [11.5cm]: It
extends from junction of floor of the mouth and
neck to the highest point on the sagittal suture.
vi. Mento-vertical diameter [14cm]: It extends
from junction of floor of mouth and neck to the
center of the bregma.

III. POWER:
I. UTERINE CHANGES:
A. FUNDAL DOMINANCE:
 Each uterine contraction starts in the fundus near
one of the cornua and spreads across downwards.
 The contraction lasts longest in the fundus where
it is also most intense, but the peak is reached
simultaneously over the whole uterus and the
contraction fades from all parts together.
B. POLARITY OF THE UTERUS:
 It is the neuromuscular harmony between upper
and lower pole of the uterus throughout the labor.
C. CONTRACTION AND RETRACTION:
 Contraction is temporary shortening of muscle
fibre followed by relaxation.
 Relaxation is regaining of original length of
muscle fibres.
 Retraction is a phenomenon of the uterus in labor
in which muscle fibre are permanently shortening
once and for all.
D. FORMATION OF UPPER AND LOWER
UTERINE SEGMENTS:
 Before the onset of labor, there is no complete
 anatomical or functional division of the uterus.
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 During labor the demarcation of an upper segment
and a relative passive lower segment is more
pronounced.

 The wall of the upper segment becomes

progressively thickened with progressive thinning
of the lower segment
 This is pronounced in late first stage, especially
after rupture of the membranes and attains its
maximum in second stage.
E. DEVELOPMENT OF RETRACTION RING
{BANDL’S RING}:
 When upper uterine segment contracts and
retracts, the lower segment thins out to
accommodate the presenting part and the ridge is
formed between upper and lower segment called
Bandl’s ring.

II. CERVICAL CHANGE:

A. CERVICAL RIPENING:
 Cervical ripening refers to the softening of the
cervix that typically begins prior to the onset of
labor and is necessary for cervical dilatation and
passage of the fetus.

B. CERVICAL EFFECEMENT:
 It is defined as the thinning of the cervix and
shortening of the cervical canal {normal length of
2-3 cms}.
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C. CERVICAL DILATATION:
 It is the process of enlargement of external os
from closed external os to permit passage of fetus
head.
 The full dilatation of cervix is 10 cm.
D. BLOODY SHOW:
 It is defined as mucus plug stained with blood is
known as bloody show.
 It is caused by separation of the membranes due to
over stretching of the lower uterine segment.

III. MECHANICAL FACTORS:

A. GENERAL FLUID PRESSURE:
 While the membranes remain intact, the pressure of
the uterine contraction is exerted on the fluid and as
fluid is not compressible, the pressure is equalized
throughout the uterus and the fetal body: it is known
as general fluid pressure or fetal axis pressure.
B. RUPTURE OF MEMBRANE:
 Rupture of membrane is a term used during
pregnancy to describe a rupture of the amniotic sac.
 Normally, it occurs spontaneously at full term either
during or at the beginning of labor.
 ROM is also known as ‘breaking the water’ or as
ones ‘water breaking’.
C. FETAL AXIS PRESSURE:
 In longitudinal lie there is tendency of straightening
out of the fetal vertebral column due to contractions
of circular muscles of the body of uterus, this exerts
pressure on cervix and dilates cervical canal.
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D. DESCENT OF THE PRESENTING PART:
 If there is no undue bony or soft tissue
obstruction, descent is a continuous process.
 It is slow or insignificant in first stage but
pronounced in 2nd stage.
 Presenting part is expected to reach the pelvic
floor by the time the cervix id fully dilated.

IV. POSITION:
 In the last half of the 20th century, the position
used most frequently for labor in the US has
supine in a hospital bed.
 The most common position for birth has been a
lithotomy position.
 Limited ambulation of laboring women resulted
from use of continuous fetal monitoring, routine
use of IV hydration, epidural anesthesia and use of
analgesia.

V. PSYCHOLOGY OF BIRTH;
 The progress of labor and birth can be adversely
affected maternal fear and tension.
 Norepinephrine and epinephrine may stimulate
both alpha and beta receptors of the myometrium
and interfere with the rhythmic nature of labor.
 Anxiety can also increase pain perception and lead
to an increased need for analgesia and anesthesia.
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2 Summary SUMMARY: L B They
minute I L understoo
Today we have discussed, Normal
s S A d the topic
intranatal period in that definition of normal T C
and abnormal labor, introduction of stages of E K
labor, causes of onset of labor, primordial N
signs of labor, differences between true and I B
false labor and in detail about essential factors N O
of labor. G A
R
D
2 Conclusion CONCLUSION:
minute
Labor is said to be normal if:
s
 Spontaneous in nature and occurs at
term.
 Fetus in vertex presentation.
 Completed in normal time period.
 Natural termination {minimal use of
instrumental aids}.
 No complications to mother and fetus.
Any change in criteria of normal labor is
described in above definition is called
abnormal labor or dystocia.
There are four stages of labor; i.e, first,
second, third and fourth stage of labor.
Essential factors are 5P’s Passage,
Passenger, Power, Position and psychology of
birth.
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BIBLIOGRAPHY:
1. Dutta D C, “TEXTBOOK OF
OBSTETRICS”, 8th edition, Jaypee
Brothers publication, New Delhi. Page
No: 134-167.
2. Kour Sandeep, TEXTBOOK OF
MIDWIFERY AND OBSTETRICAL
NURSING, CBS Publication, 1st edition,
2020-21, New Delhi, Page No:32-36,
62-64 and 136-138.