NORMAL LABOR

DALAL ALJARRAH
CONSULTANT IN OBS & GYNE
DEFINITION

Labor is a physiologic process during which regular painful

contractions bring about effacement and dilatation of the cervix and
descent of the presenting part, leading to expulsion of the fetus,
membranes, and placenta from the uterus
ONSET OF LABOR….DIAGNOSIS OF LABOR

The onset of labor can be defined as regular painful uterine contractions

bringing about progressive cervical dilatation and effacement.
+\- "show" (blood stained plug of mucus passed from the cervix)
+\- spontaneous rupture of membranes
Both are not define the onset of labor because labor can occur before either of
these events occurs, and both may precede labor by many days
UNDERSTANDING THE PATHOPHYSIOLOGY

1 • Hormonal factors
2 • The myometrium
3 • The cervix
UNDERSTANDING THE PATHOPHYSIOLOGY
1. Hormonal factors:-
• Progesterone maintains uterine quiescence by suppressing prostaglandin production,
inhibiting communication between myometrial cells, and preventing oxytocin release.
Estrogen opposes the action of progesterone. Prior to labor, there is reduction in
progesterone receptors and an increase in the concentration of estrogen relative to the
progesterone. Oxytocin release from the pituitary and Prostaglandin synthesis by the
chorion and the decidua also increase leading to an increase in calcium influx into the
myometrial cells. This change in the hormonal milieu also increases gap junction
formation between individual myometrial cells.
• Maternal corticotrophin releasing hormone CRH increases in concentration toward term
and potentiates the action of prostaglandin and oxytocin on myometrial contractility.
• Fetal produced cortisol may contribute to the conversion of progesterone to estrogen.
• As labor becomes established, the output of oxytocin increases through the Fergusson
reflex; pressure from the fetal presenting part against the cervix is relayed via a reflex arc
involving the spinal cord and results in increased oxytocin release from the posterior
pituitary.
2. The myometrium:-
• Myometrial cells contain filaments of actin and myosin which interact and bring
about contraction, this contraction requires increased availability of intracellular
calcium which may be provoked by oxytocin and PGF2α. There is cell-to-cell
communication by means of gap junction, which facilitates the passage of various
products of metabolism and electrical current between cells these gap junctions are
absent for most of the pregnancy but appear in significant numbers at term. Gap
junctions increase in size and number with the progress of labor and tend to disappear
afterwards. Prostaglandins stimulate their formation, while beta-mimetics do the
opposite.
• Retraction is a major feature of uterine contractility during labor, after the cells
contract they relax but they do not return to their original length, this leads to the
development of the thicker active contracting segment in the upper portion of uterus.
At the same time, the lower segment of uterus becomes thinner and more stretched,
eventually this results in the cervix being taken up into the lower segment of the uterus
so forming a continuum with the lower uterine segment during progress of labor.
3. The cervix:-
The cervix contains muscle cells and fibroblasts separated by a ground
substance made up of extracellular matrix molecules; Interactions between
collagen and fibronectin during the earlier stages of pregnancy keep the
cervix rigid and closed. Contractions at this point do not bring about
effacement or dilatation of the cervix. Under the influence of prostaglandins
PGE2, and other humoral mediators, there is an increase in proteolytic
activity and collagen turnover. This causes cervical shortening or ripening
so that contractions when they begin can bring about the processes of
effacement and dilatation of the cervix.
 STAGES OF LABOR
3
First stage

Second stage

Third stage
FIRST STAGE OF LABOR
1ST STAGE OF LABOR
 SECOND STAGE OF LABOR
Begins with complete cervical dilatation and ends with the delivery of
the fetus(s)
May also be subdivided into 2 phases,
The “passive phase” is where there is no maternal urge to push and the fetal
head is still relatively high in the pelvis
The second phase “active second stage” there is maternal urge to push because
the fetal head is low, causing a nerve reflex need to bear down. In normal labor
second stage is often diagnosed at this point because the maternal urge to push
prompts the midwife to perform a vaginal examination.
 THIRD STAGE OF LABOR

• The period between the delivery of the fetus(s) and the delivery of the
placenta(e) and fetal membranes
• Delivery of the placenta often takes less than 10 minutes, but the third stage
may last as long as 30 minutes
• The third stage of labor is considered prolonged after 30 minutes, and active
intervention is commonly considered
 Characteristics Primigravida Multipara

Duration of 1st stage 6-18 hours 2-12 hours

Cervical dilatation rate during active phase 1 cm /hour 1.5 cm/hour

30 minutes to 2 hours (3hr in 5-30 minutes to1hr (2hr in

Duration of 2nd stage
epidural analgesia) epidural analgesia)

Duration of 3rd stage of labor 30 minutes 30 minutes

DEFINITIONS
 LIE

Relationship between long axis of fetus to the longitudinal axis of mother

1. Longitudinal lie(found in 99% of labor at term)
2. Transverse lie
3. Oblique lie
 PRESENTATION
The part of the fetus that lies closest to the pelvic inlet and in
relation to the cervix……3 presentations

Cephalic presentation

Breech presentation

Shoulder presentation
1. Cephalic presentation: When the head occupies the lower uterine segment
(96% of pregnancies at term)
 if the head well flexed it will be vertex presentation
 if the head partly extended it will be brow presentation
 if the head is fully extended it will be face presentation
(vertex is that part between the two fontanels and the two parietal bones)
2. Breech presentation 3%: If the buttocks occupy the lower segment.
 Frank breech
 Complete breech
 Footling breech
3. Shoulder presentation: If the fetus in oblique or transverse lie
the presentation is shoulder presentation 0.3%

Any things other than vertex presentation described as

malpresentation
a b c

d e
 POSITION
Relationship between fetal denominator and the maternal pelvis
The denominator varies according to the fetal presentation,
• In vertex presentation the dominator is the occiput,
• In face presentation it is the chin (mentum)
• In breech presentation it is the sacrum
6 positions are described for each presentation, example with vertex
presentation, the occiput could be related to:-
 ATTITUDE:- RELATIONSHIP OF FETAL PARTS TO EACH
OTHER(FLEXION\EXTENSION)

Well flexed (vertex) partialy flexed(bregma) partially extend(brow) well extend(face)

Suboccipito-bregmatic occipito-frontal occipito-mental submento-bregmatic
9.5cm 11.5cm 13.0cm 9.5cm
 Synclitism:- Asynclitism is that the sagittal sutures of the head
deflects ant towards the symphysis pubis or post towards the
sacrum

POSTERIOR ASYNCLITISM NORMAL ANTERIOR ASYNCLITISM

Frequency of presentations and positions at term:-

► Vertex → 96% (2\3 left occiput position and 1\3 right occiput)
► Breech → 3%
► Face → 0.2%
► Shoulder→ 0.3%
MECHANISM OF LABOR IN VERTEX
PRESENTATION
This refers to the series of changes in position and attitude that the fetus undergoes
during its passage through the birth canal.
As the occipitolateral position of the fetal head is the most common, the mechanism of
labor in this position would be discussed.
The cardinal movements are described as the following 8 discrete sequences :
• Engagement
• Descent
• Flexion
• Internal rotation
• Extension
• Restitution
• External rotation
• Expulsion
 1. ENGAGEMENT
• The head normally enters the pelvis in the occiput transverse position
60% (LOT in 40%), , so taking advantages of the widest pelvic diameter,
and then rotates as it passes through the pelvis by 90° clockwise to an
occiput anterior (OA) position
• Engagement is said to have occurred when the widest part of the
presenting part (biparietal diameter BPD) has passed through the pelvic
inlet or brim.
• Engagement has occurred in the vast majority of nulliparous women prior
to labor, usually by 37 weeks’ gestation, while in multigravida, it may
occur only during the first stage of labor.
• The indicators of engagement of fetal head is by abdominal/vaginal
examination as follows:-
 RULE OF FIFTH
The number of fifths of the fetal head palpable abdominally is often used to
describe whether engagement has taken place; if more than two-fifths of the fetal
head is palpable abdominally the head is not yet engaged. When 2/5 or less palpable
then the head is engaged.
Engaged
Vaginal examination reveals the descent of fetal head in relation to the
ischial spines. In case of an engaged head, lower pole of the head is at or
below the ischial spines.
WITH CEPHALIC PRESENTATION ENGAGEMENT IS
ACHIEVED WHEN THE PRESENTING PART IS AT OR
BELOW 0 STATION ON VAGINAL EXAMINATION
(LEVEL OF ISCHIAL SPINE) AND 2\5 OR LESS PALPABLE
BY ABDOMINAL EXAMINATION
• Engagement of the fetal presenting part is of great
importance as it helps in ruling out cephalo-pelvic
disproportion CPD.
 2. DESCENT:

Occurs progressively during labor secondary to

contraction and retraction of myometrium
 3. FLEXION:
As the head descends into the narrower midpelvis, flexion occur. This passive movement occurs due to:
1. Any ovoid body being pressed through a tube tends to adapt its long diameter to the long
axis of the tube
2. The so called head lever, the occipito-spinal joint is nearer to the occiput than to the sinciput
(forehead) so the head can be regarded as a lever with a long anterior and short posterior
arm. When the fetal breech is pressed on by the uterine fundus the fetus is subjected to axial
pressure and the lever comes into play.
The long anterior arm meets the pelvic floor with more resistance than
the short posterior arm and so the head undergoes flexion.

Flexion is important in minimizing the presenting diameter of the

fetal head from occipito-frontal diameter = 11.5cm to
suboccipito-bregmater diameter= 9.5cm into engagement
 4. INTERNAL ROTATION
If the head is well flexed, the occiput will be the leading point and it will meet the sloping gutter
of the levator ani muscles before the sinciput, which by their shape and action (the muscles)
rotate the occiput anteriorly so that the sagittal suture now lies in the AP diameter of the pelvic
outlet (i.e. the widest diameter. In the occipito-lateral position, there is anterior rotation of the
fetal head by two-eighths of the circle resulting in development of similar amount of torsion on
fetal neck.
►Note. any part hits the levator ani muscle first will rotate anteriorly.
 5. EXTENSION:
Following internal rotation, the occiput is underneath the symphesis pubis
The well flexed head now extends and the occiput escapes from underneath
the symphesis pubis and distends the vulva, this is known as "crowning" of
the head.
The head extends further and the bregma, forehead, face, and chin appear
in succession over the posterior vaginal opening and
perineal body. This extension minimizes soft tissue
trauma by utilizing the smallest diameter of the head
for the birth(the sub-occipito-frontal diameter =10cm).
 6. RESTITUTION:
When the head is delivering, the occiput is directly anterior. As soon as the head escapes from
the vulva the head aligns itself with the shoulders which have entered the pelvis in the oblique
position. Following the delivery of fetal head, the neck, which had undergone torsion,
previously, now untwists and aligns along with the long axis of the fetus.
This slight rotation of the occiput through one/eighth of the circle is called restitution.
 7. EXTERNAL ROTATION:
In order to be delivered, the shoulders have to rotate into the direct AP
plane (the widest outlet diameter). When this occurs, this movement is
visible outside in form of the external rotation of fetal head through a
further one/eighth of a circle. The occiput rotates to the transverse
position. This is called external rotation.
 8. EXPULSION:

Delivery of the shoulders and fetal body. The anterior

shoulder is under the symphesis pubis and delivers first, and
the posterior shoulder delivers subsequently. Normally the
rest of body delivered easily