Mechanism of Labour

lecture notes= Normal labour
Normal labour
mechanism, management,
monitoring
Department Obstetrics UFS
standardised lecture
Lecture 4
The lecture of today is very wide and complex and cover a

number of chapters in your standard textbooks. It is,
however important for you to understand some of the
terminology, physiology, mechanics and definitions
1
Expectations after this presentation

• Diagnose onset of labour
• Understand phases of labour
• Understand the mechanics of delivery
• Monitor and document the progress of labour
• Understand and describe the principles in management of the labour
process
We will therefore discuss the following aspects in various

detail. This presentation will be available on blackboard,
therefore pay attention to understand the concepts
2
Diagnose labour
Regular uterine contractions that lead to

progressive effacement and dilatation of the
cervix
Although the standard text books have various definitions

for true labour, this can clearly be linked to uterine
contractions resulting in progressive effacement and
dilatation of the cervix that will allow expulsion of the
baby from the uterine cavity. Before onset of labour the
job of the cervix is to retain the pregnancy
3
Onset of Labour
• labor onset represents the culmination of a series of
biochemical changes in the uterus and cervix.
These result from endocrine and paracrine signals
emanating from both mother and fetus.
Biochemical switches from both the mother and the

maturing fetus are responsible for initiation of the
physiological changes that would result in expelling the
fetus to extrauterine existence. Onset of labour is
characterised by some unique biochemical changes
resulting in stimulating production of prostaglandin from
arachidonic acid in the fetal membranes. The increasing
levels of prostaglandin facilitates changes in the cervical
tissue and stimulates receptors on the muscle cells to
allow onset of contractions
4
Receptors on the uterine muscle cells for oxytocin,

thrombin and prostaglandin F combined with calcium
channels facilitating influx of calcium allows for
contraction of the cell by changing myosin to
phosphomyosin through action of the enzyme myocin
light chain kinase. This reaction is reversed with an
enzymatic phosphatase
5
Muscle cells after the contraction in labour does not relax

to the original length, but becomes progressively shorter
– a process called retraction – this results in the uterus
steadily pushing the fetus in the direction of the cervix.
The process of retraction is only present during
contractions after onset of labour.
Prior to labour there are uterine contractions without
retraction, known as Braxton- Hicks contractions and this
can sometimes also be painful.
6
Gap junction
As the labour process advance, the muscle cells start

to synchronise better through gap junctions induced
between the muscle cells, resulting in a synchronous
movement of calcium ions with more muscle cells
contracting simultaneously.
7
Biochemical changes of the cervix is take place to shift

from an organ keeping the contents of the uterus in the
uterus to allowing it to move outside the uterus.
Reduction in collagen together with other biochemical
changes result in progressive shortening and softening of
the cervix referred to as a process of effacement.
Here is a reflection of the histology of the cervix
demonstrating the changes in structure to the cervical
tissue.
8
STAGES of LABOUR
• First stage :
Onset of labour until full dilatation of cervix
• Second stage :
Full dilatation to delivery of baby
• Third stage:
Delivery of baby to delivery of placenta
True labour is therefore characterised by regular uterine

contractions that leads to progressive shortening and
opening of the cervix. The labour process could be divided
into various stages of labour. Some would argue that there
are 4 stages, Onset of labour to full dilatation, to delivery
of the baby, to delivery of the placenta and the high risk
period in the first hour after delivery.
9
Phases of 1st stage of labour
The first stage of labour could be divided into various

phases based on the characteristics of the cervix. During
the latent phase of labour physiological changes happen
preparing the cervix for expulsion of the baby through
progressive effacement or shortening with minimal
cervical dilatation. This is followed by a phase of active
cervical dilatation referred to as the active phase of
labour. Newer research have demonstrated that this phase
can effectively be identified with a cervical dilatation of 5
cm or more.
10
PHASES of FIRST STAGE of LABOUR

PHASE Definition ACTIVITY
Latent phase From onset of labour to 5 cm Progressive effacement of

dilatation the cervix
Active phase From 5-10 cm dilation Progressive dilatation of the

cervix
Deceleration From full dilatation to Decent of the fetus

phase delivery
The latent phase of labour is predominantly characterised

by cervical softening and effacement and is associated
with a very slow rate of cervical dilatation. After
completion of the cervical changes, the rate of dilatation
increases dramatically and is known as the active phase of
labour due to the active cervical dilatation. One can with
reasonable certainty diagnose active phase when the
cervix is 5 cm or more dilated. Just before delivery there is
a short period where the process slows down and is
referred to as the deceleration phase.
11
Assessment and documenting labour

• Diagnosis and progress can only be evaluated with a vaginal
assessment
Critical required information
Cervix- the length of the cervix (effacement)
- The opening of the cervix (dilatation)
Passage – clinical pelvimetry - impression of size
Passenger - Position of presenting part - occiput?
- descent of the presenting part
Vaginal examination is essential to detect (and assess)

various elements to assist with your diagnosis of labour
and progress of labour..
With the vaginal examination you can assess the status of
the CERVIX – including effacement and dilatation of the
cervix and the basic elements important to document
progress of labour.
12
Effacement refer to the length of the cervix that shorten

over time due to the structural changes induced with
onset of labour. The latent phase of labour is allowing for
shortening of the cervix until it is incorporated into the
lower segment of the uterus. There might be some cervical
opening during this phase, but accelerated dilatation of
the cervix is usually only noted after around 5 cm
dilatation.
13

assessment
Vaginal examination also allow you to assess the pelvis. A

Clinical pelvimetry will allow you to assess the adequacy of
the passage through which the baby must travel to the
outer world. You should be familiar with the various
diameters or structures to assess.
14
Birth canal
You will have to understand some aspects of the pelvic

anatomy. The female pelvis is adapted to allow easy
delivery of a baby through a more shallow and wider oval
pelvic cavity and a wide-angle pubic arch
15
• Pelvimetry is the measurement of the female pelvis.

• Clinical pelvimetry attempts to assess the pelvis by clinical
examination.
• Obstetric conjugate The line between the closest bony points of
the sacral promontory and the pubic bone next to the symphysis
• Interspinous distance The line between the closest bone points of
the ischial spines
To decide on the adequacy of the pelvis you need to assess

the obstetric conjugate as well as the interspinous
distance.
16
The obstetric conjugate can be assessed with a digital

vaginal assessment from the sacral promontory to the
symphysis pubis. The obstetric conjugate is 1,5 cm shorter
than the measured diagonal conjugate and reflects the
true diameter of the pelvic inlet.
17
The obstetric conjugate allow you to measure the size of

the obstetric inlet whereas the measurement from the
posterior rim of the symphysis to the tip of the coccyx
allow you to measure the anterior-posterior obstetric
outlet.
18
This slide demonstrates that there are different

dimensions as the baby moves throughout the pelvis, in
terms of anterior-posterior and transverse measurements
in the inlet, mid-pelvis and outlet.
19

assessment
The measurements of the pelvis cannot be seen in

isolation. There need to be some synchronisation between
the size of the passenger and the size of the passage. A
small pelvis may allow delivery of an even smaller baby
and a large pelvis may obstruct an even bigger baby and
therefore both the passage and passenger need to be
evaluated.
20
To assesses the fetus, we need to understand a little

about the fetal anatomy. The sinciput refer to the front of
the skull while the occiput refer to the posterior aspect.
The skull bones are not fused in a fetus to allow for
accommodating a growing brain. The anterior fontanel
where the frontal and parietal bones join together is large
and has a diamond shape. Posteriorly the occipital bone
fuse with he two parietal bones forming a triangular
structure..
21
Different diameters of the head have different

measurement measuring from 9,5 to 13 cm. Therefore the
position of the head determine the size that will pass
through the pelvis. The occipital and parietal bones are not
fused. This allows for some shaping of the head by
overlapping of skull bones under pressure, but the skull
base are immobile. The process of overlapping is called
moulding.
22
The position of the fetal head in relation to the fetal spine

allows for a natural flexion of the head by pivoting on the
spine- this will allow a smaller diameter to enter the pelvis.
If the baby remains in a military attitude, a larger diameter
will present
23
The vaginal examination can tell a lot about the baby. The
sutures and fontanelles can be felt with a digital
examination. With a bimanual examination, with one
hand on the lower abdomen and the other in the vagina,
the head can be felt like a ball between the examiners
hands. This can then be used to describe engagement or
descent of the fetal head.
24
During the bimanual examination, with the thumb of the

vaginal hand placed on the symphysis pubis, and the other
hand on the abdomen, descent of the head can be
described. With proprioception the examiner can estimate
the relationship of the fetal head and the symphysis pubis.
The head is described as fifths above brim where 5/5
above brim means the head is not yet engaged and 0/5
that the dead is fully descended into the pelvis. In the
uncompromised baby this will correlate with a term
station, describing the relationship of the lower part of the
head to the ischial spines. One should be cautious using
station alone to assess descent of the head if there is a
possibility of cephalo-pelvic obstruction as station may
change due to the moulding process.
25
Because the fetal skull bones encaging the brain is not

fused, with pressure moving through a small space, they
may overlap, a term called moulding. In a normal
uncomplicated delivery there may be some slight
moulding to allow the shape of the head to move through
the bony pelvis.
26
The overlap can be felt with a digital examination. A space

can be fetlt between the skull bones. If the space is
obliterated and skull bones feels together there are
minimal moulding. Moderate moulding is where you can
clearly feel the overlap, but but the bones could be pushed
apart with some pressure by the palpating finger; and
where the overlap cannot be pushed apart by the
palpating finger, the moulding is severe. Moulding is
graded between 0 and 3 plus. Excessive moulding can
result in fetal cerebral haemorrhage
27
Another feature of the fetal head that can be felt with

vaginal examination is caput. This is oedema of the fetal
scalp, often felt over the area where the head compress
against the cervix and is an indication of good quality
uterine contractions. In cases with severe cephalo-pelvic
disproportion a broader oedema can develop due to
prolonged pressure against the bony structures. Caput is a
normal phenomena and will resolve without any
intervention. In the slide you can see the oedema that
developed where the cervix compressed against the fetal
head
28
Rarely pressure on the fetal head could cause bleeding

between the skull and the periosteum. This is called a
cephalhematoma. Note that the periosteum is adherent to
the bone and the cephalhematoma does not cross the
suture.
29
The position of the presenting fetal head can be described

by the sutures and fontanel that you have felt. The occiput
is the normal reference point. The most common position
is a left or right occipito anterior position. Monitoring the
fetal head position will allow you to document progress of
the delivery. Occipito posterior positions often result in
prolonged difficult deliveries.
30
MECHANISM OF LABOUR
• Decent
• Flexion
• Internal rotation
• Restitution
• External rotation
• Delivery of the body
To assist with a normal delivery and assess progress, you

need to understand the mechanism of labour. In all cases
the following routine happens as the baby moves through
the bony pelvis, starting with descent of the presenting
part and ending with delivery of the body of the baby.
31
As we already mentioned the different levels of the pelvis

has different measurements and therefore continuous
change is needed to allow passage of the baby through the
bony pelvis
32
As the head move into the pelvis in a transverse or

oblique position, pressure on the head allows for a natural
flection and therefore reducing the diameter of the head.
The head moves further into the pelvis and the shape of
the pelvis changes towards the mid pelvis, the head
rotates in the pelvis towards an anterior-posterior
position. With further pressure and the head following the
natural pathway, the head need to extend to move the
face along the coccyx curve. With the head now moving
below the symphysis the head is delivered through
extension
33
Once the head is delivered, now at a skew angle to the

shoulders, external rotation take place to restore the
position called restitution whereafter the head further
rotates as the shoulder now rotates through the bony
pelvis
34
This slide just represent the movement of the fetal head

through delivery of an occipito anterior position. We have
broken down the different steps of a continuous 3
dimentional process for ease of understanding
35
In case of delivery of an occipito posterior position of the

fetal head, the occiput need to move through a long
rotation to an anterior position for a normal delivery
resulting in a longer delivery process
36
Asynclitism is a term used when the head deflects either

anteriorly or posteriorly from the midline and may result in
cephalo-pelvic disproportion even in a normal size uterus
37
Video MECHANISM OF LABOUR
This video demonstrates the continuous process of

movement throughout the delivery process+
Decent
Flexion
Internal rotation
Restitution
External rotation
Delivery of the body
38
MANAGING THE NORMAL LABOUR PROCESS

Admission of woman in labour
• Careful review ANTENATAL RECORD - gestational age & risk
• Note nature of labour pains, show, vaginal bleeding, liquor and other
relevant symptoms
• General examination
• Abdominal examination
• Fetal lie, presentation and attitude
• Level of presenting part (5ths above brim)
• Uterine contractions – duration and frequency
• Fetal heart before/after contraction
Understanding how delivery takes place the require that

you need to understand how to manage someone in
labour.
On admission to the labour ward, it is important to review
the pregnancy status and risk by reviewing the antenatal
record. If this is not known – she must be clerked as you
would for an antenatal first visit.
If she presents to the labour ward, you need to assess her
properly through an proper physical examination in
addition to the vaginal examination to assess the labour
process.
39
Vaginal Examination
• External
• Cervix
• Membranes
• Presenting part
Special investigations
• Urine dipstick
• Hb
• If unbooked – rapid Rh
• HIV counselling & testing – if not known
That includes a vaginal examination and some special

investigations where appropriate. You now need to be able
to determine if she is in labour or not, the fetal lie,
position and status of the baby and any potential risks that
may be anticipated throughout the delivery process.
If the Hb, HIV status and Rh Factor is not known at onset of
the labour, this should should be repeated as a point of
care assessment.
40
10 min
Uterine contractions need to be assessed and is described

as the number of contractions in a 10 minute period, and
the duration of each of the contractions in seconds. This is
done with an abdominal examination timing when the
uterus tighten until it relaxes. The use of a cardiotocograph
does not measure the quality of contractions
41
GENERAL CARE DURING LABOUR

• Respect privacy & companionship
• Diet/fluids –normal eat/drink high risk IV Ringers @80ml/h
• Motility/posture
• Enema/Pubic hair removal – not needed
• Artificial rupture membrane
• Pain management
• Companionship
• Pethidine 100mg/promethazine 25 mg IMI
• Entonox
• Epidural
Early in labour you will allow normal fluid intake and

encourage movement. No other interventions is required
other than pain relief if needed. Good companionship is
important in reducing the pain experience of the woman,
but you may have to prescribe some analgesics. In a high
risk patient, intravenous fluids may be needed at a rate not
exceeding 80-100 ml per hour.
42
In the national maternity case record, there are specific

information regarding delivery and labour that need to be
documented on a standardised form available within the
record. Accurate completion of this page is important as it
summarises her risk factors and important antenatal
findings including her current gestational age- this must
always be checked against the earliest estimate of
gestational age. It is important to make a diagnosis,
identify risk and draft a delivery plan.
43
The format will prompt you for all the findings of the
physical examination including the abdominal
examination and vaginal findings. It is important to also
document the presenting part and position, presence of
moulding and visible meconium in the amniotic fluid.
44
PARTOGRAM
After the initial assessment, all formal assessments need

to be carefully documented. The record make provision for
such assessments including the date, time and detail of
the examination. It also prompts for comment on the
progress of labour and condition of the mother and fetus
45
Partogram
The labour progress need to be documented on a

partogram. This will visually reflect progress during the
labour. This partogram is attached to the latest version of
the maternity case record book.
46
On the partogram there is again space for the gestation

and risk factors. The chart have space for a timeline and
clinical parameters such as the fetal heart, Liquor,
moulding and caput as well as the cervical changes. There
is a clear distinction between the Latent phase of labour
and the active phase of labour
47
The previous version of the partogram had a solid line

from 3 cm cervix dilation at a rate of 1 cm/hour - this was
referred to as the alert line with the assumption that the
active phase of labour starts at when she is 3 cm dilated.
An action line was drawn 2 hours later parallel to the alert
line.
48
MS1 1600 1700 1800 1900 2000 2100 2200
More recent research have demonstrated that more

reliably accelerated cervical dilatation occur only after the
cervix is dilated around 5 cm. and that the latent phase
may have a longer duration. To start a partogram you need
to make sure she is in labour – therefore there is regular
contractions resulting in cervical changes. If you are unsure
early in the labour process, reassess her 4-6 hour later and
if the cervical dimensions changes, then make the
diagnosis of in labour. This version of the partogram has 3
parallel lines from 5 cm dilation 2 hours apart. The first is a
warning that the active phase of deceleration is slower
than expected. If you are remotely away from a designated
caesarean section site, crossing the refer line will prompt
you to refer to a comprehensive obstetric site
49
The initial documentation should be on the most left line.

Document the cervix length with a solid line, the cervical
dilatation with an x and the head above brim with a circle.
The timeline is important and must continue HOURLY from
the first documented time
49
Slide 49
MS1 ost
Marthinus Schoon, 2020/09/16
This is an example of documenting examination findings

on a partogram.
The initial documentation start on the left line at 06h00.

the time must increase chronologically at hourly intervals
as the lines represent 1 hour intervals. The space left of
the dark vertical line in the middle of the page is the
LATENT PHASE of labour
Once the cervix dilatation is 5 cm or more, transfer that

data to the solid warning line of the active phase of labour
including the time and other observations on that
timeline. From here the timeline continues hourly. Normal
50
progress during labour should be reflected to the left of the

warning line. The number and duration of uterine
contractions are also documented
50
Initial assessment
In Labour Unsure Not in labour
Latent phase of labour Active phase of labour
Labour process progress Poor progress
Obstructed labour Dysfunctional contractions
In summary, to assess progress of labour there are a few

questions you need to ask and answer
1- is she in labour or not – she is in labour if she has
regular contractions with progressive cervical
changes(softening, effacement and dilatation of the servix
– If you are unsure, delay the diagnosis of labour and
reassess her in 4-6 hours
2. If she is in labour – is she in latent or active phase of
labour – If her cervix is 5 cm or more she is in active
labour. (Please note that this is the new definition and
differ from standard text books)
3. If she is in the active phase of labour – does she
progress normal or not – If her cervical dilatation rate is
1cm per hour or faster, she progress normal
51
4. If she progress abnormal (slower than 1 cm per hour) is

there cephalo-pelvic obstruction or not- you need to assess
for Moulding and caput. Absence of moulding, especially
with irregular or few contractions may be associated with
dysfunctional contractions
51
Management second stage of labour

• Allow head to descend to pelvic floor ( 2 hrs)
• Empty bladder
• Encourage bearing down when head start to distend perinium
• Woman has urge to push

• Communicate & support
• Appropriate position
• Listen to fetal heart
• Protect perineum
• Deliver baby – assess APGAR score
• Clamp cord -1-2 minutes
Once fully dilated, the delivery process is on its way. You

can allow up to two hours for the head to descend to the
pelvic floor. Encourage her to empty the bladder but you
may need to assist with a catheter. Once the head have
descended, she will develop an urge to bear down. At this
stage an appropriate position and support of the perinium
is needed.
52
Controlled dilatation of the perinium is important to

prevent tears developing. Here we can see the head
crowning and how the midwife support the perinium
53
video
Once the head delivers allow restitution and support

delivery of the body of the baby
54
Management 3rd stage labour

• Prevent excessive bleeding – active
management
• After delivery –palpate uterus
• Give oxytocin 10E IMI
• Feel for contraction – signs of placenta
release
• Steady tension on cord with upward
pressure on uterus
• Examine placenta for completeness
After delivery of the baby, active delivery of the placenta is

needed to reduce the risk of haemorrhage. This entails
giving the mother an oxytocic after confirming there is no
undiagnosed twin to stimulate uterine contraction. With
firm traction on the umbilical cord and upward uterine
pressure, the placenta is delivered speedily
55
Remember that the bleeding from the uterus is controlled

through muscles constricting the blood vessels to the
placental bed, and therefore a contracted uterus is
essential to prevent unnecessary blood loss.
56
Inspect the placenta for completeness as a retained

cotyledon or membranes may prevent the uterus from
contracting and can result in immediate or delayed
postpartum haemorrhage
57
First hour after delivery

• At risk for haemorrhage
• Check Heart rate, BP, Respiration rate
• Uterus well contracted
• Show mother how to rub uterus
• Assist with baby – skin-to-skin, breast feeding
• Repeat BP pulse
• Give mother light meal/ something to drink
• Transfer to postnatal ward
The first hour after the delivery is regarded as an

important time, and many refer to this time as the 4th
stage of labour. Monitoring vital signs to assist early
detection bleeding is important. During this time also
spend time with the mother to ensure that there is skin to
skin contact with the baby and put the baby to the breast-
suckling will help with uterine contraction. Also teach the
mother to periodically rub her uterus to maintain a
contracted uterus.
Postpartum bleeding may be subtle and therefore an
increase in pulse rate may be the first sign to alert of a
postpartum bleeding.
58
Nation-wide an colour coded early warning chart have

been implemented to assist staff to identify the person at-
risk. The basis of this chart is that if there is any 2
observations in an amber area, or any one observation in a
red area, the next level of expertise need to be contacted
for advice/ assessment. If the midwife record a reading
within the red zone the doctor need to be informed or if
an intern identify the problem in the red zone the registrar
need to be informed. Once the next level is informed a
proper assessment and management plan must be
implemented
59
MS2
FEW RULES
• SUN = never let the sun rise of fall twice during labour
• Rule of the P’s
• Patient
• Pain relief
• Physiological status –hydration
• Psychological status and support
• Partner
• Passenger
• Passage
• Powers
As this is a very wide topic, many of the practical issues

will be shown during your rotation and mandatory
delivery of babies, I want to highlight two important rules.
Rule 1: Never let the sun rise or fall twice on someone in

true labour- if you do you are probably missing something
important and need advice from a specialist
Rule 2: When you assess a person in labour, follow the rule

of the P’s – by carefully attending to these aspects you will
be able to monitor and manage someone in labour
60
Slide 60
MS2 Marthinus Schoon, 2022/05/18

Aspects not covered

• Perform and suture episiotomy
• Referral communication
• Delivery safety checklists
• Cleanliness and sterility
There are some aspects not covered in this discussion but

would require some reading or knowledge. Additional
reading that you should engage in is the national maternity
care guidelines. A copy of this is uploaded on your
resources on the blackboard platform
This should enable you to form the basis for conducting

normal deliveries. This will be expected in the next
semester practical exposure.
61

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lecture notes= Normal labour

The lecture of today is very wide and complex and cover a

Expectations after this presentation

We will therefore discuss the following aspects in various

Regular uterine contractions that lead to

Although the standard text books have various definitions

Biochemical switches from both the mother and the

Receptors on the uterine muscle cells for oxytocin,

Muscle cells after the contraction in labour does not relax

As the labour process advance, the muscle cells start

Biochemical changes of the cervix is take place to shift

True labour is therefore characterised by regular uterine

Phases of 1st stage of labour

The first stage of labour could be divided into various

PHASES of FIRST STAGE of LABOUR

Latent phase From onset of labour to 5 cm Progressive effacement of

Active phase From 5-10 cm dilation Progressive dilatation of the

Deceleration From full dilatation to Decent of the fetus

The latent phase of labour is predominantly characterised

Assessment and documenting labour

Vaginal examination is essential to detect (and assess)

Effacement refer to the length of the cervix that shorten

Assessment and documenting labour

Vaginal examination also allow you to assess the pelvis. A

You will have to understand some aspects of the pelvic

• Pelvimetry is the measurement of the female pelvis.

To decide on the adequacy of the pelvis you need to assess

The obstetric conjugate can be assessed with a digital

The obstetric conjugate allow you to measure the size of

This slide demonstrates that there are different

Assessment and documenting labour

The measurements of the pelvis cannot be seen in

To assesses the fetus, we need to understand a little

Different diameters of the head have different

The position of the fetal head in relation to the fetal spine

During the bimanual examination, with the thumb of the

Because the fetal skull bones encaging the brain is not

The overlap can be felt with a digital examination. A space

Another feature of the fetal head that can be felt with

Rarely pressure on the fetal head could cause bleeding

The position of the presenting fetal head can be described

To assist with a normal delivery and assess progress, you

As we already mentioned the different levels of the pelvis

As the head move into the pelvis in a transverse or

Once the head is delivered, now at a skew angle to the

This slide just represent the movement of the fetal head

In case of delivery of an occipito posterior position of the

Asynclitism is a term used when the head deflects either

Video MECHANISM OF LABOUR

This video demonstrates the continuous process of

MANAGING THE NORMAL LABOUR PROCESS

Understanding how delivery takes place the require that

That includes a vaginal examination and some special

Uterine contractions need to be assessed and is described

GENERAL CARE DURING LABOUR

Early in labour you will allow normal fluid intake and

In the national maternity case record, there are specific

After the initial assessment, all formal assessments need

The labour progress need to be documented on a

On the partogram there is again space for the gestation

The previous version of the partogram had a solid line

MS1 1600 1700 1800 1900 2000 2100 2200

More recent research have demonstrated that more