Normal Labor and Delivery

Dr Narine Singh MBBS ,MSc

 Normal Labor and Delivery
• Definition of labor
• Factors influencing progress of labor
• Diagnosis of labor
• Stages of labor
• Mechanism of labor
• Management of labor
 Normal Labor
In order to maximize the patient chance of a
vaginal delivery ,it is important to understand
the basics of labor
• Stages of labor
• Mechanics of labor
• Cardinal movements of labor
• delivery
 What is Labor
Labor is a physiologic process during which the
products of conception (i.e. viable fetus
,membranes ,umbilical cord and placenta) are
expelled from the uterus
More specifically, Labor requires the onset of
regular ,effective contractions that lead to
progressive cervical effacement and dilatation of
the cervix accompanied by descent of the
presenting part
 What is Labor
• The World Health Organization (WHO) defines
normal birth as "spontaneous in onset, low-
risk at the start of labor and remaining so
throughout labor and delivery. The infant is
born spontaneously in the vertex position
between 37 and 42 completed weeks of
pregnancy. After birth, mother and infant are
in good condition"
 Normal Labour
Labour is normal when it is
• Spontaneous in onset
• At term (37 completed weeks-42 weeks)
• Single fetus
• Vertex presentation
• Within a reasonable time(not less than 3 hrs
or more than 18 hrs.)
• Without complication to the mother or the
fetus
 Normal Labour
• Any deviation from this definition is abnormal
• In late pregnant ,strong contraction can sometimes be
palpated that do not produce cervical dilatation ,even
when the cervix is normal and these do not constitute
true labour (Braxton – Hick)
• Cervical dilatation in the absence of uterine
contraction suggest cervical insuffiiciency,whereas
uterine contraction without cervical change does not
meet the definition of labour
• Delivery refers to the actual birth of the fetus
 Normal labor

Braxton –Hick uterine contraction are

contractions occurring prior to the onset of
labor and not associated with cervical change
Occur early in the middle trimester of pregnancy
• Shorter in duration
• Less intense
• Over lower abdomen and groin
• Resolves with ambulation
 Normal Labor
• Cervical dilatation alone does not confirm
labor since many women (esp. multiparous)
will demonstrate some dilatation (1-3 cm) for
weeks and months prior to the onset of true
labor
 Onset of labour
• Based on the naegel’s formula ,labour starts
approximately as follow
• In the expected date of delivery (EDD) in
40%of cases
• One week on either side in 50% of cases
• Two weeks earlier and one week later in
80%of cases
• At 42 weeks in 10%of cases
• At 43 weeks plus in 4% of cases
 Causes of onset of labour
The actual cause for the onset of labor is not
exactly known ,but several theories have been
postulated but none of them is completely
proven
• Hormonal factors
• Mechanical factors
 Labor can occur at

• Preterm labor --- prior to 37 weeks

• Term --- 37-42 weeks
• Post term --- after 42 weeks
 Onset of labour
Hormonal factors Mechanical factors
• Estrogen theory • Uterine distension theory
• Progesterone withdrawal
theory
• Prostaglandin theory
• Oxytocin theory
• Fetal cort
 Hormonal factors
• Estrogen theory
• Progesterone withdrawal theory
• Prostaglandin theory
• Oxytocin theory
• Fetal cortisol theory
 Stages of labour

Obstetricians have divided labour into 3 stages

that delineate milestones in a continuous
process
 Stages and Phases of labor
• The first stage begins with the onset of labor
and ends with full cervical dilation .
• Friedman subdivided the first stage into latent
and active phases
 First Stage of Labor
• The Latent phase begins with regular uterine
contractions and ends when there is an increase in
the rate of cervical dilation (usually at 3 to 4 cm of
dilation in a nulliparous woman and 4-5 cm in a
parous woman) . Cervical length should usually be
<1 cm .
• The onset of the latent phase is often difficult to
define. According to Friedman the onset of the
latent phase is define as the point at which the
mother perceives regular contraction
 First Stage of Labor
• During the latent phase, irregular contractions
become progressively better coordinated,
discomfort is minimal, and the cervix effaces
and dilates to 4 cm.
• The latent phase is difficult to time precisely,
and duration varies, averaging 8 h in nulliparas
and 5 h in multiparas; duration is considered
abnormal if it lasts > 20 h in nulliparas or > 12
h in multiparas.
 First Stage of Labor
• The active phase is characterized by an increase
in rate of cervical dilation and descent of the
presenting fetal part .It ends with complete
cervical dilation ,and is further subdivided into :
• Acceleration Phase A gradual increase in the
rate of dilation initiates the active phase and
marks a change in rapid dilation
• Phase of maximum slope, The period of active
labor with the greatest rate of cervical dilation
 First Stage of Labor
• Deceleration Phase . During the terminal portion of the active
phase ,the rate of dilation may slow until full cervical dilation

• During the active phase, the cervix becomes fully dilated, and
the presenting part descends well into the midpelvis.
• On average, the active phase lasts 5 to 7 h in nulliparas and 2 to
4 h in multiparas.
• Traditionally, the cervix was expected to dilate about 1.2 cm/h
in nulliparas and 1.5 cm/h in multiparas.
• However, recent data suggest that slower progression of
cervical dilation from 4 to 6 cm may be normal .
• Pelvic examinations are done every 2 to 3 h to evaluate labor
progress.
• Lack of progress in dilation and descent of the presenting part
may indicate dystocia (fetopelvic disproportion).
• During the 1st stage of labor, maternal heart
rate and BP and fetal heart rate should be
checked continuously by electronic monitoring
or intermittently by auscultation, usually with
a portable Doppler ultrasound device
• Women may begin to feel the urge to bear
down as the presenting part descends into the
pelvis.
• However, they should be discouraged from
bearing down until the cervix is fully dilated so
that they do not tear the cervix or waste
energy.
• Cervical dilation is recorded in centimeters as the diameter of a circle; 10
cm is considered complete.
• Effacement is estimated in percentages, from zero to 100%. Because
effacement involves cervical shortening as well as thinning, it may be
recorded in centimeters using the normal, uneffaced average cervical
length of 3.5 to 4.0 cm as a guide.
• Station is expressed in centimeters above or below the level of the
maternal ischial spines. Level with the ischial spines corresponds to 0
station; levels above (+) or below (−) the spines are recorded in cm
increments. Fetal lie, position, and presentation are noted.
• Lie describes the relationship of the long axis of the fetus to that of the
mother (longitudinal, oblique, transverse).
• Position describes the relationship of the presenting part to the maternal
pelvis (e.g, occiput left anterior [OLA] for cephalic, sacrum right posterior
[SRP] for breech).
• Presentation describes the part of the fetus at the cervical opening (e.g,
breech, vertex, shoulder
 Mechanism of labor
• The mechanisms of labor, also known as the
cardinal movements, involve changes in the
position of the fetus’s head during its passage
in labor.
• These are described in relation to a vertex
presentation.
 Mechanism of labor
Although labor and delivery occurs in a
continuous fashion, the cardinal movements are
described as the following 7 discrete sequences :
• Engagement
• Descent
• Flexion
• Internal rotation
• Extension
• Restitution and external rotation
• Expulsion
 Mechanism of labor
• Engagement is descent of the biparietal diameter of
the fetal head below the plane of the pelvic inlet
.Clinically if the lowest portion of the occiput is at or
below the level of maternal ischial spines(station
0) ,engagement has occurred .Engagement can occur
before the onset of true labor, especially in
nulliparous patients
 Mechanism of labor
• Descent of the fetal head to the pelvic floor is
an important event of labor .The highest rate if
descent occurs during the deceleration phase
of the first stage and during the second stage of
labor.
• Flexion of the fetal head is a passive movement
that permits the smallest diameter of the fetal
head (suboccipitobregmatic diameter ) to pass
through the maternal pelvis
 Mechanism of Labor
• Internal Rotation . The fetal occiput rotates
from its original position (usually transverse)
towards the symphysis pubis (occiput anterior)
or less commonly ,toward the hollow of the
sacrum (occiput posterior)
• External Rotation .The fetus resumes its face
forward position with the occiput and spine
lying in the same plane
 Mechanism of Labor
• Expulsion .Further descent brings the anterior
shoulder of the fetus to the level of the
symphysis pubis .After the anterior shoulder is
delivered under the symphysis pubis ,the rest
of the body is usually expelled quickly
 First stage of labor
Duration
• Primigravida – 8 -12 hours
• Multigravida -6-8 hours
Latent phase
• In primigravida – 8 hours
• In multigravida – 4 hours
Active phase
• In primigravida – 4 hours
• In multigravida – 2 hours
 Stages and Phases of labor
• The 2nd stage is the time from full cervical dilation to
delivery of the fetus.
• On average, it lasts 2 h in nulliparas (median 50 min)
and 1 h in multiparas (median 20 min).
• It may last another hour or more if conduction
(epidural) analgesia or intense opioid sedation is used.
• For spontaneous delivery, women must supplement
uterine contractions by expulsively bearing down.
• In the 2nd stage, women should be attended
constantly, and fetal heart sounds should be checked
continuously or after every contraction. Contractions
may be monitored by palpation or electronically.
 Second stage of labour
The second stage has 2 phases

• Passive: Cervix is fully dilated ,fetal descent continued

during the time from full dilatation until an urge to
push is felt at about station+ 2 station
• Active :Time from the onset of the urge to push until
delivery Presenting part of fetus reaches the pelvic
floor. The fetal head will become visible at the
introitus ,initially appearing and disappearing between
contractions. Once the head is crown ,it does not
recede in between contraction .The fetus moves
through the birth canal and is completely delivered
 Third stage of labour
• The third stage is the interval between delivery
of the infant and delivery of the placenta and
membranes
• Its duration is 10-20 minutes in both primi and
multipara
• The third stage is considered prolonged after 30
minutes, and active intervention ,such as
manual extraction of the placenta is commonly
considered
 Birthing Options
• Creating a satisfactory childbirth experience — Four
factors important in determining a woman's satisfaction
with her childbirth experience are personal
expectations, the amount of support she receives, the
quality of the caregiver-patient relationship (eg,
respect, communication, continuity of care), and her
involvement in decision-making. Childbirth preparation
classes inform women and their partners about what to
expect during labor and birth and provide a foundation
for developing personal plans for the birth experience
 Birthing Options
• Most women prefer hospital delivery, and most health
care practitioners recommend it because unexpected
maternal and fetal complications may occur during labor
and delivery or postpartum, even in women without risk
factors.
• About 30% of hospital deliveries involve an obstetric
complication (eg, laceration, postpartum hemorrhage).
Other complications include abruptio placentae, abnormal
fetal heart rate pattern, shoulder dystocia, need for
emergency cesarean delivery, and neonatal depression or
abnormality.
 Birthing Options
• Nonetheless, many women want a more homelike
environment for delivery; in response, some hospitals
provide birthing facilities with fewer formalities and rigid
regulations but with emergency equipment and personnel
available.
• Birthing centers may be freestanding or located in
hospitals; care at either site is similar or identical.
• In some hospitals, certified nurse-midwives provide much of
the care for low-risk pregnancies.
• Midwives work with a physician, who is continuously
available for consultation and operative deliveries (eg, by
forceps, vacuum extractor, or cesarean).
• All birthing options should be discussed.
 Birthing Options
• For many women, presence of the their partner or
another support person during labor is helpful and
should be encouraged.
• Moral support, encouragement, and expressions of
affection decrease anxiety and make labor less
frightening and unpleasant.
• Childbirth education classes can prepare parents
for a normal or complicated labor and delivery.
Sharing the stresses of labor and the sight and
sound of their own child tends to create strong
bonds between the parents and between parents
and child. The parents should be fully informed of
any complications.
 Admission
• Typically, pregnant women are advised to go to the hospital if
they believe their membranes have ruptured or if they are
experiencing contractions lasting at least 30 sec and occurring
regularly at intervals of about 6 min or less.
• Braxton-Hicks contractions must be differentiated from true
contractions
• Within an hour after presentation at a hospital, whether a
woman is in labor can usually be determined based on the
following:
• Occurrence of regular and sustained painful uterine contractions
• Bloody show
• Membrane rupture
• Complete cervical effacement
• If these criteria are not met, false labor may
be tentatively diagnosed, and the pregnant
woman is typically observed for a time and, if
labor does not begin within several hours, is
sent home.
 Management of Labor-Admission

• History
• The initial assessment of labor should include a review of the
patient's prenatal care, including confirmation of the
estimated date of delivery. Focused history taking should
elicit the following information:
• Frequency and time of onset of contractions
• Status of the amniotic membranes (whether spontaneous
rupture of the membranes has occurred, and if so, whether
the amniotic fluid is clear or meconium stained)
• Fetal movements
• Presence or absence of vaginal bleeding.
• When pregnant women are admitted, their blood
pressure, heart and respiratory rates, temperature, and
weight are recorded, and presence or absence of edema is
noted.
• A urine specimen is collected for protein and glucose
analysis, and blood is drawn for a CBC and blood typing. A
physical examination is done. While examining the
abdomen, the clinician estimates size, position, and
presentation of the fetus, using Leopold maneuvers .
• The clinician notes the presence and rate of fetal heart
sounds, as well as location for auscultation.
• Preliminary estimates of the strength, frequency, and
duration of contractions are also recorded.
 Physical examination

The physical examination should include

documentation of the following:
• Maternal vital signs
• Fetal presentation
• Assessment of fetal well-being
• Frequency, duration, and intensity of uterine
contractions
• Abdominal examination with Leopold maneuvers
• Pelvic examination with sterile gloves
 Physical Examination
• Digital examination allows the clinician to determine
the following aspects of the cervix:
• Degree of dilatation, which ranges from 0 cm (closed
or fingertip) to 10 cm (complete or fully dilated)
• Effacement (assessment of the cervical length, which
can be reported as a percentage of the normal 3- to 4-
cm–long cervix or described as the actual cervical
length)
• Position (ie, anterior or posterior)
• Consistency (ie, soft or firm)

• Palpation of the presenting part of

 Physical Examination
• Palpation of the presenting part of the fetus
allows the examiner to establish its station, by
quantifying the distance of the body (-5 to +5
cm) that is presenting relative to the maternal
ischial spines, where 0 station is in line with
the plane of the maternal ischial spines.
Intrapartum management of labor
First stage of labor
• On admission to the Labor and Delivery suite,
a woman having normal labor should be
encouraged to assume the position that she
finds most comfortable. Possibilities including
the following:
• Walking
• Lying supine
• Sitting
• Resting in a left lateral decubitus position
Intrapartum management of labor
Management includes the following:
• Periodic assessment of the frequency and
strength of uterine contractions and changes in
cervix and in the fetus' station and position
• Monitoring the fetal heart rate at least every 15
minutes, particularly during and immediately
after uterine contractions; in most obstetric
units, the fetal heart rate is assessed
continuously [3]
Intrapartum management of labor
Second stage of labor
• With complete cervical dilatation, the fetal heart rate
should be monitored or auscultated at least every 5
minutes and after each contraction. [3] Prolonged duration
of the second stage alone does not mandate operative
delivery if progress is being made, but management
options for second-stage arrest include the following:
• Continuing observation/expectant management
• Operative vaginal delivery by forceps or vacuum-assisted
vaginal delivery, or cesarean delivery.
Intrapartum management of labor
Delivery of the fetus
• Positioning of the mother for delivery can be any of
the following [2] :
• Supine with her knees bent (ie, dorsal lithotomy
position; the usual choice)
• Lateral (Sims) position
• Partial sitting or squatting position
• On her hands and knees
• Episiotomy used to be routinely performed at this
time, but current recommendations restrict its use to
maternal or fetal indications
Delivery maneuvers are as follows:
• The head is held in mid position until it is delivered, followed by suctioning of
the oropharynx and nares
• Check the fetus's neck for a wrapped umbilical cord, and promptly reduce it if
possible
• If the cord is wrapped too tightly to be removed, the cord can be double
clamped and cut
• The fetus's anterior shoulder is delivered with gentle downward traction on
its head and chin
• Subsequent upward pressure in the opposite direction facilitates delivery of
the posterior shoulder
• The rest of the fetus should now be easily delivered with gentle traction away
from the mother
• If not done previously, the cord is clamped and cut
• The baby is vigorously stimulated and dried and then transferred to the care
of the waiting attendants or placed on the mother's abdomen
 Third stage of labor
• The period between the delivery of the fetus and the
delivery of the placenta and fetal membranes
• Delivery of the placenta often takes less than 10 minutes,
but the third stage may last as long as 30 minutes
• Expectant management involves spontaneous delivery of
the placenta
• The third stage of labor is considered prolonged after 30
minutes, and active intervention is commonly considered
• Active management often involves prophylactic
administration of oxytocin or other uterotonics
(prostaglandins or ergot alkaloids), cord clamping/cutting,
and controlled traction of the umbilical cord