NORMAL LABOUR

4TH MBBS CLASS

ESUT COLLEGE OF MEDICINE
2013
 OBJECTIVES

1. Define and features of a normal labour

2. Stages of labour
3. Other definitions
4. Initiation of labour
5. The 5 Ps: Passenger, Passage, pelvis, Powers,Position and Psyche
6. Mechanism of labour
7. Partograph
8. Active mgt of labour and 3rd stage
 DEFINITION

Normal labour can be defined as

spontaneous onset of contractions
of the gravid uterus at 37 to 42
weeks gestation that results in
progressive effacement and
dilation of the cervix; descent of
the presenting part and vaginal
delivery of the baby with the baby
and mother in good health.
 FEATURES OF NORMAL LABOUR
1. Spontaneous onset
2. Single cephalic presentation
3. 37—42 weeks gestation
4. No artificial interventions
5. Unassisted spontaneous vaginal delivery
6. Duration from active phase of < 12hours in nulliparous
woman, and < 8 hours in multiparous woman
7. A retrospective diagnosis
• Any labour that deviates from the above characteristics is
an ABNORMAL labour
 DIAGNOSIS OF ONSET OF LABOUR
----very important

Admission criteria:
Painful uterine contractions
accompanied by any one of the
following:
complete cervical effacement
Cx os 3-4 cm or greater
ruptured membranes
show
 True Labor False Labor
• Regular contractions • Irregular contractions
• Interval shortens • Interval same
• Increasing intensity • Intensity same or less
• Back to abdomen • Felt in abdomen
• • Walking decreases pain
Walking increases
pain • Sedation relieves pain
• No effect from mild
No show
sedation.
• No cx dilatation
• Bloody show
• Dilatation of the
 STAGES OF LABOR
Friedman 1955 defined 3 stages of labor:
The first stage: onset of labor to full cervical
dilation(10cm) i.e cervix no longer palpable on VE
The latent phase ( onset to cervical os <3cm, <16hrs)
characterized by irregular uterine contractions
low and gradual cervical effacement and dilation.
Amniotomy must be discouraged during this phase.
Sensitive to extraneous factors:
 E.g sedation → prolongation
 myometrial stimulation → shortening
The active phase(>3-4 cm to 10cm, <8hrs)
 Cervical dilation rate of at least 1cm/hour
 +/- fetal descent
The second stage: . full cervical
dilation to the delivery of the
infant, <2hr
 Mechanism of labour occur
The third stage: delivery of the
infant to delivery of the
placenta with the membranes,
<30mins
FOURTH STAGE
• 1st 6 hours after delivery
• Period of vigilance B/C most PPH occur
within 4 hours of childbirth
• Monitor closely postpartum ¼ hrly in first
2 hours then every 30 -- 60 mins:
– Blood pressure
– Pulse
– Vaginal bleeding
– Uterine firmness
• Resuscitation equipment ready
• Massaging of the uterus
• Examine the neonate
• Appreciate the mother, give her
food and drink
• Start breast feeding and bonding.
APPRECIATE THE MOTHER .
 DEFINITIONS
1. Abortion is termination of pregnancy before fetal
viability.
2. Viability - able to survive outside the uterus (24+ weeks
gestation in developed or 28+ in developing countries
3. A term pregnancy = between 37 and 42 weeks from
LMP.
4. Preterm labor is that occurring before 37 weeks of
gestational age.
5. Postdate pregnancy occurs after 40-42 weeks gestation
and requires careful monitoring.
6. Prolonged pregnancy > 42 weeks GA
 DEFINITIONS
7. Gravidity – number of previous pregnancies plus
the present pregnancy
8. Primigravida - pregnant for first time(G1P0+0)
8. Multigravida - pregnant more than once
9. Parity –number of previous pregnancies
carried to viability irrespective of the outcome
10. Nulliparous - never carried a pregnancy to viability
11. Multiparous - has had two or more deliveries that
were carried to viability
What is the difference between G3P1+1 and P1+1 ?
 INITIATION OF LABOUR
• Despite extensive research, the mechanism
of the onset of labour remains uncertain
• At term, the foetus increases its production of
cortisol and reduces the production of
placental progesterone and increases the
production of oestrone and oestradiol.
 INITIATION OF LABOUR

At term , increase in fetal cortisol causes

increase in placental production of estrogens
and decrease progesterone
 INITIATION OF LABOUR 2
• Progesterone suppresses uterine activity and while
oestradiol increases it.
• These changes also result in increased production of
placental prostaglandins and oxytocin release & all
enhance myometrial contraction and effacement of
the cervix.
• Other hormones produced in the placenta also act
directly or indirectly on the myometrium, such as
relaxin, activin A, follistatin, hCG and corticotrophin-
releasing hormone (CRH).
 INITIATION OF LABOUR 3
• Increasing cervical compliance allows progression
of labour with reduced intrauterine pressure.
• The cervix also contracts during labour up to 3?4
cm dilatation but, in the active phase of labour,
cervical dilatation occurs secondary to uterine
contractions alone. In other words, the cervix is
passively stretched by the increasing strength of
the upper uterine segment muscle contractions---
fundal dominance.
 THEORIES OF THE ONSET OF LABOR

• Changes in uterus, cervix, pituitary

• Fetal hormonal secretions
• Increasing uterine
– distension
– intrauterine pressure
• Aging placenta
 5PS THAT AFFECT LABOUR
• Passenger: the fetus
• Passageway: pelvis, uterus, vagina
• Powers: contractions, pushing
• Position: of mom
• Psych response: culture, experiences,
preparedness, etc.
 PASSENGERS

a. Fetal skull: is the largest presenting part

and least compressible fetal structure
& important in labor and birth.
b. Sutures – intermembranous spaces that
allow molding.
Moldings: the overlapping of the fetal
skull bones to permit delivery of the
head through the pelvis
Passenger– the fetal skull
Fontanels:
1.) Anterior fontanel – bregma, diamond shape, 3 x 4
cm, closes in 12 – 18 months after birth
2.) Posterior fontanel or lambda – triangular shape, 1
x 1 cm. closes in 2 – 3 months after birth.
Anteroposterior diameter:
1. Suboccipitobregmatic ------9.5 cm, presents in
fully flexed head and is the smallest AP
2. Occipitofrontal------- 12cm partial flexion
3. Occipitomental –---- 13.5 cm hyper extension
4. Submentobragmatic-----face presentation
• FETAL ATTITUDE=It refers to the posturing
.
(flexion or extension) of the joints and the
relationship of fetal parts to one another.
• FETAL LIE =The relationship of the long axis of
the fetus to the long axis of the mother. The
lie is longitudinal with a vertex or breech
presentation or otherwise transverse or
oblique, as with a shoulder presentation
 FETAL PRESENTATION
--is the part of the fetus that is lowest in the pelvis
inlet.
• the cephalic( head): 95% of the term new born
• the breech( pelvis): 3% of term births
• the shoulder( scapula): 2% of term births
• In cephalic presentation: the presenting part is
usually the occiput of the fully flexed fetal head.
• Brow or face presentation occur when there is
deflexion of the fetal head
Passenger: Presentation
 FETAL POSITION:

• The relationship between a certain landmark

on the fetal presenting part and the maternal
pelvis, as follows:
• Anterior, closest to the symphysis
• Posterior, closest to the coccyx
• Transverse, closest to the left or right vaginal sidewall.
 FETAL ENGAGEMENT:
 This is important in the vertex presentation
because it implies that the largest dimension
of the fetal head, the biparietal diameter, has
passed through the pelvic inlet
Power: Contractions
 PARAMETERS OF UTERINE CONTRACTION:

• Interval and duration

– 10 to 20 minutes interval contractions of duration <
20 secs = mild contractions and occur in early labor
– contractions of 20-40 sec duration =moderate
contraction
– 3 to 5 minutes contractions of 40 to 60 duration
second=strong contraction and occur in late labor
• Quality
– Uterus can be dented (poor quality): early labor
– Uterus is hard (good quality): late labor
 UTERINE ACTIVITY

• The uterus exhibits infrequent, low-intensity

contractions throughout pregnancy.
• At term, uterine activity increases in both the
frequency and strength of contractions.
• During labour, intrauterine pressures rises up
to 50 mmHg during contractions that may
occur every 3--5 minutes and last
approximately 40--60 seconds.
 UTERINE ACTIVITY

• Contractions become painful when amniotic pressure

exceeds 25 mmHg (3.2 kPa).
 With the additional effect of voluntary expulsive efforts
in 2nd stage, intrauterine pressure may rise to 100
mmHg.
• Each contraction causes transient decrease in placental
blood flow and oxygen deprivation to the fetus.
• The duty of the midwife and obstetrician is to ensure
that the process of labour is achieved with mother and
baby healthy and satisfied
 UTERINE ACTIVITY
 Contractions and retraction of uterine muscles
cause effacement and dilatation of the cervix .
 The lower segment becomes elongated and
thinned as labour progresses.
 Where labour becomes obstructed, the
junction of the upper and lower segments
may become visible at the level of the
umbilicus; this is known as a retraction ring
Mother Position in Labor and Birth: Best
Practice
• Allow freedom of movement and
position of choice throughout labor and
childbirth.
• Encourage any non-supine position:
– Side-lying
– Squatting
– Hands and knees
– Semi-sitting
25-34 – Sitting
 Psyche
• Woman giving birth • Health care provider
– Knowledge
– Fear
– Support • Support person(s)
– Trust
• Self
– Family
• Provider – Friend
– Beliefs, values, culture
– Doula
• Maternal Past experiences
• Preparedness
• financial stability – Unfamiliar
• impact of another child or environment
other children to care for
PASSAGE----DIAMETERS OF THE PELVIS 1

S4- 5
 .
Born February 24, 1846

.
Died September 12, 1911

Nationality Germany

Occupation gynecologist

Known for Leopold maneuvers

Christian Gerhard Leopold

Physical exam--Leopolds Maneuvers

• .
First maneuver: Fundal Grip
• While facing the woman, . palpate the woman's
upper abdomen with both hands to determine
the size, consistency, shape, and mobility of
the fetal part felt.
• The head is hard, firm, round and ballotable
i.e moves independent of the trunk or back.
• The buttocks feel softer, are symmetric, and
the shoulders and limbs have small bony
processes; unlike the head, they move with
the trunk.
 Second maneuver: Umbilical Grip

• Determine the location of the fetal back. Still facing the

woman, palpate the abdomen with gentle but also deep
pressure using the palm of the hands. First the right hand
remains steady on one side of the abdomen while the left
hand explores the right side of the woman's uterus. This is
then repeated using the opposite side and hands.
• The fetal back will feel firm and smooth while
• fetal extremities (arms, legs, etc.) should feel like small
irregularities and protrusions.
• Third maneuver: Pawlick's Grip
.
• determine what fetal part is lying above the inlet,
or lower abdomen.[2] The individual performing
the maneuver first grasps the lower portion of the
abdomen just above the pubic symphysis with the
thumb and fingers of the right hand.
• The Pawlick's Grip, although still used by some
obstetricians, is not recommended as it is more
uncomfortable for the woman. Instead, a two-
handed approach is favored by placing the fingers
of both hands laterally on either side of the
presenting part.
 Fourth maneuver: Pelvic Grip
• Facing the woman's feet the birth attendant
attempts to locate the fetus' brow.
• The fingers of both hands are moved gently down the
sides of the uterus toward the pubis. The side where
there is resistance to the descent of the fingers
toward the pubis is greatest is where the brow is
located.
• If the head of the fetus is well-flexed, the brow
should be on the opposite side from the fetal back.
• If the fetal head is extended or deflexed , the occiput
is felt and is located on the same side as the back
 MECHANISM OF LABOR
Is the changes in fetal position in relation to
the maternal pelvis
• Engagement
• Descent
• Flexion
• Internal Rotation
• Extension
• Restitution
• Expulsion
 ENGAGEMENT
• Biparietal diameter
of the baby reaches
the ischeal spines of
the mother
• 2/5 palpable head
per abdomen
DESCENT
• Pressure
• uterine contractions
• maternal bearing-
down

Measured by station r/t

ischial spines
FLEXION
• The smallest diameter
into pelvis
• Pressure of uterus on
breech causes chin to
flex on chest
INTERNAL ROTATION
• Baby turns from OT to
OA (usually)

other positions possible

e.g. OP
 EXTENSION
• Head extends
upward

In a normal vertex
delivery the head is
born by the process
of extension
EXTERNAL ROTATION
Also called restitution or
shoulder rotation
The head returns
(restitutes) to the
position it was in
when it entered the
pelvis. The shoulders
are then able to be
delivered.
 EXPULSION

The baby is delivered

 .

CCT FOR DELIVERY OF THE PLACENTA.

.
ACTIVE MANAGEMENT OF LABOR

  It refers to active control, rather than passive observation,

over the course of labor by the obstetrical provider.

It includes three essential elements

I. Careful diagnosis of labor by strict criteria
II. Constant monitoring of labor with specific standards for
normal progression-- partograph
III. Prompt intervention (e.g, ARM, Augumentation)
according to established guidelines if progress is
unsatisfactory.
 ACTIVE MGT OF 3Rd STAGE OF LABOR

3rd stage is the most hazardous part of

labour b/c PPH is the leading cause of
maternal mortality worldwide
• im/iv oxytocin
• Clamping & cutting of the cord
• CCT
• Massage of uterus every 15 mins for 15
secs in the first 2 hours
Video—active mgt 3 stage labour
rd

• .

3rd_stage_web.wmv
birth companion
 Pain in Labor is NORMAL
Caused by:
• hypoxia of compressed muscle cells
• compression of nerves in cervix
• stretching of cervix
• stretching of perineum
• bladder distension
• tension/anxiety/fear
 NON PHARMACOLOGIC PAIN
RELIEF METHODS
• Acupuncture
• TENS
• distraction
• ambulation
• imagery
• hydrotherapy
• therapeutic touch
• hypnosis
• acupressure
• Calm, gentle voice and • Reduced need
soothing touch . for analgesia
• Relaxation techniques, such
as deep-breathing exercises • Fewer operative
vaginal
and massage
deliveries
• Cool cloth on the forehead
• Encouragement, reassurance • Less
and praise postpartum
• Assistance in voiding or depression at 6
weeks
changing positions as
desired
 ANALGESIA & ANESTHESIA
ANALGESIA
• Narcotics--can sedate baby
• Tranquilizers
• Sedatives
ANESTHESIA
• Local
• Regional
– Paracervical
– Pudendal
– Epidural
– spinal
• General
– inhalation
– intravenous
 IDEAL ANESTHESIA/ANALGESIA
 simple to use without:
a. endangering mother or baby
b. efficiency of uterine contractions
c. ability of mother to cooperate
d. causing need for operative
intervention
 EPIDURAL ANESTHESIA
• Rapid infusion of RL IV to prevent
hypotension
• Causes sympathetic blockade and BP
• Position uterus off of vena cava--- L tilt
• Monitor BP
• Monitor FHT, frequently (fetal bradycardia)
 New Partograph
• .

Normal Labor and Childbirth 63

• Is a graphic representation of events in labor:
– condition of the fetus.
– progress of labour
– condition of the mother
– Medications
• guides early detection of prolonged or obstructed
labor
– informs decision-making in the management of labor
– It ensures we intervene in a timely manner to
avoid maternal and neonatal morbidity or mortality
• WHO recommends the partograph for mgt of
every woman during labor.
• The alert line, the. onset of the
active phase of labor (4 cm), the
patient is expected to reach full
dilation at the rate of 1 cm/hour.
• At the action line, which is 4
hours to the right of the alert line,
the practitioner is signaled to take
action if the patient is not following
the expected course of labor.
 BIRTH PREPAREDNESS & COMPLICATION
READINESS: IMPORTANCE
• Delay is a significant factor in many maternal and
newborn deaths and disabilities.
• Birth preparation should be made routinelly during
ANC well in advance of the EDD
• Birth preparedness ensures skilled attendance and
other factors that may contribute to a positive outcome.
• Complication readiness reduces delays in:
– recognizing the problem
– deciding to seek care
– reaching and receiving care

25-66
 BIRTH PREPAREDNESS & COMPLICATION
READINESS: BEST PRACTICE

Preparation for Readiness for possible

normal birth: complications:
 Skilled attendant  Early detection of danger
signs
 Place of birth
 Designated decision
 Transportation maker(s)
 Funds  Communication
 Essential items  Emergency transportation
 Nutrition  Emergency funds
 Blood donors

25-67
WOMAN-FRIENDLY CARE: BEST PRACTICE

• Protect the woman’s health, life and rights to information,

choice and participation.
• Provide continuous emotional and physical support.
• Be kind and courteous.
• Facilitate effective communication among all present—focusing
on listening and answering questions.
• Obtain consent when necessary.
• Ensure privacy and confidentiality.
• Respect cultural beliefs and practices, as well as the woman’s
desires and preferences.

25-68
INFECTION PREVENTION: BEST PRACTICE

WHO’s “six cleans” for labor and childbirth:

• Clean hands
• Clean perineum
• Nothing unclean introduced into vagina
• Clean delivery surface
• Clean cord-cutting instrument
• Clean cord care (clean cord ties and cutting surface)

25-69
Nutrition: Importance

• The belief that women should not have food or fluid

during labor in childbirth is common.
• Labor and childbirth require an enormous amount of
energy.
• In women deprived of food and fluid:
– Amount of ketones in blood increases
– Essential amino acids in blood decreases
– Risk of fetal ketotic hypoglycemia increases

Source: Ludka and Roberts 1993.

25-70
Nutrition: Best Practice/Evidence

• Current literature supports allowing women to eat

and drink as desired in normal labor.
• Higher fluid intake associated with:
– less incidence of prolonged labor (> 12 hours)
– shorter labor duration
– reduced need for oxytocin infusion

Source: Garite et al 2000.

25-71
Continuous Support by a Caregiver: Best
Practice

• The same caregiver, rather than several caregivers,

should be present throughout labor and childbirth.
• A Cochrane review showed that continuous support
resulted in:
– reduced need for medication for pain relief
– fewer operative vaginal deliveries
– fewer cesarean deliveries
– fewer 5-minute APGAR scores below 7

Source: Hodnett 2000.

25-72
Immediate Newborn Care: Best Practice

• Prevent heat loss.

• Ensure breathing—resuscitate if necessary.
• Facilitate immediate breastfeeding.
• Practice infection prevention, including eye care and
cord care.

25-73
 Practices No Longer Recommended

• Routine Episiotomy
• Use of enema
• Pubic shaving
• Restriction of food and fluids during labor
• Routine intravenous infusion in labor
• Repeated or frequent vaginal examinations, especially by
more than one caregiver
• Routinely moving laboring woman to a different room at
onset of second stage

Sources: Neilson 1998; WHO 1999.

25-74
 Practices No Longer Recommended
continued

• Routine use of lithotomy position with or without

stirrups during labor
• Administration of oxytocin at any time before delivery in
such a way that the effect cannot be controlled
• Encouraging sustained, directed bearing-down efforts
during the second stage of labor
• Massaging and stretching the perineum during the
second stage of labor (no evidence)
• Fundal pressure during labor

Source: Eason et al 2000.

25-75
 EBM -Conclusions

• Women and newborns deserve the safest and best

care possible---EBM.
• We should continually challenge and examine our
practices around labor and childbirth based on the
highest quality evidence available--CQI

25-76
•THANK YOU .
• QUESTIONS

• CLARIFICATIONS