Labour and Delivery

Dr. Jacob Ruiter

Assistant Professor, McGill University
 Objectives
• Define Labor and its stages
• Recognize theories of causation of labor
• List the components of labor
• Analyze the role of each component in the
process of labor
• Describe the cardinal movements of
normal labor
• Discuss the conduct of normal labor
 Definition

• Labor is regular, painful contractions that

result in progressive cervical dilation and
effacement.
 Stages of labor
1. First stage (cervical stage).
– cervical change – effacement & dilatation to
10 cms
2. Second stage (pelvic stage).
– Begins at full dilatation of cervix till the
delivery of the baby
3. Third stage (placental stage).
The third stage of labor involves the separation
and expulsion of the placenta.
 Theories of cause of labour
• Fetal cortisol levels
• Progesterone withdrawal
• Prostaglandin release
• Oxytocin stimulation
 Components of labor
(the three P’s)

• Powers - Contractions
• Passenger - The fetus
• Passage - The pelvis
 Powers - Contractions
• Increasing recruitment of myometrial fibres
• Intensity and duration increases
– Early labor – 5-10 minutes, 30 – 45 seconds,
20 – 30 mmHg
– Advanced labor - 2 – 3 minutes, 50 – 70
seconds, 40 – 60 mmHg
• Upper uterine fibres shorten & thickens
• Lower uterus thins and cervix ‘taken up’
• Includes maternal effort in second stage
 Uterine contractions

• Every 5 mins, last 1 min, pressure 50mmHg

• Depolarization
• Ca entry activates MLCK
• Activated MLCK phosphorylates myosin
• Interacts with actin and contracts
• Oxytocin CaCa efflux Dephosphorylation
• Stronger and longer contractions
Uterine Contractions
Uterine Contractions
Uterine Contractions
Uterine Contractions
 Passenger - The fetus
• Fetal Lie
• Presentation
• Fetal attitude or Posture
• Position
• Changes in the Shape of the Fetal Head
 Passenger - The fetus
• Fetal Lie
– The relation of the
long axis of fetus to
that of mother –
longitudinal or
transverse or oblique
– 99% of labors have
longitudinal lie
Passenger - The fetus
• Presentation
– indicates that portion of
the fetus that overlies the
pelvic inlet
 Passenger - The fetus
Fetal Attitude or Posture
• Fetus forms an ovoid mass
• corresponds roughly to the shape of the uterine cavity
• back convex, head sharply flexed, thighs are flexed over the
abdomen, legs bent at knees, arches of feet rest on the anterior
surface of the legs
• In cephalic presentations the arms are crossed over the thorax or
are parallel to the sides
 Passenger - The fetus
• Position —the relation of the fetal presenting part to the maternal
pelvis.
• (1) Markers for position are:
– Occiput for vertex presentation
– Sacrum for breech presentation
– Mentum (chin) for face presentation
– Acromion for shoulder presentation
• (2) The designated fetal bony point is related to the maternal pelvis:
– Right or left
– Anterior, posterior, or transverse
Fetal Skull
 Passenger - The fetus
• Changes in the Shape of the Fetal Head
– Molding
– Caput succedaneum
 Diagnosis of Fetal Presentation
and Position
• Abdominal palpation
• Vaginal examination
• Auscultation
• Ultrasound
Passage - The pelvis
Passage - The pelvis
Passage - The pelvis
Passage - The pelvis
Bony Pelvis – Curve of Carus
 NORMAL LABOR IN THE
OCCIPUT PRESENTATION
Second stage of labor and Cardinal
movements of fetus
• Engagement
A process of positional adaptation of the
• fetal head to the various segments of the
Descent
• pelvis
Flexionis required to complete childbirth.
• Internal rotation
• Extension
• External rotation (Restitution)
• Expulsion
Cardinal movements of fetus
Engagement & Descent

BPD passing through the pelvic inlet in

occiput presentations
 Cardinal movements of fetus
• Flexion
– causes a
smaller
diameter of
fetal head
(biparietal
diameter) to
be presented
to the pelvis,
instead of the
longer
occipito-
https://www.youtube.com/watch?v=Xath6kOf0NE
Conduct of labor
Identification of labor
Characteristics of True versus False Labor

Characteristic True Labor False Labor

Contractions

Rhythm Regular Irregular

Intervals Gradually shorten Unchanged

Intensity Gradually increases Unchanged

Discomfort

Location Back and abdomen Lower abdomen

Sedation No effect Usually relieved

Cervical dilatation Yes No

 Detection of rupture of
membranes
• Pooling

• Nitrazine “dye” test

• Ferning

• Amnisure/Actimprom
– Detects Placental Alpha Microglobulin-1 (PAMG-1) protein in
amniotic fluid
Cervical examinations
 First stage of labor
• Latent phase of labor
– uterine contractions vary in intensity and frequency
– slow dilation and effacement of the cervix
– prolonged latent phase > 20 hours in the primigravida > 14
hours in multigravida
• Active phase of labor
– rapidly progressive phase
– characterized by progressive cervical dilation
– three identifiable components: acceleration phase, linear phase
of maximum slope and deceleration phase.
– primigravida dilates 1.2 cm/hr
– multigravida dilates 1.5 cm/hr
WHO Partogram
Second stage
Second stage
Second stage
Stages of labour

• Third stage
– Delivery of the fetus (baby)
– complete expulsion of placenta and
membranes
Third stage
Third stage
Third stage
Caesarean
section
Caesarean
section
Fetal monitoring
in labor
CardioTocoGraphy
Pain relief

• Support, ambulation
• Hydrotherapy (bath, shower)
• Hypnosis
• Entonox (NO, O2)
• Opiates
• Epidural
Epidural
 Maternal changes in labour
• Cardiovascular
– Increased BP (?falling progesterone)
– Increased cardiac output
• Respiratory
– Increased respiratory rate (?pain)
• Renal
– Decreased urine output (increased fluid loss)
– Difficulty voiding (tissue edema, pelvic
pressure)
 Maternal changes in labour
• Skin
– Introitus stretches and distends (?E2, ?relaxin)
• Musculoskeletal
– Fatigue, mild pyrexia, leucocytosis, leg cramps
(increased muscular activity)
• Neurological/Psychiatric
– Euphoria (?endophins)
• Gastro-intestinal
– Constipation, nausea/vomitting (fluid loss,
pressure, and decreased intestinal peristalsis)
Conclusions

• Complex interaction of uterus, fetus,

and pelvic cavity
• Health, age, support, education, parity -
all have an effect
• Most go well!!
• Complications can be catastrophic for
mother and baby
Questions?