Process of Labour and its

related problem
 Outline for anatomy
• Female pelvis and fetal skull
• Pelvis :
-true (lesser) and false (greater) pelvis
-pelvic inlet (superior aperature) and pelvic
outlet (inferior aperature) and its diameters
• Fetal skull
PELVIS
The female bony pelvis is divided into:
•Greater/ False pelvis : above the pelvic brim and has no obstetric
importance. *part of abdominal cavity
•lesser/ True pelvis: below the pelvic brim and related to the child -
birth. ** composed of inlet, cavity and outlet
Pelvic brim or inlet = superior border of
symphysis pubis to sacral promontory
Pelvic outlet= inferior border of symphysis
pubis to sacral promontory
 True pelvis (area below pelvic
1. Pelvic inlet (
brim/inlet)
2. Pelvic outlet (
superior border symphysis pubis to sacral inferior border symphysis pubis to
promontory) coccyx)
• Boundaries • bounded by;
 •sacral promontory,  •the lower border of symphysis pubis,
 •alae of the sacrum,  •pubic arch,
 •sacroiliac joints,  •ischial tuberosities,
 •iliopectineal lines,  •sacrotuberous & sacrospinous ligament
 •iliopectineal eminences,  •tip of the coccyx.
 •upper border of the superior pubic rami,
 •pubic tubercles, Diameter:
 •pubic crests and - AP =13.5cm (widest than tranverse)
 •upper border of symphysis pubis. - Tranverse =11cm

Diameter: 3. Pelvic –mid cavity (round shape, middle of symphysis

- AP (antero-posterior)= 11cm pubis to 2nd, 3rd sacral vertebrae)
- Tranverse =13.5cm (widest than AP)
Diameter:
-similar for tranverse and AP =12cm
 False pelvis (area above pelvic
brim/inlet)
• Bounded
- Posteriorly : lumbar vertebrae
- Laterally : iliac fossa and iliacus muscle
- Anteriorly: lower part of abdominal wall
Female Pelvis
Fetal Skull
 Labour
• Painful and regular contraction of uterine,
with cervical dilatation and effacement,
with descend of presenting part -> for
expulsion of fetus.
 Stages of labour
• 1st stage
= the time from the diagnosis of labour to full
dilatation of cervix
– Latent – from the diagnosis
of labour to cervix up to
4cm. Cervix is fully effaced.
Duration: 3-8 hours
– Active – from 4cm to full
cervical dilatation (10cm).
Duration: 2-6 hours
• 2nd stage
= time from full cervix dilatation to fetus delivery

– Passive phase  time between full dilatation and

involuntary expulsive contraction
– Active phase  time when mother starts to have the
urge to push.

• 3rd stage
= time from delivery of fetus until delivery of placenta
 Mechanism of labour

The series of changes in position and

attitude which the fetus undergoes during
its passage through the birth canal
Normal mechanism of labor
Engagement
Descent
Flexion
Internal Rotation
Extension & Crowning
Restitution
External rotation
Delivery of anterior & posterior shoulders
( EDF ICE RED)
Engagement

• Occurred when the widest part of fetal

presenting part had passed successfully through
the pelvic inlet

• on physical examination: the number of fifths of

fetal head palpable abdominally. If more than
2/5 , the head is not yet engaged.
 Descent
• Downward passage of presenting part
through the pelvis
• Occur secondary to uterine contraction &
voluntary use of abdominal musculature
and valsava maneuver
 Flexion
• As the head enter
the narrower mid
cavity, flexion
should occur.
 Internal rotation
• Rotation of presenting
part from its original
position (usually
transverse with regard
of birth canal) to
occipital anterior (OA)
position as it passes
through pelvis
• Usually occur at level
of ischial spine
 Extension and Crowning
• Head extends and
distend the
perineum until it is
delivered
Restitution External rotation

• Spontaneous • Shoulder rotate until

realignment of head the biacromial
and shoulder in diameter is AP.
oblique position
 Delivery of shoulders and fetal
body
• In the end of external rotation, shoulders
are in AP position.
• The anterior shoulder under pelvis deliver
first and posterior shoulder delivers
subsequently.
Abnormal labor
 Normal labor staging

Labor period
The first stage From regular uterine contraction to complete cervical dilation
The latent phase From regulation uterine contraction to 3cmcervical dilation
The active phase From 3cm cervical dilation to the full cervical dilation
The second stage From the full cervical dilation to delivery of baby
The third stage From delivery of baby to delivery of placenta
 Abnormal labor
• Abnormal labor refers to difficult labor.

• Also known as dystocia.

• This problem is the most common cause

for primary caesarean
 PATTERN OF ABNORMAL
LABOR
• PROTRACTION DISORDERS
– Refer to slower-than-normal progress

• ARREST DISORDERS
– Refer to complete cessation of progress
 The diagnostic criteria of abnormal labor

pattern Nulliparous criteria Multiparous criteria

Prolonged latent phase Duration>16h Duration>8h
Protracted active phase Cervical dilation <1.2cm/h Cervical dilation <1.5cm/h
Arrested active phase Cessation of cervical dilation >2h As same as nulliparous criteria
Prolonged active phase Duration>8h Duration>4h
Protracted descent Descent<1cm/h As same as nulliparous criteria
Arrested descent Cessation of descent >1h As same as nulliparous criteria
Prolonged second stage Duration>2h Duration>1h
 RISK FACTORS
• Old age
• Diabetes
• Previous pregnancy complications
• Nulliparity
• Epidural anaesthesia
• Chorioamnionitis
 PROBLEMS OF DYSTOCIA
• Mother
– Exhaustion
– Need of ceserean
• Neonate
– Need of neonatal intensive care unit
admission
– Have meconium at birth
– Depressed Apgar score
 CLASSIFICATION OF
DYSTOCIA

• Abnormal POWER

• Abnormal PASSAGE

• Abnormal PASSENGER
 Abnormal uterine contractions
• The uterine contraction is the most
important expulsive force.

• Bring about dilation of cervix and

expulsion of fetus and placenta.

• Common causes of dystocia

 ABNORMAL POWER
• Uterine dysfunction
Hypotonic uterine dysfunction :
• Infrequent
• Insufficient uterine contraction

Management
1 – Maternal rehydration.
2 – Good pain relief and emotional support.
3 – IV oxytocin.
4- ARM (artificial rupture of memebranes)

**If progress fails to occur despite 4-6 hour of agumentation with oxytocin, a
cesarean will usually be recommended.
 ABNORMAL POWER
Hypertonic uterine dysfunction :
•Hyperstimulation
•High intense constriction

Uncoordinated uterine dysfunction :

•Dyssynchronus
•High resting tone
•Constriction ring

•Treatment :
Reduce oxytocin
Tocolysis
C-section
 ABNORMAL PASSAGE

•Pelvic structure: pubis, sacrum and ischium.

•Pelvic plane: inlet, midpelvic and outlet

•Bony marker: ischial spine

 Ischial spine
• The Ischial spine is halfway of birth canal.

• Station of fetal presentation is described in

relationship with the ischial spine.

• The axis of birth canal above and below the

ischial spine is divided into five respectively.

• As the presenting part reaches the ischial spine,

the designation is 0 station.
 Cephalopelvic disproportion
• Anatomical disproportion between fetal
head and maternal pelvis
• Criteria :
– Labor progress is slow
– Fetal head is not engaged
– Vaginal examination shows severe moulding
– Fetal head poorly applied to cervix
 Bony Pelvic Abnormlities
• Contracted pelvis
contracted inlet plane
contracted midpelvis
contracted outlet plane

• Deformed pelvic
– Osteomalacia
– Kyphosis
 Contracted inlet plane
• Criteria: sacral-pubic diameter<18cm

• Clinical findings:
– fetal head palpable above the inlet plane
prolonged latent phase
Contracted midpelvis and outlet
plane
 Soft tissue abnormalities
• Congenital anomalies

• Scarring of birth canal

• Pelvic masses
 ABNORMAL PASSENGER
•Fetal malpresentation/malposition
– Breech
– Transverse lie
– occipito-transverse position
– occipito-posterior position
– Face/ Brow presentation
•Macrosomia
– Large for gestational age (>4000g)
– Associated with maternal diabetes
•Fetal malformation
 ABNORMAL PASSENGER
• Management
– Forceps operation
– Vacuum delivery
– Cesarean section

Abnormalities of fetus
Abnormalities of birth canal
Abnormalities of labor force
Summary
Abnormalities of fetal development
Abnormalities of fetal size
Abnormalities of fetal position Cephalopelvic
disproportion
Contracted pelvis
Pelvic malformation
Abnormalities of soft tissue increased resistance
Secondary inertia
dystocia
Primary inertia
 Management
• Vaginal examination

• Supportive mangement

• Augmentation
 The Vaginal Examination
• To determine fetal presentation, position
and station.

• To assess the cephalopelvic relation.

• To consider the route of delivery.

 The supportive management
• Sufficient rest

• To relieve anxiety and fear.

• Fluid and food intake.

 Augmentation
• Increase the frequency and force of the
existing uterine contractions.

• Methods: amniotomy
oxytocin administration
 oxytocin
• Capable of inducing uterine contraction in
the third trimester.
• Relatively safe in nulliparous woman

• Contraindiction: severe cephalopelvic

disproportion and severe fetal malposition.
 Partograph
• Defi: Is a pre-printed paper form on which
labour observations are recorded.
• Aim:
1.Pictorial overview of labour
2.Alert midwives and obstetricians to
deviation in maternal or fetal wellbeings
and labour pogress
* Alert line and action line start on 4cm,when entering active labour.
• WHO recommendation on
augmentation of labour (2014):
- Active phase partograph with a four-hour action
line is recommended for monitoring the progress
of labour (strong recommendation, very low
quality of evidence)
• Fetal Heart Rate
- Intermittent monitoring (pinard, doppler transducer) for at
least 1 minute, every 30 minutes after a contraction when
in active labour for 1st stage, every 5 mins for 2nd stage.

- Continuous monitoring (electronic fetal monitoring, CTG) if

have:
1. High blood pressure or pre-ecclampsia
2. DM
3. Baby is smaller than expected.
4. BMI is 40 or higher
5. Water brokes before labour started and have been broken for > 24
hours.
6. Crossed action line due to delayed in labour progress.

• Fetal heart rate plots with dot, and linked the dots together.
• Liquor State
• C- clear
• M- mecomium, indicate fetal distress, advise
continuous fetal monitoring and fetal blood
sampling.
1. light meconium state liquor(LMSL)
2. moderate meconium state liquor(MMSL)
3. think meconium state liquor (TMSL)
• B- might indicate placenta abruption.
• Liquor not demonstratable- this need to inform
Dr. Either wrong technique in accessing liquor,
or having very thick meconium liquor sate.
• Head moulding
- Moulding is an important indication of how
adequate the pelvix can accommodate the
fetal head.
- Increasing moulding with the head in the
pelvix is sign of cephalopelvic disproportion.
- 0: bones are separated and sutures can be easily felt
- +1: bones are just touching each other.
- +2: bones are overlapping but can be reduced.
- +3: bones are severely overlapping and irreducible.
• Cervical Dilatation
- Active labour starts when cervical
dilatation is 4cm.
- It is recorded as “X”.
- With 2 pre-printed line => alert line and
action line, which is 4 hour apart.
- If progress is satisfactory, plotting will
remain on the left or the alert line.
- If progress is unsatisfactory, plotting will
be to the right of the alert line.
• The diameter of internal os of the cervix is
measured from 0-10cm, with 10cm
corresponding to complete cervical
dilatation.
• Normally, cervical dilatation at rate of
1cm/hour for primigravida and 1.5cm/hour
for multigravida.
• When delayed:
1. Consider amniotomy if membrane intacted
2. Advise vaginal examination 2 hours later
3. Consider oxytoxin.
4. Advise continuous fetal monitoring.
• Head Descent
• Assessed by abdominal palpation.
• Recorded as “O”.
• Refer to the part of the head which can be
palpated above symphysis pubis..
• At 0/5, means the sinciput is at the level of
symphysis pubis.
• Head Station
• Uterine Contraction
• Assessed every 30 minutes.
• Strong contraction in 10 minutes aimed for
the 2nd stage of labour.
• Put the hand on the abdomen to feel for the
contraction occur for how long.
- < 20s : weak contraction
- 20-40s : moderate contraction
- > 40s : strong contraction
• Blood Pressure
• Monitor every 4 hours during labour.
• Those with pre-eclampsia, monitor every
30 mins.
• Pulse
• Monitor every hour.
• Temperature
• Monitor every 4 hourly.
• Chorioamnionitis if maternal temperature >
38°c & 2 following signs:
- WBC count > 15000cells/mm3
- Maternal tachycardia > 100bpm
- Fetal tachycardia >160bpm
- Tender uterus
- Foul smelling discharge
• Urine
• protein: suggest pre-eclampsia or contamination
by liquor fluid
• Glucose: underlying DM
• Ketone: suggest maternal starvation, body cannot
get enough glucose to produce energy. This can
lead to metabolic acidosis which reduces the
contractibility of uterus, prolonging labour.
• Blood: suggest UTI or obstructed labour.
• Volume: urine output decrease when there is
MgSo4 toxicity. Low acetone and low volume
indicate dehydration.
 References
• Dr. Leo Leader. Partogram or instagram?
FRANZCOG. Publications/O&G
Magazine/O&G Magazine Issues/Vol 16 No 3
Spring 2014.
• Lavender T, Hart A, Smyth. Effect of
partogram use on outcomes for women in
spontaneous labour at term. John Wiley &
Sons. Cochrane Database of Systemic
Reviews 2013, Issue 7. (published on 3 Nov
2014 by WHO Reproductive Health Library)
• www.acog.org
 References
• Obstetric by ten teachers chapter 14 (m/s
186-191)
• 'Antenatal care : routine care for the
healthy pregnant woman(NICE clinical
guideline 62)
• Intrapartum care :care of woman and their
babies during childbirth (NICE clinical
guideline 55)