Normal Labor

Labor
LA. ( MSc, Ass't professor in Maternity 1

Saturday, October 7, 2023 Health)
Objectives
At the end of this session, the students will be able to:

 Define labor
 Identify the difference between true and false labor.
 Discuss classification/stage of labor
 Discuss physiology of normal labor
 Discuss premonitory sign of labor
 Discuss the management of labor at each stage
 Discuss the components of partograph.
Saturday, October 7, 2023 LA. ( MSc, Ass't professor in Maternity Heal 2

th)
Definition
• Labor is a process where regular uterine contraction results in progressive
dilatation and effacement which ends in the delivery of the fetus, placenta
and membranes or
• Labor is a process by which a viable fetus i.e. at the end of 28 wks or
more is expelled or is going to be expelled from the uterus.
• Delivery means the actual birth of fetus.
LA. ( MSc, Ass't professor in Maternity

Saturday, October 7, 2023 3
Health)
True labor (parturition) is a continuous process in which;
 Progressive regular uterine contractions
 Progressive effacement and
 Progressive dilatation of the cervix result in the expulsion
of the products of conception from the uterus.

Health)
• False labor is irregular contractions of the uterus prior to actual labor pains
resembling those of normal labor.
Signs of false labor are:

 Mild pain and irregular contractions.
 There is no mucous blood-stained discharge (show).
 No progressive cervical dilatation observed on follow up.

Health)
Difference between true and false labor

Health)
Labor can be:-
Preterm:-if started before 37 wks
Term:- if started 37-40wks
Post term:- if started > 42 wks

Health)
Normal Labor and Delivery
• Labor is considered normal when the following conditions are fulfilled:

 Parturient without any apparent risk (e.g., pre-eclampsia, previous scar,
etc.)
 Labor should start spontaneously
 Labor should start at term
 Vertex presentation
 Spontaneous vertex delivery, with minimal assistance
 Normal duration for all stages of labor
 Good neonatal and maternal outcome

Health)
Classification of labor
Normal labor is classified / staged as:

1. First stage of labor: The period between onset of regular uterine
contractions to full cervical dilatation. It is subdivided into two phases: -
A. Latent phase: The phase of labor between the onset of regular uterine
contraction to 5 cm of cervical dilatation (often slow & unpredictable rate of
cervical dilatation).

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First stage of labor…
B. Active phase: The phase of labor after 5 cm of

cervical dilatation to full cervical dilatation (more rapid
rate of cervical dilatation).

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2. Second stage of labor: The stage of labor between full cervical
dilatation and delivery of the last fetus (often associated with
involuntary bearing down urge because of expulsive uterine
contraction).
3. Third stage of labor: The stage of labor between delivery of the last
fetus and delivery of the placenta & membranes.

Health)
Physiology of Normal labor
There is still no full understanding of the biochemical substance and

interaction that stimulate labor and birth.
But different theory are given:

 Hormonal
 Mechanical
 Biochemical
10/07/2023 LA..(MSc, Ass't prof.in MHN) 12

Hormonal
A. Rise in estrogen and falling in progesterone

 Estrogen is known to stimulate uterine muscle contraction to permit
softening , stretching eventually thinning of the cervix.
 Collagen fibers in the cervix broken down by the action of enzymes such
as collagenase & elastase.

Function of estrogen
 Increase oxytocin releasing from maternal pituitary.
 Promote the synthesis of receptors oxytocin.
  prostaglandin secretion.
 Increase actinomyosine activity.
 Permit softening , stretching eventually thinning of the cervix.

Function of progesterone's
 Progesterone produced by placenta relaxes uterine smooth muscle.

 Due to this uterus w/o contraction during pregnancy but near term
fetus produces more cortisol and this inhibits progesterone production.
 Decrease in progesterone leads to increase in prostaglandin and
oxytocin production.
 Myometral contractility and enhancement of labor start.

B. Decrease placenta efficacy.
 Occurs due to decrement in progesterone and estrogen production(ratio)

C. The prostaglandin theory ( Increase in
prostaglandin)
Production of cortisol :
 This inhabits production of progesterone.
Decrease in progesterone .
Increase in prostaglandin .
Labor start.
2. Mechanical cause
A. Uterine distention theory (optimal uterine distention)
Any hollow viscous tends to contract and empty it self when distended to a
certain point.
 Increase pressure on myometrium
 Contraction
 Initiation of labor

Mechanical cause…
B. Increased in intensity of Braxton's contraction.

C. Pressure of the presenting part on the cervix(lower uterine segment)

Diagnosis and management of labor
Before Dx of labor we should have to know the critical factor for labor.
Those are;
1. Power ( uterine activity/contraction)

 Characterized by: Frequency, intensity and duration
 Adequate uterine contraction 3-5contractions in 10 minutes lasting 40-

60 seconds

Power…
 Has its own effect:

1. Effacement, dilatation, descent: vaginal delivery or
2. Increasing caput succedaneum, molding, slow effacement, dilatation:

CPD

Method of uterine activity assessment.
 Simple observation.
 Manual palpation.
 External tocodynamometry
– Contractions Abdominal shape change Graphic uterine activity
– Correlates FHR with uterine activity.

 Internal tocodynamometry via internal uterine
catheter pressure.
 Performed with indication

 Most precise method
 Risks: uterine perforation, placental disruption, intrauterine
infection (HIV)

2. Passenger
 Fetal variables influence course of labor & delivery.
A. Fetal size: abdominal palpation or ultrasound

 Macrosomia: actual birth weight greater than 4kg
increased likelihood of failed trial of labor
B. Lie : longitudinal axis of the fetus relative to the
longitudinal axis of the uterus
 Longitudinal, transverse, or oblique
C. Malpresentation: any presentation other than vertex

during labor

D. Attitude: position of head with fetal
spine
 Flexion facilitates engagement
 Chin optimally flexed onto the chest:

sub occiputo bregmatic diameter (9.5
cm)
 Deflexed (extended) head: brow and
face

E. Position: Relationship of the
fetal presenting part to the maternal
pelvis
 Malposition refers to any
position in labor that is not
ROA, OA, or LOA
26
10/07/2023 LA..(MSc, Ass't prof.in MHN)
F. Station: Measure of descent of the
bony presenting part of the fetus through the
birth canal
• Classification (-3 to +3) based on a
quantitative measure in centimeters of the
distance of the leading bony edge from
the ischial spines

Cont…

3. Passage
 Size of maternal pelvis

 Types of maternal pelvis
 Ability of the cervix to dilate
 External opening of the vagina to
distend

4. Psychosocial
 Mental and physical preparation for child birth

 Socio-cultural values and beliefs
 Previous child birth experience
 Support from significant other
 Emotional status
 Parent’s psychosocial readiness including ; Fears, anxieties, birth fantasies,
level of social support
 Factor affects both the mother and father , their expectation during labor
and birth experience.

Premonitory sign of labor
 Most primi and multi gravida mother experience one or more of the
following s & s of coming labor.
 Lightening (from engagement)
 Braxton hicks contraction
 Vx secretion, Bloody show
 ROM
 Nausea & vomiting
 Sweating
10/07/2023  Softening of LA..(MSc,

cervixAss't prof.in MHN) 31
Management of labor at each stage
Stage of labor
To assist care givers common terms have been developed as benchmarks to
subdivide the process of labor in to stages and phases.
This include :-
First stage
Second stage
Third stage

First stage of labor
 From onset of first true contraction to complete cervical

dilatation at 10 cm and effacement of cervix.
 It is average duration is 12 to 14 hrs for primigravida and 6
to 8 for multi gravida mother.
Subdivided into:
 Latent FSL
 Active FSOL

Latent FSOL
 From onset of true labor to 4cm of cervical dilatation.

 Little or no fetal descent.
 Contraction usually :
 Duration-lasting for 20 or more seconds
 Intensity- mild
 Progress every 5min and irregular in pattern
 Frequency -every 5-20 min

Latent FSOL…
 Lasts 6 to 8 hrs in primi & 4 multigravida.
 Cervical dilatation is at <1cm/hr.
 If the client is in LFSOL and fulfill admission criteria,

admit the mother and follow her using the latent phase
follow-up chart.

Latent FSOL follow-up chart

Active FSOL
 From 5 to 7 cm of cervical dilation.
 Contraction usually:
 Frequency- every 2-5 min
 Duration- lasting for 30-50 seconds
 Intensity - mild to moderate
 Cervical dilation rate is 1cm/hr for primi and 1.5 cm/hr for
multigravida.

Transition phase
 From 8 to 10cm of cervical dilatation.

 Contraction is usually:
 Frequency -every 2-3 min
 Duration - lasting for 50-60 seconds
 Intensity- moderate to strong

Characterized by:
 Hyperventilation as they increase their breathing rate
 Restlessness
 Difficulty understanding direction.
 A sense of confusion and anger at contraction.
 General discomfort, low back pain, shaking and
cramping in the leg.
 Increase sensitivity to touch.

Cont…
 Increase need for partner and /or HCP presence

for support, apprehension and irritability.
 Statement that she can’t take it anymore, requests
for medication
 Increase rectal pressure
 Curling of her toes
 Loss of control
 Crying

Physiology of FSOL
1. Contraction with retraction of uterine muscle.

 Retraction: Is the process by which the upper uterine
segment become gradually shorten and its cavity
diminished.
 Contraction: Rhythmic tightening and shortening of
uterine muscle during labor.

Expressed in terms of:
A. Tone:
Determined by:
 Contractility of uterine muscle
 Intra-abdominal pressure
 Over distension of uterine muscle as in cases of :
Multiple pregnancy
Hydramnios
Big baby

B. Frequency
 Number of times contraction occurs
with in 10 min
 Normally 2-5/10min contractions
C. Duration
 How long it lasts.

D. Intensity
 Is degree of uterine contraction.
 Can be:
Mild (<20 seconds in duration)
Moderate ( 20 to 40 sec. in duration)
Strong (40 to 60 sec. in duration)

2. Formation of upper and lower uterine
segments.
 Upper Uterine segment
 Thick and muscular
 Formed from body of fundus
 Responsible for contraction and retraction
 Lower uterine segment
 Thin and responsible for dilation and distension

3. Polarity
 Is neuromuscular harmony between the upper and

lower uterine segments.
 If it is disorganized the progress of labor inhabited.

4. Development of retraction ring
 Is a ring b/n the upper and lower uterine

segments
 Is normally invisible, if visible sign of
obstructed labor
 Also called retraction or Bandl’s ring,
indicates mechanically obstructed labor

5. Cervical effacement
 Is up taking of cervix
 Usually in z last month of pregnancy z cervix begins to stretch
and thin
 A thin cervix will also allow the cervix to dilate more easily
 There is two believes about it:
 Above down ward i.e. Internal OS drawn upward and
external OS unchanged
 External OS upward and internal OS affected later
6. Dilatation of cervix
 Is the process of the cervix

opening in preparation for
childbirth.
 Results from:
 Uterine action/contraction
 Counter pressure applied by
bag of membrane
/presenting part or both
7. Show: jelly like discharge
8. Formation of bag of water:
 Can be fore water (in front of the
head ) or behind of the head.

Management at FSOL
Is a care given through out FSOL.
This include:
A. Admission: this include well coming of the mother and the partner on
arrival.
B. Admission criteria
Cervical dilatation of ≥ 5, ROM, regular uterine contraction with progressive

cervical dilatation.
C. Quick history: information from the mother( Gr, Pr, A , L,…., LMP, ANC
follow up…..)
Ask the mother time of onset of LA..(MSc,

10/07/2023
contraction and sign of severity.
Ass't prof.in MHN) 51
D. P/E:
 GA , exhausted, anemic , dehydration, general edema…..
 V/S.
 Abdominal examination:
o Inspection
o Palpation
o Auscultation

E. Vaginal examination
Information to be get during vaginal examination:
1. Presenting part: presentation and position, station, caput, molding,

attitude(flexion),
2. Membrane: R/I, clear/ stained.
3. Cervix: effacement, dilatation, edematous,
4. Pelvis: cavity, sacral promontory, ischial spine.
F. Investigation: all basic investigation(if not done at ANC)

Second stage of labor
 From complete cervical dilatation and ends with

delivery of the fetus
 Completed with in :
• 15-30 min for multi
• 45min -1hr for primi
 Prolonged if it exceeds 3 hours with provision of
regional anesthesia or 2 hrs in the absence of
regional anesthesia for nulliparas
 2 hrs with provision of regional anesthesia or 1
hrs in the absence of anesthesia for multiparas.

S&S of SSOL
 No cervix felt on Vaginal examination
 Contractions are much stronger, and last 30-50 seconds
 The patient wants to push (urge to push)
 Sometimes head can be seen at the vulva
 Opening of the anus (Passing of stool)
 Sweating

Cardinal movement of labor
 Cardinal movements: Changes in position of fetal

head during its passage through the birth canal.
 Due to asymmetry of the shape of both the fetal head and

the maternal bony pelvis, rotations are required for the
fetus to successfully negotiate the birth canal.

Cardinal movements - cont’d
1. Engagement:
 The passage of widest diameter of presenting part(the largest
diameter the fetal occiput is the biparietal diameter) enters the
maternal pelvis to a level below the plane of pelvic inlet.
 On the pelvic examination, the presenting part is at 0 station,
or at the level of the maternal ischial spines.

Health)
2. Descent: Downward passage of presenting part through the
birth canal
- This occurs intermittently with contractions.
- Greatest descent occurs in deceleration phase (late active
stage) & second stage

th)
3. Flexion: as the fetal vertex descents it encounters
resistance from the bony pelvis or the soft tissues
of pelvic floor,resulting in passive flexion of the
fetal occiput.
- The chain is brought in to contact with the fetal

thorax to present the smallest presenting diameter
(i.e. from occipitofrontal (11.0 cm) to
suboccipitobregmatic (9.5 cm) for optimal passage
through the pelvis.).

Health)
4. Internal rotation: as the head decends,the presenting
part usually transverse position is rotated about 45
degree to Ap position under the symphysis .
- Brings to AP diameter of the fetal head in line with the
AP diameter of the pelvic outlet.

Health)
5. Extension: with further descent and full flexion of the
head, the base occiput comes in contact with the inferior
margin of the pubic symphysis.
- Upward resistance from the pelvic floor and the down
ward forces from uterine contractions causes the occiput
to extend and rotate round the symphysis. This is
followed by the delivery of fetus’ head.

th)
6. External rotation: also called as restitution
- When the fetus head is free of resistance, it untwists about 45
degree left or right, returning to its original anatomic
position in relation to the body.
7. Expulsion: Delivery of rest of fetus.

Health)
Health)
Management of second stage of labor
 Once the patient is in the second stage, don’t leave her

alone and careful supervision must be kept on her:
 General condition, pulse, BP, uterine contractions
 Bladder should be empty
 Fetal heart rate more frequently
 Descent of the presenting part

Preparation for delivery
1. Equipment ( delivery set, PPE, resuscitation

material…..)
2. Patient ( transfer to SSR, position, guiding)
3. Conduct delivery in step

Delivery steps
1. Perineum stretching
2. Control of fetal head to
prevent tear.
3. Nose/mouth suctioning/clean.
4. Palpate neck for nuchal cord

Delivery steps…
5. Gentle traction(down & up

ward) to avoid brachial plexus
injury.
6. Slippery infant.
7. Delivery the neonate on
maternal abdomen.
8. Clump the cord & cut

Delivery steps…
9. Dry , stimulate and cover the new born baby.

10. Determine APGAR score and resuscitation if needed.
11. NBC by assisted person.

Active management third stage of labor.
 AMTSL refers to a sequence of clinical actions

taken by a skilled birth attendant to facilitate the
delivery of the placenta, by promoting uterine
contraction and placental expulsion.
 Every woman who deliver vaginally in the health
facility should be managed with AMTSL.

Components of AMTSOL
1. Administer uterotonic medication within one

minute of the birth of the last baby.
2. Controlled cord traction.
3. Verification of uterine tone and if the uterus is
not well contracted, uterine massage.

Drugs used for AMSTOL
1. Oxytocin: the preferred drug for AMTSL and 1st line drug
for PPH caused by uterine atony.
2. Ergometrine: the 2nd line drug for PPH though associated

with more serious adverse events. Ergometrine is
contraindicated in hypertensive women and in those with
cardiac problems.
3. Misoprostol: is cheap and stable at room temperature.

Steps of AMTSOL
1. Use of uterotonic agents.

2. CCT
3. Verification/ checking of uterine tone, examine the
placenta and perineal tear.

Partograph
 Partograph is the most important tool for health workers at
any level to assess the progress of labor and take
appropriate actions
 Graphic recording of the progress of labor and condition

of mother and fetus
 Partograph is applicable for the active phase of first stage

of labor i.e., from cervical dilatation ≥5cm to full
dilatation of cervix.
Importance of partograph
 A single sheet of paper that can provides details of

necessary information at once
 No need of recording labor events repeatedly
 Predicates deviation of labor from normal easily
 Facilitates hand overing of the procedure
 Reduces the prevalence of prolonged labor and C/S rate

Observation on partograph
1. Patient information:
 Name
 Gravida, para
 Hospital number
 Or MRN
 Date and time of admission, and
 Time of ruptured membranes

2. Fetal condition:
2.1. FHR
 Normal FHR is 100 to 180
bpm.
 Tachycardia >180bpm
 Bradycardia <100bpm.
 Count FHB Q30 mn.

2.2. Amniotic fluid
 Clear (C)
 Meconium (M)
 Blood (B)
 Absent (A)

2.3. Molding the fetal skull
 Separated bones……O
 Bones just touching each
other …….+
 Overlapping bones
(separate).......++
 Severely overlapping bones
(non separate )..+++

3. Progress of labor
3.1. Cervical dilatation
 Begin plotting in AFSOL
 Plot initial finding at alert
line.(X)
 Note the time first.
 Repeat PV after 4hrs.
3.2. Descent
 Plot the descent (O)

3.3. Uterine Contraction
 Frequency.. how often are they felt ?
 Assessed by number of contractions in

a 10 minutes period
 Duration.. how long do they last ?
 Measured in seconds from the time

contraction is first felt abdominally to
the time of the contraction phases off

4. Maternal
condition
 Record maternal pulse
Q30mn & plot as ( . )

 Maternal BP Q4 hrs. & plot
as ( )
 Temperature Q2hrs.
 Urine out put: ASAP

Labor pain management
 The management of pain during labor involves more
than the act of administering the best anesthetic agent
available in a timely fashion.
 Successful control of pain in labor requires active
management of the entire process (prenatal education
&counseling).
 Appropriate measures are used early in the process of
labor, analgesic needs decrease.

Labor pain management…
 HCP support women’s sexual and reproductive rights through
advocacy for women’s access to:
1. Prenatal and parenting education
2. Privacy
3. Hydration and nourishment during labor
4. Labor companions
5. Pharmacological pain relief for certain gynecological procedures
as well as in labor and following cesarean section surgery.
6. Choice of labor and birth positions

Support measure during labor
 Encouragement and facilitation of position
changes and mobility.
 Reduction of fear and anxiety by providing
information and support.
 Facilitation of appropriate rest.
 Provision of a labor companion.
 Listen to her complaints, and ensure hydration &
breathing techniques.
Non-pharmacological labor pain management
 Techniques that reduce painful stimuli.
o Maternal movement and position change.
o Counter-pressure against the woman’s sacrum.
 Techniques that activate peripheral sensory receptors.
o Superficial heat and cold
o Immersion in water during labor
o Touch and massage
o Acupuncture and acupressure
o Transcutaneous electrical nerve stimuli.
o Intracutaneous injection of sterile water in the sacral area
o Aromatherapy
Pharmacological labor pain
management.
 The primary mechanism of action is heavy

sedation.
 Analgesics relieve pain without causing total
loss of feeling or muscle movement.
 Analgesics drugs do not always stop pain
completely, but they reduce it.

Reference
 Obstetrics Management Protocol for Hospitals.
MOH, Ethiopia, Revised 2021.
 Fourth Edition Of The Alarm International
Program.
 DC- Duttas – text books of obstetrics eighth
edition 2020.

th)

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Labor

LA. ( MSc, Ass't professor in Maternity 1

At the end of this session, the students will be able to:

 Identify the difference between true and false labor.

 Discuss classification/stage of labor

 Discuss physiology of normal labor

 Discuss premonitory sign of labor

 Discuss the management of labor at each stage

 Discuss the components of partograph.

Saturday, October 7, 2023 LA. ( MSc, Ass't professor in Maternity Heal 2

LA. ( MSc, Ass't professor in Maternity

LA. ( MSc, Ass't professor in Maternity

Signs of false labor are:

 There is no mucous blood-stained discharge (show).

 No progressive cervical dilatation observed on follow up.

LA. ( MSc, Ass't professor in Maternity

LA. ( MSc, Ass't professor in Maternity

LA. ( MSc, Ass't professor in Maternity

• Labor is considered normal when the following conditions are fulfilled:

LA. ( MSc, Ass't professor in Maternity

Normal labor is classified / staged as:

LA. ( MSc, Ass't professor in Maternity

B. Active phase: The phase of labor after 5 cm of

LA. ( MSc, Ass't professor in Maternity

LA. ( MSc, Ass't professor in Maternity

There is still no full understanding of the biochemical substance and

But different theory are given:

10/07/2023 LA..(MSc, Ass't prof.in MHN) 12

A. Rise in estrogen and falling in progesterone

as collagenase & elastase.

10/07/2023 LA..(MSc, Ass't prof.in MHN) 13

 Increase oxytocin releasing from maternal pituitary.

 Promote the synthesis of receptors oxytocin.

 Increase actinomyosine activity.

 Permit softening , stretching eventually thinning of the cervix.

10/07/2023 LA..(MSc, Ass't prof.in MHN) 14

 Progesterone produced by placenta relaxes uterine smooth muscle.

10/07/2023 LA..(MSc, Ass't prof.in MHN) 15

 Occurs due to decrement in progesterone and estrogen production(ratio)

10/07/2023 LA..(MSc, Ass't prof.in MHN) 16

10/07/2023 LA..(MSc, Ass't prof.in MHN) 18

B. Increased in intensity of Braxton's contraction.

10/07/2023 LA..(MSc, Ass't prof.in MHN) 19

1. Power ( uterine activity/contraction)

 Adequate uterine contraction 3-5contractions in 10 minutes lasting 40-

10/07/2023 LA..(MSc, Ass't prof.in MHN) 20

 Has its own effect:

2. Increasing caput succedaneum, molding, slow effacement, dilatation:

10/07/2023 LA..(MSc, Ass't prof.in MHN) 21

– Contractions Abdominal shape change Graphic uterine activity

– Correlates FHR with uterine activity.

10/07/2023 LA..(MSc, Ass't prof.in MHN) 22

 Performed with indication

10/07/2023 LA..(MSc, Ass't prof.in MHN) 23

 Fetal variables influence course of labor & delivery.

A. Fetal size: abdominal palpation or ultrasound

C. Malpresentation: any presentation other than vertex

10/07/2023 LA..(MSc, Ass't prof.in MHN) 24

 Chin optimally flexed onto the chest:

10/07/2023 LA..(MSc, Ass't prof.in MHN) 25

10/07/2023 LA..(MSc, Ass't prof.in MHN) 27

10/07/2023 LA..(MSc, Ass't prof.in MHN) 28

 Size of maternal pelvis

10/07/2023 LA..(MSc, Ass't prof.in MHN) 29