NORMAL LABOUR

 Labour is the process by which contractions of gravid uterus expel the fetus
and other products of conception after 24 weeks from the last menstrual
period.

 Normal labour
Occurs at term
Spontaneous in onset
Low risk thorough out to both the mother and fetus
Fetus presenting by the vertex between 37 and 40 completed weeks of
pregnancy
Not exceeding 12-18 hours for primigravida or 6-12 hours for multigravida.
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 Stages of labour

First stage: Third stage Fourth stage

Second stage

• Begins with regular • Is the period • Is a period of 1

rhythmic contractions • Stage btw full from the birth of hour after the
and ends when the
cervix is fully dilated. dilation of the baby to birth of placenta
• It is the longest and cervival os to complete • The period is
involves three phases
viz: birth of the baby separation and given
• Latent: dilation is 0 to • It is the stage of expulsion of the recognition to
4cm & effacement
from 3cm to <0.5cm expulsion placenta and emphasize the
• Active: more rapid
dilation from 4– 10cm
• Stronger &longer membranes and importance of
• Transitional: 8-10 cm; contraction control of continuous
associated with
expulsive contractions • Takes 15-45 mins haemorrhage. vigilance for the
and feeling of urge to
in primigravida • It lasts for about risk of PPH
push
and 5-15 mins in 5-15 minutes. • Not affected by
multigravida parity
Duration of Labour

 There are wide variations in the duration of labour. The length of

labour is influenced by:
 Parity,
 Time of the last delivery,
 Type of pelvis,
 Size and presentation of the foetus,
 Strength and frequency of uterine contractions.

The greatest part of labour is taken up by the first stage. The most
important thing is the progress of labour provided the woman is
comfortable and the foetus is well. The labour lasts longer in
primigravidae than in multigravidae 3
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 Duration of Labour

1st Stage 2nd Stage 3rd Stage

Pimigravida 8-12hrs 30-60mins 5-15mins

Average 11 hrs 45 mins 15mins

Total = 12hrs

Multipara 6 ½ - 8 hrs 15-30mins 5 – 15mins

Average 6½ hrs 15 mins 15mins

Total = 7hrs

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Second stage of labour

The following signs and symptoms will be observed when a woman

reaches the second stage of labour:
 On vaginal Examination, OS fully dilated
 Expulsive uterine contractions
 Trickling of blood rupture of membranes
 Tenseness between coccyx and anus
 Anus pouts and gapes
 Urge to push
 Presenting part is visible
 Perineum stretches and bulges

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Second stage of labour

Source: Myles Textbook of Midwifery

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Physiological processes of 2nd stage of labour

 Descent:
 descent of presenting part reached its maximum pace towards the end of 1 st stage of labor,
continues its rapid pace through the second stage until reaches the pelvic floor.
 The average maximum rate of descend is 1.6cm/hour in nulliparas and 5.4cm/hour in
multiparas.

 Uterine action:
 contractions become stronger, longer, more frequent and expulsive, approximately every two
minutes lasting 60-90 seconds.
 There is continuous contraction and retraction of upper uterine segment while the lower
uterine segment progressively dilates and thin out.
 The uterus becomes very irritable due to the drainage of liquor from ruptured membranes
which lead to more contractile power as the baby is more applied to the uterus.
 Fetal axis pressure increases flexion of the presenting part, resulting in smaller presenting
diameters, more rapid progress and less trauma to both mother and fetus.
 The contractions become expulsive as the fetus descends further into the vagina.
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Physiological processes cont.
Pressure from the presenting part stimulates nerve receptors in the pelvic floor.
This reflex may lead to compulsive, overwhelming and involuntary pushing. The
mother’s response is to employ her secondary powers of expulsion by contracting
her abdominal muscles and diaphragm.

Soft tissue displacement: As the fetal head descends, the soft tissues of the pelvis
become displaced.
Anteriorly: the bladder is pushed upwards into the abdomen where it is at less
risk of injury during fetal descent
Posteriorly: the rectum becomes flattened into the sacral curve, the pressure of
the advancing head expels any residual fecal matter
Laterally: The levator ani muscles dilate, thin out and displaced laterally.
The perinea body is flattened, stretched and thinned causing the vaginal orifice
to be directed upward and the passage is ready for delivery.
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Physiological processes cont.

Expulsion of the fetus:

The fetal head becomes visible at the vulva, advancing with each
contraction and receding between contractions until crowning takes
place.
The head is then born, the shoulders and body followed with the next
contraction, accompanied by a gush of amniotic fluid and sometimes
of blood.

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 Presumptive signs of second stage & differential diagnosis

1. Expulsive contraction: she may feel strong desire to push before the cervix is fully dilated if:
 the fetus is in an OP Position
 the rectum is full
 the woman is highly parous

2. Rupture of membranes: membranes normally rupture at the onset of second stage. However,
this may occur at any time during labour

3. Dilation and gaping of anus and perinea bulging:

 deep engagement of presenting part
 premature maternal effort at latter part of the first stage.

4. Progressive visibility of fetal head at the introitus:

 Excessive molding may result in the formation of a caput succedaneum, which can protrude
through the cervix prior to full dilation.
 Breech presentation may be visible when the cervix is only 7 to 8cm dilation.
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Management of second stage of labour

Active management
 Patient should be transferred to the second stage room or lie on her bed in
the first stage room. She should not be left alone.
 Vaginal examination is done to confirm full dilatation of the cervix.
 Patient can lie in any position she finds most comfortable for her. If
membranes are intact it should be ruptured artificially using a pair of
cockers or artery forceps.
 Observations and recordings continues and more frequently between
contractions, viz:
 (i)Uterine contractions (ii) Descent of the presenting part (iii) maternal pulse
5 – 15 minutes – intervals. (iv) Fetal heart rate every 5 minutes.
 Any irregularity must be reported as oxygenation to the fetus may be less
due to compression of head or cord.
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Management cont.

 Evaluation of maternal well-being should include the following:

Vital signs,
Bladder care,
Hydration and general condition,
Maternal pushing effort, analgesics and
Anesthesia and perinea integrity

 Explain all the procedures to the patient to allay her anxiety.

 Ensure the room is warm with spotlight available
 A clean area should be prepared to receive the baby
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Management cont.

 The Bladder: must be kept emptied by catheterization at the end of

first stage or at the beginning of second stage, if the bladder is full can
cause delay in the engagement of the head and postpartum
haemorrhage in third stage.
 Only a sip of glucose drink is allowed if the second stage is getting
prolonged and the woman’s condition permits it, because of danger of
vomiting.
 The hands and the face could be sponged with cold water. Two nurses
should do a delivery at a time. One clean nurse and one assistant.
 Head should be delivered slowly to prevent injuries to the perineum.
The woman should be discouraged from active pushing until the head
is visible. 13
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Management cont.

 She can practice breathing exercise – Rhythmic, easy breathing,

avoid shallow panting, very deep breathing and prolong breath –
holding.
 She should feel be free to express herself – cry, shout, etc. it helps her
to cope.
 Position: Depend on maternal & fetal conditions, mother preference,
the environment, Midwife’s confidence.
 Positions include: Dorsal, Left lateral, Squatting, Kneeling, or
standing, the birthing chair.

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Dorsal Position

The woman lies on her back with her knees Flexed and wide apart
The advantages of this position are :
The woman can push more effectively.
Can rest and relax between contractions.
Observation of the abdomen is carried out
close observation on her face and general condition, early signs of distress
detected.
No changing of position for the third stage.
Clearer view on the perineum. 05/14/2024
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Left Lateral Position

The woman lies on her left side with the buttocks at the edge of the bed
and leg slightly flexed.
The midwives stands behind the patient facing her feet while the
assistant raises, the leg sufficiently enough to take the cot of the
midwife’s hand, she passes her hand between the thighs down to the
vulva.
The rest of the delivery is the same with the other methods.
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Positions in labour

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Management cont.
 Conducting the delivery
 Clean the perineum by swabbing
 Place a clean pad under the woman to absorb any feaces or fluids

The midwife should:

 Continue with observation of the fetus
 Support the perineum as the fetal head advances to prevent trauma
 Swab the face immediately the head is born
 Check for cord round the neck
 If cord is felt round the neck and is loose, deliver the baby through the
loose loop but if it is tight double clamp and cut and unwind the cord
from the neck 18
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Management cont.

The midwife should:

 Allow restitution to take place
 Observe for external rotation of the head
 Deliver the anterior shoulder first then followed by the posterior shoulder
 Deliver the rest of the body by lateral flexion over the mother’s abdomen
 Wait for 30-60 seconds for the pulsation to stop, double clamp and cut the cord
 Palpate abdomen to rule out second twin
 Give 10 i.u oxytocin intramuscularly
 Note and record the time of delivery
 Show baby to mother to identify the sex
 Place in skin to skin position with the mother
 Apply identification band

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Mechanism of labor
 The Mechanisms of labour are the positional movements that the fetus undergoes
to accommodate itself to the maternal pelvis.
 This is necessary in as much as the larger diameters of the fetus must be in
alignment with the larger diameters of the maternal pelvis in order for the full
term fetus to negotiate its way through the pelvis to be born.

Terms used in labor mechanism

 Lie: is the relation of the fetus to the longitudinal axis of the uterus. It can be
longitudinal, transverse or oblique
 Attitude: is the relationship of the fetal head and limbs to its trunk. It is the
posture of the fetus which can be flexion, deflexion or extension
 Presentation: is the part of fetal anatomy that is lowest in the birth canal i.e.
vertex (cephalic), breech, face, shoulder

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Terms cont.

 Denomination: is the arbitrary part of the presentation that enables its description during labour e.g.
occiput in a vertex presentation, sacrum in breech presentation, mentum (chin) in a face presentation

 Position: is the relationship of the fetal presenting part to the left or right side of the pelvis i.e. LOA,
LOP, LOL, ROA, ROP, ROL

 Presenting part of the fetus: is that part which is in or over the pelvic brim and in relation to the cervix

 Descent: is the progress of the presenting part through the pelvis.

 Flexion: as the fetus descends through the pelvis, fundal dominance of uterine contraction exerts
pressure down the fetal spine towards the occiput, forcing the occiput to come into contact with the
pelvic floor. When this occurs the fetal neck flexes (chin to chest) allowing the circumference of the
fetal head to reduce to sub-occipitobregmatic (9.5cm). The fetal skull with this diameter is smaller
which assists passage through the pelvis.

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Terms cont.

 Engagement: is when the widest diameter of the fetal head descends/successfully

negotiating its way down deep into the maternal pelvis. Engagement is identified
by abdominal palpation, where the fetal head is 3/5 th palpable or less.

 Internal rotation of the head: the pelvic floor has a gutter shape with a forward
and downward slope, encouraging the fetal head to rotate from the left or right
occipito-transverse position a total of 90 degrees, to an occipito-anterior (occiput
facing forward) position, to lie under the subpubic arch.

 Crowning: is when the widest diameter of the fetal head successfully negotiated
through the narrowest part of the maternal bony pelvis, which is clinically
evident when the head visible at the vulva, no longer retreats between
contractions. 22
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Terms cont.

 Extension of the head: is when the occiput slips beneath the suprapubic
arch allowing the release of sinciput, face and chin to sweep the perineum.
 Restitution: is the external rotation of the fetal head to the right or left of
medial thigh of the mother to untwist the torsion/tie on the neck.
 Internal rotation of the shoulders: is when the anterior shoulder reaches
the pelvic floor and rotates anteriorly 1/8th of a circle. The shoulders come
to lie in the anteroposterior diameter of the pelvic outlet
 Lateral flection: is when the anterior shoulder slips beneath the sub-pubic
arch and the posterior shoulder passes over the perineum. The remainder
of the body is born by lateral flexion as the spine bends sideways through
the curved birth canal.

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Main movements of the fetus in labor mechanism

 The Lie is longitudinal

 The Attitude is complete flexion
 The Presentation is vertex
 The denomination is occiput
 The position is left occipito-anterior
 The presenting part is posterior part of the left parietal bone
 Presenting diameter is occipito bregmatic of 10 cm
 Engaging diameter is sub-occipito bregmatic of 9.5 cm

 Descent: with good uterine contraction and adequate pelvis, descent takes
place with increase flexion.
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Mechanisms cont.

Internal rotation of head: the occiput becomes the leading part, meets
with the resistance of the pelvic floor muscles, rotates 1/8 th of a circle
forward and lies under the symphysis pubis
Crowning: with further uterine contractions, the occiput escapes
under the symphysis pubis, when the biparietal bones distend the
perineum and the head is said to be crowned
Extension of the head: the sinciput, the face and the chin sweep the
perineum and the head is born by movement of extension

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Mechanisms cont.

Restitution: occiput turns 1/8th of a circle to undo the twist on the neck,
leaving the head and shoulders in anteroposterior diameter of the pelvic
outlet
Internal rotation of the shoulders: shoulders enter the pelvis in left
oblique diameter, anterior shoulder becomes the leading part, meets
with resistance of pelvic floor muscles, rotates 1/8th of a circle forward;
the internal rotation of the shoulders is followed by external rotation of
the head.
Lateral flexion of the body: anterior shoulder escapes under the
symphysis pubis, the posterior shoulder sweeps the perineum and the
baby is born by movement of lateral flexion over the mother’s abdomen
following the curve of birth canal. 05/14/2024
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