Stages of labor

The first stage (the period of dilatation and effacement) is the

interval between the onset of labor (from the begining of
regular contracions which occur every 10 minutes, from the
moment of rupture of membranes) and full cervical dilatation
(10 cm)
- the latent phase which comprises cervical
effacement and early cervical dilatation (to 3-4 cm)
- the accelerated phase (from 5 to 7 cm)
- the transition phase (from 8 to 10 cm)

Stages of labor
The second stage (the period of expulsion) lasts from
complete cervical dilatation till the delivery of the
infant
The third stage (the placental stage) begins immediately
after delivery of the infant and ends with the delivery
of the placenta
The fourth stage is defined as the early postpartum
period of approximately 2 hours after delivery of the
placenta. During this period the patient undergoes
significant physiologic adjustment and must be under
close medical control

Abnormal labor - dystocia

(difficult labor)
It results when:
- anatomic or functional abnormalities of the fetus
- abnormalities of the maternal bony pelvis
- abnormalities of the uterus and cervix
- or combination of these abnormalities
interfere with the normal course of labor
Abnormal labor describes complications of the normal labor
process: slower than normal progress or a cessation of
progress

Abnormal labor (or dystocia) is divided into:

- prolongation disorders
- arrest disorders

Patterns of abnormal labor - dystocia:

A prolonged latent phase
A latent phase of labor is abnormal when it lasts
> 20 hours in primigravid patients
> 14 hours in multigravid patients
The causes of such situation:
- abnormal fetal position
- unripe cervix
- administration of excess anesthesia
- fetopelvic disproportion
- disfunctional uterine contractions

A prolnged latent phase does not itself

pose a danger to the mother or fetus.
Some patients who are initially thought
to have a prolonged latent phase turn out
only to have false labor.

Patterns of abnormal labor - dystocia:

A prolonged active phase
An active phase is abnormal when it lasts longer than:
- 12 h in the primigravid patients
- 6 h in the multigravid patients
or when the rate of cervical dilatation is less than
- 1,2 cm/h in primigravid patients
- 1,5 cm/h for multiparas
or when descend of the presenting part is less than
- 1,0 cm/h for primigravidas
- 1,5 cm/h for multiparas

Causes of prolonged active phase:

- abnormal fetal position
- fetopelvic disproportion
- excessive use of sedation
- inadequate contractions
- rupture of fetal membranes before the

Patterns of abnormal labor- dystocia:

Arrest disorders:
Secondary arrest of dilatation:
no cervical dilatation for > 2 h in any case in
the active phase of labor
Arrest of descend:
no descent of the presenting part in > 1 h in the
second stage of labor

It occurs when:
- the contractions are no longer sufficient to maintain
the progress of labor
or
the labor arrests in spite of adequate uterine
contractions associated with:
- too large fetus
- fetal lie or position that prevents progress in labor
- too small or abnormally shaped pelvis

Correct diagnosis and management of

abnormal labor requires evaluation of the
mechanisms of labor:
- the power (uterine contractions)
- the passenger (fetal factors - presentation, size)
- the passage (maternal pelvis)

Evaluation of the power includes:

strenght, duration and frequency of uterine
contractions

- manual palpation of the maternal abdomen during

a contraction (subjective evaluation)
- external tocography (more objective)

- a tocodynamometer is an

external strain gauge, which is placed on the maternal abdomen, it records

when the uterus tightnes and relaxes but does not directly measure how
much force the uterus is generating for a given contraction

- internal tocography (the most objective) - an intrauterine pressure

catether is placed into the uterine cavity and it transmits the actual
intrauterine pressure to the external strain gauge, which then records
duration and frequency as well as the strength of the contractions

For cervical dilatation to occur, each contraction

must generate at least 25 mm Hg of pressure. The
optimal intrauterine pressure during contraction is
50-60 mm Hg.
In generating a normal labor pattern the frequency of
contractions is also very important. A minimum three
contractions in a 10 minute window is usually
considered adequate.

During the first stage of labor arrest of labor should

not be diagnosed until the cervix is at least 4 cm
dilated (before ending the latent phase of labor).
During the second stage of labor, the power include
both, the uterine contractile forces and the voluntary
maternal expulsive efforts (pussing)

Evaluation of the passenger

This includes:
- estimation of the expected fetal weight
-clinical evaluation of fetal lie, presentation, position
If the estimated fetal weight is > 4000 g the incidence of
dystocia, including shoulder dystocia or fetopelvic
disproportion is greater.
Cephalopelvic disproportion is a disparity between the size or
shape of the maternal pelvis and the fetal head

If the fetal head is extended a larger cephalic

diameter (> 32 cm) is presented to the pelvis, therby
increasing the possibility of dystocia
A brow presentation (forehead - the largest cephalic diameter
is 36 cm) (1/3000 deliveries) typically converts to
either a vertex or face presentation, but if persistent,
causes dystocia requiring cesarean section.
A face presentation also requires cesarean section in
most cases, although a mentum anterior presentation (chin toward
mothers abdomen) sometimes may be delivered vaginally.

Persistent occiput posterior positions are also

associated with longer labors (about 1 hour in
multiparous patients and 2 hours in nulliparous
patients)
Fetal anomalies like hydrocephaly and soft tissue
tumors may also cause dystocia. The use of prenatal
ultrasound significantly reduces the incidence of
unexpected dystocia for these reasons.

Evaluation of the passage

Measurements of the bony pelvis are relatively poor
predictors of successful vaginal delivery. It depends
on the inaccuracy of these measurements as well as
case-by-case differences in fetal accomodation and
mechanisms of labor. Only in rare cases, when the
pelvis is completely contracted (the pelvic
diameters are very small) manual evaluation of the
diameters of the pelvis can predict that the fetus will
not passage the birth canal.

In some cases the X-ray or computed

tomographic pelvimetry can be helpful, but
the best test of pelvic adeqacy is the progress
or lack of progress of descending of the fetal
presenting part in the birth canal.
Except the bony pelvis, there are soft tissues
causes of dystocia, such as:

Management of abnormal labor

Augmentation of labor is the stimulation of
uterine contractions that began spontaneously but
are either too infrequent or too weak, or both.

Induction of labor is the stimulation of uterine

contractions before the spontaneous onset of labor,
with the goal of achieving delivery.

Stimulation or induction of labor is usually carried

out with intravenous oxytocin (sometimes
prostaglandines) administrated by means of metered
pump.
The incidence of prolongation of the first stage of
labor can be minimized by avoiding unnecessary
intervention, i.e:
labor should not be induced when the cervix is not
well prepared or ripe (softened, anteriorly rotated,
partially effaced)

The Bishop score is used to quantify the degree of

cervical ripening and readiness for labor.

A score of 0 to 4 points is associated with the highest

likelihood of failed induction.
A score of 9 to 13 points is associated with the
highest likelihood of successful induction
Induction of labor is indicated if the anticipated
benefits of delivery exceed the risks of allowing the
pregnancy to continue

Indications

Post-term pregnancy
Maternal medical problems
Pregnancy-induced hypertension
Premature rupture of membranes
Chorioamnionitis

Contraindications

Placenta or vasa previa

Cord presentation
Abnormal/unstable fetal lie
Prior two or more cesarean sections
Prior classical uterine incision
Prior uterine incision of unknown type
Active genital herpes

When the cervix is unripe, Prostaglandin E 2

(Prepidil, Propess) is administrated intracervically
or to the posterior fornix of the vagina. In the
majority of these cases labor begins without the
need of oxytocin stimulation.

A prolonged latent phase can be managed by

either rest or augmentation of labor with
intravenous oxytocin after excluding
mechanical factors.

If the patient is allowed to rest, one of following will

occur:
- the conractions can stop, in which case the patient
is not in labor (false labor)
- the contractions can become more frequent and
intensive, in which case the patient will go into
active labor
- the contractions may be as before, in which case
oxytocine may be administrated to augment the
uterine contractions

The use of amniotomy (artificial rupture of membranes) is also

advocated with prolonged latent phase.
After amniotomy the fetal head will provide a better dilating
force than would the intact bag of waters. Additionaly there
may be a release of prostaglandines, which could aid in
augmenting the force of contractions.
The risk of amniotomy is:
- an umbilical cord prolapse (the presenting part should be firmly applied to
the cervix)

- abruption of the placenta

- intrauterine infection

In the active phase of labor mechanical

factors such as abnormal position or
presentation as well as fetopelvic
disproportion must be considered before use
of oxytocin.
If the woman is tired which results in
secondary arrest of dilation, rest followed by
augmentation with oxytocin is often effective.
Artificial rupture of the membranes is also
recommended.

Risks of prolonged labor

Maternal
Fetal

infection
maternal exhaustion
lacerations
uterine rupture
uterine atony with
possible hemorrhage

asphyxia
trauma
infection
cerebral damage

Prolonged labor is associated with the passage of

meconium into the amniotic fluid and subsequently
the risk of meconium aspiration syndrome (MAS).
Fetuses who inhale meconium-stained fluid during
labor may suffer this syndrom, which includes both
mechanical obstruction and chemical pneumonitis
from the meconium material.
Pathologic factors include:
- atelectasis
- consolidation
- barotrauma
- removal of pulmonary surfactant by free fatty acids

Amniodilution is a method of intrapartum treatment

of meconium-stained amniotic fluid. A normal saline
solution is slowly infused through a tube inserted in
the uterus, washing meconium-stained fluid out and
replacing it with the saline solution.
As the fetal head is delivered, but before delivery of
the fetal chest, suctioning of the nasopharynx should
be performed. After delivery of the fetus suctioning
out of meconium in the deeper parts of respiratory
tract (below the vocal cords) must be done.

Techniques of operative delivery include:

- obstetric forceps
- vacuum extraction
- cesarean section
The purpose of the forceps maneuver is to:
1. augment the forces expelling the fetus
when the mothers voluntary efforts in
conjunction with uterine contractions are
insufficient to deliver the infant
and eventually to:
2. rotate the fetal head in the birth canal, if
it isnt completely rotated

Necessary conditions to apply forceps :

Cervix
Membranes
Position and station
of fetal head
Feto-pelvic
disproportion
Fetus

Fully dilated
Ruptured
Known and engaged
Excluded
Alive

Forceps Classification
Outlet forceps - the fetal skull has reached the perineal
floor, the scalp is visable between contractions, the
sagittal suture is in the anteposterior diameter
Low forceps - the leading point of fetal skull is +2
station or more
Midforceps - the head is engaged but the leading point
of the skull is above +2 station
High forceps - the head is high above inlet and isnt
engaged, the leading point of the skull above 0
(not performed in current obstetrics)

To avoid the potential risk of trauma to

both maternal and fetal parts application
of obstetric forceps should be performed
by an experienced clinician

Before application of the forceps the physician

should reassess the fetal position.
The neonatologist should be notified in advance,
before application of the forceps.
Forceps should be applied only after the cervix is
completely dilated and if there is no evidence of
cephalopelvic disproportion.
Forceps sshould be applied only (!!) after the
biparietal diameter has passed through the inlet, and
the skull has passed below the ischial spines.

After delivery the genital tract and infant should be

examined carefully.
Potential risks:
- lacerations of: the cervix, vagina, perineum,
bladder and rectum
- injuries of the fetus: intracranial hemorrhage, skull
fracture, brachial plexus injury, cephalhematoma,
facial paralysis, clavicular fracture

Vaccum extraction
This maneuver is similar to forceps delivery.
Its purpose is to augment the forces expelling the
fetus when the mothers voluntary efforts in
conjunction with uterine contractions are
insufficient to deliver the infant.
Advantages of the vacuum extractor include:
- less force applied to the fetal head
- reduced anesthesia requirements
- easier aplication
- less perineal trauma
-the ability to permit the head to find its path out
of the maternal pelvis

Disadvantages of the vacuum extractor include:

- the application of traction only during contractions
- limitation of its use only to term infant
- prolonged delivery in comparison to forceps delivery
The head must be engaged and the membranes must
be ruptured. There is no danger of catching vaginal
mucosa or cervical tissue between the vacuum and the

Cesarean section
About 20-25% of gravidas are now delivered by
cesarean section. Appropximately two-thirds of
these procedures are perforemd after the onset of
labor.

In elective or not very emergency situations such as

- abnormal presentation
- placenta previa without bleeding
- large fetus
- abnormal pelvis
- some maternal diseases
- prolonged labor
- begining of fetal depresion
transverse abdominal incision in the lower part of

In emergency situations such as:

- fetal depresion
- prolapsed umbilical cord
- ruptured uterus
- severe abruptio placente
- placenta previa with extensive hemorrhage
a midline vertical abdominal incision (from the
nevel to the pubic bone) provides more rapid access