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LABOR AND DELIVERY

MECHANISM AND PHYSIOLOGY

Dr. Rhoda Abesamis Juson MD, FPOGS

introduction
Labor is the process that begins
with repeated, forceful uterine
contractions. Uterine contractions
supply the power that makes birth
possible. Contractions
cause the
3
cervix to dilate and help move the
baby through the birth canal .

Labor

Defined as effective onset of uterine


contractions leading to progressive
effacement and dilatation of
cervix resulting in expulsion of fetus,
placenta and membranes.

NORMAL LABOR (EUTOCIA)


Labor is called normal if it fulfils the following
Criteria
Spontaneous in onset at term
With vertex presentation
Without undue prolongation
Natural termination with minimal aids
Without having any complication

ABNORMAL LABOR(DYSTOCIA)

Any deviation from the definition of Normal


Labor is called Abnormal Labor.

Events of labor are divided


in to four stages
First stage
Second stage
Third stage
Fourth stage

FIRST STAGE
It starts from the onset of true labor pain, and
ends with the full dilatation of the cervix. Its
average duration is 12 hrs. in primigravidae and
6 hrs in multiparae1.1.
FIRST STAGE comprises of 3 phases

Latent phase
Active phase
Transitional phase

Latent phase : is prior to active first stage


of labor and may last 6-8 hrs. in first time
mothers when the cervix dilates from 0 cm
to 3-4 cm dilated and cervical canal shortens
from 3 cm to less then 0.5 cm long2.

Active phase : is the time when cervix


undergoes more rapid dilatation. This begins
when the cervix is 3-4 cm dilated2.

Transitional phase : is the stage of labor


when the cervix is around 8cm dilated until it
is fully dilated2. also known as the
deceleration phase.

SECOND STAGE

The second stage is that of expulsion


of the fetus. It begins when the cervix
is fully dilated and the women feels
urge to expel the baby. It is complete
when baby is born2.

THIRD STAGE

The third stage is that of separation and


expulsion of placenta and membranes ; it
also involves control of bleeding. It lasts
from the birth of the baby until the placenta
2
and membranes have been expelled
.

Fourth stage

It is the stage of observation for at


least one hour after expulsion of the
after-births. During this period,
general condition of the patient and
the behavior of the uterus are to be
carefully watched1.

Onset of spontaneous normal


labor
Recognition of spontaneous labor is not
always easy. Both the woman midwife being
aware of the latent phase of the labor and
allowing this time to pass with no
intervention
Spurious labor: many woman experience
contractions before the onset of labor ,
causing the women to think that labor has
started.

The 2 features of true labor that


are absent here,
1} Effacement
2} Cervical dilatation

PHYSIOLOGY OF FIRST STAGE


OF LABOR

Duration

Uterine actions
(a) Fundal dominance
(b) Polarity
(c) Contractions and retraction
(d) Formation of upper and lower uterine
segment
(e) The retraction ring
(f) Cervical effacement
(g) Cervical dilatation

Mechanical factors
(a) Formation of the forewaters
(b) Rupture of the membranes
(c) Fetal axis pressure

DURATION

Length of labor is influenced by parity,


birth interval, psychological state,
presentation and position, maternal
pelvic shape and size, character of
uterine contractions.

In primipara women, average duration


is 12 hours.

In multipara women it is 6 hrs.

Uterine actions

FUNDAL DOMINANCE
Each uterine contraction starts in the
fundus near one of the cornua and
spreads across and downwards.
contraction lasts longest in the fundus
where it is also more intense and
contraction fades from all parts
together.
This pattern permits the cervix to
dilate and the strongly contracting
fundus to expel the fetus.

POLARITY
Polarity is the term used to describe
the neuromuscular hormony that
prevails between the two poles or
segments of the uterus through out
the labor.
polarity disorganized = labor inhibited

Contractions AND
RETRACTION

contraction
Contraction is the
temporary reduction in the
length of the fibers

Uterine muscles have unique property.


During labor the contraction does not pass
off entirely ,but muscle fibers retain some of
the shortening of contraction instead of
becoming completely relaxed, this termed as
retraction .

Intensity : gradually increases with


advancement of labor until it become
maximum in the second stage during
delivery of the baby.
Intrauterine pressure raised to 40-50 mm
Hg in first stage.
Duration : In the first stage, the
contraction last for about 30 sec., but
gradually increase in duration with the
progress of labour.
Frequency : in early stage, the contraction
come at intervals of 10-15 mints. By the
end of the second stage they occur
at 2-3 minutes.
Intervals, last for 501
60 seconds and are very powerful .

Retraction

Is the phenomenon of the uterus in labor in which


the muscle fibers are permanently shortened.

Effects of retraction

Help

in formation of lower segment


Maintains advancement of presenting part
Favoring separation of placenta
Hemostasis

Formation of upper and lower


uterine segment

By the end of the pregnancy body of the uterus


is described as having divided into two
segments.
The upper segment, have been formed from
the body of fundus, and is mainly concerned
with contraction and retraction, it is thick and
muscular.
The lower segment is formed of the isthmus
and cervix, about 8-10 cm.
The lower segment is prepared for distention
and dilatation.

The retraction ring


The wall of the upper segment become
progressively thickened with progressive
thinning of the lower segment.
Distinct ridge is produced at the junction
of two, called physiological retraction ring.
Physiological retraction ring should not be
confused with pathological retraction
ring also called as Bandls
ring .
1
Once the cervix is fully dilated and the
fetus can leave the uterus, the retraction
ring rises no further .

Bandls ring

Effacement ( taking up of
cervix)
Here cervix is drawn up and gradually
merges in to the lower uterine
segment.
In the primiparous women it may
result in complete effacement.
In multiparous women perceptible
canal may remain.

Effacement is the gradual thinning, shortening, and


drawing up of the cervix, This is measured in

percentages from 0 to 100 percent.


DESCRIPTION

EFFACEMENT OF
CERVIX

No changes to cervix

0% Effaced

Cervix is half of the


normal thickness

50% Effaced

Cervix is completely
thinned out

100% Effaced

Cervical dilatation

Cervical dilatationis the opening of


thecervix, the entrance to the uterus
duringchildbirth,miscarriage,induced
abortion, or gynecological surgery. Cervical
dilation may occur naturally, or may be
induced by surgical or medical means.
6
General guidelines for cervical dilation:
Latent phase: 0-3 centimeters
Active Labor: 4-7 centimeters
Transition: 8-10 centimeters
Complete: 10 centimeters. Delivery of the
infant takes place shortly after this stage is
reached

Duringpregnancy, the os (opening) of


the cervix is blocked by a thick plug
ofmucus to prevent bacteria from
entering the uterus. During dilation, this
plug is loosened. It may come out as one
piece, or as thick mucus discharge from
the vagina. When this occurs, it is an
indication that the cervix is beginning to
dilate.
Bloody show : is another indication
that the cervix is dilating. Bloody show
usually comes along with the mucus
plug, and may continue throughout labor,
making the mucus tinged pink, red or
brown.

Closed cervix

Mechanical factors

Formation of forewaters
The sac of amniotic fluid is described as
having two sections the forewaters (in front
4
of babys head) and the hind waters (behind
babys head).
During labor forewaters are formed as the lower
segment of the uterus stretches and the chorion
4 from it .
(the external membrane) detaches
The well flexed babys head fits into the
cervix and cuts off the fluid in front of the head
4
(forewaters) from the fluid behind (hind
waters) .

Pressure from contractions cause the


forewaters to bulge downwards into
the dilating cervix and eventually
through into the vagina. This protects
the forewaters from the high pressure
applied to the hind waters during a
4
contraction and keeps the membranes
intact .
The forewaters transmit pressure 4
evenly over the cervix which aids
further dilatation .

General fluid pressure

During a contraction the pressure is


equalised throughout the fluid rather
than directly squeezing the baby,
placenta and umbilical cord.

This protects the baby and his/her


oxygen supply from the effects of the
powerful uterine contractions .

Rupture of the membranes

The optimum physiological time for


the membranes to rupture
spontaneously is at the end of the first
stage of labor after the cervix become
2
fully dilated and no longer supports
the bag of forewaters .

Fetal axis pressure

In longitudinal lie, there is a tendency


of straightening out of fetal vertebral
column.

This allow the fundal contraction to


transmit through the podalic pole in to
the fetal axis and hence allow
mechanical stretching of lower
segment and opening up of cervical
canal .

In transverse lie fetal axis pressure is


absent

Management of first stage of


labor

PRINCIPLES

Non

interference with watchful


expectancy so as to prepare the patient for
natural birth.

To

monitor carefully the progress of

labour, maternal conditions, and fetal behaviour


so as to detect any intrapartum complication
early.

Management of normal labor aims


at maximal observation with minimal
intervention. The idea is to maintain
the normalcy and to detect any
deviation from the normal at the
earliest possible moment.

preliminaries
This consist of basic evaluation of the
current clinical condition.
Inquiry is to be made about the onset of
labor pains or leakage of water, if any.
Thorough general and obstetrical
examinations including vaginal
examinations are to be carried out and
recorded.
Records of antenatal visits, investigation
reports and any specific treatment given, if
available, are to be reviewed.

Actual management
Environment

Women may choose to give birth in their own


home where they control the environment and
feel comfortable in their own surroundings or
they wish the security of a hospital birth
where facilities are readily available for
prompt and efficient action should an
emergency occurs.
A trusting atmosphere between a women
and her caregivers, a feeling of being
among friends and a knowledge of the
skills required to cope with the stresses
of labor set the scene for a positive
childbirth experience.

Emotional support

Emotional support consist of helping the


mother to feel in control of herself to feel
accepted whatever her reactions and
behavior may be and to complete her labor
feeling that she is success, even if the
outcome was not what she hoped for.

Consent and information


giving
Any individual who puts herself in the
hands of professional attendants
deserves to be kept fully informed
about their actions and observations.
The Doctor/Midwife/Nurse must take
care not only to talk to the mother but
to ask for her consent to what she
plans to do and to invite her
comments and questions.

Prevention

of infection

The very nature of the care given


during labor may expose both mother
and fetus to the risk of infection.
This is the responsibility of health care
professional to acquaint herself with
the risks, prepare the woman
physically during the antenatal period
and to maintain hygiene and asepsis
in order to prevent infection occuring,
this include :

Blood : The hemoglobin level should


be adequate and anemia should be
corrected if necessary

Nutritional status: poverty may lead


to malnurition. Education in using
economic yet nutritious food,
including how to prepare them may be
an invaluable contribution from the
health care provider.

Skin

and membranes :

An intact skin provides an excellent


barrier to organisms and it is important
to protect its integrity. This involves the
avoidance of surgical wounds
whenever possible including how to
prepare them may be an invaluable
contribution from the midwife.
Hygiene

A clean body and environment will


reduce the organisms which have
assess to mother. This implies the
need for barrier methods to be used.

Rest

A tired, exhausted women will not be able to


combat infection and if the mother has been
deprived of sleep and rest prior to admission
of during labor, we may need to create an
opportunity for sleeping if necessary by mild
sedative drug.
General

health and care of


environment :
A modern maternity unit should be
constructed so as to limit the spread of
infection. It should be sighted from a distance
from any source of pathogenic organisms and
should be designed for easy and effective
cleaning and in a way which will reduce the
transfer of air born organisms.

It is our responsibility to ensure that


high standards of cleanliness are
maintained even if she does not have
managerial control over domestic
services.

Antiseptics

and asepsis:

We must always use sterile


equipments and aseptic technique in
order to avoid introduction foreign
organism in to the genital tract.

Position of mother :

several consideration govern the choice of


position during the first stage of labor, of
these the most important is that of
maternal preference.
In early labor, ambulation can be
encouraged provided the amniotic sac is
intact.
When lying down, lateral position will be
the best as this avoids compression of the
inferior venacava and consequent
hypotension.
Changing position not only improves
comfort but also help progress.

Remaining

upright and
leaning forward reduces this
pressure while allowing the
babys head to constantly
bear down on the cervix.
The result? Dilation tends to
occur more quickly.

Nutrition

Advice prior to admission : the womens need in


labor is for energy and it is carbohydrates which
provide. She should choose food that are light
and easily digested such as bread and butter,
fluids may be taken freely, although fizzy and
very sweet drinks may induce vomiting.
Intake in early labor : in some centers, no food
is permitted after labor is established, on the
basis that anesthesia could be needed.
Policies in advance labor : most obstetric units
withhold food in advanced labor. Some also
discourage drinking but allow the women to
have sips of water to keep her mouth
comfortable.

Bladder care :

The woman should be encouraged to


empty her bladder every 1-2 hrs during
labor.
The quantity of urine passed should be
measured.
If the bladder remains full, the bladder
neck can become nipped between the
fetal head and the symphysis pubis.
This may give rise to bruising which
can slough during the perineum leaving
a vesico-vaginal fistula.

Vital

signs :

Pulse rate : A steady pulse rate is an


indication that the women is in good
condition. If the rate increases mare
than 100 beats/min. it may indicative of
infection, haemorrhage, ketoacidosis.
Temperature : this should remain with in
the normal range. It should be recorded
every 4 hrs.
Blood pressure : the effect of labor may
be to further elevate a raised blood
pressure.

Vaginal examination

Bimanual or PV examinations are


performed for a number of clinical
reasons e.g. problems relating to
menstruation, irregular bleeding,
dyspareunia, abnormal vaginal
discharge, pelvic pain, and here we
are going to examine for early
detection of any abnormality in labor
process.

preliminaries
Toileting hands and forearms should be
washed, a scrubbing brush should be used for
fingernails.
Sterile pair of gloves is to be put on.
Vulval toileting should be performed and same
solution is poured over the vulva by separating
the labia minora by the fingers of left hand.
Gloved middle and index finger of the right
hand smeared with antiseptic cream introduced
in to vagina after separating the labia by two
fingers of the left hand.

Complete examination should be done


before fingers are withdrawn.

Vaginal examination should be kept as


minimum as possible.

The following information are to


be noted and recorded
Degree

of cervical dilatation in centimeters


Degree of effacement of cervix
Status of membranes and if ruptured character
of fluid(meconium stained-greenish , yellowish,
clear).
Presenting part and its position by noting the
fontanelles and sagittal suture in relation to to
the quadrants of the pelvis.
Caput and moulding of head
Station of the head in relation to ishchial spines.

Fetal monitoring

Fetal condition during labor can be


assessed by obtaining information
about the fetal heart rate and
patterns. The pH of the fetal blood and
the amniotic fluid.

The doppler ultrasound apparatus can


be used for measuring fetal heart rate
and rate should be between 120-160
beats/min.

Pain management
Non

pharmacological methods :

Transcutaneous electrical nerve


stimulation (TENS) : It work be
interrupting pain transmission along
the sensory pathway.

Hypnosis

: Is also a pain relieving


technique. Women are usually taught
self hypnosis and in suitable subject it
may be successful.

Pharmacological
Sedative

methods :

and analgesics :
The sedative given were usually the chloral
derivatives. Analgesics which are used in early
labor are in mild to moderate analgesic range
e.g. paracetamol.
Narcotics : A narcotic is a strong analgesic drug
with some sedative properties. These include
pethidine, morphine, naloxone, pentazocine.
Inhalation analgesia : They offer effective
pain relief for the majority, of women with the
adnvantage that all their effects are short lived
and they donot give rise to any complication in
the neonate. The agent used is Entonox. Entonox
is the trade name used to describe an equal
mixture of oxygen and nitrous oxide.

Physiology in the
second stage of
labor

Second stage of labor begins when


the cervix is fully dilated and ends
with the babys birth, it is a time when
the whole tempo of activity changes.
The mothers passive control during
the long hours of the first stage is
replaced by intense physical effort
and exertion for a comparatively short
period. Both parents require stamina,
courage and confidence in the skill of
attendant health professional.

hoursininPrimi-gravida
Primi-gravida
22hours

30
minutes
in
multi30 minutes in multigravida
gravida

Physiology changes :

1.

Uterine actions :
contractions becomes stronger and
longer but may be less frequent affording
mother and fetus a recovery period
during the resting phase.
There are progressive, continued
contractions and retractions of the upper
uterine segment while the lower segment
and cervix passively dilate and thin. The
membrane often rupture spontaneously
at the onset of second stage.

The consequent drainage of liquor allows


the hard , round fetal head to be directly
applied to the vaginal tissues and aid
distension.
Fetal axis pressure increases flexion of the
head which results in smaller presenting
diameters, more rapid progress and less
trauma to both mother and fetus
The nature of the contraction changes.
They become more expulsive as pressure is
exerted on the rectum and pelvic floor.

2) Soft tissue

replacement :
As the fetal head descends, the soft tissue of
the pelvic become displaced. Anteriorly the
bladder is pushed upwards in to the
abdomen where it is at less risk of injury
during descent .
Posteriorly the rectum becomes flattened in
to the sacral curve and the pressure of the
advancing head expels any residual fecal
matter. The fetal head become visible at the
vulva, advancing with each contraction and
receding during the resting phase until
crowning take place and the head is born

Recognition of the second stage


:
Presumptive signs :
Expulsive uterine contractions : it is possible for a
women to feel a strong desire to push
Rupture of the fore-water : this may occur at
anytime during labor.
Dilation and gaping of the anus: Deep engagement
of the presenting part and premature maternal effort
may produce this sign.
Appearance of the presenting part
Show
Congestion of the vulva : Enthusiastic premature
pushing may also cause this.

The

Mechanism
of normal labor

As the fetus descends soft tissue


and bony structures exert pressure
which force the fetus to negotiate the
birth canal by a series of passive
movements. Collectively these
movements are called the mechanism
of labor.

CARDINAL MOVEMENTS
OF LABOR i

In a first-time pregnancy descent is usually


slow but steady; in subsequent pregnancies
descent may be rapid. Progress in descent
of the presenting part is determined by
abdominal palpation until the presenting
part can be seen at the introitus.

Station of head

The degree of descent is


measured by the station of
the presenting part As
mentioned, little descent
occurs during the latent
phase of the first stage of
labor. Descent accelerates
in the active phase when
the cervix has dilated to 5
to 7 cm. It is especially
apparent when the
membranes have
ruptured.

Asynclitism
:The
head
usually
engages in the pelvis in a synclitic
position, one that is parallel to the
anteroposterior plane of the pelvis.
Frequentlyasynclitismoccurs
(the
head
is
deflected
anteriorly
or
posteriorly in the pelvis), which can
facilitate descent because the head is
being positioned to accommodate to the
pelvic
cavity.
However,
extreme
asynclitism can cause cephalopelvic
disproportion, even in a normal-size
pelvis, because the head is positioned
so that it cannot descend.

Crowning

Crowning is when babys head


remains visible at vaginal outlet
without slipping back in as mother is
pushing continuously during birth

ROLE OF NURSE

Fetal heart rate monitoring during


the 2nd stage of labor
-low risk: 15 min
-high risk: 5 min
-slowing of the FHR
: due to fetal head compression
: reduce placental perfusion
: recovery after the contraction
and expulsive effort cease

Preparation for delivery


-The dorsal lithotomy position
: increase the diameter of the
pelvic outlet
: using leg holder and stirrup
-> result in spontaneous tear or
fourth degree
-vulvar and perineal cleansing
: sterile drape and gowning,
gloving

SPONTANEOUS DELIVERY
Delivery of the head : crowning
encirclement of the largest head
diameter by the vulval ring.
- one hand: a towel-draped, gloved hand
may exert forward pressure on the chin of
the fetus through the perineum just in
front of the coccyx
- with other hand: exerts pressure superiorly
against the occiput.

SPONTANEOUS DELIVERY

Delivery of shoulder
The occiput : Turns toward one of the
maternal thigh
Fetal head: Transverse position
sucking the nasopharynx or checking for a
cord.

Clamping the cord

Between two clams: 4 or 5cm and


later 2 or 3cm from the fetal abdomen

Timing

of cord clmaping

After delivery, the infant is placed at the


level of vagina for 3 min, the feto-placental
circulation is not occluded
80 ml of blood shift to the fetus (50mg of
Fe)
After first clearing the airway (30 second)
-> then clamps the cord or when the
pulsation of the cord stops

THIRD STAGE

After the baby has been born the placenta,


which has sustained baby throughout
pregnancy, is no longer needed; mother
need to push it out along with the remaining
part of the umbilical cord that runs between
the placenta and baby.

Two Methods of Third Stage


Management

Physiologic (expectant) management


Oxytocics are not used
Placenta is delivered by gravity and maternal
effort
Cord is clamped after delivery of the placenta

Active Management
Oxytocic is given
Cord is clamped
Placenta delivered by controlled cord traction
(CCT) with counter-traction on the fundus
Fundal massage or pressure

Normal Blood Loss at Delivery


Vaginal Delivery
< 500 mL
Cesarean Section
< 1000 mL

Procedure for Active


Management
Oxytocin

Within 1 minute of birth, palpate abdomen to rule


out presence of another baby
Give oxytocin
CCT

Await strong uterine contraction (23 minutes)


Apply controlled cord traction while applying
counter-traction above pubic bone
If placenta does not descend, stop traction and
await next contraction

Details of Physiologic
Management
Try not to give oxytocic
Try not to use CCT or any manual interference
with uterus at fundus
Try to encourage mother to concentrate on
feeling for next contraction or urge to push
When mother feels contraction or urge or there
are signs of separation, encourage mother and
help her change posture
If placenta does not deliver spontaneously,
wait, try putting baby to breast and encourage
maternal effort

Details of Active Management

Try to give one ampule of oxytocic (5 units


oxytocin and 0.5 mg ergometrine routinely or 10
units synthetic oxytocin if mother has high BP)
immediately after delivery of anterior shoulder
Clamp cord 3 mints. after delivery of baby
When uterus has contracted, try to deliver
placenta by CCT with protective hand on
abdomen helping to shear off placenta and
preventing uterine inversion
Try not to give any special instructions about
posture

Physiological Versus Active Management


Physiological
Management

Active
management

Uterotonic agent

None or after placenta With delivery of


delivered
anterior shoulder or
baby

Uterus

Assessment of size
Assessment of size
and tone after delivery and tone after delivery

Cord traction

None

controlled cord
traction when uterus
contracted

Cord clamping

Variable

Early

Recommendations Concerning
Selection of Oxytocic

Use oxytocin, when available:


If oxytocin is not available, use syntometrine or
ergometrine
If oxytocic drugs are not available, use nipple
stimulation

Do not use ergometrine in women with


hypertension or heart disease
Store oxytocics in refrigerator (28C)
and away from light
Misoprostol rectally has advantages.

Immediately after delivery of the placenta


Determine the fundal position and size of the
uterus.
Ensure that the uterus is contracted (can be
enhanced with oxytocin and uterine massage).
Examine the placenta for completeness and
detection of abnormalities.
Suturing of lacerations.
- Is justified in patients with bleeding
originating high in the genital tract.

Uterine

exploration:
- No longer recommended for
normal deliveries or those
following previous cesarean
delivery.
- Is justified in patients with
bleeding originating high in the
genital tract.
- The cervix should be visualized
after all forceps deliveries

Fourth stage

Observe the vital signs.

Palpate the abdomen to assess and monitor uterine tone


and size.
Do uterine massage.
Ensure continuous infusion of oxytocin.
Encourage early breastfeeding to promote endogenous
oxytocin release.
assess the lower genital tract for bleeding.
repair of an episiotomy or any lacerations.
Close observation every 15 minute for the next hour.

Q.

Normal labour is the process by which


contractions of the gravid uterus expel the
fetus and the other products of conception

A-between 37 and 42 weeks from the last


menstrual period
B- Before 37 weeks gestation
C-After 42 weeks gestation
D- After 24 weeks gestation

Q.
R.

S.

T.

U.

Fetal lie refers to ???


longitudinal axis of the fetus in relation
to the oblique axis of the maternal
uterus
longitudinal axis of the fetus in relation
to the transverse axis of the maternal
uterus
longitudinal axis of the fetus in relation
to the long axis of the maternal uterus
longitudinal axis of the fetus in relation
to the long axis of the maternal pelvis

Q.

R.
S.
T.
U.
V.

True onset of labor is defined by


which one of the following
Passage of bloody show
Occurance of uterine contraction
Excessive fetal movement
Cervical dilation and effacement
Gush of vaginal fluid

Q.

R.
S.
T.
U.
V.

False contractions characteristics


(Braxton-Hicks) all true Except
Occur At Irregular Intervals
Intensity doesn't change
Pain primarily in lower abdomen
Pain usually relieved with sedation
Cervix dilate

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