Normal Labour and the Care

required.

Penang Medical College

 Uterus
Upper Segment * Expands with baby in
Pregnancy

* Contracts & retracts in

labour

* 70% muscle, 30%

fibrous tissue

* Above level of bladder

 Uterus
Lower Segment * Relaxes in Labour
why C-section not cut in lower segment?
when it is cut, it heals as fibrous scar which is more likely
to rupture in subsequent pregnancy
(unlike upper segment which the muscle tissue heals
better without leaving scar)
* 70% fibrous tissue,
30% muscle

* Lies behind bladder

 Uterus
Cervix * The neck of the
uterus approx 4cm long

* Stops baby from

falling out during
pregnancy
softens and shortens

* Dilates and is taken up

into lower segment in
labour
 The Uterus
The Primigravid Uterus
The Multigravid Uterus

Almost like two different biological species

Prof. Kieran ODriscoll

 The Primigravid Uterus
* First attempt how effective in labour
unknown
uterine
with failure to progress,
* Inefficient action common leads to deflexed head and CPD [cephalo-pelvic
disproportion, birth canal too small for fetal
head to pass through]

* Genital tract stretches with difficulty

* Almost never ruptures

 The Multigravid Uterus
* Cephalo-pelvic disproportion (CPD) rare

* Inefficient uterine action rare the uterine muscle can stretch significantly

* Genital tract stretches easily

* May rupture if labour becomes obstructed

 False labour pain
True labour pain (pg. 137)
- dull in nature
- painful uterine contractions at regular intervals
- confined to lower abdomen and groin
- frequency, intensity and duration of contractions increase progressively
- not associated with hardening of uterus
- associated with 'show'
- no features of true labour pain
- progressive effacement and dilatation of cervix
- descent of presenting part
- NORE RELIEVED by edema or sedatives
Labour - relieved by edema or sedative
- found more in primigravidae, due to
stretching of cervix and lower uterine segment
with consequent irritation of neighbouring
ganglia

No one precipitating cause

It is caused by a change in the balance of

pro-labour and pro-pregnancy factors,
particularly hormones. Braxton Hicks
- painless, irregular involuntary uterine
Normal labour
contractions throughout pregnancy
- spontaneous in onset and at term
- no effect on dilatation of cervix
- vertex presentation
- without undue prolongation
- natural termination with minimal aids
- without having any complications affecting the health of mother and the baby
 Pro-pregnancy Factors

* Progesterone

* Catecholamines
Prelabour (few weeks to few days before labour)
* Relaxin 1) 'Lightening'
- Esp in primigravidae, the presenting part sinks into true pelvis
due to active pulling up of lower pole of uterus around the presenting
part
- might be frequency of micturition or constipation due to pressure
by the engaged presenting part
- a 'welcome sign' as it rules out CPD
2) Cervical changes
- rippening of cervix - soft, effaced, dilated
3) appearance of false labour pain
 Pro-labour Factors
- increases release of oxytocin from maternal pituitary
- promotes synthesis of myometrium receptors for oxytocin & increase excitability of
myometrial cell membranes
- promote synthesis of prostaglandins
* Oestrogen - accelerates lysosomal disintegration in the decidual and amnion cells resulting in
increased prostaglandin synthesis

- stimulates synthesis and release of prostaglandin from amnion and decidua

- Ferguson reflex: vaginal examination and amniotomy cause rise in maternal oxytocin level
* Oxytocin - amount of oxytocin receptors and its sensitivity increases during labour, more present in the
fundus compared to lower segment and cervix
- act on amnion, chorion, decidual cells and myometrium
- triggered by rise of estrogen level, glucocorticosteroids, stretching in late
pregnancy, increased in cytokines (IL-1,6, TNF), infection, vaginal examination,
* Prostaglandins rupture of membranes
- stimulates release of intracellular calcium of myometrium and thus muscle
contracts
- at peak level during delivery of placenta & control postpartum hemorrhage
* Fetal steroids from fetal adrenal gland, which produces a precursor which then enters maternal
circulation, stimulating production of estrogen in mother's body
cascade of events activate fetal hypothalamic-pituitary-adrenal axis
-> increased corticotropin-releasing hormone (CRH) -> increased release of ACTH which stimulates fetal adrenals
--> increased cortisol secretion -> accelerates production of estrogen and prostaglandin from the placenta

* Uterine stretching effect on myometrium by growing fetus and amniotic fluid increases the gap junction
and receptors for oxytocin and specific contraction associated proteins (CAP)
 The Mechanism of Labour
right occipitolateral
1) Fetal head at pelvic brim ROL or LOL position
2) Head flexes on neck producing circular presenting
part.
3) Head descends and engages
occiput anterior position
4) Levator Ani on pelvic floor - rotates to OA
5) Head delivers by extension over perineum.
6) Shoulders descend & rotate to AP position
7) Head comes into line with shoulders-Restitution
8) Anterior shoulder delivers under pubic symphysis
heart rate falls during the contraction
- decceleration
- Valsava maneuver
 Fetal head dimensions.
Transverse diameter- 9.5cm irrespective of
type of presentation.
Antero-posterior diameter-
Vertex OA 9.5 cm - This is best.
Vertex OP 12.0 cm - Often too big
Brow 13.5 cm - This is much too big.
Face MA 9.5 cm - Often OK
 When Does Labour Start ?

* When patient admitted time zero

(management definition)
Friedman's curve of cervical dilatation
Latent phase - up to 3cm
Acceleration phase - 3-4cm
Phase of maximum slope - 4-9cm
Phase of deceleration - 9-10cm dilatation

There are three stages:

stage of cervical dilatation
Effacement - length of cervical canal (use percentage)
First Stage: Dilatation - diameter of external os (1,2,3 fingers or cm)

From the onset of labour until full dilatation

(a) Latent phase - onset until full effacement
of cervix (usually about 3cm dilatation).
primigravida - abt 20 hours
Can take up to 24 hours. multipara - abt 14 hours

(b) Active phase - cervical dilatation after 3cm.

Active phase < 10 hours
1cm / hour if nulliparous, faster if multiparous.
 Labour Second Stage
From full dilatation of cervix until delivery of baby
from full dilatation up to descent of the presenting part to pelvic floor

Phase (a) Propulsive - head descends to pelvic floor

initiated by nerve reflex
due to uterine contractions. of(Ferguson reflex) due to stretching
vagina by presenting part

(b) Expulsive - Active bearing down (when

pushing) maternal bearing down efforts until fetus is delivered
Prolonged propulsive phase increases risk of
pudendal neuralgia. -ADD 30min if use of epidural
use of epidural analgesic increased propulsive phase
due to loss of sensation to push

Active phase usually < 1 hr prims <1/2hr multips

Increased risk of hypoxia when pushing > 1 hr.
 Labour Third Stage
From delivery of baby to delivery of placenta and
membranes. Look for signs of placental
separation and descent, THEN deliver placenta
and membranes.

Physiologically < 30 minutes.

Quicker if oxytocics (syntocinon/syntometrine)
used, when PPH rate is reduced, but retained
placentapostpartum
is more likely
hemorrhage
Risk of PPH markedly increased if placenta is not
delivered within 1 hour of birth of baby.
Care of Mother & Baby in
Labour

pg. 605

1)Partograms are routine and universal

2) Pelvic examination findings-
usually performed every 4 hours.
Cervical dilatation, effacement and position.
Membranes- intact/ruptured. Liquor colour.
Presentation- cephalic (vertex, brow, face),
breech, shoulder, cord.
Position- OA, LOA, ROA, LOT, ROT, LOP,
ROP, OP. etc (if vertex)
1st degree: sutures apposed but not overlapping
?moulding/caput 3rd degree:
2nd degree: sutures overlapping, but reducible
sutures overlapping, and non-reducible

Station- relation to ischial spines. Head engaged

when lowest bony point is at spines (zero station)
Clinical pelvimetry. -+ififabove
below spines (+1cm +2cm etc)
spine (-1cm -2cm)
 Care of Baby during labour.
3)Fetal heart rate recording

1) Intermittent auscultation- half-hourly in first

stage, 10-15 minutely in second stage, after
every second contraction when pushing, and
after every contraction when head on view.
2) Continuous cardiotocography (CTG)- in Penang
used routinely. Elsewhere used if fetal hypoxia
is believed more likely (50% use rate in most
labour wards)
 Electrical CTG (external or
scalp clip)
1) Baseline Rate- 110-160
2) Baseline Variability- 5-20 bpm
3) Accelerations- indicate normal brain-stem
function.during contraction, there may be slowing of fetal heart rate by 10-20 bpm
which soon returns to its normal state

4) Decelerations
- Early - head compression
- Late - placental dysfunction
- Variable cord compression causing hypoxia
Fetal blood sampling (FBS) used to measure for short term changes in hypoxia status of fetus
- normal value about 7.25, <2 indicates hypoxia
 Liquor Characteristics
Signs of hypoxia
1) poor CTG
2) thick meconium
1) Clear 3) poor fetal blood sampling (FBS)

content of fetal bowel, usually excreted after the baby is bornt

2) Meconium stained
Grade 1 Slight
Grade 2 Heavy suspension
Grade 3 Thick undiluted sign of hypoxia
3) Blood stained
4) Bilibubin stained
5) Purulent
 Care of Mother
1) Friendly, open, caring, attentive
professional staff

2) Personal midwife, if possible

3) Presence of friend / partner / husband

4) Empowerment / involvement of mother in

progress and decisions
 4) Care of Mother
morphine is NOT GIVEN as it crosses blood-brain barrier to the fetus,
and fetus is much more sensitive to morphine than mother

Relief of Pain- Non pharmacological/

Opiates/ Inhalational (Nitrous
oxide/oxygen)/ Regional / Epidural / GA
Prevention of - dehydration/ ketoacidosis/
aspiration. Need IV therapy if labour
prolonged.
Observations- pulse, blood pressure,
temperature, fluid balance.
 Care of the baby at birth
Aspirate airway and remove blood and
meconium from mouth and nose.
Assess APGAR score (out of 10)- colour,
respirations, breathing, tone, heart rate.
Determine if breathing is OK. If not use bag
& mask or intubate, and give oxygen.
Define if special resuscitation is needed- call
paediatrician, ? give narcotic antagonist, ?
give NaHCO3.