NORMAL LABOUR

Under the Guidance of – Dr. Alok Das &

Dr. Sukriti Biswas
 TABLE OF CONTENTS
01 02 03
INTRODUCTION MECHANISM STAGES AND
By – Kankona Das & COURSE MANAGEMENT
By – Sreetama Choudhary By – Khusboo Salim,
& Anabil Mukherjee Nourin Nahar, Chandradwip Roy

04 05
IMMEDIATE CARE OF HOMOEPATHIC
MOTHER AND CHILD THERAPEUTICS
By – Sromona Mukherjee By – Gopal Karmakar
 01
INTRODUCTION
 LABOUR
Definition - Series of events
that take place in the genital
organs in an effort to expel the
viable products of conception
(fetus, placenta, and the
membranes) out of the womb
through the vagina into the
outer world is called Labour.
TIME OF ONSET OF LABOUR
The time of onset of labour is estimated by
Naegele’s formula.
According to the formula, approximately 4%
labour starts on the expected date, 50%
labour starts on either 1 week earlier or later,
80% 2 weeks earlier and 1 week later, 10% at
42 weeks and 4% at 43 weeks.
EDD From Naegele’s Formula
First Day of Last Menstrual
Period, – 3 months + 7 days
 TYPES OF LABOUR
NORMAL LABOUR ABNORMAL LABOUR
(Eutocia) (Dystocia)
• Spontaneous in onset and at term.
• With cephalic presentation with
Any deviation from the
vertex presenting part.
normal labour is called
• Without undue prolongation.
abnormal labour.
• Natural termination with minimal
aids.
• Without having any complication
affecting the health of the mother
and/or the baby
 LABOUR PAIN
Throughout the pregnancy,
painless Braxton Hicks
contractions with simultaneous
hardening of the uterus occurs.
These contractions changes their
character, become more powerful,
intermittent and are associated
with pain. The pains are more
often felt in front of the abdomen
or radiates towards the thighs.
 True Labour
● Painful uterine contractions at regular intervals
● Frequency of contractions increase gradually
● Intensity and duration of contractions increase
progessively
● Associated with “show”
● Progessive effacement and dilatation of the cervix
● Descent of the presenting part
● Formation of the “bag of forewaters”
● Not relieved by enema or sedatives
 False Labour
● Dull in nature
● Confined to lower
abdomen and groin
● Not associated with
hardening of the uterus
● They have no other
features of true labour pain
● Usually relieved by enema
or sedative.
 STAGES OF LABOUR
1 First stage
It starts from the onset of true labour
pain and ends with full dilatation of the
cervix.(10 cm)
Duration :-
12 hours in primigravidae
6 hours in multiparae.
 2 Second stage
It starts from the full dilatation of the cervix and
ends with expulsion of the foetus from birth
canal.

Duration :-
2 hours in primigravidae
30 minutes in multiparae.
 3 Third stage
It begins after expulsion of the foetus
and ends with expulsion of the
placenta and membrane.

Duration: Its average duration is about

15 minutes in both primigravidae and
multiparae.
 Fourth stage
It is the stage of observation of the
patient and the behavior of the uterus
are to be carefully monitored.

Duration: At least 1 hour after expulsion

of the foetus afterbirth.
 02
MECHANISM &
CLINICAL COURSE
OF LABOUR
MECHANISM OF
NORMAL
LABOUR
 DEFINITION
The series of
movements adapted by
the foetus itself during
the process of delivery,
in the birth canal of the
mother is called
Mechanism of labour.
SERIES OF EVENTS DURING MECHANISM
OF LABOUR
Internal Crowning
Engagement Descent Flexion
rotation

Birth of
External shoulder
Extension Restitution rotation and Trunk
ENGAGEMENT
➢ Engagement occurs
when the largest
transverse diameter
(biparietal diameter)of
the foetal head fits into
the largest diameter of
maternal pelvis.
 DESCENT
● Foetus descents through the
pelvic inlet towards the pelvic
floor
● In the primigravida this is likely to
occur from 38 weeks gestation
onwards, in a multigravida
woman, this may not occur until
labour is established.
● Descent occurs due to: Uterine
contraction and retraction,
expulsion effort by mother,
pressure of amniotic fluid.
 FLEXION
● As the foetal head comes in
contact with the pelvic floor,
cervical flexion occurs due to
the resistance offered by the
birth canal and pelvic floor.
● This allows the presentation
part of foetus to be sub-
occiputo-bregmatic.
● In this position, the foetal skull
has a smaller diameter which
assists passage through the
pelvis.
 INTERNAL ROTATION

● As soon as the head touches

the pelvic floor, according to
Hart’s Rule the head rotates
internally 1/8th of a circle
forward, placing the occiput
behind the symphysis pubis.
● The neck is also twisted by
1/8th of a circle.
 CROWNING
● Further descent brings the
sub-occiput underneath the
pubic arch.
● Maximum diameter of foetal
head (Biparietal diameter)
stretches the vulval outlet.
● This is clinically evident when
the head, visible at the vulva,
no longer retracts between
contraction.
 EXTENSION
● With further descent the
occiput slips beneath the
suprapubic arch
● The head too extend as it
experiences no resistance.
● The foetal head is now born
and will be facing the
maternal back with its
occiput anterior.
RESTITUTION
● It is the visible passive
movement of the head
opposite to the direction of
internal rotation of head for
untwisting of the neck.
● The movement of head
occurs by 1/8th of the circle
and it now faces the medial
aspect of mother’s thigh.
 EXTERNAL
ROTATION
● With further descent during the next
contraction, now the shoulder
comes in direct contact with pelvic
floor and according to the Hart’s
Law, it also rotates forward
internally 1/8th of a circle.
● The head externally rotates 1/8th of
a circle in the direction of restitution
as the foetus keeps its spine
aligned.
 EXPULSION OF THE TRUNK

● Anterior shoulder comes behind symphysis pubis.

● The shoulders are positioned along the antero-posterior diameter
of pelvic outlet.
● With further descent shoulder escapes the pelvic cavity.
● Rest of the trunk is delivered by lateral flexion
CLINICAL COURSE OF
NORMAL LABOUR
 1st STAGE
Intermittent painful contraction
1 followed by expulsion of blood
stained mucus.
Pains are felt more anteriorly
2 with simultaneous hardening of
the uterus
Pains are shortly felt after the
3 uterine contractions begins and
passes of before relaxation of the
uterus.
Dilatation of cervix
 Effacement of cervix
Effacement is determined by the length of cervical canal.
 2nd STAGE
Intensity of pain increases. Pain
1 comes at interval of 2-3 mins and
lasts for 1 – 1-1/2 mins.

2 Bearing down efforts are

initiates by the nerve reflex
due to stretching of vagina.

3 The woman is instructed

to exert downward
pressure.
 Descent of the foetal head
Fifth’s Formula – Descend of the head in relation to ischial
spines
 3rd STAGE
1 Pain becomes shorter. Intermittent discomfort in
lower abdomen reappears, with corresponding
uterine contractions.

2 Before separation -The uterus becomes

discoid in shape, firm in feel and non-
ballotable. Fundal height reaches slighly
below the umbilicus.
After separation – uterus becomes
globular, firm and ballotable. Fundal
3 height is slightly raised and there may be
slight buldging in the suprapubic region.
 03
STAGES AND
MANAGEMENT
 FIRST STAGE
The main events that
occur in the first stage
are – (a) dilatation
and effacement of the
cervix and (b) full
formation of lower
uterine segment.
Factors for dilatation of the cervix
1. Uterine contraction and
retraction .
There is some co-ordination
between fundal contraction and cervical
dilation called “polarity of uterus”.
Factors for dilatation of the cervix
 LOWER UTERINE SEGMENT
1. It is developed from the isthmus of the uterus which is
bounded above by anatomical and below by histological
internal os.
2. In labour it is bounded above by the physiological retraction
ring and below by the fibromuscular junction of cervix and
uterus.
3. This segment is formed maximally during labour and the
peritoneum is loosely attached anteriorly.
4. It measures 7.5 cm – 10 cm when fully formed and becomes
cylindrical during the second stage of labour.
Lower uterine segment
 MANAGEMENT OF FIRST STAGE
Principle :–
1. Non- interference with
watchful expectancy.
2. To monitor the progress
of labour, maternal
conditions and foetal
behaviors.
 Actual management
• General – a. antiseptic dressing, b. encouragement, emotional support and
assurance, c. constant observation.
• Bowel and bladder – should be emptied earlier.
• Rest and ambulation – walking is allowed if membranes are intact.
• Diet – should be withheld during active labour. Fluid intake is allowed.
• Partograph recording – Pulse – at every 30 minutes. Blood pressure every
four hours. Temperature – every 2 hours.
• Abdominal examination – a. For uterine contraction – if contractions in 10
min and duration of each contraction are recorded. b. Foetal heart sound –
are more downwards and medially. c. Foetal heart rate – increased by 10 -15
beats/min.
• Vaginal examination – a. Dilation of cervix. b. Position of head. c. Station of
head in relation to ischial spine. d. Colour of liquor e. Degree of moulding
 SECOND STAGE
The second stage begins
with the complete dilation
of the cervix and ends
with the expulsion of the
foetus. This stage
concerns `with the
descent and delivery of
the foetus through birth
canal.
Propulsive phase
● It starts from the full
dilatation of cervix till the
head touches the pelvic
floor.
● Due to dilatation of the
cervix, the membrane
usually ruptures and some
amount of liquor amni also
escapes, giving the head of
the foetus more space to
accommodate due to the
simultaneous contraction
and retraction of the uterine
cavity.
Expulsive phase

● Since the time mother has

irresistible desire to “bear
down” and push until the
baby is delivered.
● With increasing contraction
and retraction, the upper
segment becomes more
thicker with corresponding
thinning of lower segment.
Hence, the fetus is
gradually expelled from the
uterus against the
resistance offered by the
pelvic floor.
MANAGEMENT OF SECOND STAGE

Principle – 1. To
assist the natural expulsion
of the foetus slowly and steadily.
2. To prevent perineal injuries.
 Conduction of delivery

Delivery of
Delivery of head Delivery of trunk
shoulder
 Episiotomy

• Definition - A
surgically planned
incision on the
perineum and the
posterior vaginal wall
during the second
stage of labor is called
episiotomy.
 THIRD STAGE
It begins after the
expulsion of the fetus
and ends with the
expulsion of placenta
and membranes (after
birth).
.
 PLACENTAL SEPARATION
• The placenta is around 20 cm or 8 inches in
diameter at the beginning of labour.
• Mechanism of separation - There is a marked
retraction which effectively reduces the surface
area at the placental site to about its half. The
plane of separation runs through deep spongy
layer of decidua basalis, so that a variable
thickness of decidua covers the maternal
surface of the separated placenta.
Central separation – Schultze method
Marginal separation – Duncan method
 EXPULSION OF PLACENTA
• After complete separation of the placenta
it is forced down into the flabby lower
uterine segment or upper part of vagina
by effective contraction and retraction of
uterus. Then it is expelled out by voluntary
contraction of abdominal muscles or
manual procedure.
 MANAGEMENT OF THIRD STAGE
PRINCIPLE – To ensure
strict vigilance and to
follow the management
guidelines strictly in
order to prevent
complication i.e.
postpartum
haemorrhage.
 Spontaneous expulsion
• The placental separation and its descent into the vagina are allowed
to occur spontaneously, under constant watch.
• If the mother is delivering in lateral position – change her to dorsal
position so as to easily note the placental separation and to assess
the blood loss.
• During this place a hand over the fundus and notice the following
things –
(i) The signs of placental separation
(ii) Uterine activity – contraction and retraction
(iii) Rarely, by cupping the fundus we can detect early signs of
inversion of uterus.
• Examination of placenta – The placenta is placed over a tray
and is washed with running tap water to examine. Following this are to
be examined –
(i) Maternal surface – it is first inspected for completeness and
anomalies. It is covered with greyish decidua. Normally, the cotyledons
are placed in close proximity to each other.
(ii) Membrane – is inspected for chorions, amnions and blood vessels.
Chorions
are shaggy whereas, the amnions are shiny. Normally there
two umbilical arteries and one umbilical veins.
 Active management
• Principle – To excite powerful uterine contractions
within one minute of uterine delivery of the baby (WHO)
by giving parenteral oxytocic, to facilitate the quick
separation of placenta and effective uterine
contractions.
• To minimize blood loss to 1/5th approximately
• To shorten the duration of 3rd stage to half.
•
 04
FOURTH STAGE
IMMEDIATE CARE
OF MOTHER AND
CHILD
 It is the stage of
observation for at least
1 hour after expulsion
of the delivery of baby,
placenta and the
membranes that both
the mother and the
baby are well.
MOTHER
 Examination of the mother
o Routine examination –
1. Recording of weight
2. Recording of pallor
3. Recording of blood pressure
4. Tonicity of the abdominal muscles
5. Examination of breast
o Pelvic examination -
1. A cytological examination of a cervical smear
2. Insertion of Intrauterine contraceptive device, if the patient
desires.
o Laboratory investigations – depending on the clinical features
presented by the patient.
 Management of ailments
• Irregular vaginal bleeding
• Leucorrhoea
• Cervical ectopy (erosion)
• Backache
• Retroversion
• Slight degree of uterine descent
• Urinary and anal incontinence
CHILD
 Examination of vital signs
1. Temperature – at the site of rectal, oral or axillary.
2. Respiration – normal respiration – 30 – 60 breaths/min.
3. Pulse – Normal – 100 – 60 beats per min and when asleep it
is around 70 – 80 beats per minute.
4. Blood pressure – Normal – 45 – 60/25 – 40 mm Hg.
5. Birth weight – Normal – 2, 500 – 4000 gm. the birth weight of
< 2500 g was taken as the index of prematurity without taking
any consideration of the gestational period or any other
factors. But infants born at term or post-term may weigh <
2500 g and occasionally a baby of diabetic mother may weigh
much more than 2500 g even before 37 weeks.
 Apgar Scoring
Indicator 0 points 1 points 2 points

A – Appearance Pink body; blue

Blue, pale Pink
(skin colour) extremities

P - Pulse Absent Below 100 bpm Over 100 bpm

G – Grimace (relfex Minimal response to Prompt response to

Floppy
irritability) stimulations stimulation

A – Activity Absent Flexed arms and legs Active

R - Respiration Absent Slow and irregular Vigorous cry

Rooting Reflex
Sucking and swallowing reflex
Glabellar reflex
Grasp reflex
Moro reflex
HOMOEOPATHIC PROPHYLAXIS DURING
PREGNANCY
Our master Dr.C.F.S. Hahnemann in aphorism
284 foot note in 6th edition of Organon of Medicine
mentioned that……

During first pregnancy, if mild antipsoric medicine

like sulphur in lower dilution is administered,
then the foetus and mother will get rid of
hereditary ill effect of psora, which causes most of
the chronic diseases.
 05
HOMOEOPATHIC
THERAPEUTICS
FOR LABOUR
ACONITUM NAPELLUS
● Pain of labour: Violent, following rapid
succession, particularly with a large child
(head seems immovable), contractions
insufficent, pains overwhelming; hot
sweat all over. (H)
● Uterine haemorrhage, active. (Cl)
● Vagina dry, hot, sensitive. (Br)
● Sharp, shooting pains in womb. (Br)
● Fear of death during pregnancy. (A)
● Labour-like pressing in womb. (Cl)
 ARNICA MONTANA
● Fatigue of uterus, great flushing of face
and heat of head during each pain, the rest
of the body being cool. (L)
● Labour pains: violent, yet they do but little
good; weak or ceasing, wants to change
position often; feels bruised. (H)
● Great soreness of back during labour with
too great sensitiveness to pain. (L)
● Feeling as if foetus were lying crosswise.
(Br)
● Bruised parts after labour. (Br)
● Violent after pains. (Br)
 BELLADONNA
● Old maids in first delivery, muscles rigid. (L)
● Labour pains: comes and goes suddenly. (Br)
● Labour pains too distressing, spasmodic, too weak
or ceasing. (Cl)
● Spasmodic contraction of os, which is hot, tender,
red and inclined to be moist, (L)
● Os uteri thin and rigid, labour low and tedious.
● Sensitive forcing downwards, as if all the viscera
would protrude at genitals. (Br)
● Dryness and heat of vagina. (Br)
● Dragging around loins. (Br)
● Pain in sacrum. (Br)
● Labour like pains deep in pelvis, radiating to back
and loins. (H)
COLOCYNTHIS
● Bearing – down crapms, causing
her to bend double.
● Wants abdomen supported by
pressure.
GELSEMIUM SEMPERVIRENS
● False labour – pains; pains pass up back. (A)
● Insufficient labour – pain from inertia, face flushed, she
is drowsy and dull. (L)
● Pains in uterus going through to back and then up
back. (H)
● Atony of uterus, loss of contractility; passive hemorrhage.
(H)
● Labour pains gone, os widely dilated, complete atony;
face flushed; patient drwosy, dull. (L)
● In every pain child seems to ascend instead of
descending. (L)
● Insufficent labour pains from uterine inertia. (H)
● Os rounded and hard and feels as if it would not dilate.
(L)
● Nervous chill in first stage of labour.
 KALIUM CARBONICUM
● Labour pains insufficent; violent backache,
wants pressed; bearing down from back
into pelvis. (H)
● Sharp, cutting pains across lumbar region,
or passing off down buttocks, thus hindering
labour; pulse weak. (H)
● Complaints after parturition. (L)
PULSATILLA NIGIRICANS
● It corrects malposition of the foetus by stimulating the
action of the muscular walls of the womb. (L)
● Inertia of uterus. (L)
● False labour pains: cannot sit long at a time, must walk
about to relieve pain; close room is very oppressive, feels
as if she must be in open airm which is extremely grateful
to her. (H)
● Labour pains too weak, spasmodic, or ceasing. (Cl)
● Labour pains; extend from sacrum up into region of
stomach causing severe pain in stomach and vomiting. (H)
● During first stage of labour child was lying transversely (first
position, shoulder presentation), in thirty minutes vertex
presented. (H)
SECALE CORNUTUM
● During labour no expulsive action, though
everything is relaxed. (Br)
● During labour; pains irregulat; too weak;
feeble or ceasing; everything seems loose
and open but no expulsive action; fainting.
(A)
● Hour-glass contraction. (A)
● During labour; prolonged bearing down and
forcing pains in uterus. (H)
● Labour ceases, and twitching or convulsions
begin. (H)
 SEPIA
● Labour: os half open, pain insufficient,
tenderness of anterior lip of mouth of
uterus, pain above pubes, as if
everything would come out.
● Shuddering during pain, want to be
covered. (L)
● Rigid os from induration on neck of
uterus. (L)
● Shooting pain in cervix, extending
upwards. (L)
 06
REPERTORIZATION
OF LABOUR PAIN
 Kent’s Repertory of Homoeopathic
Materia Medica
PAIN, labor pains, spasmodic
spasmodic : extending into groin : Cimic., thuj.
Ambr., bell., bor., bry., Caul., Caust., Cham., cimic. heart, to : Cimic.
, cocc., coff., con., cupr., knees and up to sacrum : Phyt.
ferr., Gels., Hyos., ign., ip., kali-c., lyc., mag- thighs, into : Kali-c., vib.
p., nux-m., nux- upward : Calc., gels., puls.
v., op., plat., Puls., sec., sep., stann., vib. run : Bor., Calc., Cham., gels., lyc.
stool, causing urging to : Nux-v., plat. lancinating : Aeth., clem., meli.
stomach, felt more in, than in uterus : Bor. breathing agg. : Clem.
suppressed and wanting : Cact., carb-v., caul., urination, during : Clem.
cimic., op., puls., sec.
twitching, with : Chin-s.
walking agg. : Thuj.
weak : Aeth., arn., bell., bor., cann-i., carb-s., carb-
v., caul., caust., cham., chin., Cimic.,cocc., Gels., g
raph., Kali-c., kali-p., lyc., nat-c., Nat-m., nux-
m., nux-v., Op., plat., Puls., ruta., Sec., sep.,
sulph., thuj., ust., zinc.
 Pocket Manual of Homoeopathic
Materia Medica & Repertory
Across abdomen, doubling her up; pricking in mammæ;
PARTURITION - LABOR shivers during first stage -- Cim.
CONVULSIONS (eclampsia) -- Acon., Æth., Amyl, All over, exhaustion; fretful; shivering -- Caul.
Atn., Bell., Canth., Cham., Chloral, Cic., Cim., From back to rectum, with urging to stool, or urination --
Coff., Cupr. ars., Cupr. m., Gels., Glon., Hydroc. Nux v.
ac., Hyos., Ign., Ipec., Kali br., Merc. c., Merc. From loins down legs -- Aloe, Bufo, Carbo v., Caul.,
d., OEnanthe, Op., Piloc., Plat., Solan. n.,Spiræa., Cham., Nux v.
Stram., Ver. v., Zinc. m. Upwards -- Cham., Gels.
PAIN Spasmodic, irregular, intermittent, ineffectual, fleeting --
Backache violent, wants it pressed -- Arn., Artem., Bell., Bor., Caul., Caust., Cham., Chloral., Cim.,
Caust., Kali c. Cinnam., Cinch., Coff., Gels., Kali c., Kali p., Nat. m., Nux v.,
Excessive -- Bell., Coff Op.,
False labor pains -- Bell., Cham., Caul., Cim., Pituitrin, Puls., Sacchar. of., Sec.
Gels., Nux v., Puls., Sec., Vib. op. Dyspnea from constriction of middle of chest arresting
Hour glass contraction -- Bell., Sec. pains [with] -- Lob. infl.
Labor Hypersensitiveness to pain [with] -- Acon., Bell., Caul.,
Delayed -- Kali p., Pituitrin. Caust., Cham., Cim., Cinch., Coff., Gels., Hyos., Ign., Nux v.,
Premature -- Sab. Puls.
Needle-like prickings in cervix -- Caul. Relief from pressure in back [with] -- Caust., Kali c.
Shifting Syncope [with] -- Cim., Nux v., Puls., Sec.
 A Concise Repertory of Homoepathic
Medicines - S. R. Phatak
LABOUR PAINS (See FEMALE ORGANS, labour like pains) : Caul; Cimi; Gel; Kali-c; Kali-p;
Pul.
Back, in: Gel; Petr.
• Downward: Nux-v.
Ceasing, weak: Bell; Cimi; Gel; Kali-c; Kali-p; Nat-m; Op; PUL; SEC.
• Shivering, nervous with: Cimi.
Easing: Caul; Cimi; Vib.
Eructations, with: Bor.
Excessive, laborious, violent: Cham; Pul; Sec; Sep.
False: Bell; Calc: Caul; Pul.
Fainting, causing: Cimi; Nux-v; Pul.
Insufficient: Caul; Cof: Kali-c; Nuc-v: Pul.i
Irregular+: Caul.
Spasms, with: Caul; Caus; Cham; Gel; HYO; Ign; Pul.
Upwards, going: Calc; Cham; Gel; Lach.
 References
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(P)Ltd.2011.

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2004

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