NORMAL LABOR

MS. MAYURI PATEL

SANDRA SHROFF ROFEL COLLEGE OF NURSING, VAPI
Definition

 Seriesof events that take place in the genital

organ in an effort to expel the viable products
of conception out of the womb through the
vagina in to the outer world is called LABOR.
Definition

 Expulsionof a previable live fetus occurs through

the same process but in a miniature form is called
MINI-LABOUR.
 DELIVERY is the expulsion or extraction of a
viable fetus out of the womb.
NORMAL LABOUR

 Spontaneous in onset and at term

 With vertex presentation
 Without undue prolongation
 Natural termination with minimal aids
 Without having any complication affecting the
health of the mother and baby
Abnormal labour

 Any deviation from the definition of normal labour

is called abnormal labor
 CAUSES OF ONSET OF LABOR

 Uterine distension:-
Stretching effect on the myometrium by the growing fetus and liquor
amnii.

Increases gap junction proteins, receptors for oxytocin and specific

contraction associated proteins
 Estrogen
 Increases the release of oxytocin from maternal pituitary.
 Promotes the synthesis of myometrial receptors for oxytocin (by 100–200
folds), prostaglandins and increase in gap junctions in myometrial cells.
 Accelerates lysosomal disintegration in the decidual and amnion cells
resulting in increased prostaglandin (PGF2α) synthesis.
 Stimulates the synthesis of myometrial contractile protein—actomyosin
through cAMP.
 Increases the excitability of the myometrial cell membranes.
 Progesterone

 Increased fetal production of dehydroepiandrosterone sulfate

(DHEA-S) and cortisol inhibits the conversion of fetal pregnenolone
to progesterone.
 It is the alteration in the estrogen : progesterone ratio rather than the
fall in the absolute concentration of progesterone, which is linked with
prostaglandin synthesis.
 Prostaglandins
 It initiate and maintain labor
 The major sites of synthesis of prostaglandins are—amnion, chorion, decidual cells
and myometrium.
 Synthesis is triggered by—rise in estrogen level, glucocorticoids, mechanical stretching
in late pregnancy, increase in cytokines (IL–1, 6, TNF), infection, vaginal examination,
and separation or rupture of the membranes.
 Prostaglandins enhance gap junction (intermembranous gap between two cells through
which stimulus flows) formation.
 The prostaglandin synthesis reaches a peak during the birth of placenta probably
contributing to its expulsion and to the control of postpartum hemorrhage.
 Oxytocin and myometrial oxytocin
receptors
 Large number of oxytocin receptors are present in the fundus compared to
the lower segment and the cervix.
 Receptor number increases during pregnancy reaching maximum during
labor.
 Receptor sensitivity increases during labor.
 Oxytocin stimulate synthesis and release of PGs (E2 and F2α) from amnion
and decidua.
 Vaginal examination and amniotomy cause rise in maternal plasma oxytocin
level (Ferguson reflex).
 Neurological factor

 Labor may be also initiated through nerve pathways.

 Estrogen causing the α receptors and progesterone the β
receptors to function predominantly.
 The contractile response is initiated through the α receptors of the
postganglionic nerve fibers in and around the cervix, and the
lower part of the uterus.
Uterine muscles have two types of
adrenergic receptors

 A receptors, which on stimulation, produce a decrease in

cyclic AMP (adenosine monophosphate) and result in
contraction of the uterus and
 β receptors, which on stimulation, produce rise in cyclic
AMP and result in inhibition of uterine contraction.
 FALSE PAIN TRUE PAIN

 Dull in nature,  Painful uterine contractions at regular

intervals,
 Confined to lower abdomen and groin,
 Frequency of contractions increase gradually,
 Not associated with hardening of the
intensity and duration of contractions increase
uterus,
progressively,
 They have no other features of true labor  Associated with “show”,
pain
 Progressive effacement and dilatation of the
 Usually relieved by enema or sedative. cervix,
 Descent of the presenting part,
 Formation of the “bag of forewaters” and not
relieved by enema or sedatives.
 PRELABOR: (Synonym: premonitory
stage)
 Begin 2–3 weeks before the onset of true labor in primigravidae and
a few days before in multiparae.
 “Lightening”: A few weeks prior to the onset of labor especially in
primigravidae, the presenting part sinks into the true pelvis. It is due
to active pulling up of the lower pole of the uterus around the
presenting part. It signifies incorporation of the lower uterine
segment into the wall of the uterus. This diminishes the fundal
height and hence minimizes the pressure on the diaphragm. The
mother experiences a sense of relief from the mechanical
cardiorespiratory embarrassment.
A and B: Showing phenomenon of “lightening”.
(A) Before and (B) after lightening
 Dilatation of
Show Labor pain internal os
Cervical canal begins to dilate more in the
Expulsion of Braxton Hicks upper part than in the lower

contractions
cervical mucus
plug mixed with
blood is called
“show”.
 Formation of “Bag of waters”

Due to stretching of the lower uterine

segment
With the dilatation of the cervical canal,
the lower pole of the fetal membranes
becomes unsupported and tends to bulge
into the cervical canal. As it contains
liquor, which has passed below the
presenting part, it is called “bag of
waters”.
 STAGES OF LABOR

1st Stage 2nd Stage 3rd Stage

 It starts from the onset of It starts from the full  It begins after expulsion
true labor pain and ends dilatation of the cervix (not of the fetus and ends with
with full dilatation of the from the rupture of the expulsion of the placenta
cervix. membranes) and ends with and membranes
 “Cervical stage” expulsion of the fetus from (afterbirths).
the birth canal.  15 minutes in both
 Primi 12 hrs
 Primi 2 hrs
 Multi 6 to 8 hrs 4thStage
 Multi 30 min
 Observation stage for
1 hour after delivery
 PHYSIOLOGY OF NORMAL LABOR

1. UTERINE CONTRACTION IN LABOR

 Pacemaker of the uterine contractions is situated in the region of
the tubal ostia from where waves of contractions spread
downward.
During contraction
 uterus becomes hard
 patient experiences pain
 more on the hypogastric region, often radiating to the thighs
Probable causes of pain are:
(a) Myometrial hypoxia during contractions (as in angina)
(b)Stretching of the peritoneum over the fundus
(c) Stretching of the cervix during dilatation
(D) Stretching of the ligaments surrounding the uterus
(E) Compression of the nerve ganglion.
Tonus: It is the intrauterine pressure in between
contractions.
Intensity: The intensity of uterine contraction describes the degree
of uterine systole.
The intensity gradually increases with advancement of labor until it
becomes maximum in the second stage during delivery of the baby.
Duration: In the first stage, the contractions last for about 30
seconds initially but gradually increase in duration with the
progress of labor.
Frequency: In the early stage of labor, the contractions come at
intervals of 10–15 minutes. The intervals gradually shorten with
advancement of labor until in the second stage, when it comes
every 2–3 minutes.
 RETRACTION

 Retraction is a phenomenon of the uterus in labor in which

the muscle fibers are permanently shortened.
 Contraction is a temporary reduction in length of the
fibers, which attain their full length during relaxation
 In contrast, retraction results in permanent shortening and
the fibers are shortened once and for all.
 Effects of retraction in normal labor

 Essential property in the formation of lower

uterine segment and dilatation and
effacement of the cervix.
 To maintain the descent of the presenting
part
 To reduce the surface area of the uterus
favoring separation of placenta.
 Effective hemostasis after the separation of
the placenta.
 EVENTS IN FIRST STAGE OF LABOR

DILATATION OF THE EFFACEMENT OR TAKING UP OF

CERVIX CERVIX
 Uterine contraction and  Effacement is the process by which the muscular
fibers of the cervix are pulled upward and merges
retraction with the fibers of the lower uterine segment.
 Fetal axis pressure  Primigravidae, effacement precedes dilatation of
 Bag of membranes the cervix,
 Multiparae, both occur simultaneously
 Vis-a-tergo
 Expulsion of mucus plug is caused by effacement.
 Uterine contraction and Fetal axis pressure Bag of membranes
retraction • fetal vertebral column is In vertex presentation, the girdle of
• longitudinal muscle fibers of the straightened by the contact of the head (that part of the
upper segment are attached contractions circumference of the head which first
with circular muscle fibers of comes in contact with the pelvic brim)
the • allows the fundal strong being spherical, may well fit with the wall
contraction force to be of the lower uterine segment.
• lower segment and upper part transmitted
of the cervix in a bucket- Thus, the amniotic cavity is divided into
holding fashion • This causes mechanical two compartments (Fig. 13.5). The part
• There is some co-ordination stretching of the lower above the girdle of contact contains the
between fundal contraction and segment and opening up fetus with bulk of the liquor called
cervical dilatation called (dilatation) of the cervical hindwaters, and the one below it
“polarity of uterus”. canal. containing small amount of liquor called
forewaters.
A and B: Diagrammatic representation showing dilatation of
the cervix by the pull of the longitudinal muscles of the uterus:
(A) Before labor; (B) After labor
 A distinct ridge is produced at the junction of the two, called physiological retraction ring.

A to C: Sequence of development of the active and passive segments of the uterus. (A) Uterus at term;
(B) In early labor; (C) Late second stage
 EVENTS IN SECOND STAGE OF LABOR

 The second stage begins with the complete dilatation of the cervix and
ends with the expulsion of the fetus.
 This stage is concerned with the descent and delivery of the fetus
through the birth canal.
 Second stage has two phases:
1. Propulsive—from full dilatation until head touches the pelvic floor.
2. Expulsive—since the time mother has irresistible desire to “bear
down” and push until the baby is delivered.
 Propulsive phase

 With the full dilatation of cervix, usually membrane ll ruptured so liquor will escape
& volume of uterine cavity is reduced.
 simultaneously uterine contraction & retraction become stronger & anteroposterior
 and transverse diameters are reduced.
 Delivery of the fetus is accomplished by the downward thrust offered by uterine
contractions supplemented by voluntary contraction of abdominal muscles
 The resistance offered by bony and soft tissues of the birth canal.
 This is effectively counterbalanced by the power of retraction. Thus, with increasing
contraction and retraction, the upper segment becomes more and more thicker with
corresponding thinning of lower segment.
 Expulsive Phase

 Endowed with power of retraction, the fetus is gradually

expelled from the uterus against the resistance offered by the
pelvic floor.
 After the expulsion of the fetus, the uterine cavity is
permanently reduced in size only to accommodate the
afterbirths.
 The expulsive force of uterine contractions is added by
voluntary contraction of the abdominal muscles called
“bearing down” efforts.
 EVENTS IN THIRD STAGE OF LABOR

 The third stage of labor comprises the phase of

placental separation; its descent to the lower
segment and finally its expulsion with the
membranes.
 Mechanism of Separation
 A shearing force is instituted
between the placenta and the
placental site which brings about its
ultimate separation.
 The plane of separation runs
through deep spongy layer of
decidua basalis so that a variable
thickness of decidua covers the A and B: Diagram showing area of placental site—
(A) Before the delivery of the baby and (B) after the delivery of
maternal surface of the separated the baby. Note the reduction of the surface area of the
placenta. placental site resulting in buckling of the placenta. PS =
Placental surface
 Two ways of separation of placenta

Marginal Seperation (Mathews-

Central Separation (Schultze) Duncan)
 Detachment of placenta from its  Separation starts at the margin as
uterine attachment starts at the it is mostly unsupported.
center resulting in opening up of
few uterine sinuses and  More Frequent
accumulation of blood behind the
placenta (retroplacental
hematoma).
Central Separation (Schultze) Marginal Separation (Mathews-Duncan)
SEPARATION OF THE MEMBRANES

 The separation is facilitated partly by uterine

contraction and mostly by weight of the
placenta as it descends down from the active
part.
 EXPULSION OF PLACENTA

It is expelled out either by voluntary

contraction of abdominal muscles (bearing
down efforts) or by manual procedure
CLINICAL COURSE OF FIRST STAGE OF LABOR

PAIN:
 In normal labor, pains are usually felt shortly after the
uterine contractions begin and pass off before complete
relaxation of the uterus.
 Clinically pains are said to be good if they come at intervals
of 3–5 minutes and at the height of contraction the uterine
wall cannot be indented by the fingers.
 DILATATION AND EFFACEMENT OF THE CERVIX

 Cervical dilatation relates with dilatation of the external os and effacement is

determined by the length of the cervical canal in the vagina.
 Cervical dilatation is expressed either in terms of fingers—1, 2, 3 or fully
dilated or better in terms of centimeters (10 cm when fully dilated). It is
usually measured with fingers but recorded in centimeters. One finger equals
to 1.6 cm on average. Simultaneously, effacement of the cervix is expressed
in terms of percentage, i.e. 25%, 50% or 100% (cervix less than 0.25 cm
thick). The term “rim” is used when the depth of the cervical tissue
surrounding the os is about 0.5–1 cm.
PARTOGRAPH
 Partograph

 Friedman (1954) first devised it. Partograph is a

composite graphical record of cervical dilatation and
descent of head against duration of labor in hours.
 Information about fetal and maternal condition
 Cervical dilatation is a sigmoid curve and the first stage of
labor has got two phases—(1) Latent phase and (2) Active
phase
 Latent phase of labor is defined as the period between the onset of true
labor pain and the point when the cervical dilatation becomes 3–4 cm.
 The active phase has got three components.
 Acceleration phase with cervical dilatation of 3–4 cm.
 Phase of maximum slope of 4–9 cm dilatation.
 Phase of deceleration of 9–10 cm dilatation.
 Dilatation of the cervix at the rate of 1 cm/h in primigravidae and 1.5 cm in
multigravidae beyond 4 cm dilatation (active phase of labor) is considered satisfactory.
 STATUS OF THE MEMBRANES
Membranes usually remain intact until full dilatation of the cervix or sometimes even
beyond in the second stage.
An intact membrane is best felt with fingers during uterine contraction when it becomes
tense and bulges out through the cervical opening.
 MATERNAL SYSTEM
 Pulserate is increased by 10–15 beats per minute during contraction,
which settles down to its previous rate in between contractions.
Systolic blood pressure is raised by about 10 mm Hg during
contraction. Temperature remains unchanged.
FETAL EFFECT
 Slowing of fetal heart rate by 10–20 beats per minute which soon
returns to its normal rate of about 140 per minute as the intensity of
contraction diminishes.
 CLINICAL COURSE OF
SECOND STAGE OF LABOR
MANAGEMENT OF
NORMAL LABOR
Psychological, emotional and social impact
 The caregiver should be tactful, sensitive and respectful to her.
 Continuous emotional support
 Privacy
 Explanation about labour Process
 Comfortable environment, skill and confidence of the caregiver
and appropriate support are all essential so that a woman can
give birth with dignity.
 Management of normal labor aims at maximal observation with
minimal active intervention.
ANTISEPTICS AND ASEPSIS

VAGINAL EXAMINATION IN LABOR

PRELIMINARIES:
1. Toileting
2. Sterile pair of gloves
3. Vulval toileting
4. Gloved middle and index fingers of the right hand smeared liberally with antiseptic cream
5. Complete examination should be done before fingers are withdrawn. (6) Vaginal
examination should be kept as minimum as possible to avoid risks of infection.