NORMAL LABOR

OBJECTIVES

• DEFINTIONS AND OBSTETRIC TERMS OF NORMAL LABOR.

• ONSET OF LABOR

• STAGES OF LABOR

• EFFECTS OF LABOR

• ACTIVE MANAGEMENT OF LABOR

  LABOR:
Regular uterine contractions (30-60 seconds
DEFINTIONS duration, every 5 mins)
And progressive cervical changes (dilatation
and effacement)
  DELIVERY:
Means actual birth of the fetus.

DEFINTIONS:
WHICH DEPENDS ON 3 FACTORS:
PASSAGE, PASSENGER AND POWER
  NORMAL LABOR:
"spontaneous in onset, low-risk at the start of
labor and remaining so throughout labor and
DEFINTIONS: delivery. The infant is born spontaneously in
the vertex position between 37 and 42
completed weeks of pregnancy. After birth,
mother and infant are in good condition".

WHO, 1997
  Spontaneous expulsion
 A single, mature fetus

NORMAL  Presented by vertex

LABOR  Through the birth canal
CRITERIA  Within a reasonable time (not less than 3 hours
or more than 18 hours)
 Without complications to the mother, or the fetus.
  Presentation:
The part of the fetus related to the pelvic brim and first felt during
vaginal examination.

Cephalic (96%):

TERMS: - Vertex: when the head is flexed.

- Face: when the head is extended.
- Brow: when it is midway between flexion and extension.
2) Breech (3.5%).
3) Shoulder (0.5%).
  Position:
The relation of the fetal back to the right or left side of the
mother and whether it is directed anteriorly or posteriorly.

The denominator:
TERMS is a bony landmark on the presenting part used to denote the
position.
In vertex it is the occiput.

In face it is the mentum(chin).

In breech it is the sacrum.
In shoulder it is the scapula.
Occipito-anterior positions are more common than
occipito-posterior positions because in occipito - anterior
positions the concavity of the anterior aspect of the foetus
due to its flexion fits with the convexity of the vertebral
column of the mother due to its lumbar lordosis.

- Left occipito -anterior (LOA) 60%.

- Right occipito-anterior (ROA) 20%.
- Right occipito - posterior (ROP) 15%.
- Left occipito-posterior (LOP)5%.
- Left occipito-transverse (LOT).
- Right occipito - transverse (ROT).
- Direct occipito -anterior (DOA).
- Direct occipito - posterior (DOP).
  Lie:
It is the relation between the long axis of the fetus
and that of the mother. 
TERMS
Longitudinal in cephalic and breech presentations.
Transverse or oblique in shoulder presentation.
  Attitude:
The relation of fetal parts to each other.
- Flexion in the majority of cases.
- Extension in face presentation.
TERMS
 Synclitism:
- The posture in which the 2 parietal
bones are at the same level.
  Asynclitism:
 The posture in which one parietal bone is at a
lower level than the other due to lateral inclination
of the head.
TERMS
 Asynclitism is beneficial in bringing the shorter
subparietal supraparietal diameter (9 cm) to enter
the pelvis instead of the longer biparietal (9.5 cm).
 Slight degree of asynclitism may occur in normal
labour.
Asynclitism
  Anterior parietal bone presentation is more
favarouble because:
The head lies more in the direction of the axis
of the pelvic inlet.
During correction of asynclitism, the head
meets only the resistance of the sacral
AP>PP promontory while in posterior parietal bone
presentation the head meets the resistance of
the whole length of the symphysis pubis.
 In posterior parietal bone presentation the
head stretches the anterior wall of the lower
uterine segment with liability to rupture.
  Engagement:
It is the passage of the widest transverse
diameter of the presenting part, which is the
biparietal in vertex presentation, through the
pelvic inlet.
The engaged head cannot be easily grasped by
TERMS the first pelvic grip, but it can be palpated by
the second pelvic grip.
Rule of fifths: 2/5 or less of the foetal head is
felt abdominally above the symphysis pubis.
Vaginally : the vertex is felt vaginally at or
below the level of ischial spines.
STATION
In the primigravidas, engagement of the head occurs
in the last 3-4 weeks of pregnancy due to the tonicity
of the abdominal and uterine muscles.

In the multipara, the head is usually engaged at the

onset of labour or even at the beginning of the
second stage due to less tonicity.
  (I) Hormonal factors.
1. Oestrogen theory
2. Progesterone withdrawal theory
3. Prostaglandins theory
4. Oxytocin theory
CAUSE OF 5. Fetal cortisol theory
ONSET OF
LABOR
 (II) Mechanical factors
1. Uterine distension theory
2. Stretch of the lower uterine segment
  Prodromal (pre - labour) stage
1. Shelfing
2. Lightening
3. Pelvic pressure symptoms
4. Increased vaginal discharge
5. False labor pain

LABOR
 Onset of Labour
1. True labour pain
2. The show
3. Dilatation of the cervix
4. Formation of the bag of fore - waters
  FIRST STAGE:
 Refers to the interval between the onset of labor and full
cervical dilation.

 It is further divided into:

STAGES OF - The latent phase

LABOR This is the first 3 cm of cervical dilatation which is slow takes

about 8 hours in nulliparae and 4 hours in multiparae.
The active phase
1. acceleration phase
2. maximum slope
3. deceleration phase.
  The normal rate of cervical dilatation in
active phase is 1.2 cm/ hour in
primigravidae and 1.5 cm/hour in
multiparae.
FIRST STAGE

 If the rate is < 1cm / hour it is considered

prolonged.
  The second stage commences when the
SECOND cervix achieves full dilation (10 cm) –
STAGE not when the mother starts to push – and
ends with delivery of the fetus.
  Prolonged second stage refers to >3
hours with or >2 hours without regional
SECOND analgesia in a nullipara and >2 hours
STAGE with or >1 hour without regional
analgesia in a multipara.
  It is continuous throughout labour
particularly during the second stage
and caused by:
 a. Uterine contractions and retractions.
 b. The auxiliary forces which is bearing down
Descent: brought by contraction of the diaphragm and
abdominal muscles.
 c. The unfolding of the foetus i.e. straightening
of its body due to contractions of the circular
muscles of the uterus.
  The head normally engages in the
Engagement: oblique or transverse diameter of the
inlet.
  As the atlanto-occipital joint is nearer to
the occiput than the sinciput, increased
Increased flexion of the head occurs when it meets
flexion: the pelvic floor according to the lever
theory.
  Increased flexion results in :
 a. The suboccipito - bregmatic diameter (9.5cm) passes
through the birth canal instead of the suboccipito-
frontal diameter (10cm).
Increased  b. The part of the foetal head applied to the maternal
flexion: passages is like a ball with equal longitudinal and
transverse diameters as the suboccipito-bregmatic =
biparietal = 9.5cm. The circumference of this ball is 30
cm.
 c. The occiput will meet the pelvic floor.
  The rule is that the part of fetus meets
the pelvic floor first will rotate
anteriorly. So that its movement is in the
direction of levator ani muscles ( the
main muscle of the pelvic floor) i.e.
Internal
downwards, forwards and inwards.
rotation:

 In normal labour, the occiput which

meets the pelvic floor first rotates
anteriorly 1/8 circle.
  The suboccipital region lies under the
symphysis then by head extension the vertex,
forehead and face come out successively.
The head is acted upon by 2 forces:
Extension:  - the uterine contractions acting downwards and
forwards.
 - the pelvic floor resistance acting upwards and
forwards so the net result is forward direction
i.e. extension of the head.
  After delivery, the head rotates 1/8 of a
circle in the opposite direction of
Restitution: internal rotation to undo the twist
produced by it.
  The shoulders enter the pelvis in the
opposite oblique diameter to that
previously passed by the head. When the
External anterior shoulder meets the pelvic floor
rotation: it rotates anteriorly 1/8 of a circle. This
movement is transmitted to the head so it
rotates 1/8 of a circle in the same
direction of restitution.
  The anterior shoulder hinges below the
Delivery of the symphysis pubis and with continuous descent
shoulder and the posterior shoulder is delivered first by
lateral flexion of the spines followed by
body: anterior shoulder then the body.
  The third stage refers to delivery of the
placenta and fetal membranes and
THIRD usually lasts <10 min. In the absence of
STAGE excessive bleeding, up to 30 min may be
allowed before intervention.
  COMPOSED OF:
a) Placental separation.
THIRD
STAGE b) Placental descent.
c) Placental expulsion.
  After delivery of the foetus, the uterus
continues to contract and retract. As the
THIRD placenta is inelastic, it starts to separate
STAGE through the spongiosa layer by one of
the following mechanisms:
  (1) Schultze’s mechanism (80%): The central
area of the placenta separates first and placenta
is delivered like an inverted umbrella so the
foetal surface appears first followed by the
membranes containing small retroplacental
THIRD clot. There is less blood loss and less liability
STAGE for retention of fragments.
 (2) Duncan’s mechanism (20%): The lower
edge of the placenta separates first and placenta
is delivered side ways. There is more liability
of bleeding and retained fragments.
  (A) First stage:
minimal effects.

 (B) Second stage:

EFFECT OF - Temperature: slight rise to 37.5oC.
LABOR - Pulse: increases up to 100/min.
ON THE
- Blood pressure: systolic blood pressure may
MOTHER
rise slightly due to pain, anxiety and stress.
- Oedema and congestion of the conjuctiva.
- Minor injuries: to the birth canal and perineum
may occur particularly in primigravidas.
  (C) Third stage:
EFFECT OF - Blood loss from the placental site is
LABOR ON 100-200 ml and from laceration or
THE episiotomy is 100 ml so the total average
MOTHER blood loss in normal labour is 250 ml.
  (A) Moulding:
The physiological gradual overlapping of the
vault bones as the skull is compressed during
its passage in the birth canal.
EFFECT OF
LABOR ON One parietal bone overlaps the other and both
THE FETUS overlap the occipital and frontal bones so
fontanelles are no more detectable. It is of a
good value in reducing the skull diameters but;
severe and / or rapid moulding is dangerous as
it may cause intracranial haemorrhage.
  (B) Caput succedaneum:
It is a soft swelling of the most dependent part of the
fetal head occurs in
 prolonged labour before full cervical dilatation and
after rupture of the membranes.

EFFECT OF  It is due to obstruction of the venous return from the

lower part of the scalp by the cervical ring.
LABOR ON
THE FETUS  Large caput may:
1. obscure the sutures and fontanelles making
identification of the position difficult. This can be
overcomed by palpation of the ear,
2. give an impression that the head is lower than its true
level.
  Artificial caput succedaneum (chignon): is induced during
vacuum extraction.
EFFECT OF  Caput succedaneum disappears spontaneously within hours to
LABOR ON days of birth.

THE FETUS  As it is a vital manifestation, so it is not detected in

intrauterine foetal death.
 The presence of caput indicates that:

EFFECT OF  i) the fetus was living during labour,

LABOR ON  ii) labour was prolonged and difficult,
THE FETUS  iii) the attitude of foetal head during
labour can be expected as caput is
present in the most dependant part of it.
Aims:
 To achieve delivery of a normal healthy child with
minimal physical and psychological maternal effects.

 Early anticipation, recognition and management of any

abnormalities during labour course.
1M
. ae
trnaelducaoitn:about the physiology of labour and symptoms
of impending labour.

2B
. reah
tnigexercsie:adapt the mother to breathing during labour to
guard against respiratory alkalosis caused by
hyperventilation.
 History:
◦ Comp eeltobcseh
itrso
tiyr.
◦ Ho
sytrio
pefrsen
pe
trgnancy:
- Duration of pregnancy.
- Medical disorders during this pregnancy.
- Complications during this pregnancy as antepartum
haemorrhage.
◦ H sotiyropfe
rseanlbtou:r
- Labour pains : onset, frequency and duration.
- Passage of " show", fluid or blood per vaginum.
- Sensation of foetal movement.
 Examination:
◦ Genea
rxlamn
oa
int:
- Height and built.
- Maternal vital signs : pulse, temperature and blood
pressure.
- Chest and heart examination.
- Lower limbs for oedema.

◦ Abdom
ne
a
ixlam
n
oa
int:
- Fundal level. - Fundal grip. - Umbilical grip. - Pelvic
grips.
- FHS.
- Scar of previous operations (e.g. C.S, myomectomy or
hysterotomy).
◦ Pe
cve
ilxam
no
iaint:
- Cervix:
1. Dilatation : the diameter of the external os is measured by the
finger (s) during P/V examination and expressed in cm, one finger
= 2 cm , 2 fingers = 4 cm
and the distance resulted from their separation is added to the 4
cm in more dilatation.
2. Effacement.
3. Position (posterior, midway , central).

- Membranes: ruptured or intact. If ruptured exclude cord prolapse

and meconium stained liquor.
- Presenting part and its position.
- Station : of the presenting part.
- Pelvic capacity.
o Investigations:
◦ If not done before or if indicated:
Blood group-Rh typing.
Urine for albumin and sugar.
Hb%.
Ultrasonography.
Active procedures:
1
(E
)vacuoainth
ote
fe
rcutmbyenemaot;
i) avoid uterine inertia,
ii) help the descent of the presenting part,
iii) avoid contamination by faeces during delivery.

(2) Evacu
oainth
ote
fb
aldde:r
ask the patient to micturate every 2 - 3 hours, if she cannot
use a catheter. It prevents uterine inertia and helps descent of
the presenting part.

(3) Perpa
oa
rinth
ote
fvu
va
l:
Shave the vulva, clean it with soap and warm water from
above downwards, swab it with antiseptic lotion and apply a
sterile pad.
(4)Nou
itn
rit:
 When labour is established no oral feeding is allowed ,
but sips of water.

 15 ml magnesium trisilicate is given every 2 hours as an

oral antacid to guard against bronchospasm occurs if the
acid vomitus is inhaled during general anaesthesia "
Mendelson’s syndrome". Antacid injections may be used
instead.

 If labour is delayed more than 8 hours, IV drip of glucose

5% or saline-glucose solution is given.
5
(P
)osute
r:
 Patient is allowed to walk during the early first
stage particularly with intact membranes.

 If rest is needed the patient lies on her left lateral position

to prevent inferior vena cava compression and hence
placental insufficiency and foetal distress.
6
(A
)na
glea
si:
◦ Pethidine 100 mg IM,
◦ trilene inhalation, or
◦ epidural anaesthesia are the most common use.

N.B. Patient should not bear down during the first stage as
this is useless exhausts the patient and predisposes to
genital prolapse.
7
(T
)hepa
otrga
rm:
It is a graphical record of key data (maternal and feotal) during
labour entered against time on a single sheet of papper.

The advantages of the partogram:

 Allows right intervention in the proper time e.g.

oxytocin usage, instrumental delivery or C.S.

 Allows different staff shifts to manage the case

successively.
 A document for labour events.
 (I) The mother (II) The foetus
◦ Pulse every 30 minutes, o FHR every 15 minutes by
◦ Blood pressure every 2 Pinard’s stethoscope or
hours, better by doptone,
◦ Temperature every 4 o Descent of the presenting
hours,
◦ Uterine contractions : part,
frequency , strength and o Degree of moulding,
◦ duration every 30 minutes o Cardiotocography if available
by manual palpation or is more valuable for
better by tocography if continuous monitoring of
available,
◦ Cervical dilatation, both uterine contractions and
◦ Fluid input and output, FHR particularly in high risk
◦ Drugs including oxytocins. pregnancy.
(1) Its beginning is identified by:
 The patient feels the desire to defecate.

 The contractions become more prolonged and painful.

 Reflex desire to bear down during the contractions.

 The expulsive effort is accompanied by sustained expiratory

grunt.
 Rupture of membranes, although this is not specific as it

may occur earlier even before start of labour " prelabour

rupture of membranes" or later even to the degree that the
foetus is delivered in an intact sac.
 Full dilatation of the cervix (10 cm ) in between

uterine contractions is the most sure sign.

(2) Delivery room:
 The patient is transferred on a wheel or trolley to the

delivery room.
 Put her in the lithotomy position.

 The lower abdomen, upper parts of the thighs, vulva

and perineum are swabbed with antiseptic lotion.

 Sterile legs and towels are applied.
(3) Bearing down:
 Ask the patient to bear down during contractions and relax
in between.
(4) Delivery of the head:
The main aim during delivery of the head is to prevent
perineal lacerations through the following instructions:

i)Suppohtrfepe
nireum:
 When the labia start to separate by the head, a sterile pad is
placed over the perineum and press on it with the right
hand during uterine contractions. This is continued until
crowning occurs to maintain flexion of the head.
Co
rwnig:
 It is the permanent distension of the vulval ring by the

foetal head like a crown on the head. The head does not
recede back in between uterine contractions.
 This means that the biparietal diameter is just passed the

vulval ring and the occipital prominence escapes under

the symphysis pubis.
 After crowning, allow slow extension of the head so the

vulva is distended by the suboccipito frontal diameter 10

cm.
 If the head is allowed to extend before crowning the vulva

will be distended by the occipito-frontal 11.5 cm increasing

the incidence of perineal lacerations.
 R
gteinmanoeuver : upward pressure on the perineum by the right
hand and downward pressure on the occiput by the left
hand to control the extension of the head.
i)Epsoo
itmy:
 It is done at crowning when the perineum
is stretched to the degree that it is about
to tear.

ii)Swabandapraesit:
 the mouth and nose once the head is
delivered before respiration is initiated
and the liquor, meconium or blood is
inhaled.

)iCosloftheumbclaclodvi:ri
 if present around the neck are slipped over
the head but if tight or multiple they are
cut between 2 clamps.
(5) Delivery of the shoulders:
 Gentle downward traction is applied to the head till the
anterior shoulder slips under the symphysis pubis. The head
is lifted upwards to deliver the posterior shoulder first then
downwards to deliver the anterior shoulder.
(6) Delivery of the remainder of the body:
 Usually slips without difficulty otherwise gentle traction
is applied to complete delivery.
(7) Clamping the cord:
 The baby is held by its ankles with the head downwards at
a lower level than its mother for few seconds. This is
contraindicated in;
i) Preterm babies.
ii) Erythroblastosis foetalis.
iii) Suspicion of intracranial haemorrhage.

 This may be enhanced by milking the cord towards the baby,

to add about 100 ml of blood to its circulation.

 The cord is divided between 2 clamps to avoid bleeding

from a possible 2nd uniovular twin.
 (I) Delivery of the placenta:
Conse
ve
ra
im
te
htod:
 Put the ulnar border of the left hand just above the fundus at the
level of the umbilicus to detect any bleeding inside the uterus
known by rising level of the atonic uterus.
 Wait for signs of placental separation and descent but do
not massage the uterus.
 As soon as they are detected massage the uterus to induce
its contraction, ask the patient to bear down and push the
uterus downwards to deliver the placenta.
 Hold the placenta between the two hands and roll it to make
the membranes like a rope in order not to miss a part of it.
 Give ergometrine 0.5 mg or oxytocin 5 units IM after delivery of the
placenta to help uterine contraction and minimise blood loss.
These may be given before delivery of the placenta.
1The body of the uterus becomes smaller, harder and
globular.
2The fundal level rises as the upper segment overrides the
lower uterine segment which is now distended with the
placenta.
3Suprapubic bulge due to presence of the placenta in the
lower uterine segment.
4Elongation of the cord particularly on pressing on the
uterine fundus and it does not recede back into the vagina
on relieving the pressure.
5 Gush of blood from the vagina.
Thevae
icm
te
htodB(arnd
A
-tnderwsmehtod:)
 With delivery of the anterior shoulder, 0.5 mg ergometrine or

syntometrine (0.5 mg ergometrine + 5 units oxytocin) is given

IM.
 When the uterus contracts, put the left hand suprapubic and

push the uterus upwards while gentle downward and backward

traction is applied on the cord by the right hand when the
placenta is delivered it is rolled as in the conservative method.
Advantage:reduction of the blood loss.
D
sad
ivaa
ng
tes:
Constriction ring may occur with retention of the placenta.
Avulsion of the cord if undue pressure is applied.
Inversion of the uterus if fundus is pressed while the uterus
is lax.
(II) Routine examinations:
 E xam n
oa
inh
toefa
pclenatandmembarnes:
◦ by exploring it on a plain surface to be sure that it is
complete. If there is missed part, exploration of the
uterus is done under general anaesthesia.
E xpole
rhtegea rn
tcl:it
◦ For any lacerations that should be immediately repaired.

(III) Repair of episiotomy.

 Observation for the patient particularly atony
of the uterus and vaginal bleeding.
(1) Clearance of the air passages:
 The newborn is placed in supine position with the head
lower down. A metal, rubber or better disposable plastic
catheter is used to aspirate the mucus from the pharynx
and mouth directly by the physician’s mouth or by attach it
to an electric suction pump.

 Crying of the baby is usually occurs within seconds, if delayed

slapping its soles, flexion and extension of the legs and
rubbing the back usually stimulate breathing.
(2) Apgar score:
 is calculated at 1 and 5 minutes and further steps
of resuscitation are arranged according to it.
(3) The umbilical cord:
 A disposable plastic umbilical clamp is applied about 5 cm
from the umbilicus to avoid the possibility of tying an
umbilical hernia then cut
 about 1.5 cm distal to the clamp. Inspect for bleeding

and paint it with alcohol.

 If the plastic umbilical clamp is not available, 2 ligatures

of silk are applied instead of it.

 The umbilical stump is painted daily with an antiseptic till

its fall within 10 days.

(4) Congenital anomalies:
 The newborn is examined for injuries or congenital
anomalies as imporforate anus, hypospadius (not to be
circumcised as the cut skin will be used in the repair later
on), cyanotic heart diseases.... etc.

(5) Weight:
 the newborn and record it.
(6) Dressing:
 Dressing as well as all previous procedures should be done in
a warm place better under radiant warmer to prevent heat
loss which occurs rapidly after delivery increasing the
metabolism and acidosis.

(7) Care of the eyes:

 An antibiotic eye drops as chloramphenicol are instilled into
the eyes as a prophylaxis against ophthalmia neonatorum.

(8) Identification:
 of the baby by a plastic bracelet on which its mother’s
name is written.
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