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Labour

Prof. Mustafa Gawass FRCOG, FRCPI

objectives
Define labour.
Understand the components of labour
(passage, passenger, power).
Be able to take a focused history, examination
and anlyse the symptoms and signs to
diagnose labour.
Describe the stage sand phases of labour.
Discuss the mechanism of labour.
Discuss the management of labour.

Labour (parturition)
It Is the process where by with time regular
uterine contractions, brings about progressive
affacment and dilatation of the cervix, resulting
in delivery of the fetus from the uterus and
expulsion of the placenta at or beyond 24 (or
28) completed weeks of pregnancy.
It is a social, psycological and economical event
for the couple, family and community.

Cervical dilatation: The cervix begins


dilating and stretching beyond the normal
dimensions and is measured in
centimeters. (0-10cm).

Cervical effacement: softening,


thinning and shortening of the cervix. It is
expressed in percentage (0 100%)

A 20 year old primigravida comes to maternity unit at


39 weeks gestation complaining of regular uterine
contractions, 3-4/10min. For the past 6 hours. The
contractions are becoming more frequent lasting 45-50
sec. she denies any vaginal fluid leakage. The blood
pressure, pulse and temperature are normal.
Vaginal examination cephalic, head at s-1,90%
affaced, 5 cm dilated, soft and anterior. FH=133bpm .

What is your diagnoses?

Labour can occur at:

PTL
1 LNMP

Term
Labour
prolonged

24 W 28 W 37 W 40W 42W

Normal labour:
Spontaneous expulsion, through the
natural passages (birth canal) of a single,
mature (37-42 completed weeks of
pregnancy) Alive fetus, presenting by
vertex, within a reasonable time, without
fetal or maternal complications.

Components of labour:

types of female pelvis

passengers
The following will pass during labour
(fetus, cord, placenta and membranes).
The most important to pass is the head
and shoulder

Moulding of the skull:


means obliteration of the suture line between
the bones and overlapping of the un-united
bones of the fetal skull, and is measured by
degree.
Degree

Clinical finding

+
++
+++

Suture line closed, no overlap


Overlap of suture line reducible
Overlap of suture line irreducible

As the degree of moulding increase- means there is CPD

Fetal attitude: is the relation of the fetal parts


to each other
1- flexion attitude (common)
2- extension attitude (rare).

Clinical course of labour


Onset of labour: not definitely known however there
are several theories, but none of them is
completely proven.
Mechanical theories: - uterine distension
Hormonal theories:
1. Maternal :
o progesterone withdrawal
o oxytocin stimulation
o prostaglandins
o serotonin
2. fetal:
o fetal cortisol
o fetal membranes
3. Neuronal factors:
o sympathetic- alpha receptor stimulation

Diagnosis
A.
symptoms:
1.
True labour pains colicky pain in the abdomen and back
are characterized by:
character

True labour pain

contractions

regular

Interval between
contractions and
intensity
Changes in the cervix

Progressive (increase in
frequency and
intensity)
Associated with
effacement and
dilation of the cervix

False labour pain


Irregular
Short duration, not
progressive
Not associated with
effacement and
dilation of the cervix

Membranes

Associated with bulging


of membranes

Not associated with


bulging of
membranes

Response to analgesia

Not relieved by
sedation

Relieved by sedation

Labour

Followed by labour

Not followed by labour

2.
3.

Show blood stained mucous.


SROM

B. Signs:
o palpable or recorded uterine contraction
o
o

effacement and dilation of the cervix


formation of forewater

THE ACTIVE STAGE OF LABOUR WHEN THE CERVIX


IS MORE THAN 3 CM DILATED AND FULLY EFFACED

STAGES OF LABOUR:
I-The First stage: stage of cervical
effacement and dilatation
Definition: the first stage of labour refers to
the period from the onset of true uterine
contractions to the fully dilation of the cervix,
when the diameter of the cervical os
measures 10cm.

Duration:
o primigravida = 8-12 h
o multigravida = 6-8 h
Phases of the first stage:
Latent phase: started when the cervix dilatated
slowly and reached to about 3cm.
A. in primigravida = 8h
B. in multigravida = 4h
- Active phase: rapid dilatation of the cervix to
reach 10cm
A. in primigravda = 4h
B. in multigravida =2h

The active phase is divided into:


1. Accelerative phase
2. Slopping phase
3. Decelerative:
A. prolonged active phase
B. primary dysfunction: dilation in active
phase of<1cm/hr
C. secondary arrest: active phase dilation
stops or slow significantly.
N.B in primigravida the cervix dilates from
above
downwards,
in
multigravida
dilatation of the internal os, taking up of
the cervix and dilatation of the external os
occurs simultaneously.

Factors affecting cervical dilatation:


1. Contraction and retraction of the
uterus.
2. The bag of fore-water.
3. Absence of membranes.
4. Fitting of the presenting part to the
lower segment and the cervix.
5. Pre-labour changes in the cervix
(eg, softening)

II-The Second stage of labour: stage of


delivery of the fetus.
Definition: the second stage of labour refers
to the period from complete cervical dilatation
to the birth of the fetus.29-30
Duration:
A.in primigravida =1 h
B.in multigravida = h
however the timing of the second stage is
very different to determine and controversial
and can be extended as much as there is
progress in descent and no harm to the
mother or fetus

The second stage of labour had two


phases:
1. Passive phase stage of descent of
the presenting part and dilatation of
the vagina due to contraction and
retraction of the uterine muscle.
2. Expulsive phase stage of bearing
down due to contraction and
retraction of the uterine muscle and
voluntary efforts by diaphragm and
abdominal muscles.

Mechanism of labour in vertex presentation:


Definition: The spontaneous adjustments of
the fetal position and attitude to affect efficient
passage of the fetus through the pelvis,
marked by progressive descent until delivery of
the fetus.
Delivery of the fetal head:
A- Descent: is a continuous movement
throughout the process of delivery, however it
becomes more rapid in the second stage of
labour, it is caused by:
o-Uterine contraction and retraction.
o-bearing down effort mainly in the second
stage of labour

In normal pelvis, the fetal head enters with


the sagittal suture in the transverse
diameter (or occasionally oblique diameter
of the brim). If the sagittal suture in
between the symphysis pubis and sacral
promontory both parietal bones are felt
vaginally at the same level the head is
said to be (synclitic). In such case the
biparietal diameter (9.5cm) is the diameter
of engagement. However some degree of
lateral inclination of the head over the
shoulder (Asynclitism) is present
normally as the head enters the pelvic inlet .

*If the sagittal suture lies close to the


sacrum and the anterior patietal bone
lies over the inlet (Anterior parietal
bone presentation)
- Anterior
asynclitism.
*If the sagittal suture lies close to the
symphysis pubis and the posterior
parietal bone lies over the inlet
(posterior parietal bone presentation)
posterior asynclitism.

Causes of non-engagement:
Erroneous dates (primigravida)
Extra-uterine:
A.
B.
C.
D.
E.

A.
B.
C.
D.

full bladder or loaded rectum


Pelvic tumours
Pendulous abdomen and marked lumbar lordosis.
High angle of inclination of the pelvis.
Contracted pelvis.
-Uterine:
Poor uterine tone.
Congenital deformities.
Fibromyomata.
Placenta previa.

-Fetal:
A. polyhydramnios.
B. Short umbilical cord(acutal or relative, due

to entanglement)
C. Large baby.
D. Deflexion attitude, and malposition.
E. Multiple pregnancy.
F. Hydrocephalus.
Engagement can be assessed by
abdominal station in fifths during
antenatal period, and by abdominal and
vaginal stations during labour.

C.Increased flexion: as the head

descends, it meets resistance from the


pelvic walls and floor and this leads to
increased flexion of the head. As the
head flexed it brings the shortest
longitudinal diameter of the head (suboccipito-bregmatic 9.5cm) to pass
through the birth canal. Flexion is
explained by the (two armed lever
theory).

D-Internal rotation: the internal rotation


occurs as the head descends through the
pelvic cavity. As the head enters the pelvic
inlet in transverse diameter will rotate 3/8 of
the cycle to pass through the pelvic outlet in
antero-posterior diameter.
The rotation is favoured by the slopping
shape of the pelvic floor, angling the leading
point of the head (occiput) in downward and
forward direction, by the effect of the
contraction and retraction of the uterus.

E-Crowning, extension and delivery of the fetal


head:
The combined effect of descent and internal rotation
bring the presenting diameter to the plane of the
pelvic outlet, with the occiput lying under the pubic
arch and the sinciput at the lower border of the
sacrum or coccyx.
When the widest diameter of the fetal head is
embraced by the distended vulva, it is said to be
crowned.
The occiput remains under the pubic arch but the
sinciput sweeps forwards as the neck extends.

The head is acted upon by:


1. The downward and forward force of the
uterine contraction and retraction.
2. The upward and forward force offered by
pelvic floor resistance so the head passes
forwards i.e. extends vertex, forehead,
and face come out successively.
Frequently, especially in primigravida, the soft
tissues are not able to distend equally so
that tearing of the perineum and adjacent
tissues may occur unless steps are taken
to avoid it by making a formal incision
(episiotomy).

F-Restitution and external rotation:


Following delivery of the head the occiput
rotates to the lateral position, in the opposite
direction of internal rotation to correct the
twist of the head on the shoulders produced
by internal rotation. The internal rotation of
the shoulders inside the pelvis transmitted to
the delivered head which in turn move one
eight of a circle outside the pelvis, in the
same direction as that of the restitution, so at
the end the occiput is towards one thigh and
the face is towards the other thigh.

Delivery of the shoulder and body:


The widest diameter of the shoulders,( the biacromial diameter), pass the pelvic brim at
the time when the anterior rotation of the
head is occurring. Thus the anterior rotation
of the occiput is favourable for both the head
and the shoulders. Similarly external rotation
of the head is associated with rotation of the
shoulders to bring them into the anteroposterior diameter of the outlet. With further
descent, the anterior shoulder delivered first
from under the pubic arch, followed by
posterior shoulder, during which time lateral
flexion of the trunk is occurring. The trunk
and buttocks follow with the same or the next
contraction.

Even in the course of normal delivery,


there are many variations of the
mechanisms, dependent on the
variation in the size and shape of the
pelvis and of the fetal head.
III-The Third stage of labour: the
stage of expulsion of the placenta
and membranes.

Duration: up to 30 minutes, however


the average length of the third stage
of labour is 10 minutes.
Mechanism: the third stage is made of
two phases:
1.The first phase: phase of placental
separation occurs through the
spongiosa layer of the decidua at the
time of expulsion of the baby or very
soon afterwards. The shearing force
responsible for the separation is the
contraction and retraction of the
uterus, reducing the uterine volume
and the area of the placental site, as
the fetus is expelled.

2.The second phase: phase of placental


expulsion The separated placenta
descends from the upper (active)
segment into lower (passive) uterine
segment, cervix, and vagina by two
mechanisms:
A.-Schultze mechanism:(80%)
The placenta delivered as an inverted
umbrella with its fetal surface
presenting first followed by the
membranes
with
retro-placental
haematoma.
B.Mattews Duncan mechanism: (20%)
The placenta delivered side way and it
presents with its inferior surface first.

Stage of
labour

Definition

Duration

Stage I latent
phase
(affacment)

Begins from the onset of regular contractions.


Ends with acceleration of cervical dilatation
Prepares cervix for dilatation.

<20 hours in PG
<14 hours MG

Stage 1 active
phase
(dilatation)

Begins with acceleration of cervical dilatation.


Ends at 10 cm dilatation
Rapid cervical dilatation

<2/hours in PG
<1.5/ hrs in MG

Stage 2
(descent)

Begins from 10cm dilatation


Ends with delivery of the baby
Descent of the fetus

<2 hours in PG
<1 hours in MG
Add 1 hour in epi

Stage 3
(expulsion)

Begins with delivery of the baby.


Ends with delivery of the placenta
Delivery of the placenta

<30 min.

Management of labour
The management of labour should be
commenced during the antenatal
period, and the women should be
classified as high or low risk pregnancy.
The medical or surgical problems
should be corrected as in case of
(anaemia, hypertension, urinary tract
infection), vaccination should be given
if necessary, and all investigations
should be performed and prepared such
as
(HIV,
HCV,
Hbs
Ag,
blood
grouping.etc).

Also the patient should be advised to


attend the antenatal class (parenterful
class) and visit the hospital including
the labour ward to be familiar to the
place and staff.
Once labour is commenced and the
patient arrived to the admission room
the following to be done:

-Taking history or reviewing the


antenatal file.
1-Last menstrual period expected date
of confinement.
2-Time of onset of labour.
3-Frequency and duration of contraction
(3-4cm/10min).
4-Presence or absence of amniotic fluid
leakage.
5-Presence or absence of show or
vaginal bleeding.
6-Past obstetric history especially mode
of previous delivery, presentation,
mode of delivery, and weight of
previous children.
7-Past medical or surgical history that
may affect labour or delivery,
especially diabetes, heart disease,

A.

B-Examination:
1. .General:
a-pallor, oedema, varicosities, height, and
built.
b-Vital signs (BP, P, T)
c-Examination of heart, lungs, breast and
other organs if necessary
2. .Abdominal Examination:
a-To determine fundal height in cm using
tape measure (to determine gestational
age clinically), fetal lie, presentation,
engagement in fifths, size of the fetus,
amount of liquor, fetal heart rate.
b-The frequency and duration of the
contraction.

3. .Vaginal Examination: to assess the


following.
a-Cervical dilatation in cm and effacement in
%.
b-Length of the cervix.
c-Consistency of the cervix
d-Position of the cervix
e-State of the membranes, amount and colour
of liquor.
f-fetal presentation, position and station.
g-pelvic architecture.

DO NOT DO VAGINAL EXAMINATION IN


CASES OF VAGINAL BLEEDING BEFORE
THE PLACENTA PREVIA IS EXCLUDED.
DO STERIL SPECULUM EXAMINATION IF
SUSPECTED PLROM, IF THE WOMAN IS
NOT IN LABOUR.
If the woman diagnosed as having active
labour to be admitted to labour ward.
N.B- active labour means regular strong and
frequent uterine contraction 3-4/10min
lasting 45-50 sec, and the cervix is fully
effaced and 2.5-3cm dilated.

Arrival to the labour ward:


I-first stage of labour:
1-Ensure patients privacy by covering her
with sheaths or blankets.
2-Reassure and show great sympathy and
interest.
3-Record maternal vital signs every hour (BP,
P, T).
4-Take blood for grouping and cross match for
high risk patients.
5-Monitor:
a-high risk patients should have a continuous
electronic fetal heart monitoring.

b-low risk patients should have brief electronic


fetal heart monitoring if NORMAL, to be
followed by intermittent auscultation:
-first stage every 15min
-second stage every 5min
6-Limit oral intake to small amount of clear
fluid or frozen pineapple.
7-Give all patients in active labour Ranitidine
(Zentac) 150mg orally / 6hourly.
8-Nurse the patient in:
a-left lateral position for mediated patients.
b-sitting or semi-reclining for unmediated
patients.

9-Encourage
spontaneous
voiding,
catheterization may be necessary.
10-Test all urine specimen for proteins,
sugar, and acetone.
11-Give IV fluids during labour to avoid
dehydration
a-0.9% Nacl or hartmanns solution at 80125ml/hr
b-Supplementation with 5% dextrose to
prevent ketosis and hypoglycemia.
12-Give analgesia/anesthesia as required.
a-Pethidine (50-150mg)IM.
b-Diamorphin (5-10mg)IM. Every 3-4 hours.
*avoid giving it too early in labour < 3-4cm
cervical dilation or too late when the
delivery is expected within 1-2hours.

*if given too late:


-inform the pediatrician
-give Naloxon (Narcon) 0.02mg IM to the
neonate.
c-Use Entonox (NO2 50%+O2 50%) by mask if
available.
d-Use epidural analgesia in selected cases if
available such as Breech, Twins, preterm
delivery.
e-Give anti-emetics such as Metoclopromide
(5-10mg)IM if necessary, but should not be
routine.
13-Do vaginal examination to:
a-assess progress of labour every 2-4hr
b-or immediately after rupture of membranes
c-FHR abnormalities.

14-Recall all the observations in labour in


Partogram.
15-Consider augmentation with syntocinon if
progress of labour is slow (partogram).
-1000 ml Hartmanns solution or normal
saline + 10 units syntocinon (pitocin)
-Begin the infusion using a pump at 4
milliunits per minute and double the dose
every 20 minutes to a maximum of 32
milliunits/min.
-Or begin with 15 drops / min and increase
the rate by 10 drops every 30 minutes untill
adequate contractions.

II-second stage of labour:


Once the patient reach the second stage of labour and
have the desire to push down then:
1-Put the patient in lithotomy position or other
positions clean the vulva, and perineum with
antiseptic solution.
2-Encourage organized pushing down which she is
feeling to do so
3. -Monitor the uterine contraction and fetal heart
more frequent.
4. -Use syntocinon if progress is slow and no
contractions.
5. -When the head appears at the vulva, the perineum
is supported during uterine contraction by sterile
pad to promote flexion and prevent premature
extension of the head by pressing up on the sinciput
until crowning occur.

6. -After crowning the head is allowed to be


delivered by extension slowly in between
the contractions by sliding the perineum
over the face.
7. -DO episiotomy if necessary under local
anaesthetic ( 10-20 ml) of 1% lignocain,
but should not be routine.
8. -Wait for the next contraction to deliver
the shoulder and trunks.
9. -Clamp and deliver the cord and baby to
be handled to pediatrician.

III-Third stage of labour:


The management of third stage is
aimed at:
1-Complete delivery of the after birth
(placenta and membranes).
2-Prevention of acute inversion of the
uterus.
3-prevention of postpartum
haemorrhage

A-Delivery of the placenta and


membranes:
a-Conservative method: the left hand is
placed over the abdomen to detect any
change in the level of the fundus or
sign of placental separation and decent
are detected, the patient is asked to
bear down to deliver the placenta
spontaneously. Ergometrine 0.5mg or
Syntometrine(5 units syntocinon +
0.5mg Ergometrine) to be given
intravenouslly.

Signs of separation and decent of the


placenta:
1. -The body of the uterus becomes smaller,
harder, and globular.
2. -The fundal level rises in the abdomen
because the lower segment becomes
distended by the placenta.
3. -Suprapubic bulge may appear due to
presence of the placenta in the lower
segment.
4. -Elongation of the cord out side the vulva.
5. -Sudden gush of blood from the vagina.

b-Active
methods(prophylaxis
against
postpartum haemorrhage)
1-Give
Methargine
0.5
mg
IM
or
Syntometrine
(5units
oxytocin+0.5mg
Methargine), at the time of the anterior
shoulder is free from symphysis pubis or
as soon as possible thereafter.
2-Deliver the placenta and membranes by
control cord traction by right hand, and
the left hand is placed on the suprapubic
region, pushing the uterus upwards.
N.B. USE SYNTOCINON RATHER THAN
METHARGINE
IN
CARDIAC
AND
HYPERTENSIVE CASES.

IV-Post Delivery:
1-examine
the
placenta
for
their
completeness, anomalies, length, and
number of vessels in the cord and record
the placental weight.
2-Suture the episiotomy or any laceration.
3-Estimate blood loss, count swabs, and take
cord blood for Hb, blood group, Rh,
bilirubin, and coombs test for Rh negative
mother.
4-Check BP, P, T, Lochia and firmness of the
uterus before transferring the patient.
5-Continue an infusion of syntocinon through
the first hour if necessary.
6-Allow no food during the first hour, sips of
water may be taken, encourage nursing.

V-Care of the new born infant:


1. -Clearance of the new passages.
2. -Determine the Apgar score one and five
minutes
- heart rate
- respiratory rate
- muscle tone
- colour
- reflex irritability
3-Care of the umbilical cord stump
4-General assessment of the infant to exclude
any congenital anomalies.
5-Identification of weight, estimate the
gestational age, dress it and put a mask to
identify it.
6-Protect the baby against cold.

A-Delivery of the fetal head:


Enter the pelvis by flexion

Engagement

Increased flexion

Internal rotation

DESCENT

Crowning

Extension

Restitution

External rotation

Delivery of the fetal head


B-Delivery of the shoulder and body: