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Labor

Labor is the physiologic process by


which a fetus is expelled form the
uterus to the outside world.
It involves the sequential
integrated changes in the uterine
decidua, and myometrium.
Changes in the uterine cervix tend
to precede uterine contractions
Dilatation: the enlarging of the
cervix to 10 centimeters.
Effacement: the thinning of the
cervix. Your cervix starts out being
two inches long, and 50% effaced
would be a 1 inch cervix.
Labor - Mechanics
Uterine contractions have two major goals:

1. To dilate cervix
2. To push the fetus through the birth canal
Success will depend on the three Ps:
1. Powers
2. Passenger
3. Passage
Power
Uterine contractions
Power refers to the force
generated by the contraction of
the uterine myometrium
Activity can be assessed by the
simple observation by the mother,
palpation of the fundus, or
external tocodynamometry.
Contraction force can also be
measured by direct measurement
of intrauterine pressure using
internal manometry or pressure
transducers.
Power
There is no specific
criteria for adequate
uterine activity
Generally 3-5
contractions in a 10
minute period is
considered adequate
labor
Passenger
Passenger =fetus
Fetal variables that can affect labor:
Fetal size
Fetal Lie longitudinal, transverse or oblique
Fetal presentation vertex, breech, shoulder, compound
(vertex and hand), and funic (umbilical cord).
Attitude degree of flexion or extension of the fetal head
Position
Number of fetuses
Presence of fetal anomalies hydrocephalus,
sacrococcygeal teratoma
Cervical effacement and dilation
Station
Station degree of
descent of the presenting
part of the fetus,
measured in centimeters
from the ischial spines in
negative and positive
numbers.
-5 is a floating baby,
0 station is said to be
engaged in the pelvis,
and +5 is crowning.
Passage
Passage = Pelvis
Consists of the bony pelvis and
soft tissues of the birth canal
(cervix, pelvic floor
musculature)
Small pelvic outlet can result in
cephalopelvic disproportion
Bony pelvis can be measured by
pelvimetry but it not accurate
and thus has been replaced by a
clinical trial of labor
Passage

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The Stages of Labor
First Stage
Interval between the onset
of labor and full cervical
dilation
Two phases:
Latent phase onset o f
labor with slow cervical
dilation to ~4 cm and
variable duration
Active phase faster rate
of cervical change, 1-1.2
cm /hour, regular uterine
contractions
The Labor Curve

First stage - A: latent phase; B + C + D: active phase; B: acceleration;


C: maximum slope of dilation; D: deceleration; E: second stage.
Labor
Freidmans curve is Labor NulliG MultiG

a good guideline for


1st Stage Active phase
expected
progression in labor Duration 6-18 h 2-10 h
and therefore
helpful to note Dilation ~1 cm/h ~1.5 cm/h

abnormal labor
Arrested >2 h >2h
patterns.
2nd Stage 0.5-3 h 5-30 min

3rd Stage 0-30 min 0-30 min


Fig 1: An idealized labor pattern. The normal patterns of cervical dilation
(solid line) and descent (broken line) as they are traced against elapsed time in
labor. The distinctive phases of the first stage are shown. The active phase
comprises the interval from the onset of the acceleration phase to the
beginning of the second stage.
Labor Second Stage
Interval between full
cervical dilation to
delivery of the infant.
Characterized by descent
of the presenting part
through the maternal
pelvis and expulsion of the
fetus.
Indications of second
stage:
1. Increased maternal show
2. Pelvic/rectal pressure
3. Mother has active role of
pushing to aid in fetal
descent.
Labor Second Stage
Molding is the alteration of the
fetal cranial bones to each other
as a result of compressive forces
of the maternal bony pelvis.
Examining the fetal head
during the second stage may
become difficult due to molding
Caput is the localized
edematous area on the fetal
scalp caused by pressure on the
scalp by the cervix.
PrimiG 0.5-3 h; mulitG 0-
30min
Suctioning the
nasopharynx

Clamp the umbilical cord Cut between the clamps


Labor Third Stage
Placental separation and delivery.
The time from fetal
delivery to delivery of
the placenta
Signs of placental
separation:

a. The uterus becomes


globular in shape
and firmer.
b. The uterus rises in
the abdomen.
c. The umbilical cord
descends three (3)
inches or more
further out of the
vagina.
d. Sudden gush of
blood.
Labor Third Stage
Placenta is delivered using one
hand on umbilical cord with
gentle downward traction. Other
hand on abdomen supporting
the uterine fundus.
Risk factor for aggressive traction
is uterine inversion.
Obstetrical emergency!!
Normal duration between 0-30
min for both PrimiG and MultiG
Inspect the placenta for completeness
AMTSL = Active management of third stage of labour. RP = retained placenta.
CCT = controlled cord traction. Hb = Haemoglobin. BP = Blood pressure. MRP
= Manual removal of placenta. Hb = haemoglobine.
Labor Fourth Stage
Refers to the time from delivery of the placenta
to 1 hour immediately postpartum
Blood pressure, uterine blood loss and pulse rate
must be monitor closely ~ 15 minutes
High risk for postpartum hemorrhage from:
Uterine atony, retained placental fragments,
unrepaired lacerations of vagina, cervix or
perineum.
Occult bleeding may occur vaginal hematoma
Be suspicious with increased heart rate,
pelvic pain or decreased BP!!!!!!
Cardinal Movements of Labor
This refers to the movements
made by the fetus during the
first and second stage of
labor. As the force of the
uterine contractions
stimulates effacement and
dilatation of the cervix, the
fetus moves toward the
cervix.
When the presenting part
reaches the pelvic bones, it
must make adjustments to
pass through the pelvis and
down the birth canal
Seven distinct
movements:

1. Engagement
2. Descent
3. Flexion
4.Internal rotation
5. Extension
6.External
rotation/restitut
ion
7. Expulsion
Cardinal Movements of Labor
Engagement
Passage of the widest diameter fetal presenting part below
the plane of the pelvic inlet
The head is said to be engaged if the leading edge is at the
level of the ishial spines.
Descent
Refers to the downward passage of the presenting part
through the bony pelvis
Not steady process
Greatest at deceleration phase of first stage and during 2nd
stage of labor
Cardinal Movements of Labor
Flexion
Occurs passively as the head descends due to the shape of
the bony pelvis.
Partial flexion occurs naturally but complete flexion
usually occurs only in the labor process
Complete flexion places the fetal head in optimal smallest
diameter to fit through the pelvis
Internal Rotation
Rotation of the fetal head from occiput transverse to
occiput either in anterior or posterior position
Occurs passively due to the shape of the bony pelvis
Cardinal Movements of Labor
Extension
Occurs when the fetus has descended to the level of the
vaginal introitus
When occiput is just past the level of the symphysis, the angle
of the birth canal changes to upward position
External Rotation/Restitution
As the head is delivered, it rotates back to its original position
prior to internal rotation
It aligns anatomically with the fetal torso
The release of the passive forces on the fetal head allows it to
return to appropriate position
Expulsion
Delivery of the fetus
After delivery of the fetal head,
descent and intraabdominal
pressure by mother brings
shoulder to the level of the
symphysis
Downward traction allows
release of the shoulder and the
fetus is delivered.
Analgesia in labor
Discomfort during Labor and Birth
Pain and discomfort experienced during labor have
two neurologic origins: visceral and somatic
Neurologic origins
Visceral pain: from cervical changes, distention of lower uterine segment,
and uterine ischemia
Located over the lower portion of abdomen
Referred pain: originates in uterus, radiates to abdominal wall, lumbosacral
area of back, iliac crests, gluteal area, and down the thighs
Somatic pain: pain described as intense, sharp, burning, and well localized
Stretching and distention of perineal tissues and pelvic floor to allow passage
of fetus, from distention and traction on peritoneum and uterocervical
supports during contractions, and from lacerations of soft tissue
Perception of pain

Threshold remarkably similar in all,


regardless of gender, social, ethnic, or
cultural differences
Differences play definite role in persons
perception of and behavioral responses to
pain
Expression of pain
Pain results in physiologic effects
and sensory and emotional
(affective) responses
Emotional expressions of
suffering often seen
Increasing anxiety
Writhing, crying, groaning,
gesturing (hand clenching and
wringing), and excessive muscular
excitability
Cultural expression of pain varies
Factors influencing pain response

Physiologic factors
Culture
Anxiety
Previous experience
Childbirth
preparation
Comfort and support
Environment
Distribution of labor pain
A. Distribution of labor pain during first stage
B. Distribution of labor pain during later
phase of first stage and early phase of
second stage
C. Distribution of labor pain during later
phase of second stage and during birth

(Gray shading indicates areas of mild


discomfort; light-colored shading indicates
areas of moderate discomfort; dark-colored
shading indicates areas of intense discomfort.)
Nonpharmacologic Management
of Discomfort
Nonpharmacologic measures often simple, safe, and
inexpensive
Provide sense of control over childbirth and measures
best for woman
Methods require practice for best results
Try variety of methods and seek alternatives, including
pharmacologic methods, if measure used is not
effective
Nonpharmacologic Management
of Discomfort
Childbirth education
Dick-Read method
Lamaze method
Bradley method

Relaxing and breathing techniques


Relaxation
Imagery and visualization
Music
Touch and massage
Breathing techniques
Effleurage and counterpressure
Water therapy (hydrotherapy)
Transcutaneous electrical nerve stimulation
Pharmacologic Management
of Discomfort
Sedatives Nerve block analgesia and
anesthesia
Analgesia and anesthesia Local perineal infiltration

Anesthesia anesthesia
Prudendal nerve block
Systemic analgesia
Spinal anesthesia (block)
Opioid agonist analgesics Disadvantages
Opioid (narcotic) agonist Medication reactions (allergy)
antagonist analgesics Hypotension
Co-drugs Ineffective breathing

Ataractics Headache
Autologous epidural blood patch
Opioid (narcotic) antagonists
Pain Pathways and Sites of
Pharmacologic Nerve Blocks
A. Pudendal block; suitable B. Epidural block; suitable
during second and third stages during all stages of labor and for
of labor and for repair of repair of episiotomy
episiotomy
Pain Pathways and Sites of
Pharmacologic Nerve Blocks
Nerve block analgesia and
anesthesia
Epidural anesthesia/analgesia
Lumbar epidural
anesthesia/analgesia
Walking epidural analgesia
Epidural and intrathecal opioids
Membranes and spaces of spinal Cross section of vertebra and
cord and levels of sacral, spinal cord
lumbar, and thoracic nerves
Levels of Anesthesia Necessary for Cesarean
and Vaginal Births

Cesarean birth

Vaginal birth
Care Management
Plan of care and interventions (contd)
Administration of medication
Intravenous route
Intramuscular route

Spinal nerve block

Signs of potential problems


Safety and general care
Anesthesia in the obese woman
Key Points
Expected outcome of preparation for childbirth and
parenting is education for choice
Nonpharmacologic pain and stress management
strategies are valuable for managing labor discomfort
alone or in combination with pharmacologic methods
Gate-control theory of pain and stress response are
bases for many of the nonpharmacologic methods of
pain relief
Type of analgesic or anesthetic used is determined in
part by stage of labor and method of birth
Opioid effects can be potentiated with ataractics
In Summary
Know the different stages of labor
Know the labor curve
Know the cardinal movements of labor
Know the causes of postpartum hemorrhage
MD must understand medications, expected effects, potential adverse reactions, and
methods of administration
Maternal fluid balance is essential during spinal and epidural nerve blocks
Maternal analgesia or anesthesia potentially affects neonatal neurobehavioral response
Use of opioid agonist-antagonist analgesics in women with preexisting opioid
dependence may cause symptoms of abstinence syndrome (opioid withdrawal)
General anesthesia rarely used for vaginal birth
May be used for cesarean birth or when needed in emergency childbirth situation
Thank you for your attention!