Académique Documents
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Prepared by
Nirsuba Gurung
Assistant lecturer
MSON
NORMAL LABOUR: NORMAL ANATOMY
Labour (parturition)
• It Is the process where by with time regular
uterine contractions, brings about progressive
effacment 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.
Passenge
r
Passage
Power
Normal labour
• Normal labour is physiological process by
which the fetus ,placenta and membrane are
expelled through the birth canal after full
term pregnancy (38-42 weeks of gestation)
• Labour is called normal when it fullfill the
following criteria :
– Spontaneous onset at term
– With vertex presentation
– Without prolongation
– Natural termination with minimal aids
NORMAL LABOUR
LATENT PHASE: 0-4cm
FIRST STAGE ACTIVE PHASE: 4-10cm
B. Signs:
o palpable or recorded uterine contraction
o effacement and dilation of the cervix
o formation of forewater
THE ACTIVE STAGE OF LABOUR – WHEN THE CERVIX
IS MORE THAN 3 CM DILATED AND FULLY EFFACED
STAGES OF LABOUR:
I-TheFirststage: 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 ofthefirststage:
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.
Factorsaffectingcervicaldilatation:
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 = ½ 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.
Mechanismoflabourinvertexpresentation:
D e f i n i t i o n : 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.
Deliveryofthefetalhead:
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.
Causesofnon-engagement:
Erroneous dates (primigravida)
Extra-uterine:
A full bladder or loaded rectum
. Pelvic tumours
B. Pendulous abdomen and marked lumbar lordosis.
C. High angle of inclination of the pelvis.
D. Contracted pelvis.
E. -Uterine:
Poor uterine tone.
A. Congenital deformities.
B. Fibromyomata.
C. Placenta previa.
D.
-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 (sub-occipito-
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.
Theheadisacteduponby:
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-Restitutionandexternalrotation:
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.
Deliveryoftheshoulderandbody:
The widest diameter of the shoulders,( the bi-
acromial 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 antero-posterior 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.
DO STERIL S P E C U L U M EXAMINATION I F
SUSPECTED PLROM, IF THE WOMAN IS
NOT IN LABOUR.
I - f i r s ts t a g e o f l a b o u r :
1-Ensure patient’s 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 hartmann’s solution at 80-
125ml/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 Hartmann’s 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:
Engagement
Increased flexion
Internal rotation
DESCEN Crowning
T
Extension
Restitution
External rotation