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Normal Labour and the Care


Penang Medical College

Upper Segment * Expands with baby in

* Contracts & retracts in

* 70% muscle, 30%
fibrous tissue

* Above level of bladder

Lower Segment * Relaxes in Labour
why C-section not cut in lower segment?
when it is cut, it heals as fibrous scar which is more likely
to rupture in subsequent pregnancy
(unlike upper segment which the muscle tissue heals
better without leaving scar)
* 70% fibrous tissue,
30% muscle

* Lies behind bladder

Uterus Cervix * “The neck of the uterus” approx 4cm long * Stops baby from “falling out” during pregnancy softens and shortens * Dilates and is taken up into lower segment in labour .

The Uterus The Primigravid Uterus The Multigravid Uterus “Almost like two different biological species” Prof. Kieran O’Driscoll .

The Primigravid Uterus * First attempt – how effective in labour unknown uterine with failure to progress. birth canal too small for fetal head to pass through] * Genital tract stretches with difficulty * Almost never ruptures . * Inefficient action common leads to deflexed head and CPD [cephalo-pelvic disproportion.

The Multigravid Uterus * Cephalo-pelvic disproportion (CPD) rare * Inefficient uterine action rare the uterine muscle can stretch significantly * Genital tract stretches easily * May rupture if labour becomes obstructed .

dull in nature . irregular involuntary uterine Normal labour contractions throughout pregnancy . particularly hormones.descent of presenting part .natural termination with minimal aids .found more in primigravidae.painful uterine contractions at regular intervals . 137) .no effect on dilatation of cervix .not associated with hardening of uterus .NORE RELIEVED by edema or sedatives Labour .associated with 'show' .spontaneous in onset and at term .without having any complications affecting the health of mother and the baby .frequency.painless. intensity and duration of contractions increase progressively .progressive effacement and dilatation of cervix .no features of true labour pain . due to stretching of cervix and lower uterine segment with consequent irritation of neighbouring ganglia No one precipitating cause It is caused by a change in the balance of pro-labour and pro-pregnancy factors.relieved by edema or sedative .confined to lower abdomen and groin . Braxton Hicks .without undue prolongation . False labour pain True labour pain (pg.vertex presentation .

dilated 3) appearance of false labour pain .a 'welcome sign' as it rules out CPD 2) Cervical changes . the presenting part sinks into true pelvis due to active pulling up of lower pole of uterus around the presenting part . Pro-pregnancy Factors * Progesterone * Catecholamines Prelabour (few weeks to few days before labour) * Relaxin 1) 'Lightening' .rippening of cervix .might be frequency of micturition or constipation due to pressure by the engaged presenting part .soft.Esp in primigravidae. effaced.

stimulating production of estrogen in mother's body cascade of events activate fetal hypothalamic-pituitary-adrenal axis -> increased corticotropin-releasing hormone (CRH) -> increased release of ACTH which stimulates fetal adrenals --> increased cortisol secretion -> accelerates production of estrogen and prostaglandin from the placenta * Uterine stretching effect on myometrium by growing fetus and amniotic fluid increases the gap junction and receptors for oxytocin and specific contraction associated proteins (CAP) . * Prostaglandins rupture of membranes . vaginal examination. infection.Ferguson reflex: vaginal examination and amniotomy cause rise in maternal oxytocin level * Oxytocin . decidual cells and myometrium .at peak level during delivery of placenta & control postpartum hemorrhage * Fetal steroids from fetal adrenal gland. which produces a precursor which then enters maternal circulation.amount of oxytocin receptors and its sensitivity increases during labour.accelerates lysosomal disintegration in the decidual and amnion cells resulting in increased prostaglandin synthesis . glucocorticosteroids.triggered by rise of estrogen level.stimulates synthesis and release of prostaglandin from amnion and decidua .promotes synthesis of myometrium receptors for oxytocin & increase excitability of myometrial cell membranes . Pro-labour Factors . TNF).stimulates release of intracellular calcium of myometrium and thus muscle contracts . more present in the fundus compared to lower segment and cervix .6. chorion.promote synthesis of prostaglandins * Oestrogen .act on amnion.increases release of oxytocin from maternal pituitary . increased in cytokines (IL-1. stretching in late pregnancy.

The Mechanism of Labour right occipitolateral 1) Fetal head at pelvic brim ROL or LOL position 2) Head flexes on neck producing circular presenting part.rotates to OA 5) Head delivers by extension over perineum. 3) Head descends and engages occiput anterior position 4) Levator Ani on pelvic floor . 6) Shoulders descend & rotate to AP position 7) Head comes into line with shoulders-Restitution 8) Anterior shoulder delivers under pubic symphysis .

decceleration .heart rate falls during the contraction .Valsava maneuver .




5cm irrespective of type of presentation.Often too big – Brow 13.5 cm .0 cm .  Transverse diameter.5 cm . – Vertex OP 12. Fetal head dimensions. – Face MA 9.Often OK .  Antero-posterior diameter- – Vertex OA 9.5 cm .9.This is much too big.This is best.

When Does Labour Start ? * When patient admitted – time zero (management definition) .

primigravida .onset until full effacement of cervix (usually about 3cm dilatation).cervical dilatation after 3cm.up to 3cm Acceleration phase .abt 14 hours (b) Active phase . multipara . faster if multiparous.4-9cm Phase of deceleration .3 fingers or cm) From the onset of labour until full dilatation (a) Latent phase .diameter of external os (1.9-10cm dilatation There are three stages: stage of cervical dilatation Effacement . .abt 20 hours Can take up to 24 hours. Active phase < 10 hours 1cm / hour if nulliparous.2.3-4cm Phase of maximum slope .Friedman's curve of cervical dilatation Latent phase .length of cervical canal (use percentage) First Stage: Dilatation .

-ADD 30min if use of epidural use of epidural analgesic increased propulsive phase due to loss of sensation to push  Active phase usually < 1 hr prims <1/2hr multips  Increased risk of hypoxia when pushing > 1 hr. Labour – Second Stage From full dilatation of cervix until delivery of baby from full dilatation up to descent of the presenting part to pelvic floor Phase (a) Propulsive . .Active bearing down (when pushing) maternal bearing down efforts until fetus is delivered  Prolonged propulsive phase increases risk of pudendal neuralgia. of(Ferguson reflex) due to stretching vagina by presenting part (b) Expulsive .head descends to pelvic floor initiated by nerve reflex due to uterine contractions.

Look for signs of placental separation and descent. Labour – Third Stage From delivery of baby to delivery of placenta and membranes. THEN deliver placenta and membranes. Quicker if oxytocics (syntocinon/syntometrine) used. Physiologically < 30 minutes. when PPH rate is reduced. . but retained placentapostpartum is more likely hemorrhage Risk of PPH markedly increased if placenta is not delivered within 1 hour of birth of baby.

Care of Mother & Baby in Labour pg. 605 1)Partograms are routine and universal .

face). Head engaged when lowest bony point is at spines (zero station)  Clinical pelvimetry. but reducible sutures overlapping.  Membranes.2) Pelvic examination findings- usually performed every 4 hours.cephalic (vertex. OP. shoulder.OA. effacement and position. and non-reducible  Station. cord. -+ififabove below spines (+1cm +2cm etc) spine (-1cm -2cm) . etc (if vertex) 1st degree: sutures apposed but not overlapping  ?moulding/caput 3rd degree: 2nd degree: sutures overlapping. brow. ROA. LOT.  Presentation.  Position.  Cervical dilatation. ROT.relation to ischial spines. LOA. LOP. Liquor colour. breech.intact/ruptured. ROP.



Elsewhere used if fetal hypoxia is believed more likely (50% use rate in most labour wards) . after every second contraction when pushing. 10-15 minutely in second stage. and after every contraction when head on Penang used routinely.half-hourly in first stage. Care of Baby during labour. 3)Fetal heart rate recording 1) Intermittent auscultation. 2) Continuous cardiotocography (CTG).

placental dysfunction .head compression .5-20 bpm 3) Accelerations. there may be slowing of fetal heart rate by 10-20 bpm which soon returns to its normal state 4) Decelerations .during contraction.Variable – cord compression causing hypoxia .indicate normal brain-stem function.Late .110-160 2) Baseline Variability.Early . Electrical CTG (external or scalp clip) 1) Baseline Rate.




<2 indicates hypoxia .normal value about 7.Fetal blood sampling (FBS) used to measure for short term changes in hypoxia status of fetus .25.

usually excreted after the baby is bornt 2) Meconium stained Grade 1 Slight Grade 2 Heavy suspension Grade 3 Thick undiluted sign of hypoxia 3) Blood stained 4) Bilibubin stained 5) Purulent . Liquor Characteristics Signs of hypoxia 1) poor CTG 2) thick meconium 1) Clear 3) poor fetal blood sampling (FBS) content of fetal bowel.

if possible 3) Presence of friend / partner / husband 4) Empowerment / involvement of mother in progress and decisions . Care of Mother 1) Friendly. caring. open. attentive professional staff 2) Personal midwife.

and fetus is much more sensitive to morphine than mother Relief of Pain. Need IV therapy if labour prolonged.Non pharmacological/ Opiates/ Inhalational (Nitrous oxide/oxygen)/ Regional / Epidural / GA Prevention of . Observations. blood pressure.pulse. fluid balance. temperature. .dehydration/ ketoacidosis/ aspiration. 4) Care of Mother morphine is NOT GIVEN as it crosses blood-brain barrier to the fetus.


Care of the baby at birth  Aspirate airway and remove blood and meconium from mouth and nose. ? give NaHCO3. respirations.  Determine if breathing is OK. paediatrician. ? give narcotic antagonist.  Assess APGAR score (out of 10). and give oxygen. .colour.  Define if special resuscitation is needed. If not use bag & mask or intubate. breathing. heart rate.