PREPARED BY DR.

LUBISIA
DEFINITION
 Labor: is the process by which a viable fetus i.e. at the end
of 28 weeks or more is expelled or is going to be expelled
from the uterus
 Delivery is the actual birth of the fetus
 Premature labor: labor occurring before the
commencement of the 37th week of gestation
 Prolonged labor: labor lasting in excess of 24 hours in
primigravida and 16 hours in a multigravida
 Onset of labor: the time of onset of regular, painful uterine
contractions which produce progressive effacement and
dilatation of the cervix
 False labor: onset of painful contractions is not associated
with progressive dilatation of the cervix
CONT.
 The following criteria should be present in order to be
classified as normal labor:
i. Spontaneous onset
ii. Of a single mature fetus
iii. Presented by vertex
iv. Through the birth canal
v. Within a reasonable time (not less than 3 hours or
more than 18 hours)
vi. Without complications to the mother or fetus
CAUSES OF ONSET OF LABOR
 It is unknown but the following theories were postulated:
i. Hormonal factors
ii. Mechanical factors

1. Hormonal factors
 Estrogen theory: during pregnancy, most of the estrogen
is present in a binding form. During the last trimester,
more free estrogen appears increasing the excitability of
the myometrium and prostaglandins synthesis
CONT.
 Progesterone withdrawal theory: before labor, there is
a drop in progesterone synthesis leading to
predominance of the excitatory action of estrogen
 Prostaglandins theory: prostaglandins E2 and F2a are
powerful stimulators of uterine muscle activity.
Prostaglandin F2a was found to be increased in
maternal and fetal blood as well as the amniotic fluid
late in pregnancy and during labor
CONT.
 Oxytocin theory: although oxytocin is a powerful
stimulator of uterine contraction, its natural role in onset
of labor is not clear. The secretion of oxytocinase enzyme
from the placenta is decreased near term due to placental
ischemia leading to predominance of oxytocin’s action
 Fetalcortisol theory: increased cortisol production from the
fetal adrenal gland before labor may influence its onset by
increasing estrogen production from the placenta
 Fetoplacental theory: due to unknown factors, fetal
pituitary is stimulated with increased release of ACTH
CONT.
2. Mechanical factors
 Optimal uterine distension theory: like any hollow
organ in the body, when the uterus is distended to a
certain limit, it starts to contract to evacuate its
contents. This explains the preterm labor in case of
multiple pregnancy and polyhydramnios.
 Stretch of the lower uterine segment: by the
presenting part near term
FACTORS THAT INFLUENCE
PROGRESS OF LABOR
 The normal female pelvis: the obstetric pelvis is divided
into false and true pelvis by the pelvic brim or inlet. The
true pelvis is composed of inlet, cavity and outlet
 The types of female pelvis are:
i. Gynaecoid
ii. Anthropoid
iii. Android
iv. Platypelloid
 The important diameters of the female pelvis are:
i. Anteroposterior
ii. Oblique
iii. Transverse
CONT.
 Fetal skull: sutures, moulding and diameters
 Sagittal suture: lies between the parietal bones. It runs in
an anteroposterior direction between the anterior and
posterior fontanelles
 Coronal sutures: suture uniting the parietal bones to the
frontal bones. It extends transversely from the anterior
fontanelles and lies between the parietal and frontal bone
 Frontal/ metopic suture: is between the two frontal bones.
It is an anterior continuation of the sagittal suture
 Lambdoidal suture: is between the parietal and occipital
bones
CONT.
Moulding: ability of the fetal head to change its shape
and so to adapt itself to the unyielding maternal pelvis
during the progress of labor
Diameters of the fetal skull: they include:
i. Suboccipito-bregmatic (SOB) – 9.5 cm
ii. Suboccipital-frontal (SOF) – 10 cm
iii. Submento-bregmatic (SMB) – 9.5 cm
iv. Occipito-frontal (OF) – 11.5 cm
v. Mento-vertical (MV) – 13.5 cm
vi. Submento-vertical (SMV) – 11.5 cm
CONT.
 Power: contractions and maternal pushing
 Uterine contractions:
i. Initiated by pacemakers – uterotubal junction
ii. Contraction waves meet at the fundus
iii. Contraction waves progress downwards
iv. Shortening of muscle fibers
v. Retraction
vi. Intrauterine pressure
vii. Expulsion of the fetus
 Maternal pushing: intra-abdominal pressure
o Normal contractions are :
i. Frequency: 1 in every 2-3 minutes with at least 1 minute interval
ii. Intensity: strong (>50 mmHg)
iii. Duration: 45-60 seconds
CLINICAL MANIFESTATIONS OF
LABOR
 Prodromal/ premonitory (pre-labor) stage: the
following clinical manifestations may occur two to three
weeks before onset of true labor.
 Shelfing: falling forwards of the uterine fundus making the
upper abdomen look like a shelf when standing. This is due
to engagement of the head which brings the fetus
perpendicular to the pelvic inlet in the direction of pelvic
axis
 Lightening: relief of upper abdominal pressure symptoms
such as dyspnoea, dyspepsia and palpitation due to:
i. Descent in the fundal level after engagement of the head
into the true pelvis
ii. Shelfing of the uterus
CONT.
Pelvic pressure symptoms: with engagement of the
presenting part, the following symptoms may occur:
i. Frequency of micturition
ii. Rectal tenesmus
iii. Difficulty in walking
iv. Increased vaginal discharge
v. False labor pain
vi. Cervical changes (ripening of the cervix) become
soft, <1.3 cm in length, admit tip of a finger and is
dilatable
CONT.
 Onset of labor is characterized by true labor pain which presents as:
i. Onset of regular, painful contractions radiating to the back
increasing in frequency, duration and intensity
ii. Show: an expelled cervical mucus plug tinged with blood from
ruptured small vessels as a result of separation of the membranes
from the lower uterine segment. Labor starts several hours to few
days after show
iii. Progressive effacement and dilatation of the cervix: a closed cervix is
a reliable sign that labor has not begun. In multigravisae, the cervix
may admit the tip of the finger before onset of labor
iv. Formation of the bag of fore-waters: it bulges through the cervix and
becomes tense during uterine contractions and may rupture
spontaneously early in labor or until delivery of the fetus
STAGES OF LABOR
 First stage: stage of cervical dilatation. Begins with onset of true
labor and ends with full dilatation of the cervix It takes about 10-
12 hours in primigravida and about 6-8 hours in multipara.
Divided into 2:
i. Latent phase: the first 3 cm of cervicall dilatation. Takes about
8 hours in primigravida and 4 hours in multigravida
ii. Active phase: cervical dilatation between 4-10 cm. the normal
rate of cervical dilatation is 1 cm/ hour. If it < 1 cm/ hour, it is
considered prolonged labor. It has 3 componenets:
 Acceleration phase
 Maximum slope: the most detectable phase
 Deceleration phase
CONT.
 Second stage: stage of expulsion of the fetus. Begins with with full
cervical dilatation and ends with delivery of the fetus. Its duration is
about 1 hour in primigravida and ½ hour in multigravida
 Third stage: stage of expulsion of the placenta and membranes. Begins
after delivery of the fetus and ends with expulsion of the placenta and
membranes. Its duration is about 10-20 minutes in both primigravida
and multipara. Classical signs of placenta separation are:
i. Show of bright blood as uterus contracts
ii. Lengthening of the umbilical cord
iii. Fundus becomes globular in shape, rises above the umbilicus
and becomes palatable
 Fourth stage: stage of early recovery. Begins immmediately after
expulsion of the placenta and membranes and lasts for one hour.
Careful observation of the patient particularly for signs of PPH is
essential. Routine uterine massage is usually done after every 15
minutes during this period
FIRST STAGE OF LABOR
Causes of cervical dilatation
 Contraction and retraction of uterine musculature
(primary force)
 Mechanical pressure by the forebag of waters if
membranes still intact or the presenting part if they
had ruptured
 Softness of the cervix which has occurred during
pregnancy facilitates dilatation and effacement of the
cervix
CONT.
Mechanism of cervical dilatation
 In primigravidas, the cervical canal dilates from the
internal os downwards to the external os. Its length
shortens gradually from more than 2 cm to a thin rim
of few millimetres continous with the lower uterine
segment. This process is called effacement
 Dilatation of the cervix starts after complete
effacement of the cervix. In multigravidas, effacement
and dilatation occur simultaneously
CONT.
 In normal presentation and position, the head is
applied well to the lower uterine segment dividing the
amniotic sac by the girdle of contact into a hindwater
above it containing the fetus and forewaters below it.
This reduces the pressure in the forewaters preventing
early rupture of membranes. After full cervical
dilatation of the cervix, the hind and forewaters
become one sac with increased pressure in the bag of
forewaters leading to its rupture
MECHANISM OF NORMAL LABOR
 Refers to the series of changes in position and attitude
which the fetus undergoes during its passage through
the birth canal
 Entails delivery of the head, shoulders and body
 Engagement of the head normally occurs before the
onset of labor in the primigravid woman but may not
occur until labor is well established in a multipara
 Only 2/5 of the head will be palpable per abdomen.
 Zero station on vaginal examination
 Delivery of the head entails the following process:
CONT.
1. Descent: continuous throughout labor particularly during the second
stage of labor and is caused by:
i. Uterine contractions and retractions
ii. The auxillary forces which is bearing down brought by contraction
of the diaphragm and abdominal muscles
iii. The unfolding of the fetus i.e. strainghtening of its body due to
contractions of the circular muscles of the uterus
2. Internal flexion: as the antlanto-occipital joint is nearer to the occiput
than the sinciput, increased flexion of the head occurs when it meets
the pelvic floor. This results in:
i. The suboccipito-bregmatic diameter (9.5 cm) passes through the
birth canal instead of the suboccipito-frontal diameter (10 cm)
ii. The occiput meets the pelvic floor bringing the chin into contact
with the fetal thorax
CONT.
3. Internal rotation: the occiput of the fetus meets the pelvic floor
first and rotates anteriorly towards the symphysis pubis
4. Crowning
5. Extension: the acutely felxed head descends to distend the pelvic
floor and the vulva and the suboccipital region comes into
contact with the inferior rami of the pubis then by head
extension, the vertex, forehead and face are delivered. Maximal
distension of the perineum and introitus accompanies the final
expulsion of the head, a process known as crowning. The head is
acted upon by 2 forces:
i. The uterine contractions acting downwards and forwards
ii. The pelvic floor resistance acting upwards and forwards
CONT.
5. Restitution: after delivery, the head rotates 1/8 of a
circle in the opposite direction of internal rotation to
undo the twist produced during internal rotation and
realign with its normal relationship to the fetal
shoulders.
6. External rotation of the head: When the anterior
shoulder meets the pelvic floor, it rotates into the
anteroposterior diameter of the pelvis. This movement
is transmitted to the head so the face looks laterally at
the maternal thigh
CONT.
7. Lateral flexion of the body: involves delivery of the
shoulders and body. The anterior shoulder is delivered
first by traction posteriorly on the fetal head so that
the shoulder emerges under the pubic arch. The
posterior shoulder is delivered by lifting the head
anteriorly over the perineum. This is followed by rapid
delivery of the remainder trunk and the lower limbs
THIRD STAGE OF LABOR
 After delivery of the fetus, the uterus continues to
contract and retract.
 Placental separation is due to marked uterine muscle
retraction which reduces the surface area at the
placental site to about its half
 As the placenta is inelastic, it starts to separate
through the spongiosa layer by one of the following
mechanisms:
CONT.
 Schultze’s mechanism {central separation}(80%): the central
area of the placenta separates first and placenta is delivered like
an inverted umbrella so the fetal surface appears first followed by
the membranes containing small retroplacental clot. There is
less blood loss and less liability for retention of fragments
 Mathew-Duncan’s mechanism {marginal separation} (20%): the
lower edge of the placenta separates first and placenta is
delivered side ways. There is more liability of bleeding and
retained fragments
 The third stage is comprised of three phases:
i. Placental separation
ii. Placental descent
iii. Placental expulsion
CONT.
 After complete separation of the placenta, it is delivered by
effective contraction and retraction and expelled out by
either:
i. Voluntary contraction of abdominal muscle (bearing
down effort)
ii. Manipulative procedures
 After placental delivery, the uterine sinuses and
arterioles are occluded by effective uterine contraction
and retraction which is the principle mechanism of
haemostasis.
 However, thrombosis also occurs and is facilitated by the
hypercoagulable status of pregnanancy
INTRAPARTUM MONITORING
 What to monitor:
i. Mother
ii. Fetus
iii. Temperature
iv. Pulse rate
v. Blood pressure
vi. Urine
vii. Auscaltation
viii. Partograph
CONT.
 Temperature: every 4 hours. Normal 36.2-37.2 degrees celcius
 Pyrexia causes: infection, maternal exhaustion, dehydration
 Pulse rate: every hour. Normal 70-100 b/min
 Blood pressure: every hour. Normal 100/60 mmHg-140/90
mmHg
 Urine: every 2 hours. Volume, protein, ketones
 Fetal monitoring: auscaltation every 30 minutes, Fetal ECG
normal 110-160 b/min, fetal CTG, scalp stimulation test,
vibroacoustic stimulation, fetal oxygen saturation
 Uterine contractions: frequency and strength of contractions
 Partograph: a graphical record of key data during labor entered
against time on a single sheet of paper
CONT.
 Indications for continuous electronic fetal monitoring:
 Maternal:
i. Previous cesarean section
ii. Pre-eclampsia
iii. Post-term pregnancy
iv. Prolonged rupture of membranes
v. Induced labor
vi. Diabetes
vii. APH
viii. Other maternal medical diseases
CONT.
Fetal:
i. Fetal growth restriction
ii. Prematurity
iii. Oligohydramnios
iv. Multiple pregnancy
v. Meconium-stained liquor
vi. Breech presentation
PHYSIOLOGICAL EFFECTS OF LABOR
 On the mother:
First stage: minimal effects
Second stage:
i. Slight rise in temperature to 37.5 degrees celcius
ii. Pulse increases to 100 b/min
iii. Blood pressure: systolic blood pressure may rise
slightly due to pain, anxiety and stress
iv. Edema and congestion of the conjuctiva
v. Minor injuries to the birth canal and perineum may
occur particularly in primigravidas
CONT.
 Third stage: blood loss from the placental site is 100-200 ml
and from the laceration or episiotomy is 100 ml so the total
average blood loss in normal labor is 250 ml

 On the fetus:
 Moulding: the physiological gradual overlapping of the
vault bones as the skull is compressed during its passage in
the birth canal. One parietal bone overlaps the other and
both overlap the occipital and frontal bones so fontanelles
are not detectable. Severe and/ or rapid moulding may
cause intracranial hemorrhage
CONT.
Caput succedaneum: a soft swelling of he most
dependent part of the fetal head occurs in prolonged
labor before full cervical dilatation and after rupture of
the membranes. It is due to obstruction of the venous
return from the lower part of the scalp by the cervical
ring. Large caput may:
i. Obscure fontanelles and sutures making
identification of the fetal position difficult. This can
be overcome by palpation of the ear
ii. Give an impression that the head is lower than its
true level
CONT.
 Artificial caput succedaneum (chignon): is induced
during vacuum extraction
 Caput disappears spontaneously within hours to days
after birth
 The presence of caput indicates that:
i. Labor was prolonged and difficult
ii. The fetus was living during labor
MANAGEMENT OF NORMAL
LABOR
 General principles of management of first stage of labor:
i. Observation and intervention if labor becomes abnormal in
the partograph
ii. Emotional support of the mother
iii. Fetal monitoring
iv. Complete history taking
v. Review of antenatal record
vi. Abdominal examination to checl fetalpresentation and
position and relation of presenting part to the brim of the
pelvis
vii. Encourage patient to ambulate as it hastens descent of fetal
head and prevents vena cava occlusion
CONT.
 Abdominal examination to assess frequency and strength
of contractions
 Location, rate and regularity of fetal heart is assessed
 Vaginal examination to assess degree of cervical dilatation,
whether the membranes are intact or ruptured
 Position and station of presenting part
 Urine sample to check for protein and glucose
 Encourage patient to empty bladder regularly as full
bladder inhibits uterine contraction
 Pain relief during labor: epidural analgesia, pethidine 100
mg IM can be given when the contractions are well
established (not to be given if delivery is anticipated within
2 hours)
CONT.
 Management of second stage of labor:
 Transition from first stage to second stage of labor is
evidenced by:
 Appearance of bearing down efforts
 Complete dilatation of the cervix on vaginal examination
 Principles of management are:
i. To assist in the natural expulsion of the fetus slowly
ii. To detect cord prolapse and prepare for emergency
cesarean section
iii. Minimizing perineal injury
iv. Clamping the cord
v. Eva;uation of Apgar score
CONT.
 Signs delivery is imminent are:
 Bearing down efforts
 Bulging of the perineum
 Gaping of the anal opening during contraction
 Patient is put in lithotomy position and encouraged to intensify the
bearing down efforts during contractions
 When head crowns and perineum is fully strtched and threatens to
tear, an episiotomy is given after prior infiltration with 10 ml of 1%
lignocaine
 When the forehead, nose, mouth and chin are delivered, the mucus
and blood in the mouth and pharynx should be wiped with sterile
gauze
 The neck is then palpated to exclude the presence of any loop of cord.
If found, it should be slipped over the head or if tight, it is cut in
between two pairs of kocher’s forceps
CONT.
 When giving an episiotomy, insert index and midle fingers to create a
space between the fetal head and episiotomy site then spread apart and
cut in between the space created
 Types of episiotomies are:
1. Midline: the cut is made vertically from the centre of the fourchette and
extends posteriorly along the midline for about 2.5 cm towards the
anus.
 Advantages are:
a) Less blood loss
b) Easier to repair
c) Wound heals quicker
d) Less postpartum pain and dyspareunia
 Disadvantage:
a) Higher risk to involve the anus
CONT.
2. Mediolateral: incision starts in the midline of the
fourchette and then directed outwards either to the right or
left to avoid the anal sphincter. It is directed diagonally in a
straight line about 2.5 cm away from the anus.
3. J shaped: incision begins in the centre of the fourchette
and is directed posteriorly along the midline for about 1.5
cm and then directed downwards and outwards along 5 or
7 o’clock position to avoid the anal sphincter.
 Apposition is not perfect and the repaired wound tends to
be puckered
 This is not done widely
CONT.
Repairing an episiotomy
 Infiltrate with local anesthesia
 Principles applied when suturing an episiotomy are:
i. The apex (highest point) of the episiotomy must be
visualized and a suture put at the apex
ii. Dead space must be closed
iii. The same opposing tissue must be brought together but
not strangulated by excessive tension on sutures
iv. Hemostasis must be obtained
v. Handle needle with a pair of forceps and not by hand
and should be safeguarded and removed from the
operating field as soon as possible
CONT.
 Three layers have to be repaired:
i. The vaginal epithelium
ii. The muscles
iii. The perineal skin
 Steps in the repair of an episiotomy wound are:
 Place a suture at the apex in the vaginal epithelium. Insert
more continous sutures in the vaginal epithelium and do not
cut
 Place interrupted sutures in the muscles. Bring together to
eliminate dead space. The markers for correct alignment are:
a) The remains of the hymen
b) The junction of the skinand the vaginal epithelium
CONT.
Return to the vaginal epithelium and complete the
continuous sutures ending the junction with the skin
Use interrupted sutures to repair the perineal skin.
Mattress sutures may be used. Do not pull the sutures
tight as is uncomfortable for the patient due to the
inflammatory response causing swelling of the tissue
 Teach patient on sitz baths and encourage regularity to
encourage faster healing
CONT.
 Management of third stage of labor:
i. Recognition of placental separation
ii. Assisted delivery of the placenta with controlled
cord traction (Brandt-Andrews method)
iii. Use of oxytocic agents with delivery of the baby
iv. Observe for PPH at least for 1 hour after delivery
 After placenta and membranes delivery, observe the
mother’s blood pressure, pulse and temperature
 Observe uterine behavior to ensure it is well
contracted