Normal labor (Dr.

Lubna)
C8
Batool Alzubaidi
Batool R Alzubaidi

Normal
labour

Dr Lubna Batayneh
The Hashemite University
 Agenda

• Definitions
• Fetal skull and pelvic diameters
• Normal labour: definition, mechanisms, stages, and management
 Definitions

• Engagement: when the widest diameter of the fetal presenting part has
passed through the pelvic inlet
• Assessed abdominally (rule of 1/5th) and vaginally (station)

• Station: the level of the denominator of the presenting part above or

below the plane of the ischial spines

• Lie: the relation between the longitudinal axis of the fetus and the
longitudinal axis of the mother’s uterus (longitudinal, transverse, oblique,
unstable)
 -
From here and less the baby is engaged

F
abdomen ‫هون راس البيبي لساته بال‬

Assessment of
engagement
and station
‫ بكون‬ischial spine ‫اذا كان راس البيبي فوق ال‬
‫بالسالب اذا كان تحته بكون باملوجب‬
V
From zero and less is engaged
Fetal lie
• Presentation: the part of the fetus that occupies the lower segment or
pelvis, i.e., head (cephalic) or buttocks (breech)

• Presenting part: the lowest part of the fetus palpable on vaginal

examination. For a cephalic presentation, this can be the vertex, the brow
or the face, depending on the attitude
Flexed on chest Partially flexed Neck fully extended
& T T

• Attitude of the head describes the degree of flexion: vertex, brow or face.
(the relation between fetal parts to each others, well-flexed, deflexed,
extended …)
Presentation

Attitude
• Position: the relation between the denominator of the presenting
part and the maternal pelvis

• The denominator: is a bony landmark on the presenting part used to denote

the position;
• In vertex it is the occiput
• In face it is the mentum (chin)
• In breech it is the sacrum
• In brow it is the frontal bone
 Position

Favorable for delivery

Maternal anterior
&
Occiput
Anterior fontanell-
T
- Left side

L
Posterior fontanell
Maternal sacrum
 Fetal skull anatomy and diameters
• Largest and least compressible part of the fetus; it is the most
important in delivery - regardless of the presentation
• Landmarks:
• Anterior fontanelle
• Vertex: the area between fontanelles, bounded laterally by parietal
eminences
• Posterior fontanelle
• Occiput: the area behind and inferior to posterior fontanelle
• Sinciput (brow): the area between anterior fontanelle and glabella
• Glabella: elevated area between orbital ridges
• Nasion: the root of the nose
• When the vertex of the fetus
presents, and fetal head is
well flexed, the smallest
anteroposterior diameter
suboccipito-bregmatic
enters the birth canal

&
t Favorable

↓ Can’t achieve
vaginal E
delivery » c-
section
 Maternal pelvis anatomy
• Four bones: 2 innominate, sacrum, and coccyx
• Joints: sacroiliac, symphysis pubis, and sacroccygeal
• Planes of the pelvis: imaginary flat surfaces that extend across the
pelvis at different levels

• Inlet: transverse diameter is about 13 cm, anteroposterior diameter 11 cm

• Mid-pelvis: almost round, the transverse and AP diameters are similar. On the
lateral wall of the mid-pelvis, ischial spines are palpable vaginally. Used as
landmarks to assess the descent of the head on vaginal examination (station)

• Outlet: the anteroposterior diameter is 13 cm, transverse diameter 11 cm

• Maternal pelvis can be classified according to its shape based on
Caldwell-Malloy pelvic types into:

• Gynecoid
• Android
• Anthropoid
• Platypelloid
• Gynecoid pelvis:

• Classical female pelvis (50%)

• Most favourable for delivery
• Inlet is round oval with largest transverse diameter, straight side
walls, well-curved sacrum
• Android pelvis:

• 30% of women
• Typical male pelvis
• Restricted at all levels, arrest of descent in labour is common
• Anthropoid pelvis:

• 20% of women
• Fetal head engages in the anteroposterior diameter of pelvis
• Persistent occipitoposterior Position.
• Platypelloid pelvis:

• 3% of women
• Oval shaped inlet with wide transverse diameter
• Increased risk of obstructed labour
 Labour
• Labour: the process whereby the fetus and the placenta are expelled
from the uterus

• Diagnosis: when painful uterine contractions occur, followed by

dilatation and effacement of the cervix
• Cervical dilatation: The cervix begins dilating and stretching beyond the
normal dimensions and is measured in centimetres (0-10)
• Cervical effacement: softening, thinning and shortening of the cervix.
 Il

I
-
Normal labour
• To be called a normal labour, it should fulfil the criteria of:

1. Singleton Not twins

>
-

2. Between 37-42 weeks gestation

-

3. Spontaneous onset Not stimulated

4. Unassisted vaginal delivery
5. Vertex presentation Any other presentation is abnormal
>
-

6. Within reasonable time and without complication to the mother or the

fetus
The Cardinal movements
of head in labour
• The cardinal movements of labour refer to the changes in position of
the fetal head during its descent through the birth canal in vertex
presentation:

1. Descent (lightening) : movement of the fetal head through the pelvis

toward the pelvic floor
2. Engagement : the descent of the widest diameter of the presenting fetal
part below the plane of the pelvic inlet
3. Flexion : a passive movement that permits the smallest diameter of the
fetal head (suboccipitobregmatic diameter) to pass through the maternal
pelvis
4. Internal rotation : the fetal occiput rotates from its original position (usually
transverse) toward the symphysis pubis (occiput anterior) or, less
commonly, toward the hollow of the sacrum (occiput posterior).
5. Extension : the fetal head is delivered by extension from the flexed position
as it travels beneath the symphysis pubis.
6. External rotation : the fetal head turns to realign with the long axis of the
spine, allowing the shoulders to align in the anterior-posterior axis.
7. Expulsion : the anterior shoulder descends to the level of the symphysis
pubis
• Initiation of labour:

• Labour is a release from the state of functional quiescence maintained during

pregnancy.
• Decreased myometrial responsiveness to progesterone
• Increased responsiveness to estrogen
• Activation of the fetal hypothalamic pituitary axis, results in increased release
of cortisol, increasing the synthesis and release of prostaglandins, and
formation of myometrial gap junctions and activation of oxytocin receptors
• Irregular, painless, of mild intensity contractions of uterine smooth
muscle can occur throughout the third trimester and are often felt as
Braxton Hicks contractions, not result in cervical changes
False contractions

• Preparation for labour:

• Lightening
• False labour
• Cervical effacement
 By time they increase in strength and
↓ Do not result with crevical dilation, respond to analgesia
frequency, not relieved by analgesic
N
A
False Labour True Labour
How often are contractions? Irregular Regular
Do not get closer Get closer and stronger with time
Do they change with movement? Decrease with walking/ rest/ or Irrelevant to position
changing position
Strength Weak (may be strong then get Steadily increase in strength
weaker)
Pain site Abdomen or pelvis Start in the lower back and move to
the front to abdomen
• Diagnosis of labour:
↓ Source of contractions » funds (right side)

• Labour is diagnosed when painful regular contractions lead to effacement and

dilatation of the cervix

• This is commonly accompanied by a ‘show’ ( pink/white mucus plug) from the

cervix and/or rupture of the membranes, causing release of liquor

• Effacement: normally tubular cervix is drawn up into the lower segment until
it is flat . Due to increased water content and collagen lysis
 Stages of labour
• First stage:
# Cervical dilation is a result of uterine contractions

Begins with the onset of labour and ends with full cervical dilation
(10cm).
The descent, flexion and internal rotation described occur to varying
degrees.
It is divided into latent and active phases:

• The latent first stage is a period of time characterized by painful

uterine contractions and variable changes of the cervix, including
some degree of effacement and slower progression of dilatation up to
5 cm
• The active first stage is a period of time characterized by regular
painful uterine contractions, a substantial degree of cervical
effacement and more rapid cervical dilatation from 5 cm until full
dilatation
• Second stage:

The second stage is the period of time between full cervical dilatation and birth of
the baby, during which the woman has an involuntary urge to bear down, as a
result of expulsive uterine contractions.

Descent, flexion and rotation are completed and followed by extension as

the head delivers
• Crowning:

when the largest diameter of

the fetal head is encircled by
the vulvar ring
• Episiotomy:
Common on first deliveries, not done in all vaginal delivery

Procedure to make a controlled

incision of the perineum for
enlargement of the vaginal orifice
to facilitate difficult deliveries,
preferred in a mediolateral
orientation
• The duration of active first stage (from 5 cm until full cervical
dilatation) usually does not extend beyond 12 hours in first labours,
and usually does not extend beyond 10 hours in subsequent labours.

• In first labours, birth is usually completed within 3 hours of second

stage of labour, whereas in subsequent labours, birth is usually
completed within 2 hours.
• Alert values for first stage:
f Assess failure to progress if she is taking more time

5 cm = ≥6 h
6 cm = ≥5 h
7 cm = ≥3 h
8 cm = ≥2.5 h
9 cm = ≥2h
• Alert value for second stage:
≥3h in nulliparous women;
≥2h in multiparous women
• Third stage of labour:

• From delivery of the fetus till delivery of placenta and membranes

• Usually, < 30 minutes (can be up to 1 hour if no active management
applied)
• Normal blood loss up to 500 mL
 ‫ بنعطيها ساعة بالكتير عشان تطلع املشيمة‬physiological ‫ ال‬A

• Active management vs. physiological?

Increases risk of post postpartum hemorrhage
↑
Physiological Active

Uterus Assess size and tone Assess size and tone

Uterotonic Not used Oxytocin after delivery of

anterior shoulder

Cord traction None Controlled cord traction

(after signs of placental
separation)

‫بنضغط ب ايدنا على بطن املريضة و بنشد‬ *

placenta ‫ عشان نطلع ال‬cord ‫ال‬

Prophylactic uterotonics:

• The use of uterotonics for the prevention of postpartum

haemorrhage (PPH) during the third stage of labour is recommended
for all births.
• Oxytocin is the recommended uterotonic drug for the prevention of
postpartum haemorrhage (PPH).
Cord Clamping:

• Delayed umbilical cord clamping (not earlier than 1 minute after

birth) is recommended for improved maternal and infant health and
nutrition outcomes.
• Signs of placental separation:

• Fresh show of blood from the vagina

• The umbilical cord lengthens outside the vagina
• The fundus rises up
• The uterus becomes firm and globular
• Perineal trauma after delivery:

For women in the second stage of labour, techniques to reduce

perineal trauma and facilitate spontaneous birth (including perineal
massage, warm compresses and a “hands on” guarding of the
perineum) are recommended, based on a woman’s preferences and
options available to her.
1. First degree: injury to perineal skin and/or vaginal mucosa
2. Second degree: injury involving perineal muscles but NOT anal sphincters
3. Third degree: injury to perineum involving anal sphincter complex:
• 3a: <50% of external anal sphincter
• 3b: > 50% of external anal sphincter
• 3c: both external and internal anal sphincters torn
4. Fourth degree: involving anorectal mucosa
• Fourth stage:

• From delivery of the placenta to stabilization of the patient’s condition;

for example, suturing of perineum if needed and resolution of epidural
anaesthesia

• Usually at about 1-2 hours, maximum of 6 hours postpartum

• The recommended Routine postpartum maternal assessment:

All postpartum women should have regular assessment of vaginal

bleeding, uterine contraction, fundal height, temperature and heart
rate (pulse) routinely during the first 24 hours starting from the first
hour after birth. Blood pressure should be measured shortly after birth.
If normal, the second blood pressure measurement should be taken
within 6 hours. Urine void should be documented within 6 hours.
 General care for women in labour
• Physical health in labour observations:

• Contraction frequency recorded every 30 minutes.

• The temperature and blood pressure every 4 hours
• Pulse every 1 hour and then every 15 minutes in the second stage
• Mobility and delivery positions:

• Encouraging the adoption of mobility and an upright position during

labour in women at low risk is recommended.
• Diet:

• For women at low risk, oral fluid and food intake during labour are
recommended.
• Urinary tract:

The woman must be encouraged to micturate frequently in labour; if

she has an epidural, catheterization may be needed, routine
catheterization is unnecessary
• Pain relief:

• Should be provided as soon as the patient asks for it, even if in the latent
phase of first stage

• Multiple non-pharmacological methods:

• Music
• Breathing techniques
• Massages
• Labour in water
• Pharmacological pain relief:

• Inhalational: Etonox (50% O2/ 50% N2O)

• Parenteral: IV/IM opioids (morphine, pethidine)

• Avoid pethidine: IUFD, epilepsy, sickle cell

• Regional: offers best pain relief, might be associated with longer 2nd
stage and increased risk of instrumental delivery
 Management of labour

• History –detailed history upon presentation of patient, review of

antenatal notes

• Examination –full general, obstetric and vaginal examination

• Assessment of labour –serial observations and examinations,

monitoring of progress, and assessment of fetal wellbeing
• History:

• When did the pain start?

• Regular or not?
• Intervals between contractions?
• Vaginal passage of fluid, blood, mucus?
• Fetal movement?
• Any conditions that need special care in labour?
• Examination:

• Vital signs
• General
• Obstetric examination
• Vaginal examination
• Digital vaginal examination at intervals of four hours is recommended
for routine assessment of active first stage of labour in low-risk
women.

• Assess cervical dilatation

• Effacement
• Fetal presenting part
• Position
• Station
• Fluid passage/ bleeding
• Labour Care Guide (monitoring of progress):
 Assessment of fetal wellbeing

• Check colour of the liquor, fetal heart rate, and do fetal blood sampling
if indicated

• Fetal heart can be assessed using:

1. Pinard stethoscope
2. Hand-held doppler
3. Cardiotocography (CTG)
• Low risk pregnancies:

• Intermittent fetal heart rate auscultation

• Every 15 minutes during the first stage, and every 5 minutes in the second.
• Use Pinard’s stethoscope or a hand-held Doppler to check FH for 60 seconds
after a contraction
• CTG –Cardiotocogram

• Records the FHR on paper and electronically, either from a transducer placed
on the abdomen or from a probe in the vagina attached to the fetal scalp.
Another transducer synchronously records the uterine contractions
• When to use CTG?

• Abnormal FH on auscultation, 20-minute CTG if normal can go back to

intermittent auscultation

• High risk pregnancies: continuous electronic fetal monitoring CTG

• Medical disorders
• Vaginal bleeding
• Meconium-stained liquor (the passage of meconium by the fetus in utero during the
antenatal period or in labour)
• Previous CS (VBAC)
• CTG interpretation:

• Always take into account the whole clinical picture of the patient when
interpreting a CTG trace (medical dx, any vaginal bleeding, liquor colour, …)

• Check:
• Contractions
• Baseline FHR
• Variability
• Accelerations
• Decelerations
• Contractions:

• Once labour is established, effective uterine contractions are 3-5

contractions/ 10 minutes and each lasts for 45-60 seconds

• Hypertonus: contractions last > 60 seconds

• Tachysystole: >= 6 contractions/10 minutes
• In suspected fetal compromise:

1. Correct cause
2. Fetal blood sampling if persistent distress
3. Expedite delivery if FBS not available and persistent fetal distress
(instrumental delivery if applicable or urgent CS)
1. Improve placental blood supply: correct hypovolemia (IV fluids),
correct hypotension (left lateral position to relieve aortocaval
compression), and diminish uterine activity (stop oxytocin infusion,
or use tocolytics if necessary)
2. Vaginal examination: to exclude cord prolapse or very rapid
progress
• Fetal blood sampling interpretation:

• PH > 7.25: observe labour, repeat if any concern arises

• PH < 7.2: immediate delivery
• PH 7.2 – 7.24: repeat after 30 minutes
 Thank you!
• References:

1. Hacker & Moore’s essentials of obstetrics and gynecology

2. Obstetrics and Gynaecology an evidence-based text for the MRCOG
3. THE JOHNS HOPKINS MANUAL OF GYNECOLOGY AND OBSTETRICS