Normal labour &
Normal Position
Definition of Normal Labour
Normal labour is a physiological process in which the fetus, membranes,
umbilical cord and placenta are expelled from the uterus through the
birth canal after 37–42 weeks, with:
Spontaneous onset
Vertex presentation
No undue prolongation
Minimal maternal & fetal complications
Natural, safe outcome
Components of Normal Labour
Normal labour follows a coordinated process involving:
Regular uterine contractions
Cervical effacement & dilatation
Progressive descent of fetus
Rotation & expulsion of fetus
Separation & delivery of placenta
Important Obstetrical Terms
1. Lie
Relationship between the long axis of fetus and long axis of
uterus.
Types:
Longitudinal lie (common and normal)
Transverse lie
Oblique lie
2. Presentation
Part of fetus that occupies the lower uterine segment and is felt
on PV examination.
Types:
Cephalic (most common & normal)
Breech
Shoulder
Position & Attitude
Position
Relation of the presenting part to maternal pelvic quadrants.
For vertex, the occiput points to a quadrant.
LOA (Left Occipito-Anterior) is the most common & favourable
position.
Attitude
Relation of fetal head & limbs to
trunk.
Flexed attitude is normal → chin to
chest → smallest diameter presents.
Cardinal Movements
(Mechanism of Labour)
During vertex delivery, the fetus undergoes seven essential movements:
1. Engagement – Biparietal diameter enters pelvic brim.
2. Descent – Progressive downward movement.
3. Flexion – Chin moves to chest allowing smallest head diameter.
4. Internal Rotation – Occiput rotates anteriorly to align with maternal pelvis.
5. Extension – Head delivers by extending under
pubic arch.
6. External Rotation (Restitution) – Head realigns
with shoulders.
7. Expulsion – Shoulders and body are delivered.
Stages of Labour
Stage 1 – Dilatation
Onset of true labour pains → full dilation (10 cm)
Phases:
Latent (0–3 cm): slow progress
Active (4–10 cm): rapid progress
Duration:
Primigravida: 12–14 hrs
Multigravida: 6–8 hrs
Stage 2 – Expulsion
Full dilation → birth of baby
Duration:
Primigravida: 1–2 hrs
Multigravida: <1 hr
Stage 3 – Placental Stage
→
Birth of baby delivery of
placenta & membranes
Duration: 5–15 min
Stage 4 – Observation Stage
First 1 hour after placenta
Critical period for detection of
PPH
Monitor vitals & uterine tone
Signs of True Labour vs False
Labour
True Labour
Regular painful contractions
Increasing intensity & frequency
Cervical dilation & effacement
Show (bloody mucus discharge)
May have rupture of membranes
False labour
Irregular contractions
No cervical changes
Relieved by rest or sedation
Physiology of Uterine
Contractions
Originate from fundal “pacemaker areas”
Upper segment contracts strongly
Lower segment becomes thin and passive
Contractions cause:
✔ cervical dilatation
✔ fetal descent
✔ membrane rupture
Hormonal Factors in Onset of Labour
Prostaglandins↑→ contractions + cervical
ripening
↑ →
Estrogen near term stimulates contractions
Functional progesterone withdrawal
Oxytocin receptor numbers ↑→ uterus becomes
sensitive
↑→
Fetal cortisol →
increases estrogen initiates
labour
Mechanical Factors of Labour
Uterine overdistension
→
Cervical stretching Ferguson reflex →
oxytocin release
→
Membrane rupture PG release →
enhances contractions
Cervical Changes (Ripening)
During labour, cervix becomes:
Soft
Effaced (shortened)
Dilated
More elastic due to breakdown of
collagen
↑
Facilitated by prostaglandins
Management of 1st Stage
Admit patient, take vitals
FHR monitoring every 30 mins
Contraction assessment every 30 mins
Vaginal exam every 4 hours
Encourage movement & hydration
Ensure bladder emptying
Use partograph for monitoring labour progress
Management of 2nd Stage
Position: lithotomy / squatting
Support perineum during crowning
Instruct mother to bear down during contractions
Controlled delivery of head
Check for nuchal cord
Deliver shoulders then body
Maintain aseptic precautions
Management of 3rd Stage (AMTSL)
Active Management of Third Stage (AMTSL)
Delayed cord clamping (1–3 minutes)
Controlled cord traction (Brandt–Andrews)
Uterine massage after placenta delivery
Helps prevent postpartum hemorrhage (PPH)
Signs of Placental Separation
Sudden gush of blood
Lengthening of umbilical cord
Fundus becomes firm, globular & rises
Complications to Watch
Fetal distress
Prolonged labour
Obstructed labour
Perineal tears
Postpartum hemorrhage (PPH)
Normal labour is a coordinated, physiological event involving:
Cervical ripening
Uterine contractions
Cardinal movements
Safe expulsion of fetus & placenta
Proper monitoring ensures safety for both mother and baby.
DYSFUNCTIONAL LABOUR
&
MANAGEMENT
Introduction
Dysfunctional labour refers to
abnormal or difficult labour where the
normal progress of cervical dilatation
or fetal descent is delayed or arrested.
It results from abnormalities of the
Power, Passenger, or Passage.
Types of
Dysfunctional Labour
A. Abnormal Uterine Action (Power)
1. Hypotonic Uterine Action
2. Hypertonic Uterine Action
3. Incoordinate Uterine Contractions
4. Constriction Ring
5. Uterine Tetany
B. Abnormalities of Passenger
Malposition
Malpresentation
Cephalopelvic disproportion
(CPD)
Contracted pelvis
C. Abnormalities of Passage
Soft tissue obstruction
Pelvic deformities
Causes of
Dysfunctional
Labour
A. Causes Related to Power
1. Hypotonic contractions
Weak, infrequent uterine contractions
Often due to overdistended uterus
(polyhydramnios, twins), exhaustion,
dehydration
2. Hypertonic contractions
Painful, uncoordinated, high-tone
uterus
Seen in early labour, anxious patients
3. Incoordinate uterine action
Irregular contraction pattern →
poor cervical dilatation
B. Causes Related to Passenger
1. Malposition
Persistent occiput posterior
Deep transverse arrest
2. Malpresentation
Brow presentation
Face presentation
Breech
3. Fetal factors
Macrosomia
Hydrocephalus
4. CPD
Mismatch between fetal head size
& mother’s pelvis
Causes Related to Passage
1. Contracted pelvis
2. Pelvic tumors (fibroid, ovarian mass)
3. Full bladder or bowel
4. Cervical dystocia
5. Soft tissue resistance
Diagnosis
A. Clinical Signs
Slow cervical dilatation
Poor progress in labour
Irregular contractions
Caput and moulding in fetal head
(if obstructed)
Maternal exhaustion
Partograph Findings
Labour curve crosses or stays right of
Alert/Action line
No adequate progress in dilatation
No descent of fetal head
Complications
Maternal
Exhaustion
Dehydration
Infection
Uterine rupture (in obstructed labour)
Postpartum hemorrhage (PPH)
Fetal
Fetal distress
Asphyxia
Birth trauma
Neonatal complications
Management of Dysfunctional Labour
A. General Measures
Reassurance
Adequate hydration
Analgesia & sedation (if needed)
Empty bladder
Continuous fetal monitoring
Monitor with partograph
B. Specific Management Depending on Type
1. Hypotonic Uterine Action
Amniotomy if membranes intact
Oxytocin augmentation to improve
contractions
Monitor uterine activity & fetal heart rate
→
If no progress Cesarean section
2. Hypertonic Uterine Action
Stop oxytocin (if running)
Analgesics or sedation
Hydration
Wait and watch until contractions
become coordinated
Caesarean section if persistent & fetal
distress occurs
3. Incoordinate Uterine Contractions
Sedation
Analgesia
Reassurance
→
Rarely oxytocin after coordination
returns
→
If still no progress LSCS
4. Malposition (e.g., Occiput Posterior)
Maternal posturing (hands-knee position)
Manual rotation
Assisted delivery (forceps/vacuum) if
fully dilated
LSCS if rotation fails or fetal distress
5. Malpresentation
→
Brow LSCS
→
Face vaginal delivery possible only if
chin anterior
→
Breech trial of labour if criteria met;
otherwise LSCS
→
Transverse lie LSCS
6. CPD / Obstructed Labour
Immediate Cesarean Section
Avoid instrumental delivery
7. Soft Tissue Obstruction
Catheterization for full bladder
Treat bowel distension
Remove obstructing mass if possible
LSCS if obstruction persists
Prevention
Antenatal pelvic assessment
Identify high-risk pregnancies
Good labour monitoring
Early detection with partograph
Adequate hydration and rest during
labour
Summary
Dysfunctional labour = abnormal
progress of labour
Causes: Power, Passenger, Passage
Diagnosis: Partograph
Management: Hydration, analgesia,
oxytocin, amniotomy, LSCS as required
Early recognition prevents fetal distress
& maternal morbidity
Thank you