LABOR

- DR ARSHEYA
 INTRODUCTION
• DEFINITION: Series of events that take place in the genital organs in an effort to
expel the viable products of conception (fetus, placenta and the membranes) out
of the womb through the vagina into the outer world is called Labor.
• It may occur prior to 37 completed weeks, when it is called the preterm labor.
• Labor is characterized by the presence of regular uterine contractions with
effacement and dilatation of the cervix and fetal descent.
• A parturient is a patient in labor and parturition is the process of giving birth.
• Delivery is the expulsion or extraction of a viable fetus out of the womb.
It is not synonymous with labor; delivery can take place without labor as in
elective cesarean section.
Delivery may be vaginal, either spontaneous or aided, or it may be abdominal.
• NORMAL LABOR (EUTOCIA):
Labor is called normal if it fulfills the following criteria.
(1) Spontaneous in onset and at term. (2) With vertex presentation. (3)
Without undue prolongation. (4) Natural termination with minimal aids. (5)
Without having any complications affecting the health of the mother and/or
the baby.
• ABNORMAL LABOR (DYSTOCIA): Any deviation from the definition of
normal labor is called Abnormal labor. Thus, labor in a case with presentation
other than vertex or having some complications even with vertex presentation
affecting the course of labor or modifying the nature of termination or
adversely affecting the maternal and/or fetal prognosis is called abnormal
labor.
• DATE OF ONSET OF LABOR: Calculation based on Naegele’s formula can
only give a rough guide. Based on the formula, labor starts approximately on
the expected date in 4%, 1 week on either side in 50%, 2 weeks earlier and 1
week later in 80%, at 42 weeks in 10%, and at 43 weeks plus in 4%
 PHYSIOLOGY OF NORMAL LABOR
1. Changes During Pregnancy
• The uterus enlarges due to hypertrophy (increase in cell size) and
hyperplasia (increase in cell number) of uterine muscles.
• At term, uterus measures about 35 cm (including cervix) and becomes
pyriform or ovoid in shape.
• Cervical canal is blocked by a thick mucus plug.
 2. Uterine Contractions in Labor
a. Before Labor
• Braxton Hicks contractions: irregular, painless, and ineffective for cervical
dilatation.
b. During Labor
• The pacemaker for contractions lies near the tubal ostia (upper uterus).
• Contractions spread downward in a synchronized manner.
• Fundal dominance: upper uterus contracts more strongly and for a longer time than
lower parts.
• Normal pattern:
• Regular rhythm
• Strong contraction in upper segment
• Good relaxation between contractions (pressure falls <8 mmHg)
• Intra-amniotic pressure rises to >20 mmHg during contractions
3. Pain of Uterine Contractions
Causes:
• Myometrial hypoxia (reduced oxygen during contraction)
• Stretching of peritoneum, cervix, and uterine ligaments
• Compression of pelvic nerve ganglia
Pain areas:
• T10–L1 → hypogastric region and thighs
• Sacral plexus → referred back pain (from cervical stretching)
 4. Characteristics of Uterine Contractions
It is the intrauterine pressure in between contractions
Tonus
(2–3 mmHg in pregnancy; 8–10 mmHg in 1st stage).

The intensity of uterine contraction describes the degree of

uterine systole. The intensity gradually increases with
advancement of labor until it becomes maximum in the
Intensity
second stage during delivery of the baby.
Strength of contraction — 40–50 mmHg in 1st stage, 100–
120 mmHg in 2nd stage.
Increases as labor progresses — from ~30 sec (early) to
Duration
longer in 2nd stage.
Every 10–15 min (early), increases to every 2–3 min in 2nd
Frequency
stage.
 5. Retraction
• Unique property of uterine muscle: permanent shortening of fibers after
each contraction.
• Contraction = temporary shortening
• Retraction = permanent shortening
Functions of Retraction:
• Helps form the lower uterine segment and causes cervical dilatation &
effacement.
• Maintains descent of fetus and aids in expulsion.
• Reduces uterine surface area → assists placental separation.
• Ensures effective hemostasis after placental delivery.
 STAGES OF LABOR
1. First stage: It starts from the onset of true labor pain and ends with full dilatation of the
cervix. It is, in other words, the “cervical stage” of labor. Its average duration is 12 hours
in primigravidae and 6 hours in multiparae.
2. Second stage: It starts from the full dilatation of the cervix and ends with expulsion of
the fetus from the birth canal.
It has got two phases—(1) The propulsive phase—starts from full dilatation up to the
descent of the presenting part to the pelvic floor. (2) The expulsive phase is distinguished
by maternal bearing down efforts and ends with delivery of the baby.
sIts average duration is 2 hours in primigravidae and 30 minutes in multiparae.
3. Third stage: It begins after expulsion of the fetus and ends with expulsion of the
placenta and membranes (afterbirths).
Its average duration is about 15 minutes in both primigravidae and multiparae. The
duration is, however, reduced to 5 minutes in active management.
4. Fourth stage: It is the stage of observation for at least 1 hour after expulsion of the
afterbirths. During this period maternal vitals, uterine retraction and any vaginal bleeding
are monitored. Baby is examined. These are done to ensure that both the mother and
baby are well.
EVENTS OF LABOR
EVENTS IN FIRST STAGE OF LABOR
• The first stage of labor prepares the birth canal for delivery.
• Main events:
• Dilatation and effacement of cervix
• Formation of lower uterine segment
 1. Dilatation of the Cervix
a. Pre-labor (Phase-1)
• In some women (especially multiparae), partial dilatation may occur
before true labor begins.
• Cervix softens due to:
• Hypertrophy and increased vascularity
• Fluid between collagen fibers
• Breakdown of collagen by collagenase and elastase
• Hormonal influence of estrogen, progesterone, and relaxin
• Change in cervical matrix
• Fibrosis (from chronic cervicitis, prolapse, carcinoma) may prevent
dilatation.
b. Actual Factors Causing Dilatation
• Uterine Contraction and Retraction
• Upper uterine longitudinal fibers pull on circular fibers of lower segment and
cervix (“bucket-handle” mechanism).
• Causes the cervix to open and shorten.
• Polarity of uterus: coordination between contracting upper segment and
relaxing lower segment.
• Fetal Axis Pressure
• In longitudinal lie and well-flexed head, contraction force passes down the
fetal spine to the head, pressing it against the cervix → promotes dilatation.
• Absent in transverse lie.
• Bag of Membranes
• Membranes divide the uterine cavity into:
• Hindwaters (above the head)
• Forewaters (below the head)
• During contraction, pressure pushes the bag of forewaters
into the cervix, aiding dilatation.
• If membranes rupture early (PROM), the fetal head
directly presses the cervix.
2. Effacement (Taking Up) of Cervix
• Effacement = shortening and thinning of the cervical canal as its
fibers merge with lower uterine segment.
• In primigravidae: Effacement → then dilatation.
• In multiparae: Both occur together.
• Expulsion of mucus plug occurs during effacement.
3. Formation of Lower Uterine Segment
• Before labor: no clear separation between upper and lower parts.
• During labor:
• Upper segment → thick and active (contracts & retracts).
• Lower segment → thin and passive (stretches & dilates).
• The junction between the two forms the Physiological Retraction
Ring.
• Pathological Retraction Ring (Bandl’s ring) appears in obstructed
labor—abnormal finding.
EVENTS IN SECOND STAGE OF LABOR
Definition
• The second stage of labor starts with complete cervical dilatation
(10 cm) and ends with the delivery of the fetus.
• It mainly involves the descent and expulsion of the baby through the
birth canal.
 FALSE LABOR PAIN vs TRUE LABOR
PAIN
False Pain (False Labor / Spurious Labor)
• Seen more in: First-time mothers (primigravidae) than women who
have given birth before (multiparae).
• Timing: Appears 1–2 weeks before true labor in primigravidae, and
a few days before in multiparae.
• Cause: Stretching of cervix and lower uterus → irritation of nearby
nerves → mild, irregular pains.
 Features of False Pain
Feature Description
Nature of pain Dull pain in lower abdomen or groin.
Irregular, weak, not increasing in strength
Uterine contractions
or frequency.
Hardening of uterus Absent.
Effect on cervix No cervical dilatation or effacement.
Pain goes away after rest, sedation, or
Relief
enema.

False pain is uncomfortable but does not lead to labor progression.

 TRUE LABOR PAIN (Real Onset of Labor)
Features of True Labor:
Feature Description
Pain Regular, rhythmic uterine contractions.
Frequency & Intensity Increase gradually with time.
Duration Contractions last longer as labor progresses.
Present — mucus mixed with blood from
Show
cervix.
Cervix Progressive effacement and dilatation.
Descent of presenting part The baby’s head moves down.
Bag of waters Membranes bulge with contractions.
Relief Not relieved by sedation or enema.
 Phases of the Second Stage
• Propulsive Phase
• From full cervical dilatation until the fetal head reaches
and touches the pelvic floor.
• The fetus descends gradually through uterine contractions
and retraction.
• Expulsive Phase
• Begins when the mother feels a strong urge to push
(“bearing down”) and ends with the birth of the baby.
• In this phase, voluntary abdominal muscle contractions
assist uterine contractions.
 Physiological Events
1. Rupture of Membranes
• Usually occurs once the cervix is fully dilated.
• Leads to escape of liquor amnii, which reduces the uterine cavity
volume and brings the fetus in closer contact with the uterus for more
effective contractions.
2. Uterine Contraction and Retraction
• Become stronger, longer, and more frequent.
• The uterus becomes elongated, while its width decreases.
• The upper uterine segment thickens, and the lower segment thins
progressively.
3. Descent and Expulsion of the Fetus
• Fetus is pushed downward by:
• Uterine contractions and retraction (involuntary)
• Abdominal muscle contractions (“bearing down” efforts – voluntary)
• The fetus faces resistance from:
• Bony pelvis
• Soft tissues (vagina, perineum, pelvic floor)
• The elastic recoil of these tissues tends to push the baby backward, but
retraction of uterine muscles counteracts this, ensuring forward
movement and final expulsion.
4. After Expulsion
• Once the fetus is delivered, the uterine cavity becomes smaller—just
enough to contain the placenta and membranes (“afterbirths”).
• The powerful contractions and retraction continue to prepare for third
stage (placental separation and expulsion).
EVENTS IN THIRD STAGE OF LABOR
Definition
• The third stage of labor begins after the birth of the baby and ends with
the expulsion of the placenta and membranes.
• It mainly involves placental separation, descent, and expulsion, followed
by control of bleeding.
Phases of the Third Stage
1. Placental Separation
2. Placental Descent
3. Placental Expulsion
4. Hemostasis (control of bleeding)
 2. Placental Separation
Changes in the Uterus After Delivery
• Uterus becomes discoid in shape (~20 cm long, 10 cm wide).
• Upper segment: thick and contracted.
• Lower segment: thin, flabby, and thrown into folds.
• Uterine cavity reduces in size—enough only for the placenta and membranes.
Mechanism of Separation
• Strong uterine contraction and retraction cause marked reduction in the
placental site’s surface area (almost half).
• Since the placenta is inelastic, it cannot shrink equally → this causes
buckling and a shearing force, leading to separation.
 Methods (Types) of Placental Separation

Type Starting Point Process

Separation begins centrally →
blood collects behind placenta
1. Central (Schultze
Center → forms a retroplacental
Method)
hematoma that helps push
placenta off
2. Marginal (Mathews- Separation begins at the edge
Margin
Duncan Method) → blood escapes immediately

Marginal separation is more common.

 Separation of Membranes
• Membranes (amnion + chorion) are loosely attached and get folded
and peeled off as the uterus contracts and the placenta descends.
• Membranes from the lower segment are already separated earlier.
 Expulsion of the Placental
• Once completely separated, the placenta descends into the lower
uterine segment or vagina.
• Expelled by:
• Uterine contractions and retraction (involuntary)
• Bearing down efforts (voluntary abdominal muscle contraction)
• Or manual removal if delayed.