LABOUR

NORMAL LABOUR
 DEFINITION OF LABOUR

Labour is the process by which the fetus, placenta,

and membranes are expelled through the birth canal
after 28 weeks of gestation.

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 Signs and symptoms of labour

• Painful regular uterine contractions with increasing

strength, frequency and duration over time;
• ‘Show’. This is a bloody mucoid vaginal discharge
• Effacement and dilatation of the cervix over time.
• Rupture of membranes with drainage of liquor often
accompanies labour. Drainage of liquor may occur before
any of the symptoms and signs of labour.
The presence of any two signs above is strongly suggestive
of labour

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 CHARACTERISTIC OF
NORMAL LABOUR
Normal labour is the period from onset of painful uterine contractions to
delivery of the baby, placenta and membranes and bleeding controlled.
It begins spontaneously at term (38-42 weeks of gestation)
The fetus is presenting by the vertex
The baby is alive and healthy
Blood loss does not exceed 500cc
It is spontaneously completed within 12 hours with no complications to
mother or baby. (Prime para 8-12 hours, multiparous 6-8 hours)

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 STAGES OF LABOUR

There are four stages of labour, namely: first, second, third and fourth stage:
First stage
This is the stage of dilation of the cervix. it begins with the rhythmic contractions
and ends when the cervix is fully dilated. It is divided into the latent and active phase
It is the longest part of labour lasting 4-12 hours. The most significant occurrence is
the effacement (thinning) and dilatation of the cervix.
The latent phase
This the period of slow dilatation of the cervix from [Link] should not exceed 8 hours
The active phase
This is a period of faster cervical dilation from 4-full dilatation, on a partograph it should not
go over the alert line of the partograph.

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 SECOND STAGE:
Is a period from full dilatation of the cervix to complete delivery of the baby or babies.
During this stage there is forceful expulsion of the baby through the birth canal by uterine
forces and maternal effort.
The mother plays an active role in this stage. It usually lasts 20-45 minutes.
In a prime gravida it may last up to 45 minutes
In a multi gravida it may last up to 30 minutes

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 THIRD STAGE
Is the period from complete delivery of the baby to complete delivery of the placenta
and membranes. Normal duration of 3rd stage of labour is 5-30 minutes.
With active management it may be completed within 5-15 minutes

FOURTH STAGE
Is the first hour following delivery of the placenta and involves careful monitoring
of the mother and the baby

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 THE ON SET OF LABOUR
The cause of the onset of labour is not known but it is thought to
be a combination of hormonal and mechanical factors
1. Hormonal
Near term as the fetal adrenals mature they secrete cortisol, this
causes a change in the levels of placental hormones, estrogen rises
and progesterone falling. This change in the placental hormones is
thought to stimulate the maternal posterior pituitary gland to
release oxytocin. The rise in the oestrogen is also thought to
stimulate the decidua as to release prostaglandins

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• Both oxytocin and prostaglandins cause the uterus to contract.
• The fall in the progesterone reduces its relaxing effect on the uterine
muscles.

2. Mechanical factors which are thought to stimulate uterine contraction. the

increase in strength and frequency of Braxton hick’s contractions which
occurs towards the end of pregnancy.
• Pressure from the presenting part on the cervix
• Overstretching of the uterus as in poly hydramnios and multiple pregnancy
• Placental efficiency is diminished towards term resulting in reductions in
the level of oestrogen and progesterone.

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 PHYSIOLOGY OF THE FIRST STAGE OF LABOUR

• Uterine action- the contractions of labour are painful, intermittent and

regular
• Fundal dominance-contractions start from near one of the cornua and
spread across and down wards. They last longer and are more intense in the
fundus but reaches the peak over the whole uterus at the same time and
then fades. This pattern allows the cervix to dilate and strongly contracting
fundus to expel the fetus.
• The lower pole contracts slightly and dilates to allow expulsion to take
place

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Contraction and retraction
Polarity this is the neuromuscular harmony between the two poles of the
uterus throughout labour. the upper pole contracts strongly and retracts to
expel the fetus
The uterine does not pass off entirely but some shortening remains. This is
retraction. It assists in the progressive expulsion of the fetus. The upper
segment becomes gradually shorter and thicker and its cavity diminishes

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Formation of the upper and lower uterine segments
Towards the end of pregnancy, the body of the uterus divides into 2 segments,
the upper and lower uterine segments. The upper segment mainly contracts
and is thicker and muscular, while the lower segment which is developed
from the isthmus is thinner, longer and distended. The retractions in the
muscles of the upper segment pull up the lower segment causing it to stretch.
The retraction ring
This is the ridge which forms between the thickened upper segment and the
thinned out lower segment in normal labour.
In obstructed labour, This ridge becomes demarcated and can be seen
abdominally, this is called Bandl’s ring and is a sign of imminent rupture of
the uterus.

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Cervical effacement
This is the taking up of the cervix, it starts towards the end of pregnancy due
to increase in strength and frequency of Braxton’s hicks contractions and is
completed in labour. the muscle fibers surrounding the internal os are
gradually drawn upwards by the retracted upper segment. The internal os
opens, the cervix becomes shorter and gradually merges into the lower
uterine segment.
Cervical dilatation
This is the opening of the external os to allow the passage of the fetal head. it
occurs as a result of uterine action and pressure from the bag of fore waters
and the presenting part

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Formation of the fore and hind waters
As the lower uterine segment stretches, the chorion becomes detached from it
and loosened membranes with liquor amnii bulge down wards into the
dilating internal os. The well flexed head cuts off the fluid in front of the head
called the fore waters from that which surrounds the baby called the hind
waters.
The fore waters help in the effacement and dilatation of the cervix.
The hind water equalizes pressure in the uterus. The pressure of the uterine
contractions is exerted on the fluid and as the fluid is not compressible the
pressure is equalized throughout the uterus. This is known as general fluid
pressure.

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Rupture of the membranes
This normally occurs when the cervix is fully dilated and can no longer
support the bag of fore waters and also from the increasing force of the
uterine actions at this time. sometimes the membranes may rupture early if
there is badly fitting presenting part.

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PHYSIOLOGY OF THE SECOND STAGE OF LABOUR

UTERINE ACTION
Contractions become stronger, longer and expulsive as pressure is exerted on
the rectum and pelvic floor. the mother feels a strong desire to bear down
aided by the contracting of the secondary powers the diaphragm and the
abdominal muscles.

There is continued progressive contraction and retraction of the upper

segment while the lower segment dilates and becomes thin. The membranes
may rupture spontaneously at the onset of the second stage, the drainage of
the liquor allows the fetal head to be directly applied to the vaginal tissues
and aid distension

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Displacement of the pelvic floor and other soft tissues
As the fetal head descends the soft tissues of the pelvis becomes displaced.
the bladder is pushed upwards into the abdomen where it is at risk of injury
during fetal descent. This results in stretching and thinning of the urethra
reducing its lumen. The rectum becomes compressed into the sacral curve
and any faecal contents will be expelled. The pelvic floor muscles become
thinner and displaced
The perineal body is flattened, stretched and thinned out. the fetal head
becomes visible at the vulva advancing with each contraction until crowning
takes place and advances until the baby is born.

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 MECHANISMS OF NORMAL LABOUR
These are movements of the foetal head as it passes through the birth canal.
The foetal head is flexible and moves during labour to accommodate itself to
the diameters and curves of the pelvic canal. The main movements of the
head in occiput anterior positions (the back of the head is towards the
symphysis pubis) are described below.
Flexion (bending forward)
The chin is brought into contact with the foetal thorax, and this changes the
presenting diameter from occipito frontal to suboccipitobregmatic. This
smaller presenting diameter makes it easier for the foetal head to descend
through the pelvic inlet. The head tends to accommodate itself to the
transverse diameter of the inlet since it is larger than the antero-posterior
diameter.

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Internal Rotation
The occiput gradually rotates from its original position to the front towards
the symphysis pubis. This movement occurs when the head has reached the
level of the ischial spines. This movement will allow the larger diameter of
the head to come out through the AP diameter of the outlet (which is the
largest diameter of the outlet). The occiput slips beneath the sub-pubic arch
and crowning occurs when the head no longer recedes with contractions and
the widest transverse diameter is born.

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Extension (bending backwards):
Once crowning has occurred, the foetal head can extend. The nape of the
neck pivots on the lower border of the symphysis pubis, while the forehead,
face and chin pass over the thinned-out perineum. The twist in the neck of the
foetus which resulted from internal rotation is now corrected by a slight
untwisting movement known as restitution

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External Rotation:
The external rotation of the foetal head indicates that the shoulders are now in
the antero-posterior diameter of the pelvic outlet. The internal rotation of the
shoulders corresponds with the external rotation of the foetal head. If it is a
vertex left occiput anterior the foetal head will turn to the left while the
vertex right occiput anterior position will turn to the right. Then, the anterior
shoulder is born first followed by the posterior shoulder.

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PHYISIOLOGY OF 3RD STAGE
OF LABOUR
This involves the following features
Separation of the placenta and membranes
Descent of the placenta and membranes
Expulsion of the placenta and membranes
Arrest of hemorrhage.

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SEPARATION OF PLACENTA AND MEMBRANES

During and after the birth of the baby, there is a marked reduction in the size
of the uterus due to contraction and retraction of the uterine muscles. The
upper segment continues to contract and retract the placental site is
diminished; the placenta becomes squeezed and torn off the uterine wall at
the spongy layer of the deciduas. After separation the upper segment
contracts strongly forcing the placenta into the lower segment and then into
the vagina. The weight of the descending placenta peels the membranes off
the uterine wall.

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Descent of the placenta and membranes
Gravity makes the placenta to descend into the lower uterine segment. The
upper uterine segment contracts more effectively into a hard round mobile
mass as it is being pushed upwards by the placenta which is in the lower
uterine segment. The umbilical cord elongates at the vulva and placenta may
be seen in the vagina as it descends
Expulsion of the placenta and membranes
There are two ways by which the placenta leaves the uterus.

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 THE SCHULTZE METHOD

The placenta starts to separate from the centre. Blood collects behind the
placenta forming a retro placental clot which further helps the separation of
the placenta off the uterine wall the fetal surface appears first at the vulva
with membranes following behind like an inverted umbrella. With this
method there is less blood loss and less risk of retained membranes or
placenta.

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 THE MATHEW DUNCAN’S METHOD

The placenta begins to detach at the lower edge, (lateral borders) blood will
be seen escaping before the placenta is separated. The placenta slips down
sideways, the maternal surface appears first.
This method takes longer and with increased risk of ragged or incomplete
membranes and increased blood loss.

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Control of bleeding is brought about by
Bleeding from the torn blood sinuses is controlled even as the placenta is
separating. the retraction of the oblique uterine muscle fibers in the upper
uterine segment play the most important role in constricting the uterine
sinuses (torn vessels) and arresting hemorrhage. They are known as living
ligatures
Following the expulsion of the placenta the strong uterine contraction brings
the wall as of the uterus into opposition applying pressure on the placental
site.
Clot formation in the torn blood vessels and sinuses

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