AMU,CMHS

Physiology ,mechanism and

management of labor

BY Dr Delelegn(MD)

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 Table of contents
• Definition
• Physiology of labor
• Mechanisms of labor
• Clinical stages of labor
• References..

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 Objectivies
Students should be:-
Able to define labor ,stages and phase of labor
Able to know mechanics of labor
Able to know cardinal movements of labor
Able to know physiology of labor
Abe to know management of labor at
different stages of labor

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 Definition of labor
• Labor is a physiologic process involving a
sequential, integrated set of changes within the
myometrium, decidua, and cervix that occur
gradually over a period of days to weeks,
culminating in rapid changes over hours that
end with expulsion of the products of
conception (fetus and placenta).

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 Physiology of labor
The four phases of labor:
1. The first phase is Quiescence(Inhibtion)
2. The second phase is Activation
3. The third phase is stimulation
4. The fourth phase is Involution
NB:- The phases of parturition should not be
confused with the clinical stages of labor.

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 Conti..
Phase 0: Inhibition – The human uterus exits mostly in the nonpregnant
state. This is achieved through the action of various putative inhibitors
including, but not limited to, the following:
 Progesterone
 Prostacyclin (prostaglandin I2)
Phase 1: Myometrial activation (priming) – Although there is no
systemic progesterone withdrawal prior to the onset of labor in humans,
a functional withdrawal of progesterone activity at the level of the
uterus does occur as term approaches.

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 Cont…
Phase 2: Stimulation
• It is the phase at which uterotonics,
particularly PG and oxytocin, stimulate regular
contractions.
• It is occurring over days to weeks
Phase 3: Involution – The uterus involutes in the
days and weeks following delivery.
This process is mediated primarily by oxytocin.
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 MECHANICS OF LABOR

• Labor and delivery are not passive processes

in which uterine contractions push a rigid
object through a fixed aperture.
• Rather it depends on uterine activity, the
fetus, and the maternal pelvis (Powers,
Passenger, Passage).

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 Uterine activity

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 Uterine Activity (Powers)
• The powers refer to the forces generated by the
uterine musculature.
• Uterine activity is characterized by the frequency,
amplitude (intensity), and duration of contractions.
• Assessment of uterine activity may include:
 simple observation
 manual palpation
 external objective assessment techniques (such as
external tocodynamometry)
 direct measurement via an internal uterine
pressure catheter.
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 Cont..
• The definition of “adequate” uterine activity during
labor remains unclear.
• Classically, three to five contractions per 10 minutes
has been used to define adequate contraction.
• In labor, patients usually contract every 2 to 5 minutes,
with contractions becoming as frequent as every 2 to 3
minutes in late active labor and during the second
stage.
• Tachysystole is defined as more than 5 contractions in
10 minutes for at least 20 seconds
• Hyperstimulation is defined as tachysytole which is
accompanied by an abnormal fetal heart rate pattern.
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 The Fetus (Passenger)

Fetal variables that influence the course of

labor and delivery are:-
1. Fetal size
2. Lie
3. Presentation
4. Attitude
5. Position of the fetus
6. Station

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 The Maternal Pelvis (Passage)
• The passage consists of the bony pelvis (composed of
the sacrum, ilium, ischium, and pubis) and the
resistance provided by the soft tissues.
• The bony pelvis is divided into the false (greater) and
true (lesser) pelvis by the pelvic brim.
• Critical limit values are measurements that are
associated with a significant probability of CPD.
• Clinical pelvimetry is currently the only method of
assessing the shape and dimensions of the bony pelvis
in labor
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01/26/2025 Labor,Dr Delelegn 14
 Cont..

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 Cont..
• The inlet of the true pelvis is largest in its transverse
diameter (usually >12.0 cm).
Diagonal conjugate ( anteroposterior) diameter of the pelvic
inlet.
True conjugate ( obstetric conjugate) .
• This measurement cannot be made clinically but can be
estimated by subtracting 1.5 to 2.0 cm from the diagonal
conjugate.
• This is the smallest diameter of the inlet, and it usually
measures approximately 10 to 11 cm.
• The midpelvis ( interspinous distance should be greater than
10 cm)
• The pelvic outlet is rarely of clinical significance(AP and
transverse)
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 Cont..

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 CARDINAL MOVEMENTS IN LABOR

• The mechanisms of labor, also known as the

cardinal movements, refer to the changes in
position of fetal head during its passage through
the birth canal.
• Although labor and birth is a continuous process,
seven discrete cardinal movements of the fetus are
described: engagement, descent, flexion, internal
rotation, extension, external rotation or restitution,
and expulsion(EVERY DESCENT FAMILY IN EUROPE
EATS EGG).
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 Engagement

• Engagement refers to passage of the widest diameter of

the presenting part to a level below the plane of the
pelvic inlet i.e the biparietal diameter (9.5 cm) in
cephalic and bitrochanteric diameter in breech
prsentation.
• Engagement is achieved when the presenting part is at
0 station
• In nulliparas, engagement of the fetal head usually
occurs by 36 weeks' gestation.
• In multiparas, however, engagement can occur later in
gestation or even during the course of labor.
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 Descent

• Descent refers to the downward passage of the

presenting part through the pelvis.
Flexion
• Flexion of the fetal head occurs passively as the
head descends owing to the shape of the bony
pelvis and the resistance offered by the soft tissues
of the pelvic floor.
• The result of complete flexion is to present the
smallest diameter of the fetal head (the
suboccipitobregmatic diameter) for optimal passage
through the pelvis.
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 Cont…
• Internal Rotation
• Internal rotation refers to rotation of the presenting
part from its original position as it enters the pelvic
inlet (usually OT) to the anteroposterior position as it
passes through the pelvis.
• As with flexion, internal rotation is a passive
movement resulting from the shape of the pelvis and
the pelvic floor musculature.
• Extension
• Extension occurs once the fetus has descended to
the level of the introitus. This descent brings the
base of the occiput into contact with the inferior
margin at the symphysis
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pubis.
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 Cont..
• External Rotation
• External rotation, also known as restitution, refers to
the return of the fetal head to the correct anatomic
position in relation to the fetal torso.
• This can occur to either side depending on the
orientation of the fetus. This is again a passive
movement resulting from a release of the forces
exerted on the fetal head by the maternal bony pelvis
and its musculature and mediated by the basal tone of
the fetal musculature.
• Expulsion
• Expulsion refers to delivery of the rest of the fetus.
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 NORMAL PROGRESS OF LABOR

• Progress of labor is measured with multiple variables:

• Progress of labor can be assessed by:
1)Cervical effacement and dilation
2)Fetal station and position
• Cervical effacement refers to the length of the
remaining cervix and can be reported in length or as a
percentage.
• ≥80 percent effacement is required for the diagnosis
of active labor.

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 Cont..
• Labor has two categorizations: phases and stages.
• Phases are divided into latent and active.
• The latent phase of labor is defined as the period between the
onset of labor and the point when labor becomes active.
• The onset of labor is difficult to identify objectively.
• Usually, it is defined by the initiation of regular painful
contractions.
• In general, active labor requires ≥80 percent effacement and ≥4 cm
dilation of the cervix.
• In addition, there are three stages of labor.
• The first stage is from labor onset until full dilation.
• The second stage is from full dilation until delivery of the baby.
• The third stage is from the delivery of the baby until the delivery of
the placenta.
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 Cont..
• Second-stage durations of 1 hour for multiparous
women without an epidural, 2 hours for multiparous
women with an epidural and nulliparous women
without an epidural, and 3 hours for nulliparous
women with an epidural.
• Factors affecting the duration of labor include parity,
maternal body mass index, fetal position, and fetal
size.
• Longer labors are associated with increased
maternal body mass index and fetal position other
than OA
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 Cont..
• Mean lengths of the third stage of labor are not
affected by parity.
• The median third stage duration is 6 minutes
and exceeded 30 minutes .
SPONTANEOUS VAGINAL DELIVERY
• The goals of clinical assistance at spontaneous
delivery are the reduction of maternal trauma,
prevention of fetal injury, and initial support of
the newborn, if required.
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 Cont..
• DELIVERY OF THE PLACENTA AND FETAL
MEMBRANES
• The third stage of labor can be managed either
passively or actively.
• Passive management is characterized by patiently
waiting for the classic signs of placental separation:
(1) lengthening of the umbilical cord, and
(2) a gush of blood from the vagina signifying
separation of the placenta from the uterine wall.
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 Cont..
• After delivery, the placenta, umbilical cord, and fetal
membranes should be examined.
• Placental weight (excluding membranes and cord) varies with
fetal weight, with a ratio of approximately 1 : 6.
• Abnormally large placentae are associated with such conditions
as hydrops fetalis and congenital syphilis.
• The site of insertion of the umbilical cord into the placenta
should be noted.
• The cord itself should be inspected for length, the correct
number of umbilical vessels (normally two arteries and one
vein), true knots, hematomas, and strictures.
• The average cord length is 50 to 60 cm.
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 END

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References
• Williams 25th edition
• Gabbe 7th edition

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