NORMAL LABOUR
ABNORMAL LABOUR
• Any deviation from the definition of normal labour
• Presentation: Other than vertex
• Affecting the course of labour or modifying the nature of termination
• Adversely affecting the maternal & or fetal prognosis
DATE OF ONSET OF LABOUR
• Unpredictable
• Starts on EDD -4%
• 1 wk on either side:50%
• 2wks earlier & 1 wk later : 80%
CAUSES OF ONSET OF LABOUR
1) Hormonal Factors
2) Mechanical factors
3) Fetal factors
4) Biochemical factors
5) Neuroendocrine factors
6) Other influences
iii) Prostaglandins:
• Source:Produced in fetal mem,decidua & uterus
• Fn: Promotes cervical ripening, eff, & Dilation. Stimulates ut contractions
• Effect: Prostaglandin levels increase at the onset of labour ,facilitating the
initiation of contractions
iv) Oxytocin
Source: Produced by [Link] gland of mother & fetus
Fn: Enhances ut contractions by increasing the freq, intensity & coordination of
contractions
Effect:Oxytocin levels rise as labour approaches & it acts synergistically with
prostaglandins to strengthen contractions
v) Placental Corticotropin-releasing Hormone(CRH)
Source: Released by placenta
Fn: stimulates fetal adrenal glands to produce cortisol, & also increases
the production of prostaglandins in uterus
Effect: Elevates near term,contributing to ut contractions and cervical
ripening
[Link] FACTORS
Uterine stretch:
Mechanism: Growing fetus & amniotic fluid stretch the ut muscles
Effect: Trigger the release of prostaglandins & Oxytocin
Fetal pressure:
Mechanism: Descent of fetus into the pelvis applies pressure to the
cervix
Effect: stimulate the release of oxytocin which promotes ut contraction
and cervical dilation
[Link] FACTORS
A) Fetal hormones
Cortisol
• Source: Produced by fetal adrenal glands
• Fn: Matures fetal organs & promotes the production of surfactant in the lungs
• Effect: Increases the production of prostaglandin in fetal membrane
Adrenocorticotropic Hormone(ACTH)
• Source: Produced by fetal pituitary
• Fn: stimulates the fetal adrenal gland to produce cortisol
• Effects: plays a role in the maturation of fetal organs & initiation of labour
• B) FETAL MEMBRANES
Mechanism:The membranes that surround the fetus produce
prostaglandins
Effect: At term these membranes produce more prostaglandins aiding
in cervical ripening & onset of contractions
[Link] FACTORS
A) ENZYMATIC ACTIVITY
• Matrix Metalloproteinase(MMPs)
• Fn:Degrade collagen in the cervix leading to cervical ripening
• Effect: It increase near term, facilitate cervical effacement & dilation
B) INFLAMMATORY MEDIATORS
• Cytokines:
• Fn: Involved in inflammatory response , promoting cervical ripening &
uterine contractions
• Effect: Levels of pro inflammatory cytokines rise at term
5. NEUROENDOCRINE FACTORS
A) NEURAL STIMULI
• Mechanism: Neural signals from the uterus & cervix can stimulate the
release of oxytocin from [Link]
• Effect: Stimulus become more pronounced at term
B) MATERNAL & FETAL BRAIN
• Mechanism:Fetal & maternal hypothalamus & pituitary glands release
hormones that can trigger uterine contractions
• Effect:Coordinated release of these hormones contributes to timing of
labour onset
OTHER INFLUENCES
Maternal factors
Stress:Chronic stress may delay the onset of labour, acute stress can
sometimes can precipitate
Physical activity:Moderate excerise or increased activity can cause
labour
ulate
COMPONENTS OF NORMAL
LABOUR
4Ps
• Power
• Passenger
• Passage
• Psyche
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Labour pain
True FLASE
• Painful at regular interval • Dull in nature
• Frequency increases gradually • Confined to lower abd & groin
• Intensity & duration increases • Not associated with hardening
progressively
of uterus
• Associated with show,dilation &
effacement • Relieved by enema or sedativites
• Descent of presenting part
• Formation of forewater
• Not relieved by enema or sedatives
• Show:
With the onset of labor, there is profuse cervical secretion.
Simultaneously, there is slight oozing of blood from rupture of capillary
vessels of the cervix and from the raw decidual surface caused by
separation of the membranes due to stretching of the lower uterine
segment. Expulsion of cervical mucus plug mixed with blood is called
“show”.
Formation of “bag of waters”:
Due to stretching of the lower uterine segment, the membranes are
detached easily because of its loose attachment to the poorly formed
decidua.
With the dilatation of the cervical canal, the lower pole of the fetal
membranes becomes unsupported and tends to bulge into the cervical
canal.
As it contains liquor, which has passed below the presenting part, it is
called “bag of waters”
During uterine contraction with consequent rise of intraamniotic pressure,
this bag becomes tense and convex. After the contractions pass off, the
bulging may disappear completely.
EVENTS IN FIRST
STAGE OF LABOUR
NORMAL PATTERN OF CONTRACTION
Net effect of retraction
• Formation of lower uterine segment
• Maintain advancement of presenting part made during contractions
• Reduce the surface area of uterus in favour of placental separation
• Effective hemostatis after placental separation
CERVICAL Dilatation
• Dilatation of cervix is the process of enlargement of the OS uteri from
a tightly closed aperture to an opening large enough to permit
passage of fetal head
• Because the lower segment and cervix have lesser resistance during a
contraction, a centrifugal pull is exerted on the cervix and creates
cervical dilatation
• As uterine contractions cause pressure on the membranes, the
hydrostatic action of the amnionic sac in turn dilates the cervical canal
like a wedge
• Because of the successive shortening of the muscular fibers, the
upper active segment becomes progressively thickened throughout
first- and second-stage labor (see Fig. 21-4). This process continues
and results in a tremendously thickened upper uterine segment
immediately after delivery.
• Relaxation of the lower uterine segment mirrors the same gradual
progression of retraction. Recall that after each contraction of the upper
segment, the muscles do not return to their previous length, but tension
remains essentially the same. By comparison, in the lower segment,
successive lengthening of the fibers with labor is accompanied by thinning,
normally to only a few millimeters in the thinnest part. As a result of the
lower segment thinning and concomitant upper segment thickening, a
boundary between the two is marked by a ridge on the inner uterine
surface—the physiological retraction ring. When the thinning of the lower
uterine segment is extreme, as in obstructed labor, the ring is prominent
and forms a pathological retraction ring. This abnormal condition is also
known as the Bandl ring,
• The upper segment is firm during contractions, whereas the lower
segment is softer, distended, and more passive. This mechanism is
imperative because if the entire myometrium, including the lower
uterine segment and cervix, were to contract simultaneously and with
equal intensity, the net expulsive force would be markedly decreased.
Thus, the upper segment contracts, retracts, and expels the fetus. In
response to these contractions, the softened lower uterine segment
and cervix dilate and thereby form a greatly expanded, thinned-out
tube through which the fetus can pass.
• Changes in Uterine Shape During Labor. Each contraction produces an
elongation of the ovoid uterine shape with a concomitant decrease in
horizontal diameter. This change in shape has important effects on the
labor process. First, there is increased fetal axis pressure, that is, the
decreased horizontal diameter serves to straighten the fetal vertebral
column. This presses the upper pole of the fetus firmly against the
fundus, whereas the lower pole is thrust farther downward. The
lengthening of the ovoid shape has been estimated at 5 and 10 cm.
Second, with lengthening of the uterus, the longitudinal muscle fibers
are drawn taut. As a result, the lower segment and cervix are the only
parts of the uterus that are flexible, and these are pulled upward and
around the lower pole of the fetus.
• As the result of contraction forces, two fundamental changes—effacement and
dilatation—occur in the already-ripened cervix. For an average-sized fetal head to
pass through the cervix, its canal must dilate to a diameter of approximately 10 cm.
At this time, the cervix is said to be completely or fully dilated. Although there may
be no fetal descent during cervical effacement, most commonly the presenting
fetal part descends somewhat as the cervix dilates. During second-stage labor in
nulliparas, the presenting part typically descends slowly and steadily. In multiparas,
however, particularly those of high parity, descent may be rapid.
• Cervical effacement is “obliteration” or “taking up” of the cervix. It is manifest
clinically by shortening of the cervical canal from a length of approximately 2 cm to
a mere circular orifice with almost paper-thin edges.
• In the absence of intact membranes, the pressure of the presenting
fetal part against the cervix and lower uterine segment is similarly
effective. Early rupture of the membranes does not retard cervical
dilatation so long as the presenting fetal part is positioned to exert
pressure against the cervix and lower segment. The process of
cervical effacement and dilatation causes formation of the forebag of
amnionic fluid. This is the leading portion of fluid and amnionic sac
located in front of the presenting part.