Normal labor
[Link]
Objectives
• Definition of labor
• Uterine Action
• Cervical changes
• Causation of labor
• Stages of labor
Definition
• Labor is a physiological process during
which the foetus ,membranes, umbilical
cord ,and placenta are expelled from the
uterus.
WHO Definition
• Spontaneous in onset, low risk at the start of
labor and remaining so throughout labor and
[Link] infant is born spontaneously in
the vertex position between 37 and 42 weeks
of [Link] birth, mother and infant
are in good condition.
Causes of onset of labor
• Uterine distension
• Feto-placental contribution
• Oestrogen
• Progesterone
• Prostaglandins
• Oxytocin
• Neurological factors
False labor pains
• It is found more in primigravidae than in
parous women.
• It usually appears prior to the onset of true labor
pain, by 1 or 2 weeks in primigravidae and by a
few days in multiparae.
• Such pains are probably due to stretching of
the cervix and lower uterine segment with
consequent irritation of the neighboring ganglia.
Pre labour (premonitory
stage)
• The premonitory stage may begin 2–3
weeks before the onset of true labor in
primigravidae
• Few days before in multiparae.
Features of prelabor
• Lightening
• Cervical changes
• Appearance of false pain
phenomen
on of
‘lightening’
. (A) before
and (B)
after
lightening
True labor pain False labor pains
• Uterine contractions at regular • Dull in nature
intervals
• Confined to lower abdomen and
• Frequency of contractions increase groin
gradually
• Intensity and duration of • Not associated with hardening
contractions increase progressively of the uterus
• Associated with “show” • They have no other features of
• Progressive effacement and true labor pains as discussed
dilatation of the cervix
• Descent of the presenting part • Usually relieved by enema or
sedative.
• Formation of the “bag of
forewaters”
Stages of labor
• First stage
• Second stage
• Third stage
• Forth stage
• First stage of labour
• This starts from the onset of true labour pain and ends with
full dilatation of cervix.
• Its average duration is 12 hours in primigravida and 6 hours in
multigravida.
• There are two phases of first stage of labour:
• Latent phase: is the time between the onset of labour and 3- 4
cm dilatation and cervix becomes fully effaced. It usually lasts
between 3 and 8 hours, being shorter in multiparous women
• Active phase:the time between the end of latent phase (3-4
cm dilatation) and full dilatation (10cm). It is also variable in
length, usually lasting between 2 and 6 hours. Again it is
shorter in multiparous women.
• Second stage
• It starts from the full dilatation of the cervix (not from
the rupture of the membranes) and ends with
expulsion of the fetus from the birth canal.
• It has got two phases—The propulsive phase – starts
from full dilatation upto the descent of the
presenting part to the pelvic floor.
• The expulsive phase is distinguished by maternal
bearing down efforts and ends with delivery of
the baby. Its average duration is 2 hours in
primigravidae and 30 minutes in multiparae.
• Third stage:
• It begins after expulsion of the fetus
and ends with expulsion of the placenta
and membranes (after-births). Its average
duration is about 15 minutes in both
primigravidae and multiparae. The
duration is, however, reduced to 5 minutes
in active management.
• Fourth stage:
• It is the stage of observation for at
least 1 hour after expulsion of the
after-births. During this period, general
condition of the patient and the behavior of
the uterus are to be carefully monitored
Physiology of labor
• During pregnancy there is marked
hypertrophy and hyperplasia of the uterine
muscles and the enlargement of round
ligaments. At term length of uterus
measures about 35 cm including cervix and
the fundus is much wider
• Uterine contractions in labour
• Throughout pregnancy there is rhythmic invlountary
spasmodic uterine contractions which are painless
and have no effect on dilatation of cervix, the
character of the contractions changes with the onset
of labour.
• The pace maker of the uterine contractions is
probably situated in the region of the tubal ostia from
where waves of contraction spread downwards.
Fundal dominance
• Each uterine contraction starts in the fundus near one of
the cornua and spreads across and downwards.
• The contraction lasts longest in the fundus where it is
also most intense, but the peak is reached
simultaneously over the whole uterus and the
contraction fades from all parts together.
• Polarity
Contractions follow the
following patterns
• There is good synchronization of the contraction waves of both
halves of uterus.
• The waves of contractions follow a regular pattern
• Intra amniotic pressure rises beyond 20mmhg with the onset of
true labour pains during contractions.
• Good relaxation occur in between contractions to bring down
the intra amniotic pressure to less than 8 mmhg.
• During contraction, uterus becomes hard and some what
pushed anteriorly to make the long axis of the uterus in time
with that of pelvic axis simulataneously patient experiences
pain, often radiating to the thighs.
Causes of labor pain
• Myometrial hypoxia during contractions (as in
angina)
• Stretching of the peritoneum over the fundus.
• Stretching of the cervix during dilatation.
• Compression of the nerve ganglion.
Tonus
• It is the intrauterine pressure in between
contractions.
• During pregnancy, as the uterus is quiescent
(inactive), the tonus is of 2–3 mm Hg.
• During the first stage of labor, it varies from 8–10
mm Hg. It is inversely proportional to relaxation.
• The factors which govern the tonus are—(1)
Contractility of uterine muscles (ii) Intra-
abdominal pressure (iii) Overdistension of uterus
Intensity
• 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
second stage during delivery of the baby.
• Intensity is initially influenced probably by hormones
but subsequently depend on multiple origin of
contractions.
• Intrauterine pressure is raised to 40–50 mm Hg during
first stage and about 100–120 mm Hg in second stage of
labor during contractions.
• In spite of diminished pain in third stage, the
• Duration: In the first stage, the contractions last
for about 30 seconds initially but gradually
increase in duration with the progress of labor.
Thus in the second stage, the contractions last
longer than in the first stage.
• Frequency: In the early stage of labor, the
contractions come at intervals of 10–15 minutes.
The intervals gradually shorten with
advancement of labor until in the second stage,
when it comes every 2–3 minutes.
• RETRACTION:
• Retraction is a phenomenon of the uterus in labor in
which the muscle fibers are permanently shortened.
Unlike any other muscles of the body, the uterine
muscles have this property to become shortened once and
for all.
• Contraction is a temporary reduction in length of the
fibers, which attain their full length during relaxation
• The net effects of retraction in normal labor
are:
• Essential property in the formation of lower uterine
segment and dilatation and effacement of the cervix
• To maintain the advancement of the presenting part
made by the uterine contractions and to help in
ultimate expulsion of the fetus
• To reduce the surface area of the uterus favoring
separation of placenta
• Effective hemostasis after the separation of the
placenta
Contraction and retraction
EVENTS IN FIRST STAGE OF
LABOR
• Pre-disposing factors
• Softening of the cervix
• Hypertrophy
• Increase vascularity
• Accumulation of fluid in between collagen fibres
• Breaking down of collagen fibrils by enzymes collagenase
and elastase.
• The main events that occur in the first
stage are—
• Dilatation and effacement of the cervix
• Full formation of lower uterine segment.
• ACTUAL FACTORS RESPONSIBLE ARE:
• Uterine contractions and retractions The longitudnal
muscle fibres of upper segment are attached with circular
muscle fibres of lower segment and upper part of cervix in
a bucket holding fashion .
• Bag of membranes
• The memberanes are attached loosely to the
decidua lining the uterine cavity expect over the
internal os .
• In vertex presentation girdle of head fit in to lower
uterine segment and divides amnotic cavity in to
two parts that are forewater and hindwater.
• This generates hydrostatic pressure and dilates
the cervical canal
• Formation of fore water
• As the lower uterine segment forms and stretches, the chorion
becomes detached from it and the increased intrauterine
pressure causes its loosened part of the sac of fluid to bulge
downwards into the internal os, to the depth of 6-12 mm.
• The well flexes head fits snugly into the cervix and cuts off the
fluid in front of the head from that which surrounds the body.
• The former is known as forewaters‘ and the latter the
hindwaters‘.
• Fetal axis pressure:
• In longitudnal lie there is tendency of
straightening out of the fetal vertebral
column due to contractions of circular
muscles of the body of uterus, this exerts
pressure on cervix and dilates cervical canal
• Vis-a-tergo:
• It is the downward thrust of the presenting
part of fetus and upward pull of cervix over
lower uterine segment.
• Cervical effacement
• Effacement refers to the inclusion of the cervical
canal into the lower uterine segment.
• It takes place from above downward; that is, the
muscle fibres surrounding the internal os are
drawn upwards by the retracted upper segment
and the cervix merges into the lower uterine
segment.
• The cervical canal widens at the level of the
internal os, where the condition of the external os
remains unchanged.
Lower uterine segment
• During labor, the demarcation of an active upper
segment and a relatively passive lower segment is more
pronounced.
• The wall of the upper segment becomes progressively
thickened with progressive thinning of the lower
segment
• A distinct ring is produced at the junction of two, called
physiological retraction ring.
• Is pronounced in late first stage, specially after rupture of
the membranes and attains its maximum in second stage.
• A distinct ridge is produced at the junction of the two,
called physiological retraction ring which should not be
confused with the pathological retraction ring—a feature
of obstructed labour
• 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 the passage
of the fetal head.
• Dilatation is measured in centimeters and full
dilatation at term equates to about 10 cm
Events of second stage of labour
• This stage is concerned with the descent and
delivery of the fetus through the birth canal.
• Second stage has two phases:
• Propulsive—from full dilatation until head
touches the pelvic floor.
• Expulsive—since the time mother has irresistable
desire to ‘bear down’ and push until the baby is
delivered.
• With the full dilatation of the cervix, the
membranes usually rupture and there is escape of
good amount of liquor amnii. The volume of
the uterine cavity is thereby reduced
• Delivery of the fetus is accomplished by the
downward thrust offered by uterine contractions
supplemented by voluntary contraction of
abdominal muscles
• The expulsive force of uterine contractions is
added by voluntary contraction of the abdominal
muscles called “bearing down” efforts.
the expulsive forces in
the second stage.
Increased intra-
abdominal pressure
augments the downward
expulsive force of
uterine contraction
Events of third stage of
labour
• The third stage of labor comprises the phase of
placental separation; its descent to the lower
segment and finally its expulsion with the
membranes.
• Mechanism of separation: Marked retraction
reduces effectively the surface area at the
placental site to about its half
• There are two ways of separation of placenta
• Central separation (Schultze):
• Marginal separation (Mathews-Duncan):
• Separation of the membranes:
• The separation is facilitated partly by
uterine contraction and mostly by weight of
the placenta as it descends down from the
active part
• EXPULSION OF PLACENTA:
• Forced down into the flabby lower uterine
segment or upper part of the vagina by
effective contraction and retraction of the
uterus.
• Expelled out by either voluntary contraction
of abdominal muscles (bearing down efforts)
or by manual procedure