LABOUR
DEFINITION
Series of events that take place in the genital
organs in an effort to expel the viable
products of conception out of the womb
through the vagina into the outer world.
DELIVERY
Expulsion or extraction of a viable foetus out of
the womb
NORMAL LABOUR
(EUTOCIA)
Labour is called normal if it fulfils following criteria
Spontaneous in onset & at term
With vertex presentation
Without undue prolongation
Natural termination with minimal aids
Without having any complications affecting the
health of the mother or the baby
Date of onset of Labour
Unpredicted
Calculation based on Naegels formula
Labour starts approximately on the expected date – 4%
One week on either side – 50%
2 weeks earlier & 1 week later – 80%
At 42 weeks – 10%
43 weeks plus – 4%
STAGES OF LABOUR
FIRST STAGE (Cervical Stage)
It starts from the onset of true labor pain and
ends with full dilatation of the cervix.
Duration – primigravida – 12 hours
- Multiparae – 6 hours
SECOND STAGE
It starts from the full dilatation of the cervix and ends
with expulsion of the foetus from the birth canal.
It has got 2 phases
1. Propulsive phase – full dilatation of the cervix upto
the descent of presenting part to the pelvic floor
2. Expulsive phase – maternal bearing down efforts and
ends with expulsion of foetus
Duration – primigravidae – 2 hours
- multiparae – 30 mins
Third stage
It begins after expulsion of the foetus & ends with
expulsion of the placenta & membranes .
Duration – 15 mins in both primigravidae & multiparae
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 pt &
behaviour of the uterus are to be carefully monitored.
EVENTS IN 1st STAGE OF LABOUR
Preparation of birth canal to facilitate expulsion of the
foetus in the second stage
Main events uterine contraction and retraction
bag of membrans
foetus axix pressure
vis a tergo
Dilatation & effacement of the cervix
Full formation of lower uterine segment
physiological retraction ring
Dilatation of the cervix
Uterine contraction & retraction
The longitudinal muscle fibers of the upper segment
are attached with circular muscle fibres of lower
segment & upper part of the cervix in bucket holding
fashion.
During each uterine contraction, not only the canal is
opened up from above down but it also becomes
shortened & retracted.
There is some coordination b/w the fundal contraction
& cervical dilatation called “ Polarity of Uterus”.
Bag of membranes
The membranes are attached loosely to the decidua
lining the uterine cavity except over the internal os.
In vertex presentation, the head well fit with the lower
uterine segment, then the amniotic cavity is divided
into two compartments.
HIND WATERS – The part above the girdle of contact
contains the foetus with bulk of liquor.
FORE WATERS – The one below it containing small
amount of liquor.
with the onset of labour the membranes attached to the
lower uterine segment are detached & with the rise of intra
uterine pressure during contractions there is herniation of
the membranes through the cervical canal. There is ball
valve like action by the well flexed head.
Fetal axis pressure- In longitudinal lie, there is a
tendency to straightening out of the fetal vertebral
column due to contraction of circular muscles in the
body of uterus. This allows the fundal contraction to
transmit through the podalic pole into the fetal axis &
it allows mechanical stretching of the lower segment &
opening up of the canal.
Vis-a-tergo – the final phase of dilatation &
retraction of the cervix is achieved by downward
thrust of the presenting part of the foetus & upward
pull of the cervix over the lower segment.
EFFACEMENT or TAKING UP OF CERVIX
The muscular fibres of the cervix are pulled upward
and merges with the fibres of lower uterine segment.
Primigravidae – effacement precedes dilatation of the
cervix
Multiparae – both occur simultaneously
LOWER UTERINE SEGMENT
During labour, the demarcation of an active upper
segment & a relatively passive lower segment
The wall of the upper segment becomes progressively
thickened with progressive thinning of lower segment.
A distinct ridge is produced at the junction of two,
called physiological retraction ring.
EVENTS IN 2nd STAGE OF LABOUR
Begins with the complete dilatation of the cervix to the
expulsion of the foetus
2 phases
Propulsive phase – from full dilatation until head
touches the pelvic floor
Expulsive phase – since the time mother has
irresistible desire to bear down and push until the
baby is delivered.
EVENTS IN 3rd STAGE OF LABOUR
It comprises the phase of placental separation, its
descent to the lower segment & finally its expulsion
with the membranes.
2 ways of separation
1. Central separation (Schultze)
2. Marginal seperation (Mathew-Duncan) – common
Separation is facilitated partly by uterine contraction
& mostly by weight of the placenta as it descends
down from the active part.
Separation of placenta
definition
The series of movements that occur
on the head in the process of
adaptation, during its journey
through the pelvis
Criteria for normal mechanism of labour
Lie is longitudinal
Cephalic presentation
Position ROA or LOA
Attitude – flexion
Denominator – Occiput
Presenting part – posterior or
anterior parietal bone
Cardinal movements
Engagement bpd-synclitism and asynclitism
Descent uterine contraction and retraction
bearing down efforts
Flexion straightening of foetal ovoid
two arm lewer theory
Internal rotation slope of pelvic floor
harts rule
Crowning pelvic shape
bpt - vulvar outlet -even though contraction is over
Extension couple of force theory-successive parts to be born brow etc
Restitution rotation of the head tothe 1/8 of the circle opposite to internal
rotation
due to untwisting of neck rotation of the head is seen
External rotation internal rotation of shoulders-movement of head
Expulsion of shoulders & lateral flexion
trunk
ENGAGEMENT
When the greatest diameter (BPD) of the presenting
part passes through the pelvic brim
In primi – 38-42 wks
In multiparae – during labour, late first stage
MC cause of non engagement at term in primi
OP Position/ Deflexed head/ malpresentation
CPD
SYNCLITISM ASYNCLITISM
•When sagittal suture of head Anterior Asynclitism
of foetus lies in transverse •Sagittal suture deflected
diameter of pelvic inlet towards sacral promontory.
•Occur in 25% cases Commonly occurs in
multigravida
Posterior Asynclitism
•Sagittal suture is deflected
towards pubic symphysis ,
posterior parietal bone
becomes leading part
•Commonly occur in
nulliparous women
•Mild degree asynclitism is
common
•Major degree – CPD
DESCENT
Uterine contraction & retraction
Bearing down effects
Straightening of foetal ovoid
FLEXION
It is achieved by resistance offered by unfolding
cervix, walls of pelvis or by pelvic floor
Two arm lever theory-
Fulcrum occipito allantoid joint of head
Short arm extends from condyles to occipital
protuberances
Long arm – condyles to chin
When resistance is encountered SHORT ARM
DESCENDS, LONG ARM ASCENDS resulting in
flexion
A. Occipito-frontal B. Sub-occipito bregmatic
INTERNAL ROTATION
Slope of pelvic floor
HART’ S RULE
Pelvic Shape
CROWNING
Stage where maximum diameter of the head (BPD)
stretches the vulvar outlet without recession of the
head even after the contraction is over.
EXTENSION
Delivery of head takes place through “ COUPLE OF
FORCE” theory.
Successive parts to be born are – Vertex, brow, face,
immediately after release of chin head drops down.
RESTITUTION
Visible passive movement of head due to untwisting
of the neck.
Movement of restitution occurs rotating the head
through 1/8th of circle in direction opposite to internal
rotation.
EXTERNAL ROTATION
Movement of rotation of head visible externally due to
internal rotation of the shoulders
BIRTH OF SHOULDERS & TRUNK
By lateral flexion.
