NORMAL LABOUR

DEFINITION OF LABOUR
• Labour (parturition, childbirth, or birthing) is the
process by which the fetus and placenta are expelled
from the uterus and the vagina into the external
environment.
• Labour is the physiological process by which a viable
foetus and the products of conception i.e. at the end
of 28 weeks or more is expelled from the uterus.
 TERMINOLOGIES
• Parturition is the birth process.
• A parturient is a woman in labour.
• Labour is a coordinated sequence of involuntary
uterine contractions that result in effacement and
dilatation of the cervix and voluntray bearing-down
efforts that result in delivery, the actual expulsion of
the products of conception, the fetus and placenta.
•
 CONTD.,

• Dystocia is abnormal labour or difficult labour.

• Eutocia is normal labour;
• Delivery
It means actual birth of the foetus
 Criteria for calling it Normal labour:
• Spontaneous expulsion, of a single and mature
foetus (37 completed weeks) .
• Presented by vertex and through the birth
canal.
• Presentation within a reasonable time (not less
than 3 hours or more than 18 hours).
• Without complications to the mother and or
the foetus.
ESSENTIAL FACTORS OF LABOUR

PASSENGER

PSYCOLOGICAL
PLACENTA RESPONSE

5P’s

POWERS PASSAGE
 Essential Factors of labour
• THE PASSENGER-Fetal head size, Fetal lie,
presentation, attitude, position
• THE PASSAGE WAY
• THE POWERS
• THE PLACENTA
• PSYCHOLOGICAL RESPONSE
 The Passenger
• The passage of the fetus through the birth canal is influenced by the
size of the fetal head and shoulder,
the dimensions of the pelvic girdle,
 the fetal presentation and position.
The bones of the cranial vault are not firmly united, and
slight overlapping of the bones, or moulding of the shape of the head,
occurs during labour. This capacity of the bones to slide over one
another permits adaptation to the various diameters of the pelvis.
Moulding can be extensive, but with most neonates the head assumes
its normal shape within about 3 days after birth.
CONTD.,
The foetal head can move on the neck about 45 degrees
in flexion or extension and approximately 180 degrees
during rotation. This movement permits smaller diameters of
the foetal head to present during descent through the birth
canal.
Measurements of the foetal
skull 1)Anteroposterior
diameters
i) Occipitomental (OM): 13.5
ii) Occipitofrontal (OF): 11.5
iii) Suboccipitobregmatic (SOB):
9.5
2) Transverse diameters
i) Biparietal (Bip): 9.25
ii) Bitemporal (Bit): 8.0

Shoulders and Pelvic girdle

Because of their mobility, the position of the shoulder (the
shoulder girdle) can be altered during labour, so that one
shoulder may occupy a lower level than the other. This
permits a small shoulder diameter to negotiate the
passage. The circumference of the hips, or pelvic girdle, is
usually small enough not to create problems.
 Foetal lie
•Lie is the relationship of the long axis (spine) of the foetus to the
long axis of the mother.
•There are two lie:
i)Longitudinal, in which the long axis of the foetus is parallel with
the long axis of the mother, and
ii) Transverse, in which the long axis of the foetus is at right
•angles to that of the mother.
 Presentation
Presentation refers to that portion of the fetus that enters the
pelvis first and covers the internal os of the cervix, such as
cephalic (vertex, head), breach or shoulder.

Attitude
Attitude is the relationship of the fetal body parts to each
other.
CONTD.,
1) The shape is roughly ovoid,
2)The back is markedly flexed,
3)The head is flexed on the
chest,
4)The thighs are flexed on the
abdomen,
5)The knees are flexed at the
knee joints, and
6)The arches of the feet rest on the anterior surface of the legs; this
is the attitude of “general flexion”.
7)The arms are crossed over the thorax, and the umbilical cord lies
between them and the legs.
IN CEPHALIC PRESENTATION
1.If the head is fully flexed on the chest, the occiput (vertex) presents first andthe
posterior fontanel is palpable on vaginal examination; this is termed an occipital, or
vertex, presentation.
2.If the head is partially flexed or not flexed (moderate flexion), the anterior
fontanel presents and is palpable on vaginal examination; this is termed a sinciput
presentation or a military attitude.
3.If the head is markedly extended, the brow is the presenting part: this is
termed a brow presentation
4.If the head is hyper extended, the chin (mentum) is the presenting part; this is
termed a face or chin presentation
 Cause of Onset of Labour:
(1) Hormonal factors:
(i) Oestrogen theory
(ii) Progesterone withdrawal theory
(iii) Prostaglandins theory
(iv) Oxytocin theory
(v) Foetal cortisol theory
(2) Mechanical factors:
(i) Uterine distension theory:
(ii) Stretch of the lower uterine segment
 (1) Hormonal factors:
(i) Oestrogen theory:
• During pregnancy, most of the oestrogens are present in
a binding form. During the last trimester, more free
oestrogen appears increasing the excitability of the
myometrium and prostaglandins synthesis.
(ii) Progesterone withdrawal theory:
• Before labour, there is a drop in progesterone synthesis
leading to predominance of the excitatory action of
oestrogens.
(iii) Prostaglandins theory:
Postaglandins E2 and F2a are powerful stimulators of uterine
muscle activity
(iv) Oxytocin theory:
Although oxytocin is a powerful stimulator of uterine contraction ,
its natural role in onset of labour is doubtful. The secretion of
oxytocinase enzyme from the placenta is decreased near term due
to placental ischaemia leading to predominance of oxytocin’s
action.
(v) Foetal cortisol theory:
Increased cortisol production from the foetal adrenal gland before
labour may influence its onset by increasing oestrogen production
from the placenta
 (2) Mechanical factors:
(i) Uterine distension theory:
Like any hollow organ in the body, when the uterus in
distended to a certain limit, it starts to contract to
evacuate its contents. This explains the preterm labour in
case of multiple pregnancy and polyhydramnios.
(ii) Stretch of the lower uterine segment:
By the presenting part near term
 Clinical Picture of Labour
( A) Prodromal (pre - labour) stage:
(1) Shelfing, (2) Lightening & Engagement (3) Cervical Ripening
& Pelvic pressure symptoms, (4) Increased vaginal discharge, (5)
False labour pain.
(B) Onset of Labour:
(1)True labour pain, (2) The show, (3) Dilatation of the cervix,
(4) Formation of the bag of fore – water
 (A) Prodromal (pre - labour) stage:
(1) Shelfing: It is falling forwards of the uterine fundus
making the upper abdomen looks like a shelf during
standing position.
(2) Lightening:
• It is the relief of upper abdominal pressure symptoms as
dyspnoea, dyspepsia and palpitation due to :
• - Descent in the fundal level after engagement of the head
and
• - Shelfing of the uterus
 (A) Prodromal (pre - labour) stage:
Cervical Ripening- Softening and effacement of cervix
mediated through prostaglandins. Increase of
hyluronidase and decrease of collagens.
Engagement:
When the
maximum
transverse
diameter (Bi-
Parietal )of the
presenting
diameter crosses
the pelvic brim. 2
or 3 weeks before
the term in
primigravidae
(3) Pelvic pressure symptoms:
With engagement of the presenting part the following
symptoms may occur:
- Frequency of micturition.
- Rectal tenesmus.
- Difficulty in walking.
(4) Increased vaginal discharge.
(5) False labour pain: before 1 to 2 weeks of labor in
primi. Few days before in multi.
Irregular contractions with unrelated cervical
dilatation.
 (B) Onset of Labour:

(1) True labour pain.

(2) The show:
(3)Dilatation of the cervix:
(4)Formation of the bag of fore – waters
 PHYSIOLOGICAL EFFECTS OF LABOUR
(I) On the Mother:
(A) First stage-Minimal effects.
(B) Second stage: Temperature: slight rise to 37.5oC, - Pulse: increases
up to 100/min.
• Blood pressure: systolic blood pressure may rise slightly due to
pain, anxiety and stress.
• Oedema and congestion of the conjuctiva.
• Minor injuries: to the birth canal and perineum may occur
particularly in primigravidas
(C) Third stage:
Blood loss from the placental site is 100-200 ml and from
laceration or episiotomy is 100 ml so the total average
blood loss in normal labour is 250 ml.
(II) On the Foetus:
(A) Moulding:
The physiological gradual overlapping of the vault bones as the
skull is compressed during its passage in the birth canal. One
parietal bone overlaps the other and both overlap the occipital
and frontal bones so fontanelles are no more detectable.
It is of a good value in reducing the skull diameters but;
severe and / or rapid moulding is dangerous as it may
cause intracranial haemorrhage.
 STAGES OF LABOUR
(I) First stage:
• It is the stage of cervical dilatation.
• Starts with the onset of true labour pain and ends with
full dilatation of the cervix i.e. 10 cm in diameter.
• It takes about 10-14 hours in primi gravida and about
6-8 hours in multi para.
First Stage: Phases of cervical dilatation:
(A) Latent phase:
This is the first 4 cm of cervical dilatation which is slow takes
about 8 hours in nullipara and 4 hours in multipara. The latent
phase begins with mild, irregular uterine contractions that soften
and shorten the cervix
(B) Active phase:
Begin after 4 cm of cervical dilatation. The normal rate of
cervical dilatation in active phase is 1.2 cm/ hour in primigravidae
and 1.5 cm/hour in multiparae. If the rate is < 1cm / hour it is
considered prolonged.
(C) Transitional phase

The transitional phase happens when the mother move from

the first stage of labour to the second, pushing stage. It
usually starts when her cervix is about 8cm (3.5in) dilated,
and end when her cervix is fully dilated, or when you get the
urge to push.
 (II) Second stage:
- It is the stage of expulsion of the foetus.
- Begins with full cervical dilatation and ends with the delivery of the
foetus.
- Its duration is about 1 hour in primigravida and ½ hour in
multipara.
-(ACOG) has suggested that a prolonged second stage of labor should
be considered when the second stage of labour exceeds 3 hours in
nulliparous and 2 hours in multiparous.
 (A) Delivery of the head:
(1) Descent:
It is continuous throughout labour particularly during the second stage and
caused by:
a. Uterine contractions and retractions.
b.The auxiliary forces brought by contraction of the diaphragm and
abdominal muscles.
c. The unfolding of the foetus
(2) Engagement: The head normally engages in the oblique or
transverse diameter of the inlet.
(3) Increased flexion:
Increased flexion of the head occurs when it meets the pelvic floor
according to the lever theory.
Increased flexion results in :
a.The suboccipito - bregmatic diameter (9.5cm) passes through
the birth canal instead of the suboccipito- frontal diameter (10
cm).
b. The part of the foetal head applied to the maternal passages
is
like a ball. The circumference of this ball is 30 cm.
c.The occiput will meet the pelvic floor. Lever action producing
flexion of the head; conversion from occipitofrontal to
suboccipitobregmatic diameter typically reduces the
anteroposterior diameter from nearly 11.5- to 9.5 cm.
(4) Internal rotation:
The rule is that the part of foetus meets the pelvic floor
first will rotate anteriorly.
As the head descends, the presenting part, usually in
the
transverse position, is rotated about 45° to anteroposterior
(AP) position under the symphysis.

(5) Extension:
The suboccipital region lies under the symphysis then by
head extension the vertex, forehead and face come out
successively.
(6) Restitution:
After delivery, the head rotates 1/8 of a circle in the
opposite direction of internal rotation to undo the twist
produced by it.

(7) External rotation:

The shoulders enter the pelvis in the opposite oblique
diameter to that previously passed by the head. When the
anterior shoulder meets the pelvic floor it rotates
anteriorly 1/8 of a circle. This movement is transmitted to
the head so it rotates 1/8 of a circle in the same direction
of restitution
(B) Delivery of the shoulder and body:
The anterior shoulder hinges below the symphysis pubis and with
continuous descent the posterior shoulder is delivered first by
lateral flexion of the spines followed by anterior shoulder then
the body.
 (III) Third stage:
- It is the stage of expulsion of the placenta and membranes.
- Begins after delivery of the fetus and ends with expulsion of the
placenta and membranes.
- Its duration is about 10-20 minutes in both primi and multipara.
 (IV) Fourth stage:
- It is the stage of early recovery.
- Begins immediately after expulsion of the placenta and
membranes and lasts for one hour.
- During which careful observation for the patient,
particularly for signs of postpartum haemorrhage is
essential. Routine uterine massage is usually done
every 15 minutes during this period.