Labor and delivery

By: Mruts Aregawi

(MD)
 Definition
• Regular and painful uterine contractions that cause progressive
dilation and effacement of the cervix

• Eventually resulting in the birth of the infant and expulsion of

the placenta

• The rate of cervical dilation becomes faster after the cervix is

completely effaced
 Phases Of Labor
• parturition can be arbitrarily divided into four overlapping phases

• These phases of parturition include

– Phases 0 (Quiescence)
– Phase 1 (activation)
– Phase 2 (stimulation)
– Phase 3 (involution)
 Cont’d
• Phase 1 of Parturition: Uterine Quiescence and Cervical Softening
– Beginning even before implantation
– Tis phase normally comprises 95 percent of pregnancy
– characterized by uterine smooth muscle tranquility with maintenance of
cervical structural integrity.
– uterine muscle is rendered unresponsive to natural stimuli
– myometrial unresponsiveness of phase 1 continues until near the end of
pregnancy
 Cont’d
• Phase 2 of Parturition: Preparation for Labor
– To prepare for labor, the myometrial tranquility of phase 1 of parturition must
be suspended
• called uterine awakening or activation.
– phase 2 is a progression of uterine changes during the last 6 to 8 weeks of
pregnancy
– Abnormalities in this phase can cause either preterm or delayed labor.
– Events in this phase
• Increase in oxytocin receptor, prostaglandin F receptor, and connexin 4
• increased numbers and surface areas of gap junction proteins
• formation of the lower uterine segment from the isthmus
• Phase 3 of Parturition: Labor
– Tis phase is synonymous with active labor, which is customarily divided
into three stages.
 Normal labor and delivery
• Labor is considered normal when the following conditions are
fulfilled:
– Parturient without any risk (e.g., Pre-eclampsia, Previous scar, etc.),
– Labor should start spontaneously and at term,
– Fetal presentation must be by vertex, Singleton
– Delivery should be by spontaneous vertex delivery, with minimal aid,
– All stages of labor are lasting normal duration, and
– The neonate is alive, normal and the immediate postpartum course is normal
 The diagnosis of normal labor is established after the evolution of all the stages & 1-2 hours
after delivery.
What causes labor pain?
 Stages and phases of labor
• First stage
– The time from onset of labor to complete cervical dilation
– To document the onset of labor, patients are simply asked the time when
they believe labor began
– It is impossible to determine the precise times of both the start of labor and
complete dilation
– The first stage consists of a latent phase and an active phase
 Cont’d
latent phase
– characterized by gradual & unpredictable rate of cervical change
– The phase of labor between the onset of regular uterine contraction to 5-6
cm of cervical dilatation
– Characterized by mild, infrequent, irregular contractions with a gradual
change in cervical dilation
– Duration
• Nulliparous patients ≤ 20 hours
• Multiparous patients≤ 14 hours

Period of cervical softening and shortening(effacement)

 Cont’d
active phase
– Occurs after the latent phase at ≥ 6 cm of cervical
dilation and ends with complete (∼ 10 cm) cervical
dilation
– characterized by more rapid rate of cervical dilatation
– Nulliparous
• 4–6 hours
• Increase in rate of cervical dilation ≥ 1.2 cm/hour
– Multiparous
• 2–3 hours
• Increase in rate of cervical dilation ≥ 1.5 cm/hour
Period of rapid cervical dilation and descent of presenting part
 Cont’d
Second stage
– The time from complete cervical dilation to
delivery of the last fetus
– often associated with involuntary bearing down urge because of expulsive
uterine contraction
– Duration
• Nulliparous patients < 2 hours (< 3 hours in patients who received an epidural)
• Multiparous patients < 1 hour (< 2 hours in patients who received an epidural)
 Cont’d
• Third stage of labor
– Time period b/n delivery of the fetus and the delivery of the placenta and
fetal membranes
– Duration 30 minutes
– Signs of placental separation
• Cord lengthening
• Gush of vaginal blood(usually accompanied by a blood loss of 300 mL)
• Uterine fundal rebound (the uterus becomes less elongated and morespherical)
 Cont’d
• Fourth stage of labor
– 1-2 hour post-partum period

– First hour or two after placental expulsion when the uterus regains its tone
and begins the process of involution.
 Diagnosis of labor
• Regular painful uterine contractions

• Progressive cervical effacement and dilatation

• Show + rupture of the fetal membranes

 National guideline 2020

 The diagnosis can also be made on initial

examination in a patient who presents with
contractions and advanced cervical dilation
and effacement (≥6 cm).

Laboratory tests which are not determined during ANC visits should be completed during labor
 Management of labor
First stage of labor
– Review the prenatal record for known medical or obstetric conditions
– Determine whether new disorders have developed since the last prenatal
visit
– Evaluate fetal status
– Confirm that the patient is in labor
 First stage of labor

• During initial physical examination check for

– Whether fetal membranes are intact or ruptured
• If the membranes have ruptured, the presence of meconium should be noted
– Whether uterine bleeding is present and excessive

– Baseline cervical dilation and effacement should be documented so that

subsequent progress can be determined.
 Cont’d
• Station
– expressed as the number of centimeters of the leading bony edge of the presenting part
above or below the level of the ischial spines

– the maximum denominator is 5 (eg, 1 cm beyond the ischial spines corresponds to +1/5 cm)
• Fetal lie, presentation, and position

• Fetal size and pelvic capacity

• Fetal and maternal well-being

 Laboratory tests
• Hemoglobin/hematocrit
– normal hemoglobin result obtained at 26 to 28 weeks is enough if no major
risk
• Blood type and screen
• Human immunodeficiency virus (HIV)
• Hepatitis B and C
• Syphilis
• Group B Streptococcus (GBS)
Latent phase of first stage of labor
If the client presents before cervical dilatation of 5cm&fulfils admission criteria follow her using normal chart
 Active phase of first stage of labor
• All observations and findings should be recorded on the partograph if
the client presents with cervical dilatation of >5 cm (or when she
enters this phase after admission)
• Parts of the partograph
– Identification
– Fetal status
– Labor progress
– Medication
– Maternal condition
 Parts of partograph

i fi c a tion
Ident

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Fe t
Fetal Well -Being Monitoring
 abo r
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Pro
Monitoring of progress of labor
 M

Mat
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Maternal wellbeing monitoring
Pain management