FACTORS FOR NORMAL LABOUR

MS A.ARUNA

Introduction Uterus: pear-shaped muscle made of 3 layers: Endometrium inner lining - shed during menses. Myometrium - muscle layer middle Perimetrium - outer layer extra support to whole structure.

Labour ( eutocia)is a series of event that take place in the genital organ in an effort to expel the viable products of conception out of worm or uterus through the vagina in to outer world
Normal labour :

Criteria of normal labour: Spontaneous in onset & term With vertex presentation Without undue prolongation Natural termination with minimal aids Without any complication to mother & baby

Criteria of Abnormal labour(dystocia) 1. Any deviation from normal 2. Presentation other than vertex 3. Complication even with vertex presentation 4. Modifying natural termination 5. Adversely affecting the maternal & fetal prognosis

THEORIES of LABOR: 1. Uterine distension

Amniotic fluiddistension of lower pole

Myometriu m-baby

2. Feto placental contribution

Foetal hypothalamus (triggered by unknown factor)

Releasing factors are produced

Stimulation of anterior pituitary gland

Production of adrenocorticotrophic hormone

Stimulation of foetal adrenal gland

Increase in oestrogen level& prostaglandin

Secretion of cortisol

Decrease in progesterone level

3. Estrogen: - increase the release

of oxytocin from maternal pituitary. - Promotes the synthesis of receptors for oxytocin in the myometrium and decidua

4.Progesterone:
first produced by the corpus Luteum and then by placenta.

It has a relaxant effect on the uterus

It inhibits uterine contractility

When the oestrogen level increases , the progesterone levels decrease. This decreases at the end of pregnancy causing increase production of foetal dehydroepiandrosterone sulphate (DHEAS)

Increase fetal production of dehydroepiandrosterone sulphate (DHEAS) & cortisol may inhibit conversion of fetal pregnenolone to progesterone. Progesterone level fall before labour, thereby altering estrogen progesterone ration which is linked with prostaglandin ratio.

5. Prostaglandin: The major sites of synthesis of prostaglandins are placenta, foetal membrane, decidual cells and myometrium. It is thought that the decidua at term releases prostaglandins from the uterus in response to the release of oestrogen. They act on the uterine muscles and causes it to contract.

Synthesis is also triggered by rise in glucocorticoid, mechanical stretching in late pregnancy, infection, vaginal examination separation or rupture of membrane.

2.Oxytocin
released by the posterior pituitary gland

a stimulating action on the pregnant uterus

Towards the end of pregnancy, there is an increase in the oxytocin receptors in the decidue vera.

acts directly on the myometrium and causes the uterus to contract

it acts on the endometrial tissue and causes the release of prostaglandin.

PREMONITORING SIGN OF LABOUR: Lightening Cervical changes Appearance of false pain

Lightening: few week prior to onset of labour ( primigravida) the pp sinks into the true pelvis d/t the pulling up of the lower pole of the uterus around the pp. This deminishes the fundal height, minimise pressure on the diaphragm. Increase micturition or constipation d/t pressure by engaged pp ( welcome sign- as it can rules out CPD)

Cervical changes: Few days prior to the onset of labour the cervix become ripe. A ripe cervix is soft, less than 1.5 cm in length, admit a finger easily & is dilatable

Appearance of false pain: False pain or spurious labour. It is found more in primigravida than in parous women. It usually appears prior to the onset of true labour pain, by 1 or 2 weeks in primigravida & by few days in multipara

Feature of false labour pain Dull in nature usually confined to the lower abdomen & groin Continous & unrelated to hardening of uterus

Without any effect on dilatation of the cervix Usually relieved by enema and administration of a sedative

True labour pain The feature of true labour pain are Painful uterine contraction at regular interval Contraction with ng intensity and duration Show Progressive effacement & dilatation of cervix Formation of bag of water

True labour pain:

through out pregnancy , painless braxton hicks contraction with simultaneous hardening of uterus occur. These contraction change their character, become more powerful, intermittent and are associated with pain. The pain are more often felt in front of the abdomen or radiating towards the thighs

Show:

Expulsion of cervical mucus plug, mixed with blood is called show. With onset of labour , there is profuse cervical secretion. With slight oozing of blood from rupture of capillary vessels of the cervix.

Dilatation of cervix: with the onset of labour pain, the cervical canal begins to dilate more in the upper part than in the lower

Formation of bag of water:

due to stretching of the lower uterine segment, the membrane are detaches easily because of its loose attachment to the poorly formed decidua,

with the dilatation of cervical canal, the lower pole of the fetal membranes becomes unsupported & tends to buldge in the cervical canal as it contain liquor, which has pass below the pp is called bag of water

FACTORS OF LABOUR:

There are 5 major factors interact during normal child birth. This are often called as 5Ps of labour

1. Power: a. Uterine contraction- During 1st stage of labour uterine contraction are the primary force that move the fetus through the maternal pelvis

b. Maternal pushing effort- During the second stage along with uterine contraction the women feel an urge to push & bear down as the fetus distance her vagina & put pressure on her rectum

Passage The birth passage is the bony pelvis & soft tissue in which the fetus have to pass through during labour

d. PassengerThe passenger is the fetus membrane & placenta

e. Position- It is a point on presenting part in relation to the 4 quadrants of maternal pelvis

f. Psychological support: Anxiety & fear decreases the women ability to cope with pain in labour. Maternal catecholamine secreted in responds to anxiety & fear can inhibits uterine contractility & placental blood flow

Factor influencing labour

Medica tion

Psychologic al factor Maternal position during labour

Site of placental implantation

Maternal age

Materna l weight

Birth weight & gestatio nal age

Status of amniotic sacs Birth interval Fetal position

STAGE OF LABOUR
1. First stage: it start with true labour pain & end full dilatation of cervix. This divided into two phases a) Latent phase- 0-3cm cervical dilatation b) Active phase - acceleration 2.5-4cm - Maximum slope of 4-9cm - Deceleration phase 9-10cm

Physical characteristic of 1st stage Mild menstrual like cramp, dull back ache, show, rupture of membrane & ambulation become difficult. 12 hour for primi & 6 hour for multi

2. Second stage of labour: it start from full dilatation of cervix end with expulsion of fetus from birth canal. Phases: a. propulsive phase- it start from full dilatation of cervix up to descent of presenting part to the pelvic floor

b. Expulsive phase- it is distinguish by maternal bearing effort and end with delivery of baby. Duration for primi- 2hours for multi 30 mint

physical characteristic strong urge to push, increase pressure & bulging of perineum, emergent of presenting part

3.THIRD STAGE IT START AFTER EXPULSION OF FETUS & END WITH EXPULSION OF PLACENTA.

Duration for primi & multi - 15 mint Physical characteristic:- cessation of uterine contraction

4. Four stage of labour: stage of observation for 1 hour, during this period general condition of patient & behavior of uterus are to be carefully watch

Physical characteristics: perineal tenderness & involuntary shivering