The Ps of Labor

• 6P: Woman/Fetus: Powers, Passageway, Passenger, Position, Placenta, Psyche

• 4P: Providers/Support Persons: Patience, Persistence, Practice/ Pain Relief, Psyche
Normal myometrial contraction and retraction leads to stretching of the lower segment and thickening of
the upper segment. •This coordination leads to fundal dominance and a resultant downward force during
the process of child birth. •Lack of coordination of the upper segment and lower segment leads to lack of
fundal dominance hence abnormal uterine action.
Etiology:
As the physiology of normal uterine contraction is not fully understood, the cause of its disordered action
remains obscure. The following are the associated causes:

 Primigravida with advancing age of mother.

 Prolonged pregnancy (Post term pregnancy)
 Over distension of the uterus due to twins and/or hydramnious
 Contracted pelvis
 Malpresentation and deflexed head
 Full bladder
 Injudicious administration of sedatives, analgesics and oxytocics.
 Premature attempt at vaginal delivery or attempted instrumental vaginal delivery under light
anaesthesia.
NORMAL UTERINE CONTRACTION:

 There exists polarity in uterus i.e. when the upper segment contracts the lower segment relaxes
 There are two pacemakers situated at each cornua of uterus
 The intensity of contraction diminishes from top to bottom of the uterus.
 The contraction wave starts at the pacemaker and propagates to the lower segment.
 The duration of contraction diminishes progressively as the wave moves away from the
pacemaker
 The uterine space maker is situated at the cornua of the uterus and this generates uterine
contractions. Effective uterine contraction, starts at he cornua and gradually sweep downwards
over the uterus.
BRIEF REVIEW OF NORMAL UTERINE CONTRACTIONS

 POLARITY OF UTERUS: When upper segment contracts, lower segment relaxes.

 PACEMAKERS: Two pacemakers situated at each cornua of uterus generating the contraction in
co-ordinated manner.
 PATTERN OF CONTRACTIONS: uterine contraction starts at cornua, propagates towards lower
uterine segment with decrease in the duration and intensity of contraction as it moves away from
pacemaker.
PARAMETERS OF UTERINE CONTRACTION

 BASAL TONE: 5-20mmHg.

 PEAK PRESSURE: around 60 mm Hg pressure
  FREQUENCY OF CONTRACTION: Adequate uterine contractions are 1 in 3 minutes lasting
for 45 seconds.
(PPT)

 Fundal dominance - The activity of myometrium is greatest & longest at the fundus, shifting
&diminishing towards midline and downwards ( towards cervix).
 Polarity of uterus - When upper segment contract the lower segment relaxes.
- Lack of fundal dominance and the reverse polarity leads to spastic lower uterine segment.
Here pacemaker does not work in rhythm.
 Pace maker - Two one at each cornu from where wave of contraction spread downwards.
- Their activities must be coordinated
- Propagation of wave must also be coordinated
- Sometimes there is emergence of multiple pace maker foci leading to less efficient
contractions and hence causing primary dysfunction labour
 Coordination - Wave begins earlier in some part than other but the contraction attains maximum
in the different parts of uterus at the same time.
- At peak of contraction entire uterus acts as a single unit.
- Relaxation Starts simultaneously in all parts of uterus.
- For normal uterine action coordination is required between both halves of uterus as well as
between upper and lower segments
 Effectiveness - The effective uterine contractions results progressive cx dilatation & descent of
head within a given time. Any deviation of normal pattern of uterine contraction that affects the
course of labour is known as abnormal uterine action.
 Frequency - the amount of time between the start of one contraction to the start of the next
contraction. Frequency in the early stage of labour, contractions come at the interval of 10-
15min and increases to maximum in 2nd stage of labour.
- Clinically contractions are said to be good when they come after interval of 3-5minutes and
at the height of contractions uterine wall can not be indented by fingers.
 Duration - the amount of time from the start of a contraction to the end of the same contraction.
Normal labour is characterised by minimum of three contractions that averaged >25 mmHg in
10 minutes lasting for certain duration <20 sec: mild, 20-40 sec: mod > 40 sec: stron
 Intensity or Amplitude - a measure the strength a contraction by measuring the rise in
intrauterine pressure brought about by each contraction. Measured from baseline resting tonus
- With external monitoring, this necessitates the use of palpation to determine relative strength.
- With an IUPC, this is determined by assessing actual pressures as graphed on the paper.
 Interval- the amount of time between the end of one contraction to the beginning of the next
contraction
 Tonus (Resting tone) - intra uterine pressure in between the contractions.
- The lowest intrauterine pressure between contractions is called resting tone.
- Normal resting tone is 5-10 mmHg; during labor resting tone may rise to 10-15 mmHg.
- Pressure during contractions rises to ~25-100 mmHg (varies with stage).
- A resting pressure above 20 mmHg causes decreased uterine perfusion
- With external monitoring, this necessitates the use of palpation to determine relative strength.
- With an IUPC, this is determined by assessing actual pressures as graphed on the paper.
- During Quiscent stage- 2-3mm Hg.
- During first stage of labour 8-10mmHg.
Characteristics of the uterine contractions
1. Rhythmicity
- Each contraction increase progressively in intensity and maintains the maxium
intensity and then diminishes gradually.
- the uterine baseline tone -- from 8 to 12 mm Hg • 25 mm Hg at commencement of
labor to 50 mm Hg at the end of first stage • During second-stage labor, aided by
maternal pushing, contractions of 100 to 150 mm Hg are typical.
- At the beginning, the contracts occurs every 5-6 minutes, and last 30 s. With the
progression of labor, frequency increases to every 1-2 min and the duration increases
to 60 s when the cervix is fully dilated.
2. Symmetry
- The normal contractile wave of labor originates near the uterine end of the fallopian
tubes. Thus, these areas act as "pacemakers". Contractions spread from the
pacemaker area throughout the uterus at 2 cm/sec, depolarizing the whole uterus
within 15 seconds.
3. Polarity
- Intensity is greatest in the fundus
- Diminishes in the lower uterus.
- Presumably, this descending gradient of pressure serves to direct fetal descent
toward the cervix.
4. Retraction effect
- The muscle fiber retracts after contractions, and the cavity of the uterus becomes
small, and the fetus is forced to descend.
Maternal intra-abdominal pressure -- pushing
- Contraction of the abdominal muscles simultaneously with forced respiratory efforts
with the glottis closed is referred to as pushing.
- After the cervix is dilated fully, the most important force.
- Accomplishes little in the first stage. It exhausts the mother, and its associated
increased intrauterine pressures may be harmful to the fetus.
The contraction of levator ani contributes to:
- the internal rotation, extention and expulsion of the fetal head in the 2nd stage of
labor
- the delivery of placenta in the 3rd stage of labor.
ESSENTIAL FACTORS OF LABOR
LABOR FORCE – uterine contraion

1) Uterine contraction - it is the major force through the whole course of labor. It includes contraction and
retraction.

There are three effective features.

 Dominance and pacemaker

 Rhythm and Intermittent
 Retraction

(1) Dominance and pacemaker

 Uterine contraction in labor (patterns of contraction) there is good synchronisation of the contraction waves
of both halves of the uterus. The pacemaker of uterine contractions is probably situated in the region of the
cornu from where waves of contraction spread downwards.

 Electrical traces of the pattern of uterine contraction show that in normal labor each contraction wave starts
near one or other uterine cornu. The contraction spreads as a wave in the myometrium, taking 10-30
seconds to spread over the whole uterus.

Dominance: The upper segment contracts more strongly than the lower part, and the duration is longer
than in the lower segment, this dominance of the upper segment leads to the stretching and thinning of the
lower segment and to dilation of the cervix.

(2) The contractions are regular and rhythmic

 After contractions there is a intermittent. As labor progress, the intensity increase, frequency increase,
contractile duration prolong and intermittent shorten gradually, by the end of the first stage of labor the
contraction may come every 1 to 2 minutes and may last as long as a minute.

Intermittent : The intermittent nature of the contractions is of great importance to both the fetus and the
mother. During a contraction the circulation to the placental bed through the uterine wall is stopped; if the
uterus contracted continuously the fetus would die from lack of oxygen. The intermittent allow the placental
circulation to be re-established and give the mother time to recover from the fatigue effect of the contraction.
The uterus is a large muscle and contractions use up a lot of energy, if continued too long this would produce
maternal exhaustion.

Uterine contraction include three parts:Intensity, duration, and frequency.

- Intensity of contraction: it 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.
During the first stage intrauterine cavity pressure is raised to 40-50mmHg and during second stage it is
raised about to 100-120 mmHg.
- Frequency: in the early stage of labor, the contraction come at intervals of 10-15 min. The intervals
gradually shorten with advancement of labor until in the second stage, when it comes every one or two
minutes.
 - Duration: in the first stage, the contraction lasts for about 30-40 seconds initially but gradually
increases in duration with the progress of labor. Thus in the second stage, the contractions last longer
than in the first stage.

(3) Retraction

 Uterine contraction and retraction is throughout the full labor. The uterus not only contract but also retract.
The dilation of the cervix, descent of presenting part and progress of labor depend on the uterine
contraction and retraction.

Retraction: retraction is a phenomenon of the uterus in labor in which the muscle fibres are permanently
shortened, it is different from the contraction.

- Retraction is specially a property of upper uterine segment. Contraction is a temporary reduction in

length of the fibres, which attain their full length after the contraction passes off. In contrast, retraction
results in permanent shortening and the fibres are shortened once and for all.
- When the active contraction passes off the fibres lengthen again, but not to their original length.
- If contraction was followed by complete relaxation no progress would be made, in retraction some of
the shortening of the fibres is maintained. So the uterine cavity becomes progressively smaller with
each contraction.

The net effect of retraction in normal labor are:

- essential property in the formation of lower segment and dilation and taking up of the cervix
- to maintain the advancement of the presenting part made by the uterine contraction and to help in
ultimate expulsion of the fetus
- to reduce the surface area of the uterus favouring separation of placenta

Abdomenal muscle and diaphram

 In second stage,delivery of the fetus is accomplished by the downward thrust offered by uterine
contractions supplemented by voluntary contraction of abdominal muscles against the resistance offered by
bony and soft tissues of the birth canal.
 Help fetus and placenta delivery in the second stage and third stage.
 The expulsive force of uterine contraction is added by voluntary contraction of the abdominal muscles
called “bearing down” efforts.
 Pelvic floor (levator ani muscle) - help fetus internal rotation.
TONIC UTERINE CONTRACTION AND RETRACTION (BANDL’S RING):

- This type of uterine contraction is predominantly due to obstructed labour.

- The pattern of uterine action is normal, the upper uterine segment actively while the lower segment
remains passive.
- There is gradual increase in intensity, duration and frequency of uterine contraction.
- The relaxation phase becomes less and less; ultimately a state of tonic contraction develops.
Retraction, however, continues
- The lower segment, elongates and becomes progressively thinner to accommodate the fetus driven
from the upper segment.
- A circular groove encircling the uterus is formed between the active upper segment and the distended
lower segment called pathological retraction ring(Bandl’s ring).
- In primigravidae, further retraction ceases in response to obstruction and labour comes to a stand still –
a state of uterine exhaustion.
- Contractions may recommence after a brief period of rest with renewed vigour.
- But in multiparae, retraction continues with progressive circumferential dilatation and thinning of the
lower segment.
- There is progressive rise of the Bandl’s ring; moving nearer and nearer to the umbilicus and ultimately,
the lower segment ruptures.

CLINICAL FEATURES:

- Patient is in agony from continuous pain and discomfort and becomes restless.
- Features of exhaustion and keto acidosis

Abdominal palpation reveals:

- Upper segment is hard and tender. Lower segment is distended and tender.
- The pathological retraction ring is placed obliquely between umbilicus and symphysis pubis and rises
upwards in course of time.
- Fetal parts may not be well defined.
- FHS is usually absent.

Internal examination reveals:

- Dry, hot vagina with offensive discharge. Cervix fully dilated Membranes are absent Cause of
obstructed labour is revealed.

PREVENTION:

The abnormality either due to passage or passenger should be ruled out in antenatal period and plan for appropriate
treatment.

TREATMENT:

- Rupture of membrane is excluded.

- Correction of dehydration and ketoacidosis by infusion of Ringer’s solution.
- Adequate pain relief measures must be used
- Parenteral antibiotic is given (Ceftriaxone 1gm IV).
- Caesarean delivery is done in majority of the cases.
- Rupture of uterus must be excluded before attempting destructive operation.
SPASTIC LOWER SEGMENT:

 Fundal dominance is lacking

 Reverse polarity
 Lower segment contractions are stronger
 Inadequate relaxation in b/n the contractions
 Premature bearing down
 Cervix loose, oedematus, not well applied to the presenting part
- This is a common type of abnormal uterine action in the primigravida.
- The pain comprises mainly severe backache, intensified during contractions
- The cervix is thick edematous and is poorly applied to the presenting part.
- There is reversal of uterine action, increased tone in lower uterine segment and weakly acting upper
uterine segment.
- Fundal dominance is lacking and often there is reversed polarity.
- Inadequate relaxation in between contractions.

CLINICAL FEATURES:

- The patient is in agony with unbearable pain referred to the back.

- There are evidences of dehydration and keto acidosis.
- Bladder is frequently distended and often there is retention of urine; distension of the stomach and
bowels are visible.
- There are premature attempts to bear down.
- Abdominal palpation reveals:
- Uterus is tender and gentle manipulation excites hardening of uterus with pain which precedes and out
lasts the uterine contraction.
- Uterus remains tense and tender even after the contraction passes off.
- Palpation of the fetal parts is difficult.
- Fetal distress appears early.

Internal examination may reveal:

- Cervix which is thick, oedematous, hangs loosely like a curtain, not well applied to the presenting part.
- Inappropriate dilatation of the cervix.
- Absence of membranes.
- Varying degree of caput.
- Meconium stained liquor amnii.

MANAGEMENT:

- Caesarean section is done in majority of cases.

- Prior correction of dehydration and ketoacidosis must be achieved by rapid infusion of Ringer’s
solution.
- There is no place of oxytocin augmentation.

COLICKY UTERUS:

- In colicky uterus various parts of uterus contract independently with feeling of pain at fundus and
lower segment.
- There is lack of polarity and uterus contracts strongly.
- The contractions are very painful and felt predominantly in the hypogastrium region.
- The uterus has high resting tone, is irritable and tender.
- The cervix is thick, unaffected and poorly applied to the presenting part.
CONSTRICTION RING:

 Also called Schroeder’s ring.

 May appear in all stages of labour.
 Localized myometrial contraction forms a ring of circular muscle fibers of the uterus
 Situated at the junction of upper and lower segment Usually around constricted part of the fetus
 CAUSE: Injudicious administration of oxytocin, premature rupture of membranes, premature attempt of
instrumental delivery.
 FEATURES: Maternal condition not affected, Fetal distress may occur, ring is not palpable during per
abdomen, felt in o first stage during –caesarean section o Second stage –forceps application o Third
stage –manual removal of placent
- It is one form of inco-ordinate uterine action where there is localized spastic constriction of a ring of
circular muscle fibres of the uterus.
- It is usually situated at the junction of the upper and lower segment around a constricted part of the fetus
usually around the neck in cephalic presentation.
- It may appear in all stages of labour.
- It is usually irreversible and complete.
- The constriction ring usually results from abnormal uterine activity, which usually are not effective to
dialte cervix, or cause rupture of uterus.

CAUSES:

- Hypertonic lower uterine segment.

- Injudicious use of oxytocics.
- Premature application of instrumental delivery.
- Premature rupture of membrane.

DIAGNOSIS:

- Diagnosis is difficult.
- Constriction ring is suspected when descent of fetus is arrested for no obvious reason.
- The ring is not palpable per abdomen.
- Maternal condition is not much affected but the fetus is in jeopardy because of hypertonic state.
- It is revealed during:
- Caesarean section in first stage.
- During forcep application in second stage.
- Manual removal in third stage (hour glass formation)

MANAGEMENT:

Management is based on the stage of labour at which diagnosis is made:

First stage: The diagnosis is made during caesarean section after opening the uterine cavity. The ring may have to
be cut vertically to deliver the baby.

Second stage: Failure to deliver head even after correct and judicious application of forcep suspicious of
constriction ring. The confirmation is made by palpating the ring after removing the forceps blade.

Third stage: The diagnosis is made during attempted manual removal. Deepening the plane anesthesia is usually
effective. Alternatively, adrenaline may be administered.
GENERALIZED TONIC CONTRACTION(UTERINE TETANY):

 Also called uterine tetany No physiological differentiation between active upper segment and passive
lower segment. Pronounced retraction occurs involving whole of the uterus up to the level of internal os.
Whole uterus undergoes a tonic muscular spasm holding the fetus inside
 It is the condition in which there is pronounced retraction involving whole of the uterus upto the level of
internal os resulting in no physiological differentiation of active upper segment and passive lower segment
of the uterus.
 The uterine contraction ceases and the whole uterus undergoes a sort of tonic muscular spasm holding the
fetus inside.
 New pacemakers appear all over the uterus.

CAUSES:

- Failure to overcome the obstruction by powerful contractions of the uterus.

- Irritation caused by repeated unsuccessful attempt at assisted delivery.
- Injudicious administration of oxytocics.

CLINICAL FEATURES:

- Prolonged labour with continuous and severe pain.

- Evidences of dehydration and ketoacidosis.
- Abdominal palpation reveals somewhat small sized uterus which is also tense and tender.
- Fetal parts are neither well defined nor is FHS audible.
- Per vagina reveals jammed head with big caput formation, dry and edematous vagina.

MANAGEMENT:

- Adequate pain relief.

- Correction of dehydration and ketoacidosis by rapid infusion of Ringer’s solution.
- Antibiotic administration as per need.
- Oxytocin infusion is stopped and hyper contractility induced by oxytocics can be managed by tocolytics
administration.
- Caesarean delivery is done in majority of the cases where the obstruction is suspected.

CERVICAL DYSTOCIA:

 Failure of progressive cervical dilatation.

CAUSES:

- Inefficient uterine contraction

- Malpresentation, Malposition
- Spasm of the cervix

Cervical dystocia may be:

- Primary cervical dystocia:

It is commonly observed during the first birth where the external os fails to dilate due to ineffective uterine
contraction. The non dilatation may be due to the presence of excessive fibrous tissue or spasm of circular muscles
firms surrounding the os. The characteristic feature of this condition is the state of the cervix. The cervix is effaced
and well applied to the engaged head but it has firm ring and does not dilate normally.

- Secondary cervical dystocia:

This type of cervical dystocia results usually due to excess scarring or rigidity of cervix from the effect of previous
operation or disease. The cervix does not dilate due to previous obstetric injury or gynecological operation such as
amputation of the cervix.

MANAGEMENT:

- In the presence of associated complications as malpresentation and malposition, caesarean delivery is

performed
- If the head is sufficiently low down with only thin rim of cervix left behind, the rim is pushed up manually
during contraction or traction is given by ventouse.
- If the cervix is thinned with half dilatation ventouse extraction is quite safe and effective.

In terms of supine and lithotomy positions, unless women feel

comfortable in these positions, otherwise lithotomy and supine position should be avoided
for the increased risk of severe perineal trauma, comparatively longer labor, greater pain, and
more fetal heart rate patterns Lying on the back (supine) puts the weight of the
pregnant uterus on abdominal blood vessels and contractions may be less strong than when
upright. Effective contractions help cervical dilatation and the descent of the baby