labour

• Labour is process by which the fetus, placenta

and membranes are expelled through the birth
canal beyond 24 weeks of pregnancy after
regular uterine contractions, brings about
progressive effacement and dilatation of the
cervix.
• Cervical dilatation: The cervix begins dilating and
stretching beyond the normal dimensions and is
measured in centimeters. (0-10cm).
• Cervical effacement: softening, thinning and
shortening of the cervix. It is expressed in percentage
(0 – 100%)
 Normal labour
• Normal labour is characterized by
• Term,
• Spontaneous in onset ,with low risk,
• The fetus presented by vertex,
• No complications arise
• Within 18 hr duration.
 Labour can occur at:

Term
Labour
PTL prolonged

24 W 28 W 37 W 40W 42W
1 LMP
 Causes of onset of labor
• Not definitely known – however there are several
theories, but none of them is completely proven.
1-Hormonal:
• Decrease in progesterone.
• Release of Oxytocin – increase estrogen in
relation to progesterone.
• fetal cortisol
• 2- Mechanical :
• Over stretching of the uterus result in
prostaglandin release .
• Pressure of presenting part on cx stimulate
oxytocin release.
 Physiology of the 1st stage
• Uterine contraction:-(fundal dominance )
• Each uterine contraction starts in the fundus
near the one corn and spread across down
words .
• Contraction lasts longer in the fundus and most
intense .
• The peak is reached simultaneously over the
whole uterus.
• The contraction spreads from all part s together
.
• It allows the cervix to dilate and expel the fetus
.
• Polarity :- it is the harmony of the
neuromuscular action between the upper and
lower uterine segment , the upper contract
strongly and retract to expel the fetus and the
lower uterine segment dilate to allow expulsion
take place .
•
• Contraction and retraction :-
• The uterine muscle has a unique polarity .
• The contraction dose not pass off entirely .
• The muscle fibers retain some of the shortening
of contraction instead of complete relaxation
(retraction)
• The upper uterine segment become shorter and
thicker and decrease its capacity to assess the
expulsion of the fetus.
Premonitory signs of labor: weeks before real labor

Lightening: Fetus settles into pelvic cavity occur 10-14 days

before labor begins in PG, and occur during labour in multipara.

 Braxton-Hicks: Irregular intermittent contractions; “false

labor”; DO NOT initiate true labor.

 Cervical changes: cervix effaces [thins] & dilates slightly

 Burst of Energy: cleans house,. ↑ epinephrine resulting from

↓ progesterone
 Signs of true labor
• Beginning of regular painful uterine
contractions.

• Show is a blood stained mucoid discharge as a

result of dilatations
•
• Rupture of membranes lead to sudden gush
of fluid from the vagina .
Successful labor depend on 4 concept

• The passage, the women pelvic .

• The passenger, the fetus.
• The power .
• Psych.
 The passage
• The pelvic should be adequate in size and
shape.
• Gynecoid pelvic is the female pelvic which is
the best because it is round and wide .

• Tow diameters are important in labor

,anterior-posterior diameter and transverse
diameter.
types of female pelvis
 The passenger
• The following will pass during labour (fetus, cord,
placenta and membranes).
• The most important to pass is the head and
shoulder
• The head is the widest diameter.
• The fetal skull can pass depend on structure line
and its alignment with the pelvic.
• The structure of the skull composed of 8 bones in
the cranium, which meet together by a suture
lines .
 The passenger
• The suture lines are important in birth
because they allow the cranial bone to overlap
–molding- to decrease the size of the skull
during birth.
• Two fontanels :
• 1- Anterior fontanels , its diameter 3-4cm,
called bregma , closed at 18 month after
delivery ,
 The passenger
• 2- The posterior fontanel is triangular in shape
and closed after delivery.

• The fontanels help in determine the fetal

position.
 The Passenger
Fontanelles and Sutures
 The power
• The power of the mother
• Nutrition and fluids
• Rest/Fatigue
The power of contraction.
• The contraction must be adequate to initiate
labor.
• The psychology of the mother affect labor
also
“STAGES of LABOUR”
4 in All !
 First Stage
Onset of true labor to complete dilation = 10 cm.
~ 6-18 hrs. primapara; 2-10 hrs. multipara.

3 phases: Latent, Active, Transitional.

Latent: Dilation 0-3 cms. Contx.’s mild/irregular.
Active: 4-7 cms. Contx.’s 5-8 min. apart.
Lasts 45-60 sec; moderate - strong intensity.
Transitional: Dilation 8-10 cms. Contx.’s 1-2
min. apart; 60 –90 sec.; strong intensity.
No pushing til fully dilated.
 Second stage of labor
“Birthing of Baby”
• 2-Second stage of labor begins when the
cervix reach fully dilatation till the baby born.
• Sign of 2nd stage
• Urge to push.
• Bulging of the perineum
• .Everted anus and stool may be expelled.
• Vaginal introitus open
 Second stage of labor
• Crowning present when the head is on the
perineum .
• 2nd stage may last 1hr in multi Para , 2hr in PG
and 3hr in case of epidural

Positions: Sitting, Side Lying, Standing,

Squatting, All Fours, Kneeling.
 Third stage of labor
• Starts from the delivery of the baby till the
separation and expulsion of placenta and
membranes.
• Delivery of placenta ~ 5 - 30 min
• Signs of placental separation
• Lengthen of the cord.
• Sudden gush of blood.
• Change in the shape of the uterus.
•
 Fourth Stage

Lasts ~ 1 hr post delivery of placenta. Unless

complications arise.
Then pt. transferred to Post Partum unit.
 Factor that affect length of labor
• Parity.
• Birth interval.
• Psychological stat
• Maternal pelvic shape.
• Presentation.
• Contractions.
• Position of the fetus
 Duration of labor

• Primipara: 18 hrs.

• Multipara: 6hrs.
Comparison between true labor & false labor
character True labour pain False labour pain

contractions regular Irregular

Interval between Progressive (increase in Short duration, not
contractions and frequency and progressive
intensity intensity)

Changes in the cervix Associated with Not associated with

effacement and dilation effacement and dilation
of the cervix of the cervix

Membranes Associated with bulging of Not associated with

membranes bulging of membranes

Response to analgesia Not relieved by sedation Relieved by sedation

Labour Followed by labour Not followed by labour

 Care in 1st stage labor
• 1-Emotional support
• Complete History include medical, obstetric
• Birth plan such as exercise, position,
companion and pain relief .
• Complete Physical exam.
• Observations such as BP Q2-4 hr between
contractions and pulse Q1-2hr ,Temp Q 4HR
• Monitor FHR and contractions
 Care in 1st stage labor
• Lab test ,urine for protein, keton and sugar.
• Blood for BG,hepatitis and HB.
• Abdominal exam-Leopoids maneuver.
• Auscultate the fetal heart
• Vaginal exam-speculum exam in case of
rupture membranes.
• Bladder care Q 2hr and bowel care.
•
 Care in 1st stage labor

• Cleanliness and comfort –bathing or shower.

• Nutrition –low fat and high carbohydrate diet.

• Monitor progress in labor & record on

partograph.
•
Monitoring for fetal well-being: the evidence
 Contractions
• Record the number of contractions present in
a 10 minute period.
 Interpretation of CTG
• The normal Base line of fetal heart rate 120-
160bpm over 10 minutes.

• The variability is the variations or differing

• rhymicity in heart rate over time or
irregularity (vary 5beats over one minuets).

• ,
 Reduced variability can be
caused by:
• Foetus sleeping - this should last no longer than 40 minutes – most
common cause
• Foetal acidosis (due to hypoxia) – more likely if late decelerations also
present
• Foetal tachycardia
• Drugs – opiates, benzodiazipine’s, methyldopa, magnesium sulphate
• Prematurity – variability is reduced at earlier gestation (<28 weeks)
• Congenital heart abnormalities
• Accelerations ( increase in fetal heart rate 10-
20 beats for seconds) occur in response to
fetal movements
 Interpretation of…
• Early decelerations is a slowing in fetal heart
rate due to pressure of the fetal head during
contractions.
• Slow in FHR begin when the contractions
begin and end when the con.. End.
• Late deceleration is a slowing in FHR after
beginning of con..and continue after the end
of contraction due to uteroplacental
insufficiently
• The presence of late decelerations is taken seriously & foetal
blood sampling for pH is indicated
• If foetal blood pH is acidotic it indicates significant foetal
hypoxia & the need for emergency C-section
 Interpretation of…
• Variable deceleration is a slow in FHR that
occur un predictable time in relation to
contraction due to cord compression .
• Irregular in shape
 Care in second stage of labor
• Prepare for delivery and birthing room ,use
radiant wormer.
• Choose a position for birth such as lithotomy
or lateral.
• Evaluate for episiotomy.
• Teach the mother to push during cont..and
rest in between
 Care in second stage of labor
• Clean the perineum from up to down then
inside.
• Support and explain every procedure to the
mother.
• After delivery ,place the baby on the mother
chest in skin to skin contact
 Care in second stage of labor
• Oxytocin 10 IU IM given at delivery of anterior
shoulder or after delivery of the placenta.

• Note oxytocin increase uterine contraction

but may increase BP, SO base line BP must be
known before given oxytocin
 Care in the 3rd stage
• Active management of 3rd stage .
• Delivery of the placenta by CCT.
• Oxytocin.
• Uterine massage
• clamping of the cord
IV-Post Delivery:
1-examine the placenta for their completeness, anomalies,
length, and number of vessels in the cord and record the
placental weight.
2-Suture the episiotomy or any laceration.
3-Estimate blood loss, count swabs, and take cord blood for
Hb, blood group, Rh, bilirubin, and coomb’s test for Rh
negative mother.
4-Check BP, P, T, Lochia and firmness of the uterus before
transferring the patient.
5-Continue an infusion of syntocinon if necessary.
.6- Documentation.
7- Teaching .
8- Breast feeding
V-Care of the new born infant:
1. -Clearance of the new passages.
2. -Determine the Apgar score one and five
minutes
- heart rate
- respiratory rate
- muscle tone
- colour
- reflex irritability
3-Care of the umbilical cord stump
4-General assessment of the infant to exclude any
congenital anomalies.
5-Identification of weight, estimate the gestational
age, dress it and put a mask to identify it.
6-Protect the baby against cold.