SUB: Obstetric and gynaecological nursing

TOPIC: normal labour

SUBMITTED TO: SUBMITTED BY

Ms. payal vaghela Ms chavda tejas
Assistant professor FY msc nursing
NCN, visnagar roll no. 02
NCN VISNAGAR

SUBMISSION DATE: 18/2/2021

 Normal Labour in Obstetrics

DEFINITION
A series of events that take place in female genital organs to expel the
product of conception that are fetus, placenta, membranes) out of womb through
the vagina into the outer world.
At the National Maternity Hospital in Dublin (O’Driscoll and colleagues,
1984). Criteria for onset of labour:
At term require painful uterine contractions accompanied by any one of
the following: (1) ruptured membranes,
(2) Bloody “show,” or
(3) complete cervical effacement.

NORMAL LABOR/ EUTOCIA

1. Spontaneous in onset and at term
2. With vertex presentation
3. without undue prolongation
4. Natural termination without minimal aid
5. Without having any complications affecting the health of the mother and/or
the baby

 Causes of onset of labour

Uterine distension: -
Fetoplacental contribution activation of fetal hypothalamic pituitary axis
Increase CRT Increase ACTH Fetal adrenals Increase cortisol
secretion Accelerated production of oestrogen and PG from the placenta
Oestrogen: - Increases release of oxytocin from maternal pituitary
 Promotes synthesis of myometrial receptors for oxytocin,
prostaglandin.
 Stimulates synthesis of myometrial contraction protein
 Increases excitability of myometrial cell
 Progesterone: Alteration of oestrogen and progesterone ratio is
associated thesis.

Prostaglandin :
 Major site of production: Amnion, chorion, decidua cells and
myometrium
 Triggered by rise in estragon, glucocorticoids, mechanical stretching in
late pregnancy, separation or rupture of membrane
 Enhances gap junction formation Oxytocin
 Actions of Stimulate uterine contractions o Stimulate PG production from
amnion/decidua

TRUE AND FALSE LABOR:-

True labour
 Uterine contractions at regular intervals
 Contraction frequency, intensity, duration increases gradually
 Associated with show
 Progressive effacement and dilatation of cervix
 Descent of presenting part
 Formation of “bags of water”
 Not relieved by enema/ sedative
False labour
 Dull pain confined to groin and abdomen
 Pain interval doesn’t shorten
 Pain intensity remains same
 No cervical dilatation
 No hardening of uterus
 Relieved by enema or sedative

Physiology of normal labour

o Marked hypertrophy and hyperplasia of uterine muscles
o Length of uterus + cervix = 35 cm at term
o Uterus assumes pyriform/ ovoid shape
o Cervical canal occluded by thick, tenacious mucus plug
  PATTERN OF CONTRACTION
 Good synchronization of contraction waves from both halves of the
uterus
 Fundal dominance
 Regular wave of contraction
 Intra-amniotic pressure rises beyond 20mm Hg during uterine contraction
 Good relaxation occurs in between contraction

 RETRACTION

 Phenomenon of uterus in labour in which muscle fibers are permanently

shortened
 Effects of retraction:
 Formation of lower uterine segment and dilatation and effacement of
cervix
 Decent of presenting part
 Reduce surface area
 Effective homeostasis after separation of placenta

STAGES OF LABOR
1. First phase
2. Second phase
3. Third phase
4. Fourth phase
  FIRST STAGE
 Concerned with formation of birth canal
 Main events:
 Dilatation of cervix and effacement of cervix
 Lower uterine segment formation

FACTORS RESPONSIBLE IN DILATATION

 Uterine contraction and retraction

FACTORS RESPONSIBLE IN DILATATION

Fetal axis pressure longitudinal lie of fetus circular muscles contraction Fundal
contraction to transmit from podalic pole to head
Bag of membrane
Vis-a-tergo
EFFACEMENT OF CERVIX
Muscular fibers of cervix pulled upward and merge with fibers of lower uterine
segment
Primigravidae: effacement before dilation of cervix
Multiparae: effacement and dilatation occur at same time
Latent Phase
3 to 5 cm of dilation
After that clinically active labor can be expected
Prolonged latent phase:
> 20 hours in nullipara and 14 hours in multipara (Friedman and Sachtleben)
Following heavy sedation:
1. 85 percent to active labor
2. 10 percent uterine contraction ceased
3. 5 % persisted: require oxytocin stimulation

Active Phase
Cervical dilation of 3 to 5 cm in presence of uterine contractions: threshold
for active labor
Cervical dilatation: 1.2 to 6.8 cm/hour. Multiparas: minimum 1.5 cm/hr
Descent begins after 7 to 8 cm dilation, most rapid after 8 cm
SECOND STAGE OF LABOR
begins when cervical dilatation is complete and ends with fetal delivery.
Median duration
 2 hr in primigravidae
 30 minutes in multiparae
Uterine contractions and accompanying expulsive forces last:
 60-90 seconds and
 recur every 60 seconds
Events
 Propulsive phase:
Period of full dilation until head touches pelvic floor
 Expulsive phase:
Since the time mother has irresistible desire to ‘bear down’ and push
until the baby is delivered.
THIRD STAGE OF LABOR
 Includes separation, descent and expulsion of placenta with its membrane.

 Signs of placental separation:

 The uterus becomes globular and as a rule, firm- woody
 Sudden gush of blood
 Uterus rises in abdomen because the placenta, having separated,
passes down in the lower uterine segment and vagina.
 Umbilical cord protrudes farther out of the vagina, indicating that
the placenta has descended.
FOURTH STAGE OF LABOR
 The placenta, membranes and umbilical cord should be examined for
completeness and for anomalies
 Laceration of birth canal(vagina and perineum):
 First degree laceration: Involved the perineal skin, vaginal mucus
membrane but not underlying fascia and muscle
 2nd degree laceration: Involve in addition, the fascia and muscle of
perineal body but not anal sphincter
 3rd degree laceration: Extent further to involve the anal sphincter
 4th degree laceration: Laceration extend through the rectum’s mucosa to
exposed its lumen

MANAGEMENT OF FIRST STAGE LABOR

 Rest and ambulation
 Oral intake
 Urinary bladder function
 Bladder distention-avoided, because it can hinder descent of the fetal
presenting parts
 Pain relief
 Monitoring fetal well-being during labor
 Uterine contractions
 to evaluate the frequency, duration, and intensity of uterine contractions.
 Maternal vital signs
 Maternal temperature, pulse, and blood pressure are evaluated at least
every 4 hours
 with prolonged membrane rupture(>18 hours) antimicrobial administration
for prevention of group B streptococcal infections is recommended
 Subsequent vaginal examinations
 Maternal position position that she finds most comfortable, which will
be lateral recumbency most of the time

Management of second stage labour

Assist in natural expulsion of fetus slowly and steadily Prevent perineal injuries
1. Preparation for delivery
• Put the patient in dorsal lithotomy position or lying flat on bed
• Clean the vulva, and perineum with antiseptic solution
• Clean hands, Clean surface, Clean cutting and ligaturing of the cord
 • Catheterize the bladder, if full
2. Conduction of delivery
 Delivery of head:
• Maintain flexion of the head
• Prevent early extension
• Regulate the escape out of vulval outlet
• Patient asked for bearing down efforts during uterine contractions
• When the scalp is visible for about 5cm in diameter, push occiput downward
and backwards using thumb and index fingers while pressing the perineum by
right hand with sterile vulval pad
• BPD stretches the vulval outlet without any recession of the head even after the
contraction is over
• With each contraction, perineum bulge increasing
• Slow delivery of the head in between the contractions

• Ritgen maneuver:
• A towel-draped, gloved hand –used to exert forward pressure on the chin of
fetus through the perineum
• This maneuver allow delivery of head and also favors the neck extension so that
head is delivered with small diameter
Management of third stage labor
Expectant management
• Placental separation and its descent into the vagina are allowed to occur
spontaneously
• Constant watch
• Changed to dorsal position
• Hand placed over the fundus (signs of separation, state of uterine activity, detect
inversion of uterus)
• Expulsion of placenta
• Patient asked to bear down
• Placenta grasped by hands and twisted round and round with gentle traction
• Assisted expulsion
1. Controlled Cord Traction
 2. Fundal Pressure

Examination of placenta
• Maternal surface: completeness, anomalies
• Membranes: completeness, abnormal vessels
• Cord: number of vessels
Active management
• To excite powerful uterine contractions within one minute of delivery of the
baby by giving parenteral oxytocic
• Injection Oxytocin 10 units IM
• Controlled Cord Traction
• Massaging the uterus
• To minimise blood loss in third stage to approx 1/5th
• To shorten the duration of third stage to half
• Disadvantage: increased incidence of retained placenta and consequent
increased incidence of manual removal
• Not to be used in cardiac failure, severe pre-eclampsia
Management of fourth stage labour
• Suture the episiotomy or any laceration
• Estimate blood loss, take cord blood for Hb, blood group, Rh, bilirubin, and
Coomb’s test for Rh negative mother
• Check BP, Pulse, Temperature, abnormal vaginal bleeding and firmness of the
uterus before transferring the patient
Cardinal Movements of Labour
1. Engagement
2. Descent
3. Flexion
4. Internal rotation
5. Extension
6. External rotation
7. Expulsion
 Engagement
• The mechanism by which the Biparietal Diameter- the greatest transverse
diameter in occiput presentation crosses the pelvic inlet.
 Fetal head enters the pelvic inlet either transversely or obliquely. 1. Head
floating before engagement 2. Engagement, descent and flexion
Asynclitism
The lateral deflection of the sagital suture anteriorly toward pubic symphysis
or posteriorly towards sacral promontory.
Anterior asynclitism:
Sagital suture approaches sacral promontory
Anterior parietal presentation
Posterior asynclitism:
Sagital suture approaches pubic symphysis
Posterior parietal presentation
  Descent
• Downward passage of the presenting part through the pelvis
• Forces involved:-
Pressure of amniotic fluid
Pressure of fundus upon breech with contraction
Bearing down efforts of maternal abdominal muscles
Extension and straightening of fetal body
 Flexion
• Occurs passively as the head descends
• Resistance from cervix, pelvic walls, pelvic floor
• Chin is brought into intimate contact with the fetal thorax
• Longer occipitofrontal diameter replaced by shorter suboccipito bregmatic
diameter
 Internal Rotation
• Turning of head in such a manner that the occiput gradually moves towards the
symphysis pubis anteriorly from its original position.
 Extension
• The sharply flexed head reaches the vulva and undergoes extension
• Driving force exerted by uterus
• Resistance offered by pelvic floor and symphysis
• Resultant vector: direction of vulvar opening causing head extension
• Occiput in direct contact with the inferior margin of symphysis pubis
 External Rotation
•Movement of rotation of head visible externally due to the internal rotation of
the shoulders
•Anterior shoulder rotates towards symphysis pubis from oblique diameter
•Occiput points directly toward maternal thigh corresponding to the side to which
it originally directed at the time of engagement.
Expulsion
• Shoulders positioned in anteroposterior diameter
• Anterior shoulder escapes below pubic symphysis
• Lateral flexion of spine, the posterior shoulder sweeps over the perineum
• Rest of the trunk expelled out by lateral flexion 7. Delivery of anterior shoulder

Research article :

Research Summaries for Normal Birth

Amy M. Romano, MSN, CNM

Abstract
In this column, the author summarizes research studies relevant to
normal birth. The studies summarized include a large trial evaluating
the effect of prior vaginal births after a cesarean on outcomes in
subsequent births; a study linking umbilical cord blood pH with
intellectual outcomes in childhood; and a prospective trial evaluating
the effect of routine antenatal nonstress testing on maternal anxiety.
The author also highlights four articles about normal birth in a recent
nursing journal series dedicated to the topic.
BIBLIOGRAPHY
1. Annama Jocab, text book of comprehensive text book of ‘MIDWIFY and
GYNECOLOGY nursing JAYPEE publication 3rd edition page no.285-
287.
2. D.C. DUTTA text book of obsterical including perinatary and
contraception central publication 7th edition page no. 583-585.
3. B.T.Basvanthppa “TEXT BOOK OF MIDWIFERY AND
REPRODUCTIVE,”2006
4. www.wikipedia.com
5. www.pubmad.com