Labour

Labour: is the processes by which regular painful contraction bring about effacement and dilatation of
cervix and desend of the presenting part, ultimately leading to expulsion of the fetus and the placenta
from the mother.

The stages of labour

Labor can be divided into 3 stages:
1. First stage: this described the time from diagnosis of labor to full dilatation of the cervix (10 cm).
Duration: In primigravida = 12h & In multigravida = 6 h
The 1st stage can be divided into 2 phases
a- The 1st phase (latent phase): it is the time from onset of labour to 3-4 cm dilatation, during this time
the cervix become fully effaced (The process by which the cervix become shorting in length as it
become involve in the lower uterine segment).
▩ However, the duration of the latent phase is variable it usually last between 3-8 hours.
b- The 2nd phase (active phase) (Increased rate of cx dilatation): is the time between the end of the
latent phase 3-4 cm dilatation to full dilatation of cervix 10 cm.
▩ it also variable in length usually last between 2-6 hours,  cervical dilatation occurs at 1 cm \hour
or more and consider abnormal --> augmentation?

2. Second stage: The time from full dilatation of cervix to delivery of fetus.
This also subdivided into 2 phases
a- The 1st phase (passive phase): the time between fully dilated to the onset of involuntary expulsive
contraction (there is no maternal urge to push and the fetal head is relatively high in pelvic)
b- The 2nd phase (Active phase): there is a maternal urge to push because the fetal head is low causing a
reflex need to bear down.
▩ The normal active 2nd stage should last no longer than 2 hours in primiparous
and 1 hours in multipara.

3. Third stage: is the time from delivery of the fetus to delivery of the placenta.
▩ This stage lasts no more than 30 minute.
 Terms
This refer as change in the position and attitude that the fetus undergo during its passage through the
birth cannal.

 lie: The relation between the long axis of the fetus to that of the mother.
• Fetal and maternal axes may cross at a 45 degree forming an oblique lie ,
• Predisposing factors for transverse lie include
- multiparity,
- placenta previa and
- uterine anomalies.
 Presentation: is the portion of the fetal body that either foremost within the birth cannal
or in close proximity to it.
 Attitude or posture: the relation between the different parts of the fetus.
 Fetal position: relation between an arbitrarily chosen portion of the fetal presenting part to a fixed
point to the birth cannal .
So with each presentation there may be 4 position –>right or left, anterior or posterior (the fetal occiput
,chin (mentum),and sacrum are the determined points in the vertex ,face and breech presentation.

 Engagement: The greatest transverse diameter (biparietal diameter) passes through the pelvic inlet
- When the head is 2/5 palpable per abdomen
- When head Is at the ischial spine (at zero station)
 Station: degree of descent of the presenting part of the fetus, measured in centimeters from the
ischial spines
 left occipito- anterior (ROP) is more common than Right occipito-anterior (LOP)
 Right occipito-posterior (ROP) is more common than left occipito-posterior (LOP)
because: The left oblique diameter is reduced by the presence of sigmoid colon.
 The mechanism of labour:

1- Engagement: it occurs when the widest part of the presenting part has passed successfully
through the inlet.
The number of fifth of the fetal head palpable abdominally has taken place if more than 2/5 of fetal
head is palpable abdominally, the head is not engaged.

2- Descend: refers to the downward passage of the presenting part through the bony pelvis
- This is needed during the first stage and 1st phase of the 2nd stage of labour, and it occur due to
uterine contraction and in the active 2nd phase of the 2nd stages are helped by voluntary use of
abdominal musculature and Valsalva maneuver (pushing).
3- Flexion: occurs Passively as the head descends meets resistance of pelvic floor, cervix and walls
of pelvic
- This occur to minimizing the presenting diameter of the fetal head (Complete flexion places the
shorter suboccipito-begmatic diameter to substituted the longer occipito-frontal diameter)

4- Internal rotation: This movement consist of a turning of the head in such a manner that
the occiput gradually moves toward the symphysis pubis anteriorly from its original position or
less commonly toward the hallow of the sacrum so that the saggital suture now lie in the A-p
diameter of the pelvic inlet.
5- Extension: Following completion of internal rotation, the occiput is underneath the symphysis pubis
and the bregma near the lower border of the sacrum so the well flexed head now extended and the
occiput escape from underneath the symphysis pubis and distended the vulva (crowing the head).

6- Restitution: slight rotation of the occiput

through the one-eighth of the circle so that the head align itself with the shoulder which have
entered the pelvic in obligue direction.

7- External rotation: rotation of the occiput through a further one eighth of a circle to the
transverse position.
LEFT occipit-anterior
 Management of normal labor
 The first stage of labour:
1- History:
The following are important to note in the history:
A- Details of previous birth, the size of previous
babies and the previous Caesarean
B- Gestational age

C- The frequency, duration and the perception of the strength of contraction.

D- Whether membrane rupture or not (ROM).
E- The presence of abnormal vaginal discharge and bleeding (Passage of show).
F- The recent activity of the fetus.
G- Any medical condition that may influence labour e.g pregnancy induced hypertention ,
IUGR (Intrauterine growth restriction) .
H- Dose she have any special requirement e.g emotional and psychological need.

2- EXAMINATION: ‫ﻣﻠﺰﻣﺔ‬
 General examination: This include
 VITAL SIGNS (temperature, pulse and blood pressure)

 Abdominal examination:
 First Inspection to see if there is scar,
 Then Palpation
→ Fundal height + (Leopold's maneuvers : fundal grip, umbilical (lateral )grip,
pawlik’s grip , pelvic grip…) to see
- The lie of baby determined (longitudinal, transverse, oblique), also
- The presenting part are determined (cephalic, breech) and
- The degree of engagement.
→ also, the uterine contractions are assessed for frequency, duration and strength.
 Then auscultation (110-160 bpm)
→ In breech presentations: the heart sounds will often be heard above the umbilicus
→ In Head (vertex) presentations: the heart sounds will often be heard below umbilicus.
The fetal heart sounds are listened at a point midway between the anterior superior
iliac spine & the umbilicus on the back of the baby (usually in the right if the
presentation is cephalic)
 Vaginal Examination:
The index and middle figure are passed to the top of the vagina and cervix and the
following parameters are determined (Bishop’s score)
a- The cervix is examined for
- Length (effacement)
- Dilatation
- Consistency
- Position
[It is usually performed every 4 hours to determine when the active phase
has been reached (approximately 4 cm dilatation and full effacement).
The lower limit of normal progress is 1 cm dilatation every 2 hours once
the active phase has been reached]
b- The Membrane is examined for
- The condition of the membrane should also be determined (ruptured or not) and also
- The color (clear, blood stain, meconium) and amount of liquor is determined.
[During the first stage, the membranes may be intact, may have ruptured
spontaneously or may have been ruptured artificially. Generally speaking,
if the membranes are intact, it is not necessary to rupture them if the
progress of labour is satisfactory.]
c- The presenting part:
- Determine the presenting part (head, buttock, legs, …)
- The position: In normal labour the vertex will be presented and the position can be
determined by located the occiput (this identified by feeling for the triangular posterior
fontanelle,
- Engagement: The relation of the lowest part of the head to the ischial spine will be
estimated
- Station and descend: The d escend is crucial component of progress and should be
recorded at each vaginal examination.

d. Assessment of the pelvic:

- Inlet
- Mid
- Outlet
The Bishop score grades patients who would be most likely to achieve a successful induction. The
duration of labor is inversely correlated with the Bishop score; a score that exceeds 8 ( ‫ وﻓوك‬9 ‫)ﯾﻌﻧﻲ‬
describes the patient most likely to achieve a successful vaginal birth. Bishop scores of less than 6
usually require that a cervical ripening method (pharmacologic or physical, such as a foley bulb) be
used before other methods

They can be remembered with the mnemonic: Call PEDS For Parturition =
Cervical Position, Effacement, Dilation, Softness; Fetal Station.

The examiner assigns a score to each component of 0 to 2 or 0 to 3. The highest possible score
is 13 and the lowest possible score is 0.
  Women in FIRST STAGE of labor
• The frequency of contraction every 30 minute and
• her pulses determined hourly and
• Their temperature and blood pressure every 4 hours,
• A vaginal examination every 4 hours (Unless other factors suggest more frequent examination) .
 Once the SECOND STAGE is reached,
• The blood pressure, pulse, and vaginal examination should be performed hourly .

3- Investigation:
- Sample of urine tested for (protein, blood, glucose, ketone and nitrate)
- Sample of blood tested for (blood group, cross matching, Hb level)

4- Procedures:
 Encouraged to mobilize AND reassurance:
- Women who are in the latent phase of labor should be encouraged to mobilize
and should be managed away from the labor suite where possible. Indeed, they
may well go home, to return later when the contractions are stronger or more
frequent.
- Encouragement and reassurance are extremely important.
- Intervention during this phase is best avoided unless there are identified risk
factors.
 Diet and Dehydration:
- Latent phase: here is no reason to restrict eating and drinking, although lighter
foods and clear fluids may be better tolerated
- Active phase: Women may drink during established labor and those who are
becoming dehydrated may benefit from intravenous fluids to prevent ketosis,
which can impair uterine contractility. Light diet is acceptable if they have no
obvious risk factors for needing a general anesthetic and if they have not had
pethidine or diamorphine for pain relief.
 Analgesics: Simple analgesics (pethidine) are preferred over nitrous oxide and
epidurals.
 Evacuation of the bladder (foley’s catheter) and rectum (enema) +
preparation of vulva:
- Shaving and enemas are unnecessary and antacids need only be given to women
with risk factors for complications, or to those who have had opioid analgesia.
 Partogram: Maternal and fetal observations are carried out as described previously,
and recorded on the partogram.
ACTIVE MANAGEMENT OF LABOUR:
It’s a collection of intervention to maximized the chance of a normal birth. It include
• One-to-one midwifery care, (A variaty of study failed to show any benefit of active
management except one-to-one care)
• 2 hourly vaginal examination and
• Augmentation: Early artificial rupture of membrane and use of oxytocin augmentation
if progress fell for more than 2 hours behind the schedule of 1 cm per hour.
 The Second stage of labour:
 Diagnosis the onset of the second stage:
 If the labor has been normal, the first sign of the second phase of the second
stage is likely to be an urge to push experienced by the mother.  The woman
will get an expulsive reflex with each contraction, and will generally take a deep
breath, hold it, and strain down (the Valsalva manoeuvre).
 Full dilatation of the cervix should be confirmed by a vaginal examination if the
head is not visible.
 Positioning + partogram + pushing panting:
 Positioning: Women should be discouraged from lying supine, or semisupine, and
should adopt any other position that they find comfortable. Lying in the left
lateral position and squatting are particularly effective options.
 Partogram: Maternal and fetal surveillance intensifies in second stage, as
described previously. The development of fetal acidemia may accelerate, and
maternal exhaustion and ketosis increase in line with the duration of active
pushing.
 The pushing should be organized with the contractions to be effective.
Once the head has crowned, the woman should be discouraged from bearing
down by telling her to take rapid, shallow breaths (‘panting’).

 Descent and delivery of the head:

Vaginal and perineal tears are common consequences of vaginal birth,
particularly during first deliveries  So when you notice the crowning (the head
passed the pelvic floor and delivery is imminent).
 Use the modified Ritgen's manoeuvre: The ‘hands-on’ approach has been very
popular. As crowning occurs, the hands of the accoucheur are used to flex the
fetal head and guard the perineum. The belief is that controlling the speed of
delivery of the fetal head will limit maternal damage.
 +/- may perform  An episiotomy is a surgical cut, performed with scissors,
which extends from the vaginal fourchette in a mediolateral direction, usually to
the right, through the perineum and incorporating the lower vaginal wall.
It is performed during instrumental birth (ventouse or forceps), or to hasten
delivery if there is suspected fetal compromise.
Episiotomy
 Definition: incision through the perineum made to enlarge the diameter of the
vaginal outlet and assist childbirth.
 Prevalence: The WHO recommends that only 10% of vaginal deliveries should
incorporate episiotomy, however there is a considerable international variation.
 Procedure:
1. Consent (the need to do episiotomy should have been discussed during ANC,
and not at baby crowning).
2. Anesthesia: if the patient was already on epidural, then top it up, otherwise
local infiltration will suffice.
3. Incise the perineum at the second stage of labor with the stretching of
perineum, the cut is made from the fourchette, moving backwards straightly till
just before the anal sphincter in (midline episiotomy), or moving laterally at an
angle from fourchette in (mediolateral episiotomy).
 Complications:
- pain,
- bleeding,
- infection,
- extension to the anal sphincter

(in mediolateral episiotomy, first three complications are more yet the extension
to the sphincter is less than the way it is with midline episiotomy, a reason for
making the mediolateral more preferable.)

 Repair: is similar to a second-degree perineal trauma repair.

In 1st, 2nd degree tears: give adequate local analgesia, keep a pad high in the
vagina to prevent blood from obscuring the view , get a rapidly absorbable
suture on a large round needle and start repairing from the apex (epithelium) in
a continuous mode, the muscles in an interrupted mode, and finally the skin
(continuous or interrupted). Lastly pad should be removed and a vaginal as well
as per rectal exam done
 Delivery of the shoulders and rest of the body :
 Cord around neck: Once the fetal head is born, a check is made to see whether
the cord is wound tightly around the neck, thereby making delivery of the body
difficult. If this is the case, the cord may need to be clamped and divided before
delivery of the rest of the body.

 To aid delivery of the shoulders, the head should be pulled gently downwards
and forwards until the anterior shoulder appears beneath the pubis. The head is
then lifted gradually until the posterior shoulder appears over the perineum and
 the baby is then swept upwards to deliver the body and legs.
If the infant is large and traction is necessary to deliver the body, it should be
applied to the shoulders only, and not to the head.
 Immediate care of the neonate:
After the infant is born, it lies between the mother’s legs or is delivered directly on
to the maternal upper abdomen. The baby will usually take its first breath within
seconds. There is no need for immediate clamping of the cord, and indeed about 80
mL of blood will be transferred from the placenta to the baby before cord
pulsations cease, reducing the chances of neonatal anaemia and iron deficiency.
The baby’s head should be kept dependent to allow mucus in the respiratory tract
to drain, and oropharyngeal suction should only be applied if really necessary. After
clamping and cutting the cord, the baby should have an Apgar score calculated at 1
minute of age (see Chapter 19, Neonatology) which is then repeated at 5 minutes.
Immediate skin-to-skin contact between mother and baby will help bonding, and
promote the further release of oxytocin, which will encourage uterine contractions.
The baby should be dried and covered with a warm blanket or towel, maintaining
this contact. Initiation of breastfeeding should be encouraged within the first hour
of life, and routine newborn measurements of head circumference, birthweight and
temperature are usually performed soon after this hour has elapsed. Before being
taken from the delivery room, the first dose of vitamin K should be given (if
parental consent has been given) and the infant should have a general examination
for abnormalities and a wrist label attached for identification.
 Third stage of labour
 It’s the time from delivery of the baby to the expulsion of the placenta and the
membrane. This normally take between 5 to 10 minutes.
 Separation of the placenta occur because of the reduction in the volume of the
uterus due to uterine contraction and retraction (shortening of the the myometrial
muscle fibers).
 A cleavage plane develops within the decidua basalis and the separated placenta
lies free in the lower segment of the uterine cavity.

Sign of placental separation

1- Lengthening of the cord protruding from the vulva.
2- Small gush of blood from placental bed.
3- Rising of the uterine fundus to above the umbilicus.
4- The fundus become hard and globular compared to the broad and softer
fundus prior to separation.
 Management of the third stage of labor:
It can be described as active or physiological.
▣ Physiological (expectant) management:
Here the placenta is delivered by maternal effort ,and no utertonic drugs are given.
It's associated with heavier bleeding ,
 in the event of haemorrhage , or
 if the placenta remains undelivered after 60 minute of physiological management
active management should be recommended.

▣ Active management: [PPH  15% to 5%]

It recommended to all women because it reduce the risk of post-partum hemorrhage
from 15 to 5 percent.
It includes
1- Intramuscular injection of 10 IU of oxytocin, given as the anterior shoulder of the
baby is delivered , or immediately after delivery of the baby.
2- Early clamping and cutting of the cord.
3- Control cord traction: when a contraction is felt,
 The left hand should move suprapubically and the fundus elevated with the
palm facing toward the mother,
 At the same time, the right hand should grasp the cord and exert traction so
the placenta separated and is delivered gently.

 In approximate 2% of cases , the placenta will not be expelled.

 if no bleeding occurs, a further attempt at controlled cord traction should be made
10 minutes later.
 if this fails, the placenta is retained and will require manual removal under general
or local anesthesia.
After completion of the 3rd stage,
 The placenta is examined for any missing cotyledons or a succenturiare lobe also
 The vulva is examined for any tears or lacerations, minor tear doesn’t require
suturing, but tears extended to the perineal muscle (like episiotomy) will require
careful repair.