Normal Labor

DR FARZANA RIZWAN
PROFESSOR
 Learning Outcomes
• Describe different stages, mechanism,
&progress of normal labor
and spontaneous delivery
• List types of analgesia and anesthesia
during labor
• Describe the methods available to monit
or the wellbeing of the mother
• Describe the management of the third s
tage of labor including episiotomy repair
and complications of purpeurium
 What is labor
Fmtpaininthenald

• Uterine contraction which bring about

changes in cervix
ti
is called labor
I
 What is normal labor
• It Is the process whereby regular irregular 88m
uterine contractions, brings about
so
Pull Cervixup T
progressive ftvatg.gl
effacement
y
IIE and dilatation of
the cervix, Becomethin ifnot itiscalledfake hahha
t isfull
Os
dilatation
10Am

• resulting in Spontaneous expulsion of a

single, mature fetus 3 presented by vertex,
through the birth canal within a

Fit
reasonable time, and expulsion of the
placenta and membranes . without
I
complications to the mother and fetus.
if Return inside NotNormal
 Normal labor
• mature fetus
a

• 37 completed weeks – 40weeks),

so

• through the birth canal

• vaginal delivery

• reasonable time
• not less than 3I hours or more than 18
hours
Presepitate audit'sabnormally
Deliver
Before 3h __
 Labor can occur at:
Normal labor
Term
Labor
Pre prolonged
odf i
t Doo
Term L F
1 LNMP FFIV.is
24 W 28 W 37 W 40W 42W
are
 True vs False Labor:

True Labor: False Labor:

Contractions occur at
regular intervals Contractions are irregular
Intensity gradually Intensity remains the
increases
E of
same

__
Discomfort is in the back
and abdomen.
No cervical dilatation
e
so

Cervix dilates. Discomfort relieved by

e sedation
I Epn
e

Discomfort is not stopped as

by sedation me
Even in Cema Eclamptic Pt They Can DeliverNormally
or

the started
Due to Centiuse Contraction once
should
process
complete
 Initiation of Labor notslanted
Theoretical
Maternal factors
Éaba
Artificial
I
Cervical exam
Progesterone
Stripping of membranes
Estrogen p
Contraction
Prostaglandins
Ismath
I me I
Oxytocin9
Prostaglandin Artificial rupture of
i
Psyche Inti it membranes
Fetal factors Nipple Stimulation
Fetal cortisol fetaladrenalgland
oxytocin
talkAfifBabyhad Anencaphaly NoBrainsignalto produceCortisone NotstatNorml lobo
 SHOW it's an initial
Signal labor
• During pregnancy, the cervix is plugged with
mucus. prevent eatery affinationintruttcavity
• It act as protective barrier for the uterus and
L
its contents throughout the pregnancy.
laborstate
• As the cervix begins to soften, stretch, and thin
through effacement, there may be rupture of
the small cervical
I capillaries. Pluggenitwithood
• pressure created by engagement of the
I
presenting part may lead to the expulsion of a
É
F blood mucus plug, called bloodyI show.
Its presence often indicates that labor will begin
I
within 24 to 48 hours. initial
e

so f a signal
 Rupture Of The Membranes

• About 12% of pregnant women experience

spontaneous rupture of the amniotic sac

I
(“ruptured membranes” or “ruptured bag of
waters”) prior to the onset of labor. E
• In most pregnancies, the amniotic membranes
rupture once labor is lwell established,
J
I
spontaneously.

if rupture at age of 3,7W Before Stant at labor prematureruptureof

mens
PROM

s a Ws 37W a Pretermypiggyptureolmen
so
 I

4 Rupture
I

Is
 Lower uterine segment
• The lower uterine segment (LUS)is the
part of the uterus and the upper cervix
which lies between the attachment of the
peritoneum of the II
uterovesical pouch
superiorly & the internal cervical os
É

inferiorly .
• The isthmus of the uterus, the lower
extremity of which joins with the cervical

E
canal and during pregnancy expand to
become the lower part of the uterine
cavity
E
 Together
becameone
I
i
e
Conaltodeliver
thebaby

Cervix Become soft a short calledEffacement

EI EI E J

Las

E
or at
Tamai
Leadingto Post PartumHg

3
 ooo

I 1

I
yet
l fullalfarementCervix
C stage 2 ShoutingA Cervix
O P ftp.t standdilationwithin'm

same.it
ii
a
Cervix I
Becomesoft a short InternalOs is going up t ButNo
Dilatation
 You tube!- dilatation and
the cardinal movements
http://www.youtube.com/watch?v=Xath6kOf0N
E&feature=PlayList&p=6603A45DF81B89A9&in
dex=38&playnext=2&playnext_from=PL

• http://www.youtube.com/watch?v=Xath
6kOf0NE&feature=PlayList&p=6603A45
DF81B89A9&index=38&playnext=2&pla
ynext_from=PL
 DIAGNOSIS OF LABOR

• . Diagnosis of labor is made only when painful

__
contractions are accompanied by any one of
the following : I
ooo

• show
5 of the membranes
• Rupture
• cervical effacement.
 Stages of Labor
First stage: early, active, transition
Dilatation
Second stage
TIA
I
Pushing and birth
Third stage
Delivery of fetus

Delivery of placenta
my

Fourth stage
Stage of observation
 STAGES OF LABOUR
1st stage

The first stage of labor refers to

the period from the onset of true
uterine contractions to the full
I
dilation
I of the cervix, when the

10cm.
e F
diameter of the cervical os measures
 1st stage of labor
Duration:
o primigravida = 8-12 h
at
o multigravida = 6-8 hi
Ld
Phases of the first stage:
and reached to about 3cm.
A. in primigravida = 8h
gym
q Latent phase: started when the cervix dilated
t slowly

a
B. in multigravida = 4h
q - Active phase: rapid dilatation of the cervix to reach
10cm
3 Etta
A. in primigravda = 4h
B. in multigravida =2h
 THE 1ST
a
STAGE CONSISTS OF 3 PHASES
ask BIN
• 1. Latent phase.
• Contractions during this phase are more than 5
minutes apart, last 25 to 35 seconds, and are
considered to be mild.
• woman is excited about labor and talkative.
• 2. Active phase:
• cervical dilation is 4-7 cm.
• more active contractions.
• The contractions become more frequent (every 3
to 5 minutes), last longer (60 seconds), of a
moderate to strong intensity.
• 1 cm of dilatation per hour
 THE 1ST STAGE CONSISTS OF 3 PHASES

3. Transitional phase:
• cervical dilation is 7-10 cm yd
ski
• most intense phase of labor.
• strong contractions that occur every 2 to 3
minutes and last 60 to 90 seconds on
average.
• woman may feel rectal pressure,
• an increased urge to bear down,
• an increase in bloody show,
• and spontaneous rupture of the membranes
(if they have not already ruptured).
 II-The Second stage of labor
stage of delivery of the fetus
at
Definition:
period from complete cervical dilatation to the
birth of the fetus.
Duration:
A.in primigravida =1 h7
B.in multigravida
I = ½ h

Is
however the timing of the second stage is
very different to determine and controversial
and can be extended as much as there is
progress in descent and no harm to the
mother or fetus
Dihn Progress
É
We can wait
 8 L Butifthereisnoso youhavetodosomething
Rishon
or Babyou weather
progress

Phases of second stage of

Thecervix isnotfully
thefetus
labor
dilatedandoak presentingpartiscomes
down

1.Passive
I phase – stage of descent of the
presenting part and dilatation of the
vagina – due to contraction and
retraction of the uterine muscle.
2.Expulsive phase – stage of bearing
I
sa down – due to contraction and retraction
of the uterine muscle and voluntary
I
efforts by diaphragm and abdominal
muscles. Mother Push
E
5 Come out
Baby
 framdelivergolfetustodelivegetplacentaandmembranes

III-The Third stage of labor

if nat Refined Placenta
• Duration: up to 30 minutes, I however the
average length of the third stage of labor is
10 minutes. Delivery of Placentas Membranes
• Mechanism: the third stage is made of two
phases:
1.The first phase: phase of placental
separation occurs through the spongiosa fomutegg.la
I
layer Iof the decidua at the time of expulsion
of the baby or very soon afterwards. The
shearing force responsible for the separation
is the contraction and retraction of the
uterus, reducing the uterine volume and the
area of the placental site, as the fetus is
expelled.
I
III-The Third stage of labor

• The second phase: phase of placental

2
expulsion – The separated placenta
descends from the upper (active)
I
segment into lower (passive) uterine
I
segment, cervix, and vagina .
So have
you Temetermaydia

fjg
contains
Nat Pulling Cent X Iufggggiggiad
fundus come Auberio
becauseplacenta
letsd
nerverandrenefi

gg.gg t.neuvogeni sh
 Sign of separation of placenta
A-Gush of blood.
e Is
B-Lengthening of umbilical cord. Clausebecauseplacenta
I 3
C-contour of the uterus become globular &hard.

Common OSCE a
Tseparati

Caion f
 Delivery of the placenta and
membranes
“active management”
• 1-Give syntocinon 5 units IM at the time

geeta
of the delivery of anterior shoulder.
• 2-(Brand Andrew's method)
soonafter

Deliver the placenta and membranes by

bad

control cord
e
traction by right hand, A
and the
left hand is placed on the suprapubic

ntm.FI
region, pushing the uterus upwards.
TransienttimeatRelaxitionofuterus afterliterary of Baby Canlead to
Prevented
Hg I
bygiving oxitosinagent
 https://youtu.be/EK3HobnbXuc
OSCE
Removal of placenta
to avoid citrine inversion
hand on Symphasis
Papi
of

Contertraction of Card
downword
 Removal of placenta
Once the placenta has been delivered,

carefully

examines it to ensure that all cotyledons

are intact If any part of the placenta is
missing,. Because retained placental
fragments can contribute
to postpartum hemorrhage or infection.
 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
 stage
Veryimportantbeceasemestpostpartumagoccuratthis
so

Fourth stage of labor

observation stage
• It lasts from 1 to 4 hours after birth.
tayatobservtionrom
• -the mother and the newborn recover
from physical process of labor.

• -systems readjustment.

• Newborn body systems begins to adjust

to extra- uterine life.
 Management of normal labor
•
•
IN
History
General examination
• Abdominal examination
• Vaginal examination
• First stage
• Second stage which is stage
Deside in
• Third stage
• Fourth stage
2Delivery
in Car
 AIM OF MANAGEMENT:

• achieve delivery of normal healthy child

IIe
with minimal physical and psychological
maternal effect.

• early anticipation, recognition and

management of any abnormalities during
labor.
 ADMISSION TO LABOUR

• Welcoming the woman

• Review the referral note or pregnancy
E
card to review history.
• Check and record the vital sign: BP-RR-
Temp
• Auscultate fetal heart sound.
I
• Assess uterine contraction.

Éinvistiforation
see
• Ask to woman to empty bladder and give
urine spacemen.

at abdominal
 Fetal Lie

F
• longitudinal axis of the fetus in relation to the long
so
axis of the maternal uterus
5
• longitudinal
I transverse oblique

HeWrite Note
forabdominalex
I fetal lie
2 Presenting Pant
cephalic
Mild rate
or Mod
3Contraction
Heartsounds
4 fetal
5 head engaged or not
 seven cardinal movements
of labor
1. Engagement
2. descent.
3. flexion.
4.
5.
I
internal rotation.
extension.
Head Delivery
6. external rotation. (restitution)
7. delivery of shoulder and fetal body
 I Engagement

• Engagement occurs when the widest part of

the fetal head has passed below the
maternal pelvic inlet.
IIe
Bundries of True pelvic inlet

head the p
hardest art thefetus
Fetal is e
in
engagement
 2 Descent.

• This is specifically named by its position

relative to the ischial spines of the maternal
pelvis. can
Level iscalledischia
spine
 Descent

o
 flexion

• During flexion, the uterine

contractions pushed the head
I
against cervix
flexion

vertex
Most favorall
Diameter
for normal labor
 flexion

Headeftented
eventheheadisthepresentn
ifitisextendetnamallab
part
Diameter comithedonesses

is king

I
Can't pass
 4 Internal Rotation:

Pupil
symphesis
to

U
• With further descent, the occiput rotates
anteriorly, and the fetal head assumes
an oblique orientation. In some cases,
the head may rotate completely to the
occiput anterior position.
 e

k copit

go
AnteriT
e
Internal Rotation:

ane

EE
ane
I

I
s
Extension:
 6 External Rotation:
(RESTITUTION)

• The shoulders rotate into an oblique or

frankly anterior-posterior orientation with
further descent. This encourages the fetal
I EE
head to return to its transverse position.
This is also known as restitution.
 D
atom fgagment

o
e
c
 Station of presenting part
• -3: 3 cmfff above the ischial spines dst d.me
0: at the ischial spines, engaged
I I
+3: 3 cm below the ischial spines Deliver
set

O
 Moulding of the skull
• means obliteration of the suture line between the
bones and overlapping of the un-united bones of
the fetal skull
f and is measured by degree.
• Degree Clinical finding
+ Suture line closed, no overlap
hits only this not Tore
++ normal Overlap of suture line reducible
as

Ahmet
+++
I I
Overlap of suture line irreducible

Thefetalbrainis goingtodamage
a 1
Cervical dilatation by vaginal
examination

O O O O

Mcm
i
STAGES OF LABOUR
 Dilatation BISHOP SCORE
taught
Censintasy
Station at presentation
Cervical effacement

t
 Crowing and Episiotomy
-”crowning” occurs when the fetal head or presenting
part appears at the vaginal opening.it does not
3
recedes back during contraction .
a

Notting
time at
fit's
-”Episiotomy” surgical incision in the perineum-may
be done to facilitate delivery and avoid laceration of
the perineum.

I
Nat Nassasey for every
Pb

To avoid lasseration
crowning
 Episiotomy
I
• Evidence of maternal or fetal distress (i.e. no time to
allow perineum to stretch).

• The baby is premature or in breech position, and

his/her head could be damaged by a tight perineum.

• The baby is too large to be delivered without causing

extensive tearing.

• The delivery is being assisted by forceps.

• Existing trauma to the perineum.

Read more: http://www.surgeryencyclopedia.com/Ce-

Fi/Episiotomy.html#ixzz4z3HZFNdh
 Episiotomy

Mi Jin mitulateral
most
The favorable
Midiolatual
 Care of the newborn infant:

L
1.-Clearance of the new passages.
2.-Determine the Apgar score one and five minutes
- heart rate
- respiratory rate
- muscle tone
- color
- 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.
 TYPE OF PAIN RELIEVE
• -none pharmacologic pain management.
I
• -pharmacological pain management.
• -narcotic analgesics.
• -barbiturates.
É

• -tranquilizers.
• -regional anesthesia.
• - general anesthesia.
Nat given in normallabor
 Medical pain relief options for
childbirth
• The three main medical pain-relieving
options for labor include:
• Nitrous oxide
• Pethidine
c 0 Pioid

I
• Epidural anesthesia.
 ENTONOX
Titus ate

É
• Breathed through a tube or a mask, this 50:50
mixture of nitrous oxide and oxygen takes 20–30

Is
seconds to take effect. It takes most women a few
contractions to get the hang of it, so don’t give up
after one contraction.
• Pros
You control when and how deeply you breathe, and
the effects wear off once you stop inhaling. Most
women find it really helps.
 ENTONOX

inhale with Pain

stop if Pain Relive

and no sideettet
 NITROUS OXIDE
Not given alone give with Entoux
• Nitrous oxide doesn’t interfere with contractions and it
doesn’t linger in either the woman’s or the baby’s
body.

Possible problems with using nitrous oxide include

• :Nausea and vomiting
• Confusion and disorientation
• Claustrophobic sensations from the face mask
• Lack of pain relief – in some cases, nitrous oxide
doesn’t offer any pain relief at all (this applies to
around one-third of women).
 Pethidine

• Pethidine is a strong pain reliever

(related to morphine and heroin),
usually injected directly into a
muscle in the buttock. It may also
E

be administered intravenously
 Pethidine
• Possible problems with pethidine for
the mother include Giddiness and
nausea
• Disorientation and altered perception
• Respiratory depression (reduced
breathing)
• Lack of pain relief, in some cases.
 Epidural anesthesia
Mederen
• Epidural medications fall into a class of drugs
called local anesthetics, such as bupivacaine,
lidocaine.
• They are often delivered in combination with
opioids or narcotics such as fentanyl in order to
I
decrease the required dose of local anesthetic.
 Epidural anesthesia
• An epidural does not
• :Increase the length of the
first stage of labor
TX
• Increase the likelihood of a
caesarean section
• Cause long-term backache.x
At the level of L4 vertebra
at Active 1st stage Tabor
 PUERPERIUM
so
If Maternal Death happen at this time
Causeder MaternalMoutalility
PUERPERIUM
 Shrinkage
Involution of uterus
 Involution

e
e

I
 EE

IE
 Moffat
O Retention

s Post Punta
Hg

e so
 Points to remember for
puerperium:
• Prevention of sepsis at placental site
• Newborn care É

• Initiation of breast feeding

• Role of post-natal exercises
 Management of Normal
Puerperium
• First hour– important for PPHmy

• Early ambulation
• I
Avoid strenuous activities for 6 weeks
• I
8-10 hours sleep
• I
Needs 300 calories more thanhernormaldiet
• Care of episiotomy stitches if any
• Care of nipples and areola
 Treatment of Minor AilmentsPittman
• After pains in Utuns Due to exit sin
• Retention of urine Due to
episiotomy
• Pain at site of perineum
• Engorgement of breast
• Treatment of Anemia
 Abnormal puerperium
D

• Sepsis is the commonest

complication during puerperium
but largely preventable.
 Puerperal Fever/Pyrexia

• Oral temp. 38 degree C or more

recorded twice in the first 10 days
after delivery.
 Causes of Puerperal fever

• Uterine infection
• Breast infection
• Urinary infection
• Thrombophlebitis
• Other incidental infections
 Puerperal Sepsis
• Infection of genital tract :
Delivery-42 days after delivery
• Two or > features to be
present
pelvic pain, fever 38.5 0

C, vaginal Discharge,
smell of discharge , sub-
involution
 Risk Factors for Puerperal
Sepsis
• Anemia
• Malnutrition
• DM É

• Prolonged labor
• Obstructed labor
• Prolonged PPROM
• Frequent vaginal examinations
 Contd….
• Operative delivery
• Un-repaired tears
• PPH
• Poor hygiene
• Poor aseptic technique for delivery
• Manipulations high in the birth canal
• Retained bits of placenta or membranes
• Pre-existing STDs
 Management
Preventive
• Good antenatal care
• Proper intra-natal care
• Post natal care
Curative
• General care
• Antibiotics for infection
II
• Local care of various wounds
 Complication
• Septicemia
• Septic shock
•r DIC
• Pulmonary embolization
• Distant spread of infection
• Kidney failure
• Death
 Contd….
Late complications:
E

• Menstrual problems
• Chronic pelvic pain
• Chronic PID
• r Secondary infertility
 Conclusion
Have a skilled attendant present
Use partograph
Use specific criteria to diagnose active
labor
Restrict use of unnecessary interventions
Use active management of third stage of
labor
Support woman’s choice for position
during labor and childbirth
Provide continuous emotional
s and
physical support to woman throughout
labor
THANK

YOU