MODULE CODE: N3633 MM

BY HATUPOPI S.K
Learning objectives
 Define labour
 Define normal labour
 Describe factor influencing normal
labour ( Ps of labour)
 Differentiate between true and false
labour
Discuss the mechanism of labour
Differentiate between first, second, third
and fourth stage of labour
 Normal labour is of spontaneous onset,
occurs between 37 completed weeks and
42 weeks with the fetus presenting in
vertex presentation, and is completed
within 18 hours with both mother and
infant in good condition.
 Labouris a process in which the products
of conception ( fetus, placenta and
membranes are expelled from birth canal.
Labour is divided into 4 stages
1.First stage of labour
 The first stage of labour begins from the
onset of labour up to the time cervix is
fully dilated.
 It start from the time when woman
experiences regular and rhythmic
contractions, which accompanied by
dilatation of cervix.
First of stage of labour is divided into two
phase.
1. Latent phase : Is the period between the
onset of labour up to 3- 4cm dilatation
2. The active : Starts from the time the
cervix 5cm dilated up to the time the
cervix is fully dilated.
3. Duration: primigravida 3 -8 hours is
shorter in multipara
Diagnostic (conclusive) signs:
1. Strong, rhythmic uterine contractions
 regular in frequency and duration
 Less than 20 minutes apart
2. Dilation of the cervix
 Determine on vaginal examination
 with or without ROM
3. Show
 cervical dilatation→Thick mucoid , blood
stained vaginal discharge
 Dislodged of mucous plug (operculum)

8
Main contributing factors are a combination of
hormonal factors and Progressive mechanical change

Mechanical Hormonal

Cervical irritation and stretch.

Emotional and physical stressors stimulate maternal
hypothalamus →oxytocin
9
 Progesterone↓, oestrogens↑ at term due to
biochemical changes,
Hormonal effects Oestrogen ↑ myometrial sensitivity to oxytocin↑,
(oestrogen[stimulant] & stimulates production of Prostaglandins
and →stimulate contractions
progesterone[relaxant] Fetal adrenal glands secrete
produced by placenta) cortisol→prostaglandins release
High volume Prostaglandins are found in
amnion membrane & decidua
Fetal pituitary gland secrete oxytocin
Mechanical stimulation Uterine stretch, smooth muscles contract when
(more sensitive in stretched,
multiple pregnancies, ↑amniotic fluid volume, fetus and
polyhydramios etc… placenta→↑uterine muscles sensitivity
Cervical irritation and Cervical irritation and stretch of lower segment
stretch Pressure of presenting part →cervical irritation
& stretch.
ROM and well fitting presenting part →uterine
contractions 10
TRUE LABOUR FALSE LABOUR

Regular ,rhythmic May be painful, not regular , no

contractions- painful , increase increase in intensity
in intensity
Intervals between contractions Interval varies
shorten gradually
Contractions intensify when up Pain relieved by walking
and about
Show is present (operculum Show is absent
shed)
Cervical Effacement Cervical Effacement - but no
accompanied by progressive dilatation
dilatation 11
 Starts from the time the cervix is fully dilated
up to the time the fetus is completely
expelled from birth canal.
It is also divided into two phases
1.Pelvic floor phase
2. Perineal phase
Duration
Primigraivida : Up to two hours
Multipara : up to 45 minutes
 Begins from the time the baby is
delivered up to the time the placenta and
membranes are completely delivery
including control of vaginal bleeding.
Duration
 depends on the method used , active
management between 5- 15 minutes
while passive 45 to 60 minutes.
 Passage: bony pelvis and related soft tissues
should be adequate to accommodate the
fetus.
 Passanger: the size of the fetus in relation to
the type of pelvis and degree of flexion
 Powers: the nature of contraction, it should
be rhythmic and should increase in duration
and intensity.
❑The psyche pain: previous labour and
child be experiences may affect the
emotional well being of women, tension
can interfere with birth.
❑Physiological wellbeing of the mother
and fetus; risk factors can alter the course
of labour.
❑Professional assistance.
➢ Fundal dominance : This is the pattern allows
the cervix to dilate and the fundus, which s
contracting strongly to expel the fetus.

➢ Polarity : Refers to the neuromuscular

harmony that occurs between the two poles or
segments of the uterus (upper uterine segments
and lower uterine segments.
➢ Show: When the cervix dilates,
the operculum which formed the
cervical plug during pregnancy
falls and shed.
Formation of the forewaters
➢ As the lower uterine segment stretches, the chorion is
detached from it and becomes loose.
➢ The uterine pressure causes the loosened part of the
sac to bulge downwards into the internal os.
➢ Forewaters: is the fluids in front of the head.
➢ Hind waters: The fluid that which surrounds the rest
of the body is known as the hind waters.
19
 Contraction: Are regular, rhythmic and occur
over a specified period. Initially they are weak. In
early labour, uterine contractions may last about
30 seconds ( weak or mild) occur every 15-20
minutes.
N.B As labour progress, contractions increase in
intensity, duration and frequency.
 Retraction: During labour, the uterine muscles
do not relax completely following contraction. It
retain some form of shortening called retraction.
 Retraction assists in expulsion of the fetus ,
because the cavity of the uterus is reduced as
the upper segment becomes shorter and
thicker.
 Cervical effacement: During effacement the
muscle fibres around the internal os of the
cervix are drawn upwards and merge into the
lower uterine segment.
 Dilatation of the cervix: Is the process
whereby the cervix opens (from a small
aperture to an opening large enough to allow
passage of the fetal head. Or to allow passage
of the fetus during labour
https://youtu.be/lX5e_o2MxHA 23
 General fluid pressure: Describe the pressure
is exerted by the uterine contractions on the
amniotic fluid during labour.
 Rupture of membranes: The best time for the
membranes to rupture is at the end of the first
stage of labour, when the cervix is fully
dilated and delivery is imminent.
 This helps to minimize intrauterine and fetal
infection, especially in cases of HIV and
gonococcal infection.
 By the end of pregnancy , the uterus is divided
into upper and lower segments.
 The lower uterine segment has developed from
ithmus
 The upper uterine segment is thick and
muscular to enable it to contract and expel the
fetus during labour while the lower segment is
thinner to allow for distension and dilatation
during labour.
 Spontaneous onset of labour occurs between
37 -42 weeks, with a fetus presenting in the
vertex.
 Ideally, normal labour will be completed
within 18 hours, provided both the mother
and the infant in good physical and
psychological condition.
 Normal delivery is the natural physiological
process of birth, with limited or no
intervention.
 Mechanism normal of labour
 Lie is longitudinal; lie is the
relationship of the long axis of the fetus,
to that of the long axis of the uterus.
 Presentation is cephalic ; Presentation is
that part of the fetus which lies in the
lower pole of the uterus, and which
presents at the pelvic brim
 Attitude is that of complete flexion; the attitude
of the fetus is the relationship of the fetal parts to
one another; that is the relationship of the fetal
limbs and head to the fetal trunk.
 Denominator is the occiput; The denominator is
that part of the presentation which indicates the
position of the presentation in relation to the
pelvic brim and gives the position its name.
 Position should be LOA, ROA; The position
of the fetus is indicated by the relationship of
the denominator to six points or landmarks on
the pelvic brim.
 N.B LOA; Left occiput anterior ,and the
sagital suture of the fetal skull will lie in the
right oblique diameter of the pelvis
 ROA, Right occipito anterior , where the occiput lies
adjacent to the right ilio- pectineal eminence.
 NB Sagittal suture of the fetal head skull will lie
in the left oblique diameter
 Presenting part is that part of the presentation
which lies over the cervical os during labour and
therefore it is upon this portion of the presentation
that the caput forms.
 Descent of the fetal head; the amount of descent
of the fetal head into the mothers pelvic is
assessed on abdominal examination and is
calculated as fifths of the fetal above the pelvic
brim.
 Engagement , engagement of the fetal head has
taken place when the largest presenting
diameter and the bi-parietal diameter have
passed through the brim of the pelvis.
 Known as a series of passive movement with
changes in the posture of the fetus during labour
 Fetus negotiates his pathway through the birth
canal by means of uterine contractions and
maternal bearing down efforts
 Knowledge of the female pelvis, pelvic floor,
fetal skull and physiology of normal labour is
essential to understand the mechanism of normal
labour
 Engagement
 Descent
 Flexion
 Internal rotation of the head
 Crowning
 Extension of the head
 Restitution
 Internal rotation of the shoulders
 External rotation of the head
 Birth of the shoulders
 Delivery of the rest body in lateral flexion position
 Occurs when the widest part of the
presenting part enters the pelvic brim
 At 36 weeks in primigravida's and after
onset of labour in multigravidas
 In cephalic presentation, bi-parietal
diameter is the widest (9.5cm)
 Engagement demonstrate that the pelvis is
adequate for that particular fetus
 Begins before onset of labour in primigravidas when the
head becomes engaged into pelvis, Descent is a
continuous process during labour
 Occurs in the latter weeks of pregnancy in primigravida
due to tight abdominal muscles
 In multipara it may not occur until the onset of labour
 Descent occurs when there is softening of cx, other
pelvic organs and effacement
 Contractions and retraction of the uterine muscles aid
descent during the first stage of labour
 In the second stage, descent is rapid because the woman
is bearing down
 Increased flexion of the fetal head takes place through
labour
 The natural attitude of the fetus in utero occurring
before onset of labour throughout labour
 Flexion increases as labour progresses due to the
resistance from the pelvis, partially dilated cervix and
the pelvic floor
 Increased flexion of the head, the smaller sub-occipito
bregmatic diameter(9.5cm) enters the pelvic brim and
the occiput becomes the leading part of the fetal head
 Whatever reaches first on the pelvic floor, it rotates
forwards due to the pressure from the contractions
 Resistance from pelvic floor causes the occiput to glide
forward
 In vertex presentation, when the head is well flexed the
occiput leads and meets the pelvic floor first and rotates
 The occiput rotates anteriorly 1/8th or 45 degrees of the
circle along the left side of the pelvis towards the
symphsis pubis e.g. (until the sagittal suture lies in the
occipitoanterior (OA) pelvic diameter and the occiput
directly behind the symphysis pubis)
 Internal rotation of the head is not accompanied by internal
rotation of shoulders
 Occurs when the occiput escapes under the symphysis
pubis
 The bi-parietal diameter(9.5cm) is born
 If flexion is maintained, the sub-occipito-bregmatic
diameter distends the vaginal orifice
 The stage at which the largest presenting diameter of the
fetal head passes through the vulva orifice
 The opposite of flexion
 Following crowning, the fetal head becomes
extended on the neck releasing the sinciput, face and
chin
 The head is delivered by a movement of extension
 Extension takes place due to the uterine contraction,
maternal bearing down and the resistance of the
perineum
 The untwisting of the twist of the fetal neck that occurred
during internal rotation of the head
 After the head is completely delivered and is free of pelvic
resistance, it returns to its original position (head aligned with
shoulders as before internal rotation of head)
 The midwife should wait for restitution to take place as it
indicates the position of the fetus
◦ Prevent turning fetal head on wrong direction
◦ May cause trauma
◦ Help prevent both shoulders passing through simultaneously
◦ Decrease risk of potential perineal laceration
 Similar to the head but opposite
 Anterior shoulder reaches the pelvic floor first and
rotates anteriorly to lie under the symphisis pubis
 Accompanied by external rotation of the head
 The fetal head rotates further 4 degrees after restitution
so that the occiput lies laterally
 This allow for smaller diameters of the fetus to present
at the outlet.
 Occurs simultaneously with internal
rotation of the shoulder
 When the shoulders turn the head
also has to turn in the same
direction
 Occurs simultaneously with internal rotation
of the shoulder
 When the shoulders turn the head also has to
turn in the same direction
 READ THROUGH ON YOUR
PRESCRIBED BOOK
 Sellers 2012, page 323 ,332 and seller ,
2018
Management of first stage of labour
Objectives
▪ Define vaginal examination
▪ Perform a complete vaginal examination
during labour
The following women should be delivered in a
facility that offers emergency obstetric care.
 The primigravida
 Any woman presenting with risk factors who
has not been seen by a medical practitioner
prior to onset of labour
 The grand multipara
 Any woman who has a bad obstetric history
 Any identified risk factor in the woman or any
abnormal condition of the fetus
 A woman younger than 16 or older than 35
years of age.
▪ Vaginal examination as an essential clinical
assessment tool that provides the most exact
measure of labour progress.
▪ NB The procedure should be fully
explained to woman and should clean or
swab the perineum before V.E and should
be done 4 hourly or when is needed.
On admission , is to find out if the woman is in
labour
To establish a baseline for the assessment of
labour
To determine the state of the membranes,
dilatation of the cervix, which part is presenting
To assess the relationship of the presenting part
to the cervix and the pelvis
 To assess the state of the presenting part, if
moulding or caput are present and if how
much.
 To ascertain the position of the fetus
 To confirm the findings made earlier
abdominal palpation
 Where there is a history of previous vaginal
bleeding during the pregnancy or where
vaginal bleeding is present
 Where the examination is not strictly needed
 In preterm labour

 Premature rupture of membranes

 The condition of the vulva and perineum
 The condition of the vagina
 The condition of the anus and rectal wall
 The state of the cervix
 The consitency of the cervix
 The effacement of the cervix
 The dilatation of the cervix
 The position of the cervix
 The station of the presenting part
 The condition of the membranes
 Which part of the fetus is presenting , the
position of the denominator , sutures, and
fontanels.
 The state of the presenting part whether
there moulding or caput
 The progress of labour
 Sellers,
P.M. 2012 Midwifery. Sellers `s
revised edition.