Physiology and Mechanics of ‘Normal’ Labour and Pregnancy

• Understand the physiological changes that occur in a normal pregnancy • Understand the physiology and mechanics influencing the four stages of a normal labour. • Pass the DRCOG

Physiology of Pregnancy (From 38 weeks after conception or 40 weeks after first day of last period) .

i.e. blood flow to uterus is approx 1L/min • Most changes are reversed by 6 weeks postpartum . it reacts more strongly to exercise etc. peaking at approx 24/40 • Mediated by increased pulse and stroke volume • Renin level increase  angiotensin I level increase • Blood volume increases in proportion to CO • Circulation becomes hyperdynamic. This leads to murmurs becoming more apparent • At term.Cardiovascular Changes • Cardiovascular output increases by 30-50%.

Respiratory Changes • Progesterone-mediated increase in tidal volume + resp rate  reduced pCO2 • O2 consumption increases by approx 20% to meet additional metabolic needs • Hyperaemia and oedema of respiratory tract Increased Tidal volume Respiratory rate Minute volume Decreased Inspiratory reserve Expiratory reserve Residual volume PCO2 No Change Vital capacity PO2 .

g. leading to decreased urea + creatinine • Marked hydroureter + dilatation of renal pelvises due to influence of progesterone and pressure of foetus. hence it increases markedly in positions that relieve uterine pressure on IVC e. lateral.Renal + Urological Changes • GFR increased in proportion to CO. This persists for 6-12 weeks after delivery • RF heavily influenced by blood supply. .

GI System Changes • Mechanical constipation occurs • Hormone-mediated relaxation of all smooth muscle  decreased GI motility • Increase in ALP due to placental production • Heartburn common. decreased motility. • Reduced HCl production  GI ulcers much less common in pregnancy . and relaxation of sphincter. due to pressure of uterus.

• Plasma volume increases more than cell count. thus Hb tends to lower by dilution • Total iron requirement (in addition to normal) = 1G for duration of pregnancy (easily obtained in diet) • Reduced protein C and protein S and increase in other clotting factors  tendency to clot • ESR raised .Haematological Changes • White cell count increased.

Endocrine Changes • Pregnancy alters systemic protein binding. leading to increased thyroid function (and sometimes Sx resembling hyperthyroid) • Metabolic rate rises by approx 25% • Placenta secretes CRH  ACTH production  increased aldosterone + cortisol which contribute to oedema of pregnancy • Pituitary enlarges and prolactin increases tenfold • Increased corticosteroids and progesterone lead to increased insulin resistance . subtly altering all hormone systems • Placenta secretes hormone similar to TSH.

Physiology of Labour .

e.g.Late Pregnancy • Braxton-Hicks contractions start around 26 weeks but may not be felt until much later • CO becomes more sensitive to body position. especially recumbent • Marked leucocytosis just prior to and during labour .

• Membranes can rupture at any time (often assisted but ARM is NOT part of normal labour). Likely also mediated by prostaglandins. This event tends to trigger active labour. again likely due to the release of prostaglandins (true mechanism not fully understood) .First Stage – Latent Phase • • • • Few days leading up to active labour Prostaglandin mediated ‘ripening’ of cervix Irregular contractions begin effacement ‘Bloody show’ – mucous and blood which previously plugged cervix liquefies.

First Stage – Active Phase • Said to begin once regular contractions established. or effaced cervix 3cm dilated • Cervix dilates at approx 1cm/hr and is incorporated into lower segment • Upper segment progressively shortens and thickens. due to spirals of smooth muscle contracting • Lower segment stretches and thins • Ends when cervix is 10cm dilated (‘Fully’) .

Second Stage • Begins when cervix fully dilated • Lasts about 1hr in primip. Majority of fetus in lower segment • Head passes intraspinous diameter – the narrowest part of the pelvis • Perineum softened by congestion with blood (not unlike arousal) • Delivery accomplished by the following six manoeuvres: . 30mins in multip but lenthened by epidural analgesia • Upper segment continues to shorten and thicken.

Descent and flexion of the fetal head Internal rotation. Engagement of the fetal head in the transverse position. The shoulders repeat the corkscrew movements of the head. The fetal head turns through 45 degrees to restore its normal relationship with the shoulders. 3. 5. Delivery by extension. The baby is looking across the pelvis at one or other of the mother's hips. External rotation. . The fetal head passes out of the birth canal. which can be seen in the final movements of the fetal head. 2. Its head is tilted backwards so that its forehead leads the way through the vagina. 4. The fetal head rotates 90 degrees to the occipito-anterior position so that the baby's face is towards the mother's rectum. 6.Six manoeuvres of delivery 1. Restitution. which are still at an angle.

exuding downwards pressure • Active management is now so common to be considered NORMAL • Oxytotic (commonly syntocinon) given by IM injection to stimulate uterine contraction • Placenta can be delivered by maternal effort or by controlled cord traction (CCT) • Active Management has been shown to reduce PPH . contractions tend to stop for brief period • Placenta separated due to ‘shearing effect’ of uterus contracting after foetus delivered.Third Stage • From delivery of fetus to delivery of placenta • Usually within 15-30 mins (depends on choice of active or expectant management) • Immediately after delivery. thereby reducing size of site of attachment • Retroplacental haematoma forms.

info/mcq%20papers%201%20%205.drcogmrcog.htm .Past DRCOG Questions • http://www.

per hour • the active phase starts when the cervix is effaced and 2 cm.Regarding Labour: • the latent phase may last for more than four hours • the active phase should be associated with cervical dilatation at a rate of at least 1 cm. stage of labour T T F F T F . dilated • involves artificial rupture of the membranes • is best charted using a partogram • epidural anaesthesia has an adverse effect on the rate of progress in the 1st.

• may be prolonged in association with regional anaesthesia. • opiates should be used for pain relief. • continuous electronic monitoring should be used in all cases. F F F F T . • should not last more than one hour in the primigravida.The second stage: • starts with the onset of maternal expulsive effort and ends with the delivery of the baby.

Active management of the third stage: • always involves the use of an intravenous oxytocic • signs of placental separation should be awaited before cord traction is used • the cord should be clamped immediately to prevent haemorrhage from the baby • reduces the incidence of retained placenta • reduces the incidence of post-partum haemorrhage F F F F T .

Normal Labour: • • • • • • • • • is associated with internal rotation of the head is associated with extension of the delivered head does not occur with mento-posterior position does not occur with brow presentation should not be attempted after two Caesarean sections carries less risk to the mother than Caesarean section involves episiotomy involves physiological management of the third stage is associated with blood loss < 350 ml T T T T F T F F F .

but return to normal within two weeks of delivery • iron supplementation should be given routinely F T T T F F T T F F .Normal pregnancy: • the key stages of organogenesis occur between 10 and 12 weeks • maternal metabolic rate increases by about 25% • increased maternal metabolic rate is mainly caused by the foetus and placenta • blood volume increases by about 30% • red cell mass increases by about 40% • erythrocyte sedimentation rate remains within the nonpregnant range • cardiac output increases • glomerular filtration rate increases by up to 50% • ureters and renal pelves dilate. WH/StagesOfLabor.accd.References • http://www.merck.html • http://www.pdf .do?topicKey=labordel/10159 • ch260b.

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