Physiology and Mechanics of

‘Normal’ Labour and Pregnancy

 Aims

• 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)
 Cardiovascular Changes
• Cardiovascular output increases by 30-50%, 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, i.e. it reacts more
strongly to exercise etc. This leads to murmurs
becoming more apparent
• At term, blood flow to uterus is approx 1L/min
• Most changes are reversed by 6 weeks postpartum
 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 Decreased No Change
Tidal volume Inspiratory reserve Vital capacity
Respiratory rate Expiratory reserve PO2
Minute volume Residual volume  
  PCO2  
 Renal + Urological Changes
• GFR increased in proportion to CO, leading to
decreased urea + creatinine
• Marked hydroureter + dilatation of renal
pelvises due to influence of progesterone and
pressure of foetus. This persists for 6-12 weeks
after delivery
• RF heavily influenced by blood supply, hence
it increases markedly in positions that relieve
uterine pressure on IVC e.g. lateral.
 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, due to pressure of
uterus, decreased motility, and relaxation of
sphincter.
• Reduced HCl production  GI ulcers much
less common in pregnancy
 Haematological Changes

• White cell count increased.

• 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
 Endocrine Changes
• Pregnancy alters systemic protein binding, subtly
altering all hormone systems
• Placenta secretes hormone similar to TSH, 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
Physiology of Labour
 Late Pregnancy

• Braxton-Hicks contractions start around 26

weeks but may not be felt until much later
• CO becomes more sensitive to body
position, e.g. especially recumbent
• Marked leucocytosis just prior to and
during labour
 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. Likely also mediated by
prostaglandins.
• Membranes can rupture at any time (often assisted but
ARM is NOT part of normal labour). This event tends to
trigger active labour, again likely due to the release of
prostaglandins (true mechanism not fully understood)
 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, 30mins in multip but
lenthened by epidural analgesia
• Upper segment continues to shorten and thicken.
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:
 Six manoeuvres of delivery
1. Engagement of the fetal head in the transverse position. The
baby is looking across the pelvis at one or other of the
mother's hips.
2. Descent and flexion of the fetal head
3. Internal rotation. The fetal head rotates 90 degrees to the
occipito-anterior position so that the baby's face is towards the
mother's rectum.
4. Delivery by extension. The fetal head passes out of the birth
canal. Its head is tilted backwards so that its forehead leads the
way through the vagina.
5. Restitution. The fetal head turns through 45 degrees to restore
its normal relationship with the shoulders, which are still at an
angle.
6. External rotation. The shoulders repeat the corkscrew
movements of the head, which can be seen in the final
movements of the fetal head.
 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, contractions tend to stop for brief
period
• Placenta separated due to ‘shearing effect’ of uterus contracting
after foetus delivered, thereby reducing size of site of attachment
• Retroplacental haematoma forms, 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
 Past DRCOG Questions

• http://www.drcog-mrcog.info/mcq%20pape
rs%201%20-%205.htm
 Regarding Labour:
• the latent phase may last for more than four hours  T
• the active phase should be associated with cervical
dilatation at a rate of at least 1 cm. per hour  T
• the active phase starts when the cervix is effaced and F
2 cm. dilated 
• involves artificial rupture of the membranes  F
• is best charted using a partogram  T
• epidural anaesthesia has an adverse effect on the rate
of progress in the 1st. stage of labour F
 The second stage:
• starts with the onset of maternal expulsive effort
and ends with the delivery of the baby.  F
• should not last more than one hour in the
primigravida. 
F
• continuous electronic monitoring should be used
in all cases. 
F
• opiates should be used for pain relief.  F
• may be prolonged in association with regional
anaesthesia. T
 Active management of the third
stage:
• always involves the use of an intravenous
F
oxytocic 
• signs of placental separation should be awaited F
before cord traction is used 
• the cord should be clamped immediately to F
prevent haemorrhage from the baby 
• reduces the incidence of retained placenta  F
• reduces the incidence of post-partum haemorrhage
T
 Normal Labour:
• is associated with internal rotation of the head  T
• is associated with extension of the delivered head  T
• does not occur with mento-posterior position  T
• does not occur with brow presentation  T
• should not be attempted after two Caesarean sections  F
• carries less risk to the mother than Caesarean section  T
• involves episiotomy  F
• involves physiological management of the third stage  F
• is associated with blood loss < 350 ml 
F
 Normal pregnancy:
• the key stages of organogenesis occur between 10 and 12 F
weeks
• maternal metabolic rate increases by about 25% T
• increased maternal metabolic rate is mainly caused by the T
foetus and placenta
T
• blood volume increases by about 30%
• red cell mass increases by about 40% F
• erythrocyte sedimentation rate remains within the non- F
pregnant range
• cardiac output increases T
• glomerular filtration rate increases by up to 50% T
• ureters and renal pelves dilate, but return to normal within
two weeks of delivery F
• iron supplementation should be given routinely F
 References

• http://www.merck.com/mmpe/sec18/ch260/
ch260b.html
• http://www.uptodate.com/patients/content/t
opic.do?topicKey=labordel/10159
• www.accd.edu/sac/nursing/rnsg2261/PDF
WH/StagesOfLabor.pdf