Mechanism of Normal

Labour
 Definition of labour
• Occurrence of regular, painful uterine
contractions
• Coupled with progressive dilatation of the
cervix
• Plus or minus progressive descent of the
presenting part
• Onset of labour usually difficult to pin-point
 Stages of labour
• First stage – from onset of labour to full
dilatation of the cervix
• Second stage – from full dilatation of the
cervix to delivery of the baby
• Third stage – from delivery of the baby to
delivery of the placenta
• Latent phase of labour is from onset of
labour to full effacement of the cervix
• After that is active phase of labour
Determinants of progress in labour
• Powers – strength of the uterine
contractions
• Passenger – size, presentation and
position of the foetus
• Passage – diameters of the maternal
pelvis
 Presentation lie, and position
• The presenting part is that part of the
foetus which is lowermost & closest to the
pelvic brim
• The presentation is cephalic if head is
lowermost & breech if buttocks
• The lie describes long axis of the foetus in
relation to the maternal spine
• Lie may be longitudinal, transverse or
oblique
 Presentation, lie and position
(continued)
• Position refers to the relationship of a
designated point of presenting part in
relation to maternal right & maternal left
sides
• Occiput for cephalic presentation
• Sacrum for breech presentation
• Chin (Mento) for face presentation
• Shoulder or back for transverse lie
 Presentation, lie and position
(continued)
• With cephalic presentation may have
ROA, ROP, ROT, LOA, LOP, LOT
positions
• Face presentation may have RMA, RMP,
RMT, LMA, LMP, LMT
• Breech presentation, RSA, RSP, RST,
LSA, LSP, LST
• Dorso-anterior & dorso-posterior for
transverse lie
 The Pelvic Cavity
• Divided into the pelvic inlet, mid-cavity and
outlet
• The transverse diameter is the widest at
the inlet (a transverse oval)
• The diameters are equal at the mid-cavity
(circular in cross-section)
• The antero-posterior diameter is the
widest at the outlet (anteroposterior oval)
 Cardinal movements of labour
• Refers to the changes in position and
attitude of the foetus as it descends
through the birth canal
• Refers mostly to the presenting part
• These are, engagement, descent, flexion,
internal rotation, extension, external
rotation or restitution, and expulsion.
 Stages in mechanism of labour
• Head of foetus enters pelvic inlet with its
longest AP diameter in the transverse
diameter of the pelvic inlet
• Head undergoes FLEXION as it reaches
the pelvic floor
• The occiput rotates anteriorly in
INTERNAL ROTATION
• Both facilitated by gutter shape of pelvic
floor (slopes downwards and anteriorly)
 Mechanism of labour
(continued)
• N.B. – rotation of the occiput to the
posterior position results in occipito-
posterior position
 Mechanism of labour (continued)
• Head begins to undergo EXTENSION
• Distends the perineum and is born by
extension
• At the same time the shoulders enter the
pelvis in the transverse diameter and also
undergo internal rotation
• After head is born it undergoes
RESTITUTION and is born by further
EXTENSION then Delivery
 The partogram
• Is a graphical presentation of the progress
of labour
• After the work of friedman (1954)
• Philpott introduced use of the partogram in
Zimbabwe as a composite labour graph
• Partogram also captures maternal and
foetal condition
• Allows progress of labour to be assessed
at a glance
 Foetal condition
• Parameters captured on partogram
include foetal heart, presence of moulding
and caput
• Normal foetal heart rate is 120 to 160
beats per minute
• Foetal heart may be auscultated with
foetal stethoscope, hand-held doppler or
cardio-tocograph
 Grades of the foetal heart
• Grade 1 – foetal heart 120 to 160 beats
per minute, no change during contractions
• Grade 2(a) – Foetal tachycardia (>160
beats per minute
• Grade 2(b) – Foetal heart of 100 to 120
beats per minute
• Grade 3(a) – Early deceleration during a
contraction, normal baseline
 Grades of foetal heart
(continued)
• Grade 3(b) – Early deceleration during a
contraction, abnormal baseline
• Grade 4(a) – Late deceleration during a
contraction, normal baseline
• Grade 4(b) – Late deceleration during a
contraction, abnormal baseline
• Grade 5 – bradycardia persistently below
100 beats per minute
 State of the foetal membranes
• Space for recording whether membranes
are intact or ruptured
• If intact capital letter ‘I’ inserted when a
vaginal examination done
• If ruptured, whether liquor clear (‘C’),
meconium-stained (‘MSL’) or blood-
stained (‘BSL’)
 Caput & moulding
• Caput – scalp oedema over the head in a
cephalic presentation
• May be severe enough to prevent sutures
of foetal scalp from being felt
• Caput is presented on the partogram as +,
++ or +++
• Moulding is overlapping of the scalp bones
at the sutures
Caput and moulding (continued)
• Moulding may be between the two parietal
bones (pp)
• May be between the occipital bones & the
parietal bones (op)
• Denoted with a + when bones are just
touching
• ++ when bones are overlapping but
separable by digital pressure
• +++ when bones are overlapping and not
separable by digital pressure
 Cervicograph
• Cervicograph part of partogram plots
cervical dilatation versus time
• As a guide, vaginal examination done
every 4 hours during latent phase & every
2 hours during active phase
• Primiparas dilate at average of 1cm per
hour & multiparas at 1,5cm per hour
 Cervicograph (continued)
• Partograph has section for latent phase
• Graph can be transferred to the active part
when patient is in active phase
• Alert, transfer & action lines drawn at 8hr,
10hr & 12hr marks of graph
• Alert & transfer lines meant for workers in
the peripheries on when to be alert to slow
progress & when to transfer those with
poor progress to a higher level hospital
 Uterine contractions
• Like foetal heart, monitored during last 10
minutes of every 30 minutes during labour
• Mild contractions – last less than 20
seconds (depicted with distinct dots)
• Moderate – last 20 to 40 seconds
(depicted with diagonal lines)
• Strong – last more than 40 seconds
(depicted with complete shading)
 Maternal condition
• Partogram also has space for regular
recording of:
– Maternal blood pressure
– Maternal pulse
– Maternal temperature
– Urinalysis findings
– Drugs given
– IVI fluids given
Breech and other malpresentations
• Breech is when foetus presents by the
buttocks
• Occurs in about 2% of singleton deliveries
and 3.17% of deliveries overall
• High risk of perinatal morbidity and
mortality (four times higher than cephalic
presentation)
 Factors associated with breech
presentation
• Multiparity – softer and more pliable uterus
• Prematurity – Breech presentation more
common at premature gestations
• Uterine abnormalities – congenital or caused by
position of the placenta
• Placenta praevia
• Multiple pregnancy
• Congenital foetal abnormalities
• Cephalo-pelvic disproportion
 Types of breech
• Extended, incomplete or frank breech –
flexed at the hips but extended at the
knees
• Flexed or complete – flexed at the hips
and flexed at the knees
• Footling breech – One or both legs slips
through the cervix and leads ahead of the
buttocks (high risk of cord prolapse)
 Diagnosis
• Breech felt above the pelvic brim – softer
and irregular compared to head
• Firmer, regular and ballotable head felt
above the umbilicus
• Foetal heart heard best above the
umbilicus
• Confirmation by ultrasound
• Ultrasound also shows position of placenta
and rules out foetal abnormalities
Hazards of vaginal breech delivery
• Trauma to the aftercoming head –
intracranial haemorrhage
• Fractures of the humerus, femur or
clavicle
• Injury to the brachial plexus
• Injury to intra-abdominal organs
• Cord prolapse with intrapartum asphyxia
Selection for delivery by caesarean
section
• Primigravidas
• Multigravidas with bad obstetric history
• Elderly primigravidas (e.g. – greater than 35
years old)
• Previous caesarean section
• Estimated foetal weight > 3.5kg
• Presence of other complications such as
moderate to severe hypertension or gestational
diabetes
Selection for delivery by caesarean
section (continued)
• Premature labour where breech is
estimated to be between 1000 to 1500g
• Premature labour where gestation is
between 28 to 31 weeks
• Where ultrasound scan shows
hyperextended foetal head
 Vaginal breech delivery
• May be spontaneous, assisted or breech
extraction
• Spontaneous likely in premature breech
deliveries in multiparous patients
• Associated with higher foetal morbidity
and mortality because delivery is
uncontrolled
Assisted vaginal breech delivery
• Monitor foetal heart closely
• Monitor progress of labour closely to
detect disproportion
• Adequate analgaesia
• Wait for full dilatation until breech distends
perineum
• Ease out the legs and gently hold baby at
hips with back uppermost
 Assisted vaginal breech delivery
(continued)
• Allow baby to descend until scapulas and
one axilla are seen
• Turn baby through 180 degrees to deliver
anterior shoulder and opposite 180
degrees to allow delivery of posterior
shoulder
• Back of baby stays uppermost all the time
• Allow further descent until nape of neck is
seen
 Assisted vaginal breech delivery
(continued)
• Hold baby by the feet to allow delivery of
the head
• Face and head born by sweeping motion
across perineum
 Breech extraction
• In cases of foetal distress or cord prolapse
• Exclude disproportion
• Hand placed into the uterus to pull down
anterior leg first
• Leg might need to be flexed at the knee
first if it is an extended breech
• Then delivery through precedures
described for assisted breech delivery
 Other Malpresentations –
Transverse Lie
• Predisposing factors for transverse lie
– Multiparity
– Placenta praevia
– Cephalo-pelvic disproportion
– Congenital uterine abnormalities
– Prematurity
– Foetal death
– Multiple pregnancy
 Transverse Lie - continued
• May be diagnosed antenatally by a height
of fundus lower than expected for dates
• Foetal head felt in one iliac fossa and
breech in the other
• Possible positions are dorso-anterior and
dorso-posterior
• Sometimes back may be superior or
inferior
 Transverse Lie - continued
• Diagnosis may be made in labour
• Associated with premature rupture of the
membranes and possible arm and/or cord
prolapse
• Result commonly obstructed labour and
possible uterine rupture
• Deliver by caesarean section
 Compound presentation
• An arm or foot presents alongside the
head
• An arm presents alongside the breech
• Diagnosis usually made after rupture of
the membranes
• It is possible for arm or foot to recede as
labour progresses
• Delivery by caesarean section if no
progress during the labour