Normal and Abnormal

Labour
 NORMAL LABOUR
• Defined as the progressive effacement and dilatation of the cervix in the
presence of regular uterine contractions’.

• Effacement occurs when the entire length of the cervical canal has been
taken up into the lower segment of the uterus.

• Loss of a ‘show’ (a blood-stained plug of mucus passed from the cervix)

or spontaneous rupture of the membranes (SROM) does not define the
onset of labour,
 Patient Approach
1.History taking

- LMP/ EDD / Antenatal issue

- PMH/PSH/Social hx / Family hx
- Past Obs history : Details of previous births, the size of previous babies & any complications
- Presenting complaint : Contraction pain/ SROM/ Show / Fetal movement
- Any special issues

2. General Examination
- Vital signs ( BP/ PR /PS )
- Time the contractions (LPC)
- BMI
3. Abdominal Examination
• Inspection for scars
• Lie of the fetus
• Presenting part
• Cephelic or breech
• Assess the engagement
• Transabdominal Scan
- Confirm the presentation
- Assess the Estimate Fetal Weight
- Assess the AFI
- Plot the growth chart
4.Vaginal
Examination
• Examine cervix for
• Os dilatation
• Cervix effacement
• Application of the presenting part
• Condition of Membrane intact or absent, if absent :
assess colour of liquor
- Heavily blood stained or meconium stained fluid –
• warning sign for fetal compromise
• Feel for cord or placenta
FIRST STAGE OF LABOUR
“Time from the diagnosis of labour, to full dilatation of the cervix (10 cm)”

Divided into 2 stages

- Latent phase ( Os less than 3 cm )
- Active phase ( Os 3cm – 10cm )

Descent of the fetal head is measured in labour by:

1. Abdominal examination.
2. Vaginal examination,
• the ‘station’ of the fetal head with respect to the ischial spines
• The ischial spines are designated station zero.
• When the head is above the spines, it is said to be at -1, -2, -3, -4 -5cm
• When the head is below the spines it is +1, +2, +3, +4 and +5cm ,
• +5cm representing crowning of the head.
 FIRST STAGE OF LABOUR
• Progress is measured in terms of dilatation of the cervix and descent of the
presenting part.
• Progress is recorded by means of a partogram.
• The average rate of cervical dilatation in primigravidae
is 1cm per hour.
SECOND STAGE OF LABOUR
• Begins with full dilatation to the delivery of fetus

• Progress is measured in terms of descent and rotation of the fetal head on

vaginal examination.

• Two phases:
• Passive phase: From full dilatation until the head reaches the pelvic floor.
• Active phase: When fetal head reaches pelvic floor. Usually associated with strong
desire to push.
MECHANISM OF LABOUR
• Engagement
• Flexion
• Descent
• Internal rotation (Head has now rotated from a lateral(occipito-transverse) position
at the pelvic brim to an antero-posterior position at the pelvic outlet.) The position of
the head as it traverses the canal is described according to the position of the occiput.
The head usually rotates from an occipitotransverse to an occipitoanterior position.
• Extension (as the head delivers).
• External rotation (back to transverse position, allows rotation of shoulders to
anteroposterior position.)
• Expulsion
EPISIOTOMY & PERINEAL TEARS
• An episiotomy is a surgical procedure in
which the perineum is cut with a scissors
with the intention of widening the soft
tissue diameter in order to prevent a
severe perineal tear or accelerate
delivery.

• There is little evidence to support routine

use of episiotomy. Indications include: A
rigid perineum and shoulder dystocia.
EPISIOTOMY & PERINEAL TEARS

Royal College of Obstetricians and Gynaecologists (RCOG). The management of third- and fourth-degree perineal tears. Green-top Guideline No. 29 . RCOG Press. London. Mar
2007
THIRD STAGE OF LABOUR
 Signs of placental separation:
 Lengthening of umbilical cord
 Gush of blood per vaginam
 ‘Rising up’ of the fundus

1. The third stage of labour is actively managed to minimise the risk of postpartum haemorrhage.
2. Active management involves administration of Syntocinon (oxytocin) or Syntometrine (oxytocin
and ergometrine) and delivery of the placenta via controlled cord traction.
3. The uterine fundus is rubbed up to ensure that it is well contracted and the placenta is
examined to ensure that it is complete.
4. Inspect placenta for missing cotyledons or succenturiate lobe
• If anything suspected -> manual removal (US guided)
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ABNORMAL LABOUR
Normal Labour
Defined as:
Beginning from 37- 42 weeks, progressing at an acceptable rate
and resulting in the spontaneous vaginal delivery(SVD) of a live
neonate in good condition in the occipitoanterior position

Any deviation from this is ‘abnormal labour’

Landmarks on the Fetal Skull
 Fetal skull from superior
and lateral view

Obstetrics by Ten Teachers 19th Edition JMJ 24

 FETAL SKULL DIAMETERS
• Biparietal diameter 9.5 cm. 
Between parietal eminences The greatest transverse diameter

• Suboccipitobregmatic 9.5 cm. 

Middle of the bregma (forehead) to undersurface of the occipital bone at the neck
The presenting diameter of the well flexed head in labour

• Occipitofrontal 11.5 cm 
Root of the nose to the most prominent point of the occiput
A deflexed head presents with this diameter

• Occipitomental 13 cm 
Chin to most prominent point of the occiput
The presenting diameter in brow presentation
The largest diameter of the fetal head

• Submentobregmatic 9.5 cm 
Chin to middle of bregma
The presenting diameter in face presentation
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Obstetrics by Ten Teachers 19th Edition
Abnormal labour

1. Abnormal Progress in Labour

2. Abnormal Cardiotocograph(CTG) in Labour

Prolonged Labour
• Normal progress in labour is plotted on a partogram

• Prolonged Labour refers to prolongation of the first stage of labour

• The latent phase of labour (up to 3cm),when the cervix is effacing but dilatation is
minimal, can take up to 6 hours

• In the active phase of labour (3-10cm) appropriate progress is 1cm/hr in a primigravida

and 1-2cm/hr in a multigravida

• Prolonged labour is often defined as >12 hours from onset of labour until delivery in a
primigravid.
Causes of Prolonged Labour
1. ‘The Powers’
• inefficient uterine action

2. ‘The Passages’
• maternal pelvic abnormalities

3. ‘The Passenger’
• fetal macrosomia or malpresentation
Inefficient Uterine Action
• Efficient Uterine Contractions:
• are regular contractions, lasting 60-80 seconds and have frequency of up to 7 in 15
minutes

• Inefficient Uterine Contractions:

• Contractions are not strong enough or are in-coordinate (irregular)

• Commonest cause of failure to progress in labour in primigravid patients is

inefficient uterine action
 Inefficient Uterine Action
• Management:
– Oxytocin (syntocinon)
– Intravenous infusion
– Start at low dose and increase gradually
– Aim to achieve 4 contractions in 10 minutes
– Important to monitor fetal heart rate when using oxytocin

• Caution with the use of oxytocin in a multigravida

– A multigravid woman is less likely to have inefficient uterine action
– If not progressing, it is essential to out rule a malposition or malpresentation
– The use of oxytocin in these circumstances can result in uterine rupture
Cephalopelvic Disproportion
• Presenting fetal head seems too big to pass through the pelvis

• May occur because

• Pelvis is too small or may be abnormally shaped
• Fetus is large – macrosomia, hydrocephalus
• Malpresentation of the fetal head : the larger diameter of fetal head is
presenting to the pelvis
 Management of Prolonged Labour
• Allow the labour to continue:
• If maternal and fetal well being are satisfactory
• Continue in the hope of achieving a vaginal delivery

• Indications for Delivery by Caesarean Section

• Suspected Fetal compromise
• Arrest in cervical dilatation despite good contractions (with or without use of oxytocin)
• Cephalopelvic disproportion
Occipitoposterior Position
• In 20% of labours the fetal head is in the OP position

• The occipitoposterior diameter is 12cm

• In the majority of cases spontaneous rotation occurs to
OA and only 4.5% are in persistent occipitoposterior
( POP) position at delivery.

• Diagnosis in labour is on vaginal examination when the

anterior fontanelle is felt behind the symphysis pubis.
• There can be significant caput and moulding as the
vertex is compressed passing through the birth canal.
Occipitoposterior Position
• Uterine contractions may be ineffective because the poorly flexed head
fails to press down on the cervix to aid dilatation.
– Prolonged first stage of labour.
– This is corrected with oxytocin.
• The second stage is also prolonged.
– In most cases the occiput rotates forwards and normal delivery takes place or the
occiput rotates posteriorly and the baby is delivered face up.
• If rotation is incomplete then this results in deep transverse arrest
– There is an increase in operative vaginal delivery and caesarean section rate due to
failure to advance in the second stage in cases of persistent OP position
 Deep Transverse arrest of the Head
• This is an arrest in the 2nd stage of labour

• The fetal head has descended to the level of the ischial

spines and the sagittal suture lies in the transverse position

• Management:
• Delivery by caesarean section
• Rotational Instrumental Delivery
Malpresentation
• Presentation: The part of the fetus which is at the pelvic brim

• Normal presentation is vertex

• Malpresentation: any non-vertex presentation

• Face
• Brow
• Breech
• Arm/shoulder (with a transverse or oblique lie)
Face Presentation
• The head is fully extended

• Occurs in 1 in 2000 labours

• The widest diameter is the

submentobregmatic
diameter at 9.5cm

• May be mentoanterior or
mentoposterior
Face Presentation
• 90% of face presentations engage in the transverse position
and rotate to the mentoanterior (chin to front) position.

• The head is born by flexion then restitution and external

rotation occurs as in vertex presentations

• Mentoposterior position: delivery is by caesarean section

because extending the head increases the diameter and this
rarely fits through the pelvis
Face Presentation in Labour
Brow Presentation
• 1 in 10,000 labours
• Presenting Diameter: Mentovertical Diameter – 13cm
• The labour is prolonged and on vaginal examination the
supraorbital ridges and the bridge of the nose are palpable
• The head may flex and vaginal delivery is possible
• If brow presentation persists delivery is by caesarean section
Transverse / Oblique Lie
• 1 in 300 labours

• Occurs in women with high parity

because of the laxity of abdominal
wall

• Risk factors: •Vaginal delivery is not possible

• preterm labour •Delivery is by caesarean section
• placenta praevia if external cephalic version to
• abnormal uterus cephalic presentation not
• polyhydramnios possible.
Transverse / Oblique Lie
• Diagnosis is made on
abdominal palpation

• If spontaneous labour occurs

the shoulder or arm presents

• If membranes rupture there is

a risk of cord prolapse
Breech Presentation

Breech: Fetus presenting bottom-

first.
Incidence: 2-3% at term 20% at
28 weeks
 Types of Breech Presentation
• Frank/ Extended Breech (70%) – Both hips flexed, extended at knees
• Complete/ Flexed Breech (10%) – Both legs flexed at hips and knees

• Footling Breech (20%) – One or both feet tucked underneath the buttocks
 Causes of Breech Presentation
• Chance occurrence

• Obstruction to head entering pelvis

• Fibroid in lower uterine segment

• Ovarian cyst

• Placenta praevia/low lying placenta

• Fetal anomaly

• Polyhydramnios

• Uterine anomaly (e.g bicornuate uterus)

• Multiple pregnancy
Mode of Delivery for Term Breech
• If a breech presentation at term is confirmed, mode of delivery
should be discussed with the patient.

• Consideration should be given to offering the woman with a

breech presentation an external cephalic version (ECV).

• It is reasonable to offer the woman an Elective Caesarean

section.
External Cephalic Version (ECV)
• Manipulation of the fetus through the
maternal abdomen in an attempt to
turn it from a breech presentation to a
cephalic presentation

• Tocolysis may be used during ECV and

improves success rates

• Performed after 36 weeks gestation

 ECV – Success and Risks
• Success Rate – 50%
• Higher in multiparas

• Risks – Complication rate very low

• Minor: Transient CTG abnormalities, Rupture of membranes

• Major: Fetomaternal Haemorrhage, Placental Abruption

• Risk of emergency CS within 24 hours – 0.5%

• Anti-D should be administered to rhesus negative patients following

ECV
Abnormal CTG in Labour
• The CTG in labour shows the fetal heart rate and records
uterine activity

Department of Obstetrics & Gynaecology, RCSI

CTG + Decelerations
• Early Deceleration:
• Begins at the onset of a contraction and recovers by the end of a contraction
Aetiology: compression of the fetal head during a contraction

• Variable Deceleration:
• Inconsistent with the shape and relationship to contractions. Accelerations often proceed and
follow a variable deceleration
Aetiology: Transient compression of the umbilical cord

• Late Deceleration:
• occurs after the onset of a contraction and recovers more than 15sec after the peak of the
contraction
Aetiology: Fetal Acidosis
Examples of CTG
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