NORMAL LABOR

DR. NATASHA GUPTA

OBSTETRIC & GYNAECOLOGY
ASSISTANT PROFESSOR
AIIMS, VIJAYPUR, JAMMU
LABOR –

Series of events that take place in genital organs in an effort to expel the viable
products of conception (fetus, placenta and the membranes) out of the womb
through vagina into the outer world is called Labor.

PARTURIENT – The patient in labor

PARTURITION – The process of giving birth

DELIVERY – Expulsion or extraction of a viable fetus out of the womb.

Vaginal/ abdominal

Not synonymous with labor.

NORMAL LABOR (EUTOCIA)

• Spontaneous in onset

• Term

• Vertex presentation

• Without undue prolongation

• Natural termination with minimal aid

• No complication
ABNORMAL LABOR (DYSTOCIA)

• Any deviation from criteria of normal labor

• Presentation other than vertex

• Vertex presentation but with associated complication

• Complication affecting the course of labor/modifying the nature of

termination/adversely affecting maternal or fetal prognosis
CAUSES OF ONSET OF LABOR

• ENDOCRINE

• BIOCHEMICAL

• MECHANICAL
1. UTERINE DISTENTION

Gap junction proteins, receptors for oxytocin and specific

contraction associated proteins

2. FETOHYPOTHALAMIC-PITUITARY-ADRENAL AXIS

INC CRH - INC ACTH - FETAL ADRENALS -INC CORTISOL- INC E +

P FROM PLACENTA
ROLE OF ESTROGEN

• Increase release of oxytocin from maternal pituitary

• Promotes synthesis of myometrial receptors for oxytocin, PGs, and

increase in gap junctions

• Stimulates lysosomal disintegration – Inc PGs synthesis

• Stimulates synthesis of myometrial contractile protein – actomyosin Camp

• Increase excitability of myometrial cell membranes

PROGESTERONE

• DHEA-S & Cortisol inhibit conversion of fetal pregnenolone to

progesterone

• Progesterone level fall before labor

• Alteration in E:P ratio – PGs synthesis

PROSTAGLANDINS

• Sites of synthesis of PGs – amnion, chorion, decidua, myometrium

• Est, Glucocorticoids, Mechanical stretching, cytokines infection,

vaginal examination, separation or rupture of membranes

• PGs enhance gap junctions

BIOCHEMICAL MECHANISMS

• PhospholipaseA2 in lysosomes of fetal membranes – Esterified

arachidonic acid – AA – PGs synthesis – act on SR – inhibit Camp
generation – increase local free Ca2+ - uterine contraction

• PGs synthesis reaches peak during placental expulsion – to control

PPH
OXYTOCIN AND MYOMETRIAL OXYTOCIN RECEPTORS

Maximum at fundus

Maximum during labor

Receptor sensitivity increases during labor

Ferguson reflex – Vaginal examination and amniotomy cause rise in

maternal plasma oxytocin level

Fetal plasma oxytocin – increases during spont labor

NEUROLOGICAL FACTOR

Alpha and beta adrenergic receptors are present in myometrium

Estrogen – alpha

Progesterone - Beta
CONTRACTILE SYSTEM OF
MYOMETRIUM
• Actin

• Myosin

• ATP

• Myosin light chain kinase MLCK

• Ca2+
• Calcium stored within the cells of SR and in mitochondria

• Progesterone promotes storage of Ca2+

• PGF2 , E2, Oxytocin – stimulate its release

• Intracellular Ca2+ - Calmodulin calcium complex – MLCK –
Phosphorylation of M+A complex – Myometrial contraction

• Decrease of intracellular Ca2+ - dephosphorylation of myosin light

chain – inactivation of MLCK – myometrial relaxation
FALSE PAIN

• Stretching of cervix and LUS with irritation of neighbouring ganglia

• Appear prior to onset of true labor pain by 1-2 weeks in primigravida/ few days
before in multigravida

• Dull in nature

• Confined to lower abdomen and groin

• No hardening of uterus

• Relieved by enema and sedation

TRUE LABOR/PREMONITORY STAGE
Begins 2-3 weeks before onset of true labor in primigravida and few days before in
multigravida

1. Lightening

PP sinks into true pelvis

Active pulling up of lower pole of uterus around the PP

Incorporation of LUS into wall of uterus

Fundal Height Decreases

Sense of relief due to decrease pressure on diaphragm, Increase in frequency of

micturition
2. Cervical changes

Riped cervix

Soft

80% effaced

Admits one finger

Canal dilated
TRUE LABOR PAIN

• Painful uterine contractions at regular intervals

• Frequency, intensity and duration of contractions increase

progressively

• Associated with show

• Bag of waters formed

• Not relieved by enema/sedatives

SHOW

• Profuse cervical secretion

• Slight oozing of blood from rupture of capillary vessels of cervix

• Expulsion of cervical mucus plug mixed with blood is called show

BAG OF WATERS

• With dilatation of cervical canal , lower pole of fetal membranes

become unsupported and tends to bulge into cervical canal.

• It contains liquor – Bag of Water

• With intense uterine contractions - bag becomes tense and convex

STAGES OF LABOR
• FIRST STAGE
Onset of true labor pain and ends with full dilatation of cervix.
Average duration – 12 hrs in Primigravida
6 hours in multigravida

• SECOND STAGE
Full dilatation of cervix to expulsion of fetus from birth canal
Propulsive Phase – FD to descent
Expulsive Phase – Delivery after the descent
• THIRD STAGE
After expulsion of fetus to expulsion of placenta.
15 min – duration

FOURTH STAGE
Stage of Observation - 1 hour
PHYSIOLOGY OF NORMAL LABOR

Marked hypertrophy and hyperplasia of uterine muscle

Enlargement of uterine muscle

Length of uterus on term – 35 cm

Uterus is pyriform/ ovoid

Cervical canal – thick, tenacious and mucus plug

UTERINE CONTRACTIONS

• Pacemaker – Tubal Ostia

• Waves of contraction travel downward

• Good synchronization of contraction waves of both sides

• Fundal dominance
• Regular pattern

• Upper segment contract more strongly

• Intra- amniotic pressure rises beyond 20 mmHg during contraction

• Good relaxation occurs in between contractions to bring down the

intra-amniotic pressure to less than 8 mmHg

• During contraction – uterus become hard and pushed anteriorly to

make long axis of uterus in line with pelvic axis

CAUSES OF PAIN DURING LABOR

Myometrial Hypoxia

Stretching of peritoneum over fundus

Stretching of cervix during dilatation

Stretching of ligaments

Compression of nerve ganglions

Pain of uterine contractions – T10 –L1

Pain of cervical dilatation and stretching – referred to back – Sacral plexus

UTERINE CONTRACTION
• TONUS

IUP between contractions

1st stage - 8-10 mmHg

• INTENSITY

Degree of uterine systole

1st stage IUP – 40-50 mmHg

2nd stage IUP – 100-120 mmHg

UTERINE CONTRACTION

• DURATION

Increase gradually

• FREQUENCY

Increase gradually
RETRACTION
• Muscle fibers of uterus become permanently shortened in labor.

• Once for all

RETRACTION HELPS IN

• Formation LUS, dilatation and effacement of cervix

• Descent and expulsion of fetus

• Reduce surface area and separation of placenta

• Effective hemostasis after separation of placenta

EVENTS IN FIRST STAGE OF LABOR

First stage is chiefly concerned with preparation of birth canal so to

facilitate expulsion of fetus in second stage

Main events in 1st stage –

Dilatation and effacement of cervix

And full formation of LUS

• UTERINE CONTRACTION AND RETRACTION

• FETAL AXIS PRESSURE

• BAG OF MEMBRANES

• VIS - A - TERGO
UTERINE CONTRACTION AND RETRACTION

• Polarity of uterus –

• US – Canal is opened up from above down

• LS and cervix dilate in response to forces of contraction of US

FETAL AXIS PRESSURE

Fetal vertebral column is straightened by contractions of circular

muscle fibers of body and uterus

Fundal strong force transmitted to fetal podalic pole

Mechanical stretching and opening of cervical canal

Absent in transverse lie

BAG OF MEMBRANES

Membranes are attached loosely to decidua lining the uterine cavity except over
the internal os

Hind waters – Fetus with bulk of water above the girdle of contact

Fore waters – Water below the girdle of contact

Uterine contractions generate hydrostatic pressure in forewaters – dilate cervical

canal like a wedge
VIS - A - TERGO

Downward thrust of presenting part of fetus and upward pull of cervix

over the lower segment.- final phase of dilatation and retraction of
cervix

This phenomenon is lacking in transverse lie

EFFACEMENT

Process by which the muscular fibers of cervix are pulled upward and merges
with fibers of LUS.

Cervix becomes thin during first stage of labor or even before that in
primigravida

Primigravida – Effacement preceeds dilatation of the cervix.

Multiparae - E and D occur simultaneously

LOWER UTERINE SEGMENT
• Developed from isthmus ( Anatominal – histological IO)

• Formed maximally during labor

• 7.5 – 10 cm

• Become gradually thin

• Poor retractile property

CLINICAL SIGNIFICANCE
• Receptive relaxation enables expulsion of fetus by formation of complete
birth canal along with fully dilated cervix

• Implantation of placenta in LUS – Placenta Previa

• Cesarean section is performed through this segment

• Poor decidual reaction in this segment – morbidly adherent placenta

• Obstructed labor – LUS stretched and ruptures

• Poor retractile property - PPH

EVENTS IN SECOND STAGE OF
LABOR
• Descent and delivery of fetus through birth canal

2 phases

• Propulsive – From FD until head touches the pelvic floor

• Expulsive – Time mother has irresistible desire bear down and push
until the baby is delivered
• With FD of cervix , membranes rupture

• Uterine retraction and contraction become stronger

• Delivery of fetus – downward thrust offered by contractions of

circular muscle fibers to keep fetal axis straight
• Voluntary contractions of abdominal muscles

• Tendency of fetus to push the fetus back into the uterine cavity by
elastic recoil of the tissue of the vagina and the pelvic floor – counter
balanced by power of retraction

• US – becomes thicker, LS – becomes thinner

• Fetus counteracts against resistance offered by pelvic floor

• After expulsion of the fetus – uterine cavity permanently reduced in
size
EVENTS IN THIRD STAGE OF LABOR

Placental Separation

Descent to lower segment

Expulsion of fetus and placenta

• PLACENTAL SEPARATION

Placental attachment corresponds to 20 cm in diameter

Mechanism of separation

Marked retraction reduces surface area at placental site to half.

Placenta is inelastic – ultimate separation

Plane of separation – deep spongy layer of D. basalis

2 ways of separation
CENTRAL SEPARATION (SCHULTZE)
Detachment from centre
Facilitated by weight of placenta and retroplacental blood

MARGINAL SEPARATION (MATHEWS – DUNCAN)

Detachment starts from margin
More frequent
SEPARATION OF MEMBRANES

• Membranes which are attached loosely in active part – thrown into multiple
folds

• Membranes attached to lower segment –already separated during stretching

of LUS

• Separated partly by uterine contraction and weight of placenta

• Membranes separated carry with them remnants of D. Vera giving the outer
surface of chorion its characteristic roughness
EXPULSION OF PLACENTA

• After complete separation of placenta, it is forced down into flabby

lower uterine segment by contraction and retraction of the uterus

• Expelled out by either voluntary contraction of abdominal muscles

(bearing down effort) or by manual procedure
MECHANISM OF CONTROL OF
BLEEDING
Innumerable torn sinuses which have free circulation of blood from
uterine and ovarian vessels have to be obliterated

• Complete retraction

• Living ligature

• Thrombosis

• Apposition of walls of the uterus - myotamponade

THANK YOU…………..