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CHAPTER 12

Normal Labour

DEFINITIONS

Labour - series of events that take place in the genital organs in an effort to expel the viable products of conception out of the womb through the vagina into the outer world.

Delivery - the expulsion or extraction of a viable fetus out of the womb.

Normal Labour (Eutocia) - Labour is called normal if it fulfils the following criteria:

1. delivery of a single baby

2. by vertex presentation

3. vaginally

4. at or near term

5. with spontaneous onset

6. the whole process of delivery getting over within 24 hours

7. with minimal intervention

8. leaving behind a healthy mother and a healthy fetus.

Abnormal Labour (Dystocia) — any deviation from the definition of normal labour.

CAUSE OF ONSET OF LABOUR

It is unknown but the following theories were postulated:

(I) Hormonal factors:

1. Oestrogen theory: During pregnancy, most of the oestrogens are present in a binding form. During the last trimester, more free oestrogen appears increasing the excitability of the myometrium and prostaglandins

synthesis.

2. Progesterone withdrawal theory: Before labour, there is a drop in progesterone synthesis leading to predominance of the excitatory action of oestrogens.

3. Prostaglandins theory: Postaglandins E2 and F2 are powerful stimulators of uterine muscle activity. PGF2 was found to be increased in maternal and fetal blood as well as the amniotic fluid late in pregnancy and during labour.

4. Oxytocin theory: Although oxytocin is a powerful stimulator of uterine contraction, its natural role in onset of labour is doubtful. The secretion of oxytocinase enzyme from the placenta is decreased near term due to placental ischaemia leading to predominance of oxytocin’s action.

5. Fetal cortisol theory: Increased cortisol production from the fetal adrenal gland before labour may influence its onset by increasing oestrogen production from the placenta.

(II) Mechanical factors:

1.Uterine distension theory: Like any hollow organ in the body, when the uterus in distended to a certain limit, it starts to contract to evacuate its contents. This explains the preterm labour in case of multiple pregnancy and polyhydramnios. 2.Stretch of the lower uterine segment: by the presenting part near term.

CLINICAL PICTURE OF LABOUR

Prodromal (pre - labour) stage:

The following clinical manifestations may occur in the last weeks of pregnancy- 1.Shelfing: It is falling forwards of the uterine fundus making the upper abdomen looks like a shelf during standing position. This is due to engagement of the head which brings the fetus perpendicular to the pelvic inlet in the direction of pelvic axis. 2.Lightening: It is the relief of upper abdominal pressure symptoms as dyspnoea, dyspepsia and palpitation due to :

a. descent in the fundal level after engagement of the head and

b. shelfing of the uterus.

3.Pelvic pressure symptoms: With engagement of the presenting part the following symptoms may occur:

a. frequency of micturition,

b. rectal tenesmus, and

c. difficulty in walking.

4.Increased vaginal discharge. 5.False labour pain:

False labour pains are differentiated from true labour pain as follows:

True Labour Pain

False Labour Pain

Regular

Irregular

Increase progressively in frequency, duration and intensity

do not

Pain is felt in the abdomen and radiating to the back

is felt mainly in the lower abdomen and groin

Progressive dilatation and effacement of the cervix

No effect on the cervix

Associated with ‘show’

Not associated with ‘show’

Formation of “bag of waters”

No formation of “bag of waters”

Not relieved by antispasmodics or sedatives

Can be relieved by antispasmodics and sedatives

Onset of Labour:

It is characterised by:

1.True labour pain. 2.The show: It is an expelled cervical mucus plug tinged with blood from ruptured small vessels as a result of separation of the membranes from the lower uterine segment. Labour usually starts several hours to few days after show. Expulsion of cervical mucus plug, mixed with blood, is called “show.” 3.Dilatation of the cervix: A closed cervix is a reliable sign that labour has not begun. In multigravidae the cervix may admit the tip of the finger before onset of labour. 4.Formation of the bag of fore-waters: Due to stretching of the lower uterine segment, the membranes are detached easily because of its loose attachment to the poorly formed decidua. With the dilatation of the cervical canal, the lower pole of the fetal membranes becomes unsupported and tends to bulge into the cervical canal. As it contains liquor which has passed below the presenting part, it is called bag of waters. During uterine contraction with consequent rise of intra-amniotic pressure, this bag becomes tense and convex. After the contractions pass off, the bulging may disappear completely. This is almost a certain sign of onset of labour.

STAGES OF LABOUR

Labour is divided into four stages:

(I) First stage:

- It is the stage of cervical dilatation.

- Starts with the onset of true labour pain and ends with full dilatation of the cervix i.e.10 cm in diameter.

- It takes about 12 hours in primigravida and about 6 hours in multipara.

(II) Second stage:

-

It is the stage of expulsion of the fetus.

-

Begins with full cervical dilatation and ends with the delivery of the fetus.

-

Its duration is about 2 hours in primigravida and ½ an hour in multipara.

(III)

Third stage:

-

It is the stage of expulsion of the placenta and membranes.

-

Begins after delivery of the fetus and ends with expulsion of the placenta and membranes.

-

Its duration is about 15 minutes in both primi and multipara.

(IV)

Fourth stage:

-

It is the stage of early recovery.

-

Begins immediately after expulsion of the placenta and membranes and lasts for one hour.

-

During which careful observation of the patient, particularly for signs of postpartum haemorrhage is essential.

1. Dilatation and effacement of the cer vix

Causes of cervical dilatation:

1. Contraction and retraction of u terine musculature.

2. Mechanical pressure by the fo rebag of waters, if membranes still intact, or the presenting part, if they have ruptured. This in turn w ill release more prostaglandins which stimula te uterine contractions and cervical effacement.

3. Softness of the cervix which h as occurred during pregnancy facilitates dilat ation and effacement of the cervix.

Mechanism of cervical dilatation:

In primigravidae, the cervical c anal dilates from above downwards i.e., from t he internal os downwards to the external os. So its length s hortens gradually from more than 2 cm to a thin rim of few millimetres

and expressed in percentage been taken up.

continuous with the lower uteri ne segment. This process is called effacement so when we say effacement is 70 % it means that 70% of the cervical canal has

2. Full formation of lower uterine segm ent

canal has 2. Full formation of lower uterine segm ent • Before the onset of labour,
canal has 2. Full formation of lower uterine segm ent • Before the onset of labour,

Before the onset of labour, there is n o complete anatomical or functional division o f the uterus. During labour,

segment and a relatively passive lower segme nt is more pronounced. The

wall of the upper segment becomes progressively thickened with progressive thin ning of the lower segment.

the demarcation of an active upper

This is pronounced in late first stage , especially after rupture of the membranes an d attains its maximum in second stage.

A distinct ridge is produced at the ju nction of the two, called physiological retractio n ring, which should not be confused with pathological retraction ring (a feature of obstructed labour). The lowe r segment is limited

superiorly by physiological retraction

ring, and inferiorly by the fibromuscular junc tion of cervix and uterus.

Clinical Significance

1. The phenomenon of receptive rela xation enables expulsion of the fetus by formati on of complete birth canal along with the fully dilated cervix

2. Implantation of placenta in lower segment gives rise to placenta praevia

3. Caesarean section is performed th rough this segment

4. Because of poor retractile property , there is chance of PPH if placenta is implant ed over the area

5. Poor decidual reaction facilitates m orbid adherent placenta

6. In obstructed labour, the lower seg ment is very much stretched and thinned out especially in multiparae.

and is likely to give way,

In normal presentation and positio n, the head is applied well to the lower ut erine segment dividing the amniotic sac by the girdle of contact into a hindwaters above it containing the fetu s and a forewaters below it. This reduces the pressure in the fore waters preventing early rupture of membrane s. After full dilatation of the cervix the hind and forewaters beco me one sac with increased pressure in the bag of forewaters leading to its rupture.

EVE NTS IN SECOND STAGE OF LABOUR

The second stage begins with the com plete dilatation of the cervix and ends with th e expulsion of the fetus.

This stage is concerned with descent and delivery of the fetus through the birth can al.

With the full dilatation of the cervix, the membranes usually rupture and there is e scape of good amount of liquor amnii. The volume of the uteri ne cavity is thereby reduced. Simultaneously, uterine contraction and retraction become stronger.

Delivery of the fetus is accomplished by the downward thrust offered by uterine con tractions supplemented by

and soft tissues of the birth

voluntary contraction of abdominal m uscles against the resistance offered by bony

canal.

The expulsive force of uterine contra ctions is added by voluntary contraction of the abdominal muscles called “bearing down” efforts.

EV ENTS IN THIRD STAGE OF LABOUR

Comprises of placental separation an d it’s expulsion with membranes.The plane of separation runs through deep spongy layer of decidua basalis.

Mechanism:

1.Marked retraction reduces effe ctively the surface area at the placental site to about half 2.As it is inelastic, it undergoes b uckling 3.A shearing force is initiated be tween the placenta and placental site 4.Plane of separation runs throu gh deep spongy layer of decidua basalis.

There are two ways of separation:

1.Central separation (Schultze): Separation starts in the centre collection of blood behind placenta (retroplacental hematoma) whole placenta s eparates

2.Marginal (Mathews-Duncan): S eparation starts at margin and progressively i nvolves more & more area. Then there is separation of membranes.

more & more area. Then there is separation of membranes. • Expulsion of Pl acenta -

Expulsion of Pl acenta - After complete

separation of the pla centa, it is forced down into the flabby lower ute rine segment or upper part

of the vagina by retraction of the

expelled out by eith er voluntary contraction of abdominal muscles ( bearing down efforts) or by manipulative proced ure.

effective contraction and uterus. Thereafter, it is

Signs of placental separation:-

1. Fresh gush of bloo d

2. Extra-vulval lengt hening of the cord

3. Suprapubic bulge with a depression above it.

MECHANISM OF LABOUR

Definition - series of movements tha t occur on the head in the process of adaptation , during its journey through the pelvis.

The principal movements are:

1. Engagement

The head normally engages in the oblique or transverse diameter of the inlet.

When the fetal head is not engaged

at the onset of labour, and the fetal head is fr eely mobile above the pelvic

inlet, the head is said to be floating .

Engagement may take place durin g the last few weeks of pregnancy, or it may no t occur until labour begins.

2. Descent

It is continuous throughout labour particularly during the second stage and cause d by:

a. Uterine contractions and retract ions.

b. The auxiliary forces which is bea ring down brought by contraction of the diaph ragm and abdominal muscles.

c. The unfolding of the fetus i.e. str aightening of its body due to contractions of th e circular muscles of the uterus.

due to contractions of th e circular muscles of the uterus. 3. Flexion • The descending

3. Flexion

The descending head meets resis tance

from either the cervix, the walls o f the

of the

pelvis, or the pelvic floor, flexion

fetal head normally occurs.

This movement causes a sm aller diameter of fetal head to be pres ented to the pelvis than would occur i f the head were not flexed.

4. Internal rotation

The movement involves the gr adual

turning of the occiput from its ori ginal

position anteriorly toward symphysis pubis.

the

The main purpose of internal rotat ion is

pubic

to place the occiput behind the

symphysis.

Theories which explain the an terior rotation of the occiput:

fetal

skull which presses on the le vator ani muscle is pushed anteriorly with each recoil.

2. Pelvic shape: Pelvic outlet is gr eater

1. Hart’s rule: The part of the

in AP diameter. Hence, the

head

tries to accommodate in maximum available diameter.

the

5. Crowning

After internal rotation of the head, further descent occurs until the

subocciput lies underneath the pub ic

arch.

At this stage, the maximum diame ter of the head (BPD) stretches the vulva l outlet without any recession of the head even after the contraction is over - called “crowning of the head”.

6. Extension

The suboccipital region lies under t he symphysis then by head extension the vert ex, forehead and face come out successively.

The head is acted upon by 2 forces:

- the uterine contractions acting - the pelvic floor resistance acting extension of the head.

downwards and forwards. upwards and forwards, so the net result is for ward direction i.e.,

7. Restitution

After delivery, the head rotates 1/8 th of a circle in the opposite direction of interna l rotation to undo the twist produced by it.

8. External rotation

The shoulders enter the pelvis in t he opposite oblique diameter to that previously passed by the head.

When the anterior shoulder meets the pelvic floor it rotates anteriorly 1/8 th of a ci rcle.

This movement is transmitted to t he head so it rotates 1/8 th of a circle in the same direction of restitution.

9. Expulsion of the trunk

The anterior shoulder hinges below is delivered first by lateral flexion

After delivery of the shoulders, the rest of the infant's body is extruded quickly.

the symphysis pubis and with continuous des cent the posterior shoulder of the spines followed by anterior shoulder.

CERVICAL DILATATION

Cervical dilatation is expressed in te rms of fingers (1, 2, 3 or fully dilated); or better , in terms of centimeters (10 cm when fully dilated). It is usua lly measured with fingers but recorded in cms. 1 finger = 1.6 cm on average.

fingers but recorded in cms. 1 finger = 1.6 cm on average. MA NAGEMENT OF NORMAL

MA NAGEMENT OF NORMAL LABOUR

Aims:

1. To achieve delivery of a normal he althy child with minimal physical and psycholo gical maternal effects.

2. Early anticipation, recognition and

management of any abnormalities during lab our course.

First Stage of Labour:

(I) History:

(1) Complete obstetric history. (2) History of present pregnancy:

- Duration of pregnancy.

- Medical disorders during this pregnancy.

- Complications during this

disorders during this pregnancy. - Complications during this pregnancy such as antepartum haemorrhage. (3) History of

pregnancy such as antepartum haemorrhage. (3) History of present labour:

- Labour pains: onset, frequenc y and duration.

- Passage of “show", fluid or blo od per vaginum.

- Sensation of fetal movement. (II)Examination:

(1) General examination:

- Height and build.

- Maternal vital signs: pulse, temp erature and blood pressure.

- Chest and heart examination.

- Lower limbs for oedema. (2) Abdominal examination:

- Fundal level.

- - Scar of previous operations (e.g. CS, myomectomy or hysterotomy).

- Fundal grip.

- Umbilical grip.

- Pelvic grips.

FHS.

(3) Pelvic examination:

a. Cervix:

- Dilatation: the diameter of the external os is measured by the finger(s) during P/V examination and expressed in cm, one finger = 2 cm, 2 fingers = 4 cm and the distance resulted from their separation is added to the 4 cm in more dilatation. - Effacement. - Position (posterior, midway, central).

b. Membranes: ruptured or intact. If ruptured exclude cord prolapse and meconium stained liquor.

c. Presenting part and its position.

d. Station: of the presenting part.

e. Pelvic capacity.

(4) Investigations:

If not done before or if indicated:

1. Blood grouping & Rh typing.

2. Urine for albumin and sugar.

3. Hb%.

4. Ultrasonography.

(III) Active procedures:

(1) Evacuation of the rectum by enema to; i) avoid uterine inertia, ii) help the descent of the presenting part, iii) avoid contamination by faeces during delivery.

(2) Evacuation of the bladder:

Ask the patient to micturate every 2-3 hours, if she cannot use a catheter. It prevents uterine inertia and helps descent of the presenting part.

(3) Preparation of the vulva:

Shave the vulva, clean it with soap and warm water from above downwards, swab it with antiseptic lotion and apply a sterile pad.

(4) Nutrition:

When labour is established no oral feeding is allowed, but sips of water allowed in early labour. If labour is delayed more than 8 hours, IV drip of glucose 5% or saline-glucose solution is given.

(5) Posture:

Patient is allowed to walk during the early first stage particularly with intact membranes. If rest is needed the patient lies on her left lateral position to prevent IVC compression and hence placental insufficiency and fetal distress.

(6) Analgesia:

- Pethidine 100 mg IM,

- Trilene inhalation, or

- Epidural anaesthesia is the most commonly used.

(7) The partogram:

It is the graphic recording of the course of labour.

Second Stage of Labour:

(1) Its beginning is identified by:

1. The patient feels the desire to defecate.

2. The contractions become more prolonged and painful.

3. Reflex desire to bear down during the contractions.

4. Rupture of membranes, although this is not specific as it may occur earlier even before start of labour

“premature rupture of membranes" or later even to the degree that the fetus is delivered in an intact sac.

5. Full dilatation of the cervix (10 cm) in between uterine contractions is the surest sign.

(2) Delivery room:

The patient is transferred on a wheel or trolley to the delivery room.

Put her in the lithotomy position. The lower abdomen, upper parts o f the thighs, vulva and perineum are swabbed with antiseptic lotion. Sterile leggings and towels are ap plied.

(3) Bearing down:

Ask the patient to bear down duri ng contractions and relax in between.

(4) Delivery of the head:

The main aim during delivery of t he head is to prevent perineal lacerations thro ugh the following instructions:

i) Support of the perineum: When the labia start to separate by the head, a steril e pad is placed over the perineum and press on it with the right hand during uterine contractions. This i s continued until crowning occurs to maintain flexion of the h ead.

Crowning is the permanent diste nsion of the vulval ring by the fetal head lik e a crown on the head. The head does not recede back in bet ween uterine contractions. This means that th e BPD has just passed the vulval ring and the occipital prom inence escapes under the symphysis pubis.

After crowning, allow slow exten sion of the head so the vulva is distended diameter 10 cm. If the head is allo wed to extend before crowning the vulva will frontal diameter 11.5 cm increasin g the incidence of perineal lacerations.

by the suboccipito- frontal be distended by the occipito-

Ritgen

upward pressure on the perineum by the right hand and downward pressure on the occiput by the left hand to control the extension of the head.

manoeuvre:

left hand to control the extension of the head. manoeuvre : is stretched to the degree

is stretched to the degree that it is about to t ear.

ii) Episiotomy: It is done at crowning when the perineum

iii) Swab and aspirate: the mouth and nose, once the head is delivered before res piration is initiated and the liquor, meconium or blood is in haled.

iv) Coils of the umbilical cord: if p resent around the neck are slipped over the he ad but if tight or multiple they are cut between 2 clamps.

(5) Delivery of the shoulders:

Gentle downward traction is ap plied to the

head till the anterior shoulder

the symphysis pubis. The hea d is lifted

upwards to deliver the posteri or shoulder

first then downwards to deliver shoulder.

the anterior

slips under

(6) Delivery of the remainder of the b ody:

Usually slips without difficulty ot herwise gentle traction is applied to compl ete delivery.

ot herwise gentle traction is applied to compl ete delivery. (7) Clamping the cord: The baby

(7) Clamping the cord:

The baby is held by its ankles wit h the head downwards at a lower level than its mother for few seconds. This is contraindicated in:

i) Preterm babies. ii) Erythroblastosis fetalis. iii) Suspicion of intracranial ha emorrhage. This may be enhanced by milking the cord towards the baby, to add about 100 m l of blood to its circulation. The cord is divided between 2 cla mps to avoid bleeding from a possible 2 nd uniov ular twin.

Third Stage of Labour:

(I) Delivery of the placenta:

i) Conservative method:

Put the ulnar border of the le ft hand just above the fundus at the level of th e umbilicus to detect any bleeding inside the uterus kn own by rising level of the atonic uterus.

Wait for signs of placental se paration and descent but do not massage the u terus.

As soon as they are detected massage the uterus to induce its contraction, a sk the patient to bear down and push the uterus downwa rds to deliver the placenta.

Hold the placenta between th e two hands and roll it to make the membrane s like a rope in order not to miss a part of it.

Give ergometrine 0.5 mg or o xytocin 5 units IM after delivery of the placent a to help uterine contraction and minimise blo od loss. These may be given before delivery of t he placenta.

Signs of placental separation and descent:

1. The body of the uterus bec omes smaller, harder and globular.

2. The fundal level rises as th e upper segment overrides the lower uterine s egment which is now distended with the placent a.

3. Suprapubic bulge due to p resence of the placenta in the lower uterine seg ment.

4. Elongation of the cord part icularly on pressing on the uterine fundus and it does not recede back into the vagina on relieving the pressure.

5. Gush of blood from the vag ina.

ii) The active method (Brandt- And rews method):

1. Principle:

To excite powerful uterine c ontractions following birth of the anteri or shoulder by parenteral oxytocin which fa cilitates early separation of the placenta a nd produces

effective uterine contraction s following its

separation.

2. Advantages:

a. to minimize blood loss in third stage approximately to one-fifth

b. to shorten the duration of third stage to half.

3. Disadvantages:

a. increased incidence of ret ained placenta

b. increased incidence of ma nual removal of

placenta.

4. Procedures:

incidence of ma nual removal of placenta. 4. Procedures: a. Injection ergometrine 0.2 5 mg or

a. Injection ergometrine 0.2 5 mg or methergin 0.20 mg is given IV followin g the birth of anterior shoulder. If administered prior to this, there is chance of imprisonment of the shoulder behind the symphysis pubis.

b. This is followed by slow d elivery of the baby taking at least 2-3 minutes.

c. The placenta is expected t o be delivered following delivery of the buttock s. If the placenta is not delivered instantaneously , it should be delivered by controlled cord tracti on after clamping the cord

while the uterus still rema ins contracted .If the first attempt fails, anoth er attempt is made after 2- 3 minutes failing which an other attempt is made at 10 minutes.

d. If this still fails, manual r emoval is to be done.

5. Limitation:

a. To be effective, it should b e administered at proper time followed by slow

followed by rapid delivery of the placenta.

delivery of the baby and

b. It should not be used in c ardiac cases or severe pre-eclampsia. It may pr ecipitate cardiac overload in cardiac cases, and aggr avate blood pressure in severe pre-eclampsia.

(II) Routine examinations:

(1) Examination of the placenta a nd membranes: by exploring it on a plain surf ace to be sure that it is complete. If any part is missi ng, exploration of the uterus is done under gen eral anaesthesia. (2) Explore the genital tract: For any lacerations that should be immediately re paired.

(III) Repair of episiotomy

Fourth Stage of Labour:

Observation for the patient particularly atony of the uterus and vaginal bleeding.

Care of The Newborn

(1) Clearance of the air passages: The newborn is placed in supine position with the head lower down. A plastic catheter is used to aspirate the mucus from the pharynx and mouth. Crying of the baby usually occurs within seconds, if delayed slapping its soles, flexion and extension of the legs and rubbing the back usually stimulate breathing. (2) Apgar score: is calculated at 1 and 5 minutes and further steps of resuscitation are arranged according to it. (3) The umbilical cord: A disposable plastic umbilical cord clamp is applied about 5 cm from the umbilicus to avoid the possibility of tying an umbilical hernia then cut about 1.5 cm distal to the clamp. Inspect for bleeding and paint it with alcohol. If the plastic umbilical clamp is not available, 2 ligatures of silk are applied instead of it.The umbilical stump is painted daily with an antiseptic till its fall within 10 days. (4) Congenital anomalies: The newborn is examined for injuries or congenital anomalies such as imperforate anus, hypospadias (not to be circumscised as the cut skin will be used in the repair later on), cyanotic heart diseases etc. (5) Weight: Weigh the newborn and record it. (6) Dressing: Dressing as well as all previous procedures should be done in a warm place better under radiant warmer to prevent heat loss which occurs rapidly after delivery increasing the metabolism and acidosis. (7) Care of the eyes: An antibiotic eye drops such as chloramphenicol are instilled into the eyes as a prophylaxis against ophthalmia neonatorum. (8) Identification: of the baby by a plastic bracelet on which its mother’s name is written.

 

PREVIOUS EXAMINATION QUESTIONS FROM THIS CHAPTER

 

1. Define full term normal delivery. Describe how you conduct normal labour.

LONG

ESSAY

2. Write the diagnosis of term pregnancy and management of normal labour in a primi.

3. Describe the duration and stages of labour.

 

1. Write in brief physiology of 3rd stage of labour. How will you conduct 3rd stage? List the

complications.

2. Management of Maternal Distress.

3. What are the differences between true and false labour?

4. What is lower segment and write its obstetric importance?

5. Second stage of labour.

SHORT

ESSAY

6. Third stage of labour and its management.

7. Signs of placental separation.

8. Changes in third stage of labour.

9. Partogram.

10. Gravidogram.

11. Brandt – Andrew’s technique.

12. Management of first stage of labour.

 

1. Mention the three complications of first stage of labour.

2. Active management of third stage of labour.

3. Signs of placental separations.

SHORT

4. What is crowning and its clinical importance?

ANSWERS

5. Describe moulding of fetal head and its importance

6. Differentiate false from true labour pains.

7. Conduct of third stage of labour.

8. Define active management of 3rd stage of labour.

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