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 Tidal volume Respiratory rate Minute volume Decreased Inspiratory reserve Expiratory reserve Residual volume PCO2 No Change Vital capacity PO2

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

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2. 3. 4. 5.

6.

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. Descent and flexion of the fetal head 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. 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. Restitution. The fetal head turns through 45 degrees to restore its normal relationship with the shoulders, which are still at an angle. 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.drcogmrcog.info/mcq%20papers%201%20%205.htm

Regarding Labour:
the latent phase may last for more than four hours the active phase should be associated with cervical dilatation at a rate of at least 1 cm. per hour the active phase starts when the cervix is effaced and 2 cm. dilated involves artificial rupture of the membranes is best charted using a partogram epidural anaesthesia has an adverse effect on the rate of progress in the 1st. stage of labour

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The second stage:

starts with the onset of maternal expulsive effort and ends with the delivery of the baby. should not last more than one hour in the primigravida. continuous electronic monitoring should be used in all cases. opiates should be used for pain relief. may be prolonged in association with regional anaesthesia.

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Active management of the third stage:

always involves the use of an intravenous oxytocic signs of placental separation should be awaited before cord traction is used the cord should be clamped immediately to prevent haemorrhage from the baby reduces the incidence of retained placenta reduces the incidence of post-partum haemorrhage

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Normal Labour:
is associated with internal rotation of the head is associated with extension of the delivered head does not occur with mento-posterior position does not occur with brow presentation should not be attempted after two Caesarean sections carries less risk to the mother than Caesarean section involves episiotomy involves physiological management of the third stage is associated with blood loss < 350 ml
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Normal pregnancy:
the key stages of organogenesis occur between 10 and 12 weeks maternal metabolic rate increases by about 25% increased maternal metabolic rate is mainly caused by the foetus and placenta blood volume increases by about 30% red cell mass increases by about 40% erythrocyte sedimentation rate remains within the nonpregnant range cardiac output increases glomerular filtration rate increases by up to 50% ureters and renal pelves dilate, but return to normal within two weeks of delivery iron supplementation should be given routinely F
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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