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NORMAL LABOUR INTRODUCTION Labor is a physiologic process during which the products of conception (ie, the fetus, membranes, umbilical cord, and placenta) are expelled outside of the uterus. Labor is achieved with changes in the biochemical connective tissue and with gradual effacement and dilatation of the uterine cervix as a result of rhythmic uterine contractions of sufficient frequency, intensity, and duration. DEFINITION The onset of labor is defined as regular, painful uterine contractions resulting in progressive cervical effacement and dilatation that ends with the delivery of baby and expulsion of placenta.

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MANAGEMENT OF LABOUR Women are admitted to the labour suite for frequent observation until delivery If labour is active, pt should receive little or nothing, to avoid aspiration of gastric contents Enemas and shaving or clipping of vulval hair are no longer indicated Saving IV line is all that required to hydrate the patient and for the infusion of drugs if needed Hydration with atleast 500-1000ml Ringer’s lactate solution should be given Analgesics may be given during labor as needed, but as little as possible should be given because they cross the placenta and may depress the neonate's breathing Many obstetric units now use a combined labor, delivery, recovery, and postpartum (LDRP) room, so that the woman, father or other support person, and neonate remain in the same room throughout their stay The feto-maternal monitoring s/b the prime aim during the management of labour In the delivery room, the perineum is washed and draped, and the neonate is delivered After delivery, the woman may remain there or be transferred to a postpartum unit


PHYSIOLOGY OF BIRTH PROCESS DEFINITION Traditional teachings has emphasized on the mutual relationship of the following three participants . The powers(uterine activity in labour) The passages(birth canal) The passenger(fetus)

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PROSTAGLANDINS THE BACKBONE REGULATORS OF PARTURITION Without PG’S, labour is impossible, while when they appear in abundance, labour is irresistible PGF2α is the principal PG generating myometrial contractility PGE2 is responsible mainly for cervical repining PGDH, a prostaglandin degrading enzyme(from chorion) is at the checkpost on production of these prostaglandins throughout pregnancy Premature excessive production of PG’S due to trauma, haemorrhage and infection(pre-maturelabour)


STAGES OF LABOUR FIRST STAGE begins at the onset of uterine contractions uptil full cervical dilatation SECOND STAGE from full cervical dilatation till the complete delivery of the baby THIRD STAGE begins with the delivery of the baby uptil the delivery of placenta and membranes FOURTH STAGE the immediate post-partum period also known as stage of observation


FIRST STAGE OF LABOUR TOTAL DURATION 13 hrs= nullipara 07 hrs= multipara PHASES Latent phase: extends from the onset of regular uterine contractions to the beginning of cervical dilatation uptil 3cm Phase of acceleration: time when the latent phase converts in to active phase often goes un-recognized Active phase: begins at 4cm dilatation and ends at the phase of deceleration Phase of deceleration: friedman described this phase as the phase prior to full dilatation(9-10cm)


DIAGNOSIS OF LABOUR Diagnosis of labour is made at history, abdominal and vaginal examination HISTORY Uterine contractions Show Sudden loss of fluid from vagina/liquor amnii ABDOMINAL EXAMINATION Frequency, duration and severity of contractions Level of presenting part is noted PELVIC EXAMINATION Includes BISHOP’S scoring


LEOPOLDS MANAEUR BISHOP’S SCORING partogram Partogram is a composite graphical record of key data (maternal and fetal) during labour entered against time on a single sheet of paper. Relevant measurements might include statistics such as cervical dilation , fetal heart rate , duration of labour and vital signs It is intended to provide an accurate record of the progress in labour, so that any delay or deviation from normal may be detected quickly and treated accordingly. Components: Patient identification Time: It is recorded at an interval of one hour. Zero time for spontaneous labour is time of admission in the labour ward and for induced labour is time of induction. Fetal heart rate: It is recorded at an interval of thirty minutes. State of membranes and colour of liquor: "I" designates intact membranes, "C" designates clear and "M" designates meconium stained liquor. Cervical dilatation and descent of head Uterine contractions: Squares in vertical columns are shaded according to duration and intensity. Drugs and Fluids Blood pressure : It is recorded in vertical lines at an interval of 2 hours. Pulse rate : It is also recorded in vertical lines at an interval of 30 minutes. Oxytocin : Concentration is noted down in upper box; while dose is noted in lower box. Urine analysis Temperature record

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ADVANTAGES OF PARTOGRAM Provides information on single sheet of paper at a glance No need to record labour events repeatedly Prediction of deviation from normal progress of labour Improvement in maternal morbidity , perinatal morbidity and mortality

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SECOND STAGE OF LABOUR TOTAL DURATION 1 HR=MULTIPARA 2 HR=NULLIPARA PHASE-I: starts with full cervical dilatation and ends with the beginning of maternal bearing down effort PHASE-II: also known as the descent phase or expulsive phase, the uterine contractions along with maternal efforts make the head to rotate and descent resulting in stretching and dilatation of vagina, with subsequent contraction the baby is born

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MECHANISM OF LABOUR Engagement of the fetal head in the transverse position. The baby's head is facing 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 forwards so that the crown of its head 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.

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DEFINITIONS ATTITUDE describes the relationship of fetal head and limbs to the trunk and normally it is flexion LIE defined as the relationship of the long axis of the fetus to the long axis of the uterus. The normal lie is longitudinal PRESENTATION is that part of the fetus which is present in the lower pole of the uterus or pelvic brim. Normal presentation is cephalic PRESENTING PART it is the leading part of the presentation. Normal presenting part is vertex POSITION defines as the relationship b/w specified point on presenting part to a specified point on maternal pelvis ENGAGEMENT the fetal head is set to be engaged when the widest diameter of the presenting part has crossed the plain of pelvic brim CROWNING the head is set to be crowned when the occipital prominence escapes under pubic symphysis and the head no more recedes from the introitus in b/w uterine contractions CAPUT SUCCEDANEUM it is an area of oedema forms in the leading part of scalp during first stage due to the pressure of cervical rim against the descending head MOLDING The fetal head may temporarily change shape substantially (becoming more elongated) as it moves through the birth canal. This change in the shape of the fetal head is called molding and is much more prominent in women having their first vaginal delivery

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THIRD STAGE OF LABOUR PLACENTAL EXPULSION begins as a physiological separation from the wall of the uterus. The period from just after the fetus is expelled until just after the placenta is expelled is called the third stage of labor . The average time from delivery of the baby until complete expulsion of the placenta is estimated to be 10-12 minutes dependent on whether active or expectant management is employed

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ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR OXYTOCIC DRUGS includes oxytocin and ergometrine, which can be given alone or in combination( IV, IM) TIME OF ADMINISTRATION IM usage of oxytocin or syntometrine is better carried out at crowning of head or after its delivery IV ADMINISTRATION is commonly carried out at delivery of anterior shoulder of the baby CONTROLLED DELIVERY OF PLACENTA the aim of controlled delivery is to accelerate its separation and to remove it before it is retained. The sign of separation are Passage of gush of blood Narrowing of uterine body Increase mobility of uterus Lengthening of umbilical cord

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Normal labour/labor is the spontaneous onset of labour with a singleton cephalic presentation A single fetus with head presentation; head is pointing towards the vagina After 37 weeks of pregnancy. The liquor (amniotic fluid) is clear, the fetal heart rate is within 120-160 beats per minute and the cervix dilates at 1 cm or more in every hour with progressive descent of head. Mother should not have post partum (after delivery) complications as well.

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