2. THEORIES:
Direct pressure exerted on cervix by fetus.
Progesterone Withdrawal: ↓ progesterone by placenta &
↑ prostaglandins in chorioamnion results in ↑ uterine
contractions.
Oestrogen Stimulation: ↓ progesterone allows oestrogen
to ↑ contractile response of uterus.
Fetal Cortisol: Changes biochemistry of fetal membrane:
↓ progesterone & ↑ prostaglandin in placenta.
Distension: uterine muscles stretch causing ↑
prostaglandin.
Amniotic membranes (sac) converts arachidonic acid →
Prostaglandin uterine contractility.
2
3. Premonitory signs of labour: weeks
before real labour
Lightening: Fetus settles into pelvic cavity.
Braxton-Hicks: Irregular intermittent
contractions; “false labor”.
Cervical changes: cervix effaces [thins] & dilates
slightly
Baby's head in pelvis pushes against cervix
causing relaxation and effacement.
3
4. Signs True Labor: closer to time of
delivery
Uterine Contractions: regular & frequent compared to
Braxton-Hicks
Which becomes stronger with time.
Bloody Show: pink tinged secretions due to softening
cervix.(aka mucous plug)
Rupture of Membranes: (ROM) Labour in 24 hrs.
Multiparas sooner.
Clear/odorless.
4
5. Difference Between True & False Labor
True Labor
Contractions occur at
regular intervals.
Intervals (b/n conxn.)
gradually shorten.
Intensity gradually
increases.
Discomfort is in the back
and abdomen.
Cervix dilates.
Discomfort is not stopped by
False Labor
Contractions occur at
irregular intervals.
Intervals remain long.
Intensity remains
unchanged.
Discomfort is chiefly in the
lower abdomen.
Cervix does not dilate.
Discomfort usually is
relieved by sedation.
5
7. First Stage
Start of regular uterine contractions until the
completion of cervical dilation(=10cm)
~ 6-18 hrs. primapara; and 2-10 hrs. multipara.
3 phases : latent, active and transition
Latent phase:- the period between the onset and
the point at which a change in the slope of cervical
dilatation is noted.
Dilation 0-3 cms. Contx.’s mild/irregular.
7
8. Cont.
Active phase:- phase of a rapid acceleration of
cervical dilatation (begins @ 3cm)
4-7 cms. Contx.’s 5-8 min. apart. Lasts 45-60 sec;
moderate - strong intensity.
Transitional: Dilation 8-10 cms. Contx.’s 1-2 min.
apart; 60 –90 sec.; strong intensity.
No pushing until fully dilated.
8
9. Second stage
Delivery of infant:
up to 1 hr. or ~ 20 contx’s – primip.
20 min. or ~ 10 contx’s in multip. Can last up to 3 hrs.! Esp.
in case of EPA
Cardinal movements occur here.
Most difficult & uncomfortable part of labor.
Strong urge to push & bear down as infant passes through
9
10. Third Stage
Delivery of placenta ~ 5 - 30 min.
Separation should be automatic [uterus contracts &
mum bears down]
Manual presses on contracted uterus. “ Crede’s
Maneuver”
Syntocinon placenta delivered to avoid retained
placenta.
10
11. Fourth stage
Placenta out; mother recovers.
Lasts ~ 1 hr. unless complications arise.
Then patient is transferred to postnatal unit.
11
12. Assessing Progress of Labor
Dilation: 0–10 cm. [opening cervix]
Effacement: 0 –100 % [thinning cervix]
Station: Relationship of presenting part to pelvic ischial spines midway in pelvic cavity.
“0 ” station aka “engaged”.
-1 to -5 above “0”
+1 to +5 (outlet) below “0”
+4/+5: baby's head out.
12
13. Cont.
The progress of labor may be abnormal and can
be classified as a
Slow latent phase,
Arrest of active phase, and
Arrest of descent.
13
15. Mechanism of Labour
Passage of fetus through birth canal involves position
changes called Cardinal Movements of Labour:
Engagement: presenting part enters midpoint of pelvis at
ischial spines.
Descent: downward movement through pelvic inlet
through dilated cervix, reaches posterior vaginal wall.
Mum feels like pushing. Widest part [head] passes through
pelvis.
15
16. Cont.
Internal Rotation: occiput in diagonal position &
rotates towards face down position (OA) (occurs
as body parts press on bony pelvic structures)
Extension: top of head delivered & extends as
face & chin are delivered.
External Rotation: head rotates back to previous
lateral position. Rest of body is delivered.
16
18. Passenger: [infant]
A. Fetal head: widest part of body; most difficult to
pass through vaginal canal;
Passage depends on bones, sutures, fontanelles.
Cranium - 8 bones meet @ suture lines
Cranial bones move & overlap, allows skull to pass
thru birth canal.
Fontanelles: soft spaces created by junctures of
suture lines - covered by membranes; compress
during delivery to aid in passage of fetus.
18
19. Cont.
Skull widest @ antero-posterior diameter than @ transverse
diameter.
Antero-posterior diameter measures differently @ different
locations.
Occipitomental diameter- widest - measured from chin to
posterior fontanelle = 13.5 cm
Smallest diameter - lower occiput to anterior fontanelle
(suboccipitobregmatic) = 9.5 cm
19
20. Cont.
B. Fetal Attitude: degree of flexion of fetal head.
Complete flexion: allows smallest diameter of
skull to pass through pelvic cavity. Best position!
Moderate flexion: head less flexed making
diameter wider.
Poor flexion: brow or face presentation; presents
presents skull diameter too wide making delivery
20
21. Cont.
C. Fetal lie: relationship of long axis of fetus
[spine] to long axis of mother:
1. Longitudinal – vertex/breech; vertical in
relation to mum; ~ 99%.
2. Transverse – horizontal in relation to mum; < 1
%.
3. Oblique - diagonal
21
22. Cont.
D. Fetal presentation: part of fetal head
enters pelvis;
1. Cephalic 95.5%
2. Breech 3.5%
3. Face 0.3%
4. Shoulder 0.4% [transverse lie]
22
23. Cont.
E. Fetal position: “occiput is landmark”
Presenting part [occiput, mentum, sacrum]
Landmark is anterior, posterior, transverse in
relation to mother’s spine.
Occiptito-anterior (OA) back of head against
symphysis pubis & face towards spine.
Occipito-posterior (OP) Back of head = mother’s
23
24. Passageway:
Refers to fetus passing through uterus, cervix, vaginal canal.
Single most important determinant to mechanism of labor.
A. Shape of pelvis:
1. Gynaecoid – 50% of women; rounded, oval shape;
easy vaginal delivery; considered “normal female
pelvis”
24
25. Cont.
2. Android – 20 % of
women; vaginal delivery
difficult; prob. C/S;
“true male pelvis”
3. Anthropoid – oval;
assisted vaginal birth
usually with forceps;
20-25%
25
27. Cont.
B. Structure of Pelvis
False Pelvis: Outer - broader. Hip bones.
True Pelvis: Internal – narrower. Holds bladder, rectum, &
reproductive Organs.
True pelvis - has 3 parts - inlet, midpelvis, outlet
[Most important in childbirth]
Contractions of the pelvic inlet, the midpelvis, the
27
28. Cont.
Powers:
Uterine contx’s: primary force moving fetus
thru maternal pelvis during 1st stage of
Maternal Efforts: woman adds voluntary
pushing force to force of contx.’s during 2nd
of labor to propel fetus thru pelvis.
28
29. Physiology of pain in labor and
Neural pathways
Perception of pain by the parturient is dynamic
process
It Involves both peripheral and central mechanisms
Many factors affect degree of pain experienced by
woman including:-
Psychological preparation,
Emotional support during labor,
Past experiences,
The patient's expectations of the birthing
29
30. Cont.
1st stage of labor – mostly visceral
◦ Dilation of the cervix and distention of the lower
uterine segment
◦ Dull, aching and poorly localized
Slow conducting, visceral C fibers, enter spinal cord at
T10 to L1 to synapse in the dorsal horn.
The chemical mediators involved are bradykinin,
leukotrienes, prostaglandins, serotonin, substance P
30
31. Cont.
2nd stage of labor – mostly somatic
◦ Distention of the pelvic floor, vagina and
perineum stimulation of pudendal nerve.
◦ Sharp, severe and well localized
Rapidly conducting A-delta fibers, enter spinal cord
at S2 to S4 impulses pass to dorsal horn cells and
finally to the brain via the spino-thalamic tract.
31
33. Physiological response to labor pain
System Response to pain
CVS Pain increases catecholamine level increase in
contractility and SVR, all of which increases
oxygen demand
Placenta Pain increases catecholamine levels
of umbilical vessels and consequently reducing
placental blood flow
Respirat
ry
Pain increases MV maternal hypocapnoea
respiratory alkalosis shifts the oxy-hgb disso.
Lt decreased O2 offloading to the fetus
GIT Pain reduces gastric emptying increasing risk of
33
Researches on humans, not enough cuz of ethical issues
The laboring human uterus does manifest ↑ prostaglandin production, an increase in oxytocin receptors, and increased myometrial gap junction formation.
In sheep, the fetus apparently triggers parturition by a surge in fetal cortisol production. In women, progesterone concentrations do not fall before the onset of labor, and no surge in fetal cortisol secretion occurs.
premonitory = early warning signs
Prolonged ROM – intrauterine infection [pathogens reach fetus]
ROM results in surge of fluid…clear/odorless….if green/brown….danger sign that the fetus might have aspirated meconium & is distressed.
Then comes true labor which may be confusing with false labor, but has some distinctive features…like
Although labor is a continuous process, it has traditionally been divided into 3/4 stages. activity of the uterus is measured in frequency, duration, and intensity of contractions
The most commonly used measure of uterine activity by obstetricians, however, is the Montevideo unit, which is defined as the average intensity frequency per 10 minutes.
Usually two phases…and can also be divided in to three phases
During active phase of 1st stage of labor, Ux conxn. Occur Q 3min for 1min and achieve an intrauterine pressure of 50-70mmhg.
Normally during normal labor the cervix should dilate at a rate of 1cm/hr.
When Ux conxn is not optimal (<50mmhg), Q 3min an oxytocic agent is administerd
Interval between full cervical dilatation till delivery of the infant
Duration typically 1hr, but up to 3hrs with allowances made for epidural analgesia.
From fetal delivery until placenta and membranes are expelled
Wait for signs of placental separation before applying traction of z umbilical cord
Don’t palpate non-contracted uterus –possible eversion. Maternal vessels still open.
This is a phase of stabilization…
patient must be watched carefully for bleeding. More than 90% of cases of postpartum hemorrhage result from uterine atony.
Ass’t of progress includes the ff but not limited to…
At +5 station, delivery is imminent.
Progress of labor may be abnormal…. Collectively called prolonged labor
The mechanism of labor refers to the changes in fetal conformation and position that occur during descent through the birth canal during the late first stage and second stage of labor
THE CARDINAL MOVEMENTS OF LABOR
• Engagement
• Descent • Flexion
• Internal rotation • Extension
Passenger fetus
Passageway the pelvic cavity
Powers ux conxn. And maternal force
So the skull w/c is the widest part of the body is widest…
A. A. Flexion poor. B. Flexion moderate. C. Flexion advanced. D. Flexion complete.
Transverse lie- pts usually end up in C/S
oblique lie, which is unstable and always becomes longitudinal
or transverse during labor.
The presenting part is that portion of the fetal body that is either
foremost within the birth canal or in closest proximity to it.
Position refers to the relationship of an arbitrarily chosen portion
of the fetal presenting part to the right or left side of the
birth canal.
Passageway is usually affected by shape of the pelvis …
CPD - cephalopelvic disproportion,
PELVIC INLET:
AP diameter of PI is ~ 11 cm
Fetal suboccipitobregmatic diameter in complete flexion = 9.5cm
Transverse diameter [across] ~ 13.5 cm
Fetal occipitomental diameter ~ 13.5 cm
MIDPELVIS: narrowest part of pelvis that fetus must pass through - “ischial spines”
PELVIC OUTLET: Trouble passing through pelvic opening, pelvis too small or poor fetal attitude.
Second stage additional factors, such as
Traction and pressure on the parietal peritoneum, uterine ligaments, urethra, bladder, rectum, lumbosacral plexus, fascia and muscles of the pelvic floor increase the intensity of pain.
Figure 69-6 Pathways of labor pain illustrating the nerve pathways responsible for pain in the various stages of labor and the types of blocks that can block nerve impulse transmission through these pathways to alleviate labor pain