LABOUR

 Physiologic process by which a fetus is

expelled from the uterus to the outside
world.

An increase in myometrial activity or,

more precisely, a switch in the myometrial
contractility from ”contractures” (long
lasting, low frequency activity) to
“contractions ”(frequent, high intensity,
high frequency activity) resulting in
effacement and dilatation of uterine
cervix.
Mean duration of human singleton pregnancy is
280days(40 weeks) from the last menstrual period.

“term pregnancy” refers to period from 37.0weeks

to 42.0 weeks of gestation

“preterm pregnancy” : onset of labour prior to 36

completed weeks of gestation

“postterm pregnancy” : pregnancy continuing

beyond 42.0 weeks of gestation
Diagnosis
clinical diagnosis
classic diagnosis of labor includes:-
Regular painful uterine contractions
Progressive cervical effacement and
dilatation
Show + rupture of the fetal membranes
Physiology of normal labour at term
factors responsible for initiation and
maintenance of labor at term are not well
defined.
Theories
 progesterone withdrawal
 oxytocin induction
 fetal control
 Regulation of uterine activity during
pregnancy is divided into four distinct
physiologic phases:-.

Phase 0 : state of functional uterine

quiescence
Phase 1: phase of uterine activation
(awakening)
Phase 2: phase of uterine stimulation
Phase 3: phase of uterine involution
Mechanisms of labour

 The ability of the fetus to successfully

negotiate the pelvis during labour and
delivery is dependent on the complex
interactions of three variables:-

The power
The passenger
The passage
The power
Force generated by uterine musculature
Characterized by frequency, amplitude
(intensity), and duration.
Assessment may include
simple observation,
manual palpation,
external objective assessment techniques
(external tocodynamometry), or
direct measurement of intrauterine pressure
using (internal manometry or pressure
transducers)
 .cont’d
“adequate” uterine contractions

progressive cervical effacement and

dilatation

3_5 contractions in 10minutes

200_250montevidio units
The passenger
Fetal variables that influence the course of labor
and delivery

Absolute fetal size (macrosomia >4500gms)

Lie: the longitudinal axis of the fetus in relation to

the
longitudinal axis of the uterus. It could be
either:
longitudinal, transverse or oblique

Presentation : the fetal part that directly overlies

the
Malpresentation is any presentation that is not
cephalic with occiput leading, accounting for 5%
of all term labor

Attitude: position of head with regard to the

fetal spines

Position: the relationship of a nominated site of

presenting part to the nominating location of the
internal pelvis and can be most accurately
assessed on transvaginal examination.
Nominated sites presentation

 Occiput vertex
 Sacrum breech
 Mentum face
 Acromium shoulder
Malposition is any position in labor which is
not ROA,OA or LOA

Station is a measure of descent of the

presenting part of the fetus through the birth
canal.
old classification is by subjective arbitrary
assignment of seven stations(-3 to +3) but the
new classification attempts to quantitate in
centimeter the distance of the leading bony
edge from the ischial spines of the maternal
pelvis(-5 to +5).
N.B in both classifications the midpoint (0
station) is defined as the plane of the
Number of fetuses (single/multiple)
Presence of fetal anomalies (eg,
sacrococcygeal teratoma)

A small fetus in longitudinal lie, with vertex

presentation, a flexed head in anterior
position that has passed through the pelvic
inlet is the ideal candidate for negotiating the
maternal pelvis.
The passage
consists of the bony pelvis (composed of the
sacrum, ilium, ischium and pubis) and the
resistance by the soft tissues of the pelvis.
The pelvis has a series of planes that must be
negotiated by the fetus during passage
through the birth canal which can be broadly
classified into:-
pelvic inlet,
midpelvis cavity and
outlet
The shape of the female bony pelvis can be
classified as: gynecoid, anthropoid, android
and platypelloid.

N.B. although the assessment of fetal size

along with pelvic shape and capacity is useful
to predict women at risk of CPD in labor, an
adequate trial of labor is the only way to
determine whether a given fetus will be able
to safely negotiate a given pelvis.
 Stages of labor
For reasons of study and to assist in clinical
management, labor has traditionally been
divided into three stages, with the first stage
further subdivided into three phases

First stage: the interval between the onset of

labor and full cervical dilatation
- has been subdivided into three phases
according
to the rate of cervical dilatation
 Latent phase : the interval between the
onset of labor and a point at which a change
in the slope of the rate of cervical dilatation is
noted usually 3-4cm.
-characterized by slow cervical dilatation
and is of
variable duration
 Active phase: interval between 3-10cm of
cervical dilatation
- associated with a greater rate of cervical
dilatation
and usually begins at 3-4cm

Second stage : interval between full cervical
dilatation(10cm) and delivery of an infant.
- Characterized by descent of the presenting
part
through the maternal pelvis culminating in
expulsion
of the fetus.
Third stage - the delivery of the placenta
and fetal membranes
- usually lasts less than 30
minutes.
Cardinal movements in labor:

refers to the changes on position of fetal

head during its passage through the birth
canal.

Although labor and birth is a continuous

process seven discrete movements of the
fetus are described.
Engagement

passage of the widest diameter of the

presenting part to a level below the plane of
the pelvic inlet.

The sagital suture is frequently deflected

either posteriorly to the promontory or
anteriorly to the symphysis pubis such lateral
deflection the fetal head is known as anterior
and posterior asynclitism respectively.
Descent
downward passage of the presenting part
through the pelvis.

 The greatest rate of descent occurs at the

descent phase of the first stage of labor and
2nd stage of labor.
Flexion
flexion of the fetal head occurs passively as
the head descends due to the shape of the
bony pelvis and the resistance offered by the
soft tissues.

The result of complete flexion is to present

the smallest diameter of the fetal head for
optimal passage through the pelvis
Internal rotation
rotation of the presenting part from its
original position (usually transverse with
regard to the birth canal) to the anterior
position as it passes through the pelvis

As to flexion, internal rotation is a passive

movement resulting from the shape of the
pelvis and pelvic floor musculature.
Extension
occurs once the fetus has reached the level of
the introitus.

It brings the base of occiput in contact to the

inferior margin at the symphysis pubis. At
this point the birth canal is directed upwards
thus, the fetal head is delivered by extension.
External rotation (restitution)
 is return of the fetal head to the correct
anatomic position in relation to the fetal
torso.

Expulsion
delivery of the rest of the fetal body