8-Physiology of Labour

Physiology and Management of Labour
Prepared by
Dr/ Nadia Abd–Elhamed Eltohamy

Associate prof. of Women’s Health Nursing
Presenter : Dr. Nadia Eltohamy

Normal Spontaneous Delivery
Presenter : Dr. Nadia Eltohamy

Objectives
• By the End of this session every learner should be

able to:-
1-Explain stages of labour
2-Perform focused assessment on a patient in labour
3-Demonestrate techniques in spontaneous delivery
4. Develop management during labour process
3
Terminologies
• Labour is the series of events by which the foetus and placenta are expelled from
the woman's uterus after viability.
• Delivery is the actual provision of the baby.
Normal labor
Spontaneous delivery of full term, mature, living fetus, presenting by its vertex,
through the birth canal, within reasonable time (24 hours) without
interference and without fetal or maternal complications delivery
Terminologies
• Viability :- Is a reasonable chance of the foetus for extra uterine survival.
• Lightening: Is the descent of the presenting part into the pelvic cavity 2 to 3 weeks before
the onset of labour.
• Preterm labor : Interruption or termination of pregnancy between the 28th : 38th weeks
gestation.
N.B: Babies delivered between 20: 28 weeks are termed immature babies.
• Pos-term labor : Prolongation of pregnancy 2 weeks or more beyond the expected date of
delivery
Terminologies
▪ Dilatation :-The widening of the external os of the uterine cervix from

closed to a maximum of 10 cm . Or 5 fingers
▪ Effacement :The cervix is shortening and taken up i.e., the cervical canal
becomes incorporated into the lower uterine segment
Effacement
In primigravida:
Effacement occurs first followed by dilatation i.e. the cervix dilate from
above downwards
In multigravida:
Effacement and dilatation occurs at the same time

Theories of Labor onset
1- Main cause un Known

- But some theory can explain this onset :-
A- Prostaglandin theory:
- Prostaglandin stimulate uterine contraction and ripening of the cervix.

- prostaglandins are stored in the membranes so rupture of membranes (
amniotomy ) can stimulate labor.
B- Progesterone withdrawal theory:

Before labor, progesterone withdrawal occurs
C- Estrogen- oxytocin Theory :
As pregnancy advances, estrogen increases oxytocin receptors in the uterus
( at the end of pregnancy the uterus is well prepared for oxytocin to act)
D- Uterine distension theory :
- This explains preterm labor in twins and hydramnios.
E- Placental Ischemia theory: there is decrease production of enzyme

( oxytocinase) this allow oxytocin to act .
F- Stretch of the lower uterine segment: this increase prostaglandin
and initiate uterine contraction
G- Fetal Cortisol theory
Increased cortisol production from the foetal adrenal gland before
labour may influence its onset by increasing estrogen production
from the placenta.
Factors Affecting the Progress of Labour
There are 5Ps essential factors that affect the process of labour:
1- power ( Uterine Cont. ( primary and secondary power)

2- Passages ( Birth canal and bony pelvis).
3- Passenger ( fetal as presentation, lie, attitude and position .
4-Psychological status of the mother.
5- Positioning during labour and delivery
POWERS
This refers to the frequency, duration, & strength of uterine

contractions to cause complete cervical effacement &
dilatation.
This power divided into :-

1- Primary involuntary Force
2- Secondary (Axillary Force )
A. Primary forces: Uterine contractions
( True labor pain )
▪ During pregnancy there are painless intermittent uterine

contractions, which are felt by palpating the uterus.
▪ These are known as Palmer's sign in early pregnancy and

Braxton-Hicks contractions in late pregnancy ( False labor
pains)
Brainstorming
What are the difference between true labour pain and false
labour pain ?
Differences Between True and False Labor Pains:-
True Labor Pains False Labor Pains
(Braxton Hicks Contraction)
Site of Pain Abdomen & lower back Abdominal
Rhythm regular irregular
Frequency, Strength increasing Not increasing

& Duration of
contraction
Bulging Membranes Present Absent
( Bag of water)
Cervical Dilatation Progressive Absent
Sedation Not relived by sedatives Relived by sedatives

15
description of Uterine Contractions
Onset of Onset of
Contraction Contraction
Intensity Intensity
Relaxation Relaxation
Duration Duration
Frequency of Contractions Frequency of Contractions

Phases of uterine contraction
Each contraction has three phases:
** Increment: A period during which the contraction begins slowly.

**Acme: A period during which the contraction reaches a peak.
** Decrement: A period during which the contraction diminishes.
Description of uterine contraction
1- Frequency :- refers to number of contraction. It is the period of time

between the beginning of one contraction to the beginning of the next one.
2- Interval :- the period of time between the end of one contraction to the
beginning of the next contraction.
3- Duration :- It is measured from the beginning of increment to the
completion of decrement.
4- Intensity:-Refers to strength of uterine contraction during acme ( Mild,
Mod. ,severe)
Methods to assessing U. Contraction
1- Subjective description as perceived by mother
2- By Palpation by using the fingertips
3- By Electronic fetal monitoring

Diagnosis of Onset of labor
A. Symptoms:
• True labor pains
• The show
B. Signs:
• Dilatation of the internal OS
• Formation of bag of fore water
2- The show
▪It is a blood-stained mucous discharge noticed at the start of

labor.
•The mucous is the cervical mucous plug which falls down when
the cervix starts to dilate.
•The blood is due to separation of the membranes from the
lower uterine segment
▪Labor usually starts within 24 hours after the passage of show
Dilation of Cervix
• Dilatation: How far has the cervix opened (in cm)
• Effacement: How thin is the cervix (in %)

Formation of bag of fore water “Sure sign”
The lower pole of fetal membranes separate from lower
uterine segment to form a bag of water which bulges
from cervix and become tense during uterine
contractions
First Stage =
Stage of
cervical Dilatation
Second Stage =
1 Stage of
Fetal Expulsion
Stages of
Labor Third Stage =
Stage of
Placental separation
Fourth Stage =
Recovery ( 1st 2 hours
After delivery of placenta)
Prodromal stage
• False labor pain

• Increased vaginal discharge
• After engagement of presenting part, the following occurs:-
✓ pelvic pressure symptoms
✓ Lightening
✓ Shelfing :-The fundus of the uterus descends slightly and falls forwards as a shelf
,It is detected in the standing position
• Cervical changes ( softening and ripening)
• Diarrhea
• Nausea and vomiting
• Burst of energy
First stage:
(Stage of cervical dilatation)
Start: with onset of true labor pains
End: with full dilatation of cervix
Duration: in primigravida about 12 – 16 hours while in
multigravida about 6:8 hours
Phases of 1st stage of labor
Characteristics
1- Latent Phase Active Active / transition
Cervical Changes A-Acceleration Phase B- Deceleration Phase
• Dilatation 1-3 cm 4-7 cm 8-10 cm
• Effacement 30 % 50 % 100 %
Uterine Contraction
• Frequency 1/10 to 2/10 3/10 to 4/10 5/10 to 6/10
• Duration 15-30 sec. 31-60 sec. 60-90 sec.
• Intensity Mild Moderate Severe
Maternal Behavior -Talkative -Irritable -Hyperventilation
-Comfortable -Uncooperative -Intense
-Excited -Fatigued -Difficulty in relaxing
-Afraid -Diaphoresis
-Cooperative -Involuntary bear down
-Desire to defecate
Duration
Primi 6-8 hrs 3-5 hrs 1-2 hrs
Multi 3-5 hrs 1-2 hrs <1 hr
Second stage:
(Stage of fetal expulsion)
Starts: with full dilatation of cervix
End: with delivery of the fetus
Duration: in primigravida up to 1 hour , and in
multigravida about 20 minutes
1. Descend
5. Extension
2. Engagement
Fetal
Head 6. Restitution
3. Increase Delivery
Flexion
7. External
4. Internal
Rotation
Rotation
Signs of the Second Stage of Labor
• Increase frequency and duration of uterine contractions.

• Involuntary bearing down.
• Full cervical dilatation and effacement.
• Bulging of the perineum and the anal orifice starts to dilate.
• Rupture of bag of waters.
• Desire to defecate.
• She is apprehensive, irritable, unwilling to be touched and may cry if
disturbed.
• Grunting voice of the mother.
Third stage:
(Stage of expulsion of afterbirth)
Start : with delivery of the fetus
End: with expulsion of placenta, cord and membranes
Duration : 10:30 minutes
Mechanisms of Separation
Schultz mechanism Duncan’s mechanism
( 80 %) ( 20 %)
The placenta starts separation The placenta starts separation at its
centrally and is delivered like lower pole and delivered side
inverted umbrella with the fetal ways presenting by its lower
surface presenting followed by edge.
the membranes containing small
retro placental clot.
There is less blood loss and less There is more liability of bleeding
liability to retention of and retained fragments.
fragments.
32
Signs of Placental Separation
• Uterus becomes smaller, globular, harder and more mobile.
• Supra-pubic bulge is noticed due to the presence of placenta in the lower

uterine segment
• Gush of blood from the vagina
• Elongation of the cord

• Loss of pulsation of the cord when pressure is exerted on the fundus
Fourth Stage of Labor
• It is the recovery period after delivery of the fetus

(2 hours ).
Topic: References
References
• Lowdermilk, D.L,Perry ,S.E, (11th Ed.) (2016). Maternity and Women’s Health Care. Elsevier
Inc.
• Normal labor and delivery: GLOWM. Global Library of Womens Medicine. (n.d.). Retrieved
October 6, 2021, from https://www.glowm.com/section-
view/heading/Normal%20Labor%20and%20Delivery/item/127

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Physiology and Management of Labour

Dr/ Nadia Abd–Elhamed Eltohamy

Presenter : Dr. Nadia Eltohamy

Presenter : Dr. Nadia Eltohamy

• By the End of this session every learner should be

1-Explain stages of labour

2-Perform focused assessment on a patient in labour

3-Demonestrate techniques in spontaneous delivery

4. Develop management during labour process

• Viability :- Is a reasonable chance of the foetus for extra uterine survival.

▪ Dilatation :-The widening of the external os of the uterine cervix from

Effacement and dilatation occurs at the same time

1- Main cause un Known

- Prostaglandin stimulate uterine contraction and ripening of the cervix.

B- Progesterone withdrawal theory:

E- Placental Ischemia theory: there is decrease production of enzyme

1- power ( Uterine Cont. ( primary and secondary power)

This refers to the frequency, duration, & strength of uterine

This power divided into :-

▪ During pregnancy there are painless intermittent uterine

▪ These are known as Palmer's sign in early pregnancy and

Site of Pain Abdomen & lower back Abdominal

Rhythm regular irregular

Frequency, Strength increasing Not increasing

Cervical Dilatation Progressive Absent

Sedation Not relived by sedatives Relived by sedatives

Frequency of Contractions Frequency of Contractions

Each contraction has three phases:

** Increment: A period during which the contraction begins slowly.

1- Frequency :- refers to number of contraction. It is the period of time

1- Subjective description as perceived by mother

2- By Palpation by using the fingertips

3- By Electronic fetal monitoring

▪It is a blood-stained mucous discharge noticed at the start of

• Dilatation: How far has the cervix opened (in cm)

• Effacement: How thin is the cervix (in %)

• False labor pain

• Increase frequency and duration of uterine contractions.

• Uterus becomes smaller, globular, harder and more mobile.

• Supra-pubic bulge is noticed due to the presence of placenta in the lower

• Gush of blood from the vagina

• Elongation of the cord

• It is the recovery period after delivery of the fetus

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