Physiology of labour

Dr. Savelo Anna

Labour
Childbirth, also known as labour and delivery, is the
ending of pregnancy where one or more babies leaves a
woman's uterus by passing through the vagina or by 
Caesarean section.

Vaginal labour is the physiologic process

03
TERM or PRETERM?
Preterm labor occurs when regular contractions result in the opening of cervix after
week 22 and before week 37 of pregnancy.
How do we call if pregnancy ends before week 22?
How much does the fetus weight at 22 weeks of gestation?

Extremely preterm Very preterm Moderate to late preterm

22,0 -27,6 28,0 – 31,6 32,0 – 36,6

22 28 32 36,6

Preterm Birth

?
Braxton Hicks Labor
contraction contractions

There is one
simple difference
between Braxton
Hicks and labor
contractions: the
end result.

Have a baby?
Those were labor
contractions. No
baby? Braxton
Hicks.
Uterine contractions have two major goals:
To dilate cervix
To push the fetus through the birth canal

Success will depend on the three P’s:

• Powers
• Passenger
• Passage
Three P Passenger Passage
Powers

Fetal size
Power refers to the force generated by Fetal Lie – longitudinal, transverse or oblique
Fetal presentation – vertex, breech, shoulder, Consists of the bony pelvis and
the contraction of the uterine
compound (vertex and hand), and funic soft tissues of the birth canal
myometrium
Activity can be assessed by the simple (umbilical cord). (cervix, pelvic floor musculature)
observation by the mother, palpation of Attitude – degree of flexion or extension of Bony pelvis can be measured by
the fundus, or external the fetal head pelvimetry
tocodynamometry. Position
Contraction force can also be measured Station – degree of descent of the presenting
by direct measurement of intrauterine part of the fetus, measured in centimeters
pressure using internal manometry or from the ischial spines
pressure transducers. Number of fetuses
Presence of fetal anomalies – hydrocephalus,
sacrococcygeal teratoma
 Passenger - Fetus
FETAL LIE
The relation of the long axis of the fetus to that of the mother
Longitudinal lie is found in 99% of labours at term
Predisposing factors for transverse lie/oblique lie
 multiparity, placenta previa, hydramnious, & uterine
anomalies

FETAL PRESENTATION
The presenting part is the portion of the body of the fetus that is
foremost in the birth canal
The presenting part can be felt through the Cx on vaginal
examination
Longitudinal lie
 cephalic presentation
breech presentation
Transverse lie
 shoulder presentation
Passenger - Fetus
POSITION
The relation of an arbitrary chosen point of the fetal
presenting part to the Rt or Lt side of the maternal birth
canal
The chosen point
Vertex presentation  occiput
Face presentation  mentum
Breech presentation Sacrum
Each presentation has two positions Rt or Lt
Each position has 3 varieties : Ant, transverse, post

ATTITUDE
Posture of the fetus
folded on itself to accommodate the shape of the uterus
What lie all of them have?
What presentation all of them have?
Fetal Head
The fetal head, from an obstetrical viewpoint, and in
particular its size, is important because an essential feature
of labor is the adaptation between the fetal head and the
maternal bony pelvis. Only a comparatively small part of the
head at term is represented by the face. The rest of the head
is composed of the firm skull, which is made up of two
frontal, two parietal, and two temporal bones, along with the
upper portion of the occipital bone and the wings of the
sphenoid.

These bones are separated by membranous spaces, or sutures. The most important sutures are the
frontal, between the two frontal bones; the sagittal, between the two parietal bones; the two coronal,
between the frontal and parietal bones; and the two lambdoid, between the posterior margins of the
parietal bones and upper margin of the occipital bone. Where several sutures meet, an irregular space
forms, which is enclosed by a membrane and designated as a fontanel. The greater, or anterior
fontanel, is a lozenge-shaped space that is situated at the junction of the sagittal and the coronal
sutures. The lesser, or posterior fontanel, is represented by a small triangular area at the intersection
of the sagittal and lambdoid sutures. The localization of these fontanels gives important information
concerning the presentation and position of the fetus. The temporal, or casserian fontanels, have no
diagnostic
Fetal size
Measurement of the symphysis-fundal
height (SFH) is a common screening
method used to estimate the gestational
age and fetal growth after 24 weeks
gestation. The SFH is measured using a
tape placed over the mother's abdomen.
The mother's bladder should be empty
when the measurement is done. The
distance from the top of the pubic bone
Estimated fetal weight (symphysis pubis) to the top of the
pregnant uterus (fundus) is measured in
= SFH (cm) x abdominal circumference(cm) centimeters (cm). The SFH in centimeters
should be equal to the gestational age in
= (SFH (cm) + abdominal circumference(cm)) / 4 weeks. A measurement discrepancy of
more 3 cm is suggestive of a fetus with
growth problems , an abnormal amniotic
SFH 98 SFH 112 fluid level , a transverse lie, a twin
AC 36 AC 39 pregnancy, or uterine fibroids
Multiple pregnancy
Passage
The pelvis is composed of four bones—the sacrum, coccyx, and two innominate bones.

The innominate bone is composed of the pubis (brown), ischium (red), and ilium (blue). Of the three
anteroposterior diameters of the pelvic inlet, only the diagonal conjugate can be measured clinically.
The important obstetrical conjugate is derived by subtracting 1.5 cm from the diagonal conjugate.
PASSAGE
2
1

4
PASSAGE
Labor
First Stage - stage of cervical effacement and dilation
Begins when uterine contractions of sufficient frequency, intensity, and duration are attained to bring about
effacement and progressive dilation of the cervix
Ends when the cervix s fully dilated (10 cm) to allow passage of the fetal head

In order to avail for more uniform terminology, the first stage of labour is divided into "latent" and "active"
phases, where the latent phase is sometimes included in the definition of labour, and sometimes not.

First stage: latent phase

The latent phase is generally defined as beginning at the point at which the woman perceives regular uterine
contractions. In contrast, Braxton Hicks contractions, which are contractions that may start around 26 weeks
gestation and are sometimes called "false labour", are infrequent, irregular, and involve only mild cramping.

Cervical effacement, which is the thinning and stretching of the cervix, and cervical dilation occur during the
closing weeks of pregnancy. Dilation is about 4 cm by the end of the latent phase. The degree of cervical
effacement and dilation may be felt during a vaginal examination. The latent phase ends with the onset of the
active first stage.
First stage: active phase
The World Health Organization describes the active first stage as "a period of time
characterized by regular painful uterine contractions, a substantial degree of cervical
effacement and more rapid cervical dilatation from 5 cm until full dilatation for first and
subsequent labours.
In the US, the definition of active labour was changed from 3 to 4 cm, to 5 cm of cervical dilation
for multiparous women, mothers who had given birth previously, and at 6 cm for nulliparous
women, those who had not given birth before.

Active phase:
cervical dilation rate of 1.2 cm/hr for nulliparas and 1.5 cm/hr for parous women
Second stage: fetal expulsion

The expulsion stage begins when the cervix is fully dilated, and ends when the baby is born. As pressure
on the cervix increases, women may have the sensation of pelvic pressure and an urge to begin pushing.
At the beginning of the normal second stage, the head is fully engaged in the pelvis; the widest diameter
of the head has passed below the level of the pelvic inlet. The fetal head then continues descent into the
pelvis, below the pubic arch and out through the vaginal introitus (opening). This is assisted by the
additional maternal efforts of "bearing down" or pushing. The appearance of the fetal head at the vaginal
orifice is termed the "crowning". At this point, the woman will feel an intense burning or stinging sensation.
Six phases of a typical vertex or cephalic (head-first
presentation) delivery: Cardinal movements

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 is bowed, chin on
chest, so that the back or crown of its head leads the way
through the birth canal, until the back of its neck presses
against the pubic bone and its chin leaves its chest,
extending the neck—as if to look up, and the rest of its
head passes out of the birth canal.
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.
https://www.youtube.com/watch?v=lYh93HEgUSA
Third stage: placenta delivery
The period from just after the fetus is expelled until just after the placenta is expelled is called the third stage of
labour or the involution stage. Placental expulsion begins as a physiological separation from the wall of the
uterus. 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. In as many as 3% of all
vaginal deliveries, the duration of the third stage is longer than 30 minutes and raises concern for retained
placenta.

Placental expulsion can be managed actively or it can be managed expectantly, allowing the placenta to be
expelled without medical assistance. Active management is the administration of a uterotonic drug within one
minute of fetal delivery, controlled traction of the umbilical cord and fundal massage after delivery of the
placenta, followed by performance of uterine massage every 15 minutes for two hours.[54] In a joint statement,
World Health Organization, the International Federation of Gynaecology and Obstetrics and the International
Confederation of Midwives recommend active management of the third stage of labour in all vaginal deliveries
to help to prevent postpartum hemorrhage.
Nuchal Cord

Following delivery of the anterior shoulder, a finger should be passed to the fetal neck to determine
whether it is encircled by one or more coils of the umbilical cord. A nuchal cord is found in approximately 25
percent of deliveries and ordinarily causes no harm. If a coil of umbilical cord is felt, it should be slipped
over the head if loose enough. If applied too tightly, the loop should be cut between two clamps and the
neonate promptly delivered

Clamping the Cord

The umbilical cord is cut between two clamps placed 4 to 5 cm from the fetal abdomen, and later an
umbilical cord clamp is applied 2 to 3 cm from the fetal abdomen. A plastic clamp that is safe, efficient, and
fairly inexpensive, such as the Double Grip Umbilical Clamp
Timing of Cord Clamping

If after delivery the newborn is placed at or below the level of the vaginal introitus for 3 minutes and the
fetoplacental circulation is not immediately occluded by cord clamping, an average of 80 mL of blood may
be shifted from the placenta to the neonate (Yao and Lind, 1974). This provides approximately 50 mg of
iron, which reduces the frequency of iron-deficiency anemia later in infancy. At the same time, however,
increased bilirubin from the added erythrocytes contributes further to hyperbilirubinemia
 Labor
Pain in contractions has been described as feeling similar to very strong menstrual cramps. Women are
often encouraged to refrain from screaming. However, moaning and grunting may be encouraged to help
lessen pain. Crowning may be experienced as an intense stretching and burning. Even women who show
little reaction to labour pains, in comparison to other women, show a substantially severe reaction to
crowning.
During the later stages of gestation there is an increase in abundance of oxytocin, a hormone that is
known to evoke feelings of contentment, reductions in anxiety, and feelings of calmness and security
around the mate. Oxytocin is further released during labour when the fetus stimulates the cervix and
vagina, and it is believed that it plays a major role in the bonding of a mother to her infant and in the
establishment of maternal behavior. The act of nursing a child also causes a release of oxytocin.

Pain management during childbirth is the treatment or prevention of pain that a woman may experience during labor and delivery. The amount of
pain a woman feels during labor depends partly on the size and position of her baby, the size of her pelvis, her emotions, the strength of the
contractions, and her outlook.

Some women do fine with "natural methods" of pain relief alone. Many women blend "natural methods" with medications and medical
interventions that relieve pain. Building a positive outlook on childbirth and managing fear may also help some women cope with the pain. Labor
pain is not like pain due to illness or injury. Instead, it is caused by contractions of the uterus that are pushing the baby down and out of the birth
canal. In other words, labor pain has a purpose.
 Non-pharmacological
• Breathing and relaxation techniques
• Warm showers or baths
• Massage
• Warm or cold compresses, such as heat on lower back or cold washcloth on forehead
• Use of a labor ball
• Listening to music
• Acupuncture
• Continuous supportive care of a loved one, hospital staff member, or doula
• Other methods include hypnosis, biofeedback, sterile water injection, aromatherapy

Medical and pharmaceutical methods of pain control

Opioids
These medications may cause unwanted side effects like drowsiness, itching, nausea, or vomiting to the laboring mother. All opioids can cross the placenta and may poorly affect
the baby by causing problems with heart rate, breathing, or brain function. For this reason, opioids are not given close to delivery.They can be beneficial in early labor, however,
since they can help dull pain, but do not impair the mother’s ability to move or push
Epidural and spinal blocks
An epidural is a procedure that involves placing a tube (catheter) into the lower back, into a small space below the spinal cord. Epidural and spinal blocks allow most women to be
awake and alert with very little pain during labor and childbirth.
Although movement is possible, walking may not be if the medication affects motor function. An epidural can lower blood pressure, which can slow your baby's heartbeat. Fluids
given through IV are given to lower this risk. Fluids can cause shivering. But women in labor often shiver with or without an epidural. If the covering of the spinal cord is punctured by
the catheter, a bad headache may develop. Treatment can help the headache. An epidural can cause a backache that can occur for a few days after labor. An epidural can prolong
the first and second stages of labor. If given late in labor or if too much medicine is used, it might be hard to push when the time comes. An epidural increases risk of assisted
vaginal delivery.
Pudendal block
In this procedure a doctor injects numbing medicine into the vagina and the nearby pudendal nerve
Inhaled analgesia
Fetal monitoring
• Simple stethoscope or doppler fetal monitor ("doptone")
• Cardiotocography
• Amniotic fluid color
• Fetal scalp pH testing
Episiotomy and lacerations
https://www.ypo.education/gynecology/c-section-t251/video/

https://www.youtube.com/watch?v=nQoxtHMVZX8