Mechanism of Normal Labour

Preamble

• Lie

• The lie of the fetus is the relationship between the long axis of the fetus and the long axis of the
uterus in the majority of cases the lie is longitudinal owing to the ovoid shape of the uterus

• Attitude

• Attitude is the relationship of the fetal head and limbs to its trunk. The attitude should be one of
flexion. The fetus is curled up with chin on chest, arms and legs flexed, forming a snug, compact
mass, which utilizes the space in the uterine cavity most effectively. If the fetal head is flexed
the smallest diameters will present and, with efficient uterine action, labour will be most
effective

• Presentation: refers to the part of the fetus that lies at the pelvic brim or the lower pole of the
uterus presentation can be vertex ,breech shoulder ,face or brow vertex, face and brow are all
head or cephalic presentation

• Denominator

• Denominate means 'to give a name to; the denominator is the name of the part of the
presentation, which is used when referring to fetal position. Each presentation has a different
denominator and these are as follows:

• in the vertex presentation it is the occiput

• in the breech presentation it is the sacrumn

• in the face presentation it is the mentum.

• Position

• The position is the relationship between the denominator of the presentation and six points on
the pelvic

Positions in a vertex presentation

• Left occipito anterior (LOA) The occiput points to the left ilio pectineal eminence; the sagittal
suture is in the right oblique diameter of the pelvis

• Right occipito anterior (ROA) The occiput points to the right iliopectineal eminence; the sagittal
suture is in the left oblique diameter of the pelvis

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 • Left occipitolateral (LOL) The occiput points to the left ilio pectineal line midway between the
iliopectineal eminence and the sacroiliac joint; the sagittal suture is in the transverse diameter
of the pelvis

• Right occipitolateral (ROL) The occiput points to the right iliopectineal line midway between the
ilio pectineal eminence and the sacroiliac joint; the sagittal suture is in the transverse diameter
of the pelvis

• Left occipit oposterior (LOP) The occiput points to the left sacroiliac joint; the sagittal suture is in
the .left oblique diameter of the pelvis

• .Right occipit oposterior (ROP) The occiput points to the right sacroiliac joint; the sagittal suture
is in the right oblique diameter of the pelvis

• .Direct occipit oanterior (DOA) The occiput points to the symphysis pubis; the sagittal suture is in
the antero posterior diameter of the pelvis.

• .Direct occipito posterior (DOP) The occiput points to the sacrum; the sagittal suture is in the
antero posterior diameter of the pelvis.

• In breech and face presentations the positions are described in a similar way using the
appropriate denominator

Engagement

• is said to have occurred when the widest presenting transverse diameter has pass through the
brim of the pelvic, in cephalic presentation it is the bi periatal diameter and in breech
presentation is the bi-trochanteric diameter. Engagement demonstrate that the maternal pelvic
is likely to be adequate to size for the fetus and that the baby will be birth vaginally

Mechanism of labour

• Is the series of passive movement of the fetus in its passage through the birth canal. The skilful
management of normal deliver is based on a good knowledge of mechanism of labour.

• Terms used in mechanism (movement)

• 1. Flexion of the head: Bending of the head over the chest and the limbs over the abdomen. The
head is normally flexed at the beginning of labour, with good uterine contractions flexion of the
head is increased, thereby helping descent. The smaller presenting part facilitates descent.

• 2. Internal Rotation (of the head): This is a turning forward of whatever part of the fetus
reaches the pelvic floor first.

• 3. Crowning of the head: This is when the occipital eminence passes under the symphysis pubis
and the head no longer recedes between contractions.

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• 4. Extension: is a movement by which the flexion of the head is undone.

• Descent: Downward movement of the presenting part of the fetus. It is aided contraction of the
uterus, abdominal muscles, positioning of the fetal body, Amniotic fluid and uterine pressure.

• 5. Restitution: This is the turning of the head to undo the twist in the neck which took place
during the internal rotation of the head. Usually towards the back of the baby, it reveals the

• position of the fetus.

• 6. Internal rotation of the shoulder: The shoulders engage in oblique diameter of the pelvis. The
anterior shoulder reaches the pelvic floor first and rotate forwards, bringing the shoulders into
anterior posterior diameter of the pelvic outlet. It takes place during contraction after the head
has been born.

• 7. External Rotation of the head: This is the turning of the head which accompanies the internal
rotation of the shoulders. That is the occiput turns a further 1/8th of a circle and it should
always be in the same direction as in restitution. The body is ready to be born. Not the same as
restitution so should be allowed to occur before the shoulders are born.

• 8. Lateral flexion of the body: This is a sideways bending of the spines which takes place while
the body is being expelled so that it conforms to the curve of the birth canal.

• Common Principles to all mechanisms

• 1. Descent takes place throughout. Whichever part leads and meets the resistance of the pelvic
floor relates forwards until it comes under the symphysis pubis.

• 3. Whatever emerges from the pelvic will pivot around the pelvic bone.

• Mechanism of labour

• Lie-longitudinal

• Attitude –complete flexion

• Presentation –cephalic

• Denominator –occiput

• Position right /left occipitor anterior

• Presenting diameter –sub-occipitor anterior

• Engaging diameter –sub –occipitur bregmatic

• Presenting part –posterior area of bi-parietal bone

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MAIN MOVEMENTS

• The occiput faces the left ilio pectineal eminence while the sinciput faces the right sacro iliac
joint. The sagittal suture lies in the right oblique diameter of the pelvic brim while the shoulders
are in the left oblique diameter of the pelvis.

• With good uterine contractions descent of the head takes place with increased flexion. The
engaging diameter now reduced from sub-occipito frontal (10cm) to sub-occipito bregmatic
(9.5cm).

• The occiput being the leading part reaches the pelvic floor first and rotate 1/8th of a circle
forward (along left side of the pelvis.

• This causes a slight twist in the neck as the head is not in alignment with the shoulders. With
further descent the occiput slips beneath the symphysis pubis,

• Crowning occurs, sinciput, face and the chin sweep the perineum and the head is born by
extension.

• Restitution, takes place (the occiput turns towards the left of mother).

• The shoulders enter in left oblique diameter of the pelvis, with further descent, the anterior
shoulder reaches the pelvic floor first and rotate 1/8th of a circle forwards along the right side of
the pelvis). This internal rotation of the shoulders is accompanied by:

• External rotation of the head. The shoulders are now in anterior posterior diameter of the pelvic
outlet. The anterior shoulder slips under the symphysis pubis, the posterior one passes over the
perineum and the body is born by lateral flexion towards the mother’s abdomen.

(this is further explaination but the premble must be recited

• Descent

• The occiput faces the left ilio pectineal eminence while the sinciput faces the right sacro iliac
joint. The sagittal suture lies in the right oblique diameter of the pelvic brim while the shoulders
are in the left oblique diameter of the pelvis.

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•

• Engagement

• With good uterine contractions descent of the head takes place with increased flexion. The
engaging diameter now reduced from sub-occipito frontal (10cm) to sub-occipito bregmatic
(9.5cm).

• The occiput being the leading part reaches the pelvic floor first and rotate 1/8th of a circle
forward (along left side of the pelvis.

• This causes a slight twist in the neck as the head is not in alignment with the shoulders. With
further descent the occiput slips beneath the symphysis pubis,

Crowning occurs, sinciput, face and the chin sweep the perineum and the head is born by
extension

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 • Restitution, takes place (the occiput turns towards the left of mother).

Internal rotation

• The shoulders enter in left oblique diameter of the pelvis, with further descent, the anterior
shoulder reaches the pelvic floor first and rotate 1/8th of a circle forwards along the right side of
the pelvis).

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• This internal rotation of the shoulders is accompanied by external rotation of the head.

• Delivery of the shoulders and body

• The shoulders are now in anterior posterior diameter of the pelvic outlet. The anterior shoulder
slips under the symphysis pubis, the posterior one passes over the perineum and the body is
born by lateral flexion towards the mother’s abdomen.

• Downward traction

• Delivery of the anterior shoulders

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 • Delivery of the posterior shoulder

• Pain relief in labour

• It is not possible to assess how much pain a person is feeling. Pain leads to physical and
emotional exhaustion and lessen the woman’s confidence. The pain threshold varies from one
individual to another so the woman in labour must be relieved from pain and baby’s safety must
be ensured

Factors that influence perception of pain:

• a. Fear and Anxiety: Heighten the individual’s response to pain. e.g. fear of unknown, previous
bad experiences etc.

• b. Personality; Plays a part in the woman’s response to pain .a tense and anxious woman will
respond poorly to pain and cope less.

• c. Fatigue: A woman who is fatigued will tolerate pain less: prolonged labour.

• d. Culture & social Factors: Also play a part while some cultures encourage stoicism others
encourage expression of feelings.

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 • e. Expectations: A woman who is realistic in her expectation is well equipped and will cope
better with labour pain

• Labour Pain

• Pain in labour is caused by uterine contractions, dilatation of the cervix and stretching of the
vagina and the pelvic floor muscles to accommodate the presenting part (In late 1st and 2nd
stage). The pains are said to be transmitted by the thoracic, lumber and sacral nerves

Methods of Pain relief in labour

• 1. Psychological method: This is the most important aspect of pain relief, because a woman who
is already apprehensive with labour pain will relax if she is admitted into a clean, well-organized,
calm and reassuring environment. The midwife must be sympathetic and understanding. These
will alley her fears, relax more and be able to cope with the pain.

• The personality of the Midwife should reflect kindness, interest in the patient with kind words
and deeds. These include:

• a. giving of information: as necessary

• b. Allaying of anxiety

• c. Participating in Planning and care.

• d. Giving of physical care

Support during labour

• Massage the back during contractions. Provide hygiene and comfort positioning and bladder and
bowel care.

• While in labour, the woman should be encouraged to adopt whichever position she finds most
comfortable. A foam rubber wedge under the side of the mattress will help to prevent supine
hypotensive syndrome by giving a lateral tilt. It may be preferable for her to adopt a left lateral
position, well supported by pillows or a beanbag. A birthing chair or a reclining chair, if available,
may be more comfortable than a conventional labour suite birthing bed.

2. The Use of Drugs (Chemotherapy)

• It is not possible to classify accurately the action of groups of drugs. A small dose of narcotic
would act as sedative, while a large dose of tranquilizer would acts hypotic. Since drugs are used
for various reasons the Midwife must know the reason for administration of a drug that is to
relief pain, alley apprehension, and induce sleep. The Midwife must have a good knowledge and
understanding of the principle underlying the administration of various drugs, and the main
action of the drug she administers. Success and safety of drugs depend on: The choice of the
appropriate drug or combination of drugs,

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 • Adequate dosage, Proper timing, and checking the dose.

3. Drugs used in labour

• Analgesics

• These are drugs that are supposed to relief pain without rendering the patient unconscious.
Examples are paracetamol, etc.

• Narcotics: Allay anxiety and induce sleep – strong analgesic with some sedative effects e.g.
pethidine, morphine, pethilorfan, pentazocin, tramal

• Hypnotics: Induce sleep, anti convulsant – chlorahydrate, diazeperin, omnopon, paraldehyde

• Tranquillisers: Calm patient: Phenergan

• Sedatives: Induce sleep – Barbiturate groups

Inhalational analgesia

• It is used on healthy women in late first stage of labour or in 2nd stage of labour. They are
volatile agents which are excreted fairly quickly from the body. They include Entonox: Pre mixed
nitrous oxide 50% and Oxgyen 50%.

• Obstetric anesthesia

• Anaesthesia means absence of sensation and free from pain or reversible depression of all the
senses.

• Types of anaesthesia are:

• General anaesthesia,

• Regional anaesthesia(e.g epidural block, spinal anaesthesia, pudendal block), and

• Local anaesthesia(e.g. lignocane).

Spinal Anaesthesia

• Technique whereby local anaesthetic solution is injected into the subarachnoid space i.e. into
the CSF.

• Pudendal block – Local anaesthetic solution is injected adjacent to the pudendal nerves just
below the ischial spines where they supply pelvic floor, vulva and perineum.

• Paracervical block: Paracervical plexus are blocked. It is used in prolonged labour – 10mls of
1% lignocaine solution is injected into the lateral fornices of the vagina. It reduces pain and

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 backache in the last 2-3hrs. There is risk of bradycardia –fetal death may occur due to spasm of
uterine vessels.

• Local anaesthesia

• 10mls of 0.5% Lignocain is infiltrated into the perineum for episiotomy. The technique used will
depend on the type of episiotomy.

• Transcutaneous Electrical Nerve stimulation (TENS)

• It is a widely recognized method of pain relief during labour, it stimulates the production of
natural endorphins and blocks any inbound pain

Woman in labour undergoing TENS

The role of the midwife in pain management

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