NORMAL LABOUR, MECHANISMS

OF LABOUR
Prof. Israel Jeremiah
Department of Obstetrics and Gynaecology
Niger Delta University
 LABOUR
• Labour – is a physiologic process during which
the products of conception (i.e., the foetus,
membranes, umbilical cord and placenta) are
expelled outside the uterus i.e. It is the natural
process of child birth.

• It is characterised by regular painful uterine

contractions, increasing in frequency, intensity
and duration, with associated effacement and
dilatation of the cervix and decent of the
presenting part ultimately leading to the
The following criteria should be present to
call it normal labour:
• Spontaneous expulsion,
• of a single,
• mature foetus,
• presented by vertex,
• through the birth canal,
• within a reasonable time (not less than 3 hours or
more than 12 hours),
• without complications to the mother, or the foetus.
 Cause of Onset of Labour
It is unknown but the following theories were postulated:

1. Hormonal factors
• Oestrogen theory:
– During pregnancy, most of the oestrogens are
present in a binding form. During the last
trimester, more free oestrogen appears increasing
the excitability of the myometrium and
prostaglandins synthesis.
• Progesterone withdrawal theory:
– Before labour, there is a drop in progesterone
synthesis leading to predominance of the
excitatory action of oestrogens.
 Cause of Onset of Labour
It is unknown but the following theories were postulated:

• Prostaglandins theory:
– Prostaglandins E2 and F2α are powerful stimulators of uterine muscle
activity. PGF2α was found to be increased in maternal and foetal blood
as well as the amniotic fluid late in pregnancy and during labour.
• Oxytocin theory:
– Although oxytocin is a powerful stimulator of uterine contraction, its
natural role in onset of labour is doubtful. The secretion of oxytocinase
enzyme from the placenta is decreased near term due to placental
ischaemia leading to predominance of oxytocin’s action.
• Foetal cortisol theory:
– Increased cortisol production from the foetal adrenal gland before
labour may influence its onset by increasing oestrogen production
from the placenta.
 Cause of Onset of Labour
2. Mechanical factors
• Uterine distension theory:
– Like any hollow organ in the body, when the
uterus in distended to a certain limit, it starts to
contract to evacuate its contents. This explains the
preterm labour in case of multiple pregnancy and
polyhydramnios.
• Stretch of the lower uterine segment:
– by the presenting part near term.
 Onset of Labour
• It is characterised by:
• True labour pain.
• The show:
– It is an expelled cervical mucus plug tinged with blood from ruptured
small vessels as a result of separation of the membranes from the
lower uterine segment. Labour is usually starts several hours to few
days after show.
• Dilatation of the cervix:
– A closed cervix is a reliable sign that labour has not begun. In
multigravidae the cervix may admit the tip of the finger before onset
of labour.
• Formation of the bag of fore-waters:
– It bulges through the cervix and becomes tense during uterine
contractions.
 STAGES OF LABOUR
• Labour is divided into three stages:
• First stage
• Second stage
• Third stage
 STAGES OF LABOUR
• First stage
– It is the stage of cervical dilatation.
– Starts with the onset of true labour pain
and ends with full dilatation of the cervix
i.e. 10 cm in diameter.
– It takes about 10-12 hours in primigravida
and about 6-8 hours in multipara.
 STAGES OF LABOUR
• Second stage
– It is the stage of expulsion of the foetus.
– Begins with full cervical dilatation and ends
with the delivery of the foetus.
– Its duration is about 1 hour in primigravida
and ½ hour in multipara.
– It is said to be prolonged when it lasts more
than 2 hours.
 STAGES OF LABOUR
• Third stage
– It is the stage of expulsion of the placenta and
membranes.
– Begins after delivery of the foetus and ends with
expulsion of the placenta and membranes.
– Its duration is about 10-20 minutes in both primi
and multipara.
– When it takes longer than 30mins the placenta is
said to be RETAINED.
 First Stage
• Causes of cervical dilatation
• Contraction and retraction of uterine musculature.
• Mechanical pressure by the forebag of waters, if
membranes still intact, or the presenting part, if they
had ruptured. This in turn will release more
prostaglandins which stimulate uterine contractions
and cervical effacement.
• Softness of the cervix which has occurred during
pregnancy facilitates dilatation and effacement of the
cervix.
 Mechanism of cervical dilatation
• In primigravidae,
• The cervical canal dilates from above downwards i.e.
from the internal os downwards to the external os.
So its length shorts gradually from more than 2 cm to
a thin rim of few millimetres continuous with the
lower uterine segment. This process is called
effacement and expressed in percentage so when we
say effacement is 70% it means that 70% of the
cervical canal has been taken up.
• Dilatation of the cervix (external os) starts after
complete effacement of the cervix.
 Mechanism of cervical dilatation
• In multigravidae
• Effacement and dilatation occur simultaneously.
• In normal presentation and position, the head is
applied well to the lower uterine segment dividing
the amniotic sac by the girdle of contact into a
hindwaters above it containing the foetus and a
forewaters below it.
• This reduces the pressure in the forewaters
preventing early rupture of membranes. After full
dilatation of the cervix the hind and forewaters
become one sac with increased pressure in the bag
of forewaters leading to its rupture.
 Phases of cervical dilatation
• Latent phase:
– This is the first 4 cm of cervical dilatation which is slow takes about 8
hours in nulliparae and 4 hours in multiparae.
• Active phase:
– It has 3 components:
• acceleration phase,
• maximum slope, and
• deceleration phase.
• The phase of maximum slope is the most detectable and the
two other phases are of shorter duration and can be detected
only by frequent vaginal examination.
• The normal rate of cervical dilatation in active phase is 1.2
cm/ hour in primigravidae and 1.5 cm/hour in multiparae. If
the rate is < 1cm / hour it is considered slow.
 STAGES OF LABOUR
• Second stage
– It is the stage of expulsion of the foetus.
– Begins with full cervical dilatation and ends
with the delivery of the foetus.
– Its duration is about 1 hour in primigravida
and ½ hour in multipara.
– It is said to be prolonged when it lasts more
than 2 hours.
 Its beginning is identified by:
• The patient feels the desire to defecate.
• The contractions become more prolonged and
painful.
• Reflex desire to bear down during the contractions.
• The expulsive effort is accompanied by sustained
expiratory grunt.
• Rupture of membranes, although this is not specific as
it may occur earlier even before start of labour "
prelabour rupture of membranes" or later even to the
degree that the foetus is delivered in an intact sac.
• Full dilatation of the cervix (10 cm) in between uterine
contractions is the most sure sign.
 Lie, presentation, attitude, &position
FOETAL LIE
• The relation of the long axis of the foetus to that
of the mother
• Longitudinal lie is found in 99% of labours at term
• Transverse lie
• Oblique lie
• Predisposing factors for transverse lie/oblique lie
 multiparity, placenta previa, hydramnious, &
uterine anomalies
FETAL PRESENTATION
• The presentation is that part of the foetus that
occupies the lower uterine pole.
• 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
• Transvrse lie  shoulder presentation
 Lie, presentation, attitude, &position
CEPHALIC PRESENTATION
• Head is flexed sharply  vertex / occiput
presentation
• Head is extended sharply  face presentation
• Partially flexed  bregma presenting (sinciput
presentation)
• Partially extended  brow presentation
ATTITUDE
• The relationship of various parts of the foetus to
one anothe
• Posture of the fetus folded on itself to
accommodate the shape of the uterus
• Flexed head, thighs, knees &feet
• The arms crossed over the chest
• Face presentation extended concave contour
of the vertebral column
.
'
"
'

I
!
1\

1
1

A
B
ii

c
D (A) vertex (B) sinciput (C) brow (D) face

Longitudinal lie. Ce­phalic presentation. Differences in attitude of fetal

body,
Note changes in fetal attitude in relation to fetal vertex as the fetal head
becomes less flexed.
I
I

Longitudinal lie. Frank breech Longitudinal lie. Complete breech

presentation. presentation.
 Longitudinal lie. Incomplete, or footling,
breech presentation.
 POSITION
The relation of an arbitrary chosen point of the
fetal presenting part to the maternal pelvis
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
 OA

ROA LOA

ROT LOT

ROP
LOP

OP
 LONGITUDINAL LIE VERTEX PRESENTATION

LOA LOP

~
'
t
J
 A. Right occiput posterior (ROP) Right occiput transverse (ROT)

Longitudinal lie. Vertex presentation

~

S
f
a
!

C
Right occiput anterior (ROA).
c

h
t
p
(
f
i
t
t
b

f
e

c
a
l
t
a
 FREQUENCY OF VARIOUS PRESENTATIONS &
POSITIONS AT TERM
• Vertex  96%
2/3 Lt
1/3 Rt

• Breech  3.5%

• Face 0.3%

• Shoulder 0.4%
Lt mento-ant Rt mento-ant Rt mento-post

Longitudinal lie. Face presentation. Left and right

anterior and ri posterior positions.
~

Longitudinal lie Breech presentation LSP

 Transverse lie. Right acromiodorsoposterior position (RADP). The
shoulder of the fetus is to the mother's right, and the back is posterior.
MECHANISMS OF LABOUR
 CARDINAL MOVEMENTS OF LABOUR
Delivery of the head

• Descent:
– It is continuous throughout labour particularly during the
second stage and caused by:
• Uterine contractions and retractions.
• The auxiliary forces which is bearing down brought by
contraction of the diaphragm and abdominal muscles.
• The unfolding of the foetus i.e. straightening of its body
due to contractions of the circular muscles of the
uterus.
• Engagement:
• Is when the widest transverse diameter of the presenting part
crosses the maternal pelvic brim
– The head normally engages in the oblique or transverse
diameter of the inlet.
 Delivery of the head
• Increased flexion:
– As the atlanto-occipital joint is nearer to the occiput than
the sinciput, increased flexion of the head occurs when it
meets the pelvic floor according to the lever theory.
– Increased flexion results in:
• The suboccipito-bregmatic diameter (9.5 cm) passes
through the birth canal instead of the suboccipito-
frontal diameter (10 cm).
• The part of the foetal head applied to the maternal
passages is like a ball with equal longitudinal and
transverse diameters as the suboccipito-bregmatic =
biparietal = 9.5 cm. The circumference of this ball is 30
cm.
• The occiput will meet the pelvic floor.
 Delivery of the head
• Internal rotation:
– The rule is that the part of foetus meets the pelvic floor
first will rotate anteriorly. So that its movement is in the
direction of levator ani muscles (the main muscle of the
pelvic floor) i.e. downwards, forwards and inwards.
– In normal labour, the occiput which meets the pelvic floor
first rotates anteriorly 1/8 circle.
• Extension:
– The suboccipital region lies under the symphysis then by
head extension the vertex, forehead and face come out
successively.
– The head is acted upon by 2 forces:
• the uterine contractions acting downwards and
forwards.
• the pelvic floor resistance acting upwards and forwards
so the net result is forward direction i.e. extension of
the head.
 Delivery of the head
• Restitution:
– After delivery, the head rotates 1/8 of a circle in
the opposite direction of internal rotation to undo
the twist produced by it.
• External rotation:
– The shoulders enter the pelvis in the opposite
oblique diameter to that previously passed by the
head. When the anterior shoulder meets the
pelvic floor it rotates anteriorly 1/8 of a circle. This
movement is transmitted to the head so it rotates
1/8 of a circle in the same direction of restitution.
 Delivery of the head
• The main aim during delivery of the head is to
prevent perineal lacerations through the
following instructions:
• i) Support of the perineum:
– When the labia start to separate by the head, a
sterile pad is placed over the perineum and press
on it with the right hand during uterine
contractions. This is continued until crowning
occurs to maintain flexion of the head.
 Delivery of the head
• Crowning:
– is the permanent distension of the vulval ring by the foetal head like a
crown on the head. The head does not recede back in between
uterine contractions.
– This means that the biparietal diameter is just passed the vulval ring
and the occipital prominence escapes under the symphysis pubis.
– After crowning, allow slow extension of the head so the vulva is
distended by the suboccipito frontal diameter 10 cm.
– If the head is allowed to extend before crowning the vulva will be
distended by the occipito-frontal 11.5 cm increasing the incidence of
perineal lacerations.
– Ritgen manoeuvre: upward pressure on the perineum by the right
hand and downward pressure on the occiput by the left hand to
control the extension of the head.
• Episiotomy:
 Delivery of the shoulder and body

• Gentle downward traction is applied to the

head till the anterior shoulder slips under the
symphysis pubis. The head is lifted upwards to
deliver the posterior shoulder first then
downwards to deliver the anterior shoulder.
 LACERATIONS AND EPISIOTOMY
• EPISIOTOMY:
• It is done at crowning when the perineum is
stretched to the degree that it is about to tear.
 Clamping the cord
• The baby is held by its ankles with the head
downwards at a lower level than its mother for few
seconds.
• This is contraindicated in:
– Preterm babies.
– Erythroblastosis foetalis.
– Suspicion of intracranial haemorrhage.
• This may be enhanced by milking the cord towards
the baby, to add about 100 ml of blood to its
circulation.
• The cord is divided between 2 clamps to avoid
bleeding from a possible 2nd uniovular twin.
 Delivery of the remainder of the body

• Usually slips without difficulty otherwise

gentle traction is applied to complete delivery.
 STAGES OF LABOUR
• Third stage
– It is the stage of expulsion of the placenta and
membranes.
– Begins after delivery of the foetus and ends with
expulsion of the placenta and membranes.
– Its duration is about 10-20 minutes in both primi
and multipara.
– When it takes longer than 30mins the placenta is
said to be RETAINED.
 Signs of placental separation and
descent:
• The body of the uterus becomes smaller, harder and
globular.
• The fundal level rises as the upper segment overrides
the lower uterine segment which is now distended
with the placenta.
• Suprapubic bulge due to presence of the placenta in
the lower uterine segment.
• Elongation of the cord particularly on pressing on the
uterine fundus and it does not recede back into the
vagina on relieving the pressure.
• Gush of blood from the vagina.
 Third Stage
• After delivery of the foetus, the uterus continues to
contract and retract. As the placenta is inelastic, it
starts to separate through the spongiosa layer by one
of the following mechanisms:
• Schultze’s mechanism (80%)
• The central area of the placenta separates first and
placenta is delivered like an inverted umbrella so the
foetal surface appears first followed by the
membranes containing small retroplacental clot.
• There is less blood loss and less liability for retention
of fragments.
 Third Stage
• Duncan’s mechanism (20%)
• The lower edge of the placenta separates first and
placenta is delivered side ways.
• There is more liability of bleeding and retained
fragments.

• The 3rd stage is composed of 3 phases:

• Placental separation.
• Placental descent.
• Placental expulsion.
 Delivery of the placenta
• Conservative method:
• Put the ulnar border of the left hand just above the fundus at
the level of the umbilicus to detect any bleeding inside the
uterus known by rising level of the atonic uterus.
• Wait for signs of placental separation and descent but do not
massage the uterus.
• As soon as they are detected massage the uterus to induce its
contraction, ask the patient to bear down and push the uterus
downwards to deliver the placenta.
• Hold the placenta between the two hands and roll it to make
the membranes like a rope in order not to miss a part of it.
• Give ergometrine 0.5 mg or oxytocin 10 units IM after delivery
of the placenta to help uterine contraction and minimise
blood loss. These may be given before delivery of the
placenta.
 The active method (Brandt- Andrews
method):
• With delivery of the anterior shoulder, 0.5 mg
ergometrine or syntometrine (0.5 mg ergometrine +
5 units oxytocin) is given IM.
• When the uterus contracts, put the left hand
suprapubic and push the uterus upwards while
gentle downward and backward traction is applied
on the cord by the right hand (controlled cord
traction) .
• When the placenta is delivered it is rolled as in the
conservative method.
• Advantage:
• reduction of the blood loss.
• Disadvantages:
– Constriction ring may occur with retention of the
placenta.
– Avulsion of the cord if undue pressure is applied.
– Inversion of the uterus if fundus is pressed while
the uterus is lax.
• Routine examinations
• Examination of the placenta and membranes:
– by exploring it on a plain surface under running
water to be sure that it is complete. If there is
missed part, exploration of the uterus is done
under general anaesthesia.
 The umbilical cord
• A disposable plastic umbilical clamp is applied about
5 cm from the umbilicus to avoid the possibility of
tying an umbilical hernia then cut about 1.5 cm distal
to the clamp. Inspect for bleeding and paint it with
alcohol.
• If the plastic umbilical clamp is not available, 2
ligatures of silk are applied instead of it.
• The umbilical stump is painted daily with an
antiseptic till its fall within 10 days.
• Congenital anomalies
• The newborn is examined for injuries or
congenital anomalies as imperforate anus,
hypospadias (not to be circumcised as the cut
skin will be used in the repair later on),
cyanotic heart diseases.... etc.

• Weight:
• the newborn and record it.
 PHYSIOLOGICAL EFFECTS OF LABOUR

• On the Mother
• First stage:
– minimal effects.
• Second stage:
– Temperature: slight rise to 37.5oC.
– Pulse: increases up to 100/min.
– Blood pressure: systolic blood pressure may rise slightly due to pain,
anxiety and stress.
– Oedema and congestion of the conjuctiva.
– Minor injuries: to the birth canal and perineum may occur particularly
in primigravidas.
• Third stage:
– Blood loss from the placental site is 100-200 ml and from laceration or
episiotomy is 100 ml so the total average blood loss in normal labour
is 250 ml.
 On the Foetus
• Moulding
• The physiological gradual overlapping of the vault bones as
the skull is compressed during its passage in the birth canal.
• One parietal bone overlaps the other and both overlap the
occipital and frontal bones so fontanelles are no more
detectable. It is of a good value in reducing the skull
diameters but severe and / or rapid moulding is dangerous as
it may cause intracranial haemorrhage.
• Degree of Moulding
• + Suture lines closed but no overlap.
• ++ Overlap of the bones but reducible.
• +++ Overlap of the bones but irreducible.
 Caput succedaneum
• It is a soft swelling of the most dependent part
of the foetal head occurs in prolonged labour
before full cervical dilatation and after rupture
of the membranes.
• It is due to obstruction of the venous return
from the lower part of the scalp by the
cervical ring.
 Caput succedaneum
• Large caput may:
– obscure the sutures and fontanelles making identification
of the position difficult. This can be overcomed by
palpation of the ear,
– give an impression that the head is lower than its true
level.
• Artificial caput succedaneum (chignon): is induced
during vacuum extraction.
• Caput succedaneum disappears spontaneously
within hours to days of birth.
• As it is a vital manifestation, so it is not detected in
intrauterine foetal death.
 Caput succedaneum
• The presence of caput indicates that:
• The foetus was living during labour,
• Labour was prolonged and difficult,
• The attitude of foetal head during labour can
be expected as caput is present in the most
dependant part of it.
 The Golden Hour
• This is the 1st hour following delivery (referred
to by some as the fourth stage of labour)
– It is the stage of early recovery.
– Begins immediately after expulsion of the placenta
and membranes and lasts for one hour.
– During which careful observation for the patient,
particularly for signs of postpartum haemorrhage is
essential.
– Routine uterine massage is usually done every 15
minutes during this period.
• ACTIVE MANGEMENT OF LABOUR
 ACTIVE PROCEDURES
• Evacuation of the rectum by enema to;
• avoid uterine inertia,
• help the descent of the presenting part,
• avoid contamination by faeces during delivery.
• Evacuation of the bladder:
• ask the patient to micturate every 2-3 hours, if she
cannot use a catheter.
• It prevents uterine inertia and helps descent of the
presenting part.
 MATERNAL MONITORING
• The partogram:
• It is the graphic recording of the course of labour
including the following observations:
– The mother:
• Pulse every 30 minutes,
• blood pressure every 2 hours,
• temperature every 4 hours,
• uterine contractions: frequency, strength and duration every 30
minutes by manual palpation or better by tocography if available,
• cervical dilatation,
• fluid input and output,
• drugs including oxytocins.
 MATERNAL MONITORING
• Cardiotocography if available is more valuable for
continuous monitoring of both uterine contractions
and FHR particularly in high risk pregnancy.
• The advantages of the partogram:
– Allows right intervention in the proper time e.g. oxytocin
usage, instrumental delivery or C.S.
– Allows different staff shifts to manage the case
successively.
– A document for labour events.
 FETAL MONITORING
• The foetus
• FHR every 15 minutes by Pinard’s stethoscope or better
by doptone,
• descent of the presenting part,
• degree of moulding.
• Cardiotocography if available is more valuable
for continuous monitoring of both uterine
contractions and FHR particularly in high risk
pregnancy.
 POSITION DURING LABOUR
• Patient is allowed to walk during the early first
stage particularly with intact membranes.
• If rest is needed the patient lies on her left
lateral position to prevent inferior vena cava
compression and hence placental insufficiency
and foetal distress.
 ANALGESIA
• Pethidine 100 mg IM,
• Entonox
• Trilene inhalation, or
• Epidural anaesthesia are the most common
use.
 NUTRITION
• When labour is established no oral feeding is
allowed, but sips of water.
• 15 ml magnesium trisilicate is given every 2 hours as
an oral antacid to guard against bronchospasm
occurs if the acid vomitus is inhaled during general
anaesthesia "Mendelson’s syndrome". Antacid
injections may be used instead.
• If labour is delayed more than 8 hours, IV drip of
glucose 5% or saline-glucose solution is given.
 PURPERIUM
• Vital signs
• Lochia
• Uteirne involution
• Perinium