STAGES OF LABOUR :

FIRST STAGE
ONSET OF LABOUR

 Uterine contractions that bring about demonstrable effacement and dilatation of

cervix
 Start of painful uterine contractions accompanied by one of the following :
 Ruptured membranes
 Bloody show
 Complete cervical effacement
PREPARATORY STAGE

 2 or 3 weeks before onset of labour in a primigravida; few days before in

multigravida
 Lightening –Decrease in fundal height seen at term. Formation of
lower uterine segment, which allows the presenting part to descend into
cervix. Falling forward of uterus with head sinking into pelvis; shelving
sign.
 Gradual shortening of cervical canal
 False pains
 False labour pains :
 Before onset of labour
 Irregular and they do not progress
 Not accompanied by cervical dilatation or uterine contractions
 Pain felt over the abdomen
 Due to loaded rectum or temporary indigestion.
PRELABOUR

 Prelabour : Prior to onset of labour and may

last from a few days to weeks. Increase in
oxytocin receptors in myometrium.
 cervical softening and effacement , and slight
to modest cervical dilatation.
 Cervical ripening-
 Once labour starts, Cervix becomes dilatable and fundus starts
contracting.
 Cervix- collagen, extracellular matrix, smooth muscle
 Decrease in collagen, relative change in GAGs ( increase in
hyaluronic acid with decrease in dermatan sulfate.
 Cervical ripening, softening and relaxation
 Prostaglandins
LABOUR
 First stage : Onset of true labour pains to
complete cervical dilation (10cm)
 Second stage: complete cervical dilation to
delivery of the fetus or fetuses.
 Third stage: separation and expulsion of
placenta and membranes.
 Latent phase – preceds active labour by several hours ,
 Slight discomfort with irregular contractions associated with slow
effacement and dilatation
 Fourth stage - follows placental explusion ie. Till 2 hours
 Contraction of the myometrium and retraction with vessel thrombosis
FIRST STAGE

 Extends from the onset of true labour pains to complete dilatation

Of of cervix .
 Latent phase – cervical effacement and dilatation upto 3-4cm
 6-8 hrs in nullipara
 4-6 hrs in multipara
 Duration depends on extent of cervical ripening at onset of labour.
 Active phase :
 Extends from 3-4cm dilatation to complete cervical dilatation
 Contractions are stronger and more frequent
 5 hrs in nullipara and 3 hrs in multipara
 1.2 cm / hr in nullipara and 1.5 cm/ hr in multipara
 Minimal acceptable progress – 1cm/ hr.
EVENTS IN FIRST STAGE

 Uterine contractions.
 Cervical changes
 Show
 Formation of lower uterine segment
 Descent of fetus
 Formation of bag of waters and finally rupture .
UTERINE CONTRACTIONS

 Regular and increase in duration and frequency – last for 30-90sec ,

frequency is 3 in 10 min. In between contractions, the uterus relaxes to
allow the placental circulation to flow and thus prevent hypoxia.
 Fundal dominance : intensity is strongest at fundus and gradually
decreases downwards.
 Synchronisation
 Intraamniotic pressure – resting tone is 6-10 mm Hg. In first stage – 40-
50 mm Hg and in second stage is 80-100 mm Hg. It becomes painful
when the pressure rises above 25 mm Hg.
 Retraction : property of uterine muscle fibres whereby the muscle fibres,
which are shortened during a contraction do not regain their original
length even after the contraction wears off. Effects are formation of
lower uterine segment, effacement and dilation of cervix, explusion of
fetus, separation and expulsion of placenta and effective hemostasis after
placental expulsion.
 Pain : myometrial ischemia during contractions
 Segments of uterus differentiate
upper segment- contracts and retracts
Lower segment- dilates and becomes thinner
 CERVICAL CHANGES

 Cervical effacement (taking up of cervix) is the shortening of cervical

canal to a circular opening with paper thin edges .
 The cervix is incorporated into lower segment.
 Above downwards until only the external os remains as a rim.
 In nullipara , effacement precedes dilatation, but in multipara both
occur simultaneously
 DILATATION OF CERVIX

 Mechanism of dilatation of cervix

 Result of contracting and retracting upper segment, lifting up and
thinning out of lower segment, ultimately pulling the cervix over
the advancing presenting part, without significantly altering the
level of external os in thr pelvis
 The uterine contractions exert hydrostatic pressure through the
intact membranes , which dilates the cervix like a wedge.
 Once the membranes are ruptured, the presenting part is
forced directly against the cervix and lower segment. Induces
stronger uterine contractions and more rapid dilatation
 Dilatation of external os , depends on contractions and its
capacity to soften and stretch which depends on its preparation
during pregnancy by estrogen , progesterone and
prostaglandins.
 Process of dilatation of cervix :
 In a primipara, during commencent of labour , the whole of
cervical canal is closed. Dilatation takes place from above
downwards, the internal os dilating first then cervical canal and
last of all the external os.
 In multipara , at commencement, the external os is patulous
usually admitting 1 finger freely and the internal os is not
completely occluded.
Dilatation is more rapid and easier .
 Pattern of cervical dilatation .
 Friedman’s curve
 When cervical dilatation that takes place during labour takes
the shape of a sigmoid curve, when plotted against time
 Relatively flat latent phase
 Rapidly progressing active phase
 Mechanical dilatation of cervix enhances uterine activity –
ferguson reflex (PGs) ; stripping or sweeping of membranes
SHOW

 Softening and effacement of cervix releases cervical mucous

plug, which in turn leads to a discharge of mucous mixed with
blood called show
 Evidence of cervical dilatation and effacement and frequently
the descent of the presenting part
FORMATION OF LOWER UTERINE SEGMENT

 Part of uterus below the uterovesical fold of peritoneum , where the peritoneum is
only loosely attachment. (7-10cm ). Develops from isthmus and cervix
 Develops gradually as pregnancy proceeds.
 After effacement and dilatation , cervix incoporated into lower uterine segment
 Upper part contracts , becomes smaller and thicker. ( Retraction )
 Lower segment distends becomes thinner and fibres lengthen with each contraction
 Junction seen as a demarcation, called physiological retraction ring.
 Clinical significance : caesarean section ,placenta previa, pathological retraction ring (
bandl ring)
FETAL DESCENT

 Minimal in latent phase and early active phase

 Begins with the phase of maximum slope
 Maximum in decelaration phase and second stage
 Increases progressively
 Assessed by abdominal and vaginal examination
FORMATION OF BAG OF MEMBRANES

 Due to stretching of the lower uterine segment, the membranes are detached from
their loose attachment to decidua and bulge into cervical canal as cervix dilates.
 It contains liquor, it is called bag of membranes
 During contractions the bag becomes tense and convex. It is certain sign of labour
 Hydrostatic pressure is the pressure exerted by uterine contractions when the bag
of membranes is intact , which in turn dilates the cervical canal like a wedge.
 Towards the end of first stage, the membranes rupture .
 In vertex presentation,as head fits into the lower segment and the bag of membranes
is well applied to the head- hour glass appearance.
 conical appearance – malformations *
MANAGEMENT OF FIRST STAGE OF LABOUR

 PREPARATION OF PATIENT
 Clean the vulva and the perineum
 If hair in the lower part is likely to interfere in the time
of delivery it may be clipped with with scissors
 Routine shaving is not advocated
 Mother should be encouraged to walk about in
first stage and advised to empty the bladder and
bowel frequently
 The maternal temperature and pulse is recorded
every hour
 Labour involves 3 functional division
 Preparatory division : shows considerable changes in the
connective tissue and collagen of cevix takes place with only a little
cervical dilatation. This stage is affected by sedatives and anasthesia
 Dilatation phase : cervical dilatation occurs at a maximum rate of
1.0cm/hr in primigravida and 1.5cm/hr in multigravida. The phase is
not affected by sedation and anasthesia
 Pelvic division : full dilatation with descent and delivery of
fetus . Cardinal movement of fetus takes place during this
phase .
AMNIOTOMY
 Performed after the women goes into active labour
 Benefits
 rapid labour
 Detection of meconium staining of liqour
CARE OF URINARY BLADDER
 Women should be asked to void urine and bladder distension should
be avoided
 If she cannot void urine catheterisation is indicated
ASSESSMENT OF PROGRESS OF LABOUR
 PARTOGRAM
 Course of labour during first stage and second stage of
labour is monitored by plotting the cervical dilatation and
descent of fetus in against time in hours . This is refered to
as partogram
 USE
 Detecting delay at various stages of labour to provide
prompt treatment
 INFORMATION CONTAINED IN A PARTOGRAM
 Patient information :name,age,gravida,para,date and time of admission
 fetal heart rate : every half hour
 Amniotic fluid ;record the colour of amniotic fluid at every vaginal examination
o I : membrane intact
o C : membranous ruptured, clear fluid
o M : meconium stained fluid
o B : blood stained fluid
 Cervical dilatation
 Descent assessed by abdomen palpation
 Hours :time elapsed after onset of active labour
 Time : record actual time
 Contraction :these needed to be recorded in every every half an
hour
 Oxytocin : record the amount of oxytocin per volume IV fluid in
drop/minute every 30 minute when used
 Drugs :record any additional drugs if given
 Pulse: record every 30 minutes and marked with a dot
 blood pressure : record every 4 hrs and mark with arrows
 Temperature : record every two hours
 Urine records : protein , acetone and volume when passed
 MONITORING UTERINE CONTRACTION
 Time of onset and dissapearance of contraction is noted
by palpating the uterus with palm of hand
 Intensity is measured from the degree of firmness of the
uterus
 Frequency, duration and intensity are noted at regular
intervals
 FETAL HEART RATE MONITORING
 Fetal heart rate is checked immediately after contraction ,
atleast every 30 minutes in first stage of labour .
 In high risk pregnancy auscultation is done every 15 minutes
 It is identified with the sthethescope or a doppler
ultrasound device
Thank you