NORMAL LABOR AND

DELIVERY

Patricia Grace S. Lo, M.D.

Parturition
 Bringing forth of the young
 Phase 0 – prelude to childbirth
 Phase 1 – preparation for childbirth
 Phase 2 – process of childbirth
 Phase 3 – recovery from childbirth
Phases of Parturition and Onset of Labor

Phase 0 Phase 1 Phase 2 Phase 3

Quiescence Activation Stimulation Involution
Prelude to Preparation Processes of Parturient
Parturition for labor labor Recovery

Contractile Uterine Active Labor Uterine

unresponsiveness Preparedness (three stages of Involution
for labor labor) Breastfeeding
Phase 0 – Uterine Quiescence

 Myometrial smooth muscle unresponsiveness to

natural stimuli and relative contractile paralysis
 Cervical anatomical and structural integrity is
maintained
 Begins before implantation and is maintained for
about the first 95% of pregnancy
Phase 1: Preparation for Labor

 Myometrial and cervical changes

 Development of uterotonin sensitivity
 Improved intercellular communicability via gap
junctions
 Alterations in the capacity of myometrial cells to
regulate the concentration of cytoplasmic calcium
 Ripening of the cervix
Myometrial Changes
 Increase in myometrial oxytocin receptors
 Increase in gap junction between myometrial cells
 Uterine irritability
 Increased responsiveness to uterotonins (oxytocin)
 Transition from a contractile state characterized by
occasional painless contractions to one in which
more frequent contractions develop
 Formation of the lower uterine segment
Cervical changes
 Cervix becomes soft and yielding to effect
dilatation
 Collagen breakdown and rearrangement of collagen
fibers
 Alterations in relative amounts of
glycosaminoglycans
 Hyaluronic acid (retains water) increases
 Dermatan sulfate decreases
Phase 2: The Process of Labor
 Active Labor
 Uterine contractions that bring about progressive
cervical dilatation and delivery of the fetus
 Uterotonin induction of Labor
 Prostaglandins
 Oxytocin
 Striking increase in the number of oxytiocin receptors in
myometrium and decidual tissues near the end of gestation
 Promotes prostaglandin release by acting on decidual tissues
 Synthesized directly in decidual and extraembryonic fetal
tissues and their placenta
Criteria for the Diagnosis of Labor

 Documented uterine contractions (at least once in

10 minutes, or 4 in 20 minutes). Documentation
can be in the form of direct observation or
electronically using a cardiotocogram
 Documented progressive changes in cervical
dilation and effacement, as observed by one
observer
 Cervical effacement of greater then 75-80%
 Cervical dilatation of greater than 3 cm
The 3 Stages of Labor
First stage Uterine contractions, No increase in oxytocin
cervical effacement up levels
to full cervical Increase in
dilatation prostaglandin levels

Second stage Full dilatation up to fetal Increase in maternal

expulsion plasma oxytocin

Third stage Delivery of the fetus up

to placental separation
and expulsion
First Stage of Labor

Latent Phase Active Phase

• Onset of labor at which the mother • Cervical dilatation of 3-4 cm
will feel REGULAR UTERINE
CONTRACTIONS with regular uterine contraction
• Prior to entry to active phase, the
(not hypertonic) is considered
cervix dilates at a rate of 1.2 cm./hr entry into active phase.
(primis) and 1.5 cm./hr (multis); but • Most rapid rate of cervical
the start of this dilatation cannot be dilatation beginning at 3-4 cm.
pinpointed, that is why it can take so
long. and continues at rates of 1.2 –
• Factors that affect latent phase: 6.8 cm/hr on average.
• Epidural or conduction blocks • REMEMBER:
(slows) 1.2 cm./hr (primis) and 1.5
• Myometrial stimulation or cm./hr (multis)
augmentation (quickens)
Management of the First Stage of Labor
 Position and Movement
 Uterine Contractions
 Fetal Monitoring
 Maternal Vital Signs
 Oral intake and IVF
 Pain Management
 Bladder Function
 Enema and Vulvar and Perineal Preparation
 Subsequent Vaginal examination
Position and Movement
 Most comfortable position
 Walking, lying supine, sitting, LLD
 Supine
 compression of aortocaval system – reduce blood flow
to the uterus
 Reduces intensity of contractions
Uterine Contractions
 Intensity/Strength
 Duration
 Interval
 Assessed every 15 minutes
 Active Phase – every 2-3 minutes, mod, lasting 40
to 60 secs
Fetal Monitoring
 Fetal Heart rate – 110-160
 Variability- 6 to 25
 Accelerations, decelerations
Second Stage of Labor
• Begins when cervical dilatation is complete and ends with the
expulsion of the fetus.
• The mean duration is 50 minutes for primis and 20 minutes for
multis. However, it is still highly variable.
• Factors that lengthen second stage:
– Contracted pelvis
– Large fetus
– Impaired expulsive efforts
– Anesthesia
• ACCEPTED DURATION OF SECOND STAGE:
– 2 hours for nullipara and extended to 3 hours when under regional
anesthesia
– 1 hour for multipara and extended to 2 hours under regional anesthesia
Third Stage of Labor
 Begins after delivery of the fetus until the delivery
of the placenta.
 10 to 30 minutes
Early signs of Labor
 “Bloody Show” - spontaneous discharge of a small
amt of blood tinged mucus from vagina; represent
extrusion of mucus plug; sign of the impending onset
of active labor
 Painful Uterine Contractions
 Hypoxia of contracted myometrium (like angina pectoris)
 Compression of nerve ganglia @ cervix & lower uterine
segment
 Stretching of cervix during dilatation FERGUSON REFLEX
 Stretching of peritoneum overlying fundus
 Uterine changes during labor
 Uterus differentiates into 2
distinct parts
 Upper segment
 Active segment
 Lower segment (Lower
uterine segment + cervix)
 Passive segment
UPPER SEGMENT LOWER SEGMENT
*actively contracting  thick *passive (“relatively inactive”)  thin
during contractions: more firm/hard during contractions: less firm, distended
contracts, retracts and expels fetus dilate, form expanded, thinned-out
  muscular & fibromuscular tube
contracts down to diminishing content  
BUT myometrial tension constant = slack analogous to expanded, thinned out
= maintain advantage gained in isthmus in nonpreg women ( NOT
expulsion, & keep uterine musculature SOLELY a phenomenon of labor)
in firm contact w/ intrauterine contents.  
  relaxation is not complete! (rather, it is
retraction = each successive cntrxn starts the opposite of retraction – stretch w/
where previous ended. each contraction)

myometrium DOESN’T relax thru DOESN’T return to previous length but

original length after cntrcxn. (instead remains fixed @ longer length.
becomes relatively fixed @ shorter  
length)  
 
retract only to the extent that the lower
segment distends and dilates.
Cervical Effacement and Dilatation
 During a contraction, the LUS and cervix are
subjected to distention and exert a centrifugal pull
on the cervix.
 Amniotic sac
 Presenting part
Effacement
 “obliteration” or “taking up” of
the cervix
 Shortening of the cervical canal
from a length of 4cm to a circular
orifice with paper-thin edges
 Upward pulling of the muscular
fibers in the vicinity of the
internal os which becomes a part
of the LUS while the external os
remains temporarily unchanged
Pattern of Cervical Dilatation
 Friedman Curve
 Cervical dilatation –
sigmoid curve
 Fetal Descent – hyperbolic
curve
Dilatation Curve

 1.Latent phase - up to 3-4 cm dilatation

(approximately 8 hours long)
 2. Active phase
 a. Acceleration phase – not always present
 b. Phase of Maximum Slope (PMS)
occurs at approximately 9 cm dilatation
 fetus is considered fully descended as it falls one station
below the ischial spines
 c. Deceleration - always present
Fetal Descent

 1. Latent phase - no fetal descent occurs

 extends beyond dilatational phase of descent curve
 2. Active phase - comes much later
 a. Acceleration
 b. Phase of maximum descent
 occurs at around 9 cm dilatation
 corresponds to the deceleration of dilatation
 fetus fully descended at +1(station at the level of ischial
spines)
Friedman Curve  Functional Divisions of
Labor
 Preparatory- little

cervical dilatation occurs,

significant changes in the
ground substance of the
cervex; affected by
sedation and analgesia
 Dilatational-dilatation at

its most rapid rate;

unaffected by sedation or
analgesia
 Pelvic-commences with

the deceleration phase of

cervical dilatation;
cardinal movements of
labor
Vaginal and Pelvic floor changes
 Stretching of the fibers of the levator ani muscle
 Thinning of the central portion of the perineum
Placental Separation
 Results primarily from a disproportion between the
unchanged size of the placenta and the reduced size
of the underlying implantation site
 As the fetus is extruded, the uterus contracts and
the uterine cavity is nearly obliterated
 Sudden diminution in uterine size  decrease in
the area of placental implantation site
 The weakest layer of the decidua (spongiosa) gives
way and cleavage at that site takes place
Placental Extrusion
 Schultze mechanism
 Separation occurs initially at the central portion of the
placenta
 Fetal surface appears first
 Duncan mechanism
 Separation occurs initially at the periphery
 Placenta descends sideways
 Maternal surface appears first
Phase 3: Puerperium
 Myometrium must be held in a state of rigid &
persistent contraction & retraction  for
compression & thrombosis of uterine vessels
(Prevent post partum hemorrhage)
 Onset of lactogenesis & milk-“letdown”
 Involution of uterus (4-6 wks) restore to
nonpregnant state
 Reinstitution of ovulation - dependent on duration
of breastfeeding (lactation induced, prolactin
mediated anovulation & amenorrhea)
THE PASSAGES
Labor- accomodation of the fetal head to the
bony pelvis
Diagonal Conjugate

- The only AP diameter

measured clinically
- measured from the lower
border of symphysis
pubis to the midpoint of
the sacral promontory
- if < 11.5:
shortened/inadequate
Tests to determine adequacy of PELVIC
INLET:
 Diagonal conjugate determination
 Engagement
 Fixation (No more movement left to right)
 Mueller-Hillis maneuver – Bimanual exam to
ensure position of the BPD at station 0.
Tests to determine adequacy of
MIDPELVIS:
 Ischial spines are not prominent
 Sidewalls are not convergent
 Deep sacral concavity
 MPI – 14.0 considered adequate. IS + PS = MPI
Tests to determine adequacy of PELVIC
OUTLET:

 Subpubic arch (90-1000)

 Biischial diameter - done by placing a closed fist
on the perineum (Normally > 8 cm because the
closed fist is approximately 8 cm.)
PASSENGER
Attitude
Lie
Presentation
Position
Fetal Attitude
 Posture or Habitus
 Relationship of the fetus’ body
parts to one another.
 The fetus forms an ovoid mass
that corresponds to the shape of
the uterine cavity
 Head tucked down to the chest.
 Legs & arms drawn towards the
center of the chest.
Fetal Lie
 Relationship between the longitudinal axis of fetus
and longitudinal axis of mother.
 Longitudinal lie
 Transverse lie
 Oblique lie
Lie of the Fetus
 Longitudinal Lie
 Parallel head to
tailbone axis of the
fetus and mother
 99% of labors at term
Lie of the Fetus
 Transverse Lie
 If the head to tailbone
axis of the fetus and
mother are at 90
degree angle to each
other.
 Oblique lie - unstable
Fetal Presentation (Presenting part)
 Portion of the fetal body that is either foremost
within the birth canal or in closest proximity to it.
 Can be felt through the cervix on vaginal
examination
 Cephalic presentation
A. Vertex/occiput
B. Sinciput/military
attitude
C. Brow presentation
D. Face presentation
Vertex or occiput presentation
 Head is sharply flexed
 Chin is in contact with the thorax
 Posterior fontanel is the presenting part
 AP diameter: Suboccipitobregmatic
(9.5 cm)
 Term fetus: uterus is pyriform
Face presentation
 Neck is sharply extended
 Occiput and back of the fetus
come in contact
 Face is foremost in the birth
canal
 Submentobregmatic (9.5 cm)
 Permits advancement through the
pelvis but vaginal delivery may
result in injury to the cervical
spinal cord
Brow presentation
 Fetal head is partially extended
 Occiptomental plane (13.5 cm)
 Almost always converted into face presentation
Sinciput or Military attitude
 Partially flexed
 Anterior fontanel or bregma presenting
 AP diameter: Occipitofrontal (12.5 cm)
 Gradually changes to full flexion (Vertex)
Breech Presentation

 Buttocks enter before

head
 Bitrochantine diameter
(9.5 cm)
 Fetus often turns
spontaneously to
cephalic presentation
before onset of labor
Footling – one or both feet below the breech
 Shoulder Presentation

• In transverse lie
• The shoulder or the acromnion
•Side of mother on which acromnion rests (L or R)
•Bisacromial diameter (11 cm)
Compound Presentation
 Fetal hand or foot prolapses
alongside presenting vertex
or breech
 Cause – conditions that
prevent complete occlusion
of pelvic inlet by presenting
part
 Fetal foot + head = cord
prolapse
Fetal Position

relationship of chosen portion of the fetal presenting

part to the maternal birth canal

Vertex Occiput

Face Chin

Breech Sacrum
Leopold’s Maneuver

 Presentation & position

 Extent of descent of presenting part into pelvis
 Latter months; intervals between uterine
contractions of labor
 LM1-3 - face upper part of mother
 LM4 - face lower part of mother
 LM1
 “Fundal grip”
 Fetal pole

occupying
fundus
 Tips of fingers

of both hands
LM1

Breech Head
- large - hard & round
- nodular mass - more mobile &
- buttocks ballotable
- fetal head
LM2
 “Umbilical grip”
 Orientation of fetal
back
 Palms on either side
of abdomen
 Gentle but deep
pressure
LM2

Fetal back Fetal extremities

- hard,resistant, - numerous,
convex structure small, irregular,
mobile parts

 Disclose whether back is in anterior,

transverse or posterior orientation
LM3
 Thumb & fingers of 1
hand
 Pawlick’s grip
 Lower portion of
maternal abdomen
grasped just above
symphysis pubis
LM3

Engaged Not engaged

- lower pole of - movable, round
fetus is fixed in & hard bony
pelvis or structure
engaged (cephalic)
LM4

 Tips of 1st 3
fingers of each
hand
 Deep pressure in

direction of axis
of inlet
LM4

Engaged Not engaged

- both hands - cephalic
diving from prominence
each other palpated
LM4

Flexed head Extended head

- cephalic - cephalic
prominence on prominence on
same side of same side as
small parts fetal back
- vertex - face
Vaginal Examination
Vaginal Examination
 Diagnosis of presentation and position
 Presentations are identified through the following:
 Sutures and fontanels for
vertex
 Portions of the fetal face for

fetal presentation
 Sacrum and coccyx for breech

presentation
 Acromion for shoulder presentation
Techniques in Vertex Presentation
 Two fingers of a gloved hand is introduced into the vagina
and carried upto the presenting part.(vertex, face and breech)
 Vertex presentation: fingers are directed into the posterior
vagina. Fingers are swept forward over the fetal head toward
the maternal symphysis. Fingers necessarily cross the fetal
sagittal suture and its course is delineated.
Techniques in Vertex Presentation
 The position of the two fontanels then are ascretained. The
fingers
are passed to the most
anterior extension of the
sagittal suture.
 The presenting part that

has descended into pelvis

can be established at this time.
Ausculatation

 Not very reliable

 Best heard:
 through fetal back at vertex position
and breech position
 Through the fetal thorax in face
presentation
 Point of Maximal Intensity
 in cephalic position: midway between
the maternal umbilicus and the ASIS
of the ileum
 In breech: above the level of the
umbilicus
Sonography

 Breech or shoulder
presentation in obese
women with rigid
abdominal wall
 Without potential hazards
of radiation
Cardinal Movements of
Labor

 Engagement
 Descent
 Flexion
 Internal Rotation
 Extension
 External Rotation
 Expulsion
Thank You!