Kazan Federal University

PARTURITION

ZHELEZOVA
MARIA EVGENIEVNA
Professor of
obstetrics and gynecology Department
 CLINICAL COURSE OF LABOR

The last few hours of human pregnancy are characterized by

uterine contractions that effect dilatation of the cervix and force the
fetus through the birth canal.

Much energy is expended during this time; hence the use of the
term labor to describe this process. The myometrial contractions of
labor are painful, which is why the term labor pains is used to
describe this process.

Before these forceful, painful contractions begin, however, the

uterus must be prepared for labor.
 THE THREE STAGES OF LABOR
Active labor is divided into three stages.
-the first stage of labor begins when uterine contractions of sufficient
frequency, intensity, and duration are attained to bring effacement and
progressive dilatation of the cervix.
The first stage of labor ends when the cervix is fully dilated (about 10
cm) to allow passage of the fetal head. The first stage of labor is the
stage of cervical effacement and dilatation.
-the second stage of labor begins when dilatation of the cervix is
complete, and ends with delivery of the fetus. The second stage is the
stage of expulsion of the fetus.
- the third stage of labor begins immediately after delivery of
the fetus, and ends with the delivery of the placenta and fetus
membranes. The third stage of labor is the stage of separation
and expulsion of the placenta.
 CLINICAL ONSET OF LABOR

A rather dependable sign of the impending onset of active labor

(provided rectal or vaginal examinations have been not performed in
the preceding 48 h.) is the discharge of a small amount of blood-tinged
mucus from the vagina.
The represents the extrusion of the plug of mucus that had filled the
cervical canal during pregnancy, and is called “show” or “bloody
show”. This is a late sign, because commonly labor is already in
progress or likely will ensue during the next several hours to few days.
Normally, only a few drops of blood escape with the mucus plug; more
substantial bleeding is suggestive of an abnormal cause.
 The interval between contractions decreases gradually from
about 10 minutes and onset of the first stage of labor to as
little as 2 minute or less in the second stage.
Period of relaxation between contractions, however, is
essential to the welfare of the fetus. Unremitting blood flow,
and ultimately, fetal-placental flow, sufficiently to cause fetal
hypoxemia.
 CERVIX

The effective force of the first stage of labor is the uterine

contraction, which in turn exerts hydrostatic pressure through the
fetal membranes against the cervix and lower uterine segment.
In the absence of intact membranes, the fetal presenting part is
forced directly against the cervix and lower uterine segment.
As the result of the action of these forces, two fundamental changes
– effacement and dilatation – take place in the already softened
cervix.
 EFFACEMENT

•The muscular fibers at about the

level of the internal cervical os
are pulled upward to become a
part (both anatomically and
functionally) of the lower uterine
segment.
 RUPTURE OF THE MEMBRANES

Spontaneous rupture of the membranes most often occurs

sometime during the course of active labor. Typically, rupture is
evident by a sudden gush of normally clear or slightly turbid,
nearly colorless fluid.
Less frequently, the membranes remain intact delivery of the
infant.
Rupture of the membranes before the onset of labor at any
stage of gestation is referred to as premature rupture of the
membranes.
 PLACENTAL SEPARATION

As the baby is born, the uterus spontaneously contracts. This

sudden diminution in uterine size is inevitably accompanied by a
decrease in the area of the placental implantation size.
For the placenta is accommodate itself to this reduced area it
increases in thickness, but because of limited placental elasticity it
is forced to buckle.
 By convention , fetal orientation is described with respect to fetal lie, presentation, attitude, and
position.
Fetal lie. The lie is the relation of the long axis of the fetus to that of the mother, and is either
longitudinal or transverse.

Occasionally, the fetal and maternal axes may cross at a 45-degree

angle, forming oblique lie.

45ºC
90ºC

longitudinal transverse oblique

 FETAL PRESENTATION
The presenting part is that portion of the body of the fetus that is
either foremost within the birth canal or closest proximity to it. The
presenting part determines the presentation.
Accordingly, in longitudinal lies, the presentation part is either the
fetal head or breech, creating cephalic and breech presentations,
respectively
 MECHANISMS OF NORMAL LABOR

At the onset of labor, the position of the fetus, with respect to the
birth canal, is critical to the rout of delivery. If at the time of labor the
fetus is transverse to the birth canal, either cesarean delivery or
podalic version to a longitudinal lie are the
only options for delivery of a viable infant.
It is thus of paramount importance to know
the fetal position within the uterine cavity
at the onset of labor.
FETAL POSITION
 DIAGNOSIS OF FETAL PRESENTATION AND POSITION

Several methods can be used to diagnose fetal presentation and

position. These include abdominal palpation, vaginal examination,
combined examination, auscultation, and in certain doubtful cases,
imaging studies such as ultrasonography.
ABDOMINAL PALPATION – LEOPOLD MANEUVERS.
Abdominal examination should be conducted systematically
employing the four maneuvers described by Leopold and Sporlin in
1894. The mother should be supine. During the first three maneuvers,
the examiner stands at side of the bed faces the patient; the examiner
reverses this position and faces her feet for the last maneuver.
 VAGINAL EXAMINATION

With the onset of labor and after cervical dilatation, important

information may be obtained. In vertex presentations, the position
and variety.
In vertex presentation, the position and variety are recognized by
difference of the various sutures and fontanels.
Breech presentations are identified by palpation of the sacrum and
maternal ischial tuberosities.
In attempting to determine presentation and position by vaginal
examination you must perform four maneuvers.
STATION. The level of the presenting fetal part in the birth canal is
described in relationship to the ischial spines, which are halfway
between the pelvic inlet and the pelvic outlet.
When the lowermost portion of the presenting fetal part is at the level
of the ischial spines, it is designated as being at zero (0) station.
The plane located above station 0 is designated -5,-4,-3,-2,-1
Below the ischial spines the presenting fetal part passes
+1,+2,+3,+4,+5. Station +5 corresponds to te fetal head being visible
at the introitus.
 OCCIPUT ANTERIOR PRESENTATION

Due to irregular shape of the pelvic canal and relatively large

dimensions of the mature fetal head, it is evident that not all
diameters of the head can necessarily pass through all diameters of
the pelvis. It follows that a process of adaptation or accommodation
of suitable portions of the head to the various segments of the pelvis
is required for vaginal delivery. These positional changes in the
presenting part constitute the mechanisms of labor.
The cardinal movements of labor are engagement, descent, flexion,
internal rotation, extension, external rotation, and expulsion.
 are engagement, descent, flexion,
The CARDINAL MOVEMENTS OF LABOR

internal rotation, extension,

external rotation, and expulsion.
The mechanism of labor consist of
a combination of movements that
are ongoing simultaneously.
Under the pressure of strong
uterine contractions, cranial plates
overlap one another at the major
sutures, a process referred to as
molding
 EXTENSION

When, after internal rotation, the sharply flexed

head reaches the vulva, it undergoes extension
which is essential to birth. This brings the base of
the occiput into direct contact with the inferior
margin of the symphysis pubis.
With progressive distention of the perineum and
vaginal opening, an increasingly larger portion of
the occiput gradually appears. The head is born by
further extension as the occiput, bregma, forehead,
nose, mouth and chin pass over the anterior margin
of the perineum.
Immediately after the birth, the head drops
downwаrd so that the lies over maternal anal region
 EXTERNAL ROTATION
There is an external rotation of the head and the internal rotation
of the shoulders. Thus, one shoulder is anterior behind the
symphysis and other is posterior. Almost immediately after external
rotation, the anterior shoulder appears under the symphysis pubis,
and the perineum soon becomes distended by the posterior shoulder.
After delivery of the shoulders, the rest of the body is quickly
extruded.
CONDUCT OF NORMAL LABOR AND
DELIVERY
IDENTIFICATION OF LABOR. One of the most critical
diagnoses in obstetrics is the accurate diagnosis of labor. Although
the differential diagnosis between false and true labor is difficult at
times, it usually can be made on the basis of the contractions.
Contractions of true labor Contractions on false labor
-Contractions occur at regular -Contractions occur at irregular
intervals intervals
-Intervals gradually shorten -Intervals remain long
-Intensity gradually increases -Intensity remains unchanged
-Discomfort is in the back and -Discomfort is chiefly in lower
abdomen abdomen
-Cervix dilatation -Cervix does not delate
-Discomfort is not stopped by -Discomfort is usually relived by
sedation sedation
 MANAGEMENT OF FIRST STAGE OF LABOR

When all examinations, including record and laboratory review are

completed, the rational plan for monitoring labor based on the needs of the
mother and the fetus can be established.
FETAL HEART RATE.
The most ominous changes in the fetal heart rate are detected right after
uterine contraction.
Normal fetal heart rate are between 110 to 160 bpm.
During the first stage of labor the absence of any abnormalities, the fetal
heart should be checked immediately after a contraction at last every 30
min.
For women with pregnancies risk, auscultation is performed at last every 15
min.
 UTERINE CONTRACTIONS
With the palm of the hand lightly on the uterus, the examiner
determines the time of onset of the contraction. The intensity of the
contraction is checked from the degree of firmness the uterus
achieves.
Next, the time that be contraction disappears is noted. This sequence
is repeated in order to evaluate the frequency, duration, and intensity
of uterine contractions.
MATERNAL VITALS SIGNS
Temperature, pulse and blood pressure are evaluated at last every 4
hr.
If the fetal membranes have been ruptured for many hours before
the onset of labor, or if there is a borderline temperature elevation,
the temperature is checked hourly. With prolonged membrane rupture
– defined as greater more than 18 hr – antibiotically administration
for prevention intrauterine infection.
VAGINAL EXAMINATION carry on: after membrane rupture,
before analgesia and every 4 hours.
ORAL INTAKE. Food should be withheld during active labor and
delivery. Sips of clear liquids are permitted.
MATERNAL POSITION DURING LABOR. The mother should
have the option to stay out of bad during the early stage of labor.
ANALGESIA. Most often analgesia is initiated on the basis of
maternal discomfort. The kinds of analgesia, amounts, and frequency
of administration should be based on the need to allay pain on the one
hand and the likelihood of delivering a depressed infant on the other.
 MANAGEMENT OF SECOND - STAGE LABOR

This stage begins when cervical dilatation is complete and ends with fetal
expulsion. Its median duration is 50 min for nulliparas and 20 min for multiparas,
but it is also highly variable.
The woman typically begins to bear down, and with descent of the presenting
part she develops the urge to defecate. Uterine contractions and the
accompanying expulsive forces may last 1,5 min and recur at times after a
myometrial resting phase of no more than a minute.
FETAL HEART RATE. The heart rate should be auscultation after every
uterine contraction. Slowing of the fetal heart rate induced by head compression
is common during a contraction and the accompanying maternal expulsive
efforts. If recovery of the fetal heart rate is prompt after the expulsive efforts
cease, labor is allowed to continue.
 DELIVERY OF SHOULDERS. Most often, the shoulders appear
at the vulva just after external rotation and are born spontaneously.
TIMING OF CORD CLAMPING. Our rules is to clamp the cord
after first clearing the airway, all of which usually takes about 1 min.
The infant is not elevated above the introitus at vaginal delivery or
much above the maternal abdominal wall at the time cesarean
section.
 MANAGEMENT OF THE THIRD STAGE
Immediately after delivery of the infant, the height of the uterine
fundus and its consistency are ascertained.
As long as the uterus remains firm and there is not usual bleeding,
watchful waiting until the placenta is separated.
SIGNS OF PLACENTAL SEPARATION. Because attempts to
express the placenta prior to its separation are futile and possibly
dangerous, is most important that the following signs of placental
separation by recognized:
1. The uterus becomes globular and, as a rule, firmer. This sign is the
earliest to appear.
2. There is often a sudden gush of blood.
3. The uterus rises in the abdomen because the placenta, having
separated, passes down into the lower uterine segment and vagina,
where its bulk pushes the uterus upward.
4. The umbilical cord protrudes farther out of the vagina.
 The hour immediately following delivery is critical and it has
been designated by some as the “fourth stage of labor”.
Even though oxytocic are administrated postpartum hemorrhage
as the result of uterine atony is more likely at this time.
The uterus is frequently evaluated every 15 minutes during this
time. The perineum likewise is inspected frequently to detect
excessive bleeding.
The maternal blood pressure and pulse should be recorded
immediately after delivery and every 15 min for the first time.
 CARE OF THE NEWBORN IN THE DELIVERY ROOM

With delivery of the head, either vaginally or by cesarean

delivery, the face is immediately wiped and the mouth and nares
are suctioned.
Once the cord has been divided, the infant is placed supine with
the head lowered and turned to the side in a heated unit. To
minimize heat loss, the baby is wiped dry.
The infant is inspected for any visible abnormalities.
 APGAR SCORE

A useful aid to evaluate the need for infant is the Apgar scoring
system applied at 1 minute and again at 5 minutes after birth.
THANK YOU FOR YOUR
ATTENTION