normal labour.pptx labour and its stages

SEMINAR ON
LABOUR, STAGES AND
ITS PHYSIOLOGY
ROLE OF NURSE MIDWIFERY
PRACTICE
L BHAVANI
M.Sc. Nursing(OBG)
Batch 2023

 Definitions
 Normal labour
 Causes of onset of labour
 False labour pain and true labour pain
 Stages of labour
 Physiology of first stage of labour
 Physiology of second stage of labour
 Mechanism of normal labour
 Physiology of third stage of labour
 Fourth stage of labor
 Management and role of a nurse in midwifery practice
Contents

Introduction
• While it takes nine months to grow a full-term baby, labor and delivery occurs in a
matter of days or even hours. However, it’s the process of labor and delivery that
tends to occupy the minds of expectant parents the most. Labor is characterized by
the presence of regular uterine contractions with effacement and dilatation of the
cervix and fetal descent.
• A parturient is a patient in labor and parturition is the process of giving birth. Delivery
is the expulsion or extraction of a viable fetus out of the womb. It is not synonymous
with labor; delivery can take place without labor as in elective cesarean section.
Delivery may be vaginal, either spontaneous or aided, or it may be abdominal.

LABOR
DEFINITION
Series of events that takes place in the genital organ s in an effort to
expel the viable products of conception(fetus, placenta and the
membranes) out of the womb through the vagina into the outer world
is called “labor”

Normal labour (Eutocia)
Labour is called normal if it fulfills the following criteria:
• Spontaneous in onset and at term.
• With vertex presentation
• Without undue prolongation
• Natural termination with minimal aids
• Without having any complications affecting the health of
mother and/or baby.

Date of onset of labour
• It is unpredictable to foretell
precisely the exact date of
onset of labour.
• Calculation from Naegele's
formula is only a rough
guide.

CAUSES OF ONSET OF LABOR
• MECHANICAL
oUterine contractions
• HARMONAL
oFeto-placental contribution
oEstrogen
oProgesterone
oProstaglandins
oOxytocin
oNeurological factor

MECHANICAL FACTORS
UTERINE DISTENSION THEORY/Uterine
contractions
• When the uterus is distended to a certain
limit, it starts contraction to evacuate its
contents.
• Stretch of the lower uterine segment
• It is dine by the presenting part near term.

HARMONAL FACTORS
Estrogen
• Increase the release of oxytocin from maternal pituitary.
• Promotes the synthesis of receptors for oxytocin in the myometrium
and decidua.
• Accelerates lysosomal disintegration in amnion cells resulting in
amnion cells resulting in increased prostaglandin synthesis.
• Stimulates the synthesis of myometrial contractile protein ---
actinomyosin through CAMP.
• Increases the excitability of the myometrial cell membranes.

Progesterone
• Increased fetal production of dehydro-epiandrosterone sulphate (DHEA-S)
and cortisol inhibits the conversion of fetal pregnenolone to
progesterone. Progesterone levels therefore fall before labour.
• It is the alteration in the oestrogen:progesterone ratio rather than the fall
in the absolute concentration of progesterone which is linked with the
prostaglandin synthesis.

Prostaglandins
• Prostaglandins are the important factor which initiate and maintain
labour.
• The major sites of synthesis of prostaglandins are amnion, chorion,
decidual cells and myometrium.
• Synthesis is triggered by -rise in oestrogen level, glucocorticoids,
mechanical stretching in the late pregnancy, increase in cytokines,
infection, vaginal examination, separation or rupture of membranes

Oxytocin
• Oxytocin receptors are increased in the uterus with the onset of
labour.
• Oxytocin promotes the release of prostaglandins from the decidua.
• Oxytocin synthesis is increased in the decidua and in the placenta.
• Vaginal examination and Amniotomy cause rise in maternal plasma
oxytocin level (Ferguson reflex).
• Presence of this hormone causes the initiation of contraction of the
smooth muscles of the body & the labor pain starts

Neurological factor
• Both a and ẞ adrenergic receptors are present in the myometrium;
estrogen causing the a receptors and progesterone the ẞ receptoors
to function predominantly.
• The contractile response is initiated through the a receptors of the
post ganglionic nerve fibres in and around the cervix and the lower
part of the uterus.

Fetal cortisol theory
• Increased cortisol production from the fetal adrenal gland before
labor may influence the onset of labor by increasing Estrogen
production from the placenta

PREMONITORY STAGE – PRELABOR STAGE
• Lightening
• Shelfing
• Vaginal secretions increase in amount
• Loss of weight-excretion of body water
• Sciatic nerve pressure
• Cervical ripening
• Appearance of false labor pains
• Show
• Dilatation of internal os
• Greater frequency of urination
• Spurt of energy
• Occasional rupture of membranes

Shelfing
• It is falling forwards of the uterine
fundus making the upper abdomen looks
like a shelf during standing position.

• Vaginal secretions increase in amount
• t is normal to have more vaginal discharge in pregnancy. This helps
prevent any infections travelling up from the vagina to the womb.
Towards the end of pregnancy, the amount of discharge increases
further. In the last week or so of pregnancy, it may contain streaks of
sticky, jelly-like pink mucus.
• Loss of weight-excretion of body water

Sciatic nerve pressure
• As the hormone relaxin builds in a pregnant person’s body, the
ligaments begin to loosen to prepare for birth. As a result, body’s
center of gravity shifts which can cause the nerve to pinch. As the
weight of the fetus and uterus can add extra pressure to the sciatic
nerve, especially when baby is positioned in certain ways.

Cervical ripening
• Cervical ripening is a normal process of softening and opening the
cervix before labor starts. The cervix is stiff and closed through most
of pregnancy to hold baby inside uterus. But during labor, cervical
dilation (widening) allows baby to pass through birth canal.

Cervical ripening/Dilatation of internal os

Dilatation of internal os
• Dilatation of the internal
cervical os was defined as any
U or V shape of the internal os,
a funnel width of >5 mmor
≥5 or a funnel length measured
along the lateral border of the
funnel of ≥3 mm.

Greater frequency of urination
• Towards the end of pregnancy, mother may wet a
little when:
coughing
sneezing
lifting things
• This happens because these actions place more
pressure on pelvic floor. In many people the
pelvic floor becomes weakened during pregnancy.

Spurt of energy
• Extreme nesting: Mother might start cleaning, organizing, setting up
the nursery, and making sure everything is just perfect. But about 24
to 48 hours before labor, body might go into panic mode, in which
case you have a sudden burst of energy and an increased drive to
clean and organize.

Appearance of false labor pains
•Features
1. Dull in nature
2. Confined to the lower abdomen and groin.
3. Not continuous and unrelated with
hardening of the uterus
4. Without any effect on dilatation of the
cervix.
5. Usually relieved by medications.

True labour pains
Features of true labour pain:
• Painful uterine contractions (labour pain)
at regular intervals
• Contraction with increasing frequency,
intensity and duration
• Show
• Progressive effacement and dilatation of
the cervix
• Formation of the -bag of waters.
• Not relieved by enema or sedatives

Occasional rupture of membranes

STAGES OF LABOR
1. First Stage
2. Second Stage
3. Third Stage
4. Fourth Stage

PHYSIOLOGY OF
FIRST STAGE OF LABOUR

First stage of labour-cervical stage of
labour
• This starts from the onset of true labour pain and ends with full dilatation of
cervix. It is in other words, the "cervical stage" of labour.
• Its average duration is 12 hours in primigravida and 6 hours in multigravida.
• There are two phases of first stage of labour:
Latent phase
Active phase
Transition phase

Phases of first stage of labour
• The latent phase: is the time between the onset of labour and 3-4 cm
dilatation and cervix becomes fully effaced. It usually lasts between 3 and 8
hours, being shorter in multiparous women.
• The second phase: is the active stage and describes the time between the
end of latent phase (3-4 cm dilatation) and full dilatation (10cm). It is also
variable in length, usually lasting between 2 and 6 hours. Again it is shorter
in multiparous women.

During active phase
Cervical dilatation during the active phase usually occurs at
1cm/hour or more in a normal labour.

Transition phase
• The last and shortest part of 1st phase of
labour
• It is more intense phase of labouring
women
• Contraction оссur every 2-3 minutes
lasting 60-10 seconds.
• Duration: primi 2 hours, multi 1 hour.

Second stage of labour
• It starts from the full dilation of the cervix and ends with
expulsion of foetus from the birth canal.
• It has got two phases
1. Propulsive phase-starts from full dilatation up to
the descent of the presenting part to the pelvic floor
2. 2. Expulsive phase- is distinguished by maternal
bearing down efforts and ends with delivery of the
baby.
• Average duration is 50mints in primigravida and 30mints
in multipara.

Third stage of labour
• The third stage begins after
the expulsion of foetus and
ends with expulsion of
placenta and membranes;
• Average duration is about
15min in both primi & multi

Fourth stage of labour
• It is the stage of observation for at least
one hour after expulsion of the after birth
• Begins with delivery of placenta and
extends to the first 1-4hours post partum.
• The maternal vitals, uterine retraction &
vaginal bleeding are monitored, baby is
examined during this period.

PHYSIOLOGY OF FIRST STAGE OF
LABOUR- UTERINE ACTION

PHYSIOLOGY OF FIRST STAGE OF LABOUR- UTERINE
ACTION
Fundal dominance:
• Each uterine contraction starts in the fundus near one of
the cornua and spreads across and downwards.
• The contraction lasts longest in the fundus where it is also
most intense, but the peak is reached simultaneously
over the whole uterus and the contraction fades from all
parts together.

Polarity
• Polarity is the term used to describe the neuromuscular harmony that
prevails between the two poles or segments of the uterus throughout
labour. During each uterine contraction, harmoniously. these two
poles act
• The upper pole contracts strongly and retracts to expel the fetus; the
lower pole contracts slightly and dilates to allow expulsion to take
place. If polarity is disorganized then the progress of labour is
inhibited.

Characteristics of uterine contractions
• Frequency: contractions occurs intermittently throughout labour, they begin
at 20-30 m apart & become closer together until 2-3min
• Regularity contractions occur more regularly as labour becomes more
established
• Duration - contraction may last from 30sec to between 60-90 sec near full
dilatation of the cervix
• Intensity - the strength of the contraction increases as labour progresses, from
weak contractions noted early in labour, strong expulsive contraction.

Formation of upper and lower uterine segments
• The upper uterine segment, having been formed from the body of the fundus,
is mainly concerned with contraction and retraction; it is thick and muscular.
• The lower uterine segment is formed of the isthmus and the cervix, and is
about 8-10 cm in length. The lower segment is prepared for distention and
dilatation.
• The muscle content reduces from the fundus to the cervix, where it is thinner.

Cont…
• When the labour begins, the retracted longitudinal fibres in the
upper segment pull on the lower segment causing it to stretch; this
is aided by the descending presenting part.

The Retraction ring
• The ridge forms between the upper and lower uterine segments; this
is known as the retraction ring.
• The physiological ring gradually rises as the upper uterine segment
contracts and retracts and the lower uterine segment thins out to
accommodate the descending foetus. Once the cervix is fully dilated
and the foetus can leave the uterus, the retraction ring rises no
further.

Cervical dilatation
• Dilatation of cervix is the process of
enlargement of the os uteri from a tightly
closed aperture to an opening large enough
to permit the passage of the fetal head.
Dilatation is measured in centimeters and
full dilatation at term equates to about 10
cm.

Formation of fore water
• As the lower uterine segment forms and stretches, the chorion
becomes detached from it and the increased intrauterine pressure
causes its loosened part of the sac of fluid to bulge downwards into
the internal os, to the depth of 6-12 mm.
• The well flexes head fits snugly into the cervix and cuts off the fluid in
front of the head from that which surrounds the body.
• The former is known as fore waters' and the latter the _hind waters'.

PHYSIOLOGY OF
SECOND STAGE OF LABOUR

1.Second stage begins with the complete dilatation of the cervix and ends with
the expulsion of the fetus. Stage is concerned with the descent and delivery of
the fetus through the birth canal.
- D.C.DUTTA.
2.The second stage of labour has traditionally been regarded as the phase
between full dilatation of the cervical os, and the birth of the baby.
- MYLES.
3.Second stage of labour starts from the full dilatation of the cervix to the
expulsion of fetus from the birth canal.
- NEELAM KUMARI,SHIVANI SHARMA.
SECOND STAGE OF LABOUR DEFINITION

Landmarks of pelvis
SACRAL
PROMONTARY
ALA OF SACRUM
SACROILIAC JOINT
ILIOPECTINEAL LINE
ILIOPUBIC EMINENCE
PECTINEAL LINE
PUBIC TUBERCLE
PUBIC CREST
SYMPHYSIS
PUBIS

Presenting part
• Is defined as the part of the
presentation which overlies the
internal os and is felt by the
examining finger through the
cervical opening.

Attitude
• The relation of the different parts of
the fetus to one another is called
attitude of the fetus. The universal
attitude is that of flexion. Head is
flexed so the chin is on the chest with
arms crossed over the chest, and the
legs flexed at the knee with thighs on
the abdomen.

• It is an arbitrary bony fixed point on the presenting
part which comes in relation with the various
quadrants of the maternal pelvis.
• The following are denominators of the different
presentations- occiput in vertex, mentum in face,
frontal eminence in brow, sacrum in breech and
acromion in shoulder
Occiput---0
Sacrum---S
Mentum---M
Frontal---F
Acromion---AC

Mechanism of labour
• As the fetus descends, soft tissue and bony
structures exert pressures which lead to
descent through the birth canal by a series
of movements. Collectively, these
movements are called the mechanism of
labour

Definition
• The series of movements that occur on the head
in the process if adaptation, during its journey
through the pelvis
• Acc. To Dc Dutta

Principles common to all mechanism
• Descent takes place
• Whichever part leads and first meets the resistance of the pelvic floor
will rotate forwards until it comes under the symphysis pubis.
• Whatever emerges from the pelvis will pivot around the pubic bone.

Factors facilitating descent
• Uterine contraction & retraction
• Pressure of amniotic fluid
• Bearing down efforts
• Extension & straightening of fetal body

Indications
• In elastic rigid perineum
• Anticipating Perineal tear: Big baby, face to pubis delivery, Breech
delivery, dystocia Shoulder
• Operative delivery: Forceps delivery, Ventouse delivery
• Previous Perineal surgery: Pelvic floor repair, Perineal reconstructive
surgery
• Common indications are:
1. Threatened Perineal injury in primigravida
2.Rigid perineum
3. Forceps, breech, occipito-posterior or face delivery

Advantages
• Maternal:
• A clear and controlled incision is easy to repair and heals better than a
lacerated wound that might occur otherwise.
• Reduction in the duration of second stage
• Reduction of trauma to the pelvic floor muscles
• Fetal:
• It minimises intracranial injuries specially in premature babies or after
coming head of breech

Structure cut are
• Posterior vaginal wall
• Superior and deep transverse perineal
muscles, bulbospongiosus and part of
levator ani.
• Fascia covering those muscles
• Transverse perineal branches of
pudendal vessels and nerves
• Subcutaneous tissue and skin

Steps of episiotomy
• Provide emotional support and encouragement.
• Use local infiltration with lignocaine.
• Make sure there are no known allergies to lignocaine or related drugs.
• Infiltrate beneath the vaginal mucosa, beneath
• the skin of the perineum and deeply into the perineal muscle.
• Note: Aspirate (pull back on the plunger) to be sure that no vessel has been penetrated
• Steps of episiotomy
• Wait 2 minutes and then pinch the incision site with forceps.

Steps of episiotomy
• Wait to perform episiotomy until: the perineum is thinned out; and 3-
4 cm of the baby's head is visible during a contraction.
• Use scissors to cut 2-3 cm up the middle of the posterior vagina.
• Control the baby's head and shoulders as they deliver.
• Carefully examine for extensions and other tears and repair

Repair of episiotomy
• Apply antiseptic solution to the area around the episiotomy.
• If the episiotomy is extended through the anal sphincter or rectal
mucosa, manage as third or fourth degree tears, respectively
• Close the vaginal mucosa using continuous 1-0 suture
• Start the repair about 1 cm above the apex (top) of the episiotomy.
Continue the suture to the level of the vaginal opening.

Repair of episiotomy
• At the opening of the vagina, bring together the cut
edges of the vaginal opening
• Bring the needle under the vaginal opening and out
through the incision and tie.
• Close the perineal interrupted 1-0 sutures muscle using
• Close the skin using interrupted (or subcuticular) 1-0
sutures

Post operative care
• Dressing
• Comfort
• Ambulation
• Removal of stitches

Complications
• Immediate
• Extension of the incision to involve the rectum
• Vulval haematoma
• Infection
• Wound dehiscence
• Injury to anal sphincter causing incontinence of flatus or faeces
• Rectovaginal fistula (Rarely)
• Necrotising fasciitis
• Remote
• Dyspareunia
• Chance of perineal lacerations
• Scar endometriosis (rare)

PHYSIOLOGY OF
THIRD STAGE OF LABOUR

THIRD STAGE OF LABOUR DEFINITION :
1.The third stage of labour comprises the phase of placental separation;
its descent to the lower segment and finally its expulsion with the
membranes.
- D.C.DUTTA.
2.The third stage of labour can be defined as the period from the birth of
the baby to complete expulsion of the placenta and membranes.
- MYLES.
3.The third stage, is the separation, descent and expulsion of placenta
takes place.
- NEELAM KUMARI,SHIVANI SHARMA.

Management of third stage of labour

manual removal of placenta
• MRP is performed when the
placenta fails to deliver within
30 minutes of childbirth. It
involves inserting fingers into
the uterus to locate and
detach the placenta from the
uterine wall while supporting
the fundus.

PHYSIOLOGY OF
FOURTH STAGE
LABOUR

INTRODUCTION
• The recovery phase immediately after delivery of the
placenta often is referred to as the fourth stage of
labour. This is misnomer because labor and delivery
are completed with the expulsion of the placenta.
The fourth stage is critical time that begins after
delivery of the placenta and ends when the mother's
system has stabilized, usually 1 to 4 hours later.

Fourth stage of labour- definitions
• This is the period from the delivery of the
afterbirth to the time when the woman is
examined and then transferred to her room.
• It is the stage of observation for at least one
-two hour after expulsion of the afterbirth.

MATERNAL ASSESSMENT
• EVALUATION AND INSPECTION
• Pain
• Evaluation of the uterus
• Inspection of cervix and upper vaginal vault.
• Inspection and evaluation of the placenta, Membranes and
umbilical cord.
• Repairs
• Perineal cleansing and positioning of legs

•PAIN
• Assess the type, location and intensity of pain.
• Look for signs of discomfort.
•EVALUATION OF THE UTERUS
• After delivery of the placenta, the uterus is normally found in the
midline of the abdomen approximately two thirds to three
fourths of the way up between the symphysis pubis and
umbilicus.
• A uterus found the above the umbilicus is indicative of blood
clots inside, which need to be expressed and expelled.
• A uterus found above the umbilicus and to one side usually the
right side indicates a full bladder.
• The uterus is assessed every 15 minutes for the first hour. The
woman is positioned with knees flexed and head flat.

• The nurse uses one hand to stabilize the uterus just above the
symphysis pubis and the outer edge of the other hand to locate the
fundus
• Position of the fundus is noted in relation to the umbilicus and
recorded as centimeters above or below the umbilicus.
• During the fourth stage, the fundal height usually is at the level of
the umbilicus.
• Placement of the uterus also is noted in relation to midline
• Consistency is noted. If the uterus is not firm, it is referred to as
boggy, and the fundus is massaged gently in a circular motion until
the uterus contracts and becomes firm.

INSPECTION OF CERVIX AND UPPER VAGINAL VAULT
• The uterus is well contracted but there continues to be steady trickle
or flow of blood from the vagina.
• The mother was pushing prior to complete dilatation of the cervix.
• The labour and delivery were rapid and precipitous.
• Traumatic second stage of delivery such as prolonged shoulder
dystocia or large baby.

Inspection and evaluation of the placenta,
membranes and umbilical cord
• They are done before repairing any laceration or episiotomy.
• This is because, if during examination of the placenta, the midwife
determines that the uterus needs to exposed manually because of a
retained placental fragment, it needs to be done as soon as possible
since it has the potential for causing hemorrhage

• REPAIRS
• The repair of any laceration or an episiotomy is done after the examination
of the placenta and membranes. If a uterine exploration for retained
placental fragments is necessary, it is done prior to the repair. The uterus is
checked again for consistency and repair is begun.
• PERINEAL CLEANSING AND POSITIONING OF LEGS
• The next nursing action is wash off the mother's entire perineal area
including the perineum, vulva, inner thighs, buttocks and the rectal area.
• A perineal pad is then placed against the perineum and mother assisted to
put her legs together.
• A perineal pad is then placed against the perineum and mother assisted to
put her legs together

POTENTIAL COMPLICATIONS
• HYPOTHERMIA
• POSTPARTUM HEMORRHAGE

APGAR SCORE
• Taken at 1 and 5 minutes after birth
• Heart rate, respiratory rate, and colour are
used as the basis for resuscitation need
TOTALS
• 0-2 = Severe distress
• 3-6 = moderate distress
• 7-10 = minimal distress

REFLEXES
• Tonic neck reflex
• Grasp reflex
• Step reflex
• Crawl reflex
• Sucking reflex
• Babinskis reflex

normal labour.pptx labour and its stages

normal labour.pptx labour and its stages

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