PARTURITION (LABOUR)

Physiological Processes

The Ferguson Reflex is trigger as the foetal presenting part impinges on the
cervix.
This causes the release of oxytocin from the pituitary gland which binds to
the oxytocin receptors in the myometrium causing the muscle fibres to
contract.

Labour is diagnosed when regular painful uterine contractions effect

progressive cervical dilation. The nerves that supply the uterus arise from
the lumbosacral spinal segments and pain in labour is referred to the
corresponding dermatomal areas.

Passage of bloodstained mucus usually occurs in labour and the membranes

rupture late in the first stage. The rate of cervical dilation is plotted as a
sigmoid curve.

Signs of Labour

Prior to the onset of labour, painless intermittent uterine tightenings, known

as Braxton Hicks contractions, become increasingly frequent. As the
presenting part becomes engaged, the uterine fundus descends, reducing
upper abdominal discomfort, and pressure in the pelvis increases.

Signs of labour are:

Show (release of mucus plug from the cervix)
o And cervical dilatation and ripening
Rupture of the membranes (breaking of waters)
Painful regular contractions
o 2-3 per 10 minutes
o Lasts longer 40 seconds

Labour is diagnosed when there are regular painful contractions in the

presence of a fully effaced cervix, which is 4cm or more dilated, with or
without a show or ruptured membranes.
The exact cause of the onset of labour is not known. To some degree it is
thought to be mechanical, since preterm labour is seen more commonly in
circumstances in which the uterus is overstretched, such as multiple
pregnancies and polyhydramnios. Inflammatory
Stages of Normal Labour

Once the diagnosis of labour has been made, progress is assessed by

monitoring:

Uterine contractions
Dilatation of the cervix
Descent of the presenting part

Stage 1 = regular contractions (latent phase) to full ~10cm cervical

dilatation (active phase)

Latent phase = 0 3 cm cervical dilation

Active phase = 3 10 cm dilation

Braxton-Hicks contractions lead to painful rhythmic contractions every

2 3 minutes
Myometrial fibres contract and relax
Lower uterus thins and stretches over the presenting part

Stage 2 = full cervical dilatation to delivery of foetus

Propulsive phase = from full dilatation to presenting part reaching

pelvic floor
Expulsive phase = from reaching pelvic floor to delivery of baby

Uterus and vagina form a continuous tube

Uterine contractions are supplemented by voluntary abdominal muscle
contractions
Pelvic floor muscles are stretched backwards

Stage 3 = foetus delivery to expulsion of the placenta

Tonic contraction of uterine muscles to constrict blood vessels passing

between fibres
Placenta separates and is expelled by uterine contractions
Duration: 20 30 minutes
 PARTURITION (LABOUR)

Passage, Passenger and Powers in Normal Labour

Progress is determined by three factors: Passages, Passenger, Power

Passages
Pelvis
Pelvic inlet oval shape
Pelvic cavity round shape
Pelvic outlet oval shape

The presenting part of the fetus must

negotiate the axis of the birth canal
(curve of corus) with the change of
direction occurring by rotation at the
pelvic floor.

Pelvic floor muscles

Levator ani group of muscles: pubococcygeus and iliococcygeus
Helps rotation of the presenting part

Passenger
The foetal skull cranium is made up of two
parietal bones, two frontal bones and the
occipital bone, held together by a
membrane (fontanelles) that allows
movement. This allows the bones to overlap
and allow the head to pass through the
pelvis during labour (known as moulding).

Powers
The myometrium acts as the power to deliver the foetus. From early
pregnancy, the uterus contracts painlessly and intermittently (Braxton Hicks
contractions). These contractions increase after the 36th week until the
onset of labour. In labour, a contraction spreads down and across the uterus
with its greatest intensity in the upper uterine segment.

During labour, the contractions are monitored for: intensity, frequency and
duration.
The resting tone of the uterus is about 612 mmHg; to be effective in labour
this increases to an intensity of 4060mmHg. There are usually three or four
coordinated contractions every 10 minutes, each lasting approx 60 s, in order
to progress in labour.
In the second stage of labour, additional power comes from voluntary
contraction of the diaphragm and the abdominal muscles as the mother
pushes to assist delivery.
Complications of Labour: Stages 1 & 2

Passenger
Size
Macrosomia gestational/maternal diabetes, maternal obesity,
prolonged pregnancy
Microsomia placental insufficiencies

Number
Twins all complications of pregnancy are more common
Mother anaemia, pre-eclampsia, miscarriage, pre-term labour
Foetus conjoint, congenital abnormalities, polyhydramnios, twin-to-
twin transfusion (monochorionic), IUGR

Presentation/position
Breech position bottom down
Transverse lie baby lying across
Consider ECV, rotational forceps or C-section

Passage
Contracted pelvis
Give C-section

Placenta praevia
Low-lying placenta covering cervical os
Have a C-section if doesnt move up

Soft tissue tumour

Cervical or uterine fibroids may obstruct labour

Pendulous abdomen
Musculature doesnt sit back together after previous pregnancies

Powers
Uterine inertia
Give syntocinon (synthetic oxytocin) carefully

Inco-ordinate contractions
Contractions have to be regular to contract cervix muscles

Hypertonic contractions

Uterine rupture
 PARTURITION (LABOUR)

Complications of Labour: Stage 3

Retained placenta
Risk of haemorrhage

Uterine atony
Uterus doesnt contract down well
Associated with multiple pregnancies or long labour

Soft tissue lacerations

1st degree (superficial), 2nd degree (peroneal muscles) or 3rd degree
(into anus)

Uterine inversion
Can cause parasympathetic shock

Placenta accrete
Placenta implantation into previous C-section scar?