Objectives
Labour is divided into three stages: markers such as cytokines, and prostaglandins might
play a role. The latter are thought to be present in the
First stage: from the onset of established labour
decidua and membranes in late pregnancy and are
until the cervix is fully dilated.
released if the cervix is digitally stretched at term to
Second stage: from full dilatation until the fetus
separate the membranes (a cervical sweep).
is born.
Third stage: from the birth of the fetus until
delivery of the placenta and membranes. PROGRESS IN LABOUR
190 190
180 180
170 170
fetal 160
heart 160
rate 150 150
140 140
130 130
120 120
110 110
100 100
90 90
80 80
liquor
10 10
9 9
8 8
7 7
cervix
dilatation 6 6
5 5
4 4
descent 3 3
of pp
2 2
1 1
0 0
5
contractions 4
per 10 min 3
2
1
syntocinon
units
drugs
and
IV fluids
200 200
190 190
180 180
170 170
160 160
blood 150 150
pressure 140 140
and
pulse 130 130
120 120
110 110
100 100
90 90
80 80
70 70
60 60
urine
protein
ketones
glucose
volume
temperature
comments
The passage that these bones make can be divided different ethnic groups. The presenting part of the
into inlet, cavity and outlet (Fig. 38.2). The pelvic fetus must negotiate the axis of the birth canal with
inlet is bounded by the pubic crest, the iliopectineal the change of direction occurring by rotation at the
line and the sacral promontory. It is oval in shape, pelvic floor.
with its wider diameter being transverse. The cavity
of the pelvis is round in shape. The pelvic outlet is
bounded by the lower border of the pubic symphysis, Soft tissues
the ischial spines and the tip of the sacrum. The soft passages consist of:
Again the shape is oval, but the wider diameter is Uterus (upper and lower segments).
anteroposterior (Fig. 38.3). Cervix.
When a woman stands upright, the pelvis tilts Pelvic floor.
forward. The inlet makes an angle of about 55 with Vagina.
the horizontal; this varies between individuals and Perineum.
216
Plane of inlet
Cavity
Plane of outlet
Ischial spine
Ischial tuberosity
Coccyx
Sacroiliac
joint
Anterior
Pubic arch
Ischial
Transverse tuberosity
diameter
Sacrotuberous
Anteroposterior ligament
diameter
Coccyx
Sacrococcygeal
joint
Posterior
The upper uterine segment is responsible for the arising from the bony pelvis to form a muscular
propulsive contractions that deliver the fetus. The diaphragm along with the internal obturator
lower segment is the part of the uterus that lies muscle and piriformis muscle (see Chapter 28). As
between the uterovesical fold of the peritoneum the presenting part of the fetus is pushed out of the
and the cervix. It develops gradually during the third uterus it passes into the vagina, which has become
trimester, and then more rapidly during labour. hypertrophied during pregnancy. It reaches the pelvic
It incorporates the cervix as it effaces, to allow the floor, which acts like a gutter to direct it forwards and
presenting part to descend. allow rotation. The perineum is distal to this and
The pelvic floor consists of the levator ani group of stretches as the head passes below the pubic arch and
muscles, including pubococcygeus and iliococcygeus delivers.
217
A B
Coronal Anterior Parietal Posterior
Anterior Coronal Sagittal Posterior Lambdoid suture fontanelle eminence fontanelle
fontanelle suture suture fontanelle suture
Frontal
bone
Frontal Brow
suture
Frontal
bone
Occipital
bone Lambdoid
Parietal suture
Biparietal diameter eminence
Occipital
bone
Fig. 38.4 The fetal skull from above (A) and from the side (B), showing the landmarks.
218
retract so that the fibres become progressively shorter. occipito-transverse or occipito-anterior position. As
This effect is seen in the upper segment muscle: labour progresses (Fig. 38.7), the neck becomes fully
progressive retraction causes the lower segment to flexed so that the suboccipitobregmatic diameter is
stretch and thin out, resulting in effacement and presenting (see above).
dilatation of the cervix (Fig. 38.6). As descent occurs, internal rotation brings the
occiput into the anterior position when it reaches the
pelvic floor. In the second stage of labour, the occiput
descends below the symphysis pubis (Fig. 38.8) and
DELIVERY OF THE FETUS delivers by extension. Increasing extension round the
pubic bone delivers the face (Fig. 38.9).
Active contractions of the uterus of increasing Delivery of the head brings the shoulders into the
strength, frequency and duration cause passive pelvic cavity in the transverse diameter, with the head
movement of the fetus down the birth canal. At the oblique to the line of the shoulders. External rotation
beginning of labour, the fetus usually engages in the or restitution occurs: the head rotates in relation
38th week
B B
During first
stage
of labour
End of first
stage
of labour
219
Maternal monitoring
The patient is encouraged to mobilize if possible
and is allowed to eat, depending on her risk of
needing an operative procedure. There is delayed
gastric emptying during pregnancy and labour.
Fig. 38.9 Delivery of the head. Extension of the fetal neck occurs as the Therefore if an emergency general anaesthetic is
head passes under the pubic symphysis to deliver the head. needed, there is an increased risk of inhalation
220
Fetal monitoring
Different degrees of fetal monitoring are appropriate,
Fig. 38.10 External rotation (restitution). The head distends the
depending on the clinical picture. For example, in a
perineum as it delivers in the occipitoanterior position and the external high-risk pregnancy such as the presence of IUGR or
rotation occurs. if there is meconium-stained liquor, then continuous
fetal monitoring is advisable (see Chapter 15). In
a low-risk pregnancy, intermittent monitoring
either electronically or with a Pinard stethoscope
of regurgitated acid stomach contents, causing might be sufficient, every 15 min during and after a
Mendelsons syndrome. contraction.
The need for analgesia during labour varies In some patients, abdominal monitoring can be
markedly between different women, different ethnic difficult, for example, if the patient is obese, and so
groups and depending on their antenatal preparation. a fetal scalp electrode can be applied directly once
Non-pharmacological techniques include the the cervix dilates and the membranes are ruptured. If
use of psychoprophylaxis, hypnosis, massage and monitoring suggests that the fetal heart rate pattern
transcutaneous electrical nerve stimulation (TENS). is abnormal, it might be appropriate to measure the
The pharmacological methods are summarized in fetal pH by taking a blood sample from the fetal scalp
Fig. 38.12. (see Chapter 15).
221
Oxygen/ Inhalation of 50:50 First stage < 50% Time of Does not relieve pain
nitrous mixture with onset Takes 2030 s inhalation
oxide of contraction for peak effect only
Pethidine Intramuscular First stage <50% Approximately Nausea and vomiting
injection Takes 3h give with an antiemetic
100150 mg 1520 min Respiratory depression
for peak effect in the neonate (this is
easily reversed with
intramuscular naloxone)
Pudendal Infiltration of right Second stage for Within 5 min 4590 min
block and left pudendal operative delivery
nerves (S2, S3 and
S4) with 0.5%
lidocaine
Perineal Infiltration of Second stage Within 5 min 4590 min
infiltration perineum prior to episiotomy
with 0.5% lidocaine Third stage for
at posterior suturing of perineal
fourchette lacerations
Epidural Injection of 0.25% First or second Complete pain Bolus injection Transient hypotension
anaesthesia or 0.5% bupivicaine stage relief in every 34 h or give intravenous fluid
via a catheter into Caesarean approximately continuous load
the epidural space section 95% of infusion Dural tap
(L34) women Risk of haemorrhage if
abnormal maternal
clotting
Increased length of
second stage because of
reduced pelvic floor tone
and loss of bearing-down
reflex
Spinal Injection of 0.5% Any operative Immediate Single Respiratory depression
anaesthesia bupivicaine into the delivery; manual effect injection
subarachnoid space removal of the lasting 34 h
placenta
222
include:
McRoberts position - the hips are flexed in knee-
chest position in order to widen the pelvis INDUCTION OF LABOUR
suprapubic pressure to dislodge the anterior
shoulder Definition
internal rotation techniques to try and rotate the
Induction of labour is the artificial initiation of
baby
uterine contractions prior to spontaneous onset
deliver the posterior arm.
resulting in delivery of the baby.
Indications
MANAGEMENT OF THE THIRD The rate of induction varies widely between different
STAGE OF LABOUR units and even within different units. Figure 38.14
shows possible reasons for induction of labour,
Active management of the third stage has been shown maternal or fetal. In the UK, the most common
to reduce the incidence of postpartum haemorrhage indication is prolonged pregnancy.
(see Chapter 42). Management involves:
Using an oxytocic drug.
Methods
Clamping and cutting the cord. Prior to induction of labour, the favourability of the
Controlled cord traction. cervix should be assessed. This is usually done by
using the Bishop score (Fig. 46.12); a higher score
In most units, syntocinon (5 units of oxytocin) is suggests a more favourable cervix.
given intramuscularly with delivery of the anterior
shoulder; it takes about 23 min to act. As the
placenta detaches from the uterine wall, the cut cord
will appear to lengthen. There is slight bleeding and
With regard to the Bishop score to assess
the fundus becomes hard. Brandt-Andrews method
the cervix:
of controlled cord traction is commonly used once Unfavourable cervix = hard, long,
the placenta has separated to reduce the incidence closed, not effaced (low Bishop score).
of uterine inversion (Fig. 38.13). The placenta and Favourable cervix = soft, beginning to dilate and
membranes must be checked to ensure that they are efface (high Bishop score).
complete.
Finally, the vagina, labia and perineum are examined
for lacerations. The uterine fundus is palpated to check
that it is well contracted, approximately at the level Prostaglandins
of the umbilicus. The estimated blood loss should be Local application of a prostaglandin, usually prosta-
recorded. glandin E2, given as a vaginal gel, has been shown
223
Fig. 38.14 Indications for the induction of labour Amniotomy and oxytocin associated complications
224
confirmed assessing station on vaginal examination not cause slow progress in labour because they rise
and by the presence of caput (swelling under the up out of the pelvis as the uterus increases in size.
fetal scalp caused by reduction in venous return) and
moulding. Failure to progress related
to the passenger
Failure to progress related Fetal size
to the soft tissues of the pelvis
The possibility of a large infant might be suggested
Uterus by the patients past medical history, for example,
A uterine malformation, such as the presence of insulin-dependent diabetes or from the antenatal
a midline septum, might prevent the fetus from history, with development of gestational diabetes or
lying longitudinally, so that a malpresentation is hydrops fetalis, e.g. with rhesus isoimmunization or
responsible for failure to progress. This can also be parvovirus infection (see Chapter 12).
caused by uterine fibroids, which may increase in size Abdominal palpation is not particularly accurate
during pregnancy and obstruct labour. The presence as a method of diagnosing a large baby, although
of a cervical fibroid might even necessitate caesarean it should be suspected if the presenting part fails
section. to engage in labour. Ultrasound is more accurate,
provided that gestational age has been correctly
estimated early in pregnancy. During labour, signs
Cervix
of cephalopelvic disproportion may indicate a large
Failure of the cervix to dilate during labour despite infant (see above).
adequate uterine contractions is rarely secondary to
cervical scarring causing stenosis. This could be the Fetal abnormality
result of cervical amputation or cone biopsy.
Routine ultrasound scanning is likely to diagnose
abnormalities such as a congenital goitre or a
Vagina lymphangioma. These extend the neck, resulting in a
Congenital anomalies of the vagina rarely cause face presentation. Abdominal enlargement such as in
problems with respect to labour and delivery, except the presence of ascites or an umbilical hernia may make
for patients who have had reconstructive surgery. delivery difficult.
Other types of surgery, such as a colposuspension Abnormalities of the fetal skull such as anencephaly
for urinary stress incontinence or repair of a should be suspected in labour if the head does not
vesicovaginal fistula, generally indicates the need engage and the sutures feel widely spaced on vaginal
for an elective caesarean section at term, but more to examination.
prevent recurrent symptoms rather than because of
possible slow progress in labour. Fetal malposition
Labour is more prolonged if the occiput is in the
Vulva posterior or transverse (OP or OT) position. This
Previous perineal tears or episiotomy should not can be determined abdominally by palpation of
present difficulties during delivery. More problematic fetal parts and confirmed on vaginal examination by
is a female circumcision (FGM female genital checking the positions of the sutures and fontanelles
mutilation), which usually necessitates an anterior (see Chapter 46).
episiotomy to prevent more severe tears and the risk
of fistula formation. Fetal malpresentation
Malpresentation of the fetus is defined as a non-
Ovary vertex presentation (see Chapter 39). This can be:
Ovarian cysts in pregnancy are usually incidental Face.
findings at routine ultrasound. They can present Brow.
with abdominal pain during pregnancy, secondary Breech.
to torsion or haemorrhage (see Chapter 11). They do Shoulder.
225
226