2. Mechanism normal and abnormal of labor?

NORMAL LABOR

The Four Stages of Labor

There are four stages of labor.
1. First Stage of Labor
Thinning (effacement) and opening (dilation) of the cervix
During the first stage of labor, contractions help your cervix to thin and begin to open. This
is called effacement and dilation. As your cervix dilates, your health care provider will
measure the opening in centimeters. One centimeter is a little less than half an inch. During
this stage, your cervix will widen to about 10 centimeters. This first stage of labor usually
lasts about 12 to 13 hours for a first baby, and 7 to 8 hours for a second child.
The first stage of labor has three parts:

1. Early labor
Your cervix opens to 4 centimeters. You will probably spend most of early
labor at home. Try to keep doing your usual activities. Relax, rest, drink clear
fluids, eat light meals if you want to, and keep track of your contractions.
Contractions may go away if you change activity, but over time they'll get
stronger. When you notice a clear change in how frequent, how strong, and
how long your contractions are, and when you can no longer talk during a contraction,
you are probably moving into active labor.
2. Active labor
Your cervix opens from 4 to 7 centimeters. This is when you should head
to the hospital. When you have contractions every 3 to 4 minutes and they
each last about 60 seconds, it often means that your cervix is opening faster
(about 1 centimeter per hour). You may not want to talk as you become
more involved in dealing with your contractions. As your labor progresses,
your bag of waters may break, causing a gush of fluid. After the bag of waters breaks,
you can expect your contractions to speed up.
Slow, easy breathing is usually helpful at this time. Focusing on positive, relaxing
images or music may also be helpful. Changing positions, massage, and hot or cold
compresses can help you feel better. Walking, standing, or sitting upright will help
labor progress. Relaxing during and between contractions saves your energy and helps
the cervix to open. Many hospitals have whirlpool or soaking tubs that may help you
relax and ease discomfort.
 3. Transition to second stage
Your cervix opens from 7 to 10 centimeters. For most women, this is the
hardest or most painful part of labor. This is when your cervix opens to its
fullest. Contractions last about 60 to 90 seconds and come every 2 to 3
minutes.
There is very little time to rest and you may feel overwhelmed by the
strength of the contractions. You may feel tired, frustrated, or irritated, and
may not want to be touched. You may feel sweaty, sick to your stomach, shaky, hot, or
cold. Although you may find slow, easy breathing to be most effective throughout
labor, you may also find an uneven breathing pattern most helpful at this time.

2. Second Stage of Labor

Your baby moves through the birth canal
The second stage of labor begins when the cervix is completely dilated (open), and ends
with the birth of your baby. Contractions push the baby down the birth canal, and you may
feel intense pressure, similar to an urge to have a bowel movement.
Your health care provider may ask you to push with each contraction. The contractions
continue to be strong, but they may spread out a bit and give you time to rest. The length of
the second stage depends on whether or not you've given birth before and how many times,
and the position and size of the baby.
The intensity at the end of the first stage of labor will continue in this pushing phase. You
may be irritable during a contraction and alternate between wanting to be touched and talked
to, and wanting to be left alone. It isn't unusual for a woman to grunt or moan when the
contractions reach their peak.

3. Third Stage of Labor

Afterbirth
After the birth of your baby, your uterus continues to contract to push out the placenta
(afterbirth). The placenta usually delivers about 5-30 minutes after the baby arrives.

4. Fourth Stage of Labor

Recovery
Your baby is born, the placenta has delivered, and you and your partner will probably feel
joy, relief, and fatigue. Most babies are ready to nurse within a short period after birth. Others
wait a little longer. If you are planning to breastfeed, we strongly encourage you to try to nurse
 as soon as possible after your baby is born. Nursing right after birth will help your uterus to
contract and will decrease the amount of bleeding.

NORMAL LABOR
World Health Organization (WHO)
defines normal labor based on the following features;
(1)spontaneous onset of labor between 37 and 42 completed weeks of pregnancy,
(2) low riskat the start and remaining so throughout labor and delivery,
(3) spontaneous birth of an infant in the vertex presentation,
(4) mother and baby in good condition after birth.

Society of Obstetricians and Gynaecologists of Canada (SOGC), defines normal labor same as
WHO, plus;
(1) normal birth includes the opportunity for skin-skin holding and breast feeding in the first hour
after the birth,
(2) a normal birth does not preclude possible complications such as postpartum haemorrhage,
perineal trauma and repair, and admissionto the neonatal intensive care unit. A normal birth does
not include elective induction of labor prior to 41+0 weeks, spinal analgesia, general anaesthetic,
instrumental delivery, cesarean delivery, routine episiotomy, continuous electronics fetal
monitoring for low risk birth and fetal mal presentation.

Mechanisms of Labor with Occiput Anterior Presentation

The 7 Cardinal Movements of Labor
The positional changes in the presenting part required to navigate the pelvic canal constitute the
mechanisms of labor. The cardinal movements of labor are engagement, descent, flexion, internal
rotation, extension, external rotation, and expulsion.

Mechanism of labor for left occiput anterior position.

I.Engagement

Left occipitoanterior engagement.

The mechanism by which the biparietal diameter (the greatest transverse diameter in anocciput
presentation) passes through the pelvic inlet is designated engagement. The fetal

head may engage during the last few weeks of pregnancy or not until after labor
commencement. In many multiparous and some nulliparous women, the fetal head is freely
movable above the pelvic inlet at labor onset. In this circumstance, the head is sometimes referred
to as "floating." A normal-sized head usually does not engage with its sagittal suture directed
anteroposteriorly. Instead, the fetal head usually enters the pelvic inleteither transversely or
obliquely.
II. Descent

Descent in left occipitoanterior position.

 In nulliparas, engagement may take place before the onset of labor, and further descent may not
follow until the onset of the second stage. In multiparous women, descent usually begins with
engagement. Descent is brought about by one or more of four forces: (1)pressure of the amnionic
fluid, (2) direct pressure of the fundus upon the breech with contractions, (3) bearing-down efforts
of maternal abdominal muscles, and (4) extension and straightening of the fetal body.

III. Flexion
In this movement, the chin is brought into more intimate contact with the fetal thorax, and the
appreciably shorter suboccipito bregmatic diameter is substituted for the longer occipitofrontal
diameter.

IV. Internal Rotation

Anterior rotation of head.

This movement consists of a turning of the head in such a manner that the occiput gradually
moves toward the symphysis pubis anteriorly from its original position or less commonly,

posteriorly toward the hollow of the sacrum. Internal rotation is essential for the completion of
labor, except when the fetus is unusually small.

V. Extension

After internal rotation, the sharply flexed head reaches the vulva and undergoes extension. If
the sharply flexed head, on reaching the pelvic floor, did not extend but was driven farther
downward, it would impinge on the posterior portion of the perineum and would eventually be
forced through the tissues of the perineum. When the head presses upon the pelvic floor, however,
two forces come into play. The first force, exerted by the uterus, acts more posteriorly, and the
second, supplied by the resistant pelvic floor and the symphysis, acts more anteriorly. The resultant
vector is in the direction of the vulvar opening, there by causing head extension. This brings the
base of the occiput into direct contact with the inferior margin of the symphysis pubis.
 Extension of the head.

With progressive distension of the perineum and vaginal opening, an increasingly larger portion
of the occiput gradually appears. The head is born as the occiput, bregma, forehead, nose, mouth,
and finally the chin pass successively over the anterior margin of the perineum. Immediately after
its delivery, the head drops downward so that the chin lies over the maternal anus.

VI. External Rotation

External rotation of the head.

The delivered head next undergoes restitution. If the occiput was originally directed toward the
left, it rotates toward the left ischial tuberosity. If it was originally directed toward the right, the
occiput rotates to the right. Restitution of the head to the oblique position is followed by
completion of external rotation to the transverse position. This movement corresponds to rotation
of the fetal body and serves to bring its bisacromial diameter intorelation with the anteroposterior
diameter of the pelvic outlet. Thus, one shoulder is anterior behind the symphysis and the other is
posterior. This movement apparently is brought about by the same pelvic factors that produced
internal rotation of the head.
VII. Expulsion

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 quickly passes.

Delivery of anterior shoulder. Delivery of posterior shoulder.

Causes of abnormal labor

POWER
“Power” refers to the forces that move baby through the birth canal. This is mostly
accomplished by the uterus. Did you know that the uterus is one of the strongest muscles in the
human body? Strong, coordinated uterine contractions are needed for the cervix to thin and dilate
(open) and to allow the baby to descend through the birth canal. Special nerves that travel
through the lower spine and pelvis supply the uterus and control how quickly and how strong the
uterus is able to contract. During dystocia, these contractions may not be strong enough or they
may not be coordinated properly. To allow for optimal “power” to push the baby, these nerves
need to be functioning at an optimal level and the muscles need to be strong and efficient.

PASSAGE
The “Passage” is the space that is available for the baby to pass through. This passage is
formed by Mom’s pelvic bones – her physical anatomy. Although the overall shape of Mom’s
pelvis is determined by her body type, hormones released during pregnancy (such as relaxin)
allow for increased mobility of the pelvis during pregnancy and birth. If the joints in the pelvis
are unable to move properly to create space or the bones in the Mom’s pelvis are out of balance,
the birth is more likely to be difficult for both Mom and baby. We want a good balance of
position and mobility for the bones and joints of the pelvis to create a nice, open birth passage
way.

PASSENGER

The “Passenger” is, of course, the baby! Now we need to consider the size of the baby and
how he or she is positioned in relation to the mother. The ideal position for the baby is head
down, chin tucked, with their body/back aligned on the left side of the mother. Often, when the
baby is in this position, Mom will feel the baby kicking on the upper right side of her abdomen.
This position typically allows for the best set-up for an easier labour and delivery.

This “3 P” approach to considering and preparing for your best birth experience is taught by
the International Chiropractic Paediatric Association (ICPA) during Webster Chiropractic
Technique training. This technique is designed specifically to cater to the physical and
neurological needs of Mom’s changing body throughout pregnancy in preparation for the big
day. Taking care of yourself throughout pregnancy, including regular chiropractic care and
massage therapy, can address these 3 P’s. Chiropractic adjustments and soft tissue release
support optimal alignment and mobility of Mom’s pelvis, which helps to create more space for
the baby to move as needed (and influences both the “Passage” and “Passenger.”) This treatment
is also important for supporting the function of the nerves that supply the pelvis and uterus,
which is important for the “Power” aspect birth.

1. Simkin P., Ancheta R. What is normal labor? Chapter 2: Dysfunctional Labor :

GeneralConsiderations. In The Labor Progress Handbook; Early Interventions to Prevent
andTreat Dystocia. 3rd Edition. UK. Wiley-Blackwell. 2011; pp 16-7.2.
2. Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y.
WilliamsObstetrics. Mechanisms Of Labor. Normal Labor and Delivery. 23rd Edition.
UnitedStates of America. The McGraw-Hill Companies. 2010; Pp 378-83