Normal Labor

JI Ramil M. Bonifacio

Normal Labor
In Latin, the word labor means a troublesome
effort or suffering. Another term for labor is
parturition which comes from the Latin Parturire to
be ready to bear young and is related to partus to
produce. To labor in this sense is to produce.
Labor is a physiologic process that begins with the
onset of rhythmic contractions which bring about
changes in the biochemical connective tissue
resulting in gradual effacement and dilatation of the
cervix and end with the expulsion of the product of
conception.
The contractions are characterized by a progressive
increase in frequency, intensity and duration.
Labor is a clinical diagnosis.
Cervical dilatation in the absence of uterine

The criteria for the diagnosis of labor

1. Uterine contractions (at least 1 in 10
minutes or 4 in 20 minutes) by direct
observation or electronically using a
cardiotocogram
2. Documented progressive changes in
cervical
dilatation and effacement as observed
by one
observer
3. Cervical effacement of > 70-80%
4. Cervical dilatation > 3cm

True labor pains

True labor contractions come at regular
intervals and last about 30-70 seconds
As time progresses, they get closer
together
Contractions continue despite
movement or changing positions
Contractions steadily increase in
strength
Contractions usually start in the lower
back and move to the front of the
abdomen.

False labor pains

False labor contractions are often
irregular and do not get closer together.
Contractions may stop when you walk
or rest, or may even stop if you change
positions.
Contractions are usually weak and do
not get much stronger; or they may be
strong at first and then get weaker.
Contractions are usually only felt in the
front of the abdomen or pelvic region.

I. FIRST STAGE OF LABOR

A. MONITORING OF FETAL WELL-BEING DURING
NORMAL LABOR
The monitoring of the fetal heart rate in labor aims to
identify hypoxia before it is sufficient to lead to long
term poor neurological outcome for babies.
B. INDUCTION OF LABOR
Induction of labor is defined as an intervention designed
to artificially initiate uterine contractions leading to
progressive dilatation and effacement of the cervix and
birth of the baby (RCOG, 2001).
confirmation of parity
confirmation of gestational age
Presentation
Bishops score
uterine activity

I. FIRST STAGE OF LABOR

Cervical effacement
Obliteration or taking up of the cervix. Manifest clinically by shortening of the cervical
canal from a length of about 2 cm to a mere circular orifice with almost paper-thin edges.
Muscular fibers at about the level of the internal cervical os are pulled upward, or taken
up, into the lower uterine segment.
Causes expulsion of the mucous plug as the cervical canal isshortened
Cervical dilatation
Results from a centrifugal pull exerted on the cervix due to the fact that the lower
segment of the uterus and the cervix have lesser resistance during a uterine contraction
As uterine contractions cause pressure on the membranes, the hydrostatic action of the
amnionic sac in turn dilates the cervical canal like a wedge > formation of the forebag
of amnionic fluid
Divided into latent and active phases:
Latent phase duration is more variable and sensitive to changes; has little bearing in
the subsequent course of labor
Slow and long
Can extend up to 20 hours in primigravids
When the cervix dilates up to 3.5-4 cm, it starts to enter the active phase
Duration is more variable and sensitive to extraneous factors (e.g. sedation)3
Active phase further divided into acceleration phase, phase of maximum slope,
and deceleration phase; predictive of a particular labor outcome. Short and rapid

AMNIOTOMY
Artificial rupture of the membranes may be used
as a method of labor induction, especially if the
condition of the cervix is favorable.
Used alone for inducing labor, amniotomy can
be associated with unpredictable and sometimes
long intervals before the onset of contractions.

I. FIRST STAGE OF LABOR

C. INTRAPARTUM NUTRITION
The management of oral intake of parturients seeks to
provide adequate hydration and nutrition while
maintaining safety for the mother and baby.
Many obstetricians restrict oral food and fluid intake during
active labor because of the possible risk of aspirating
gastric contents with the administration of anesthesia.
However, sources of energy need to be replenished during
labor in order to ensure fetal and maternal well-being.
The use of epidural anesthesia for intrapartum pain
management in an otherwise normal labor should not
preclude oral intake.
The correct approach for normal childbirth should include
an assessment of the risk of general anesthesia.

I. FIRST STAGE OF LABOR

D. ENEMA DURING LABOR
Enemas are thought to decrease the risk of puerperal
and neonatal infections, shorten the duration of labor
and make delivery cleaner for attending personnel.
However, enemas are upsetting and humiliating for
women in labor and may cause increased pain.
Enemas also cause watery stools and could
theoretically increase contamination and infection
rates.
There is no evidence to support the routine use of
enemas during labor. Although these results cannot
rule out a small clinical effect, it seems unlikely that
enemas will improve maternal and neonatal outcomes
and provide an overall benefit. (Level 1, Grade A)

I. FIRST STAGE OF LABOR

E. MONITORING THE PROGRESS OF LABOR
For monitoring the progress of labor, one may use the Friedmans
labor curve
The labor curve is plotted as a function of cervical dilatation (cm)
and fetal descent (stations) versus time (usually in hours from
onset of regular uterine contractions). The rate of change of these
two parameters is the measure of the efficiency of the labor
process. The end of labor takes place when there is expulsion of
the fetus and the placenta.
F. MATERNAL POSITION DURING THE FIRST STAGE OF LABOR
There is evidence that walking and upright positions in the first
stage of labor reduce the length of labor and do not seem
associated with increased intervention or negative effects on
mothers and babies well-being. Women should be encouraged to
take up whatever position they find most comfortable in the first
stage of labor.

II. SECOND STAGE OF LABOR

Stage of fetal descent
In the descent pattern of normal labor, a typical
hyperbolic curve is formed when the station of
the fetal head is plotted as a function of labor
duration.
Station describes descent of the fetal biparietal
diameter in relation to a line drawn between
maternal ischial spines. Active descent usually
takes place after dilatation has progressed for
some time.
Speed of descent is maximal and is maintained
until the presenting part reaches the perineal
floor.

IV. THIRD STAGE OF LABOR

A. USE OF EPISIOTOMY AND REPAIR
Restricted use of episiotomy preferable to routine
use (Level I, Grade A)
Median episiotomy is associated with higher rates
of injury to the anal sphincter and rectum (Level I,
Grade A)
Mediolateral episiotomy may be preferable to
median episiotomy in selected cases (LevelI,
Grade B)
Repair
In either median or mediolateral episiotomy, 2layered closure can improve postpartum pain and
healing complications vs a 3-layered closure.

III. THIRD STAGE OF LABOR

Indications:
Expedite delivery in the second stage of
labor
When spontaneous laceration is likely
Maternal or fetal distress
Breech position
Assisted forceps delivery
Large baby
Maternal exhaustion

III. THIRD STAGE OF LABOR

MANAGEMENT OF THIRD STAGE OF
LABOR
Active management includes a group of
interventions such as
1. administration of prophylactic
uterotonin within one minute after the
delivery of the baby and prior to the
delivery of the placenta
2. early cord clamping and cutting
3. controlled cord traction to deliver the
placenta

III. THIRD STAGE OF LABOR

D. DRUGS IN THE THIRD STAGE OF LABOR
Oxytocin is effective as 1st line prophylactic uterotonic
during the 3rd stage of labor in the prevention of PPH
and is safe to use on all patients. (Level I)
Use of ergot alkaloid and ergometrine-oxytocin are valid
alternatives in the absence of oxytocin. Their use have
to be weighed against maternal adverse effects. (Level
I)
Use of ergot alkaloid and ergometrine-oxytocin
combination have to be avoided in hypertensive
patients. (Level I)
In low resource area, and in the absence of other
uterotonics, Misoprostol, if legally available, is a valid
alternative and may be administered orally, sublingually
or rectally.(Level I)

III. THIRD STAGE OF LABOR

Delivery of placenta and membranes
As the neonate is born, the uterus spontaneously
contracts around its diminishing contents.
By the time the infant is completely delivered, the
uterine cavity is almost diminished and the uterus
almost becomes a solid mass of muscle with the
fundus just below the umbilicus.
Fetal membranes are peeled off the uterine wall
partly by further contraction of the myometrium and
partly by traction that is exerted by the separated
placenta.
After the placenta has separated and occupies the
lower uterine segment or upper vagina, it may be
expelled by increased abdominal pressure.

V. FOURTH STAGE OF LABOR

EARLY BREASTFEEDING
health organizations recommend exclusive
breastfeeding for the first 6 months of life.
Education
Minimize maternal medications
intrapartum
Avoid traumatic procedures on infant
Direct skin to skin contact right after
delivery
Rooming-in
Frequency of feedings

Summary

Cardinal Movements
Engagement
The mechanism by which the biparietal
diameter, the greatest transverse diameter of
the fetal head in occiput presentations, has
passed through the pelvic inlet
Distance from ischial spine to pelvic inlet = 5cm
(corresponding to the 5 stations above the
spine).
Distance from the most dependent portion of
the head to the biparietal diameter = 3 cm.
When engaged, and the head does not flex right
away, that means it is in military presentation.

Cardinal Movements
2. Descent
The only cardinal movement that occurs from
start to finish
As contractions increase in intensity and shorten
in interval, the baby is pushed downward.
First requisite for birth of the newborn
Descent is brought about by one or more of four
forces:
Pressure of the amniotic fluid
Direct pressure of the fundus upon the breech with
contractions
Bearing down efforts of maternal abdominal muscles
Extension and straightening of the fetal body

Cardinal Movements
3. Flexion
Babys head flexes due to resistance
experienced (brought about by the soft
tissues and muscles of the pelvic floor)
while the baby is being pushed
downward by the uterus.
The chin is brought into more intimate
contact with the fetal thorax, and the
appreciably shorter suboccipitobregmatic
diameter is substituted for the longer
occipitofrontal diameter

Cardinal Movements
4. Internal Rotation
The head rotates, exposing the biparietal
diameter (9cm), which is shorter than the
suboccipitobragmatic, and thus can pass
through the spine.
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.
Essential for the completion of labor, except
when the fetus is unusually small.

Cardinal Movements
5. Extension
This happens once the baby uses the posterior
border of the symphysis pubis as a fulcrum and the
babys head extends
If sharply flexed head failed to extend on reaching
the pelvic floor > impinge on the posterior portion
of the perineum and would be forced through the
tissues of the perineum > 2 forces come into play:
(1) that exerted by the uterus which acts more
posteriorly, and (2) that supplied by the resistant
pelvic floor and the symphysis, which acts more
anteriorly > resultant vector is in the direction of
the vulvar opening > head extension.

Cardinal Movements
6. External Rotation
The delivered head next undergoes restitution.
The baby goes back to its previous position while
traversing the vaginal canal; otherwise the shoulders
(bisacromial diameter) will not be able to pass
through the vagina
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, a movement that corresponds to
rotation of the fetal body

Cardinal Movements
7. Expulsion
BABY OUT
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.

Thank You!