NORMAL LABOUR

PRESENTED BY Dr Tsitsi Vimbayi Chatora

Definition

Labour is a physiologic process during which the products of conception (i.e, the foetus, membranes, umbilical cord, and placenta) are expelled outside of the uterus. Labour is said to be normal only when the foetus is term(37 weeks to 42 weeks) and the process is spontaneous and uncomplicated with foetus in vertex position.
Labour is a clinical diagnosis. The onset of labour is defined as regular, painful uterine contractions resulting in progressive cervical effacement and dilatation. Bloody show (a small amount of blood with mucous discharge from the cervix) may precede onset of labour by as much as 72 h. The stimulus for labour is unknown, but digitally manipulating or mechanically stretching the cervix during examination enhances uterine contractile activity, most likely by stimulating release of oxytocin by the posterior pituitary gland.

Definition

Cervical dilatation in the absence of uterine contraction suggests cervical insufficiency. Labour should also be distinguished from Braxton Hicks Contractions which are non-painful practice contractions, e.g to 15mmHg pressure( in labour pressure is ~60mmHg) These occur from the first trimester and are commonest after 36 weeks. Labour or intra-partum period is traditionally divided into 3 stagesFirst, Second and Third stage of labour. Fourth stage of labor" is a term used in two different senses: It can refer to the immediate puerperium(, or the hours immediately after delivery of the placenta (usually 4 hours) It can be used in a more metaphorical sense to describe the weeks following delivery. The average duration of the stages of labour depends on whether the patient is nulliparous or miltiparous

The stages of labour

a.

b.

First stage is the time from the onset of regular contractions until the cervix is fully dilated (no cervix felt around the head). It comprises Latent phase- irregular contractions become progressively better coordinated, discomfort is minimal, and the cervix effaces and dilates to 4 cm. Active phase-4cm dilated to full dilatation associated with stronger more regular contractions and descent of the presenting part Second stage from full dilatation to delivery of the baby Third stage after delivery of the baby to delivery of the placenta.

Stages of labour
nullipara First stage latent phase First stage active phase Second stage Third stage 12 -18 hours(<20) 8 -10 hours 1 -2 hours 15- 20 minutes Multipara 6-8 hours(<14) 6-8 hours ~30 minutes 15 20 minutes

Mechanism of labour
The ability of the fetus to successfully negotiate the pelvis during labor involves changes in position of its head during its passage in labor. The mechanisms of labor, also known as the cardinal movements, are described in relation to a vertex presentation, as is the case in 95% of all pregnancies. Engagement The widest diameter of the presenting part (with a well-flexed head, where the largest transverse diameter of the fetal occiput is the biparietal diameter) enters the maternal pelvis to a level below the plane of the pelvic inlet. On the pelvic examination, the presenting part is at 0 station, or at the level of the maternal ischial spines. Descent The downward passage of the presenting part through the pelvis. This occurs intermittently with contractions. The rate is greatest during the second stage of labor. Flexion As the fetal vertex descents, it encounters resistance from the bony pelvis or the soft tissues of the pelvic floor, resulting in passive flexion of the fetal occiput. The chin is brought into contact with the fetal thorax, and the presenting diameter changes from occipitofrontal (11.0 cm) to suboccipitobregmatic (9.5 cm) for optimal passage through the pelvis. Internal rotation Extension Restitution and external rotation When the fetus' head is free of resistance, it untwists about 45 left or right, returning to its original anatomic position in relation to the body. Expulsion After the fetus' head is delivered, further descent brings the anterior shoulder to the level of the pubic symphysis. The anterior shoulder is then rotated under the symphysis, followed by the posterior shoulder and the rest of the fetus.

Management of Labour
According to the WHO Care in Normal Birth :A practical guide, the aim in management of normal birth is to achieve a healthy mother and child with the least possible level of intervention that is compatible with safety The tasks of the caregiver are fourfold:

support of the woman, her partner and family during labour, at the moment of childbirth and in the period thereafter.

observation of the labouring woman; monitoring of the fetal condition and of the condition of the infant after birth; assessment of risk factors; early detection of problems.
performing minor interventions, if necessary, such as amniotomy and episiotomy; care of the infant after birth.

referral to a higher level of care, if risk factors become apparent or complications develop that justify such referral

Management of labour

Throughout labour and delivery the woman's physical and emotional wellbeing should be regularly assessed. This implies measuring of temperature, pulse and blood pressure, checking fluid intake and urine output, assessing pain and need of support. This monitoring should be maintained until the conclusion of the birthing process. Measuring the temperature every 4 hours, according to the WHO partograph, is important, because a rise in temperature may be a first sign of infection, and thus may lead to early treatment, especially in case of prolonged labour and ruptured membranes; this may prevent sepsis. Sometimes it may be a sign of dehydration. Taking the blood pressure at the same intervals, is an important check on maternal well-being. A sudden rise in blood pressure can indicate the need to expedite delivery or transfer the woman to a higher level of care. The assessment of the woman's well-being also comprises attention to her privacy during labour, respecting her choice of companions and avoiding the presence of unnecessary persons in the labour room

Management of Labour
Monitoring fetal Heart Intermittent auscultation and continuous electronic surveillance are the two methods of fetal heart monitoring. Auscultation is usually performed once every 15-30 minutes during the first stage of labour, and following every contraction during the second stage Sensitivity of continuous electronic surveillance with respect to the detection of fetal distress is high, but the specificity is low (Grant 1989). This means that the method results in a high rate of false positive signals, and a concomitant high number of (unnecessary) interventions, especially if used in a group of low-risk pregnant women heart. Abnormalities include Bradycardia (<120/min), Tachycardia (>160/min), Reduced variability Decelerations

Assessment of amniotic fluid

Analgesia in management of labour

Non-pharmacological methods of pain relief include Support during labour the opportunity to assume any position the woman wishes, in or out of bed, during the course of labour Shower or a bath. Use of a Touch and massage by a companion Attention-focusing techniques like patterned breathing, verbal coaching and relaxation, drawing a woman's attention away from her pain Transcutaneous electrical nerve stimulation (TENS). Systemic Pharmacological agents A number of drugs have been and are being used for pain relief: opioid alkaloids, of which by far the most popular is pethidine, followed by phenothiazine derivatives (promethazine), benzodiazepines (diazepam) and others. inhalation analgesia particularly nitrous oxide combined with 50 percent oxygen. Regional Pharmacological Methods These include epidural,spinal,caudal, paracervical anaesthesia.

Management of the 2nd stage of labour

Fundal pressure-the practice of fundal pressure during the second stage of labour is common. It is meant to expedite the delivery, is sometimes performed shortly before delivery, sometimes from the beginning of the second stage. Apart from the issue of increased maternal discomfort, there is suspicion that the practice may be harmful for the uterus, the perineum and the foetus, but no research data are available. The impression is that the method is at least used too often, with no evidence of its usefulness. Prolonged 2nd stage If there are signs of fetal distress or if the presenting part fails to descend there is good reason to terminate labour, but if the mother's condition is satisfactory, the fetus is in good condition, and there is evidence of progress in the descent of the fetal head, there are no grounds for intervention. However, after a second stage of >2 hours in nulliparous women and >1 hour in multiparae the chance of spontaneous delivery within a reasonable time decreases, and termination should be contemplated.

Active management of the Third stage of Labour

Active management of the third stage (as opposed to management of the third stage) is the standard recommended management of the third stage of labour. It has been proven to reduce incidence of post partum haemorrhage. It comprises; Routine administration of Uterotonic drugs e.g. Oxytocin at delivery of the anterior shoulder Early clamping and cutting of the cord Contolled cord traction Fundal massage

I.

II. III. IV.

*Physiological management excludes use of uterotonics, no cutting of cord until pulsation of the cord has ceased and delivery of placenta by maternal effort.

References

http://emedicine.medscape.com/article/260036overview. http://www.merckmanuals.com/professional/gynec ology_and_obstetrics/normal_pregnancy_labor_a nd_delivery/management_of_normal_labor.html

Oxford Handbook of Clinical Specialties, 7th Edition Care in Normal Birth WHO/FRH/MSM/96.24 http://en.wikipedia.org/wiki/Childbirth#Fourth_stag e