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Definitions
Normal labor
Spontaneous delivery of full term, mature, living fetus, presenting by its vertex, through the birth canal, within reasonable time (12 hours) without interference and without fetal or maternal complications

Preterm labor
Interruption or termination of pregnancy between the 28th : 38th weeks gestation. N.B: Babies delivered between 20: 28 weeks are termed immature babies.

Posterm labor
Prolongation of pregnancy 2 weeks or more beyond the expected date of delivery

Post term Full term Preterm Immature Baby

- 42 - 40 - 38

- 28
- 20

Abortion

L.M.P

-0

Gestational weeks

Calculation of the date of delivery

1. Menstrual labor interval: (Naegele's rule) The duration of pregnancy is 280 days or 40 weeks calculated from the first day of last menstruation. So we add 7 days and 9 calendar months. This is the commonest method used in practice, it is correct within 7 days, it is not the true duration of pregnancy. The fertilization labor interval is 266 days E.g. Last Menstrual Period (LMP) = 1-1-2007 Expected Date of Delivery (EDD) = 8-10-2007

Calculation of the date of delivery

2. Date of single coitus: Date of coitus (e.g. Rape) + 9 calendar months 7 days 3. Date of Quickening: Quickening = Date of feeling first fetal movement. It occurs in primigravida in the 20th weeks, and in multigravida in the 18th weeks. In primigravida add 20 weeks = EDD In multigravida add 22 weeks = EDD

Calculation of the date of delivery

4. Mc-Donald's rule: Applied when the duration of pregnancy more than 24 gestational weeks. The height of fundus measured in cm above the symphysis pubis multiplied by: 8/7 =... Duration of pregnancy in weeks 2/7 =... Duration of pregnancy in lunar months

Calculation of the date of delivery

5. Engagement of the head

6. Fundal Level

At 36 weeks
At 32 weeks At 28 weeks At 24 weeks

Xiphysternum

Umbilicus

At 20 weeks At 16 weeks
At 12 weeks
Gestational age Symphysis pubis

Calculation of the date of delivery

7. Radiological examination (X-ray) 8. Ultrasonography 9. Amniocentesis 10. Shelfing The fundus of uterus falls forwards after the engagement of head 11. Lightening: In late pregnancy after engagement of head (in the last 3:4 weeks of pregnancy), there is relive of dyspnea and palpitations and the patient feels frequency of micturation, heaviness in the pelvis and difficulty in waking.

Fetal age by ultrasound

Bi-parital Diameter Femur Length

Difference between the 32ed and th 40 weeks

Symptoms:
1. Duration of amenorrhea 2. Date of quickening and lightening

Signs:
1. Size of the uterus 2. Engagement of the head 3. Ultrasonic examination and amniocentesis

Diagnosis of Onset of labor

A. Symptoms:
1. True labor pains 2. The show

B. Signs:
1. Dilatation of the internal Os 2. Formation of bag of forewater

Forces of labor A. Primary forces: Uterine contractions

During pregnancy there are painless intermittent uterine contractions, which are felt by palpating the uterus. These are known as Palmer's sign in early pregnancy and Braxton-Hicks contractions in late pregnancy

False labor pains

Sometimes there are intermittent uterine contractions during pregnancy causes some discomfort and abdominal pains for several days or weeks before the onset of true labor pains. These false labor pains are irregular and relived by enema (Braxton-Hicks contractions ).

True uterine contractions are:

1. Painful: may be due to: a. Hypoxia of the contracted myometrium b. Compression of nerve ganglia in the uterus by interlocking muscle bundles c. Stretching of the cervix during dilatation d. Stretching of the peritoneum 2. Regular 3. Colicky in nature 4. Felt in the lower abdomen

True uterine contractions are:

5. 6. Gradually increase in strength , frequency , and duration Effective: i.e. causes dilatation of the cervix Enchanted by enema Accompanied by hardening of the uterus Bag of forewater: becomes tense during contractions

7. 8. 9.

Differentiation of myometrial activity

During labor, the uterus becomes differentiated into 2 distinct parts: 1. Upper uterine segment: The actively contracting upper uterine muscle becomes thicker segment as labor advances 2. Lower uterine segment lower uterine segment and cervix: The lower portion of uterine muscle and cervix are relatively passive and thinner

Forces of labor
B. Secondary forces: Axillary forces
After full dilatation of the cervix, the chief force that expels the fetus is the increased intra-abdominal pressure created by contraction of the abdominal muscles and diaphragm (maternal bearing down efforts). The contractions of abdominal muscles also play an important role in the third stage of labor

The show
It is a blood stained mucous discharge noticed at the start of labor. The mucous is the cervical mucous plug which falls down when the cervix starts to dilate. The blood is due to separation of the membranes from the lower uterine segment or minute lacerations of the cervical mucosa Labor usually starts within 24 hours after the passage of show

Dilatation of internal Os
A closed internal Os means that labor has not started, however the external Os or even the internal Os may admit 1 finger before the onset of labor especially in multigravida

Formation of bag of forewater: Sure sign

The lower pole of fetal membranes separate from lower uterine segment to form a bag of water which bulges from cervix and become tense during uterine contractions

First Stage = Stage of cervical Dilatation

Stages of 1 Labor

Second Stage = Stage of Fetal Expulsion

Third Stage = Stage of Placental separation

Stages of labor
First stage:
(Stage of cervical dilatation)
Start: with onset of true labor pains End: with full dilatation of cervix Duration: in primigravida about 12 hours while in multigravida about 6:8 hours

Stages of labor
Second stage:
(Stage of fetal expulsion)
Starts: with full dilatation of cervix End: with delivery of the fetus Duration: in primigravida up to 1 hour , and in multigravida about 20 minutes

Stages of labor
Evidence of second stage:
1. 2. Full dilatation of the cervix (4 inches or 5 fingers or 10 cm). Bearing down during uterine contractions due to pressure of the presenting part on the rectum and pelvic floor causing reflex contractions of the axillary muscles

Stages of labor
Third stage:
(Stage of expulsion of afterbirth)
Start : with delivery of the fetus End: with expulsion of placenta, cord and membranes Duration : 10:30 minutes

A. Cervical dilatation
Causes:
1. Polarity of uterus i.e. while the upper uterine segment contract and retract, the lower uterine segment and cervix relax and dilate 2. The bag of forewater before rupture of membranes (Hydrostatic pressure) and the fetus after rupture of membranes acts as a central column pressing upon the LUS and the cervix 3. The changes in the cervix during pregnancy makes it more easily dilatable e.g. glandular hypertrophy, edema and increased vascularity

A. Cervical dilatation
Uterine contractions undergoes 2 phenomena: 1. Contraction: Temporary shortening and
complete relaxation of the muscle fibers 2. Retraction: Permanent shortening and incomplete relaxation of the muscle fibers

Effacement
The cervix is taken up i.e. the cervical canal becomes incorporated into the lower uterine segment

In primigravida:

Cervical Canal

Effacement occurs first followed by dilatation i.e. the cervix dilate from above downwards Internal Os

In multigravida:

External Os

Effacement and dilatation occurs at the same time

Freidman's graph of cervical dilatation

1. Latent phase: Variable in duration, sedation prolongs and oxytocin shortens 2. Acceleration phase: Starts at 2:3 cm dilatation 3. Phase of maximum slope: From 3:9 cm dilatation, takes in primigravida 1.2 cm/hour, and in multigravida 1.5 cm/hour 4. Deceleration phase: From 9:10 cm dilatation N.B: Shift of the graph to the left = accelerated labor. Shift of the graph to the right = dysfunctional labor

Freidman's graph of cervical dilatation

B. Expulsion of the fetus

The following movements occur to the head during delivery
1. 2. 3. 4. 5. 6. 7. Descend. Engagement Increased flexion Internal rotation Extension Restitution External rotation.

1. Descend
5. Extension 2. Engagement

3. Increase Flexion
4. Internal Rotation

Fetal Head Delivery

6. Restitution

7. External Rotation

1. Descend
It is a constant movement during labor caused by:
1. Uterine contractions retractions
2. Axillary forces of labor 3. Unfolding of the fetus caused by contractions of the circular muscle fibers of uterus

and

2. Engagement
The bi-parital diameter of the fetal head had passed through the pelvic brim

3. Increased flexion
As the head descends it meets resistance from the pelvic floor and the lateral pelvic walls causing increase flexion

Causes: 2 armed lever theory;

The head acts as a lever with a fulcrum at the atlanto-occipital joint. The short arm extends from the occiput to the joint while the long arm extends from the joint to the sinciput.

3. Increased flexion
Atlanto-occipital joint

Occiput

Sinciput

3. Increased flexion
When the head meets resistance during its descend the force applied to the long arm is greater than the short arm. This leads to descends of the occiput and ascend of the sinciput i.e. increased flexion.
Flexed Head

3. Increased flexion
Advantages:
1. It brings the shortest longitudinal diameter of the head (Suboccipito-bregamtic = 9.5 cm) to pass through the birth canal 2. It brings the occiput to be the most dependent part, so facilitate internal rotation

4. Internal rotation
After flexion has been completed, the occiput becomes the most dependent part
In occipito-anteior position the occiput rotates forwards 1/8 of a circle In occipito-posterior position the occiput rotates forwards 3/8 of a circle The occiput now hinges behind the symphysis pubis

Internal rotation in Occipito-anterior

1/8 of a circle 1/8 1/8

Internal rotation in Occipito-posterior

3/8 of a circle 1/8 1/8

1/8

4. Internal rotation
Causes:
1. The slope of pelvic floor (main factor): 2 levator ani muscles forms the pelvic floor, one on each side. The 2 levator ani are directed downwards, forwards, and medially, when the occiput meets the pelvic floor it moves in the same direction i.e. internal rotation 2. The shape of pelvis: The pelvic inlet is a transverse oval while the pelvic outlet is a longitudinal oval, this will acts as a screw action

1. The slope of pelvic floor

levator ani muscles are directed downwards, forwards, and medially

1. The shape of the pelvis

The pelvic inlet is a transverse oval

The pelvic outlet is a longitudin al oval

5. Extension
The head continue to descend until the suboccipital region appears below the symphysis pubis and the head is delivered by extension Causes: The head is under the influence of 2 forces: 1. Downwards and forwards by the uterine contractions 2. Upwards and forwards by the pelvic floor The upward and downward forces now are neutralized. The head will travel now by the forward movements i.e. Extension

6. Restitution
After delivery of the head, the occiput rotates 1/8 of a circle in the opposite direction to that of internal rotation to correct the twist of the neck

7. External rotation
The occiput undergoes another rotation 1/8 of a circle in the same direction to that of the restitution. It is due to internal rotation of the anterior shoulder 1/8 of a circle which is transmitted to the delivered head. So the final feature is that the occiput is directed to one thigh and the face towards the opposite thigh

Delivery of the shoulder

The bi-acromial diameter (12 cm) descends in the opposite oblique diameter of the pelvis to that of the head.

The anterior shoulder meets the pelvic floor first and rotates forwards 1/8 of a circle, with further descend, the anterior shoulder hinge below the symphysis pubis.

Delivery of the shoulders & body

The posterior shoulder is delivered first by lateral flexion of the fetal spines then the anterior shoulder. Finally the trunk is delivered by lateral flexion of the fetal spines around the symphysis pubis

C. Mechanism of the third stage

After delivery of the fetus, the uterine contractions and retractions continue in the same frequency as that of the second stage.

However they are painless (Low amplitude), so the placental area diminishes from 20 cm to 7 cm, the placenta is inelastic and unable to shrink, so it starts to separate.
Expulsion of the placenta and membranes is helped by bearing down efforts of the mother

C. Mechanism of the third stage

1. Schultze mechanism: (80 % of cases)
The central part of the placenta separates first because the placenta is firmly adherent at its edge. Retroplacental hematoma forms and the placenta is delivered by its fetal surface. This mechanism is less liable for bleeding or retained fragments

C. Mechanism of the third stage

2.Duncan mechanism:
The placenta separates from its lower edge and delivered sideways it is more liable for bleeding or missed fragments

Functions of retraction
1. Dilatation of the cervix

2. Expulsion of the fetus

3. Separation of placenta 4. Control of postpartum bleeding 5. Involution of the uterus during puerperium

Management of the first stage

1. Asepsis:
Although the danger of infection has been minimized by the use of antibiotics, it is very important to take all antiseptic measures

2. Examination of the patient:

General, abdominal and vaginal examinations are carried out Urine sample is taken for sugar and albumin

3. The vulva:
It is shaved and washed with antiseptic solution

Management of the first stage

4. The urinary bladder:
Kept empty by frequent micturation or passing a catheter at strict antiseptic measures

5. The rectum:
Evacuated by low enema (warm water), to avoid inertia and soiling of the perineum by feces during delivery

Management of the first stage

6. Patient position:
The patient is allowed to walk if the head is engaged. The weight of the head and bag of fore-water helps mechanical dilatation of the cervix, also pressure on the LUS and the cervix reflexly stimulate uterine contractions "Reflex polarity". Rest in bed is recommended when membranes are ruptured or the head not engaged

Management of the first stage

7. Diet:
Nothing is given by mouth except sugary fluid to avoid vomiting. I.V glucose is given in prolonged labor

8. Sedative and analgesics:

To avoid exhaustion from pains e.g. pethedine 50 mg IM

Management of the first stage

9. Observations:
a. Maternal observations Pulse, temperature, blood pressure every hour Uterine contractions: Frequency and duration from 1/2 - 1 hour Time of rupture of membranes Degrees of cervical dilatation b. Fetal observations: Fetal heart sound: every 30 minutes Degrees of head engagement

Second stage of labor

It is the time of greatest physical strain for the mother and the fetus Longest journey in the world 6 cm from ischeal spines to the perineum.

Phases of the second stage:

Descend phase: During descend the head rotates, the vagina becomes dilated, and the mother develops an urge to push Outlet phase : Head on the thin pelvic floor and becomes visible, crowning occurs

Features of the second stage

2 features distinguish first from second stage a. Uterine contractions:
At the end of first stage, contractions occurs 4 times every 10 minutes, with amplitude of 70:85 mmHg, lasting 45:50 sec During the urge to push (which physiologically separates the first from second stage of labor) a peak pressure of 160 mmHg occurs

Features of the second stage

b. Increased head compression:
Fetal response to second stage: 1. Normal base line F.H.R and variability 2. Early deceleration 3. Delivery of the baby

Techniques of second stage

A. Delivery positions
Dorsal lithotomy: provides: Maximum perineal exposure The patient is in emergency position e.g. shoulder dystocia

B. Organized pushing:

Dorsal lithotomy

Bearing down efforts should be restricted to 5 seconds with 4:5 pushes/contraction, without closing glottis and with 1:2 breaths of oxygen

Delivery of the head

When the head appears at the vulva, the perineum is supported during contractions by a sterile pad to keep the head flexed till crowning. After crowning the head is delivered by sliding the perineum over the face inbetween contractions not at the summit of contractions.

Delivery of the head

Episiotomy is performed when the perineum is threatened to rupture After delivery of the head, the mouth and nose are cleaned with sterile piece of gauze to remove mucous The neck is inspected if the cord is coiled around, try to slip it , if failed the cord is divided between 2 clamps

Second stage of labor

D. Delivery of the shoulders

The head is grasped between 2 hands (After external rotation has been completed), traction is applied downwards and backwards till the anterior shoulder appears below the symphysis pubis. Then the head is elevated upwards to deliver the posterior shoulder. The trunk is delivered by gentile traction

D. Delivery of the shoulders

E. The umbilical cord

The cord is massaged towards the fetus several times this brings 60:90 cc blood from placenta.
When pulsation ceases the cord is divided between 2 clamps

E. The umbilical cord

Crowing
Definition:
The bi-parital diameter of the fetal head had just passed outside the vulval ring and not recedes back. So the sub-occipital region now hinges below the symphysis pubis

Value:
If the head is allowed to be delivered before crowning extension occurs and head passes by the occipito-frontal diameter (11.5 cm) which causes perineal tear, so the head must be supported till crowning to allow delivery by suboccipito-bregmatic diameter

Crowing
sub-occipital region now hinges below the symphysis pubis

Head

C. Management of the third stage

Signs of placental separation:
The hand is placed over the fundus to detect signs of placental separation and descend 1. The body of uterus becomes smaller, harder and more globular (the earliest sign) 2. The fundus rise up because the LUS now distended by the placenta 3. A supra-pubic bulge due to presence of placenta in LUS 4. Elongation of the cord outside the vulva 5. Sudden gush of blood from the vagina

C. Management of the third stage

When the placenta appears at the vulva it is rolled between 2 fingers to make a rope of membranes, then the placenta and membranes are examined If fragment is missing the uterus is explored under general anesthesia

The genital tract is explored if any lacerations are detected it should be sutured immediately or within 24 hours otherwise it is considered as septic or potentially septic wounds

C. Management of the third stage

C. Management of the third stage

Repair of episiotomy and any perineal lacerations immediately after placental delivery

C. Management of the third stage

The patient should be observed for at least 1 hour after delivery (4th stage of labor) to detect postpartum hemorrhage

Methods of placental delivery

a. The conservative methods:
After delivery of the fetus, the left hand is placed over the fundus to detect signs of placental separation and descend. When these signs appear the uterus is massaged to contract and the patient is asked to bear down to deliver the placenta. This can be helped by gentle traction on the cord and 0.5 mg ergometrin given I.V or I.M given after placental delivery to diminish bleeding

Methods of placental delivery

b. The active method:
With delivery of the fetus, ergometrin 0.5 mg is given IV or IM or Syntometrin vial I.M. The placenta is then delivered by BrandtAndrews or Crede's methods (see retained placenta). The advantages of active methods are to avoid postpartum hemorrhage but ergometrin may cause contraction ring and retained placenta.