CHAPTER II

LITERATURE REVIEW

2.1

Normal Labor
Labor is a physiologic process during which the products of conception (the

fetus, membranes, umbilical cord, and placenta) are expelled outside of the uterus.
Delivery is the mode of expulsion of the fetus and placenta. Labor and delivery is
a

normal

physiologic

process

that

most

women

experience

without

complications.5,6
2.1.1 Stages of Labor
Normal labor is a continuous process that has been divided into three stages
for purposes of study, with the first stage further subdivided into two phases, the
latent phase and the active phase. The first stage of labor is the interval between
the onset of labor and full cervical dilatation. The second stage is the interval
between full cervical dilatation and delivery of the infant. The third stage of labor
is the period between the delivery of the infant and the delivery of the placenta. 5,6
The first stage begins with regular uterine contractions and ends with
complete cervical dilatation at 10 cm. In Friedmans landmark studies of 500
nulliparas, he subdivided the first stage into an early latent phase and an ensuing
active phase. The latent phase begins with mild, irregular uterine contractions that
soften and shorten the cervix. The contractions become progressively more
rhythmic and stronger. This is followed by the active phase of labor, which usually
begins at about 3-4 cm of cervical dilation and is characterized by rapid cervical

dilation and descent of the presenting fetal part. The first stage of labor ends with
complete cervical dilation at 10 cm. Characteristics of the average cervical
dilatation curve is known as the Friedman labor curve. 5,6
The second stage begins with complete cervical dilatation and ends with the
delivery of the fetus. The American College of Obstetricians and Gynecologists
(ACOG) has suggested that a prolonged second stage of labor should be
considered when the second stage of labor exceeds 3 hours if regional anesthesia
is administered or 2 hours in the absence of regional anesthesia for nulliparas. In
multiparous women, such a diagnosis can be made if the second stage of labor
exceeds 2 hours with regional anesthesia or 1 hour without it. 5,6
The third stage of labor is defined by the time period between the delivery
of the fetus and the delivery of the placenta and fetal membranes. During this
period, uterine contraction decreases basal blood flow, which results in thickening
and reduction in the surface area of the myometrium underlying the placenta with
subsequent detachment of the placenta. Although delivery of the placenta often
requires less than 10 minutes, the duration of the third stage of labor may last as
long as 30 minutes. The third stage of labor is considered prolonged after 30
minutes, and active intervention, such as manual extraction of the placenta, is
commonly considered. 5,6
2.1.2 Mechanism of Labor
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. Although

labor and delivery occurs in a continuous fashion, the cardinal movements are
described as 7 discrete sequences:
1. 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.
2. 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.
3. 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.

4. Internal Rotation: As the head descends, the presenting part, usually in the
transverse position, is rotated about 45 to anteroposterior (AP) position under
the symphysis. Internal rotation brings the AP diameter of the head in line with
the AP diameter of the pelvic outlet.
5. Extension: With further descent and full flexion of the head, the base of the
occiput comes in contact with the inferior margin of the pubic symphysis.
Upward resistance from the pelvic floor and the downward forces from the

uterine contractions cause the occiput to extend and rotate around the
symphysis. This is followed by the delivery of the fetus' head.
6. 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.
7. 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. 5,6

2.2

Caesarean section
Cesarean birth is the delivery of a baby through incisions made in the

mothers abdomen and uterus. An incision is made through the skin and the wall
of the abdomen. The skin incision may be transverse (horizontal or "bikini") or
vertical, near the pubic hairline. The muscles in abdomen wall are separated and
may not need to be cut. Another incision will be made in the wall of the uterus.
The incision in the wall of the uterus also will be either transverse or vertical. The
baby will be delivered through the incisions, the umbilical cord will be cut, and
then the placenta will be removed. The uterus will be closed with stitches that will
dissolve in the body. Stitches or staples are used to close your abdominal skin.7,8
2.2.1 Risk and Benefit
Childbirth by its very nature carries potential risks for the woman and her
baby, regardless of the route of delivery. The National Institutes of Health has

commissioned evidence-based reports over recent years to examine the risks and
benefits of cesarean and vaginal delivery as shown in Table 1. For certain clinical
conditions, such as placenta previa or uterine rupture, cesarean delivery is firmly
established as the safest route of delivery. However, for most pregnancies, which
are low-risk, cesarean delivery appears to pose greater risk of maternal morbidity
and mortality than vaginal delivery.7,8,9

Table 1 Risk of Adverse Maternal and Neonatal Outcomes by Mode of Delivery

Risk
Outcome
Vaginal Delivery
Caesarean Delivery
Maternal
Overall
severe
8.6% / 0.9%
9.2% / 2.7%
morbidity and mortality
Maternal mortality
3.6:100,000
13.3:100,000
Amniotic
fluid
3.37.7:100,000
15.8:100,000
embolism
Third-degree or fourth1.03.0%
NA (scheduled delivery)
degree
perineal
laceration
Placental abnormalities
Increased with prior cesarean delivery versus vaginal
delivery, and risk continues to increase with each
subsequent cesarean delivery.
Urinary incontinence
No difference between cesarean delivery and vaginal
delivery at 2 years.
Postpartum depression
No difference between cesarean delivery and vaginal
delivery.
Neonatal
Laceration
NA
1.02.0%
Respiratory morbidity
< 1.0%
1.04.0% (without
labor)
Shoulder dystocia
1.02.0%
0%

2.2.2 Indication

The following situations are some of the reasons why a cesarean birth is
performed:
1. Multiple pregnancyIf a woman is pregnant with twins, a cesarean birth
may be necessary if the babies are being born too early, are not in good
positions in the uterus, or if there are other problems. The likelihood of
having a cesarean birth increases with the number of babies a woman is
carrying.
2. Failure of labor to progressContractions may not open the cervix enough
for the baby to move into the vagina.
3. Concern for the babyFor instance, the umbilical cord may become
pinched or compressed or fetal monitoring may detect an abnormal heart
rate.
4. Problems with the placenta, such as placenta abruption or placenta previa
5. Malpresentation, such as transverse lie/arrest, Breech (if vaginal criteria not
met), Brow, or face mentum posterior
6. A large baby (macrosomia)
7. Maternal infections, such as human immunodeficiency virus or herpes
8. Maternal medical conditions, such as repeat caesarean delivery, diabetes or
high blood pressure7,8
2.2.3 Complication
Most common complications occur in a small number of women and usually
are easily treated:
1. Infection
Endometriosis 35-40 % if not given intraoperative prophylactic

antibiotics (usually Ampicillin or Cefazolin)

Wound infection usually appear within 24-48 hours or 4-7 days
postpartum. Wound may need to be reopened and heal by secondary
intention while patient on antibiotics (refer to OB/GYN)

2. Hemorrhage
2-3 % require blood transfusion due to uterine atony, accreta, uterine
injury, disruption of uterine arteries
3. Injury to pelvic organs
Most common bladder damage occurs rarely when surgery complicated
by adhesions or emergency surgery being done quickly
4. Thromboembolic disease
Deep Venous Thrombosis (DVT) and Pulmonary Embolus (PE),
prevent by using enoxaparin and early mobilization
Long term risks include abnormal placental implantation in subsequent
pregnancies and increased risk of uterine rupture if delivers vaginally next time.7,8