LABOR, DELIVERY, POSTPARTUM
As effacement begins, the
--continuation
Ancillary Forces in Labor
After the cervix is dilated fully:
 Maternal Intraabdominal Pressure
• the most important force in fetal
expulsion
Pushing
• Contraction of the abdominal muscles
simultaneously with forced respiratory
efforts with the glottis closed
• Necessary to complete 2nd-stage of
labor
• Accomplishes little in the 1st stage
Cervical Changes
• Contraction Forces leads to effacement
and Dilatation
• Effacement - “obliteration” or “taking
up” of the cervix.
-shortening /thinning of the cervical
canal
• Dilatation - Full Dilatation: 10 cm
Schematic showing effacement and dilatation.
A. Before labor, the primigravid cervix is long
and undilated in contrast to that of the
multipara, which has dilatation of the internal
and external os. B.
multiparous cervix shows dilatation and
funneling of the internal os. This is less apparent
in the primigravid cervix. C. As complete
effacement is achieved in the primigravid cervix,
dilation is minimal. The reverse is true in the
multipara
EFFACEMENT - sometimes is accomplished
before active labor begins
- causes expulsion of the mucous plug as the
cervical canal is shortened
STAGES OF LABOR
• First Stage- Cervical Stage
• Second Stage - From Full Cervical
dilatation to fetal expulsion
• Third Stage - From Fetal Expulsion to
Placental Delivery
• Fourth Stage – Early postpartum period
Latent Phase
• Duration is more variable and sensitive
to changes by extraneous factors
• has little bearing on the subsequent
course of labor
• Sedation PROLONGS the Latent
• Myometrial stimulation shortens it
Active Phase
• the accelerated phase are - predictive
of labor outcome.

Second Stage of Labor: Fetal Descent

• In many nulliparas, engagement of the

head is accomplished before labor
begins
• Station- descent of the fetal biparietal
diameter in relation to a line drawn
between maternal ischial spines
• In nulliparas: ↑ rate of descent are
observed during cervical dilatation
phase of maximum slope.
Placental Separation:
• further contraction of the myometrium
• partly by traction that is exerted by the
separated placenta.
Schultze mechanism
• blood from the placental site pours into
the membrane sac and does not escape
externally until after extrusion of the
placenta
Duncan mechanism
• placenta separates first at the periphery
• blood collects between the membranes
and the uterine wall and escapes from
the vagina
• the placenta descends sideways, and its
maternal surface appears first.

Fetal Membrane Separation and Placental

Extrusion
Phase 4 of Parturition: The Puerperium
 Persistent rigid myometrial contraction
and retraction
 Control of hemorrhage
 Remodeling processes
 Lactogenesis
 Reinstitution of ovulation
• Persistent rigid myometrial
contraction and retraction
 directly compresses large uterine
vessels and allows thrombosis of their
lumens to prevent hemorrhage
 typically augmented by uterotonics
• Remodeling processes
 Includes: Uterine involution and cervical
repair
 restore organs to the nonpregnant state
 protect the reproductive tract from
invasion by commensal microorganisms
 restore endometrial responsiveness to
normal hormonal cyclicity
• Lactogenesis
 Milk production – Prolactin, ↓Estrogen
 Milk Let-down – Oxytocin
• Reinstitution of ovulation
 signals preparation for the next
pregnancy.
 Occurs within 4 to 6 weeks after birth
 Dependent on:
 duration of breast feeding and
lactation-induced, prolactin-mediated
anovulation and amenorrhea
OXYTOCIN
• central role in spontaneous human
labor
• Activation of myometrial oxytocin
receptors ↑phospholipase C activity
 ↑cytosolic calcium levels  ↑
uterine contractility
Primary regulators of oxytocin receptor
expression
 Progesterone and estradiol
ESTROGEN:
increases myometrial oxytocin receptor
concentrations
PROGESTERONE:
Increase oxytocin-receptor degradation
inhibit oxytocin activation of its receptor at the
cell surface
PHARMACOLOGY: OXYTOCIN
 peptide hormone secreted by the
posterior pituitary
• stimulates muscular contractions in the
uterus and myoepithelial contractions
in the breast
• involved in parturition and the letdown
of milk
• At 2nd half of pregnancy: ↑expression
of oxytocin receptors  ↑ sensitivity to
endogenous oxytocin
Pharmacokinetics
Routes:
• IV: for initiation and augmentation of
labor
• IM: for control of postpartum bleeding
Metabolism and Elimination:
• not bound to plasma proteins
• rapidly eliminated by the kidneys and
liver
Half life: 5 minutes
Mechanism of action
• acts through G protein–coupled
receptors and the phosphoinositide-
calcium second-messenger system to
contract uterine smooth muscle.
• also stimulates the release of
prostaglandins and leukotrienes 
augment uterine contraction
• contraction of myoepithelial cells
surrounding mammary alveoli  milk
letdown
• At HIGH CONCENTRATION: weak
antidiuretic and pressor activity
Indications: CONTRAINDICATIONS
• used to induce labor for conditions  fetal distress
requiring expedited vaginal delivery  fetal malpresentation
such as:  placental abruption,
 uncontrolled maternal diabetes  other predispositions for
 worsening preeclampsia uterine rupture, (previous extensive uterine
 intrauterine infection surgery
 ruptured membranes after 34
gestational weeks
• used to augment protracted labor
• used in the immediate postpartum
period to stop vaginal bleeding due to
uterine atony

Before Delivery:
• administered IV via an infusion pump
with appropriate fetal and maternal
monitoring.
• For INDUCTION OF LABOR
 Initial infusion rate: 0.5–2 mU/min
 Increased every 30-60 minutes until a
physiologic contraction pattern is
established
• maximum infusion rate: 20 mU/min

For Postpartum uterine bleeding

 10–40 units are added to 1 L of 5%
dextrose
o infusion rate is titrated to control
uterine atony
Alternative:
 IM: 10 U

TOXICITY:
• due either to:
 excessive stimulation of uterine
contractions
o fetal distress, placental abruption, or
uterine rupture
 inadvertent activation of vasopressin
receptors.
o excessive fluid retention, or water
intoxication
o hyponatremia, heart failure, seizures,
and death.
 Bolus injection of Oxytocin:
HYPOTENSION