LABOUR

PRESENTED

BY
MR. ANTHONY NSAMA
 What is labour?

• This is the process by which the foetus,

placenta and its membranes(products of
conception) are expelled through the birth
canal after 28th week of gestation.
 What is Normal Labour?

• It is a process by which the foetus is born

spontaneously at term, with vertex
presentation, within 18 hours from the onset
of labour, with no complications to either the
mother or the baby.
 What causes labour?

• The cause of labour is not known or fully

understood, but a combination of factors
which are hormonal and mechanical are said
to be the cause of onset of labour.
 Hormonal factors
• Progesterone- during pregnancy progesterone is
available to sedate the uterus to term. This is initially
secreted by the corpus luteum, later on by the placenta.
Towards term the placenta begins to age causing a
reduction in progesterone production failing to maintain
the uterus sedated and contractions will start.
• Oestrogen –will provoke the placenta to release
protaglandine which in turn releases proteolytic and
cyclooxygenase enzymes to digest cervical collagen to
soften the cervix.
 Hormonal factors cont’
Probable modes of action of oestrogen :
* Increase release of oxytocin from maternal
pituitary
* Promotes the synthesis of receptors for oxytocin in
the myometrium and decidua

* Stimulates the synthesis of myometrial contractile

protein –actomyosin through activation of adenosin
triphosphate
* Increase the excitability of the myometrial cell
membranes
 Hormonal factors cont’
• Prostaglandins- these are released due to the
sharp rise in oestrogen and will inhibit the
effect of progesterone and initiate uterine
contraction.

• Foetal cortisol theory:-Increased cortisol

production from the foetal adrenal gland before
labour may influence its onset by increasing
oestrogen production from the placenta
 Mechanical factors
• Uterine distension- common in multiple
pregnancy and polyhydramnios
 Premonitory signs of Labour
These signs occurs 3 weeks before labour starts and includes the
following;

1. Lightening- this is the sinking of the uterus 2-3 weeks before term.
The fundus nolonger clouds the lungs and breathing is easier. This is
due to:
* softening of the pelvic ligament.
* widening of the symphysis pubis.
• Shelfing:
It is falling forwards of the uterine fundus making the upper abdomen
looks like a shelf during standing position. This is due to engagement
of the head which brings the foetus perpendicular to the pelvic inlet in
the direction of pelvic axis.
 
 Premonitory signs cont’
2. Frequence of micturition
• mild incontinence of urine occurs due to weakened
bladder control as a result of relaxed pelvic floor muscles.
• Pressure of the fetal head on the bladder limits its
capacity requiring it to be empty at all times.
• Pelvic pressure symptoms:
With engagement of the presenting part the following
symptoms may occur:
Frequency of micturition, rectal tenesmus and difficulty in
walking.
 Premonitory signs cont’
3. False pain
- the brackstone hit contraction are more
intense but iratic, irregular and not
accompanied by cervical dilatation.
4. Taking up of the cervix
- it is drown up and imerges into the lower
uterine segment.
 Signs of true Labour

1. Presence of show – this is due to the plugging

off the operculum and it will be blood stained
2. Dilatation of the cervix-
3. Painful rhythmic uterine contractions

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4. Effacement and presence of descent of the
presenting part as the other two.
THE DIFFERENCE BETWEEN FALSE AND TRUE LABOUR PAINS

True Labour Pain False Labour Pain

Regular. Irregular.
Increase progressively in frequency, Do not.
duration and intensity.

Pain is felt in the abdomen and radiating Pain is felt mainly in the
to the back. abdomen.
Progressive dilatation and effacement of No effect on the cervix.
the cervix.
Membranes are bulging during No bulging of the membranes.
contractions.
Not relieved by antispasmodics or Can be relieved by
sedatives. antispasmodics and sedatives.
 STAGES OF LABOUR
• FIRST STAGE
- from the onset of rhythmic painful uterine
contraction to full dilatation the cervix.
- there are two phases
a. Latent phase – 0-3cm dilatation
b. Active phase – 4-full dilatation of the cervix
*It is the longest stage of labour which lasts about
11-14hrs in P/gravida and 6-9hrs in M/gravida.
 STAGES OF LABOUR cont’

• SECOND STAGE( the descent/perineal phase)

Starts from the full dilatation of the cervix to the
delivery of the baby.
- lasts about 30-45min not exceeding 1hr in
P/gravida and 15-30min not exceeding 30min
in M/gravida
 STAGES OF LABOUR cont’
• THIRD STAGE
Involves separation, descent of the placenta and
control of bleeding.
Starts from the complete birth of the baby to the
complete expulsion of the placenta and its
membranes.
Duration depends on the type of mgt.
- passive mgt lasts about 10-15min in both and
active mgt( use of oxytocin) lasts 5min in both
 PHYSIOLOGY OF FIRST STAGE OF
LABOUR
• Fundal dominance- contractions starts from the
fundus near one of the cornua and spreads
across down but lasts longer in the fundus.
The pic is reached simultaneously in the all
uterus and contractions fades from all parts
together. This allows the contracting uterus to
expel the fetus.
• Polarity- this is nuero-muscular Harmon that
occurs btn the two segments of the uterus.
The upper segment contracts and retracts
while the lower segment contracts slightly and
dilates slowly to allow the expulsion the fetus.
• Contraction and retraction- when the uterine
muscle contract does not go to its original size
instead retain some of the shortening of the
contraction(retraction). This helps in the
pushing of the fetus out.
• Formation of lower and upper uterine
segment- towards term the uterus is divided
into two segments. The upper segment
Contracts and retracts and becomes thicker in
muscular, while the lower segment Contracts
and relaxes allowing it to dilate and stretch.
The few longitudinal fibre from upper
segment causes the lower segment to be
pulled up and dilate.
• Formation of retraction ring- is the
physiological ridge which develops as the
result of retraction from the upper uterine
segment producing progressive thickening
from the walls of the upper segment at the
same time progressive thinning of the walls in
the lower segment accommodating the
descending fetus. If the ring becomes vssible it
is called bandils ring indicating an obstructed
labour(pending uterine rapture)
• Cervical effecement – this may occur latter in
preg. Or until labour begins. As muscle fibres
surrounding the internal os are drawn upward
by the retracting upper uterine segment, the
internal os dilates and the cervix is pulled up
becoming incoperated into the lower
segment. The cervical canal widens at the
level of the internal os. The external os which
is now called os uteri is dilated by the
continue retraction exerted by the upper
segment.
• Dilatation – the process of enlargement of the
external os from the tightly closed aperture to
opening large enough for the passage of the fetus.
This is assessed on V/E and measured from 0-10cm
as fully dilatation.
• Show- as the effecement and dilatation is taking
place, the opeculum which formed the plug during
pregnancy is displaced or lost from the cervical canal
and is shade through the vagina as show. The woman
see a few mucoid blood stained discharge a few
hours after the onset of labour. The blood come from
the raptured capillaries of the decidua vila where the
chorion had detached.
• Formation of fore water- as the lower uterine
segment forms, the chorion becomes detached and
the increased pressure causes this loosened part of
the membrane containing a small quantity of
amniotic fluid to bulge down towards into the internal
os. The well flexed fetal head fits well into the cervix
and cuts off the fluid in front of the head from that
which surround the body. The one surrounding the
body is called Hind waters. Fore waters prevents the
pressure applied by the hind water during uterine
contraction from being applied to the fore water. This
helps to keep the membranes intact in the second
stage of labour.
• General fluid pressure- as long as the
membranes remains intact, the pressure of
the uterine contraction is exerted on the fluid
and because the fluid is not compressable, the
pressure is equalised through out the uterus
and over the fetal body which is refered to as
General fluid pressure. When membranes
raptures and the fluid goes out, the placenta
and the cord are compressed btn walls of the
uterus and the fetus during contractions
diminishing oxygen supply to the fetus.
• Fetal axis pressure- during each contraction
the uterus leans forward. The force of the
fundal contraction is transmitted to the upper
body of the fetus down the long axis of the
fetus and applied by the presenting part to the
cervix. It becomes more significant after the
rapture of membranes and during 2nd stage of
labour.
MANAGEMENT OF FIRST STAGE OF LABOUR

AIMS
• To confirm if the woman is in labour
• To reassure the woman and alley anxiety
• To detect any abnormality and take action
• To prepare the woman for labour
 Admission of a woman in labour ward
Requirements – prepare the trolley as follows:
Top shelf- a sterile pack with 2 gallipots, 2 artery forceps, cord scissors, episiotomy scissors, 5 cotton wool
swabs and a pad
• Bottom shelf – clean sheets, macintosh with
draw sheet, receiver for used swab,
observation tray, savlon 1:200 for swabbing,
foetal stethoscope, multistick reagents, clean
gloves, sterile gloves, identity band, galliopot
with cotton wool, obstetric cream
procedure
• Greet the woman, introduce yourself in a friendly
and reassuring manner to alley anxiety and to give
her confidence.
• Quickly assess the G/Condition by observing her
behaviour and appearance.
• Ask her how she is feeling. Ask if she has a support
person.
• Review the antenatal card noting the past obstetric
history, medical history, anything unusual about
the present pregnancy and relevant personal data.
• Obtain details concerning the present labour:
- time and onset of labour regular uterine
contraction.
- history of any show
- any vaginal bleeding
- does she have any danger sign; severe
headache, blurred vision, dizziness, fever.
- if membranes have ruptured and if so at what
time?
- colour of liquor.
• Check for vital signs and record.
• Obtain a clean urine specimen and do
urinalysis (note- albumin, sugar or acetone)
measure the amount and record.
• Ask her to lie on the couch, remove her pants
and adopt the supine position. Cover her with
a bed sheet.
• Carry out a head to toe examination taking
particular note of abnormalities like anaemia,
oedema, varicose veins, lymphadenopathy and
any vaginal discharge or vulval sores.
Abdominal examination
Inspection
• Size in in relation to gestational age
• Shape and contour of the abdomen
• Scar or ski changes
• Uterine contraction, type, frequency and
duration
• Foetal movements and activity
Palpation
• Estimate the height of fundus
• Fundal palpation
• Lateral palpation
• Pelvic palpation( assess the descent of the PP)
Auscultation – check for the foetal heart sounds
which should be between 120-160 beats/min
regular.
Vaginal examination
Objectives
- to confirm and make a diagnosis of labour
- to form the baseline data for subsequent examination
- To detect any abnormalities and to make appropriate
interventions.
Indications
• If a woman comes in labour
• If membranes ruptures
• To assess the progress of labour
 Observations
• You must be alert in labour and do all observations as this will help
you detect complications early and as a base line data.

Monitoring the progress of labour

• All findings in the active phase of labour must be recorded on a
partograph, a tool used by midwives to monitor the progress of
labour
• Foetal wellbeing – foetal heart rate to be assessed ½ hourly using
the foetal scope or Doppler, which should be within the normal
range between (120 – 160 beats per minute). State of liquor to
R/O foetal distress if it is meconium stained. Ask the woman if she
is having fetal movements. During VE assess for moulding to R/O
excessive moulding which may cause damage to the foetal head.
 Observations CONT’
• Progress of labour- this is done by assessing cervical
dilatation every after 4 hours (1 to 1.5cm /hour) descent of
the foetal head, and uterine contraction every 30 minutes
(strength) see if she is pressing well, from mild, moderate to
strong contraction.
• Maternal wellbeing-
• Findings of maternal wellbeing are entered at the bottom of
the partograph. Vital signs – pulse record every 30 min, BP
every 2-4hrs and temperature 4 hourly
• Urinalysis – do urinalysis every after 2hours to R/O
proteinurea, glucosurea and acetone. Measure the amount.
 
 Diet and fluid intake

• Give food rich in glucose as the woman has increased

need for energy during labour for the vigorous uterine
muscle contraction. Inadequate glucose level may lead
to uterine inertia and this may prolong labour.
• Encourage the her to take a lot nourishing drinks and
water to prevent dehydration which may exhaust her.
• Encourage her to eat easily digested foods rich in
carbohydrate such as biscuits, soup, light porridge and
cereals.
• Labour process may expose the woman and the foetus to
a lot of infection. So a midwife should make sure that
aseptic technique is used to prevent infection. When doing
a VE clean the vulva with savlon 1:200 and use sterile
gloves. Avoid unnecessary VEs as this may introduce
infection in the birth canal. Avoid artificial rupture of
membranes.
• Reduce traffic in and out of the ward
• Clean the delivery bed
• Personal hygiene.-encourage the woman to take a birth if
she can afford, mouth wash and wipe the arm pits for
refreshment.
 Bladder and bowel care
• Encourage the woman to empty the bladder every after 2
hours because a full bladder may prevent descent of the
presenting part from entering the pelvis also inhibit good
uterine contractions and may be nipped between the
foetal head and the pubic bone which may cause VVF. If
she cant pass urine you can insert a catheter.
• *clean her after opening the bowel, if possible she can
have bath. Tell her that an urge to pass to pass stool is an
indication of perineal phase of 2nd stage of labour. She
should not be allowed to use a toilet for fear of delivering
in the toilet
 Position and mobility

• Adoption of upright position during labour will

facilitate uterine contraction and shortens the
latent phase.
• Encourage movements to promote descent of
the presenting part.
 IEC in labour
• Nutrition in labour
• Positions used in labour
• Importance of movements in labour
• Importance of good personal hygiene in
labour
Mgt of 2 stage of labour
nd
Position - ROA
 Mgt of 2 stage of labour
nd

• The mgt is divided into two phases

a. The descent phase – its calculated calculated
from the time of full cervix, when the head is
still high in the pelvic canal to the time head
reaches the perinium.
b. The perineal phase – it constitute the actual
delivery or birth of the baby. At this time, only
one person should deliver the woman and be
able to give instructions.
 Emotion support

• Explain to woman that, its time to give birth,

in which she is expected to put more effort
when pushing and she should follow
instructions in order to shorten the duration
of 2nd stage of labour.

• Tell the woman that may increase, but soon

after the baby is out the pain will reduce.
 position
• Position the woman in the modified dorsal
position which will give full view of the vulva
be able to conduct the delivery easily
especially when alone.
• Other positions which can be used are:
- kneeling position
- squatting position
- lateral position
 Care during the actual delivery
• Make sure what ever you prepared in the first stage of
labour is readily available to avoid running up and down
during the procedure.
• Wash your hands and put on sterile gloves.
• When effacement is complete and the cervix is fully
dilated, the woman is told to bear down and strain with
each contraction to move the head through the pelvis
and progressively dilate the vaginal introitus so that
more and more of the head appears.
• Wait and watch for the presenting part progress during a
contraction.
• Rapture membranes if intact.
 Care cont’
• Place a pad gently over the anus to prevent
contamination and change it if soiled.
• Apply gentle pressure on the head to maintain flexion of
the head.
• After crowning hold the head (parietal eminences )
between the thumb and fingers and aid in the extension
of the head when the occiput escapes the sub pubic arch.
• Feel for cord around the neck when the head is delivered.
If present and tight clamp it in two places and cut. If
loose, slip it over the shoulder.
 Care cont’
• Clean the eyes from inside out, mouth, and nose
to remove the mucus.
• Facilitate the expulsion of the shoulders by holding
the head between the fingers of the 2 hands and
make a gentle down ward movement towards the
mothers perineum to deliver the anterior shoulder
and upward for the posterior shoulder.
• Deliver the baby unto the mothers abdomen.
Clamp the cord on two places and cut. Show the
mother for sex identification.
 Care cont’
• Wipe and dry the baby to prevent hypothermia,
weigh the baby and wrap the baby in warm linen

• Palpate the abdomen to R/O the second twin.

• Give oxytocin 0.5mg IM start, if not administered

at the birth of the anterior shoulder to help in
uterine contraction and control bleeding.
 Mgt of 3rd stage of labour
• This can be done in two ways
1. Passive mgt – allows nature to take its course. The
midwife waits patiently for the physiological process to
continue and intervention is only taken if haemorrhage
occurs. Wait for the signs of placental
separation( hoozing of blood, elongation of the cord,
increased fundal height).
- the baby is put to the breast if the mother is stable
because the sucking reflex triggers maternal pituitary
gland to release oxytocin which will aid in the
contraction of the uterus. This will help in the
separation of the placenta.
• Active mgt of 3rd stage of labour
-This is done now routinely in hospitals to prevent
haemorrhage after delivery.
-Give oxytocin 0.5mg IM start, if not administered at the birth
of the anterior shoulder to help in uterine contraction and
control bleeding.
-Deliver the placenta by controlled cord traction(CCT)
method.
-Inspect the birth canal for lacerations and the perineum for
tears, repair if present.
-Clean the mother, put a pad, change soiled linen, bring the
baby to the mother for breast feeding to promote bonding
and uterine contraction.
-Start vital ¼ hourly for 1hr, ½ hourly for 2hrs and hourly for
3hours.