Definition:

Is the process whereby the products of conception are

expelled from the uterine cavity after 24 weeks of gestation. It
is characterized by a regular, painful uterine contractions,
accompanied by cervical dilation and effacement.= labour is
the process by which the contents of the pregnant uterus are
expelled.

About 93 %—94% deliver at term between, 37—42 weeks.

About 7 %—8 % deliver is preterm, between 24—37
weeks.
Postterm is delivery after 42 weeks.
 Definition:
• Labor: is a series of continuous, progressive contractions of
the uterus which help the cervix to open (dilate) and to thin
(efface), allowing the fetus to move through the birth canal
and expel from the women’s body
• Labour Is the physiological process during which the
products of conception (i.e. the fetus, membranes, umbilical
cord and placenta) are expelled outside the uterus.
• It is a social, psychological and economical event for the
couple, family and community.
• Delivery means actual birth of the foetus.
• Childbirth includes both labor (the process of birth) and
delivery (the birth itself)
WHO definition of normal labor:

WHO define normal birth as: spontaneous in

onset, low-risk at the start of labour and
remaining so throughout labour and delivery.
The infant is born spontaneously in the vertex
position between 37 and 42 completed weeks of
pregnancy. After birth mother and infant are in
good condition.
 Learning objectives
The aims of this module are to review:
• The anatomy of the fetal skull (head)and maternal pelvis,
relevant to labour
• Changes in the uterus during pregnancy
• Define the onset of labour and understand The factors involved
in the onset of labour
• The initiation of human labour – molecular mechanisms
• Understand the normal delivery of the fetus and the mechanism
of normal labour and delivery
• Understand that the normal progress in labour is multifactorial
• Be familiar with the stages of labour
• Be familiar with the basic care offered to a woman in labour
 Health professionals must be aware that:
• Appointment Premature labor and delivery is a major
problem
• Obstructed labor can cause maternal and fetal problems
• Labor is a major contributor to maternal problems of
prolapse and incontinence in later life.
• There are risks of asphyxia, perinatal infection and trauma
to the fetus.
 Learning objectives
• Management of 1st, 2nd and 3rd stages of normal labour
– monitoring of maternal well being
– monitoring of fetal well-being
– monitoring progress of labor

• Assess failure to progress in labour

• Describe the benefits and side effects of pharmacological
methods of analgesic
The following criteria should be present
to call it normal labour:
– Spontaneous expulsion,
– of a single,
– mature foetus,
– presented by vertex,
– through the birth canal,
– within a reasonable time (not less than 3 hours or more than 18
hours),
– without complications to the mother, or the foetus.
– No intervention is required to augment progress or assist
delivery
– During the course of such normal labour the force generated by
UC and maternal pushing overcome resistance to the delivery of
the fetus through the birth canal.
 Diagnosis of labour
• Determine the true onset of labour which can be very
difficult, reflecting the fact that the onset phased over a
period of time rather than occur at a specific moment.

• The process preceding labour last weeks and are not

always clearly distinguishable from the acute event.

• Diagnosis of labour is normally defined as follow

• The onset of regular painful uterus contractions
associated with effacement and dilatation of the cervix.
 Onset of labor
. It is often difficult to be certain of the exact time the
onset of labor because contractions may be irregular
and may start and stop with no cervical change (false
labor).

N.B: Labor consists of regular, frequent, uterine

contractions which lead to progressive dilatation of
the cervix.
 Onset of labor
Definition
Onset of regular involuntary coordinated,
painful uterine contractions associated with
cervical effacement and dilatation
• Delivery is the expulsion of the product of the
conception after fetal viability.
 Onset of labor
Labour is diagnosed when there are regular
painful contractions in the presence of a fully
effaced cervix which is 4cm or more dilated, with
or without a show or ruptured membrane.
Others accept the diagnosis if regular painful
contraction are accompanied by spontaneous
rupture of the membranes in the absence of
cervical dilatation.
 Difficulties can arise as a result of reliance on a
definition such as:

The diagnosis of labor may not be obvious for several reasons:

1. Braxton-Hicks contractions are uterine contractions occurring
prior to the onset of labor. They are normal and can be
demonstrated with fetal monitoring techniques early in the
middle trimester of pregnancy. These innocent contractions
can be painful, regular, and frequent, although they usually
are not.

2. Not all women find the contractions painful (relatively rare):

While the uterine contractions of labor are usually painful,
they are sometimes only mildly painful, particularly in the
early stages of labor. Occasionally, they are painless.
3. Cervical dilatation alone does not confirm labor, since many
women will demonstrate some dilatation (1-3 cm) for weeks or
months prior to the onset of true labor.
Thus, in other than obvious circumstances, true labor will usually
be determined by observing the patient over time and
demonstrating progressive cervical changes, in the presence of
regular, frequent, painful uterine contractions. False labor is
everything else.

4. Effacement of the cervix prior to dilation is characteristic of

multiparous labour rather than nulliparous labour.

5. Some women complain of contractions in the absence of cervical

change. These women are normally experienced the latent phase
of the labour
The clinical signs of the onset of labour
are:

A. The show
B. Painful regular uterine contractions
or true labour pains
C. Cervical effacement and dilatation
D. Formation of bag of forewaters
E. Rupture of the membrane
 The clinical signs of the onset of labour are:
A. The Show: (bloody show):
 passage of a mucoid plug from the cervix, often blood-
stained.
– sign of the impending onset of active labor
– Extrusion of mucus plug of the cervical canal

 Discharge of small amount of blood-tinged mucus from

the cervix..

Nursing implication:
Assess for the colour of vaginal discharge
* Greenish- meconium stained
* Bright red- vaginal bleeding.
B. True labor pain or Painful regular uterine contractions
 Uterine contractions characteristic of labor.
Painful regular uterine contractions that increase in frequency
and duration accompanied by cervical dilation and effacement.

 Muscular contractions, those of the uterine smooth muscle of labor

are painful

 Cause of pain is not known definitely:

1. Hypoxia of contracted myometrium
2. Compression of nerve ganglia in cervix and lower uterus by the
tightly interlocking muscle bundle.
3. Stretching of the cervix during dilatation
4. Stretching of peritoneum overlaying the fundus
 C. Cervical dilatation and effacement

 Effective force of the 1st stage of labor is uterine

contractions.

 As the result of the action of these forces, two

fundamental changes take place in the already ripened
cervix
1. Effacement, and
2. Dilatation

 The cervix is said completely or fully dilated : 10 cm

Normal Labor Curve
 C. CERVICAL EFFACEMENT
 Obliteration or taking up of the cervix
 Shortening of the cervical canal (2cm→ mere
circular orifice with almost paper thin edge)
 Muscular fibres at about the level of the internal os
are pulled upward or “taken up” into the lower
uterine segment.
 D. FORMATION OF BAG OF FOREWATERS

• The process of cervical effacement and dilatation

causes the formation of the fore bag of amniotic
fluid which is the leading portion of amniotic sac
and fluid located in front of the presenting part.
• Rupture ofEthe. Rupture of can
fetal membrane thebe fetal
the onsetmembrane
of the labour, but this
is variable and may occur without contractions.
• It is called prelabour rupture if the interval between the rupture and
onset of the painful contraction is greater than 4 hours. This occurs
at term and in the preterm period (PPROM)

• Rupture of Membranes: (ROM):

• Labor in 24 hrs. Multiparas sooner.
• Big gush or slow trickle.
• Clear/odorless. Green/brown, danger sign
• Meconium aspiration > distress/infection.
• Immediate medical attention.

PROM or prolonged ROM – intrauterine infection [pathogens reach

fetus]
 Ruptured ROM or BOW
 Important nursing considerations:
A. Ruptured BOW: initial nursing action
- Put her immediately in bed and take FHT.
- Instruct the client not to ambulate--- fetal cord compression

B. Cord prolapse: initial nursing action

- Put her on Trendelenburg position to reduce pressure on the
cord.
- Remember only 5 minutes of umbilical cord compression can
already lead to CNS damage and even death.
- Apply a warm saline saturated OS on the cord to prevent drying
of the cord.
Prodromal (pre-labour) stage or Premonitory Signs of labor
The following clinical manifestations may occur in the last weeks of
pregnancy.
1.lightening: the descent of the fetus presenting part into the pelvic
2.Shelfing:
3.Sudden burst of energy: Nesting instinct; cleans house, sets up
nursery. ↑ epinephrine resulting from ↓ progesterone
4.Braxton-Hicks contraction : Irregular intermittent contractions;
“false labor”; DO NOT initiate true labor.
5.Slight decrease in maternal weight
6.Cervical ripening or softening of the cervix: Baby's head in pelvis
pushes against cervix causing relaxation and effacement
7.Cervix in posterior position.
 CLINICAL PICTURE OF LABOUR
1. Lightening:

his is the descent/ setting of the presenting part into the pelvic inlet which
happens in 10-14 days before labor in a nulliparas and 1 day before labor
in a multipara. And when the largest diameter of the presenting part passes
the pelvic inlet, the head is called to be engaged.

owever, lightening is heralded by the following signs:

elief of the dysapnea

elief of the abdominal tightness.

he relief of upper abdominal pressure symptoms as dyspnoea, dyspepsia

and palpitation due to:
•descent in the fundal level after engagement of the head and
•shelfing of the uterus.
 CLINICAL PICTURE OF LABOUR
1. Lightening: with engagement of the presenting part the
following symptoms may occur:
• Pelvic pressure symptoms
Increased frequency of voiding (Frequency of micturition)
 Increased lordosis as the fetus enters the pelvis and falls
further forward .
 Increased varicosities
 Shooting pain down the legs because of pressure on the sciatic
nerve.
 rectal tenesmus and
 difficulty in walking.
 Increased amount of vaginal discharge
 CLINICAL PICTURE OF LABOUR
2. 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 of labor
3. Braxton Hick’s Contraction : in the last week or days
before the labour. These are false labour contractions,
painless, irregular, abdominal and relived by walking,
and are also known as a practice contractions.
4. A sudden burst of maternal energy/activity: because of
hormone epinephrine. This is meant to prepare the body
for the “labor” ahead.
5. Slight decrease of maternal weight. Loss of weight is about
2-3lbs. One to two days before the onset of labor because
of the decrease in progesterone level and probably loss of
appetite.
6. Softening/ “ripening” of the cervix (Goodell’s
 False labour
 Contractions are irregular and don't progress
 Discomfort in abdomen only
 Walking has no effect
 No change in dilation or effacement of cervix
 Change of activity causes contractions to decrease
 True Labor
 Contractions are at regular intervals and frequent compared
to Braxton-Hicks.
 Intervals shorten as time progresses
 Duration and intensity increase
 Discomfort begins in the back and radiates around to the
abdomen
 Walking increases intensity of contractions
 Cervical dilation and effacement progress
 Change of activity doesn't cause contractions to decrease
 Bloody Show: pink tinged secretions d/t softening cervix.(aka
mucous plug)
 ROM
 Sedation does not decrease the pain
 TRUE LABOUR & FALES LABOUR
True labour False labour
• Regular contractions • Irregular contractions
• Interval between contractions
become shorter • Remain the same
• Contractions increase
i in
frequency, duration and intensity
• intensity of contractions ↑ with • Unchanged
ambulation
• progressive cervical • Ambulation has no effect
dilation/effacement
• unchanged
• No relive with sedation
• discomfort begins in back &
spreads to abdomen • Relive
• discomfort localized in
lower abdomen
 Comparison of true and false labour
True labour False labour
Contractions occur regular intervals 2—3minutes Irregular intervals, no
apart, intensity gradually increase , pattern, intensity remains
and can last for 1 minute steady.
Intervals between contractions Usually no change
gradually shortens

discomfort Discomfort begins in back and Discomfort is usually in

radiates around to abdomen Lower abdomen
Intensity usually increases with Walking has no effect on
walking or lessens contractions

Dilatation Cervical dilation and effacement are No change in cervix

progressive

Effect of
Membrane Contractions
Membranes areare not affected
bulging during Contractions
No aremembranes.
bulging of the relieved or
sedation contractions. stopped
 Duration of labour
• Accordingly , almost 80-90% of women will
delivered within 10—12hours of admission.

• Prolonged labour is traditionally defined as

lasting longer than 24 hours.
 Cause of Onset of Labour Introdu
ction
terus: pear-shaped muscle made of 3 layers:

Endometrium – inner lining - shed during menses.

Myometrium - muscle layer – middle

Perimetrium – outer layer -extra support to whole structure.

he cause of labor is not known but may include both maternal and fetal factors.

o some degree it is thought to be:

echanical, since preterm labour is more common in circumstances in which the

uterus is overstretched, such us multiple pregnancies and polyhydramnios.

nflammatory markers such us cytokines and prostaglandin might play a role.

Which is released in the decidua and membranes in the late pregnancy if the
cervix is digitally stretched at the term to separate the membrane (cervical
sweep).
 Cause of Onset of Labour

HEORIES of LABOR:

ombination of factors start labor:

ormonal : Oxytocin & prostaglandin - most important

biochemical factors in stimulating uterine contractions.
Estrogen ↑ uterus response & progesterone ↓ it .

echanical

heory of aging placenta

 Cause of Onset of Labour
the following theories were postulated:
1. Hormonal factors
 Oestrogen theory:
• During pregnancy, most of the oestrogens are present
in a binding form. During the last trimester, more free
oestrogen appears increasing the excitability of the
myometrium and prostaglandins synthesis.
• Estrogen Stimulation: ↓ progesterone allows estrogen
to ↑ contractile response of uterus.
 Cause of Onset of Labour
 Progesterone withdrawal or deprivation theory:
• Progesterone inhibit uterine motility. A decrease in
progesterone → uterine contraction.
• Before labour, there is a drop in progesterone synthesis
leading to predominance of the excitatory action of
oestrogens.
– Progesterone Withdrawal: ↓ progesterone by fetus & ↑
prostaglandins in chorioamnion results in ↑ uterine
contractions.
 Cause of Onset of Labour
 Prostaglandins theory:
– Increase prostaglandin synthesis → uterine contraction.
– Prostaglandins E2 and F2α are powerful stimulators of
uterine muscle activity. PGF2α was found to be
increased in maternal and foetal blood as well as the
amniotic fluid late in pregnancy and during labour.
 Cause of Onset of Labour
 Oxytocin theory:
• Production of the oxytocin from posterior pituitary
gland →contraction of the uterus.
• Although oxytocin is a powerful stimulator of uterine
contraction, its natural role in onset of labour is
doubtful. The secretion of oxytocinase enzyme from
the placenta is decreased near term due to placental
ischemia leading to predominance of oxytocin’s action.
• Oxytocin Stimulation: Term uterus sensitive to
oxytocin ↑ d/t pressure exerted on cervix by fetus.
 Cause of Onset of Labour
 Foetal cortisol theory:
• Increased cortisol production from the foetal adrenal
gland before labour may influence its onset by
increasing oestrogen production from the placenta.

– Fetal Cortisol: Changes biochemistry of fetal

membrane: ↓ progesterone & ↑ prostaglandin in
placenta.
 Cause of Onset of Labour
2. theory of aging placenta:

– Decrease in blood supply of the placenta →

contraction of the uterus.
 Cause of Onset of Labour
2. Mechanical factors
• Uterine distension theory:
–Like any hollow organ in the body, when the uterus is
distended to a certain limit, it starts to contract to evacuate its
contents. This explains the preterm labour in case of multiple
pregnancy and polyhydramnios. (this theory is supported by
the observation that multifetal pregnancy and pregnancies
associated with polyhydramnios are at much greater risk for
preterm labour than singletons)
–Distention: uterine muscles stretch causing ↑ prostaglandin.
–Amniotic membranes (sac) makes arachidonic Acid →
Prostaglandin - ^ uterine contractility.
 Cause of Onset of Labour
U
terine stretch theory:

hallow organ when stretched to capacity contract and empty.

F
ergusons reflex

tretch of the lower uterine segment: mechanical stretching of cervix

by the presenting part near term, enhances uterine activity, release
of oxytocin has been suggested but not proven.

anipulation of the cervix and stripping foetal membranes is

associated with an increase in PGF2α metabolite in blood.

xact mechanism ; not clear.

 Cause of Onset of Labour
• The onset of labor involves progesterone withdrawal and increases in
estrogen and prostaglandin action. The mechanisms that regulate these
actions are unresolved but likely involve placental production of CRH.
• During pregnancy there is Braxton-Hicks contraction which is minimal
in early pregnancy and greater with advanced gestation. There is a
cascade of events regulate and controlled by the foetal placental unit. At
the end of gestation, there is gradual down regulation of those factors
that keep uterus and cervix quiescent and up regulation of procontratile
influence.
• Placental development across gestation leads to increase in the number of
syncytiotroplast nuclei. In which transcription of the CRH gene occurs.
This maturational process leads increase level of maternal and foetal
plasma of CRH. The CRH has direct actions on the placenta to increase
the synthesis of oestrogen and reduce progesterone synthesis.
 Cause of Onset of Labour

• CRH stimulate the fetal zone of the adrenal gland a to produce

dehydroepiandrosterone (DHEA) the procures of placental estrogen
synthesis.
• CRH also stimulates the synthesis of prostaglandin by the membrane.
• The fall in progesterone and increase in estrogen and prostaglandins
leads to increases in connexin 43 that promotes connectivity of uterine
myoctes and changes myocyte electrical excitability, which turns leads
increases in generalized uterine contractions.
The process of labor
 Progression of the labor
• What are the expectations for the progress of normal
labor?
• A scientific approach was begun by Friedman 1954, who
described a characteristic sigmoid pattern for labor by
graphing cervical dilatation against time.
 Friedman’s Curve
 Friedman's Curve describes progress of two variables over
time: dilation of cervix and descent of baby.

 Labor is “dysfunctional” when cervix stops dilating or fetal

descent stops or both.

 Possible diagnosis of "failure to progress"

 C-section indicated.
 Maybe due to CPD (cephalo pelvic disproportion or epidural
anesthesia (can slow labor).
 Friedman labor curve

• First stage = A + B + C + D where

• A=latent phase
• B=acceleration phase
• C=phase of maximum slope
• D=deceleration phase
Second stage = E
FRIEDMAN’S CURVE
 STAGES OF THE LABOR
–Labor and delivery are divided into three stages. Each stage
involves different concerns and considerations.
1.First stage
2.Second stage
3.Third stage

The definitions of these stages rely predominantly on anatomical

criteria and has little clinical significance but its importance are
diagnosis of labor and the maternal urge to push, which is
corresponds with the full dilatation and the baby’s head resting
on the perineum.

N.B: some books add Fourth stage which is the early recovery
 STAGES OF LABOUR
• First stage is characterized by cervical dilatation and
effacement and lasts from the onset of the labour
until full dilatation.
•
• Second stage is characterized by expulsion of the
fetus and it lasts from full dilatation to the delivery of
the fetus.

• Third stage is characterized by delivery of the

placenta and extends from delivery of the baby to
delivery of the placenta and membranes.
 The First stage
tage of cervical effacement and dilatation.

Preparatory" - prepares the cervix to dilate in response to contractions:

Softening, Shortening (Effacing)

The first stage of labor entails effacement and dilatation. It refers to the
period from the onset of labor means when uterine contractions becomes
sufficiently frequent, intense to the fully dilation of the cervix ~10 cm in
diameter.

It takes about 10-14 hours in primigravida and about 6-8 hours in

multipara.

The first stage can be divided functionally into two phases:

1. the latent phase and
2. the active phase. .
Duration:
o
STAGES OF LABOUR
 The First stage
Latent phase:
describes the progress of labour from 0 cm to 3—4 cm dilatation.

The onset of the latent phase is the point when the mother perceives
painful uterine contractions.

Progress in terms of cervical dilatation can be slow in the phase in

contrast with the active phase.

The woman may feel at this time that she is in labor but these degrees
of dilatation may occur during the process of cervical ripening prior
to the labour itself.

A. in primigravida = 8h
B. in Multigravida = 4h
 The First stage

omen in latent phase labor:

re less than 4 cm dilated.

ave regular, frequent contractions that may or may not be

painful.

ay find their contractions wax and wane dilate only very slowly.

an usually talk or laugh during their contractions

ay find this phase of labor lasting hours to days or longer.

The First stage
 The First stage

Active phase:

ctive phase labor is a time of rapid change in cervical dilatation,

effacement , and station and lasts until the cervix is completely dilated.

his phase is normally characterized by progress of at least 1cm per

hour.

• Active phase: rapid dilatation of the cervix to reach 10cm

• in primigravida = 4h
in multigravida =2h
 The First stage

Active phase:

omen in active phase labor:

 Are at least 4cm dilated
 Have regular , frequent contractions that are usually moderately
painful
 Demonstrate progressive cervical dilatation of at least 1.2-1.5 cm
per hour.
 Usually are not comfortable with talking or laughing during their
contractions.
The active phase is divided into:

1. Accelerative phase
2. Slopping phase
3. Decelerative:

A. prolonged active phase

B. primary dysfunction: dilation in active phase
of<1cm/hr
C. secondary arrest: active phase dilation stops or slow
significantly.
N.B – in primigravida the cervix dilates from above
downwards, in multigravida dilatation of the internal os,
taking up of the cervix and dilatation of the external os
occurs simultaneously.
FRIEDMAN LABOR CURVE
Factors affecting cervical dilatation:

1. Contraction and retraction of the uterus.

2. The bag of fore-water.
3. Absence of membranes.
4. Fitting of the presenting part to the lower segment
and the cervix.
– Pre-labour changes in the cervix (e.g., softening)
 2-The second stage

Stage 2 is from the time of full dilation until delivery of the infant. Its
involves the expulsion of the foetus.

I
ts duration is about 1 hour in primigravida and ½ hour in multipara.
‘
Passive second stage’ refers to the period defined above but in the absence
of pushing (normally to allow descent of the foetal head prior to pushing)

‘
Active second stage’ refers to the active process of maternal pushing
directed to achieving delivery.
 The third stage

Stage 3 of the labour involves the separation and expulsion

of the placenta.

It begins after delivery of the infant and ends with delivery of

the placenta.
 The fourth stage

Stage 4: The hour immediately following

delivery
–Postpartum hemorrhage as a result of atony may
occur
 PROGRESS IN LABOUR
Once the diagnosis of labour has been made, progress is assed by
monitoring:
1. Uterine contraction
2. Dilation of the cervix
3. Descending of presenting part.

• The rate of cervical dilatation is expected to be approximately:

• Nullipara woman 1cm/hour
• Multipara woman 1—2cm/hour

• A partogram is commonly used to chart the observation made in

labour and to highlight slow progress, particularly a delay in
cervical dilatation or failure of the presenting part to descend.
 PROGRESS IN LABOUR

progress is determined by the interaction of three

factors:
1. The powers
2. The pelvis
3. The fetus
FACTORS THAT INFLUENCE
PROGRESS OF LABOUR
Four major factors determined labor and
delivery
1. The powers
2. The pelvis
3. The foetus
4. Psychological factors
 The Five “Ps” of Labor

1. Passageway: maternal bony pelvis and soft tissues

(the pelvis and maternal soft
parts)
2. Passenger: the fetus
3. Powers: uterine contraction
(primary and secondary forces of
labor )
4. Psychological : psychological component of mother or
maternal psychological status
5. Placenta:
 The powers
• The powers refer to the force generated to ensure expulsion of
the fetus from the genital tract.
• This force is generated by the uterine activity alone for the 1st
stage of the labour and the passive 2nd stage, and by the
uterine activity combined with maternal expulsive effort in
the activity 2nd stage
• Uterine activity in labour: the power
 Uterine contractions: primary force moving fetus through the
maternal pelvis during 1st stage of labor.
 Maternal Efforts: woman adds voluntary pushing force to
force of contractions during 2nd stage of labor to propel fetus
through pelvis.
 Efficient uterine contractions produce progressive cervical
dilatation but cause temporary impairment of fetal
oxygenation by impairing intervillous blood flow.
 Uterine activity in labour:
the power
• The myometrial component of the uterus acts as the power to
deliver the fetus.
• It contains the three layers:
• Thin outer longitudinal
• Thin inner circular layer
• Thick middle spiral layer
• From early pregnancy, the uterus contract painlessly and
intermittently (Braxton hicks contractions) which increase
after the 36th week until the onset of labour.
• In labour, a contraction start from the junction of the
fallopian tube and the uterus on each side, spreading down
and across the uterus with its greatest intensity in the upper
uterine segment.
 Uterine activity in labour: the power
• Uterus exhibits infrequent, low-intensity contractions
throughout pregnancy. Uterine activity increases in frequency
intensity and duration as labour progress and is greater in total
in nulliparous labour than in multiparous labour.
• By palpation and external tocography can identify the duration
and frequency of the uterine contractions but are a poor guide
to contraction intensity.
• Pain levels are not a good guide to contraction intensity either as
they are depend on an individual’s pain threshold.
• Internal catheter pressure are needed to assess the strength of
contractions.
• During the labour, the contractions are monitored for:
• Intensity
• Frequency
• duration
 Uterine activity in labour:
the power

• Establishment of labour is likely if 2—3 contractions with

duration for > 20 seconds are observed in 10 minutes.
• Normal resting tonus in labor start at ~ 6—12 mmHg and
increases slightly during the course of labour.
• Contractions increase in intensity to reach pressures of 40-60
mmHg ~ 5 kPa ?
• There are usually 3 or 4 coordinated contractions every 10
minutes, each lasting approximately 60s, in order to
progress in labour.
• In the 2nd stage of labour, additional power comes from
voluntary contraction of diaphragm and abdominal muscles
as the mother pushes to assist delivery.
 Uterine activity in labour:
the power
• In terms of active pressure in the first stage of labour (Figure 1).

• Uterine contractions reach pressures of 50 mmHg (6.5 kPa) with first

stage of labour. Contractions become painful when amniotic pressure
exceeds 25 mmHg (3.2 kPa).
 Uterine activity in labour:
the power

• In the second stage, with the additional effect of voluntary

expulsive efforts, intrauterine pressure may rise to 100
mmHg. Throughout labour, contractions produce effacement
(Figure 2) and dilatation of the cervix as the result of
shortening of myometrial fibers in the upper uterine segment
and stretching and thinning of the lower uterine segment.
 Mechanism of normal delivery: action of
the uterus
• The myometrium contracts and relaxes like all
muscles, but it also has the ability to retract so that
the fibers become progressively shorter especially
in the upper segment must: progressive retraction
causes the lower segment to stretch and thin out,
resulting effacement and dilatation of the cervix.
 Uterine activity in labour:
the power
• Progressive uterine contractions cause effacement and
dilatation of the cervix as the result of shortening of
myometrial fibers in the upper uterine segment and
stretching and thinning of the lower uterine segment. This
process is known as retraction.
• The lower segment becomes elongated and thinned as labour
progresses and the junction between the upper and lower
segment rises in the abdomen. Where labour becomes
obstructed, the junction of the upper and lower segments
may become visible at the level of the umbilicus; this is
known as a retraction ring. Also known as Bandli’s ring
 Uterine activity in labour:
the power
• A pacemaker for the uterus has never been demonstrated by
anatomical, pharmacological, electrical or physiological
studies. The electrical contraction impulse starts in one or the
other uterine fundal region esp. in the left uterine cornua and
spread downwards through the myometrium. Contractions
are stronger and last longer in fundus and the upper segment
than in the lower segment. This phenomenon is known as
fundal dominance and is essential to progressive effacement
and dilatation of the cervix. As the uterus and the round
ligaments contract, the axis of the uterus straightens, and
pulls the longitudinal axis of the fetus towards the anterior
abdominal wall in line with the inlet of the true pelvis.
• The realignment of the uterine axis promotes descent of the presenting
part as the fetus is pushed directly downwards into the pelvic cavity

• Figure 2. Cervical Effacement

 2. UTERINE CHANGES
As labor contractions progress, the uterus is gradually
differentiated into two distinct portions. These are
distinguished by a ridge formed in the inner uterine surface,
the physiological retraction ring.
a) Upper uterine segment– this portion becomes thicker and
active, preparing it to exert the strength necessary to expel
the fetus during the expulsion phase.
b) Lower uterine segment: this portion becomes thin-walled,
supple, and passive so that the fetus can be pushed cut of the
uterus easily.
c) Contour of the uterus changes from a round ovoid to a
structure markedly elongated in a vertical diameter than
horizontally. This serves to straighten the body of the fetus
and place it in better alignment to the cervix and pelvis.
 Interval between contractions:
10 minutes at the onset of the first stage
→diminishes gradually
→ 1 minute or less in the second stage.

 Uterine contractions characteristic of labor

The surest sign that labor has begun is the initiation of effective ,
productive, involuntary uterine contractions.

 There are three phases of the uterine contractions

1. Increment/Crescendo—intensity of the contraction increases.
2. Apex/Acme—the height or peak of the contraction.
3. Decrement/Decrescendo—intensity of the contraction decreases.
3 Phases of UC:
a. increment ↑
b. acme [peak]
c. decrement

As contractions intensify, labor progresses.

Vaginal Exam - dilation, effacement, station, & presentation.
2.characteristic of contractions
1. Frequency of contractions. This is timed from the
beginning of one contraction to the beginning of the next .

2. Duration of contractions. This is timed from the moment

the uterus first begins to tighten until it relaxes again.

3. Intensity of contractions. It may be mild, moderate or

strong at its acme.
 Mild contraction
 Moderate contraction
 Strong contraction:
2.characteristic of contractions
 Mild contraction: the uterine muscle becomes somewhat
tense, but can be indented with gentle pressure.

 Moderate contraction: the uterus becomes moderately

firm and a firmer pressure is needed to indent.

 Strong contraction: the uterus becomes so firm that it has

the feel of wood like hardness, and at the height of the
contraction, the uterus cannot be indented when pressure
is applied examiner’s hand.
4. Periods of relaxation between contractions:
 Essential to welfare of the fetus
 Unremitting contraction of the uterus compromises
uteroplacental blood flow, cause fetal hypoxia.

5. Duration of contraction in active phase

 Duration 30-90 seconds (average 60 sec)
 Pressure 20-60 mmHg (average 60 sec)
 2. The passages or passageway

• Passageway: Refers to fetus passing through

uterus, cervix, vaginal canal and pelvic . Single
most important determinant to mechanism of
labor.
 Introduction:
 Knowledge of the shape and dimensions of the normal
female pelvis is essential for a proper understanding
of the second stage of labour and its abnormalities
since the body pelvis is an important component
which determines the birth canal structure.

 The human female pelvis shows adaptations that are

of obstetric advantage and relate also to the relative
“big” head of the foetus. These adaptations develop
chiefly in childhood and puberty
he size and shape of the pelvis vary from woman to woman and not all women
have a gynecoid pelvis ; some may have platypelloid, anthropoid or android
pelvis thus influencing the outcome of labour.

oftening of the sacroiliac ligaments and the pubic symphysis allow expansion
of the pelvic cavity, and this feature along with the dynamic changes of the
head diameter brought about by flexion, rotation and molding facilitate
normal progress and spontaneous vaginal delivery.

he soft tissues also become more distensible than in the non-pregnant state
and substantial distension of the pelvic floor and vaginal orifice occurs during
the descent and birth of the head. This distensible nature of the pelvic soft
tissue, vagina and perinium help to reduce the risk of tearing and disruption
of the external anal sphincter during descent and the birth of the head.
 Anatomy of the Female Pelvis
Bony Pelvis Functions: to support and protect the internal
organs of reproduction.
The bony pelvis consists of four pelvic bones together by
ligaments.
 Two innominate Bones (nameless or hip bones)
Sacrum – 5 fused vertebrae, sacral promontory
Coccyx – (Tail bone) triangular bone last on vertebral
column, moves backward in childbirth
(Sometimes can get fixed during childbirth)
Two innominate Bones
 Ilium: upper prominence of hip
 Ischium: under the ilium, ends in ischial tuberosity,
serves as reference point for station
 Pubis: (2 separate bones) front of innominate, meets
other to form symphysis pubis
 pelvisbb

By Dr. fatouma
• Joints

Sacro-iliac
joint Sacro-
coccygeal joint

Symphysis
pubica

By Dr. fatouma
 Ligaments:
Each of the pelvic joints is held together by ligaments
1. Interpubic ligaments at the symphysis pubis
2. Sacro-iliac ligaments
3. Sacro-coccygeal ligaments
4. Sacrospinous ligament : Extend from the lateral border
of the sacrum and coccyx to the spine of the ischium
5. Sacrotuberous ligament : Extend from the posterior aspect of the
lower 3 sacral vertebrae to the ischial tuberosity
The sacro-tuberous ligament runs from the sacrum to the ischial
tuberosity and the sacro-spinous ligament from the sacrum to
the ischial spine. These two ligaments cross the sciatic notch and
from the posterior wall of the pelvic outlet and play an
important role in midwifery.
 Pelvis

False pelvis True pelvis

(major) (minor)

To support the pregnancy Sacrum and coccyx

Bounded by lumbar posteriorly
vertebrae posteriorly, Ischium and pubis
iliac fossa bilaterally bilaterally
abdominal wall anteriorly and anteriorly
 Anatomy of the Female Pelvis
The pelvis is broadly divided into true pelvis and false pelvis.

False pelvis: outer-broader. Hip bones. is divided by the linea

terminalis into the false pelvis above this demarcation and the
true pelvis below it. the pelvic area above the ilio-pectineal line
(pelvic brim) and has no obstetric importance because it does
not take part in the mechanism of delivery.

True pelvis: Internal – narrower.

The area below the pelvic brim and related to the child -birth.
Holds bladder, rectum, & reproductive Organs
The true pelvis constitutes the bony passage through which the
fetus must pass through to be born vaginally. Therefore, its
construction planes and diameters are of utmost interest in
obstetrics.
 General anatomy

Martin’s pelvinometer

•Intercristal diameter [IC ~29 cm]: widest point on

lateral aspect of iliac crest

•Interspinous diameter [IS ~26 cm]: distance between

the lateral tips of the anterior superior iliac spines

•External conjugate [AP] diameter [EC ~20 cm]:

distance between apex of spine of 5th lumbar vertebra
and centre of the superior border of symphysis pubis.
 The Boundaries of true pelvis has the following :
1. Superiorly it is bounded by the sacral promontory, linea terminals
and the upper margin of pubic bones.

2. Inferiorly it is bounded by the inferior margins of the ischial

tuberosities and the tip of the coccyx.

3. Laterally it has sacroiliac notches and ligaments, and inner

surface of ischial bones

4. Anteriorly by the obturator foramina and the posterior surface of

the symphysis pubis, pubic bones and the ascending rami of ischial
bones.

5. Posteriorly bounded by the anterior surface of sacrum and coccyx.

The female pelvis has a wide
birth canal and wide pubic
arch (Figure 3).
 THE TRUE PELVIS
•The wall of true pelvis is formed by a sacrum and coccyges
posteriorly, the ischial bones, the sacrosciatic notches and
ligaments laterally, and anteriorly by pubic rami, the
obturator fossae and membranes, the ascending rami of the
ischial bones and the pubic rami. [Most important in
childbirth]

•The true pelvis has three parts namely

 Inlet or brim
 Cavity, and
 Outlet.
 If pelvis too small, home birth not done.
 CPD - cephalopelvic disproportion > C/S.
Clinical pelvimetry involves assessment of the:

The passage that these bones make can divided into:

1.Pelvis inlet (sacral promontory)
2.Mid-cavity (pelvic side walls including ischial spines, the
interspinous diameter and the hallow of the sacrum)
3. Pelvic outlet (subpubic angel and intertuberosit diameter)

In a normal female or gynecoid pelvis, because the sacrum is

evenly curved, maximum space for the fetal head is provided
in the pelvic mid-cavity. The sacrum should feel evenly curved.
If the sacrum feels flat, then the pelvis may contract towards
the pelvic outlet, as in the android or male –like pelvis, and may
lead to impaction of the fetal head as it descent through the
pelvis.
Pelvic planes
 • Pelvic planes
Four planes
The pelvic inlet:
The midplane or cavity: the greatest
The pelvic outlet(two planes) the least
•
 THE TRUE PELVIS

• The True Pelvis is that portion below the pelvic brim.

• It determines the size and shape of the birth canal.

• Brim or pelvic inlet is extended from the centre of the sacral

promontory along the ilio-pectineal lines to the posterior aspect
of the upper surface of the pubic bones or the upper margins of
pubic bones, the ilio-pectineal lines and the promontory.
Posteriorly by promontory of sacrum
Bilaterally by linea of iliac-pubis
Anteriorly by superior surface of pubis
•Its oval in shape with its wider diameter being
transverse
 Cavity
• concavely shaped towards the pubic bones.
• It is between outlet and the inlet.
• Formed by the pubic bones, ischium, ilium, and sacrum.
Posteriorly by the sacrum
Anteriorly by the lower border of pubis
Bilaterally by ischial spines
It is very important clinically because arrest of fetal
descent occurs most frequently
• The levator ani muscles originate at the level of a plane which
extends from the inferior margin of the symphysis pubis via
the ischial spines to the tip of sacrum.
• An obstetric ‘mid cavity’ lies between this plane and the pelvic
inlet.
 Outlet:
•Outlet: diamond-shaped, is bounded by the lower border
of the pubic symphysis, the ischial spines and the tip of the
coccyx . The wider diameter is anteroposterior.
• Irregular
 Consisting of two triangles
 It is bounded by
 Posteriorly: the tip of coccyx
 Laterally : ischial tuberosities and sacrotuberous ligaments
 Anteriorly: the lower border of pubis symphysis
 The plane of pelvic Inlet (Brim)
1. Posteriorly by the sacral promontory
2. Laterally by the ilio-pectineal line and
3. Anteriorly by the superior pubic rami and margin of the pubic
symphysis .
The plane is almost circular in normal gynecoid pelvis but is
slightly larger transversely than anteroposteriorly.

1. The true conjugate or anatomical antero-posterior diameter is

the distance between the midpoint of the sacral promontory and
the superior border of the symphysis pubis anteriorly. The
diameter measures approximately 11cm.
 The Pelvic Inlet (Brim)
2. Obstetric conjugate diameter: is the shortest distance and
the one of the greatest clinical significance . This is the
distance between the midpoint of the sacral promontory
and the nearest point on the posterior surface of the
pubis symphysis . It is approximately 10.5 cm

• It is impossible to measure either the true conjugate and

obstetric diameters by clinical examination. The only
diameter at the pelvic inlet that is amenable to clinical
assessment is the diagonal conjugate diameter.
 The Pelvic Inlet (Brim)
. 3. The diagonal conjugate diameter is the distance
between the midpoint of the sacral promontory and the
inferior margin of the pubic symphysis. The diameter
measures approximately 12.5 cm.

•N.B: in practical it is not usually reachable the sacral

promontory on clinical examination, and the highest
point that can be palpated is the 2nd or 3rd piece of the
sacrum. If the sacral promontory is easily palpable, the
pelvic inlet is contracted.
 The Pelvic Inlet (Brim)
4. External conjugate : from the depression below the
last lumbar spine to the upper anterior margin of the
symphysis pubis measured from outside by the
pelvimetry. It has not a true obstetric importance.
Vaginal examination to
determine the diagonal
conjugate. (sp = sacral
promontory)
Vaginal examination to
determine the diagonal
conjugate.
Diameters of pelvic inlet
 2. Transverse diameters:
– a. Anatomical transverse diameter =13cm
►between the farthest two points on the ilio-pectineal lines.
►It lies 4 cm anterior to the promontory and 7 cm behind
the symphysis.
►It is the largest diameter in the pelvis.

– b. Obstetric transverse diameter:

• It bisects the true conjugate and is slightly shorter than
the anatomical transverse diameter.
 Oblique diameters:

Right oblique diameter =12 cm

from the right sacroiliac joint to the left ilio-pectineal eminence.

Left oblique diameter = 12 cm

from the left sacroiliac joint to the right ilio-pectineal eminence.

Sacro-cotyloid diameters = 9-9.5 cm

from the promontory of the sacrum to the right and left ilio-pectineal
eminence, so the right diameter ends at the right eminence and vice versa.
 Brim Cavity Outlet

Transverse 13.1 12.5 11.8

Oblique 12.5 13.1 11.8

Anteroposterior 11.3 13.1 12.5

Inclination of the Pelvic brim: ~120

By Dr. fatouma
 Plane Of The Pelvic Inlet
• Passing with the boundaries of pelvic brim and
making an angles of 55⁰ with the horizon (angle of
pelvic inclination)

• When a woman stands upright, the pelvis tilts forward. The

inlet makes an angle of about 55⁰ with horizontal.
• This varies between individuals and different ethnic groups.
• The present part of the fetus must negotiate the axis of the
birth canal with the change of direction occurring by
rotation at the pelvic floor.
 The Pelvic Cavity
• The pelvic cavity extends from the pelvic brim to the
pelvic outlet. It forms the curve of Carus, which the fetus
has to navigate in order to be born and has no specific
landmarks.

It is a segment, the boundaries of which are:

the roof is the plane of pelvic brim,

 the floor is the plane of least pelvic dimension,
 anteriorly the shorter symphysis pubis,
 posteriorly the longer sacrum.
 The Pelvic Cavity
Plane of the Pelvic Cavity.

It is the plane of greatest pelvic dimensions.

t passes between the middle of the posterior surface of the symphysis

pubis and the junction between 2nd and 3rd sacral vertebrae.
Laterally, it passes to the centre of the acetabulum and the upper
part of the greater sciatic notch.

t is a round plane with diameter of 12.5 cm—12.7cm.

nternal rotation of the head occurs when the biparietal diameter

occupies this wide pelvic plane while the occiput is on the pelvic
floor i.e. at the plane of the least pelvic dimensions.
 T
he plane of greatest pelvic dimensions has little clinical significance and
has anteroposterior and transverse diameter approximately 12.7cm.
A
nteroposterior diameter extends from the midpoint of the posterior aspect
of pubic symphysis to the junction of the 2nd and 3rd pieces of the sacrum.
T
he transverse diameter passes laterally through the middle of the
acetabuli or acetabulum.
T
he only indication of the shape of the pelvis at this level is the curvature
of the sacrum and the shape of the sacrosciatic notch, which subtend an
angle 90⁰.
T
his normally allows the admission of two fingers along the sacrospinous
ligaments which extend from ischial spines to the lateral aspects of the 2 nd
and 3rd pieces of sacrum.
 The Pelvic outlet
• The pelvic outlet
• This is either an ovoid or diamond-shaped space; its
perimeter is partially comprised of ligaments.
• Lower border of the symphysis pubis
• Pubic arch
• Ischial spines and ischial tuberosities
• Sacrotuberous and sacrospinous ligaments
• Lower aspect of the sacrum and the coccyx
 Outlet of the pelvis

• It consists of two triangular plans:

• It has the following boundaries:
1. anteriorly: the pubic arch
2. laterally: the ischial tuberosities
3. posterolaterally: the inferior margin of the
Sacrotuberous ligament
4. posteriorly: the tip of the coccyx
 Outlet of the pelvis
• Anterior triangle is bounded anteriorly by the area
under the pubic arch and this should subtend an
angle 90⁰ and Posteriorly by the transverse
diameter or which is the distance between the
ischial tuberosities~11 cm.
• Posterior triangle is formed anteriorly by
intertuberosit diameter and posteriorly by the tip of
coccyge the and laterally by sacrosciatic ligaments.
Outlet of the pelvis
 The Pelvic outlet

N.B: clinically the intertuberosous diameter can be assessed

by placing the knuckles of the clenched fist between the
ischial tuberosities.
The subpubic angle can be assessed by placing the index
fingers of both hands along the inferior pubic rami or by
inserting two fingers of the examining hand under the
pubic arch.
• The Pelvic outlet
• The Pelvic outlet
By Dr. fatouma
 Pelvic Axes

Anatomical axis (curve of Carus)

* It is an imaginary line joining the centre points of
the planes of the inlet, cavity and outlet.
* It is C shaped with the concavity directed
forwards.
* It has no obstetric importance.
 Pelvic Axes
Obstetric axis
*It is an imaginary line represents the way passed
by the head during labour.

* It is J shaped passes downwards and backwards

along the axis of the inlet till the ischial spines
where it passes downwards and forwards
along the axis of the pelvic outlet.
 The Passages or passageway

Pelvis type and Pelvis size

soft tissue
Caldwell- Moloy Classification of Pelvic
Types (1933)
♦ Four types of female pelvis were described.
Gynecoid pelvis(50%):
Anthropoid pelvis (25%):
Android pelvis (20%):
Platypelloid pelvis (5%):

♦ Actually, the majority of pelvis are of mixed types:

Android
• Four types of female pelvis
 Gynecoid pelvis

50% of women
It is oval shape
easy vaginal delivery
considered “normal female pelvis”
Inlet is slightly transverse oval.
Sacrum is wide with average concavity and
inclination.
Side walls are straight with blunt ischial spines.
Sacro-sciatic notch is wide.
Subpubic angle is 90-100⁰.
 Anthropoid pelvis
20-25% of women
It is oval shape
It is ape-like type.
Assisted vaginal birth usually with forceps
All anteroposterior diameters are long.
All transverse diameters are short.
Sacrum is long and narrow.
Sacro-sciatic notch is wide.
Subpubic angle is narrow.
 Android pelvis
20 % of women
vaginal delivery difficult prob. C/S
It is a male type.
Inlet is triangular or heart-shaped with
anterior narrow apex.
Side walls are converging (funnel pelvis) with
projecting ischial spines.
Sacro-sciatic notch is narrow.
Subpubic angle is narrow <90o.
 Platypelloid pelvis

< 5 % of women
It is a flat female type (Flattened pelvis)
Vagina delivery is difficult
All anteroposterior diameters are short.
All transverse diameters are long.
Sacro-sciatic notch is narrow.
Subpubic angle is wide.
 Soft tissue
• The soft passages consist of:
1. Uterus (upper and lower segments)
2. Cervix
3. Pelvic floor
4. Vagina
5. Perineum
• The upper uterine segment is responsible for the expulsive
contractions that deliver the fetus.
• The lower segment is the part of the uterus that lies between the
uterovesical fold of the peritoneum and the cervix.
• It develops gradually during the 3rd trimester, and then more
rapidly during labour.
• It incorporate the cervix as it effaces, to allow the presenting part
to descend.
 Soft tissue
The pelvic floor consists of the levator ani group of muscles,
including pubococcygeus and iliococcygeus.
Arising from the bony pelvis to form a muscular diaphragm
along with internal obturator muscle and piriformis muscle.
As the presenting part of the fetus is pushed out of the uterus it
passes the vagina, which has become hypertrophied during
pregnancy.
It reaches the pelvic floor, which acts like a gutter to direct
forwards and allow rotation.
the perineum is distal to this and stretches as the head passes
below the pubic arch and delivers.
THANK YOU
 3. PASSENGER (FETUS)

• The term refers to the fetus, through it the placenta and the
membrane must also pass through the birth canal.
• At the beginning of the normal labour the fetal head will lie
over the pelvic inlet and be well flexed.
• The area between the biparietal eminence and the anterior
and posterior fontanelles, entering the pelvic first.
• The maximum diameter of the FH will be approximately
9.5cm. This represents a tight fit circumstance which
prevent optimal engagement of the FH into the pelvic.
3. PASSENGER (FETUS)
Factors determined the impediment labour progression
• Fetal weight, larger babies will have greater difficulty in
passing through the pelvis.
• Unfavorable position of the presenting part such as occipito
posterior position. There is an increase in the relative
diameter of PP to the size of pelvis.
• Some fetal abnormality such as hydrocephalus.
3. PASSENGER
(FETUS)
1. Fetal head & Moulding
2. Feto-pelvic relationships
3. Cardinal movements
 3. PASSENGER (FETUS)
The fetal head & Moulding: Moulding: the change in shape of
the fetal skull produced by the uterine contractions
pressing the vertex against the non- yet dilated cervix.

• Fontanel's: Intersection of sutures, allows for moulding,

helps identify position of head

• Anterior
Diamond shaped;
Approx. 2-3 cm Ossifies in ~12-18 months

• Posterior
Triangle shaped
Closes in 8-12 weeks
 3. PASSENGER (FETUS)

• The fetal skull consists of the face and the cranium.

• The cranium is made up of two partial bones, two frontal bones
and the occipital bone held together by a membrane that
allows movement.
• Up until early childhood, these bones are not fused and so can
overlap to allow the head to pass through the pelvis during
lobour; this overlapping of the bones is known as moulding.
• There are important landmarks that can be felt on vaginal
examination and enable the position of the fetus to be assessed.
• The position can be described in terms of the occiput in a
cephalic presentation, and sacrum in a breech presentation.
 3. PASSENGER (FETUS)
• The size and position of the fetal skull determine the ease with
which the fetus pass through the birth canal.
• the diameter that presents during the labour depends on the
degree of flexion of the head.
• Thus the smallest diameter for delivery are the
suboccipitobregmatic diameter which represent a flexed vertex
presentation, and the submentobregmatic diameter , which
correspond face presentation.
• The widest diameter is mentovertical, a brow presentation,
which usually precludes vaginal delivery.
 FETAL ORIENTATION IN THE
UTERUS

• LIE , PRENTATION, ATTIDUTE , POSITION

AND STATION
Landmarks: Head is divided into designated areas
(1) the sinciput or brow portion
(2) the vertex, or top of the head between the 2 fontenelles
(3) the occiput or back of the head over the occipital bone.

Diameters: During birth it is desirable that the smallest

diameter of the fetal head move through the maternal bony
pelvis. The diameter that presents through the pelvis
depends on the amount of flexion or extension of the head
(attitude).
 Feto-pelvic Relationships
Attitude: the degree of flexion of the fetus or the relation of
fetal parts to each other.
 Complete flexion = good attitude.
 Moderate flexion : (military position )
 Partial extension (Brow) = poor flexion
 Complete extension (face presentation)

Fetal Lie: refers to the relationship of the long axis of the

fetus, as related to the spinal column, to the long axis of
the mother. (vertical lie = most common). Or Horizontal
(transverse)
 FETAL LIE
Definition:

The fetal lie is the relation of the long axis of the fetus to
that of the mother (long axis of the uterus), and is either
longitudinal or transverse but the most common lie is
longitudinal.
Occasionally, the fetal and maternal axes may cross at a
45-degree angle, forming an oblique lie, which is
unstable and always becomes longitudinal or transverse
during the course of labour.
 FETAL LIE
– ♦ Longitudinal – 99% : fetus and mother are in same
vertical axis.
–
– ♦ Transverse – fetus at a right angles to mother
– Multiparity,
– Placenta previa,
– Hydramnios,
– Uterine anomalies

– ♦ Oblique- unstable : fetus at 45 degree angle to

mother
 Longitudinal – Cephalic
•Transverse – shoulder or Breech

Oblique
Physical examination:
• Examiner face the feet of the mother with left hand placed
along the left side of the maternal abdomen and the right
hand on the right lateral aspect of the uterus.
• Systematic palpation towards the midline with the left then
the right hand will reveal either the firm resistance of the
fetal back or the irregular features of the fetal limbs.
• Longitudinal lie: the head or breech will be palpable over or
in the pelvic inlet.
• Oblique lie: the presenting part will be palpable on the iliac
fossa.
• Transverse lie: the poles of the fetus are palpable in the
flanks.
Physical examination:
• Having ascertained the lie and location of the fetal back , it is
important to feel for the fetal head and breech by firm
pressure with alternate hands:
• The head is hard, round and discrete, it can be bounced
between the examining hand an is described as being
ballottable
• The buttocks are soft and more diffuse and is not ballottable.
 FETAL PRESENTATION
he presenting part is the portion of the fetus body that is foremost within the birth canal or
in close proximity to it or

he part of the fetal body that enters or presents to the maternal pelvis. Most common =
cephalic presentation (head first).

CEPHALIC
PREENTATION: The head is the body part that first contacts the cervix (95%) means the head
comes down first.
vertex or
occiput (occipital fontanelle or occiput presentation) →good full flexion
face
presentation→ Poor attitude
Brow
presentation→ Moderate (military)
Sinciput
presentation or Military presentation :(anterior fontanelle) → Mentum – Very poor
attitude
 FETAL PRESENTATION

– Why does the term fetus usually presents with

vertex presentation?
– because:

1. the uterus is pyriform shaped.

2. Breech and its flexed extremities is bulkier and

more mobile than the cephalic pole.
 FETAL PRESENTATION

► BREECH PRESENTATION: Breech: Buttocks or feet are

the first parts to contact the cervix (3%)
–incidence:
– 3—4% at term
– 14% between 29 an 32 weeks gestation
–Types:
 Frank breech
 Complete breech
 Incomplete breech or footling
 FETAL PRESENTATION
► SHOULDER PRESENTATION
In transverse lie, the fetus is lying horizontally in the
pelvis (acromion process is the presenting part) or the iliac
crest, a hand or an elbow.
Common among:-
• Grand multiparas
• Pelvic contraction (horizontal space larger than
vertical space).
• Placenta previa
 FETAL ATTITUDE OR POSTURE OR
HABITUS

s a rule , the fetus forms an ovoid mass that corresponds

roughly to the shape of the uterine cavity.

he fetus becomes folded or bent upon itself in such a manner

that the back becomes markedly convex, the head sharply
flexed so that the chin is in contact with chest, the thighs are
flexed over the abdomen, the legs are bent at the knees, and
the arches of the feet rest upon the anterior surfaces of the
legs. The arms are usually crossed over the thorax.
 Types of attitude

• A--Complete flexion.
B-- Moderate flexion
C--Poor flexion.
D--Hyperextension Types of attitude
• A—flexed head
• B—neutral position head
• C—deflexed head
 FETAL POSTION
– Position refers to the relationship of an arbitrarily
chosen portion of the fetal presenting part to the right
or left side of the maternal birth canal.
– Fetal occiput, mentum, sacrum are the determined
points in vertex, face, and breech presentations,
respectively.
– ~ ⅔ of vertex presentation are in left occiput
position ,& ⅓ in the right
Fetal positions in relation to maternal pelvis
Occiput Anterior
Transverse
Posterior
Anterior
mentum Transverse
Posterior

Sacrum Anterior
Transverse
Posterior
acromion Anterior
Transverse
Posterior
Diagnosis of fetal presentation and position
• Several methods can be used to diagnose fetal
presentation and position

• These include abdominal palpation, vaginal examination,

auscultation, and, in certain doubtful cases, Sonography.

• Occasionally plain radiographs, computed tomography,

or magnetic resonance imaging may be used.
Abdominal Palpation-Leopold-Maneuvers
• Four maneuvers described by Leopold in 1894
• High sensitivity—88%
• The mother lies supine and comfortably positioned with
her abdomen bared.
• These maneuvers may be difficult not impossible to
perform and interpret.
1. If the patient is obese
2. If there is excessive amniotic fluid, or
3. If the placenta is anteriorly implanted.
 LEOPOLD’S MANEUVER

• First maneuver: what occupies the uterine fundus

• Second maneuver: palms placed on either side of the
maternal abdomen.
• Third maneuver: if presenting part not engaged
• Fourth maneuver: if present part deeply engaged.
 L1 Fundal Grip

• Cephalic or Podalic pole?

• The breech gives the sensation of a large ,
nodular mass
• Head feels hard and round and is more
mobile and ballottable.
 L2 Umbilical Grip

• Palms are placed on either side of the

maternal abdomen, and gentle but deep
pressure is exerted.
• The back- a hard, resistant structure is felt.
• The fetal extremities- numerous.
 L3 Pawlik’s Grip

• Grasping with thumb and fingers of one

hand the lower portion of the maternal
abdomen just above the symphysis pubis.

• Engaged?
 L4 Pelvic Grip
• The examiner faces the mother’s feet and, with
the tips of the first three fingers of each hand,
exerts deep pressure in the direction of the
axis of the pelvic inlet.

• Cephalic prominence?
• Flexion-same as fetal parts
• Extension-same as fetal back
Vaginal Examination
 Sonography and Radiography
• Sonographic techniques can aid identification of fetal position,
especially in obese women with rigid abdominal walls.
• In some clinical situations, information obtained
radiographically justifies the minimal risk from a single x-ray
exposure.

• Zahalka and collogues (2005) compared digital examination

with transvaginal and transabdominal sonography for
determination of fetal head position during second-stage labor
and reported that

• Transvaginal sonography was superior.

 Mechanism of labor
Definition:
Is the series of changes in position and attitude
that the fetus undergoes during its passage
through the birth canal.
The relation of the fetal head and body to the
maternal pelvis changes as the fetus descends
through the pelvis. So that the optimal diameters
of the fetal skull are present at each stage of the
descent.
This mechanism of adaptation is involving seven
cardinal movements.
CARDINAL MOVEMENTS OF LABOR
 CARDINAL MOVEMENTS OF LABOR
7 movements of labor and delivery occurs sequentially in
the following order
1. ENGAGEMENT
2. DESCENT
3. FLEXION
4. INTERNAL ROTATION
5. EXTENSION
6. EXTERNAL ROTATION
7. ESPULSION
– The fetal ovoid is transformed into cylinder, with the
smallest possible cross section passing through the birth
canal.
 ENGAGEMENT
Is the mechanism by which the biparietal diameter, average
from 9.5 to as much as 9.8 cm—the greatest transverse diameter
of the fetal head in occiput presentation, passes through the
pelvic inlet or enters the inlet.
Fetal head usually enters the pelvic inlet either transversely or
obliquely
* Engagement usually precedes active labor in nulliparous women
•Engagement may not occur until the second stage in Multiparous women
•When engagement occurs , the lowest point of presenting part is, by
definition, at the level of the ischial Spines, which is designated as 0 station ,
level 1,2,3,4, and 5. Above the spines are designated as -1,-2,-3,-4, and -5
station respectively.
• Levels 1,2,3,4, and 5 cm below the spines are designated as
+1,+2,+3,+4, and +5 station respectively. At +3 , the presenting
part is on the perineum.
 ENGAGEMENT
• Floating : when the fetal head is not engaged at the onset of the
labor and the fetal head is movable above the pelvic inlet the
head is said floating.
• In the normal process of labour the fetal head enters in the
pelvic inlet transversely as this present least resistance.
• It descends in this position through mid cavity until it reaches
the level of the levator ani muscles where it occur the fetal head
internal rotation. The head rotate normally to the more
favourable OAP (Occipito Anterior Position).
• These measurements relate to normal gynecoid pelvis. Seen
• It can be seen that the normal process of labour is one in which
the natural mechanism take advantage of the most favourable
diameter at each level.
• The fetus must rotate and flex accordingly.
•
 ENGAGEMENT

• There are variants shape of the normal shape of the pelvis

which can impair descent as a result of lack of space, and
which can encourage the to descend in an unfavorable
position such as with OP
ENGAGEMENT
ENGAGEMENT
ENGAGEMENT
 ASYNCLITISM
he sagittal suture of the fetal head may not lie exactly midway between
the symphysis and the sacral promontory.

ateral deflection of the fetal head to a more anterior or posterior position

in the pelvis

nterior asynclitism: is when the sagittal suture approaches the sacral

promontory, so that more of the anterior parietal bone presents itself to
the examining fingers.

osterior asynclitism: the sagittal suture lies close to the symphysis, and
more of the posterior parietal bone will present and with extreme
posterior asynclitism, the posterior ear may be easily palpated.
 DESCENDENT
This movement is the first requisite for birth of the newborn.
– In nulliparas, engagement may take place before the onset of
labor and further descend may not occur until the 2nd
stage of labor.
– In multiparous women, descent usually begins with
engagement.
– Descent is brought about by one or more of four forces:

the 4 forces that contribute to descent:

1. Pressure of amniotic fluid
2. Direct pressure of the contracting fundus upon the breech with
contractions
3. Pressure of Valsalva manoeuvre: bearing-down efforts of maternal
abdominal muscles
4. Straightening and extension of the fetal body
 FLEXION

– When the descending head meets resistance from

either the cervix, the walls of the of pelvic or pelvic
floor , flexion of the head normally occurs.
– In this movement, the chin is brought into more
intimate contact with the fetal thorax, and the
appreciably shorter sub-occipito-bregmatic diameter
is substituted for the longer occipito-frontal diameter.
- causing the 9.5cm diameter (smallest) to be
presented to the maternal pelvis than would occur if
the head were not flexed.
Note: pelvic sling muscles help this happen naturally
FLEXION
FLEXION
FLEXION
 INTERNAL ROTATION

– This movement is always associated with descent of PP and

usually is not accomplished until the head has reached the
level of the ischial spines (0 station).
– This movement consists of a turning of the head in such a
manner that the occiput gradually moves toward the
symphysis pubis anteriorly from its original position or less
commonly, posteriorly toward the hollow of the sacrum.
– the inlet of the pelvis is greatest transversely - but the outlet is
greatest anterior to posterior --> so the head must rotate to
the anterior position to be expelled.
INTERNAL ROTATION
 OCCIPUT POSTERIOR POSITION

 With effective contractions, adequate flexion of the head,

and a fetus of average size, the great majority of posteriorly
positioned occiput rotates promptly as soon as they reach
the pelvic floor
 Factors that predispose to incomplete rotation:
1. poor contractions
2. faulty flexion of the fetal head
3. epidural analgesia

 PERSISTENT OCCIPUT POSTERIOR - if no rotation

towards the symphysis takes place and the occiput remains
in direct occiput posterior position
CHANGES IN THE SHAPE OF THE FETAL HEAD

CAPUT SUCCEDANEUM
– swelling at the portion of the fetal scalp immediately
over the cervical os

– in prolonged labors before complete cervical

dilatation, the portion of the fetal scalp immediately
over the cervical os becomes edematous. This swelling
known as the CAPUT SUCCEDANEUM
CHANGES
MOLDING
IN THE SHAPE OF THE FETAL HEAD
 Is the change in fetal head shape from external compressive
Forces (molding) results in a shortened suboccipitobregmatic
diameter and a lengthened mentovertical diameter.
These changes are of greatest importance in women with
contracted pelvis or asynclitic presentations. In these
circumstances, the degree to which the head is capable of
molding may make the difference between spontaneous
vaginal delivery and an operative delivery.
Most cases of molding resolve within the week following
delivery , although persistent case have been described.
Most studies indicate that there is seldom overlapping of the
biparietal bones. A “locking” connections actually prevents
such overlapping.
 Moulding
Reshaping of the fetal skull:
 Obliteration of the sutures
 Overlapping of the bones of the vault
1. One parietal bone overlaps the other
2. Both overlap the occipital bone
It accounts for diminution of the biparietal
diameter and suboccipitobregmatic diameter by
o.5-1cm. Or even more.
Moulding
Moulding
 EXTENSION

–Extension of the fetal head is essential during the birth process.

This happens at the last turn of the birth canal to deliver the
head. When the sharply flexed head reaches in contact with the
vulva, the occiput is brought in direct contact with inferior
margin of the symphysis. undergoes extension.
–Note:
a.Because the vulvar outlet is directed upward and forward,
extension must occur for the head to pass through it.
b.The expulsive forces of the uterine contractions and the
patient’s pushing ,along with the resistance of the pelvic
floor ,result in the anterior extension of the vertex in the
direction of the vulvar opening.
 EXTENSION
–When the head presses upon the pelvic floor, however, two
forces come into play.
–The first force, exerted by the uterus, acts more posteriorly,
and the second, supplied by the resistant pelvic floor and the
symphysis, acts more anteriorly. The resistant vector is in the
direction of the vulvar opening thereby causing head
extension.
–These bring the base of the occiput into direct contact with
inferior margin of the symphysis pubis.

–Note: The uterus pushes down posteriorly on the back of the

neck and the tissue resistance in the tissues and symphysis
push up on the face --> extension of the head for delivery.
EXTENSION
 EXTERNAL ROTATION

he delivered head next undergoes restitution.

n this movement the occiput returns to the oblique position from

which it started and then to the transverse position, left or right.

his movement corresponds to rotation of the fetal body and serves to

bring its (shoulders) bisacromial diameter into relation with the
antero-posterior diameter of the pelvic outlet. Thus, one shoulder is
anterior behind the symphysis and the other is posterior.

s the head delivers the posterior shoulder comes into contact with
the pelvic floor and the forces causing internal rotation rotate the
body so that the shoulders are in the anterior/posterior diameter of
the pelvis.
 EXTERNAL ROTATION
• If the occiput was originally directly toward the left, it
rotates toward the left ischial tuberosity.
 EXPULSION
–
Almost immediately after external rotation, the
anterior shoulder appears under the symphysis pubis
and is delivered. The perineum soon becomes
distended by the posterior shoulder. After delivery of
the shoulders, the rest of the body quickly passes.

– Note: Once the anterior shoulder drops below the

symphysis and the posterior negotiates the perineum,
the body is quickly extruded.
EXPULSION
MANAGEMENT OF NORMAL
LABOUR AND DELIVERY
 Management of Normal Labour

• Monitor maternal well-being

• Monitor fetal well-being
• Monitor the progress of labour
 MECHANICS OF LBOUR,
OR,
HOW DOES THE HEAD
NEGOTIATE THE PELVIS?

(1) change it’s shape and size (moulding)

(2) change it’s position (flexion and rotation)
 ANATOMY OF THE FETAL
HEAD
• Largest and least compressible part of the fetus
– therefore the most important obstetrically
• Comprises of
– (1) base of skull (ossified, non compressible, protecting brain
stem)
– (2) cranium
• (a) bones: occipital, 2 parietal, 2 frontal and 2 temporal
interconnected with membrane; therefore compressible
• (b) sutures (where the bones meet): saggital, lambdoid, coronal
• © fontanelles (where the sutures meet): ant and post
• The compressibility of the fetal skull means the bones can overlap
(moulding) in order for the skull to change shape negotiating the
maternal pelvis
 PELVIC MUSCLES
• The pelvic muscles include the muscles of:
 The pelvic sidewall and
 The pelvic floor.

• The pelvic sidewall muscles are:

 The obturator internus and
 The piriformis

The skeletal muscles of the pelvic floor include:

1. the levator ani muscles
2. the coccygeus muscle
3. the external anal sphincter
4. the striated urethral sphincter and
5. the deep and superficial perineal muscles
 Muscles of the pelvic floor
The levator ani muscle complex consists of:
1. The pubococcygeus (also called pubovisceral),
2. The puborectalis, and
3. The iliococcygeus muscles
The fusion of levator ani in the midline creates the so-called
“levator plate.”
The urogenital hiatus is the space between the levator ani
musculature through which the urethra, vagina, and
rectum pass.

The muscles of the pelvic floor, particularly the levator ani

muscles, provide support to the pelvic visceral organs
and play an integral role in urinary, defecatory, and
sexual function.
 Arcus tendineus lavator ani
• There is a linear thickening of the fascial covering of the
obturator internus muscle called the arcus tendineus levator
ani.
• This thickened fascia forms an identifiable line from the
ischial spine to the posterior surface of the ipsilateral
superior pubic ramus.
• The muscles of the levator ani originate from this
musculofascial attachment.
 The levator ani muscle
• The puborectalis muscle originates on the pubic bone, and its
fibers pass posteriorly, forming a sling around the vagina,
rectum and perineal body. This results in the anorectal angle
and promotes closure of the urogenital hiatus.
• The pubococcygeus muscle originates on the posterior
inferior pubic rami and inserts on the midline-visceral
organs and the anococcygeal raphe.
• The iliococcygeus originates from the arcus tendineus
levator ani and inserts in the midline onto the anococcygeal
raphe and coccyx.
 PERINEUM
• The area between the vagina and anus is often clinically
referred to as the “perineum;” however, anatomically, the
perineum is the entirety of the pelvic outlet inferior to the
pelvic floor.
• The area between the vagina and anus is more aptly termed
“the perineal body”
Female pelvic muscles at the level of the
pelvic floor
Muscles of the female perineum
 The second stage
• The 2nd stage of labor begins when full dilatation first
recognized.
• Descent of the FH is the sole determinant of progress.
• At the onset of the 2nd stage the FH is at the level of ischial
spines or lower.
• Maternal effort with superimposed on the force generated
by the uterus contraction, the vertex will emerge at the level
of introitus.
• At the first the FH will recede between the contraction, but
when the biparietal diameter has passed the pelvic outlet,
the vertex no longer recede and crowing have to occur.
• With epidural anesthesia immediate pushing is avoidable
until the vertex is visible at the introitus because this
increased need for rotational forceps deliveries.
 Episiotomy
• Definition
• Purpose
• Indications
• Advantages
• Types
• Perineal repair
• Perineal Care
• Complication
 Episiotomy
• Episiotomy is a surgically planned incision or cutting on the perineum and the
posterior vaginal wall with the scissors or knife during the 2 nd stage of labour
with intention of widening the soft tissue diameter at the introitus in order to
prevent tearing of the tissue at delivery and also to prevent the damage of
supporting tissue at the level of the introitus due to excessive stretching.
• It is similar to a 2nd degree perineal tear.
• It is not advocated for every delivery and it is done only in certain indications.
Definition:
Episiotomy is the surgical enlargement of the posterior aspect of the vagina by an
incision to the perineum during the last part of the second stage of labor. The
incision is performed with scissors or scalpel and is typically midline (median) or
mediolateral in location.

•
 Purpose or objectives of
episiotomy
• To enlarge the vaginal introitus so as to facilitate
easy & safe delivery of the fetus- spontaneous or
manipulative.
• To minimize overstretching and rupture of the
perineal muscles & fascia.
• To reduce stress and strain on fetal head.
 Benefits
1. Prevention of perineal lacerations by anatomical incision
and repair of the episiotomy.
• Prevent tearing of the tissue at delivery and damaging of
supporting tissue at the level of the introitus due to
excessive stretching. Episiotomy is thought to result in less
damage to the anal sphincter comparing with third
degree tearing.

2. Prevention of prolonged and overstretch of the perineum

which predisposes to prolapse and stress incontinence.
 Benefits
3. Expedite delivery of the fetus –Episiotomy may be used to shorten
the 2nd stag of labour in case of serious fetal distress. Episiotomy
is only helpful if delivery is being blocked by perineal tissue (i.e.,
episiotomy will not improve maternal expulsive efforts).
• Minimizing compression and decompression of the head which
causes intracranial hemorrhage.
• Episiotomy may be indicated in preterm delivery
4. Operative vaginal delivery –Episiotomy can be used to facilitate
placement of the forceps or vacuum extractor in women with a
narrow vaginal outlet.
5. Shoulder dystocia –performing an episiotomy can increase space
for the operator's fingers and thus facilitate delivery of the
posterior shoulder and other internal procedures, but does not
appear to prevent shoulder dystocia or release the impacted
anterior shoulder.
 Indications
Absolute indications:
previous perineal surgery
- previous perineal reconstructive surgery.
- previous pelvic floor surgery.
Operative delivery or an instrumental: Forceps or ventouse delivery.
Relative indications:
- In rigid perineum.
- Anticipating perineal tear
- Big baby
- Face to pubis delivery
- Breech delivery
- Shoulder dystocia.

-
- fetal distress.
 Indications
Absolute indications:
previous perineal surgery
- previous perineal reconstructive surgery.
- previous pelvic floor surgery.
Operative delivery or an instrumental: Forceps or ventouse delivery.
Relative indications:
- In rigid perineum.
- Anticipating perineal tear
- Big baby
- Face to pubis delivery
- Breech delivery
- Shoulder dystocia.
- Fetal distress.
 Indications

Common maternal indications are:

1. Nearly in all primiparas: Threatened perineal injury in
primigravida
2. Forceps, breech, occipito-posterior or face delivery
3. Prolonged 2nd stage due to rigid perineum
4. Old perineal scar about to rupture
5. Prior to most instrumental vaginal delivery as forceps and
vacuum
6. Vulval oedema.
 Indications

Common fetal indications are:

1. Large sized baby
2. Preterm baby
3. Direct occipito-posterior
4. Breech delivery
 Advantage
Maternal Fetal
• A clear and controlled • Minimizes
incision is easy to repair intracranial injures
and heals better than a esp. in a premature
lacerated wound that babies or after
might occur otherwise coming head of
• Reduction in duration 2nd breech
stage of labour
• Reduction of trauma to
the pelvic floor muscles
 Timing of episiotomy
• Bulging thinned perineum during contraction just
prior to crowning
• when the introitus is distended by the presenting
part or the cup of the ventouse with a visible
diameter not less than 3-4 cm, and done at the
maximum of a uterine contraction. If forceps will
be used episiotomy is done just before its
application.
 PROCEDURES AND SELECTION
• The most common types of episiotomy are:
1. Median (midline) and
2. Mediolateral .
3. Other less common incisions include the
a) J shaped
b) T shape and
c) lateral
N.B: The decision to perform an episiotomy is a clinical judgment,
and routine use of episiotomy is not advised
 PROCEDURES AND SELECTION
Median episiotomy, the perineum is incised vertically within 3 mm
of the midline, or 6 o'clock position, on the introitus. Means it
starts from the fourchette for a few centimeters towards the anus.
• Midline incision that follows the natural line of insertion of the
perineal muscles.
Merits
• The muscles are not cut Demerits
• Associated with less blood loss • Extension may involve the
• it is easier to perform and to repair rectum
• Less pain and discomfort in the • Damage to anal sphincter
puerperium. • Not suitable for
• heals well and quicker compared with manipulative delivery or
the mediolateral episiotomy. in malpresentation
• Post operative comfort is maximum • it is associated with more
• Wound disruption is rare 3rd and 4th degree tears
because of the straight
• Dyspareunia is rare easy extension into the
• Better end-result cosmetic appearance. anus.
 PROCEDURES AND SELECTION
Mediolateral episiotomy, The incision extends from the midline of
the fourchette mediolaterally at 5 or 7 o’clock towards the
direction of the ischial tuberosity
the incision is made at the vaginal introitus in a lateral direction
→ starting from the fourchette going laterally to 45◦.
• Towards a point midway between the ischial tuberosity & the
anus.
MERITS • DEMERITS
• Safety from rectal involvement • Difficult to perform and to repair.
good Apposition of tissue not so good
• Incision can be extend. More if • More pain and discomfort in the
necessary . puerperium
• Extension to the anal sphincter • Blood loss is little more
is less common so it is more
• Wound disruption is more
suitable for instrumental
delivery and in short perineum. • Dyspareunia is more
• Less end-result cosmetic appearance
 PROCEDURES AND SELECTION

• When an episiotomy is to be performed, we suggest a mediolateral

episiotomy. Mediolateral episiotomy reduces the risk of anal sphincter
laceration (i.e., third or fourth degree obstetric injury) compared with
median episiotomy.

• Its inadvertent extension will injure the external anal sphincter and
rectum. This can be prevented by extending the incision by the scissors in
a J-shaped manner to avoid the external sphincter.

• J incision — The J incision is less widely used. The incision starts at the
fourchette, is initially extended caudally in the midline, and then curved
laterally at an angle, similar to the letter J.

•
Types of episiotomy
Types of episiotomy
 episiotomy
• Step 1: Preliminaries

• Step 2: Incision

• Step 3: Repair
 Step 1: Preliminaries:
1. Consists preparation of the equipments
• Sterile drape
• Sterile gown and gloves
• Gauze swabs and tampon
• Needle holder
• Sponge holder
• Scissors
• 10 ml syringe
• Toothed forceps
• Suture material
• 1% lidocaine
 Step 1: Preliminaries:
2. Preparation of the patient
• Provide emotional support and encouragement.
• The perineum is thoroughly swabbed with antiseptic lotion
• Draped properly
• Incision line- Infiltrated with 10 ml of 1% lignocaine solution.
• Make sure there are no known allergies to lignocaine or related
drugs.
• Infiltrate beneath the vaginal mucosa, beneath the skin of the
perineum and deeply into the perineal muscle.
• Note: Aspirate (pull back on the syringe) to be sure that no vessel
has been penetrated
• Wait 2 minutes and then pinch the incision site with forceps.
• Wait to perform episiotomy until: - the perineum is thinned out;
and - 3–4 cm of the baby’s head is visible during a contraction.
 Step 2: Making Episiotomy
• Incision: Two fingers the index and middle fingers of one hand
are placed in the vagina between the presenting part & posterior
vaginal wall to protect the presenting part and support the
tissues that will be incised.
• The incision is made by straight or curved blunt pointed sharp
scissors
• The open blades are positioned.
• Incision should be made at the height of an contraction.
• Cut should be made starting from the centre of the fourchette
extendening laterally either to the left or right.
• It is directed diagonally in a straight line which runs about 2.5
cm away from the anus
 Step 2: Making Episiotomy

• The incision is usually 3-5 cm length, including the posterior

vaginal wall, fourchette, perineal muscles and perineal skin.
• If delivery of the head does not follow immediately, apply
pressure to the episiotomy site.
• Control delivery of the head to avoid extension of the
episiotomy.
 Anesthesia options
• Local infiltration
• pudendal nerve block
• A neuraxial anesthetic (i.e., spinal or epidural)
• General anesthesia
• Local infiltration and pudendal nerve block, (e.g., 5 to 20 mL of
1% lidocaine injected into the planned episiotomy site)
• In cases of normal vaginal delivery it can be done under
pudendal nerve block or local infiltration of the perineum.
• In cases of instrumental deliveries it should be done under
epidural or spinal anesthesia.
Performing episiotomy:
 Technique of repair of episiotomy or tear

-A sharp scissors is used to make a single incision about 3–6 cm

depending on the size of the perineum.

-The depth involves the superficial perineal muscles like a second

degree tear.

-The episiotomy must be made in a single cut. If it is enlarged by

several small cuts , a zigzag incision will be produced which will
be difficult to repair.

-The episiotomy should begin in the midline at the fourchette.

 Structures involved

• Posterior vaginal wall

• Superficial & deep transverse perineal muscles
• Fascia covering the muscles
• Transverse perineal branches of pudendal
vessels& nerves
• Subcutaneous tissue & skin.
How to perform episiotomy
 Step 3: Making Episiotomy

• Repair is done soon after the expulsion of the placenta.

• Purpose of Repair
– To control bleeding
– To prevent infection
– To assist wound healing by primary intention.
 The most common suture type
1. polyglactin 910 suture:
 Coated Vicryl
 Vicryl RAPIDE (> 70%)

2. polyglycolic acid:
 Safil,
 Safil Quick
 Dexon II (12%)

3. Traditional sutures :
 Catgut
 chromic catgut) (10%).
Step 3: Making Episiotomy: Preliminaries
• The patient is placed in lithotomy position
• A good light source from behind is needed to find the apex first.
• Wearing high-level disinfected gloves
• The perineum &the wound area is cleaned with antiseptics
• Blood clots are removed from the vagina & the wound area
• The patient is draped properly &repair should be done under
strict aseptic precaution
• A vaginal pack is inserted & is placed high up.
• Place two fingers between the baby’s head and the perineum.
• Use scissors to cut the perineum about 3– 4 cm in the mediolateral
direction.
• Control the baby’s head and shoulders as they deliver. • Carefully
examine for extensions and other tears and repair
 Step 3: Making Episiotomy:
Preliminaries
• Principles in suturing:
• Close all dead space
• Ensure hemostasis and
• prevent infection
• Cotton balls must not be used.
• Handle tissue gently using nontoothed forceps.
• Ensure good anatomical restoration and alignment to facilitate healing.
• Use minimal amount of suture material, and do not over tighten suture
this may impede healing.
• Following the repair a rectal examination should be performed to
ensure no suture material has been inserted through the rectal mucosa.
 Layers of perineal repair
• Vaginal mucosa & submucosal tissue.
• Perineal muscles
• Skin & subcutaneous tissue

• Repair: Cut gut O, Dexon or vicryl 2/0 may be used to close the
posterior vaginal wall by continuous sutures where the first
stitch should be above the apex of the vaginal incision, then the
muscles with interrupted sutures and lastly the skin with
interrupted or subcuticular sutures.
Layers of perineal repair
 Step1: Suturing the vagina
• Apply antiseptic solution to the area around the episiotomy.
• Identify the apex
• Insert the anchoring suture about 0.5 or 1cm above the apex (top) of the
episiotomy.
• Repair the vaginal wall with a continuous non-locking stitch with
approximately 0.5 cm between each stitch up to the level of the vaginal
opening.
• Close the vaginal mucosa using continuous 1-0 suture
• If the episiotomy is extended through the anal sphincter or rectal
mucosa, manage as third or fourth degree tears, respectively
• At the opening of the vagina, bring together the cut edges of the vaginal
opening
• Bring the needle under the vaginal opening and out through the incision
and tie.
 Step2: Suturing the perineal muscle
• Check the depth of the trauma.
• Repair the perineal muscles in one or two layers with the same
continuous stitch.
• Ensure the muscle edges are apposed carefully leaving no dead
space.
• Close the perineal muscle using interrupted 1-0 sutures • Close
the skin using interrupted (or subcuticular) 1-0 sutures
• On completion of the muscle layer, the skin edges should align
• So that they can be brought together without tension.
 Step3: Suturing the skin
• Reposition the needle at the inferior end of the wound
commence.
• Stitches are placed below the surface of the skin,
• The point of the needle should be repositioned between each
side, So that it faces the skin edge being sutured.
• Continue taking bites of tissue from each side until the superior
wound edge is reached.
 Immediate care

• Inspect the repair to check that hemostasis has been achieved

• Remove the vaginal tampon, if used,•
• Account for all instruments, swabs and needles
• Discard sharps safely
• Apply sterile pad following thorough perineal wash
• Wait for minimum one hour to shift the patient to ward
• Check for bleeding & urine output
•
 Post operative care
1. Dressing: the wound is to be dressed each time following
urination and defecation to keep the area clean and dry.
 Dressing is done by using antiseptic soaked swabs.
 The attendant should wear a mask while doing dressing.
2. Comfort: to relieve pain in the area, magnesium sulphate
compress to be given.
 Analgesic drugs may be given according to instruction.
 A non- steroidal anti-inflammatory agent as Diclofenac is used
as an analgesic for the first 72 hours.
 Local antiseptic lotion and antibiotic powder or spray is used
for 7 days.
3. Ambulation: the is allowed to move out of the bed after 24 hours.
4. Removal of stitches: the stitches are to be cut on 6th day.
 Complications of episiotomy
Immediate Remote
• Extension of the incision to • Dyspareunia
involve the rectum • Chance of perineal
• Vulval hematoma lacerations
• infection • Scar endometriosis
• Recto vaginal fistula
• Wound dehiscence
• Injury to anal sphincter causing
incontinence of flatus or faces •
Rectovaginal fistula (Rarely)
• Necrotising fascitis
 Health education
• • Eat a diet high in fibre and fluids to prevent constipation
• Ask the women to walk with thighs apposed, not to use squatting
position since the wound is healing.
 Perineal hygiene

• Change sanitary pads at least every 4 hours to help prevent

infection.
• Squirt warm tap water over the perineum, beginning at the front
and moving toward the back .
• Sit in a tub of warm water
• Always wash hands thoroughly before and after going to the
bathroom.
• Always keep the wound clean & dry after each urination &
defecation.
 kegal’s exercise

• Squeeze the perineal muscles as if you were trying to stop the

flow of urine.
• Hold for 5 to 10 seconds and then relax.
• Do this exercise 10 times a day to regain muscle strength.
•
 ADVERSE OUTCOMES OF EPISIOTOMY

• Extension of the incision, leading to third and fourth degree

tears, particularly for median episiotomy
• Risk of unsatisfactory anatomic results (e.g., skin tags,
asymmetry, fistula, narrowing of introitus).
• Increased blood loss (Bleeding which can be heavy).
• Higher rates of infection and dehiscence
• Increased risk of severe perineal laceration in subsequent
deliveries
• If the episiotomy is performed too far laterally it will not
increase the diameter of the vulval outlet but may cause
damage to the right Bartholin’s gland which cause a decrease in
vaginal lubrication or cyst formation.
• Dyspareunia.
Repair of episiotomy:
 CLASSIFICATION AND REPAIR OF PERINEAL
LACERATIONS AND EPISIOTOMY
1. First-degree perineal laceration:
a) extends only through the vaginal and perineal skin

b) Repair : Place a single layer of interrupted 3—0 chromic or

Vicryl sutures about 1 cm apart
 CLASSIFICATION AND REPAIR OF PERINEAL
LACERATIONS AND EPISIOTOMY
2 . Second-degree perineal laceration &repair midline
episiotomy :
a) Extends deeply in to the soft tissues of the perineum,
down to means include the deep perineal muscles, but
not including, the external anal sphincter capsule. The
disruption involves the bulbocavernosus and transverse
perineal muscles.
 CLASSIFICATION AND REPAIR OF PERINEAL
LACERATIONS AND EPISIOTOMY
2 . Second-degree perineal laceration &repair midline
episiotomy :
b) Repair
1. Proximate the deep tissues of the perineal body by placing 3—4
interrupted 2-0 or 3-0 chromic or Vicryl absorbable sutures.
Reapproximate the superficial layers of the perineal body with a
running suture , extending to the bottom of the episiotomy.
2. Identify the apex of the vaginal laceration suture the vaginal
mucosa with running, interlocking , 3-0 chromic or Vicryl
absorbable sutures.
3. Close the perineal skin with running, subcuticular suture. Tie off
the suture and remove the needle.
 CLASSIFICATION AND REPAIR OF PERINEAL
LACERATIONS AND EPISIOTOMY
2 . Second-degree perineal laceration &repair midline
episiotomy :
 CLASSIFICATION AND REPAIR OF PERINEAL
LACERATIONS AND EPISIOTOMY
3. third-degree perineal laceration &repair midline episiotomy :
A. This laceration extends through the perineum and through
the anal sphincter. (includes the external anal sphincter)
 CLASSIFICATION AND REPAIR OF PERINEAL
LACERATIONS AND EPISIOTOMY
2 . third-degree perineal laceration &repair midline
episiotomy
B. Repair
1. Identify each severed end of the external anal sphincter
capsule, and grasp each end with an Allis clamp.

2. Proximate the capsule of sphincter with 4 interrupted

sutures of 2-0 or 3-0 Vicryl absorbable sutures. Make
sure the sutures do not penetrate the rectal mucosa.

3. Continua the repair as for a second degree laceration as

above. Stool softeners and sitz baths are prescribed
postpartum.
 CLASSIFICATION AND REPAIR OF PERINEAL
LACERATIONS AND EPISIOTOMY
4 . Fourth-degree perineal laceration &repair midline
episiotomy
A. The laceration extends through the perineum, anal
sphincter, and extends through the rectal mucosa
to expose the lumen of the rectum.
 CLASSIFICATION AND REPAIR OF PERINEAL
LACERATIONS AND EPISIOTOMY
2 . Fourth-degree perineal laceration &repair midline
episiotomy
B. Repair
1. Irrigate the laceration with sterile saline solution.
Identify the anatomy, including the apex of the rectal
mucosal laceration.

2. Approximate the rectal submucosal with running

suture using 3-0 chromic a GI needle extending to
the margin of the anal skin.

3. Place a second layer of running suture to invert the

first suture line, and take some tension from the first
layer closure.
 CLASSIFICATION AND REPAIR OF PERINEAL
LACERATIONS AND EPISIOTOMY
2 . Fourth-degree perineal laceration &repair midline
episiotomy
B. Repair
4. Identify and grasp the torn edges of the external anal
sphincter capsule with Allis clamps, and perform a
repair as for a third-degree laceration. Close the
remaining layers as for a second-degree laceration.

5. A low residue diet, stool softeners, and sitz baths are

prescribed postpartum.