Overview While it takes nine months to grow a full-term baby, labor and delivery occurs in a matter of days or even hours. However, it’s the process of labor and delivery that tends to occupy the minds of expectant parents the most. Read on if you have questions and concerns around the signs and length of labor, and how to manage pain. Signs of labor Labor has started or is coming soon if you experience symptoms such as: increased pressure in the uterus a change of energy levels a bloody mucus discharge Real labor has most likely arrived when contractions become regular and are painful. Braxton Hicks contractions Many women experience irregular contractions sometime after 20 weeks of pregnancy. Known as Braxton Hicks contractions, they’re typically painless. At most, they’re uncomfortable and are irregular. Braxton Hicks contractions can sometimes be triggered by an increase in either mother or baby’s activity, or a full bladder. No one fully understands the role Braxton Hicks contractions play in pregnancy. They may promote blood flow, help maintain uterine health during the pregnancy, or prepare the uterus for childbirth. Braxton Hicks contractions don’t cause the cervix to dilate. Painful or regular contractions aren’t likely to be Braxton Hicks. Instead, they’re the type of contractions that should lead you to call your doctor.

1. Labor and delivery
MUKESH SAH
POST GRADUATE MEDICAL INTERN

2. Normal Labor and Delivery: Introduction
• Childbirth period from the onset of
regular uterine contractions until expulsion
of the placenta
• Attendants to be supportive of the laboring
woman's needs
Effective pain relief.
• Spontaneous labor and delivery
• Ineffective labor requiring augmentation
• Medical and obstetrical complications
requiring induction of labor
• Cesarean delivery

3. Mechanisms of Labor
Onset of labor, position of the fetus with
respect to the birth canal is critical to the route of
delivery
Fetal Orientation
= Relative to the maternal pelvis is described in
terms of fetal lie, presentation, attitude, and
position
Fetal Lie
= Relation of the fetal long axis to that of the
mother
= Longitudinal, transverse, or oblique
Predisposing factors:
Multiparity, placenta previa,
hydramnios, and uterine anomalies

4. Fetal Presentation
Presenting part
=Portion of the fetal body that is either
foremost within the birth canal or in closest
prox-imity
Felt through the cervix on vaginal examination
Fetal head = cephalic presentations
Breech = breech presentations
Transverse = shoulder is the presenting part

5. Cephalic Presentation
95% of cases
Are classified according to the relationship between the head and body of the
fetus
Vertex or occiput presentation
• Occipital fontanel
• Head is flexed sharply so that the chin is in contact with the thorax
Face presentation
• Neck may be sharply extended so that the occiput and back come in contact,
and the face is foremost in the birth canal
Sinciput presentation
• The fetal head is partially flexed in some cases, with the anterior (large)
fontanel, or bregma
Brow presentation
Fetal head is partially extended
• Sinciput and brow presentations
• Almost always convert into vertex or face presentations by neck flexion or
extension

7. Breech Presentation
=Fetus often changes polarity to make use of the roomier fundus for its
bulkier and more mobile podalic pole
• Three general configurations:
1. Frank= thighs flexed, legs extended over anterior surface of the body
2. Complete = thighs flexed, legs flexed upon thighs
3. Footling/ Incomplete = one or both feet or one or both knees maybe
lowermost

9. Fetal attitude or posture or habitus
• As a rule, the fetus forms an ovoid mass that
corresponds roughly to the shape of the uterine cavity

10. Fetal Position
• Position refers to the relationship of an arbitrary chosen
portion of the fetal presenting part to the right or left side
of the birth canal
• Approximately two thirds of all vertex presentations are in
the left occiput position, and one third in the right

11. Diagnosis of Fetal Presentation and
Positions
• Several methods can be used to diagnose fetal
presentation and positions
• These include abdominal palpation, vaginal examination,
auscultation, and, in certain doubtful cases, sonography.
• Occasionally plain radiographs, computed tomography or
MRI may be used

12. Abdominal palpation-Leopold Maneuver

13. 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
ballotable

14. 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 small, irregular, mobile
parts are felt

15. L3 pawlik’s grip
• Grasping with the thumb and fingers of one hand and
lower portion of the maternal abdomen just above the
symphysis pubis

16. 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
• Flexion-same as the fetal parts
• Extension-same as the fetal back

17. Four Phases of Parturition
• Phase 0 (prelude to parturition Quiescence)
– Time of contractile tranquility and uterine unresponsiveness
– Before implantation until about 35-38 weeks
– Progesterone: principal mediator
– Cervix: remains rigid and unyielding

18. • PHASE 1 (Preparation for labor)
– Uterus and cervix undergo anatomic and functional changes:
• Increase oxytocin receptors in myometrial cells, inc. number and size
of gap junctions, inc. responsiveness to uterotonins, inc frequency of
painless contractions
– Dependent on uterotonins or uterotropin-stimulating agents
– Cervix ripens: soften, yield and more readily dilatable

19. • PHASE 2(Process of Labor)
– Active uterine contractions brings about cervical effacement
and dilatation, fetal descent and delivery

20. • PHASE 3(Recovery period)
– Uterine contraction and involution to prevent hemorrhage
– Initiation of lactation and milk ejection for breastfeeding
– Regulators: uterotonins(oxytocin and endothelin-1)

21. EARLY SIGNS OF LABOR
1. “Lightening” or “Baby Drop”
- dec. fundic ht due to formation of lower uterine segment allowing fetal
head to descend and dec. in amount of AF
2. “show” or “Bloody show”
- small amount of blood-tinged mucus from vagina
-considered a late sign because labor may ensue in the next few hrs or
days or at times labor has begun.
3. False labor
- contractions of irregular interval, shorter duration, and discomfort,
confined to the lower abdomen or groin.

22. DEGREE OF EFFACEMENT
• Synonymous to “obliteration” or “taking up” of the cervix
• Shortening of the cervical canal from length of about 2cm to a
circular orifice of paper-thin edges(100% effaced)
• Upward pulling of muscular fibers of internal os while the external
os remains temporarily unchanged
• No fetal descent occurs but the presenting part descends

24. STATION
• Refers to the level to which the fetal presenting part has
descended into the maternal pelvis
• Point of reference is ischial spine: station 0
• From the ischial spine up: station -1 to -3
• From the ischial spine down: station +1 to +3
• Progressive dilatation with no change in station in woman of low
parity may signify fetopelvic disproportion

25. CERVICAL DILATATION
• Degree of opening of the external os
• True indicator of labor
• Examining fingers are swept from one margin of the
cervix to the other: max. diameter is 10cm approx 5 finger
width

26. PATTERN OF CERVICAL DILATATION
• 2 PHASES:
– 1. LATENT PHASE(0-3cm)
• Begins when mother perceives regular contraction
• 8-12hrs with irregular contactions(every 5-30mins and lasts 30sec
– 2. ACTIVE PHASE(starts at 4cm dilatation to 7cm)
• Lasts 3-5hrs with regular contactions(every 3-5 mins and lasts 1min
or more
a. Acceleration phase
-predictive of the outcome of a particular labor
b. Phase of maximum slope
-measure of the overall efficiency
a. Deceleration phase
3. Transition phase(8-10cms)
- primipara 3.6hrs
- multipara variable
- uterine contractiom every 1 and half-2 min, 60-90 sec.
moderate-strong

27. Second stage(pushing)
Complete dilatation 10cm) to delivery of fetus
• Primipara: 60 mins
• Multipara: 30mins
• Affected by epidural anesthesia, maternal pushing, position of presenting
part, size of pelvis
3 P’s
1. Power – forceful uterine contractions
2. Passenger – fetus
3. Passage – Route of fetus through Bony Pelvis

28. a. Delivery of the head
• Crowning- fetal head is seen encircled by the vulvar ring;
episiotomy prevents perineal lacerations
b. Ritgen’s maneuver
• Contols delivery of the head with extension so that
smallest diameters of the head pass over the introitus
• When the vulvar opening reaches a diameter of 5cm, a
towel draped-hand should be used to exert forward
pressure on the chin of the fetus through the perineum
• Other hand placed on the occiput
• Prevents extension of episiotomy
c. Nasopharyngeal toilette
• After delivery of the head, the face of the fetus is wiped and the
nares and throat quickly suctioned
• To prevent aspiration of amniotic fluid and blood
d. Nuchal cord care

29. Third Stage
Delivery of fetus to deliver of placenta
 Usually within 5 mins after delivery of fetus(may be upto
30mins). Retained after 30mins

30. Fourth stage
• Adaptation to blood loss
• Start of uterine involution(returning to prepregnant state

31. Patterns of descent
• Active descent takes place when the cervical dilatation
has already advanced but the maximum slope of descent
occurs during the maximum slope of cervical dilatation

32. Three functional divisions of labor
• 1. Preparatory division
– Little cervical dilatation; affected by sedation
2. Dilatational division
- Dilatation occurs at its most rapid rate
- Unaffected by sedation or conduction analgesia
3. Pelvic division
- Starts at deceleration phase of cervical dilatation
- Cardinal movements of the fetus takes place

33. WHO PRINCIPLES OF PARTOGRAPH
a. Active phase of labor begins at 4cm cervical dilatation
b. Latent phase of labor should last longer than 8 hrs
c. Rate of cervical dilatation during the active phase of labor should not be
slower than 1cm/hr
d. 4-hour lag between slowing of labor and the need for intervention is
unlikely to compromise the fetus
e. 4 hourly vaginal examination is recommended

34. The cardinal movements of labor
• Engagement, descent, flexion, internal rotation,
extension, external rotation and expulsion

35. engagement
• The mechanism by which the biparietal diameter,
average from 9.5 to as much as 9.8cm-the greatest
transverse diameter in an occiput presentation—passes
through the pelvic inlet in designated.

36. Descent
• This movement is the first requisite for birth of the
newborn
• In nulliparas, engagement may take place before the
onset of labor, and futher descent may not follow until
the onset of the second stage
• In multiparous women, descent usually begins with
engagement
• Descent is brought about by one or more of four forces:
1. pressure of the amniotic fluid
2. direct pressure of the fundus upon the breech
with contractions
3. bearing-down efforts of maternal abdominal
muscles
4. extension and straightening of the fetal body

37. Flexion
• As soon as the descending head meets
resistance whether from the cervix, walls
of the pelvis, or pelvic floor, then flexion of
the head normally results.
• In the movement, the chin is brought into
more intimate contact with the fetal thorax,
and the appreciably shorter
suboccipitobregmatic diameter is
substituted for the longer occipitofrontal
diameter

38. Internal rotation
• Two thirds, internal rotation is completed by the time the head reaches the
pelvic floor
• In about another fourth, internal rotation is completed very shortly after the
head reaches the pelvic floor
• And in the remaining 5%, anterior rotation does not take place
• When the fetal head fails to turn until reaching the pelvic floor, it typically
rotates during the next one or two contractions in multiparas. In nullipara,
rotation usually occurs during the next three to 5 contractions

39. Extension
• 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
resultant vector is in the direction of the vulvar opening,
thereby causing head extension.
• This brings the base of the occiput into direct contact with
the inferior margin of the symphysis pubis

40. External rotation
• The delivered head next undergoes restitution.
• If the occiput was originally directed toward the left, it
rotates toward the left ischial tuberosity.

41. Expulsion
• Almost immediately after external rotation, the anterior
shoulder appears under the symphysis pubis, and the
perineum soon becomes distended by the posterior
shoulder.
• After delivery of the shoulders, the rest of the body
quickly passes.

42. Mechanisms of Labor with Occiput
Posterior Presentation
• In approximately 20 percent of labors, the fetus enters the pelvis
in an occiput posterior (OP) position.
• The right occiput posterior (ROP) is slightly more common than
the left (LOP)
• It appears likely from radiographic evidence that posterior
positions are more often associated with a narrow forepelvis.
• They also are more commonly seen in association with anterior
placentation

43. Changes in Shape of the Fetal Head
• Caput Succedaneum
• 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.

44. Molding
• The change in fetal head shape from external
compressive forces is referred to as molding.
• Most studies indicate that there is seldom overlapping of
the parietal bones. A "locking" mechanism at the coronal
and lambdoidal connections actually prevents such
overlapping

45. DIFFERENTIATION OF LABOR
PARAMETER FALSE LABOR TRUE LABOR
CONTRACTION
REGULARITY
INTERVAL
INTENSITY
Irregular
Long, may disappear
Unchanged
Regular
Increase gradually
Increase gradually
Radiation of pain Mostly hypogastric Hypogastic to
lumbosacral
Effect dilatation Long and closed Open and effacing
Effect effacement Does not occur Occurs and progresses
Effect of sedation May stop contraction Not stopped

46. Spontaneous Delivery:
• Crowning- encirclement of the largest head diameter by the vulvar
ring
• Episiotomy- increased risk of a tear into the external anal sphincter
and or rectum.
• Anterior tears in the urethra and vulva are common in women
without episiotomy.
RITGEN MANEUVER- forward pressure of the chin
• allow control of the delivery of the head
• favors extension.

47. PLACENTAL SEPARATION:
• results primarily from a disproportion created between the
unchanged size of the placenta and the reduced size of
the underlying Implantation site.
• Formation of a hematoma between the separating
placenta and the remaining deciduas is the result of the
separation. It can accelerate the process of cleavage.

48. Signs of Placenta Separation:
• 1. Change in the shape of the uterus becoming globular
and firmer (Calkin’s Sign)
• 2. Sudden gush of blood
• 3. Uterus rises in the abdomen
• 4. lengthening of the cord

49. • Mechanism:
• SHULTZ – blood from the placenta site pours into the
inverted sac, not escaping externally until after extrusion
of the placenta.
• Duncan- Separation of the placenta occurs first at the
periphery; blood collects between the membranes and
the uterine wall and escapes from the vagina.

50. LACERATION OF BIRTH CANAL:
• First degree= fourchette, perineal skin, and vaginal
mucous membrane but not the underlying fascia and
muscle.
• Second degree- fascia and muscle of the perineal body
but not the anal sphincter.
• Third degree- includes anal sphincter
• Fourth- rectal mucosa.

51. EPISIOTOMY TYPES:
midline mediolateral
• Surgical repair Easy More difficult
• Faulty Healing Rare More common
• Post OP pain Minimal Common
• Anatomical Results Excellent Occ faulty
• Blood loss Less More
• Dyspareunia Rare Occasional
• Extension common uncommon

53. Suturing technique
• Vaginal mucosa – interlocking sutures until lower end of
hymenal ring; start 1cm above angle of mucosal defect
• Subcutaneous and fascial layers – interrupted sutures
• Skin – interrupted or subcuticular sutures

54. •Thank you…