Normal labour and delivery involves 3 stages: 1) dilation of the cervix as contractions increase, 2) delivery of the baby as the cervix fully dilates, and 3) delivery of the placenta. During the first stage, contractions gradually become stronger and more frequent as the cervix effaces and dilates from 3-4 cm to fully dilated at 10 cm. In the second stage, with the cervix fully dilated, the baby's head descends and is born through rotations and flexions to match the pelvis. In the third stage, the placenta is delivered either physiologically or through active management with oxytocin and controlled cord traction.
2. 1
NORMAL LABOUR
• A series of uterine contractions
• Progressive dilation and effacement of the cervix
• Divided into three recognised stages
3. 2
STAGES OF LABOUR
• First Stage
– Latent Phase
– Irregular contractions with gradual effacement and dilation up to 4cm
– Active Phase
– More frequent contractions, foetal descent, faster dilation to a full 10cm
• Second Stage
– Passive Stage
– Full dilation of cervix but without expulsive contractions
– Active Stage
– Onset of expulsive contractions through to delivery of the neonate
4. 3
STAGES OF LABOUR
• Third Stage
– Physiological
– No drugs, cord clamping or assistance with placental delivery
– May be tried for up to 60 minutes before active management is commenced
– Active
– 10iu IM Oxytocin, either when anterior shoulder is delivered or upon
commencement of active management
– Cord clamping or cutting, delivery of the cord by placental traction
5. 4
POSSIBLE SIGNS OF LABOUR
• Lightening
• Movement of foetal head deeper into pelvis causing observable drop in abdomen
and relieving DiB
• Weeks to Hours from onset
• Bloody Show
• Bloody or brown discharge – the mucus plug of the cervix being released
• Days to Hours from onset
• Ruptured Membranes
• “Waters Breaking” – PV fluid indicating rupture of the amniotic sac
• Labour within 24 hours or induced
• Contractions
• Labour begins when the cervix is effaced and 3-4cm dilated
• This usually coincides with regular contractions
6. 5
FIRST STAGE – DILATION
• Cervix effaced and dilated 3-4cm
• Uterine muscles contract pushing the foetus downwards
• The cervix begins to dilate to accommodate the foetal head
• Typically the cervix will dilate to 10cm, to allow the passage of the
foetal head
• Contractions increase in regularity and discomfort
• Initially <45 second contractions >5 minutes apart
• By late Active Phase, ~60sec contractions 2-3 minutes apart
7. 6
FIRST STAGE CARE
• One to one midwifery led care in a private, relaxed setting
• Facility to eat and drink as desired
• Full discussion of birth plans and options
• Regular obs and intermittent FHR
• Abdominal exams for descent and position 4hrly
• Vaginal exam only where clinically necessary to see cervical
effacement and dilation
• Assessment of PV discharge including “bloody show”, blood and
amniotic fluid
• 0.5cm/hr dilation rate is lower limit of normal in para 0
• 1cm/hr in para >0
8. 7
SECOND STAGE – FOETAL DELIVERY
• Begins when cervix is fully dilated to 10cm
• Foetal head is fully descended into the pelvic brim
• Pressure on the cervix gradually increases
• Expulsive contractions push the foetus from the uterus
• Assisted by maternal pushing, which should be spontaneous rather
than directed
• Upright postures are associated with higher quality of contractions
and faster labour
9. 8
FOETAL MOVEMENTS DURING DELIVERY
• Descent takes places throughout
labour
• Leading aspect of the foetus descends
through the pelvic canal, twisting to
take advantage of the widest parts
• Rotates forwards under the symphysis
pubis, guided by the pelvic floor
• Normal foetal progress is a vertex
presentation
10. 9
FOETAL MOVEMENTS DURING LABOUR
• Flexion increases throughout labour
• As pressure along the longitudinal axis of the foetus increases the
head is flexed forwards
• This position presents the smallest diameter to the pelvic canal
• Rotation of the head
• As the head and then the shoulders pass through the pelvic canal
they twist to pass match the widest axes
• Typically the foetus crowns with a 45° rotation of the head relative
to the shoulders which resolves as they follow
• Shoulders
• Shoulders are born sequentially, anterior first, twisting and passing
out under the pubic symphysis
11. 10
SECOND STAGE CARE
• 4 hourly obs, FHR after each contraction for 1 minute
• Abdo and or PV exams as required to assess descent and position
• Descent should begin within 1 hour of commencement of pushing
for para 0 or 30 mins for para >0
• Descent of foetal head and quality of contractions are the most
reliable progress indicators
• Episiotomy is not routinely indicated unless there are signs of foetal
distress or clear evidence of perineum obstructing progress
12. 11
THIRD STAGE – PLACENTAL DELIVERY
• Begins after the delivery of the neonate and lasts until the placenta
has been delivered
• Active management of third stage is recommended (NICE)
– Routine use of uterotonic drugs (oxytocin)
– Early clamping and cutting of the cord
– Controlled cord traction with uterine counterpressure
• Physiological management may be supported in low risk women if
requested
– Convert if haemorrhage, >1 hr duration, requested by mother
– Consult obstetrics if not resolved with 30 mins active
management or 1 hr physiological management
13. 12
KCND
• Keeping Childbirth Natural & Dynamic (KCND)
• Scottish Govt Program led by consultant midwives
• Aims to provide women with as natural a birth as possible by:
– Providing evidence based care
– Reducing unnecessary intervention
– Ensuring informed choice
– Developing “multiprofessional” care pathways
14. 13
PRINCIPLES OF CARE
• Ascertain the patient’s needs and expectations of labour and care
• Avoid interventions where labour is progressing normally
• Ensure 1-to-1 care is delivered wherever practicable
• Avoid leaving the woman alone
• Where necessary provide a means to summon help and a time when
staff will return
• Allow and encourage the involvement of birth partners
• Allow and encourage women to ask for analgesia at any stage
• Allow women to drink and eat lightly except where specific risks
preclude it
15. 14
BIBLIOGRAPHY
Slide Principle Source(s)
1 UofAbereen – KCDN
http://www.abdn.ac.uk/dugaldbairdcentre/projects/kcnd.shtml
2 NICE Pathway, Normal Labour & Birth
http://pathways.nice.org.uk/pathways/intrapartum-care/normal-labour-and-birth
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