normal labour

1. NORMAL
LABOUR
AHMAD FURQAN BIN NOOR AZMI
SYAZA SYAZANA BINTI NORDIN

2. STRUCTURE OF MYOMETRIUM
• Myometrium located in the middle between perimetrium and
endometrium
• Consist mainly of uterine smooth muscle (uteromyocytes).
• Has 3 types of smooth muscle :
• Longitudinal
• Circular
• Oblique

3. CONTRACTION OF UTERINE MYOCYTES

4. MECHANISM OF MYOMETRIUM
CONTRACTION
In myometrium, the thick and
thin filaments(actin and
myosin) are found in long,
random bundles throughout
the cells
Hormone such as oxytoxin
and prostaglandin are the
agent for activation the
calcium channel and allow
calcium to enter the uterine
myocyte.
The interaction of actin and
myosin with calcium and
adenosine triphosphate(ATP)
will causes contraction of
uterine myocyte
The cell membrane also
contain gap juction that allow
communication from cell to
cell to provide synchronization
contraction
Synchronization of
myometrium smooth muscle
cell by diff type of vegetative
NS causes strong myometrial
contraction during labour

5. FUNCTION OF MYOMETRIUM
• To contract during process of labour
by a positive feedback effect on
“ferguson reflex”
WHAT IS FERGUSON REFLEX????
• Contraction of uterus after the
cervix has been stimulated
• Impulse generated due to NS and
humoral factor (oxytocin)
• Ferguson reflex created the urge to
push during labour.

7. LABOUR DELIVERY
“HARD WORK” “WITH HELP”
Fully normal natural process of giving birth
process through normal which involves active
birth canal. management and medical
helps.

8. CAUSES OF LABOUR
HORMONAL FACTOR
• FETO-PLACENTA DISTRIBUTION
• -CRH → pituitary,ACTH → fetal adrenal gland,glucocorticoid →
accelerated production of estrogen and prostaglandins from
placenta → reduce progesterone production
• Increase oestrogen (increase exitabiliity of myometrium
membrane and increase synthesis of prostaglandin)
• Increase prostaglandin (maintain labour)
• Decrease progesterone (increase contractility)

9. MECHANICAL FACTOR
• UTERINE DISTENTION
• Due to extra strength : when uterus distended to a certain limit, it
start to contract to evacuate its contents.

10. SIGN OF LABOUR
REGULAR CONTRACTION
 With pain and uterine get tighten
 Oxytoxin will be release when true labour occur. Oxytoxin is a
hormone that induce contraction of myometrium
 Contraction usually start at the back and move around to the
front. The contraction can be felt as a cramping or tightening
sensation

11. SIGN OF LABOUR
PASSING THE MUCUS PLUG
The cervix is plugged with a thick
piece of mucous that helps
protect fetus during pregnancy
by blocking the entrance to the
uterus
When the cervix effaces and
dilates, the mucus plug will be
release
Labour is usually starts several
hours to few days after that.

12. BACK LABOUR
Back labor refers to the intense lower back pain
that many women feel during contractions when
they're giving birth.
The position of baby such as occiput anterior can
causes pressure from the baby’s head to be
applied to the mother sacrum

13. BRAXTON’S HICKS
• Cervix is a part of uterus.
• False contraction to prepare for cervix ripening before onset of the labour.
• Usually pain is felt at night.
CERVIX RIPENING.
• Cervical canal become short and wider
• Palpation consistency : soft

14. TRUE LABOUR
• Regular interval last
about 30-70s
• As time goes by, they
get stronger , longer
and closer
• Pain is felt at the back
to the abdomen.
FALSE LABOR /
BRAXTON HICKS
• Irregular contraction
and doesn’t get close
together.
• Pain stop when pt take
a walk/change position
• Contraction usually
weak and doesn’t get
stronger
• Pain is felt only in front
of abdomen / pelvis

15. STAGES OF LABOUR
FIRST
STAGE
SECOND
STAGE
THIRD
STAGE

16. FIRST STAGE OF LABOUR
LATENT PHASE
-Start with regular uterine contraction and
ends with the beginning of cervical dilation
and effacement
ACTIVE PHASE
-Increase velocity of cervical dilatation in
short duration( hours) from 3cm to 7cm
-Uterine contraction become intensively
increase, more frequuent longer and
stronger
DECELERATION PHASE
-Decrease velocity of cervix dilatation from
7cm to maximun dilatation 10cm and full
effacement
-It occurs because the head descend and
is it contract with the cervix . It give force to
cervix to dilate more
-Causes cervix to dilate until full dilatation
based on
velocity of
cervical
dilatation

17. GRAPH OF VELOCITY OF CERVICAL DILATATION.

18. Relationship between cervical dilatation and
fetal descent

19. UTERINE CONTRACTION AND RETRACTION UTERINE
SEGMENT
• During contraction upper segment become firm and lower
segment become softer,distended and more passive
• Refraction ring form between the upper and lower segment of
the uterus
• During first stage of labour the upper segment contract,refracts
and expels the fetus and in respond to these contraction, lower
segment become softened
• The upper segment does not relax to its original length after
contarction,it become relatively fixed at shorter length in order to
maintain and gain expulsive force of fetus

20. CERVICAL EFFACEMENT AND DILATATION
• Cervical effacement occur because of increase myometrial activity during
uterine preparation for labour just after cervix is ripened
• The cervix gradually softens, shorten and become thinner. It is called
cervical effacement
• The muscular fibre at about level of the internal cervical os are pulled
upward ot taken up into lower uterine segment. The condition of the
external os remain unchaged
• The presenting part ,applied to the cervix and forming lower uterine
segment
• Because the lower uterine segment and cervix have lesser resistance
during a contraction, the uterine contraction cause pressure on the
membrane and hydrostatic action of amniotic sac in turn dilates the
cervical canal. It is called cervical dilatation.

22. RUPTURE OF MEMBRANE
• Occur during full dilatation
• “EARLY MEMBRANE RUPTURE”
 When it occur at 6cm of dilatation
• “PRETERM MEMBRANE RUPTURE”
When it occur before the onset of labour.

23. SECOND STAGE
(FETAL EXPULSION)
• Start when cervical dilatation is complete and end with the expulsion of the fetus
• All the mechanism of labour happen in this stage.
Head of the fetus decent passes through the muscular birth canal (pelvic
inlet)
PUSH(voluntary movement)
The head of the fetus pressed on the muscle of pelvis causing increase
sensitivity on the stretch receptor on pelvic muscle and causes mother to
have the urge to push fetus out
As the fetal head continue descend ,the vagina open and the fetal scalp
appears. At first it appears slit like then become oval then circular . This is
called crowning
As she continue pushes,using her adominal muscle to aid the involuntary
uterine contraction ,the fetus is pushed out of the birth canal

24. • During this stage : mother start to feel the
new event.
1. Labour : uterine contraction
2. Pushing
Voluntary : sense at anterior
abdominal muscle and pelvic
muscle.
involuntary

25. THIRD STAGE
(PLACENTAL SEPARATION
AND EXPULSION)
 Occurs immediately after delivery of the
fetus.
 The management of placenta expulsion
only occur 30 mins to prevent excessive
bleeding/hemorrhage.
 If not,manual separation and removal of
placenta will be done.
 2 types :
 Marginal separation
 Central separation
 Mechanism :
-contraction continue after the
fetus is expulsed to help with the
membrane separation.
-contraction also continue to
provide spasm of vessel to
prevent bleeding.

27. MANAGEMENT OF NORMAL LABOUR
ADMINISTRATION PROCEDURE.
1. IDENTIFICATION OF LABOR
• To differentiate true/false labor
2. CERVICAL EXAMINATION
• Cervical effacement
• Cervical dilation
• Level of station (distance between fetal part in birth canal and inshial spine)

28. 3. VAGINAL EXAMINATION
The function of vaginal examination are to:
• Identify the fetal presentation and position
• 4 movement of vaginal examination
1. Insert 2 finger into vaginal
2. Fingers directed posteriorly and then swept forward over the
fetal head toward maternal symphysis. During the movement
,the fingers should cross the saggital suture.
3. The position of 2 fontanel are ascertained,the fingers are
passed to most anterior extension of saggital suture ,and
fontanel there is examined and identified. Then with a
sweeping motion the fingers pass along the suture to other
end of head until the other fontanel is felt and differentiated
4. The station or extent to which the presenting part has
descended into the pelvis, can also be established at this
time
4. DETECTION OF RUPTURED MEMBRANE
• Diagnosed when amniotic fluid is seen

29. MANAGEMENT OF THE FIRST STAGE OF LABOUR
Cardiotocography
• Monitor fetal heart rate at least every 30 mins (1st stage), each 15 mins (2nd stage)
Intravenous Fluids
 An intravenous infusion system is advantageous during the immediate puerperium
to administer oxytocin prophylactically and at times therapeutically when uterine
atony persists.
 Moreover, with longer labors, the administration of glucose, sodium, and water to
the otherwise fasting woman at the rate of 60 to 120 mL/hr prevents dehydration
and acidosis.

30. MANAGEMENT OF THE FIRST STAGE OF LABOUR
PARTOGRAM
A graphical representation that record the observation and information from
the monitoring of the mother and fetus
Consist
• Maternal status
• Fetal heart rate
• Dilation and descent
• Uterine contraction

31. MANAGEMENT OF THE FIRST STAGE OF LABOUR
ANALGESIC.
The pain of childbirth is likely to be most severe pain that a women experience during
her lifetime
Analgesia that usually used:
• Meperidine = 25-50 mg every 1-2 hours or 50-100mg every 2-4 hours
• Fentanyl = 50-100mcg every hours
• Nalbuphine = 10 mg IV or IM every 3 hours
• Butorphanol = 1-2 mg IV or IM every 4 hours
• Morphine, 2-5 mg IV or 10 mg IM every 4 hours
As an alternative ,regional anesthesia may be given. Anesthesia option include:
• Epidural
• Spinal
• Combined spinal-epidural

32. MANAGEMENT OF THE FIRST STAGE OF LABOUR
ACTIVE MANAGEMENT
ACTIVE MANAGEMENT OF LABOUR (AML) IS A STRUCTURED
PROTOCOL
• with the aim of reducing prolonged labour. ( to keep labour to
fewer than 12 hours and to a minimum operative delivery rates. )
• Two of its components are performed :
 -Amniotomy
 -Oxytocin
• When dilation is not increased by 1cm per hour,amniotomy is
performed.After 2 hours,high dose oxytocin infused if still not
dilated.
ARM, (Artificial rupture of the membranes) AMNIOTOMY
• Breaking the membranes that surround the baby and releasing the
amniotic fluid before it breaks naturally itself.
• This is performed with the use of a long sharp hook similar to a
crochet hook that is inserted through vagina and cervix and used
to make a small nick in the membranes allowing the waters to
escape. Patient will be required to lay on her back with her legs
open while this procedure is preformed.
• ARM’s are used to either help start labour before it is ready to
started itself, or speed up a labour that is not moving fast enough
for either the care provider or the mother.

33. MANAGEMENT OF SECOND STAGE OF LABOUR
Once cervix is fully dilated and the women is in the expulsive phase of the
second stage ,encourage her to assume the position she prefer and
encourage her to push

34. PERINEUM CLEANING
• Need 6 swab balls
• Clean sequentially as shown by the numbers
• Clean according to the direction by the arrow
• Delivery must be sterile and antiseptic
procedure
CREATE STERILE FIELD AROUND THE
VAGINAL OPENING

35. EPISIOTOMY
• Not a routine procedure and are considered preventing tear
Do not decrease:
• Perineal damage
• Future vaginal prolapse
• Urinary incontinence
Associated with
• An increase of 3rd and 4th degree tears
• Subsequent anal sphincter muscle dysfunction
Considered only in:
• Complicated vaginal delivery
Breech
Forceps
Vacuum
• Scarring from female genital mutilation or poorly heald 3rd or 4th degree tear

36. MANAGEMENT OF THE SECOND STAGE OF LABOUR
•Ritgen Maneuver is performed
•As crowning occurs, place a hand on the top of the
baby’s head and apply light pressure
•Instruct the mother to focus on her breathing. Have her
“pant like a dog” to help her stop pushing and prevent
a forceful birth.
DELIVERY OF THE HEAD
•Ask the woman to pant or give only small pushes
with contractions as the baby’s head delivers
•To control birth of the head, place the fingers of
one hand against the baby’s head to keep it
flexed (bent)
•Continue to gently support the perineum as the
baby’s head delivers

37. MANAGEMENT OF THE SECOND STAGE OF LABOUR
DELIVERING OF THE SHOULDERS
•The side of the head are grasped with two hands and gentle
traction is applied until anterior shoulder appears
•Upward movement until posterior shoulder is delivered
SUCTION THE BABY’S MOUTH AND NOSE
•Once the baby’s head delivers, ask the woman not to push
•Suction the baby’s mouth and nose
NUCHAL CORD
If the cord is around the neck, attempt to slip it over the baby’s
head.
Feel around the
baby’s neck
for the umbilical cord

38. ASSISTING WITH DELIVERY
• As the head emerges, the baby will turn to one side (for easier passage of
shoulders through birth canal)
• Check to see if the umbilical cord is looped around the baby neck. If so,
gently slip it over the head
Baby delivered
First body contact of mother
and baby and cord clamping
Clamping,cutting and tying
of umbilical cord

39. MANAGEMENT OF 3RD STAGE OF LABOR
• Talk to the women and tell her that you will be deliver the placenta
• Wash your hand and put on your sterile glove
• After having the signs of placental separation, hold the clamp close to the
perineum with one hand.
• Gently guide the placenta downward and outward by holding on the cord
• Be gentle and do not pull as it can tear or break the cord
• When the bulk of placenta is out, hold it with 2 hands
• Rotate the placenta like twisting a rope until delivered so that fetal membranes
will come out
4 SIGNS OF PlACENTAL
SEPARATION
-Uterus becomes globular
and firm
-Sudden gush of blood
-Uterus rise in the
abdomen and placenta pass
down into vagina
-Umbilical cord protrudes
farther out of vagina

40. MANAGEMENT OF THE THIRD STAGE OF LABOUR
EXPECTANT MANAGEMENT
• Feel the uterus from the abdomen and massage it to keep in contracted
• Injected an oxytoxin drug intramusculary to control bleeding
• The best time to inject oxytoxin during 3rd stage of labour
A. After delivery of baby
B. After delivery of the placenta

41. MANAGEMENT OF THE THIRD STAGE OF LABOUR
• Repair episiotomy
• Controlled cord traction
• Massage of uterus

42. ROLE OF :
• To detect any sign of possible complications.
• To prevent complications.
doctor
• Performed manual assistant during normal
labor to prevent injury to mother. ( laceration
of birth canal soft tissue )
midwives