1.normal labor & delivery.pptx

Faculty of Medicine &Health sciences
1
GUS BLOCK(4th –level- O&G DEPARTMENT)
Course Code -BMD 27
Faculty of medicine& Health sciences
Obstetrics & Gynecological Department
Bachelor of Medicine & Surgery
Dr. Hanan Mohammed
E-mail: hananmhhasan@gmil.com

NORMAL LABOR& DELIVERY
- I
Dr. Hanan Mohammed Hassen

OBJECTIVES
• Definition of normal labor & abnormal labor
• Know the minster of onset of labor
• identify the component of labor
• Define the stages of labor
• Understand the mechanism of labor
• Know the graph for progress of labor( Partogram)
• Definition of abnormal labor, causes & management

Introduction
Labor(parturition)(tocia)
event that take place in the uterus & birth canal to expel viable fetus through
vagina.
Delivery
Expulsion or extraction of a viable fetus out of the uterus. Delivery may be
surgical via an abdominal or vaginal route.
Normal labor(eutocia)
means a mature fetus presenting by vertex is delivered spontaneously through
birth canal within 24 hours without interference except episiotomy & without
fetal or maternal complication.

Abnormal labor(Dystocia)
which refer to prolong ,difficult labor or complications to mother or baby.
Preterm or premature labor
It occurring after viability of fetus 20 wks. & before completed 37 wks.
Of pregnancy.
Postterm pregnancy (postmaturity)
Prolongation of pregnancy two weeks or more beyond the expected date
of delivery(>42).

ONSET OF LABOR
• Fetoplacental theory ( fetal cortisol theory)
Fetal pituitary is stimulated prior to onset of labor ,stimulates fetal adrenals to
secret cortisol which inhibit progesterone synthesis.Alteration of estrogen &
progesterone ratio leads to PG synthesis.
• Oxytocin
Increase in oxytocin level at term.
• Uterine distension
cause uterine contractions

• Prostaglandins(PGs)
PG synthesis act by inhibiting calcium binding therapy increase in free
calcium ,which stimulates uterine contraction.
• Nervous factor
Contractile response is initiated through alpha receptor nerve fiber in and
around cervix &uterus.
• Placenta ischemia
Result in decrease oxytocinase enzyme so increase oxytocin level

COMPONENT OF LABOR
• Process of parturition involves four components commonly called the 4Ps are:
1. Power(or the force) - involuntary uterine contractions to push the fetus out.
2. Passenger( or the fetus) – must be of size & shape to negotiate through the
varying dimension of birth canal.
3. Passageway( or the birth canal or maternal pelvis) – must be of adequate size to
allow descent , rotation & expulsion of the fetus.
4. Psyche (or the maternal psychological response) – sometimes affects the
progress of labor .A n anxious women secretes catecholamine, which may inhibit
uterine contraction.

POWER (UTERINE CONTRACTION)
A. Primary forces
The primary forces are uterine contraction in labor. Uterine contraction are involuntary,
intermittent, regular &painful, pain is due to stretching &ischemia of muscle fiber. Pain of
uterine contraction is distributed along cutaneous nerve of T10-L1.Pain of cervical dilatation
is referred to back through sacral plexus.
Characteristics of uterine contraction:
• Coordination of contractions between upper &lower segment.
• Fundal dominance ,strong contractions at fundus & diminish at lower uterine segment.
• Contractions follow a regular pattern. Intrauterine pressure raised beyond 20 mmHg with
onset of labor.

• The baseline pressure(intrauterine pressure between contractions) is 8-10 mmHg.
• Intrauterine pressure rise to 40 mmHg during first stage& 80 mmHg in second stage
during contraction.
• Duration in early first stage it less than 20 sec & it be40- 60 sec in late first stage
of labor to 60-90 sec in second stage.
• Frequency in first stage it starts as 1-2contraction /10 min & increase to 4-5 /10 min
in late first &second stage.
• contraction/ relaxation/retraction.
Retraction it is special property of upper segment of uterus. The is progressive
shortening of muscle fiber following contractions. Net effect of retraction is formation
of lower uterine segment & cervical dilatation. It help in the expulsion of
fetus,sepration of placenta, control of uterine bleeding& involution of uterus.

• B. Secondary force
Contraction of voluntary muscles of abdominal wall to reinforcing uterine
contraction to expel the fetus during second stage, this is called bearing down
effort.

PASSENGER (FETUS)
Vaginal delivery need the accommodations of the fetal head to maternal bony pelvis.
The fetal skull
The skull consist of vault, face& base.
The vault
• The bones: 2 frontal,2 parietal ,2 temporal, 1 occipital bone.
• The sutures : space between bones & made of un ossified membrane ,it 6 sutures,
-frontal between 2 frontal bones
-sagittal between 2 parietal bones
-coronal between frontal &parietal bones
- lambdoid between 2 parietal bones & occipital bone
-2 temporal between parietal& temporal bones

• Fontanelles area when sutures meet membrane fill spaces
*Anterior fontanelle (bregma)
diamond shape intersection sagittal, frontal& coronal sutures, closed at 18 month.
*Posterior fontanel (lambda)
Triangular shape ,found at junction of sagittal& lambdoid sutures closed at 6-8 wks. Of
life.

• Diameters
Anteroposterior diameters(engagement diameters)
1. Suboccipto - bregmatic (9.5cm) when head completely flex in OA
2. Suboccipto - frontal (10cm) when head not completely flexed in OA
3. Occipto – frontal (11cm) when head deflexed in OP
4. Mento - vertical (13.5) when head midway between flexion &extension in brow presentation
5. Submento – bregmatic (9.5cm) when head completely extended in face presentation
• 6.Submento – vertical (11.5cm) when head is not completely extend in face presentation
• Transverse diameters
1. Biparietal ( 9.5cm)
2.Subparietal – supraparietal (9cm)
3.Bitemporal(8cm)
4.Bimastoid (7.5cm)

• Attitude it is the relation of fetal parts to each others, mostly fetus in an attitude of complete
flexion , that all joint flexed
• Lie is the relation of longitudinal axis of fetal to maternal axis, if it parallel the lie is
longitudinal& if it cross each other, the lie is oblique or transverse
- longitudinal 99.5%
-transverse
- oblique 0.5%
- unstable

• Presentation the part of fetus occupies the lower pole of uterus ( is first reach the birth canal)
Cephalic – 96 → Cephalic presentation :
Breech – 3.5% * Vertex (sharply flexed)
Shoulder – 0.4% * Face (marked extend)
Oblique – 0.1% * Sinciput (slightly flexed)
* Brow (slight deflexed)
Vertex area of vault between ant. & post. Fontanelles & the parietal eminences when head
flexed
Face area between root of nose & supraorbital ridges to junction of chin with neck when head
fully extended

Sinciput area in front of ant. Fontanelle corresponding to forehead
Brow area of forehead from root of nose (glabella) & supraorbital ridge to bregma (ant.
Fontanelle) & coronal sutures when head midway between flexion & extension (deflexed)
Occiput area limited to occipital bone
• Denominator is landmark on the presenting part by which known the position of the fetus
* occiput is denominator in vertex presentation
* sacrum is denominator in breech presentation
* frontal bone is denominator in brow presentation
*mentum is denominator in face presentation
*scapula is denominator in shoulder presentation

• Position is the relation of denominator to maternal pelvis. For that purpose maternal pelvis
divided into equal segments of 45◦ degree(8 position) in vertex presentation there are 8
position
Direct occipito –anterior (DOA) ,occiput points toward symphysis pubis
Right occipito – anterior (ROA) ,occiput points toward right iliopectineal eminence
Right occipito – transverse (ROT) , occiput points toward right iliopectineal line
Right occipito –posterior( ROP) , occiput towards right sacroiliac joint
Direct occipito –posterior (DOP) ,occiput toward sacral promontory
*Same for left position

• Occiputo anterior position are more common because concavity of fetal
spine fits into convexity of maternal spine.
• The head usually enter pelvis with it is AP diameter in oblique diameter,
more common in the right oblique as :
• The right oblique is usually slightly longer than the left oblique
• The left oblique is reduced by pelvic colon
• So LOA is more common than ROA & ROP is more common than LOP.

OA
ROA | LOA
ROT__________________|__________________ LOT
ROP | LOP
|
OP

Diagnosis of Fetal Presentation and Position
-Abdominal Palpation—Leopold Maneuvers :
Abdominal examination can be conducted systematically employing the four
maneuvers described by Leopold in 1894 .
-The mother lies supine and comfortably positioned with her abdomen bared.
These maneuvers may be difficult
- if the patient is obese.
- if there is excessive amniotic fluid
- if the placenta is anteriorly implanted.
1. Fundal grip( to detect presentation) , the first maneuver permits identification of which fetal pole that is
occupies the uterine fundus.
2. Umbilical grip ( to detect position), the second maneuver is accomplished as the palms are placed on either
side of the maternal abdomen, and gentle but deep pressure is exerted on one side, a hard, resistant structure is felt the
back. On the other, numerous small, irregular, mobile parts are felt—the fetal extremities. By noting whether the
back is directed anteriorly, transversely, or posteriorly .

3. Fist pelvic grip( to confirm presentation) ,the third maneuver is performed by grasping with
the thumb and fingers of one hand the lower portion of the maternal abdomen just above the
symphysis pubis to feel part of fetus occupying the lower uterine segment, and to identified
engagement ,if not engage it movable mass if deep engage so do second pelvic grip.
4. Second pelvic grip , the fourth maneuver, the examiner faces the mother’s feet and apply
the hands on both sides, exerts deep pressure in the direction of the axis of the pelvic inlet.
The aim is to detect engagement, to feel head of second twin, to detect degree of deflexion of
head:
- if flexed occiput is lower than sinciput
- if extend occiput higher than sinciput
- if deflexed occiput & sinciput at same level

• Vaginal Examination
• In attempting to determine presentation and position by vaginal examination,
comprising four movements:
1. The examiner inserts two fingers into the vagina and the presenting part is found.
2. If the vertex is presenting, the fingers are directed posteriorly and then swept forward over the fetal head toward the
maternal symphysis. During this movement, the fingers necessarily cross the sagittal suture and its course is delineated
3. The positions of the two fontanels then are ascertained. The fingers are passed to the most anterior extension sagittal
suture, and the fontanel encountered there is examined and identified. Then, with a sweeping motion, the fingers pass
along the suture to the other end of the 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 .

CHANGE IN FETAL SKULL DURING LABOR
• Moulding the bone of fetal skull overlap each others, one parietal bone overlaps the other
& both overlap overlaps occipital bone, slight moulding is physiological & allow
diminishes diameters of head to facilitate passage through maternal pelvis. Sever moulding
or rapid mouldind is dangerous &may leads to intracranial hemorrhage.
• Caput succedaneum is edema of fetal scalp due to prolong compression of fetal head
against maternal pelvic bone or soft tissue , leading to compress venous &lymphatic
drainage it usually formed after rupture of membrane & always during the first stage of
labor. It disappears within 1-2 days after delivery. It indicated that: 1) fetus alive , 2) labor
prolong & obstructed ,3) give idea about position of fetal head during labor because it
formed at lowest part of head.

PASSAGE(MATERNAL PELVIS)
Pelvic bone:
1. Pelvic inlet is bounded anterior by symphysis pubis & laterally by superior margin of
pubis bone & iliopectineal line & posterior by sacral promontory.
The normal transverse diameter is 13.5cm & Ap diameter is 11cm.
2. Pelvic mid-cavity area is bounded in front by the middle of symphysis pubis,lateraly by
pubic bone, obturator fascia, ischial bone & spine, posteriorly by junction of 2&3 rd. pieces
of sacrum. The cavity is almost round as transverse AP diameter are 12cm.
3. Pelvic outlet is bounded anterior by lower margin of symphysis pubis, laterally pubic
bone& ischial tuberosity ,posteriorly by last piece of sacrum. The AP diameter is 13.5cm
&transverse is 11cm.

2. Increase vaginal secretions
3. Cervix becomes soft & effaced.
4. False labor pains occur with variable frequency.
Signs of true labor
• Pain felt in front of lower abdomen& radiated to bag
• Painful uterine contractions which increase in frequency& duration associated
with hardening of uterus.
• Show-blood stained mucus discharge.
• Progressive effacement & dilatation of cervix.
• Formation of bag of membranes.
• Descend of head.

First stage (cervical stage of labor)
• Start from the onset of true labor pains to full cervical dilatation.
• Average duration of first stage is
12 hrs. in primigravida
6 hrs. in multigravida
First stage of labor is divided into:
- Latent phase : up to 4cm cervical dilatation
- Active phase : 4 – 1ocm cervical dilatation

Phases of first stage primi multi
Latent phase < 20 hrs. < 14 hrs.
Active phase 4 hrs. 2 hrs.
Rate of cervical dilatation ≥1.2 cm /hrs. ≥ 1.5 cm/ hrs.

Second stage(delivery of baby)
• Starts from full cervical dilatation to delivery of baby.
• Average duration of second stage:
- 2 hrs. in primigravida
- 1 hrs. in multigravida

Third stage (delivery of placenta)
• Starts from delivery of the baby to expulsion of placenta &membranes.
• 15-30 minute in primagravida & multigravida
Fourth stage
• It stage of observation after third stage for 1 -2 hrs. to detect any
problems.

Thank you

1.normal labor & delivery.pptx

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