NILOFAR LOLADIYA MSN: OBGY Labor consists of a series of rhythmic, involuntary or medically induced contractions of the uterus that result in effacement (thinning and shortening) and dilation of the uterine cervix. The World Health Organization (WHO) defines normal birth as follows: The birth is spontaneous in onset and low risk at the start of labor and remains so throughout labor and delivery. The infant is born spontaneously in the vertex position between 37 and 42 weeks of pregnancy. After birth, mother and infant are in good condition (1). The stimulus for labor is unknown, but digitally manipulating or mechanically stretching the cervix during examination enhances uterine contractile activity, most likely by stimulating release of oxytocin by the posterior pituitary gland. Normal labor usually begins within 2 weeks (before or after) the estimated delivery date. In a first pregnancy, labor usually lasts 12 to 18 hours on average; subsequent labors are often shorter, averaging 6 to 8 hours. Labor begins with irregular uterine contractions of varying intensity; they apparently soften (ripen) the cervix, which begins to efface and dilate. As labor progresses, contractions increase in duration, intensity, and frequency. Stages of labor There are 3 stages of labor. The 1st stage—from onset of labor to full dilation of the cervix (about 10 cm)—has 2 phases, latent and active. During the latent phase, irregular contractions become progressively coordinated, discomfort is minimal, and the cervix effaces and dilates to 4 cm. The latent phase is difficult to time precisely, and duration varies, averaging 8 hours in nulliparas and 5 hours in multiparas; duration is considered abnormal if it lasts > 20 hours in nulliparas or > 12 hours in multiparas. During the active phase, the cervix becomes fully dilated, and the presenting part descends well into the midpelvis. On average, the active phase lasts 5 to 7 hours in nulliparas and 2 to 4 hours in multiparas. Traditionally, the cervix was expected to dilate about 1.2 cm/hour in nulliparas and 1.5 cm/hour in multiparas. However, recent data suggest that slower progression of cervical dilation from 4 to 6 cm may be normal (1). Pelvic examinations are done every 2 to 3 hours to evaluate labor progress. Lack of progress in dilation and descent of the presenting part may indicate dystocia (fetopelvic disproportion). Standing and walking shorten the first stage of labor by > 1 hour and reduce the rate of cesarean delivery

1. LABOUR
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MSN (OBGY)

2. Clausen et all, 1973
Labour is rhythmic contraction and relaxation of the
uterine muscles with progressive effacement i.e thinning
and dilatation i.e. opening of the cervix, leading to
expulsion of the products of conception.
DEFINITION
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3. D.C DUTTA
A series of events that take place in the genital organs
in an effort to expel the viable products of conception
out of the womb into vagina into the outer world is
called labour.
DEFINITION
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4. THIRD
FIRST
SECOND
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5. CERVICAL
FETAL PLACENTAL
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6. FIRST STAGE
OF LABOUR
FIRST STAGE
OF LABOUR
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7. FIRST STAGE:
• It is that of dilatation of cervix.
• Begins with regular rhythmic contraction
and is complete when cervix is fully
dilated and effaced.
• In other words it is the cervical stage.
• Primigravida- 12 hours
• Multipara- 6 hours
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8. HORMONAL
ACTION
 ESTROGEN
 PROGESTERONE
 RELAXIN
 CERVICAL SOFTENING
 HYPERTROPHY
 VASCULARIZATION
 FLUID ACCUMULATION
IN COLLAGEN FIBRES
PREDISPOSING
FACTORS
BRINGS CHANGES IN
STRUCTURAL
COMPONENTS
CERVICAL
DILATATION
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DILATATION

9. Dilatation is clinically evaluated by measuring the
diameter of cervical opening in centimetres.
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12. Too much Fibrosis as in chronic cervicitis, prolapse or
organic lesion in the cervix as in carcinoma results in
deficiency of these factors. As a result cervix may fail to
dilate.
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13. A. Uterine Contraction and retraction.
B. Formation of Bag of membranes.
C. Fetal axis pressure.
D. Vis-a-tergo.
1. DILATATION
2. EFFACEMENT
3.FORMATION OF LOWER UTERINE SEGMENT
EVENTS IN FIRST STAGE OF LABOUR
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14. • The longitudinal muscle fibres of the upper segment are attached with
circular muscle fibres of the lower segment and upper part of the cervix in
the bucket holding fashion.
• Thus, with each uterine contraction not only the canal is opened up from
above down but it also becomes shortened and retracted.
• Upper segment contract, retracts and pushes the foetus,
• The lower segment and cervix dilate in response to the forces of contraction
of upper segment.
A. Uterine Contraction and retraction
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15. A. Uterine
Contraction and
retraction
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16. B. Formation of Bag of membranes.
-
• During labour the membranes attached to the lower uterine segment are
detachted
-
• Herniation of membranes through the cervical canal
-
• BALL-VALVE Action of well flexed head,
• During Uterine contraction, hydrostatic pressure in forewaters increases
Cervical dilatation NILOFAR LOLADIYA

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18. C. Fetal axis pressure.
In longitudinal lie, there is tendency of straightening out of the fetal
vertebral column due to contraction.
This allows the fundal contraction to transmit.
Allows mechanical stretching of the lower segment and opening of the
cervical Canal.
With each uterine contraction, there is elongation of the uterine ovoid and
decrease in the transverse diameter.
Absent in transverse lie.
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19. D. Vis-a-tergo.
The final phase of dilatation and retraction of the cervix.
There is downward thrust of the presenting part of the fetus and
upward pull of the cervix over the lower segment.
Absent in transverse lie.
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20.  Effacement is the process by which the muscular fibres of the
cervix are pulled upwards and merges with the fibres of the lower
uterine segment.
Shortening of cervical Canal from its usual length of 2 to 3
centimetres to one in which the cervical Canal is obliterated
leaving only the external os as a circular orifice with thin edges.
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2. EFFACEMENT or ‘taking up’ of the Cervix.

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23.  Expulsion of mucus plug is caused by effacement.
The cervix becomes thin during first stage of labour or even
before that in primigravida.
In primigravida effacement proceed dilatation of the cervix,
where as in multipara both occur simultaneously.
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PRIMIGRAVIDA MULTIGRAVIDA

25. 3.FORMATION OF LOWER UTERINE SEGMENT
Before the onset of labour there is no complete Anatomical or functional
division of the uterus.
During labour, the demarcation of an active upper segment and a relatively
passive lower segment..
The wall of the upper segment becomes progressively thickened with
progressive thinning of the lower segment.
More pronounced in late first stage, especially after rupture of membranes.
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28. ANATOMICAL FEATURES:
Developed from Isthmus.
Above: Physiological ring.
Below: Fibromuscular junction
of cervix and uterus.
7.5-10 cm when fully formed.
Gradually becomes thin.
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29. CLINICAL SIGNIFICANCE:
Enables expulsion of fetus.
Caesarean section is performed at this segment.
Poor decidual reaction facilitates morbid adherent placenta.
In obstructed labour, it gets stretched and thinned and ultimately
ruptures.
Passive segment, Poor retractile property
Chances of PPH if placenta implanted here.
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30. SECOND STAGE
OF LABOUR
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31. SECOND STAGE:
• It is the stage of expansion of the
foetus it begins with complete
dilation of the cervix through
complete birth of a baby.
• Primigravida- 2 hours
• Multipara- 30 mins
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32. The second stage begins with the complete dilatation of the cervix
and ends with the expulsion of the fetus.
It is concerned with the descent and delivery of the fetus through
the birth canal.
A. Propulsive Phase:
Full Dilatation-head touches the pelvic floor
B. Expulsive Phase:
Irresistible desire to ‘bear down’ and push until the baby is
delivered.
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33.  Expulsive uterine contractions
 Rupture of the forewaters
 Dilatation and gaping of the anus
 Appearance of the presenting part
 Show
 Congestion of the vulva
SIGNS
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34. DEFINITION: MECHANISM OF LABOUR
The series of movements that occur on the head in the
process of adaptation, during its journey through the pelvis, is
called mechanism of labour.
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35. PRINCIPLES:
Descent takes place throughout the labour.
Whichever part leads and first meets the resistance of the
pelvis floor will rotate forward until it comes under the
symphysis pubis.
Whatever emerges from the pelvis will pivot around the pubic
bone.
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36. LIE:
PRESENTATION:
ATTITUDE:
DENOMINATOR:
POSITION:
PRESENTING PART
IN LOA
ENGAGING DIAMETER: AP
Sub-occiputo Bregmatic: 9.5
Sub-occiputo Frontal: 10
ENGAGING DIAMETER:
Transverse
Biparietal: 9.5
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37. 1. ENGAGEMENT
2. DESCENT
3. FLEXION OF HEAD
4. INTERNAL ROTATION OF HEAD
5. CROWNING
6. EXTENTION OF HEAD
7. RESTITUTION:
8. INTERNAL ROTATION OF SHOULDER AND EXTERNAL ROTATION OF HEAD
9. LATERAL FLEXION
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MECHANISM OF LABOUR

38. 1. ENGAGEMENT:
The head enters the brim of the pelvis and gets fixed.
2. DESCENT:
Slow progressive throughout the labour
Factors responsible are-
• Uterine contractions and retractions
• Bearing down efforts
• Straightening of fetal ovoid specially after rupture of membranes
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39. 3. FLEXION OF HEAD:
• Flexion is achieved either due to the resistance offered by the unfolding cervix, the
walls of the pelvis or by the pelvic floor. Essential for descent, since it reduces the
shape and size of the plane of the advancing diameter of the head.
• Sagittal Suture over Rt Oblique diameter
• Shoulder over Lt Oblique diameter
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Subocciputo Frontal
(10 cm)
Subocciputo Bregmatic
(9.5cm)

40. 4. INTERNAL ROTATION OF HEAD:
• Occiput leads and meets the pelvic floor first and rotate anteriorly through 1/8th of
a circle
• From Lt Iliopectineal eminence to the symphysis pubis
• Causes a slight twist in the neck of the fetus
• Thus, head no longer in direct alignment with the shoulder
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41. 5. CROWNING:
• The occiput slips beneath the sub-pubic arch
• crowning occurs when the head is no longer
• recedes in between the contractions .
• Occiputal eminence escapes under symphysis pubis.
6. EXTENSION OF THE HEAD:
Fetal head extends the nape of the neck/
subocciputal region pivots on the
lower border of the symphysis pubis.
Sinciput, face and chin:
sweeps the perineum
• Head is born by extension
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42. 7. RESTITUTION:
Turning of the head to undo the twist in the neck
TWIST- Neck of the fetus which resulted from internal rotation is now corrected
by slight untwisting movement.
Occiput moves 1/8th of a circle towards left i.e. the side from it started
8. INTERNAL ROTATION OF SHOULDER
From Lt oblique to AP diameter
Anterior shoulder reaches the Rt side of the pelvic floor
Rotates forward bringing shoulder into the AP diameter of outlet
EXTERNAL ROTATION OF HEAD: Occiput-further 1/8th circle the same direction
as restitution
Occiput lies laterally, faces the opposite thigh
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43. 9. LATERAL FLEXION:
Anterior shoulder-first, Slips beneath the
subpubic arch
Posterior- passes over the perineum
BIRTH OF SHOULDER AND TRUNK:
Remaining by lateral flexion
Spine bends sideways through the curved
canal
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Anterior shoulder
Posterior shoulder

44. MANAGEMENT OF THE SECOND STAGE
The transition from the first stage to the second stage is
evidenced by the following features:
 Increasing intensity of uterine contractions.
 Appearance of bearing down efforts.
 Urge to defecate with descent of the presenting part.
 Complete dilatation of the cervix as evidenced on vaginal
examination
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45. PRINCIPLES:
(1)To assist in the natural expulsion of the fetus slowly and steadily,
(2)To prevent perineal injuries.
GENERAL MEASURES:
— The patient should be in bed.
— Constant supervision is mandatory and the FHR is recorded at every 5 minutes.
— To administer inhalation analgesics, if available, in the form of Gas N2O and O2
to relieve pain during contractions.
— Vaginal examination is done at the beginning of the second stage not only to
confirm its onset but to detect any accidental cord prolapse.
The position and the station of the head are once more to be reviewed and the
progressive descent of the head is ensured
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46. PREPARATION FOR DELIVERY
— Position: Positions of the woman during delivery may be lateral
or partial sitting. Dorsal position with 15° left lateral tilt is
commonly favored as it avoids aortocaval compression and
facilitates pushing effort.
—Scrubs up and puts on sterile gown, mask and gloves and stands
on the right side of the table.
— Toileting the external genitalia and inner side of the thighs is
done with cotton swabs soaked in Savlon or Dettol solution.
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47. One sterile sheet is placed beneath the buttocks of the
patient and one over the abdomen. Sterilized leggings
are to be used.
Essential aseptic procedures are remembered as 3 ‘C’s:
(a)Clean hands,
(b)Clean surface and
(c)Clean cutting and ligaturing of the cord.
— To catheterize the bladder, if it is full.
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49. Perineal lacerations:
1st = involving skin or vaginal mucosa BUT NOT into muscle
2nd = extending from skin & vaginal mucosa into m
muscles of perineum
3rd = extending from skin, vaginal muscosa into the anal
sphincter
4th = extending through the rectal mucosa into the lumen of
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71. FIRST STAGE
OF LABOUR
THIRD STAGE
OF LABOUR
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72. THIRD STAGE:
• Third stage of labour begins after
expulsion of the fetus and ends with
expulsion of the placenta and
membranes (after-births).
• Duration: 15 minutes in both
primigravidae and multiparae.
• Active management: 5Minutes
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73. Events in third stage of labour
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1. Placental Separation
a. Central Separation
(Schultze)
2. Descent into the
lower segment
3. Expulsion of the placenta
 Expectant
Manual Removal
Assisted Expulsion
b. Marginal Separation
(Mathews-Duncan)
a. Controlled cord traction
b. Fundal Method

74. Placental Separation
Progressive diminution of the area following successive retractions
Marked retraction reduces effectively the surface area at the placental site to
about its half.
As the placenta is inelastic, it cannot keep pace with such an extent of diminution
resulting in its buckling.
A shearing force is instituted between the placenta and the placental site
Placental Separation

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Signs of Placental Separation

76. • Detachment of the placenta from its uterine
attachment starts at the centre
• Resulting in opening up of few uterine
sinuses
• Accumulation of blood behind the placenta
(retroplacental haematoma).
• More and more detachment occurs
facilitated by weight of the placenta and
retroplacental blood until whole of the
placenta gets detached.
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Central separation (Schultze):

77. • Separation starts at the margin as it is
mostly unsupported.
• With progressive uterine contraction, more
and more areas of the placenta get
separated.
• Marginal separation is found more
frequently.
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Marginal separation (Mathews-Duncan):

78. • Membranes attached to the lower segment are already separated
during its stretching.
• The separation is facilitated partly by uterine contraction and mostly by
weight of the placenta as it descends down from the active part.
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Descent into the lower segment

79. Expulsion of placenta
• After complete separation of the placenta, it is forced
down into the flabby lower uterine segment or upper
part of the vagina by effective contraction and
retraction of the uterus.
• Thereafter, it is expelled out by either voluntary
contraction of abdominal muscles (bearing down
efforts) or by manual procedure.
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80. • Expulsion of placenta and membranes:-
• The expulsion is achieved either by voluntary bearing
down efforts or more commonly aided by manipulative
procedure.
• The “after-birth” delivery is soon followed by slight to
moderate bleeding amounting to 100-250 ml.
• Maternal signs:- There may be chills and occasional
shivering. Slight transient hypotension is not unusual.
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81. Assisted expulsion:
• (A) Controlled cord traction
(modified Brandt – Andrews
method) –
• The palmar surface of the
fingers of the left hand is
placed (above the symphysis
pubis) approximately at the
junction of upper and lower
uterine segment.
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82. Assisted expulsion:
(A) Controlled cord traction
The body of the uterus is pushed
upwards and backwards, towards
the umbilicus while by the right
hand steady tension is given in
downward and backward direction
holding the clamp until the placenta
comes outside the introitus.
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83. Assisted expulsion:
(A) Controlled cord traction
• It is thus more an uterine
elevation which facilitates
expulsion of the placenta.
The procedure is to be
adopted only when the
uterus is hard and
contracted.
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84. • (b) Fundal pressure –
• The fundus is pushed downwards and
backwards after placing four fingers
behind the fundus and the thumb in
front using the uterus as a sort of
piston.
• The pressure must be given only when
the uterus becomes hard. If it is not,
then make it hard by gentle rubbing.
The pressure is to be withdrawn as
soon as the placenta passes through
the introitus. .
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85. • (b) Fundal pressure –
• If the baby is macerated or premature, this method is
preferable to cord traction as the tensile strength of the
cord is much reduced in both instances.
• The cord may be accidentally torn which is not likely to
cause any problem. The sterile gloved hand should be
introduced and the placenta is to be grasped and
extracted.
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86. Mechanism of control of bleeding
• After placental separation, innumerable torn sinuses
which have free circulation of blood from uterine and
ovarian vessels have to be obliterated.
• The occlusion is effected by complete retraction whereby
the arterioles, as they pass tortuously through the
interlacing immediate layer of the myometrium, are
literally clamped.
• It (living ligature) is the principle mechanism of
haemostasis.
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Mechanism of control of bleeding

88. Clinical course of third stage of
labour:-
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89. • Oxytocic drugs for active management of third stage of
labour:-
• Commonly used drugs are,
• Oxytocin
• Ergot alkaloids (ergometrine/methyl ergometrine)
• Misoprostol
• Carboprost (15-methyl PGF2 )
• Researches suggest that oxytocin is the agent of choice for
active management of third stage of labour.
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90. Nursing Management
Nursing Priorities:-
1.Promote uterine
contractility
2.Maintain circulating
fluid volume
3.Promote maternal and
newborn safety
4.Support parent-infant
interaction
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Nursing assessment:
Blood pressure and pulse rate
Amount of blood loss
Leg cramps/body tremors
Uterine contractions
Shape and level of fundus
Signs of placental separation
Extent of perineal laceration/episiotomy
Completeness of placenta and membranes

91. WHO recommendations for optimal timing of cord clamping for
the prevention of iron deficiency anaemia in infants
• WHO guidelines on basic newborn resuscitation:
• In newly born term or preterm babies who do not require
positive-pressure ventilation, the cord should not be
clamped earlier than 1 min after birth.
• When newly born term or preterm babies require positive-
pressure ventilation, the cord should be clamped and cut
to allow effective ventilation to be performed.
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92. • Newly born babies who do not breathe spontaneously after
thorough drying should be stimulated by rubbing the back 2–3
times before clamping the cord and initiating positive-pressure
ventilation.
• WHO recommendations for the prevention and treatment of
postpartum haemorrhage
• Late cord clamping (performed approximately 1–3 min after
birth) is recommended for all births, while initiating
simultaneous essential neonatal care.
• Early umbilical cord clamping (less than 1 min after birth) is not
recommended unless the neonate is asphyxiated and needs to
be moved immediately for resuscitation.
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