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SYNOPSIS Stages of labour

Normal labour

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Onset of labour 151 The initiation of labour 152 Uterine activity in labour the powers The passages 153 154 155 152

The mechanism of labour The third stage of labour Pain in labour 156

Labour or parturition is the process whereby the products of conception are expelled from the uterine cavity after the 24th week of gestation. Premature labour is defined as labour occurring before the commencement of the 37th week of gestation. Prolonged labour is defined as labour lasting in excess of 24 hours in a primigravida and 16 hours in a multigravida. This definition is based on the fact that labours exceeding these times are more likely to be associated with increased fetal and maternal morbidity and mortality.

The management of normal labour 156 Examination at the commencement of labour 156 General principles of the management of the first stage of labour 157 Pain relief in labour 159 Narcotic analgesia 159 Inhalational analgesia 160 Non-pharmacological methods Regional analgesia 160 Posture in labour 162 Water births 162 Fetal monitoring 162 Intermittent auscultation 162 Fetal cardiotocography 163 The fetal electrocardiogram 164 Fetal acidbase balance 165 Management of the second stage of labour 165 Practical procedures preparation for delivery 165 Management of the third stage Repair of perineal damage 167 Essential information 169 166

STAGES OF LABOUR
Labour is described in three stages that are defined as follows: The first stage commences with the onset of labour and terminates when the cervix has reached full dilatation and is no longer palpable The second stage or stage of expulsion begins at full cervical dilatation and ends with expulsion of the fetus The third stage or placental stage begins with the delivery of the child and ends with the expulsion of the placenta.

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ONSET OF LABOUR
The onset of labour is defined as the time of onset of regular, painful uterine contractions, which produce progressive effacement and dilatation of the cervix. It is often difficult to be certain of the exact time of onset of labour because of the occurrence of false labour where the onset of painful contractions is not associated with progressive dilatation of the cervix. Also, in rare cases of cervical stenosis, the normal contractions of labour produce thinning and effacement of the cervix but do not result in cervical dilatation. However these exceptions do not interfere with the general definition. Thus, the clinical signs of the onset of labour include: The onset of regular, usually painful contractions that produce progressive cervical dilatation 151

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The exhibition of a vaginal show the passage of blood stained mucus. Rupture of the fetal membranes this is variable and may occur at the time of onset of contractions or it may be delayed until the delivery of the fetus.

Making a decision about the time of onset of labour has important implications for the subsequent management of labour. An assumption that labour is abnormally prolonged may result from an erroneous decision as to the time of onset of labour.

The initiation of labour


The mechanism of the onset of labour remains uncertain despite extensive research. There are many factors that change at the time of the onset of labour. Furthermore, the inhibition and promotion of certain factors can both delay or accelerate the process of parturition. It is unlikely that any one factor is sufficient to provide an explanation for the onset of labour as intervention at any one of several biochemical points can either stimulate or delay it. It is likely that there is a cascade of events regulated and controlled by the fetoplacental unit. During pregnancy, uterine activity is present but is minimal. At the end of gestation, there is a gradual downregulation of those factors that keep the uterus and cervix quiescent and an upregulation of procontractile influences. At term, the fetus increases its production of cortisol and this cortisol reduces the production of placental progesterone and increases the production of oestrone and oestradiol. Progesterone suppresses uterine activity and oestradiol increases it. These changes also result in increased production of prostaglandins by the placenta and thus a further increase in myometrial activity. These changes also stimulate oxytocin release, which also enhances myometrial activity. At the cellular level, the myocytes both contract and shorten, unlike the process in striated muscle, where cells contract but then return to their precontraction length. The formation of gap junctions between myocytes allows communication between the cells and thus the production of co-ordinated contractions. Gap junctions are composed of connexins (Cx), which are expressed throughout pregnancy but maximally during labour. Furthermore, ion channels within 152

the myometrium play an important role in influencing activity by influencing the influx of calcium ions into the myocytes and promoting contraction of the myometrial cells. The situation is further complicated by other hormones produced in the placenta that also act directly or indirectly on the myometrium, such as relaxin, activin A, follistatin, hCG and corticotrophin-releasing hormone (CRH). The cervix contains myocytes and fibroblasts and serves to contain the products of conception. Towards term, the cervix becomes softened as there is a decrease in the amount of collagen and an increase in proteolytic enzyme activity. Increased production of hyaluronic acid reduces the affinity of fibronectin for collagen and, in conjunction with the affinity of hyaluronic acid for water, there is a consequent softening and ripening of the cervix. Increasing cervical compliance allows progression of labour with reduced intrauterine pressure. The cervix also contracts during labour up to 34 cm dilatation but, in the active phase of labour, cervical dilatation occurs secondary to uterine contractions alone. In other words, the cervix is passively stretched by the increasing strength of the uterine contractions.

UTERINE ACTIVITY IN LABOUR THE POWERS


The uterus exhibits infrequent, low-intensity contractions throughout pregnancy. As full term approaches, uterine activity increases in both the frequency and strength of contractions. With the onset of labour, intrauterine pressures rise to 2030 mmHg during contractions that occur every 1015 minutes and last approximately 3040 seconds. Normal resting tonus in labour starts at around 10 mmHg and increases slightly during the course of labour. Contractions increase in intensity to reach pressures of 50 mmHg around 5 kPa in terms of active pressure in the first stage of labour (Fig. 12.1). In the second stage, with the additional effect of voluntary expulsive efforts, intrauterine pressure may rise to 100 mmHg.
In late pregnancy, strong contractions can sometimes be palpated that do not produce cervical dilatation, even when the cervix is normal and these do not constitute true labour.

NORMAL LABOUR

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70 sec 50 45 40 Amniotic pressure (mmHg) and kPa Pain 35 30 25 20 15 10 50 5 0 0 1 2 3 Time (minutes) 4 50 100 sec Tc 2 kPa 4 kPa 6 kPa

labour progresses and the junction between the upper and lower segment rises in the abdomen. Where labour becomes obstructed, the junction of the upper and lower segments may become visible at the level of the umbilicus; this is known as a retraction ring. Contractions are initiated by a pacemaker in the left uterine cornus and spread downwards through the myometrium. Contractions occur first in the fundus of the uterus, where they are stronger and last longer than in the lower segment. This phenomenon is known as fundal dominance and is essential to progressive effacement and dilatation of the cervix. As the uterus and the round ligaments contract, the axis of the uterus appears to straighten, pulling the longitudinal axis of the fetus towards the anterior abdominal wall in line with the inlet of the true pelvis. The realignment of the uterine axis promotes descent of the presenting part as the fetus is pushed directly downwards into the pelvic cavity (Fig. 12.3).

Fig. 12.1 Uterine contractions reach pressures of 50 mmHg (6.5 kPa) with first stage of labour. Contractions become painful when amniotic pressure exceeds 25 mmHg (3.2 kPa).

THE PASSAGES
The shape and structure of the bony pelvis has already been described. Because of softening of the sacroiliac ligaments and the pubic symphysis, some expansion of the pelvic cavity can occur. The soft tissues also become more distensible than in the non-pregnant state and substantial distension of the pelvic floor and vaginal orifice occurs during the descent and birth of the head. This commonly results in tearing of the perineum and of the vaginal walls and sometimes in tearing and disruption of the external anal sphincter.

Throughout labour, contractions produce effacement and dilatation of the cervix as the result of shortening of myometrial fibres in the upper uterine segment and stretching and thinning of the lower uterine segment (Fig. 12.2). This process is known as retraction. The lower segment becomes elongated and thinned as

Prelabour

Effacement

Dilatation

Fig. 12.2 Effacement and dilatation of the cervix in labour with formation of the lower uterine segment. 153

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Resting phase

Contraction phase

Fig. 12.3 Change in direction of the fetal and uterine axis during contractions in labour.

THE MECHANISM OF LABOUR


The head normally engages in the pelvis in the transverse position and the passage of the head and trunk through the pelvis follows a well-defined pattern. The passage of the fetal head in normal labour requires that the head presents by the vertex and is well flexed, as not all diameters can enter the pelvic brim. A deflexed or extended head, such as occurs in the occipitoposterior position, or a brow presentation may either delay (with an occipitoposterior position) or prevent (with the brow presentation) entry of the head into the pelvic brim. The process of normal labour therefore involves the adaptation of the fetal head to the various segments and diameters of the maternal pelvis and the following processes occur (Fig. 12.4): 1. Descent occurs throughout labour and is both a feature and a prerequisite for the birth of the baby. Engagement of the head normally occurs before the onset of labour in the primigravid woman but may not occur until labour is well established in a multipara. Descent of the head provides a measure of the progress of labour. 154

2. Flexion of the head occurs as it descends and meets the pelvic floor, bringing the chin into contact with the fetal thorax. Flexion produces a smaller diameter of presentation, changing from the occipitoposterior diameter, when the head is deflexed, to the suboccipitobregmatic diameter when the head is fully flexed. 3. Internal rotation: The head rotates as it reaches the pelvic floor and the occiput normally rotates anteriorly from the lateral position towards the pubic symphysis. Occasionally, it rotates posteriorly towards the hollow of the sacrum and the head may then deliver as a face-to-pubes delivery. 4. Extension: The acutely flexed head descends to distend the pelvic floor and the vulva, and the base of the occiput comes into contact with the inferior rami of the pubis. The head now extends until it is delivered. Maximal distension of the perineum and introitus accompanies the final expulsion of the head, a process that is known as crowning. 5. Restitution: Following delivery of the head, it rotates back to be in line with its normal relationship to the fetal shoulders.

NORMAL LABOUR

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Fig. 12.4 The mechanisms of normal labour involve: (a) descent of the presenting part; (b) flexion of the head; (c) internal rotation; (d) distension of the perineum and extension of the fetal head; (e) delivery of the head; (f) delivery of the shoulders.

6. External rotation: When the shoulders reach the pelvic floor, they rotate into the anteroposterior diameter of the pelvis. This is accompanied by rotation of the fetal head so that the face looks laterally at the maternal thigh. 7. Delivery of the shoulders: Final expulsion of the trunk occurs following delivery of the shoulders. The anterior shoulder is delivered first by traction posteriorly on the fetal head so that the shoulder emerges under the pubic arch. The posterior shoulder is delivered by lifting the head anteriorly over the perineum and this is followed by rapid delivery of the remainder of the trunk and the lower limbs.
The occiput normally rotates anteriorly but, if it rotates posteriorly, it deflexes and presents a larger diameter to the pelvic cavity. As a result, the second stage may be prolonged and the damage to the perineum and vagina is increased.

THE THIRD STAGE OF LABOUR


The third stage of labour starts with the completed expulsion of the baby and ends with the delivery of the placenta and membranes (Fig. 12.5). A fourth stage of labour is sometimes described as the time interval following expulsion of the placenta up to 6 hours after delivery. The implication of describing a fourth stage is to draw attention to the increased risk of abnormal haemorrhage that exists in the first few hours after delivery. Once the baby is delivered, the uterine muscle contracts, shearing off the placenta and pushing it into the lower segment or the vault of the vagina. The classic signs of placental separation include a show of bright blood, apparent lengthening of the umbilical cord and elevation of the uterine fundus within the abdominal cavity. The uterine fundus becomes tent shaped instead of globular and sits on top of the placenta as it descends into the lower segment. 155

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Fig. 12.5 The normal third stage: (a) separation of the placenta from the uterine wall; (b) expulsion into the lower uterine segment and upper vagina; (c) complete expulsion of the placenta from the genital tract.

The signs of placental separation may be compressed and obscured by the use of oxytocic drugs administered at the delivery of the anterior shoulder. As the placenta is expelled, it is accompanied by the fetal membranes, although the membranes often become torn and may require additional traction or uterine exploration to complete their removal. The whole process lasts between 5 and 10 minutes. If the placenta is not expelled within 30 minutes, the third stage should be considered to be abnormal.

PAIN IN LABOUR
Contractions in labour are commonly although not invariably associated with pain, particularly as they increase in strength and frequency (Fig. 12.1). The cause of pain is uncertain but it may be due to compression of nerve fibres in the cervical zone or to hypoxia of compressed muscle cells. Pain is felt in the lower abdomen and as lumbar backache and becomes apparent when the intrauterine pressure exceeds 25 mmHg.

laxis with controlled respiration, should be introduced during antenatal classes, as well as educating the mother about the regulation of expulsive efforts during the second stage of labour. Antenatal classes should also include instructions about neonatal care and breastfeeding, although this is a process that requires reinforcement in the postdelivery period. The mother should be advised to come into hospital, or to call the midwife in the event of a home birth, when contractions are at regular 1015 minute intervals, when there is a show or if and when the membranes rupture. If the mother is in early labour, she should be encouraged to take a shower and to empty her bowels and bladder. Shaving of the pubic hair is no longer considered necessary unless there is a likelihood of delivery by caesarean section, in which case the abdomen should be shaved down to the pubic hairline. It is common practice in the United Kingdom to organize domino (domiciliary in and out) deliveries, whereby the mother is discharged home 6 hours after delivery, provided that the delivery is uncomplicated.

THE MANAGEMENT OF NORMAL LABOUR


The primary aim of intrapartum care is to deliver a healthy baby to a healthy mother. The preparation of the mother for the process of parturition begins well before the onset of labour. It is important for the mother and her partner to understand what actually happens during the various stages of labour. Strategies to deal with pain in labour, including psychoprophy156

Examination at the commencement of labour


On admission, the following examination should be performed: Full general examination, including temperature, pulse, respiration, blood pressure and state of hydration; the urine should be tested for glucose, ketone bodies and protein

NORMAL LABOUR

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Obstetrical examination of the abdomen: inspection, palpation and auscultation to determine the fetal lie, presentation and position, and the station of the presenting part, as well as to determine the presence of a fetal heartbeat Vaginal examination in labour should be performed only after cleansing of the vulva and introitus and using an aseptic technique with sterile gloves and an antiseptic cream. Once the examination is started, the fingers should not be withdrawn from the vagina until the examination is completed. The following factors should be noted: The consistency, effacement and dilatation of the cervix Whether the membranes are intact or ruptured and, if ruptured, the colour of the amniotic fluid The nature and presentation of the presenting part and its relationship to the level of the ischial spines Assessment of the bony pelvis and in particular of the pelvic outlet.

The use of partograms at an applied level was first introduced in remote obstetric units in Africa, where recognition that progress in labour is becoming abnormal enables early transfer to specialist units before serious obstruction occurs. This has led to a major reduction in maternal mortality. One colleague recounted a story to the authors of seeing an ambulance in the Sudan returning to a base hospital after a 2-day journey with two women, both of whom had died in obstructed labour. Earlier recognition of these obstructed labours could have prevented this tragedy.

Fetal condition
The fetal heart rate is charted as beats/minute and decelerations of heart rate that occur during contractions are recorded by an arrow down to the lowest heart rate recorded on the partogram. These records are an adjunct to the actual recording of fetal heart rate. The time of rupture of the membranes and the nature of the amniotic fluid (i.e. whether it is clear or meconium-stained) are also recorded. Moulding of the fetal head and the presence of caput are also noted as they provide an indicator of obstructed labour.

General principles of the management of the first stage of labour


The guiding principles of management are: Observation and intervention if the labour becomes abnormal Pain relief during labour and emotional support for the mother Adequate hydration throughout labour.

Progress in labour
Progress in labour is measured by assessing the rate of cervical dilatation and descent of the presenting part. To assess the rate of progress, vaginal examination should be performed on admission to hospital and every 4 hours during the first stage of labour. Cervical dilatation is recorded in centimetres along the scale of 010 of the cervicograph and a plot of the cervical dilatation is recorded. The graph for progress in a normal labour is recorded on the chart. Dilatation of the cervix occurs in two well-defined phases. The latent phase starts at the onset of labour and ends at 3 cm dilatation. This takes up some two thirds of the whole time of labour. This is followed by the active phase that extends from the end of the latent phase until the onset of the second stage when full cervical dilatation has been reached. If the dilatation of the cervix lags more than two hours behind the expected rate of dilatation, the labour is considered to be abnormal. The rate of dilatation increases rapidly during the active phase of labour 157

Observation the use of the partogram


The introduction of graphic records has proved to be a major advance in the management of labour because it enables the early recognition of a labour that is becoming dysfunctional. The partogram (Fig. 12.6) is a single sheet of paper on which there is a graphic representation of progress in labour. The partogram should be started as soon as the mother is admitted to the delivery suite and this is recorded as zero time regardless of the time at which contractions started. However, the point of entry on to the partogram depends on a vaginal assessment at the time of admission to the delivery suite. The value of this type of record system is that it draws attention visually to any aberration from normal progress in labour.

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Fig. 12.6 The partogram is a complete visual record of measurements made during delivery (courtesy of Catherine Tamizian).

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NORMAL LABOUR

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although it slows again near the phase of full cervical dilatation. The station of the head is also charted on the partogram using the following definitions (Fig. 12.6): If the head is high, the level is five-fifths above the pelvic brim If the head is just descending into the pelvic brim, it is four-fifths above the brim If less than half the head is through the brim, it is three fifths above the brim If more than half the head is through the brim it is two-fifths above the brim If just the base of the skull is palpable abdominally, it is one-fifth above the brim. The station of the head is plotted on the 05 gradation of the partogram. Descent is also recorded by assessing the level of the presenting part above or below the level of the ischial spines. The nature and frequency of the uterine contractions are recorded on the chart by shading in the number of contractions per 10 minutes. Dotted squares indicate contractions of less than 20 seconds duration, crosshatched squares are contractions between 20 and 40 seconds duration, while contractions lasting longer than 40 seconds are shown by complete shading of the squares.

normal saline 500 ml alternating with 500 ml of Hartmanns solution, the total not exceeding 1500 ml in 12 hours.

The classic signs of dehydration in labour include tachycardia, mild pyrexia and loss of tissue turgor. Remember that labour can be hard physical work and that the environmental temperature of delivery rooms is often raised to meet the needs of the baby rather than the mother, leading to considerable insensible fluid loss.

PAIN RELIEF IN LABOUR


There are a number of strategies used in labour for the relief of pain. Essentially, these techniques are aimed at reducing the level of pain experienced in labour whilst invoking minimal risk for the mother and baby. The level of pain experienced in labour varies widely with each mother. Some women experience very little pain whilst others suffer from abdominal and back pain of increasing intensity throughout their labours. Thus, any programme for pain relief must be tailored to the needs of the individual. Often a combination of methods will provide the best results. The only technique that can provide complete pain relief is epidural analgesia.

Fluid and nutrition during labour


In most maternity units in the UK, caesarean section rates now exceed 20%. The issue of what can be taken by mouth becomes particularly important. If there is a likelihood that the mother will need operative delivery under general anaesthesia, then it is clearly important to avoid oral intake at any significant level during the first stage of labour. Delayed gastric emptying may result in vomiting and inhalation of vomitus if general anaesthesia for operative delivery is needed. On the other hand, most operative deliveries are now achieved under epidural anaesthesia and therefore there is a case for giving some fluids and light nutrition orally if labour is progressing normally and a vaginal delivery can be anticipated. Intravenous fluid replacement should be considered after 6 hours in labour if delivery is not imminent. Remember that the major cause of acidosis and ketosis is dehydration. If delivery is not imminent at the end of 6 hours, an intravenous infusion should be commenced with the alternative administration of

Narcotic analgesia
In the past, a variety of narcotic agents have been used for pain relief in labour and such agents are still widely used, particularly where epidural analgesia is not available. Pethidine is the most widely used narcotic agent and is given in doses of 50150 mg intramuscularly; the effects last about 23 hours, after which time the dose can be repeated. Current evidence suggests that pethidine has a weak analgesic action but tends to reduce anxiety and discomfort. The unwanted side effects include nausea, vomiting and respiratory depression in both the mother and the baby. The effect on the neonate is particularly important when the drug is given within 2 hours of delivery. Pethidine is often administered with phenothiazines to reduce nausea. 159

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Other opioids occasionally used in labour include papaveretum 1020 mg, diamorphine 510 mg, pentazocine 3060 mg, phenazocine 12 mg or oxymorphone 11.5 mg by intramuscular injection. However, the use of all these compounds, with the possible exception of pethidine, is becoming increasingly uncommon as the use of epidural analgesia increases. The search for more effective agents continues and a new agent, remifentanil, has recently been evaluated. This is an ultra-short-acting opioid that produces superior analgesia to pethidine and has less effect on neonatal respiration. Because some mothers are unsuitable for regional analgesia, opiates are likely to continue to play a significant role in pain relief in labour .

Regional analgesia
Epidural analgesia is the most widely used form of regional analgesia. It is also the most effective way of relieving the pain of contractions, with complete relief of pain in 95% of labouring women. The procedure may be instituted at any time and does not interfere with uterine contractility. It may reduce the desire to bear down in the second stage of labour. A fine catheter is introduced into the lumbar epidural space and a local anaesthetic agent such as bupivacaine is injected (Fig. 12.7). The addition of an opioid to the local anaesthetic greatly reduces the dose requirement of bupivacaine, thus sparing the motor fibres to the lower limbs and reducing the classic complications of hypotension and abnormal fetal heart rate. The procedure involves: Insertion of an intravenous cannula and preloading with no more than 500 ml of saline or Hartmanns solution Insertion of the epidural cannula at the L3L4 interspace and injection of the local anaesthetic agent at the minimum dose required for effective pain relief

Inhalational analgesia
These agents are commonly reserved for use in the late first stage and in the second stage. The most widely used agent is Entonox, which is a 50/50 mixture of nitrous oxide and oxygen. The gas can be self-administered and is inhaled as soon as the contraction starts. Entonox is used in the UK by about 75% of mothers in labour and is effective in about 40%. Other inhalation agents include trichloroethylene 0.30.5%, and methoxyflurane 0.35%, in air. These compounds take longer to achieve adequate analgesic concentrations because they have a high degree of solubility in body fat. They are effective in only 10% of women and their use has now been largely abandoned. Nitrous oxide has been shown to have adverse effects on birth attendants if exposure is prolonged; these effects include decreased fertility, bone marrow changes and neurological changes. Forced air change every 610 hours is effective in reducing the nitrous oxide levels and should be mandatory in all delivery rooms.

L3 L4

Non-pharmacological methods
Transcutaneous electrical nerve stimulation (TENS) involves the placement of two pairs of TENS electrodes on the back on each side of the vertebral column at the levels of T10L1 and S2S4. Currents of 040 mA are applied at a frequency of 40150 Hz. This can be effective in early labour but is often inadequate by itself in late labour. For the technique to be effective, antenatal training of the mother is essential. Other non-invasive methods include massage and relaxation techniques. 160

Fig. 12.7 Epidural anaesthesia is induced by injection of local anaesthetic agents into the lumbar epidural space.

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