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NORMAL LABOUR
Labor is the bridge between pregnancy & motherhood. For the woman in labor, this is the most intense experience of pregnancy. The process begins between 38 and 40th week.

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Definitions: Labour is the process by which a viable foetus i.e. at the end of 28 weeks or more is expelled or is going to be expelled from the uterus. Series of events that take place in the genital organs in effort to expel the variable products of conception out of the womb though the vagina into the outer world is called labour.
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The following criteria should be present to call it normal labour:

Spontaneous expulsion, of a single, mature foetus, presented by vertex, through the birth canal, within a reasonable time (not less than 3 hours or more than 18 hours), without complications to the mother, or the foetus.
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Abnormal labour / Dystocia

Dystocia (antonym eutocia) is an abnormal or difficult childbirth or labour. Can also be related to livestock. Synonyms: difficult labour, abnormal labour, difficult childbirth, abnormal childbirth, dysfunctional labour
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Stages of labour
Labour is divided into four stages: First stage
It is the stage of cervical dilatation. Starts with the onset of true labour pain and ends with full dilatation of the cervix i.e. 10 cm in diameter. It takes about 10-14 hours in primigravida and about 6-8 hours in multipara.

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 Second stage
It is the stage of expulsion of the foetus. Begins with full cervical dilatation and ends with the delivery of the foetus. Its duration is about 1 hour in primigravida and hour in multipara.

Third stage
It is the stage of expulsion of the placenta and membranes. Begins after delivery of the foetus and ends with expulsion of the placenta and membranes. Its duration is about 10-20 minutes in both primi and multipara.
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 Fourth stage
It is the stage of early recovery. Begins immediately after expulsion of the placenta and membranes and lasts for one hour. During which careful observation for the patient, particularly for signs of postpartum haemorrhage is essential. Routine uterine massage is usually done every 15 minutes during this period.

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Cause of Onset of Labour

It is unknown but the following theories were postulated: 1. Hormonal factors Oestrogen theory:
During pregnancy, most of the oestrogens are present in a binding form. During the last trimester, more free oestrogen appears increasing the excitability of the myometrium and prostaglandins synthesis.
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 Progesterone withdrawal theory:

Before labour, there is a drop in progesterone synthesis leading to predominance of the excitatory action of oestrogens.

Prostaglandins theory:
Prostaglandins E2 and F2 are powerful stimulators of uterine muscle activity. PGF2 was found to be increased in maternal and foetal blood as well as the amniotic fluid late in pregnancy and during labour.
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 Oxytocin theory:
Although oxytocin is a powerful stimulator of uterine contraction, its natural role in onset of labour is doubtful. The secretion of oxytocinase enzyme from the placenta is decreased near term due to placental ischaemia leading to predominance of oxytocins action.

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 Foetal cortisol theory:

Increased cortisol production from the foetal adrenal gland before labour may influence its onset by increasing oestrogen production from the placenta.

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2. Mechanical factors
Uterine distension theory:
Like any hollow organ in the body, when the uterus in distended to a certain limit, it starts to contract to evacuate its contents. This explains the preterm labour in case of multiple pregnancy and polyhydramnios.

Stretch of the lower uterine segment:

by the presenting part near term.
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 What or who determines when labor begins? both the fetus and the mother seem to work together in determining when labor will begin.

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Factors influencing labour

Five important factors : the passage, the fetus, the relationship between the passage and the fetus, the forces of labor, and psychosocial considerations.

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Often called the 5 Ps of labor: Passageway, Passenger, Powers, Position, and Psychologic responses

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1. PASSAGE
Birth passage 3 sections of true pelvis
inlet, pelvic cavity (midpelvis), & outlet. Four classifications : gynecoid , -most common, with diameters

favorable to vaginal delivery. android, anthropoid, & platypelloid.

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Pelvic Joints
Symphysis pubis consists of fibrocartilage, the superior and inferior (arcuate ligament) pubic ligaments. Sacroiliac joints between the sacrum and the iliac portion of the innominate bones. Relaxation of the pelvic joints results from hormonal change, commenced in early half of pregnancy, and increased during the last 3 m, regressed after parturition.
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 Sacroiliac joint mobility caused by upward gliding movements of the joint, greatest in dorsal lithotomy position, and may the diameter of the outlet by 1.5 to 2 cm. (Shoulder dystocia)

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Planes and Diameters of the Pelvis

The plane of the pelvic inlet the superior strait The plane of the pelvic outlet the inferior strait The plane of the midpelvis the least pelvic dimensions The plane of greatest pelvic dimension of no obstetrical significance
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Pelvic Inlet
4 types in shape gynecoid (50%), anthropoid, android, platypelloid. Most are intermediate type. 4 diameters anteroposterior, transverse, and 2 obliques Obstetrical conjugate the shortest distance between promontory and symphysis pubis. Estimated by substracing 1.5 to 2 cm from the diagonal conjugate. True conjugate the A-P diameter of the pelvic inlet

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Midpelvis
Plane of the least pelvic dimensions, at the level of the ischial spines. The interspinous diameter, 10 cm or so, is the smallest diameter of the pelvis. The anteroposterior diameter, 11.5 cm. The posterior sagittal diameter is around 4.5 cm.
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Pelvic Outlet
Consists of two triangles with a common base, a line drawn between the two ischial tuberosities. The apex of the posterior triangle is the tip of the sacrum, the lateral boundaries are the sacrosciatic ligaments and the ischial tuberosities. The anterior triangle the area under the pubic arch. 3 diameters A-P, trans., posterior sagittal
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Pelvic Shapes
Caldwell-Moloy classification Anterior segment Transverse diameter Posterior segment 1. Gynecoid pelvis suited for delivery of most fetuses, 50% 2. Android pelvis poor prognosis for vaginal delivery 3. Anthropoid pelvis AP diameter > trans. diameter, 1/3 4. Platypelloid pelvis short AP diameter and normal labour 36 wide transverse diameter, < 3%

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Pelvimetry
X-ray Computed tomography Ultrasound Magnetic resonance

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2. PASSENGER: Fetal head Considerations: face, base of skull, & vault of cranium (roof). Bones in face fused but vault has movable bones; overlap under pressure molding.

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Sutures membranous spaces between bones; intersections fontanelles (soft spot) Landmarks: mentum chin; sinciput brow; vertex space between fontanelles; occiput occipital bone

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Fetal attidude relationship of fetal parts to one another: norm: good flexion of head, flexion of arms unto chest, & flexion of legs to abdomen Fetal lie relationship of cephalocaudal axis (spinal column) of fetus to c. a. of mother longitudinal: parallel transverse: fetal c.a. is 90 to womans spine

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Fetal Presentation determined by fetal lie and by the body part that enters the pelvic passage first. The portion of the fetus is referred to as the presenting part. Fetal presentation may be
cephalic, breech, or shoulder.
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Cephalic presentation: head is completely flexed onto chest; smallest diameter (suboccipito-bregmatic) presents. The occiput is the presenting part. Engagement when largest diameter of presenting part reaches or passes through pelvic inlet. The biparietal diameter (BPD) of fetal head settles into inlet of pelvis. In most instances, the occiput is at the level of the ishial spines (0) station.
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Station refers to the relationshio of presenting part to an imaginary line drawn between the ischial spines of the maternal pelvis. If the presenting part is higher than the ischial spines, the station has a negative #, referring to centimeters above 0 station..Minus 5 is at the pelvic inlet. Positive #s = presenting part has passed the ischial spines. Positive (+) 4 is at the outlet.

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3. Fetal position relationship of the designated landmark of fetal presenting part to the left or right side of the maternal pelvis. The designated landmarks are vertex: the occiput; in face presentation: the mentum. In breech: the sacrum; for shoulder: the acromion process of the scapula. If directed to side, it is designated as transverse.
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 The landmark on the fetal presenting part r/t four imaginary quadrants: left anterior, right anterior, left posterior, and right posterior,

meaning:

Is the presenting part directed toward the front, back, left or right of the passage?

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Reasons for the Predominance of Cephalic Presentation

Piriform shaped uterus The breech and its flexed extremities is bulkier than the cephalic pole and more movable. More crowded amniotic cavity after 32nd week of gestation

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Three notations: Right or left (L) side of maternal pelvis The landmark of fetal presenting part: occiput (O); mentum (M), sacrum (S), or acromion process (A). Anterior (A), posterior (P), or transverse (T )
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4. Power
Primary forces: is the uterine contraction complete effacement and dilation of the cervix. Secondary forces: use of abdominal muscles to push during the 2nd stage of labor. Pushing force adds to the primary force after the cervix is fully dilated.
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Contractions have a rhythmic pattern, with periods of relaxation between, allowing the woman to rest. This resting period allows for restoration of placental circulation: important to uterine muscles but also for the babys oxygenation. Increment: the building up and longest; acme peak; and decrement or letting up.

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Characteristics: frequency:

time between beginning of one contraction to the beginning of the next. Duration: beginning to completion of a single contraction. Intensity strength of contraction. Experienced nurse can estimate by palpating the fundus (top) during the contraction. - Intensity can be measured directly with an intrauterine probe. Mild: the uterine wall can be indented; strong, it cannot be indented.
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Power

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5. Psychology of mother
Transition to new role couple; permanent change in lifestyle, relationships, & self-image.; differences between primi and multi: losing it being out of control; fear of pain; birthing plan: will it be honored?

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First stage First stage: the longest stage occurs between onset of true labor and the point of cervical dilation and effacement. First stage: divided into 3 phases a. Latent begins with onset of regular contractions, with contractions q 15 -20 min, lasting 20 -30 secs.
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b. Active phase begins 4 cm, ends

when dilated to 7cm; C.Transition phase shortest, most intense. Dilation from 8 to 10 cm.

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Clinical picture of pre- labour

Prodromal (pre-labour) stage The following clinical manifestations may occur in the last weeks of pregnancy. Shelfing:
It is falling forwards of the uterine fundus making the upper abdomen looks like a shelf during standing position. This is due to engagement of the head which brings the foetus perpendicular to the pelvic inlet in the direction of pelvic axis.
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 Lightening:
It is the relief of upper abdominal pressure symptoms as dyspnoea, dyspepsia and palpitation due to:
descent in the fundal level after engagement of the head and shelfing of the uterus.

Pelvic pressure symptoms:

With engagement of the presenting part the following symptoms may occur: Frequency of micturition, rectal tenesmus and difficulty in walking.
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 Increased vaginal discharge. False labour pain: These are differentiated from true labour pain as follow

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True Labour Pain

Regular. Increase progressively in frequency, duration and intensity.

False Labour Pain

Irregular.

Do not.

Pain is felt in the abdomen and Pain is felt mainly in the radiating to the back. abdomen. Progressive dilatation and effacement of the cervix. No effect on the cervix.

Membranes are bulging during No bulging of the membranes. contractions. Not relieved by antispasmodics or sedatives. Can be relieved by antispasmodics and sedatives.
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Causes of Labor Pain

Hypoxia of the contracted myometrium Compression of nerve ganglia in the Cx and the lower uterus by the interlocking muscle bundles Stretching of the Cx during dilatation Stretching of the overlying peritoneum
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Onset of Labour
It is characterised by: True labour pain. Painful Uterine Contractions: The onset of labour is characterized by painful, intermittent, involuntary and co-ordinated uterine contractions It cannot be relieved by medicines or rest.

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Fundal dominance: Each uterine contraction starts in the fundus near one of the cornua & spreads across & downwords. The contraction lasts longest in the fundus where it is also most intense but the peak is reached simultaneously over the whole uterus & the contraction fades from all part together. It facilitates cervix to dilate & the strongly contracting fundus.
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Polarity:
Polarity is the term used to describe the neuromuscular harmony that prevails between the two poles or segments of the uterus throughout labour. During each uterine contraction these two poles act harmoniously. The upper pole contracts strongly and retracts to expel the fetus; the lower pole contracts slightly and dilates to allow expulsion to take place. If polarity is disorganized, the progress of labour is inhibited.
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Contraction & Retraction

Retractions of the uterus helps in the progressive expulsion of the fetus, the upper segment of the uterus becomes gradually shorter and thicker and its cavity diminishes.

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Contraction detector

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Differentiation of Uterine Activity

Upper segment : Active segment, contracts, retracts and expels the fetus. Myometrial fibers become shorter and thicker. Lower segment : Passive segment, relaxed, dilated and greatly expanded, thinned-out for the passage of the fetus. Myometrial fibers become stretched and longer.
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Formation of retraction ring

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Cervical Effacement and Dilation

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Cervical Effacement and Dilation As contractions continue the cervix thins out. This stretching and thinning of the cervix results as the cervix opens wider or dilates. Definitions a. Effacement: In primigravidas, the cervical canal dilates from above downwards i.e. from the internal os downwards to the external os. So its length shorts gradually from more than 2 cm to a thin rim of few millimetres continuous with the lower uterine segment
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Measured as a percentage this is the thickness of the cervix; 50% effaced means the cervix has "thinned" half way; 70% it means that 70% of the cervical canal has been taken up 100% effaced means the cervix has thinned all the way.

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 Dilatation of the cervix:

A closed cervix is a reliable sign that labour has not begun. In multigravidae the cervix may admit the tip of the finger before onset of labour. Dilatation of the cervix (external os) starts after complete effacement of the cervix. Measured in centimeters this how much the cervix is opened; the cervix is fully closed at 0cm and fully open at 10cm.
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Causes of cervical dilatation

Contraction and retraction of uterine musculature. Mechanical pressure by the forebag of waters, if membranes still intact, or the presenting part, if they had ruptured. This in turn will release more prostaglandins which stimulate uterine contractions and cervical effacement. Softness of the cervix which has occurred during pregnancy facilitates dilatation and effacement of the cervix.
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Phases of cervical dilatation

a. Latent begins with onset of regular contractions, with contractions q 15 20 min, lasting 20 -30 secs, gradually lncrease to q 5 7 min, 30 40 secs duration. May find their contractions wax and wane Little or no cervical dilation. Women stay home.
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 Can usually talk or laugh during their contractions May find this phase of labor lasting hours to days or longer Phase ends when cervix is 3 cm. Lasts 8.6 hrs for primi, < 6 for multi.

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Latent phase

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b. Active phase : begins 4 cm, ends when dilated to 7cm; contractions 2 3 mins, 40 60 secs; cervix should dilate about 1 to 1.5 cm /hr. Primi avg 4.6 hrs, multi 2.4 hrs If the rate is < 1cm / hour it is considered prolonged.

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C.Transition phase shortest, most intense. Dilation from 8 to 10 cm; contractions q 1.5 2 mins, lasting 60 90 secs (pain & rest about same). Lasts avg 3.6 hrs for Primi; varies with multi. Woman becomes restless, angry, wants to go home, wants a C-sec, N&V, etc. Withdraws from support (spouse, coach, etc), leaving partner feeling useless. NURSE IS VITAL at this point to both. NURSE must prepare for 2nd stage.
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The show:
As a result of dilatation of the cervix, the operculum which formed the cervical plug during is lost. It is an expelled cervical mucus plug tinged with blood from ruptured small vessels as a result of separation of the membranes from the lower uterine segment.

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Show

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 Formation of the bag of fore-waters: as the lower uterine segment stretches the chorion becomes detached from it & the increased intrauterine pressure causes this loosened part of the sac of fluid. It bulges downwards through the dilating cervix to the depth of 6-12 mm. It becomes tense during uterine contractions.

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The well flexed head fits snugly into the Cx & cuts off the fluid in front of the from that which surrounds the body. The former is known as the forewaters & the latter the hindwaters. The effect of separation of the forewaters is to prevent the pressure to the hindwaters. during uterine contraction from being applied to the forewaters & keeps the membranes intact during the first stage.
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General fluid pressure

While the membranes remain intact, the pressure of the uterine contractions is exerted on the fluid &, as fluid is not compressible, the pressure is equalized though out the uterus & over the fetal body & is known as general fluid pressure.
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 When the membranes rupture: a quantity of fluid emerges, the placenta is compressed between the uterine wall & the fetus during contractions and the oxygen supply to the fetus is thereby diminished. Preserving the integrity of the membranes: optimizes the oxygen supply to the fetus and helps to prevent intrauterine infection.
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Rupture of the membranes

The physiological moment for the membranes to rupture is at the end of the first stage of labour. when the cervix becomes fully dilated and no longer supports the bag of forewaters. The uterine contractions are also applying increasing force at this time. Membranes may sometimes rupture days before labour begins or during the first stage.
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Rupture of membranes

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for any reason there is a badly fitting presenting part, the forewaters are not cut off effectively and the membranes rupture early. Caul: Occasionally the membranes do not rupture even in the second stage and appear at the vulva as a bulging sac covering the fetal head as it is born; this is known as the caul. amniotomy during the first stage of labour.

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Progress of Labor
For a woman experiencing her first baby, (primi) - labor usually lasts about 12-14 hours. If she has delivered a baby in the past (Multi), labor is generally quicker, lasting about 6-8 hours.

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Other physiological changes

Maternal responses: During labor: Blood changes: with each contraction, 300-500 mls of blood forced into maternal circulation cardiac out put which with pain and anxiety. In supine position, cardiac output , HR , stroke volume. Best to assume side-lying position. BP during contractions and pushing.
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Respiratory: anxiety & pain hyperventilation & respiratory alkalosis; muscular activity mild metabolic acidosis. Acid-base balance - norm /p 24 hrs. Renal & GI: in pressure and edema to bladder can lead to over distension; in renin & angiotension help control uteroplacental blood flow.
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GI gastric emptying delayed risk of aspiration if general anesthesia necessary. Immune/blood WBCs inc to 25,000 30,000. Blood glucose (energy during contractions), insulin requirements drop.

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Pain: gate-control theory: mechanism allows or in impulses to CNS. Pain can be reduced through tactile stimulation such as back rubs, sacral pressure, effleurage; and CNS-controlled activities such as suggestion, distractions, & conditioning. Pain varies: 1st stage: stretching, pressure, hypoxia of muscles during contraction; 2nd stage hypoxia to uterine muscles, stretching of vagina & perineum and pressure on adjoining .

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What about fetal response?

Heart rate changes in response to intracranial pressure from maternal contractions; fetal blood pressure protects fetus during contractions; fetus responds to light, sound, & touch, beg 37 wks Evaluations: Normal 120 160 bpm. Variability is the change from baseline that occurs over seconds or minutes
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Abnormal variations are > 160 bpm (tachycardia) or < 120 bpm (bradycardia). Tachycardia is considered (sustained rate of 161 bpm ) ominous if accompanied by late decelerations, severe variable decels, or variability. Bradycardia with rate < 110 120 bpm during a 10 min period can be ominous or benign. When accompanied by late decels, considered a sign of fetal distress.
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Accelerations: the transient in FHR normally caused by fetal movement. In response to contractions, considered a good sign. Decelerations: periodic decreases in FHR from norm baseline. Categorized as early, late, and variable. Early Fetal head is compressed central vagal stimulation early deceleration. Onset is before onset of uterine contraction, considered benign.
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 Late caused by uteroplacental insufficiency d/t dec blood flow & O2 to fetus during contraction. Occurs after onset of contractions. Considered non-reassuring, but not necessarily eminent for childbirth. Variable umbilical cord is compressed, blood flow between placenta & fetus. Needs further assessment.
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Second Stage
The second stage of labor occurs once the cervix is fully dilated and effaced. This stage includes pushing the baby and the actual delivery of the baby. it last up to 3 hours in a first birth and as little as 30 minutes in women who have previously given birth.

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Uterine contraction: Stronger & longer but may be less frequent. allows both mother & fetus a recovery period during the resting stage. The membranes rupture spontaneously at the onset of 2nd stage of labour. The consequent drainage of liquor allows the hard round head, to be directly applied to the vaginal tissues & aid distension.
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 Fetal axis pressure increases flexion of the head: which result in smaller presenting diameters, more rapid progress & less trauma to both mother & fetus. It becomes expulsive & as the fetus descends further into the vagina, Pressure from the presenting part stimulates nerve receptors in the pelvic floor & the women feels the needs to push.
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Soft tissue displacement: Pelvis: As the fetal head descends, the soft tissues of the pelvis becomes displaced. Bladder & rectum changes: Anteriorly the bladder is pushed upwards into the abdomen risk of injury is less. Stretching & thinning of the urethra so its lumen is reduced. Rectum becomes flattened into the sacral curve & pressure of the advancing head expels any residual faecal matter.
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Perineal muscles: The levator ani muscles dilate, thin out & are displaced laterally, the perineal body is flattened, stretched & thinned. the fetal head becomes visible at the vulva, advancing with each contraction & receding during the resting phase until crowning takes place & the head is born.
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Recognition of the commencement of the 2nd stage of labour

The transition from 1st stage to the 2nd stage is not always clinically apparent. Presumptive signs : Expulsive uterine contractions: Rupture of the forewaters Show
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Dilatation & gaping of anus: Deep engagement of the presenting part & premature maternal effort may produce this sign during the latter part of the 1st stage. Appearance of the presenting part: Excessive moulding results in the formation of a large caput succedaneum protrude through cervix prior to full dilatation. Congestion of the vulva Confirmatory evidence Vaginal examination : no cervix can be felt on examination
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Mechanism of labour
Definition : 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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Principles of mechanism
Descent takes place throughout the labour. Whichever part leads & first meets the resistance of the pelvic floor will rotate forwards until it comes under the symphysis pubis What ever emerges from the pelvis will pivot around the pubic bone.
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Criteria for normal mechanism

Lie longitudinal Presentation cephalic Position Rt/Lt occipito anterior Attitude good flexion Denominator occiput Presenting part posterior part of the anterior parietal bone
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Attitude. The normal fetal attitude when labor begins is with all joints in flexion. Lie. ; longitudinal (parallel). Presentation. This describes that part on the fetus lying over the inlet of the pelvis or at the cervical os.

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Point of Reference or direction/ denominator: This is an arbitrary point on the presenting part used to orient it to the maternal pelvis occiput, mentum (chin) or sacrum. Position. This describes the relation of the point of reference to one of the eight octanes of the pelvic inlet LOT: the occiput is transverse and to the left.
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Engagement. This occurs when the biparietal diameter is at or below the inlet of the true pelvis.

Station. This references the presenting part to the level of the ischial spines measured in plus or minus centimeters.
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The principle movements are:

1. 2. 3. 4. 5. 6. 7. 8. 9. Engagement Decent Flexion Internal rotation of the head Crowning Extension of the head Restitution External rotation of the head Lateral flexion of the body
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Mechanism of labour
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1. Engagement:
The head normally engages in the oblique or transverse diameter of the inlet. Left occipito anterior is little commoner than rirht occipito anterior. The engaging APD of the head is either suboccipito bregmatic 9.5cm or in the slight deflexion suboccipito frontal 10 cm. The engaging TD is biparietal 9.5cm.

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 In primi: 2 weeks before onset labour In multi: before the onset of labour / or in late 1st stage of labour.

Anterior asynclitism Posterior asynclitism

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Second Stage
2. Descent: It is continuous throughout labour particularly during the second stage Factors facilitating descent are: Uterine contractions and retractions. The auxiliary forces which is bearing down brought by contraction of the diaphragm and abdominal muscles. The unfolding of the foetus i.e. straightening of its body due to contractions of the circular muscles of the uterus.
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3. Flexion: as the head meets the resistance of the birth canal i. e pelvic floor during descent, full flexion is achieved. According to the lever theory. As the atlanto-occipital joint of the head, the short arm extends from the condyles to the occipital protruberance & the long arm extends from condyles to the chin. When resistance is encountered, by ordinary law of mechanics the shorter arm descends & long arm ascends resulting in flexion of head.
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Increased flexion results in:

The suboccipito-bregmatic diameter (9.5 cm) passes through the birth canal instead of the suboccipito-frontal diameter (10 cm). The part of the foetal head applied to the maternal passages is like a ball with equal longitudinal and transverse diameters as the suboccipito-bregmatic = biparietal = 9.5 cm. The circumference of this ball is 30 cm. The occiput will meet the pelvic floor.
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Flexion
Four degrees of head flexion: Indicated by the solid line the occipito-mental diameter; the broken line connects the center of the anterior fontanel with posterior fontanel: A. Flexion poor. B. Flexion moderate. C. Flexion advanced. D. Flexion complete.
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Note: flexion complete the chin is on the chest, and The suboccipito-bregmatic diameter, the shortest anteroposterior diameter of the fetal head, is passing through the pelvic inlet.

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4.Internal rotation of the head

The rule is that the part of foetus meets the pelvic floor first will rotate anteriorly. In normal labour, the occiput which meets the pelvic floor first rotates anteriorly 1/8 circle. The APD of the head now lies in the widest diameter of pelvic outlet easy escape. The shoulders move to occupy the left oblique diameter in left occipito lateral position.
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The theories which explain the anterior rotation Slope of pelvic floor: the muscles are gutter shaped & slope down. So that its movement is in the direction of levator ani muscles (the main muscle of the pelvic floor) i.e. downwards, forwards and inwards. Pelvic shape Law of unequal flexibility
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5. Crowning:
The largest diameter of the fetal head is encircled by the vulvar ring. the head no longer recedes between contraction & the widest transverse diameter (biparietal) is born. it is called crowning. the occiput slips beneath the sub-pubic arch THE OCCIPUT escapes under the symphysis pubis & the head is crowned

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6. Extension of the head: The head is acted upon by 2 forces:

the uterine contractions acting downwards and forwards. the pelvic floor resistance acting upwards and forwards so the net result is forward direction i.e. extension of the head.

the fetal head can extend pivoting on the sub occipital region around the pubic bone. It releases the sinciput, face & chin sweep the perineum & are born by a movement of extension
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7. Restitution: Then the fetal body will rotate to bring one shoulder anterior behind the symphysis pubis ( biacromial diameter into the APD of the pelvic outlet). After delivery, the head rotates 1/8 of a circle in the opposite direction of internal rotation to undo the twist produced by it.
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8. Internal rotation of the shoulders

The shoulders enter the pelvis in the right oblique diameter, the anterior shoulder reaches the pelvic floor first and rotates forwards 1/8 of a circle to lie under the symphysis pubis.
The shoulders enter the pelvis in the opposite oblique diameter to that previously passed by the head.
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9. External rotation of the head :

When the anterior shoulder meets the pelvic floor it rotates anteriorly 1/8 of a circle. This movement is transmitted to the head so it rotates 1/8 of a circle in the same direction of restitution. At the same time the occiput turns a further 1/8 of a circle to the right.

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10. Lateral flexion of the body: Delivery of the shoulder and body The anterior shoulder hinges below the symphysis pubis and with continuous descent the posterior shoulder is delivered first by lateral flexion of the spines followed by anterior shoulder then the body.

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Third Stage

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Third Stage After delivery of the foetus, the uterus continues to contract and retract. As the placenta is inelastic, it starts to separate through the spongiosa layer by one of the following mechanisms: Schultzes mechanism (80%) The central area of the placenta separates first and placenta is delivered like an inverted umbrella so the foetal surface appears first followed by the membranes containing small retroplacental clot. There is less blood loss and less liability for retention of fragments.

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 Duncans mechanism (20%) The lower edge of the placenta separates first and placenta is delivered side ways. There is more liability of bleeding and retained fragments. The 3rd stage is composed of 3 phases: Placental separation. Placental descent. Placental expulsion.
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Lacerations of Birth Canal

1st degree laceration involves the fourchette, perineal skin, and vaginal and vaginal mucous memebranes. 2nd degree lacceration 1st + the fascia and muscles of the perineal body 3rd degree laceration 2nd + anal sphincter laceration 4th degree laceration 3rd + through the rectal mucosa

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PHYSIOLOGICAL EFFECTS OF LABOUR

On the Mother First stage:
minimal effects.

Second stage:
Temperature: slight rise to 37.5oC. Pulse: increases up to 100/min. Blood pressure: systolic blood pressure may rise slightly due to pain, anxiety and stress. Oedema and congestion of the conjuctiva. Minor injuries: to the birth canal and perineum may occur particularly in primigravidas.
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 Third stage:
Blood loss from the placental site is 100-200 ml and from laceration or episiotomy is 100 ml so the total average blood loss in normal labour is 250 ml.

On the Foetus Moulding The physiological gradual overlapping of the vault bones as the skull is compressed during its passage in the birth canal. One parietal bone overlaps the other and both overlap the occipital and frontal bones so fontanelles are no more detectable. It is of a good value in reducing the skull diameters but severe and / or rapid moulding is dangerous as it may cause intracranial haemorrhage.
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Degree of Mouldin g

Suture lines closed but no overlap.

++

Overlap of the bones but reducible.

Overlap of the bones but irreducible.
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+++

Caput succedaneum
It is a soft swelling of the most dependent part of the foetal head occurs in prolonged labour before full cervical dilatation and after rupture of the membranes. It is due to obstruction of the venous return from the lower part of the scalp by the cervical ring. Large caput may:
obscure the sutures and fontanelles making identification of the position difficult. This can be overcomed by palpation of the ear, give an impression that the head is lower than its true level.

Artificial caput succedaneum (chignon): is induced during vacuum extraction. Caput succedaneum disappears spontaneously within hours to days of birth. As it is a vital manifestation, so it is not detected in intrauterine foetal death.

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 The presence of caput indicates that: the foetus was living during labour, labour was prolonged and difficult, the attitude of foetal head during labour can be expected as caput is present in the most dependant part of it.

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