dr.

Rimonta F Gunanegara, SpOG

Department Obstetric and Gynaecology

Faculty of medicine Maranatha University
Immanuel Hospital
 Definition :
Series of events that take place in
the genital organs in an effort to expel
the viable products of conception out of
the womb through the vagina into the
outer world
< 37 completed weeks preterm labor
A parturient is a patient in labor
Parturition is the process of giving birth
 Delivery is the expulsion or extraction
of a viable fetus out of womb

Delivery can take place without labor

as in elective cesarean section

Delivery may be vaginal, either

spontaneous or aided or it may be
abdominal
 Normal labor (Eutocia)

Criteria :

Spontaneous in onset and at term

Vertex presentation

Without undue prolongation

Natural termination with minimal

aids
No complications affecting the health
of the mother and / or the baby
 Causes onset of labor

The precise mechanism of initiation of

labor is still obscure
Hypothesis :
1. Uterine distension :
Stretching effect on the myometrium
by the growing size of the fetus &
liquoramnii
2. Feto placental distribution :
Due to unknown factors fetal
pituitary is stimulated prior to onset
of labor

Increased release of ACTH

Stimulated fetal adrenals

Increased cortisol secretion

Accelerated production of estrogen
& prostaglandin from the placenta
 Modes of action of oestrogen (probable
Release of oxytocin from maternal
pituitary
Promotes the synthesis of receptors
for oxytocin in the myometrium and
decidua
Increased prostaglandin synthesis
Stimulates the synthesis of
myometrial contractile protein
(actiomyosin through activation of
adenosin triphosphate)
3. Progesterone :

Dehydroepiandrosteron sulphate
(DHEA-S) and cortisol
inhibit
Conversion of fetal pregnenolone
to progesterone

Altering the oestrogen :
progesterone ratio
4. Prostaglandin :

The major sites of syntesis :

Placenta
Fetal membranes
Decidual cells
Myometrium
 Synthesis is trigered by :
Oestrogen level
Altered oestrogen-progesterone
balance
Mechanical stretching in late
pregnancy
Oxcytocin receptors
Infection
Rupture of the membranes
Vaginal examination
 5. Oxytocin :

Oxytocin level reaches the

maximum at the moment of birth
 6. Neurological factor
Labor initiated through nerve
pathways
Oestrogen receptors in the
myometrium to function
Progesteron receptors in the
myometrium to function
predominantly
Contractile system of the myometrium

The basic elements involved in the

uterine contractile system :
Action

Myometrium

Adenosine triphosphate (ATP)

Enzyme adenosine triphosphate
(ATP ase) which splits the ATP to
release the required energy
Uterine muscles have two types of
adrenergic receptors :
Receptors cyclic AMP
contraction

stimulation

Receptors cyclic AMP

inhibition

stimulation
False pain :
More in primi gravida
Prior to the onset of true labor pain
One or two weeks before in primigravida
A few days before in multipara
Features :
Dull in nature
Lower abdomen and groin
Continuous and unrelated with hardening
of the uterus
No effect on dilatation of the cervix
Relieved by enema and administration of
sedative
 Prelabor :
2-3 weeks before the onset of true
labor
Consist of :
a. Lightening:
In primigravida the presenting part
sinks into the true pelvis
Gradual process or may be felt
abrupthy
b. Cervical changes :
Ripe cervix , soft, < 1,3 cm admits a
finger easily and is dilatable
c. False pain
 True labor pains :

Painful uterine contractions

Show
Progressive effacement and
dilatation of the cervix
Stage of labor :
First stage :
The onset of true labor full
dilatation of the cervix
Second stage :
Full dilatation expulsion of the
fetus
Third stage :
Expulsion of the fetus expulsion of
the placenta & membranes (after-
births)
Fourth stage :
One hour after expulsion of the
placenta
Physiology of normal labor
During pregnancy
hypertrophy & hyperplasia of the
uterine muscles
enlargement of the uterus
at term, the length of the uterus + 35
cm including cervix
fundus much wider, transversely and
anterior-posterior than the lower
segment
Uterus assumes pyriform or ovoid
shape
 Uterine contraction in labor

Rhytmic involuntary , spasmodic uterine

contractions, painless, no effect on
dilatation of the cervix (during
pregnancy)

In labor complexity of the
mechanism
The contraction follow the
following patterns :

Good
synchronisation of the contraction
waves
Fundal dominance
Thewaves of contraction followed
regular pattern
Intra
amniotic pressured rises > 20
mmHg
Good relaxation between contractions
 Intensity : 40-50 mmHg (1st stage)
100-120 mmHg (2nd stage)
Duration : 40-60 seconds
Frequency : 3 x / 10
Retraction :
Phenomena of the uterus in labor
Musles fibers are permanently shortened
Shortened once and for all
Specially a property of upper uterine
segment
 Uterine phases of parturition
 Events in first stage of labor

The main events

Dilatation and taking up of the cervix
Full formation of lower uterine
segment
Actual factors responsible:
Uterine contraction and retraction
Bag of membranes
Fetal axis pressure
Effacement or taking up of cervix

Is a process of thining out which is

accomplished during the first
stage of labor or even before in
primigravida
In multiparae, effacement &
dilatation occur simultaneously
 Lower uterine segment

During labor demarcation of an

active upper segment and a relatively
passive lower segment is pronounced

A distinct ridge is produced at the

junction of the two physiological
retraction ring
Pathological retraction ring (Bandl ring
 Events in the second stage of labor

Descent and delivery of the fetus

through the birth canal
Full dilatation of the cervix

Membranes usually rupture

The expulsive force , uterine

contractions and bearing down
The cardinal movements of labor :
- engagement - extension
- descent - external
rotation
- flexion - expulsion
- internal rotation
Engagement :

The greatest transverse diameter (BPD) in

occiput presentation, passes through the
pelvis inlet
In many primigravida this phenomena
may takes place during the last weeks of
pregnancy
In many multiparous and some
nulliparous the fetal head is still
freely movable above the pelvic inlet
(floating)
Descent

The first requisite for birth of the infant

In nulliparas, engagement may take place
before the onset of labor and further
descent takes place at the second stage
Four forces :
a. pressure of amniotic fluid
b. direct pressure of the fundus upon the
breech with contraction
c. bearing down effort
d. extension and straightening of the fetal
body
Flexion

Resistance from the cervix, wall of the

pelvis, pelvic floor flexion of the
head
Thechin more contact with the fetal
thorax
Suboccipito bregmatic diameter is
substituted for the longer occipito
frontal diameter
Internal rotation

The occiput gradually moves anteriorly

toward the symphysis pubis or less
commonly, posteriorly toward the
hollow of the sacrum
Is always associated with descent
Is not accomplished until the head has
reached the level of the spine and
thereafter is engaged
 Extension

Extension brings the base of the occiput

into direct contact with the interior margin
of the symphysis pubis
Causes of extension :
The vulva outlet is directed upward
and forward
 Two forces come into play :
a. Exerted by the uterus act more
posteriorly
b. Resistant pelvic floor and the
symphysis acts more anteriorly the
resultant vector is in the direction of
the vulva opening causing extension
 External Rotation

The delivered head next undergoes

restitution

If the occiput was originally directed

toward the left it rotates toward the left
ischial tuberosity
 Expulsion

After delivery of the shoulders,

the rest of the left body is quickly
extruded
Labor patterns
Patterns of cervical dilatation
Events in third stage of labor

The phase of placental separation

descent expulsion
Mechanism of separation :

a. Central separation (Schultze)

b. Marginal separation (Duncan)