MECHANISM OF NORMAL LABOUR

INCLUDING ONSET OF LABOUR

LECTURE BY DR F. E. ALU
(JP, MBBS, FWACS, FMCOG, FICS, MNIM)
CHIEF CONSULTANT OBSTETRICIAN/GYNAECOLOGIST
DEFINITION
• Labour is defined as the spontaneous onset of
painful, regular strong uterine contractions
of more than one in 10 minutes associated
with progressive cervical effacement &
dilatation & descent of the presenting part
leading to the expulsion of the foetus.
• Simply put, it is the process by which the fetus
is expelled from the uterus

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 Labour may be false (spurious) or true:
• False labour is characterized by irregular weak uterine
contractions which may occur before or at term.
• These contractions are called Braxton-Hicks
contractions and are common in the last 2 months of
pregnancy. It is usually not associated with dilatation of
the cervix or descent of the presenting part
• True labour is characterised by:
 Painful regular uterine contractions
 Effacement & dilatation of the cervix
 Descent of the presenting part
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NORMAL LABOUR
• Labour begins when uterine contractions become painful
& progressive, more than one in every 10 minutes, with or
without “show” (bloodstained mucus plug from the
cervix) or rupture of the membranes
• In established labour, contractions occur more frequently
at the rate of 3 or more in 10 minutes lasting 40-60seconds
with at least 60seconds between contractions
• The essential factors of labour include:
 The passage(the bony & soft tissues of the maternal pelvis)
 The powers(the uterine contractions)
 The passenger(the foetus)

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STAGES OF LABOUR
• Labour is divided into 3 stages:
1. FIRST STAGE = from the onset or diagnosis
of labour to full cervical dilatation.
It is divided into the latent phase & the active
phase.
The active phase starts at a cervial dilatatioon of
3cm(in primigravida) & 4cm (in multigravida).
The length of the latent phase is variable while the
active phase lasts between 6-8 hours.
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2. SECOND STAGE => from full cervical
dilatation to the delivery of the foetus or
foetuses.
This stage is divided into the propulsive
phase & the expulsive phase.
It lasts upto 30 minutes (in primigravida)
& 20 minutes (in multigravida)

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3. THIRD STAGE starts from the delivery of the foetus
or foetuses to the delivery of the placenta.
 Duration is 5-10 minutes. If longer than 30 minutes it is
regarded as prolonged.
 Signs of separation of the placenta are:
 Lengthening of the cord protruding from the vulva
 A small gush of blood from the vagina
 A rising of the uterine fundus to above the umbilicus
The average total duration of labour for the primigravida is 12-14
hours and 8-10 hours for the multigravida

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DEFINITION OF TERMS
• EFFACEMENT refers to the stretching & thinning of
the cervix as it gets incorporated into the lower
uterine segment.
• DILATATION means opening up of the cervix. It is
expressed in cm between 0 and 10.
This is caused by the coordinated contraction of the
upper uterine segment.
In active phase of labour, the cervix dilates at 1-
3cm/hr (in primigravida) & upto 6cm/hr (in
multigravida).
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• ENGAGEMENT is when the widest diameter of the
presenting part has passed the pelvic brim(inlet).
In cephalic presentation this is the BIPARIETAL
diameter, while in breech it is the
INTERTROCHANTERIC diameter.
It is assessed by abdominal examination and
expressed in ‘fifths’ of the fetal head palpable per
abdominal. If less than 2/5th of the fetal head is
palpable abdominally then the head is said to be
engaged
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DEFINITION OF TERMS CONT’D
• ATTITUDE refers to the relation of the
different parts of the fetus to one another in
terms of extension and flexion
• AMNIOTOMY refers to artificial rupture of
the foetal membranes (ARM)
• CAPUT succedaneum is oedema over the
presenting part of the head crossing the suture
lines. Common in long labours

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• STATION is the level of descent of the
presenting part as assessed on vaginal
examination. At the level of the ischial spine
the station is said to be 0.
• VERTEX is the area of the foetal skull
bounded by the two parietal eminences and
the posterior and anterior fontanelles. It is the
part of the head that presents in normal labour

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• DEEP TRANSVERSE ARREST is a condition
where normal internal rotation of the foetal
head is arrested at the level of the ischial
spines in the transverse position. It is usually
associated with an ANDROID pelvis & is a
cause of delay in the 2nd stage of labour.
• DYSTOCIA refers to abnormal or difficult
labour.

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• SYNCLITISM is the relationship of the sagittal suture
to the plane of the pelvic inlet & to the sacrum
posteriorly & the pubic symphysis anteriorly when
the foetal head is in the transverse position.
• Anterior asynclitism occurs when the sagittal
suture is closer to the pubic symphysis
• Posterior asynclitism occurs when the sagittal
suture is closer to the sacrum
• Severe asynclitism is associated with CPD

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MECHANISM OF LABOUR
• This refers to the changes in position and attitude
that the foetus undergoes during its passage
through the birth canal when the vertex presents.
• These movements are:
i. Flexion
ii. Internal rotation
iii. Extension
iv. Restitution
v. External rotation

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MECHANISM OF LABOUR CONT’D
• The foetus enters the pelvis in the transverse position
with the head already flexed before labour.
• In labour, complete flexion occurs in the midcavity.
• In the 2nd stage of labour, internal rotation occurs
allowing the head to arrive the pelvic outlet in antero-
posterior position with the occiput below the pubic arch
& the sinciput (bregma) in the hollow of the sacrum.
• Extension of the head occurs next, allowing the occiput
to escape underneath the symphysis pubis and distending
the vulva. This is known as crowning of the head.

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• With delivery of the head, restitution (which is a
slight rotation of the occiput through 1/8th of a
circle) occurs thus bringing the face to look to the
right or left which is its natural relation to the
shoulders
• The shoulders rotate in the direct antero-posterior
plane with the head rotating with them through
another 1/8th of a circle (external rotation)
• Delivery of the shoulders is followed by delivery of
the rest of the body
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MANGEMENT OF LABOUR
• In the labour ward, a detailed history is obtained to confirm
the diagnosis of labour.
• The antenatal records are reviewed and the vitals signs
including temperature, pulse, respiratory rate and BP are
recorded
• Urine is taken and tested for glucose, protein and ketones
• A general physical examination is performed
• Abdominal examination is carried out noting the SFH, the
lie, presentation, position, and engagement.
• The frequency, regularity, intensity and duration of uterine
contractions are also noted
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• The FHR is auscultated and recorded
• Vaginal examination is done noting the
dilatation & effacement of the cervix, the
station & position of the presenting part,
whether membrane is ruptured or intact, & state
of the liquor.
• Pelvic assessment is done at this stage too
checking for any obvious pelvic abnormality
• Findings are recorded on a PARTOGRAPH
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MONITORING LABOUR PROGRESS
• Monitoring of labour progress is either done manual
observation of uterine contractions & recording of FHR
every 15 minutes or by means of Cardiotocograph(CTG)
• Maternal pulse rate is recorded every 15 minutes while
respiratory rate and temperature are observed every 4
hours
• BP is measured every 2-4 hours
• Urinalysis is done every 2-4hours
• VE is done every 4 hours
• Bladder must be emptied regularly
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LABOUR MANAGEMENT CONTD
• Routine perineal shaving and enema on admission are no
longer required
• Mobility should be encouraged during the first latent phase
• Low fat, low residue food & oral drinks are recommended
• If there is dehydration, correct with Normal saline
infusion(Dextrose water is to be avoided)
• Pain relief is achieved using non-pharmacological &
pharmacological methods (Education during ANC; psychological
methods; Narcotic agents; inhalational analgesia(Entonox);
epidural analgesia; TENS; companion in labour
• Episiotomy should be given as necessary

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ACTIVE MANAGEMENT OF THE 3RD STAGE
OF LABOUR
• The 3rd stage is managed actively:
Administer an oxytocic (oxytocin 10iu or
ergometrine 0.5mg or syntometrine = syntocinon
5iu + ergometrine 0.5mg)
Controlled cord traction(Brandt-Andrews method)
Uterine massage

Aim is to prevent PPH

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PARTOGRAPH
• This is the graphic representation of all events in
labour.
• It allows instant visual assessment of cervical
dilatation against expected norms
• Its introduction led to a reduction in prolonged
labour, decrease in C/S rate and a rise in SVDs.
• The composite partograph was originally designed by
Philpot and Castle in 1972 and has been modified by
WHO.

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COMPONENTS OF PARTOGRAPH
• It consists of 4 main parts:
• A cervicogram which is a graphic recording of cervical
dilatation(in centimetres) and descent of the presenting
part against time in hours
• Conditions of the mother(temperature, pulse, BP, uterine
contractions frequency, strength & duration, and urine
volume and qualities)
• Conditions of the fetus(FHR, liquor colour, and caput and
moulding)
• The therapeutics undertaken in labour viz: drugs, fluids,
oxytocin infusion and analgesics
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• The partograph contains an ALERT LINE and an
ACTION LINE which make for easy recognition of
labour progress.
• ALERT LINE: This a straight line drawn from 4cm
cervical dilatation at zero time progressing at 1cm/hr till
full cervical dilatation at 6 hours from admission time.
• ACTION LINE: This is a line drawn parallel and 4
hours to the right of the alert line and represents the
progress of parturients with cervical dilatation rate
progressing at a rate of 4 hours less than the expected
minimum rate of 1cm/hr.
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• With cervical dilatation rate delayed to the Action line,
specific actions must be taken to correct the cause of the
delay.
• Such actions may range from oxytocin augmentation (if
poor uterine contraction is the cause of the delay) to
abdominal delivery (if the delay is due to CPD)
• Repeat vaginal examination is done 4 hourly to assess
progress.
• Good labour progress is indicated by a cervical dilatation
graph which remains to the left of the ALERT LINE till
delivery.
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• Where the cervical dilatation progress crosses the Alert line it means
the labour progress has run at less than 1cm/hr
• When it eventually crosses the Action line, this confirms that
cervical dilatation has been delayed to over 4 hours less than the
expected normal 1cm/hr.
• This situation calls for some assessment and intervention.
• In Centres with poor facilities for obstetric care, this (cervical
dilatation crossing the alert line) serves to warn that labour
progress is running an abnormal course and parturient should be
transferred to a more equipped Facility.
• The 4 hour separation between the Alert and Action line is supposed
to represent the maximum time lapse for the woman to be transferred
to the next more equipped obstetric centre.
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• In an equipped Centre where transfer is
unnecessary, a cervical dilatation progress crossing
the alert line calls for more senior personnel
supervision of the labour.
• When the labour progress crosses the Action line
there is the need for careful assessment of the
labour by a senior or a more experienced staff to
delineate the cause of the delay and to institute
appropriate measures (usually oxytocin AOL or
C/S).
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BENEFITS OF THE PARTOGRAPH
• Assessment of progress of labour at a glance.
• Early recognition of abnormal progress of labor.
• Improves timing of management decisions:
oxytocin AOL
C/S
Transfer from periphery to a more equipped centre
• Facilitates handover of patients.
• Easy tool for teaching and research.

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CRITICISMS OF PARTOGRAPH

• Alert line of 1cm/hr progress may conceal slow

progress.
• 4 hours between Alert and Action lines too long
for intervention.
• Too full of details.
• Recording of the latent phase may encourage
avoidable interventions.
• Litigation instrument.
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MECHANISM OF THE ONSET OF LABOUR

• The mechanism for the onset of labour is not yet

fully understood
• It is however known that both maternal & fetal
factors are involved
• During pregnancy the uterus remains quiescent,
despite massive stretching, due to the action of
progesterone balanced by the effects of oestrogen.
• It is thought that alteration in this balance results in
increased uterine activity

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ONSET OF LABOUR CONT’D
• At term, the suppression of myometrial excitability by
progesterone decreases & this promotes the release of
arachidonic acid(precursors of prostaglandins, PGs)
• ACTH (Adrenocorticotrophic Hormone) promotes production of
DHEA in the foetal adrenal which forms oestrone & oestradiol.
(Cortisol productrion by ACTH is NOT important in initiation
of labour in humans)
• Oestrogens further stimulate production of arachidonic acid
• Prostaglandins are produced in decidua and foetal membranes &
labour is initiated
• Although the posterior pituitary gland produces OXYTOCIN
there is no increase in levels of oxytocin before onset of labour
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ACTIVE MANGAEMENT OF LABOUR

• This involves expediting labour through some

interventions with the aim of shortening the duration
and improving the outcome of labour thereby
reducing perinatal mortality & caesarean section
rate. Principle is based on cervical dilatation rate of
1cm/hr
• Some of the interventions include oxytocin use, early
amniotomy, companion in labour, pain relief in
labour, and early resort to operative interventions if
there is deviation of labour from the expected norm

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KEY POINTS
• Active management of labour aims to prevent
prolonged labour and its sequelae as well as reduce
C/S rate.
• Correct diagnosis of the onset of labour and careful
assessment of progress in labour using a
PARTOGRAPH and thorough consideration of
underlying causes of abnormal labour permit effective
use of oxytocin and reduce unnecessary C/S.
• The importance of CPD, malposition, and poor uterine
action must be noted.
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THANK YOU

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