NORMAL LABOUR

Characterised by onset of regular uterine contractions of increasing intensity and

frequency at term accompanied by progressive cervical effacement and dilation.
According to WHO it defines it as low risk throught, spontanious in onset with the fetus
presenting by the vertex, cultimating in the mother and infant in good condition folowing
birth.

CHANGES DURING THE LAST WEEKS OF PREGNANCY

Physiological transition from being a pregnant woman to becoming a mother means an

enorminous change for each woman and they include;

Mood swings are common and usually surge of energy may be experienced

Walking may be difficult for some women at the end of the pregnancy because the
symphisis pubis is more mobile and the relaxation of the sacroiliac joint may give rise to
backache.

2-3 weeks before the onset of labour the lower uterine segment expands and allows
the fetal head to sink lower and it may engage in the pelvis, particularly in the first time
mothers.

In a healthy pregnancy the placenta naurishes and protects the growing fetus, the body of
the uterus remains relaxed and the cervix closes. Normal labour occurs between 37-42
weeks gestation.

STAGES OF LABOUR

We have four stages of labour

a)

Stage 1-its also known as the latent phase which is prior to active first stage of labour
and may last 6-8 hours in first time mothers when the cervix dilates from 0cm to 3-4cm
dilated.

The active first stage is the time when the cervix undergoes more rapid dilation. The
transitional phase is the stage when the cervix is from around 8cm dilated until it is fully dilated.
b)Stage 2-in these stage expulsion of fetus occurs and it begins when the cervix is fully dilated;
in physiological labour the woman feels the urge to expel the fetus. Its complete when the baby
is born.
c)Stage 3-theres separation and expulsion of placenta and membranes, and it also involves
bleeding. Lasts from birth of child until placenta and membranes have been expelled.

d)Stage 4-also known as the recovery stage and its defined as the first one hour after delivery of
the placenta. Many maternal physiologic readjustments occur and usually the average blood loss
from a vaginal delivery is 250 to 300ml. Because of the blood loss and the return of a more
normal abdominal anatomy as the uterus returns to a more normal size (involution), there is a
decrease in blood pressure and pulse rate.
ONSET OF PHYSIOLOGICAL LABOUR

Women should have adequate information prior to labour to ensure comprehension of the
changes labour brings.

Anxiety can increse adrenalin(epinephrine), which inhibits uterine activity and may in
turn prolong labour.

Attitude of the midwife and the advice and guidance given during pregnancy influences
the progress of labour.

FACTORS AFFECTING ONSET OF LABOUR

The onset of labour is determined by a complex interaction of maternal and fetal

hormones.

a) Progesterone- Has opposite effect of that of oestrogen, causing lowering and stabilization
of the resting membrane poential and has a relaxing effect on the uterine smooth muscle.
Levels of maternal oestrogen rise sharply during the last weeks of pregnancy, resulting in
changes that overcome the inhibiting effects of progesterone.

Oestrogen stimulates the placenta to release prostaglandins that induce production of

enzymes that digest collagen in the cervix hence helping it to soften.

b)Oxytocin-Comes from the posterior hypophysis, appears to play a role in maintaining labour.
In early pregnancy, the uterine muscle is refractory to oxytocin, but the myometrium becomes
more and more sensitive to this hormone as pregnancy progresses. Oxytocin, stimulates the
release of prostaglandins from the myometrium where they sensitize the contractile response to
oxytocin. Stimulation of cervix leads to increased oxytocin release(Ferguson reflex).
c) prostaglandins-Released by the lysosomes of the decidual and myometrium cells. It facilitate
the entry of ca++ into the cells and the intercellular electrical connections which improves
coordination.
d)Intra-amniotic volume-Distension of the uterus may play a role and usually the rupture of
membranes, with a decrease in uterine volume, is often used to induce labour.
e)Fetus-Hippocrates postulated that at the right time, the fetus pressed against the fundus with its
feet and pushed itself out.

PHYSIOLOGY OF THE FIRST STAGE LABOUR

1. Duration
The length of labour varies widely and is influenced by; parity, birth interval, psychological
state, presentation and position of fetus. Also maternal pelvic shape and size. Its common to
expect the active phase to be completed within 6-12 hours. The duration of the latent phase of
labour should not be longer than 8 hours.
2.Uterine action
Fundal dominance- Each uterine contraction starts in the fundus near one of the cornua and
spreads across and downwards.The contraction lasts longest in the fundus where it is also
intense.
Polarity- Used to describe the neuromuscular harmony that prevails between the two poles or
segments of the uterus throughout labour. Upper pole contracts strongly and retrtacts to expel the
fetus while the lower pole contracts slightly and dilates to allow expulsion to take place. If
polarity is disorganized then labour is inhibite.
Contraction and retraction-During labour the contraction does not pass off entirely, but muscle
fibres retain some of the shortening of contraction instead of becoming completely
relaxed(retraction).Uterine contractions may occur every 15-20 minutes and may last 30seconds.

Characteristics of contractions

a) Intensity of the uterine contractions is greater in fundus towards the lower segment and in
an established labour it causes a rise in intra-amniotic pressure to between 25 and 60
mmHg above the basal tone.
b) Tone is the basal intra-amniotic pressure between contractions and averages btwn 5 and
12mmHg.
c) Duration is the time between the start and end of a contraction.ususally btwn 40 to 50
seconds.
d) Frequency which is the number of contractions per 10minutes and at the end of first stage
is normally 3-4 contractions in 10 minutes.
Formation of upper and lower uterine segments- By the end of pregnacy the uterus is divided
into two anatomical segments, upper uterine segment, formed from the body of fundus is
concerned with contraction and retraction;its thick and muscular. The lower uterine segment is
formed by the isthmus and the cervix, and is about 8-10 cm in lenght and its for distension and
dilation.

Retraction rings- A ridge forms between the upper and lower uterine segments(retraction, or
Bandls ring). It rises as the upper utrine contracts and retracts and the lower uterine segment
thins out to accommodate the descending fetus.

MECHANICAL FACTORS

1. Formation of forewaters-As the lower uterine segment forms and stretches, the chorion
becomes detatched from it and the increased intrauterine pressure causes this loosened
part of the sac of fluid to bulge downwards into the internal os. The well-flexed head fits
snugly into the cervix and cuts off the fluid in front ot the head from that which surrounds
the body.
2. General fluid pressure- While the membranes remain intact, the pressure of the uterine
contractions is exerted on the fluid and, as fluid is not compressible, the pressure is equalized
throughout the uterus and over the fetal body.
3. Rupture of the membranes- this usually occurs at the end of the first stage of labour after
cervix become fully dilated and no longer supports the bag of forewaters.
4.Fetal axis pressure- During each conntraction, the uterus rises forward and the force of the
fundal contraction is transmitted to the upper pole of fetus, down the long axis of the fetus and
applied by the presenting part of the cervix.

Management of the
First stage of labor

Management of first stage of labor includes the diagnosis of labor, management of early
labor and initial evaluation of mother and fetus

ADMISION TO LABOR AND DELIVERY UNIT

When the woman is admitted, she undergoes an admission procedure which generally includes
the following;

Changing from street clotting to a hospital gown

Safeguarding the womans personal belongings or returning them to the family

Applying identification band for the woman

Filling out chart forms

Carrying out an evaluation of the woman and fetus including history , physical and pelvic
examination and laboratory tests

Admission orders and procedures for a woman in labor include;

perineal shave

oral or intravenous fluids

ambulation

medication and

Monitoring of maternal and fetal well-being.

PERINEAL SHAVE

The purpose of a perineal shave is to attempt to prevent infection. Preparation of the

perineum involving the shaving of the mons pubis, vulva and anal region, provides for
cleanliness and easy viewing of the perineum.

FOOD AND FLUIDS BY MOUTH

A woman, even in early labor, should not eat solid food. If she does, it will mostly likely
remain in her stomach throughout labor or be vomited during transition. This is because
of the severe decrease in the secretion of gastric juice, gastric motility and absorption
during labor.

The best liquid for the woman to have are the clear liquid which to which sugar (for
energy) has been added, such as tea or coffee and water to provide fluid. Fluids are not
desirable as they may produce nausea.

If general inhalation anesthesia is anticipated, restrict even fluids.

INTRAVENOUS INFUSION

Intravenous infusion serves as a means to maintain maternal nutrition and a lifeline for
medication, fluids or blood in the event of an obstetric disaster.an intravenous infusion is
mandatory if one of the following conditions is present:

Gravida 4 or greater

An over distended uterus for any reason including multiple gestation, polyhydramnios
and excessively large baby

A Pitocin induction or augmentation

Maternal dehydration or exhaustion

Any obstetric or medical condition which is life-threatening, such as abruptio placentae,

placental Previa, pre-eclampsia, or eclampsia

History or presence of any other condition that predisposes an immediate postpartum

hemorrhage.

POSITION AND AMBULATION

A woman in labor should assume apposition that is comfortable for her, provided there
are no contraindications to it. Positions may include supine or flat, lateral recumbent,
sitting, standing or waking .if the membranes ruptured and the fetus presents problems
such as transverse lie. Breech presentation or small size (less than 2000gms), it poses a
risk of prolapsed or lateral recumbent.

The lateral recumbent position has several beneficial effects, which are as follows:

Better coordination and greater efficiency of uterine contractions

Facilitation of kidney function
Facilitation of fetal rotation in posterior positions
Relief of uterine pressure on, and compression of, the major maternal blood vessels

In order to avail these benefits, women with the following conditions should be instructed
to assume lateral position during the first stage of labor.

Maternal supine hypotensive syndrome

Fetal distress
Severe pre-eclampsia
Mild hypertonicity or ineffectual uterine contractions
A woman in labor should be allowed to ambulate for as long as she desires, provided
there re no complications. Walking in early labor may stimulate labor.

I.
II.

There are however times when the woman should not be out of bed or ambulating.

These are:
When the membranes ruptured and the fetus either small or in a footling or ill-fitting
breech presentation or transverse lie
When the woman has been medicated with any drug which might make her light headed,
dizzy or unsteady of her feet.

III.

During rapidly progressive labor, or late first stage labor in multiparas.

IV.

Any obstetric or medical complications requiring the woman in bed

Medication

Medications used during labor are for the following purposes.

Pain relief decreased of anxiety and apprehension

Sedation

Control of vomiting

The commonly used drugs are Demerol, phenargan, (promethazine), vistaril and seconal.
The midwife may have to administer these drugs combined in divided doses.

In making decision regarding medication administration, the midwife must consider the
following factors.

Womans desire for medications

Some women want as much medication as the can get. Usually such women do not
understand why you cant give them enough to take the pain away even after explanation.
On the other hand there are women who want to experience or tolerate as much as they
can without medications.

Timing of medications

This is important in the care of the woman in labor. The following principles should be
followed:

The progress of labor evaluated carefully and giving the medications timed so that it will not be
at its peak action at the time of babys birth. Otherwise the baby might be sleepy and have some
respiratory depression. The principle does not apply if a single small dose (e.g. 25 mg of
Demerol) given early in labor.

A narcotic analgesia should not be given until the woman is in active labor. If given
before the contractions are well established, the drug will mostly render the contractions
ineffectual by diminishing their frequency. After the woman is in well-established active
labor, a narcotic analgesic will not affect on the contraction pattern.

Tranquilizers do not affect uterine contractions and will not slow or delay the process of
labor. Because of their calming effect on the woman, progress of labor is often facilitated.

The sedatives are for use:

 When the woman is in false labor

When the woman is in early labor and exhausted and needs a rest
As part of the treatment for hypertonic uterine dysfunction and to stop the present labor
with its abnormal contraction pattern

Fetal size

Because of the developmental immaturity and high risk of respiratory distress in a

preterm or small-for gestational age fetus, all medications are withheld from the woman
during labor in order not to distress the baby. Unlike full-term babies, small or premature
babies cannot handle any amount of drugs crossing the placental barrier.

Vital signs

Blood pressure rises during contractions with the systolic rising average of 15 to 20 mm
Hg and the diastolic raising an average of 5 to 10 mmHg. Between contractions the Bp
returns to its pre-labor level. A shift of a womans position from supine to lateral
eliminates the change in Bp during contractions. Pain, fear and apprehension may also
raise the blood pressure. In order to ascertain the true Bp, it is to be checked between
contractions.

An increase in pulse rate during the increment o contractions, a decrease during the acme
and increase during the decrement are usual. Prolonged hyperventilation may result in
alkalosis

Renal system

Bladder distension commonly occurs due to increased glomerular filtration. The bladder
must be evaluated and emptied every two hours to prevent obstruction o labor and trauma
to the bladder.

Gastrointestinal changes

Gastric motility and absorption of solid foods taken are severely reduced. Secretion of
gastric juice is reduced. Digestion is stopped and gastric emptying is prolonged. Oral
intake should be limited to liquids. Nausea and vomiting are not uncommon during the
transition stage. Pain medications, fear and apprehension may be the contributing factors.

Hematologic changes

Blood coagulation time decrease and plasma fibrinogen level increases. The changes
decrease the risk of postpartum hemorrhage. The white cells count increase during the
first stage.

Blood glucose decreases during labor dropping markedly in prolonged and difficult
labors probably as a result of the increased uterine and skeletal muscle activity.

Monitoring the fetal well-being

Assessment of feta well-being includes continuing evaluation of the following:

Normality of the fetal lie, presentation, attitude, position and variety

Fetal adaptation to pelvis

The fetal heart rate and pattern

Evaluation of the fetal lie, presentation, attitude, position and variety is done by
abdominal palpation and confirmed by vaginal examination.

All the information in these two categories of evaluation of fetal well-being is obtained
when the client is evaluated upon admission to the labor and delivery suite and at any
other time a vaginal examination is done during labor.

The fetal heart rate and pattern are checked by one of the following methods:

Intermittent auscultation of the fetal heart

Intermittent external fetal monitoring

Continuous external fetal monitoring

Continuous internal fetal monitoring

The decision should be based on the indicated need and the established policy of the
institution

The frequency of evaluation of the fetal heart rate and the pattern, using auscultation with
a fetoscope or ultrasonic method is every 30 minutes during active labor

In addition, the fetal heart rate is checked at other times during the course of the normal labor,
including the following:

When the membranes rupture

After the expulsion of an enema

Whenever there is sudden change in the contraction or labor pattern

After giving medications, as its peak action time

Whenever there is any indication that an obstetric or medical complication is developing

In using a fetoscope, it helps to be able to hear the fetal heart if you remember that the
fetoscope is constructed to take advantage of bone conduction of sound.

CONTINUING CARE AND EVALUATION

As the mother continues to labor, the midwife is responsible for carrying out all of the
following, which may be going on simultaneously.

Evaluation of the maternal well-being

Evaluation of the fetal well-being

Evaluation of the progress of labor

Screening for maternal or fetal complications

Bodily care of the woman

Supportive care of the woman and her significant other/family.

Evaluation of maternal well-being

This includes continuing evaluation of the following:

Vital signs
a) Blood pressure
b) Temperature
c) Pulse
d) Respiration

Bladder care

Urine testing

A)Protein

B)Ketones

Hydration

Fluids

General condition

a) Fatigue
b) Behavior and response
c) Pain and coping ability

Vital signs

All of the vital signs are checked upon admission to the labor and delivery suite.
Thereafter, the frequency of checking vital signs may have a policy regarding this to
assure a minimum standard.

A generally accepted norm of frequency for a normal laboring woman during the active
phase of first stage is as follows.

Blood pressure_ every hour

Temperature, pulse and respirations:

Every two hours (or every four hours) when the temperature is normal and the
membranes are intact.

Every hour (or every two hours)after, the membranes have ruptured

BLADDER CARE

During the active phase of first stage of labor. The womans bladder should be evaluated
for distention, at least every two hours. With the descent of the fetal presenting part into
the true pelvis, the bladder is compressed so that distension occurs even with100ml of
urine in the bladder. This distention is above the symphysis pubis. If the bladder is not
carefully attended to and emptied, the following may result:

Obstructed labor- an over distended bladder can impede the progressed of labor

URINE TESTING

Subsequent to the initial specimen collected at the time of admission for a routine
microscopic examination, when a woman void during labor, the urine should be
examined for protein and ketones. Dipstick may be used if available for this test. If there
is protein in the urine it is important to know whether or not this is proteinuria. Urine,
contaminated with bloody show, may have positive result due to the contamination of

blood protein. The results from carefully collected clean catch specimens may be
considered valid.

Examination of the urine for ketones is for purpose of screening the patient for maternal
exhaustion and distress due to dehydration, electrolyte imbalance, and nutritional
deficiency during labor. Presence of ketones means that there is unmet fetal demands
leading to breakdown of fat to provide energy It is most vital to use dipstick testing of the
urine or ketone to evaluate the well-being of the laboring woman who does not have an
intravenous infusion in order to evaluate the adequacy of her oral intake of fluids for
maintenance of hydration. Ketonuria will indicate a need for infusion

HYDRATION

The maintenance of hydration of labor throughout labor is essential for the well being of
a woman. Signs of dehydration such as dry and cracked lips ,a dry mouth or parched
throat may not always be due to dehydration at all in a woman in labor but may indeed be
die to the type of breathing she is based on the screening for ketonuria and knowledge of
the womans intake(by whatever route) and loss ( output). Concentration of the urine
should also be noted.

Excessive nausea or vomiting in a woman worth or without IV fluids must be counter

balanced with IV fluid. While strict intake and output records need fluid intake, urinary
output and the amount of any emesis.

EVALUATION OF FETAL WELL-BEING

Assessment of fetal wellbeing includes continuing evaluation of the following:

Normality of the fetal lie, presentation, attitude, position and variety

Fetal adaption to pelvis

The fetal heart rate and pattern

Evaluation of the fetal lie, presentation, attitude, position and variety is done first by
abdominal palpation and confirmed by vaginal exam; information needed to evaluate
fetal adaptation to the pelvis includes asynclitism/asynclitism, molding of the fetal skull,
and the formation of caput succedaneum and the parameters of normal for each.

All the information in these two categories of evaluating fetal wellbeing is obtain when
the client is evaluated upon admission to the labor and delivery suite and at any other
tone a vaginal examination is done during labor.

The fetal heart rate and pattern are checked by any of the following methods:

Intermittent auscultation of the fetal heart

Intermittent external fetal monitoring

Continuous external fetal monitoring

Continuous internal fetal monitoring

The decision should be based on the indicated need and the established policy of the
institution.

The frequency of evaluation of the fetal heart rate and the pattern, using auscultation with
a fetoscope or ultrasonic method (e.g. doptone) in every 30 minutes during active labor.
In addition, the fetal heart rate is checked at other time during the course of a normal
labor, including the following:

When the membrane rupture

After expulsion of an enema

Whenever there is sudden change in the contraction or labor pattern

After giving medication, at its peak action time

Whenever there is any indication threat on obstetric or medical complication is

developing.

In using a fetoscope, it helps to be able to hear the fetal heart of you remember that the
fetoscope is constructed to tale advantage of bone conduction of sound. For this reason, leap
your fingers off the fetoscope while listening. Fingers on the fetoscope distract the conduction of
sound.

ELECTRONIC FETAL MONITORING

Electronic monitoring is the use of electronic devices in monitoring frequency, intensity

and duration of contractions and, for continuous recording of fetal heart rate patterns. It
should be obvious that continuous monitoring of the fetus is more accurate, in term of
detecting fetal distress, than is periodic evaluation with fetoscope. Intermittent
stethoscopic monitoring during labor and delivery, when the fetus is at the highest risk of
the entire pregnancy, allows detection of only gross changes in the fetal heart rate and
therefore provides little useful information. Only ominous changes are likely to be
detected by fetoscopeic or stethoscopeic monitoring as usually practiced. It has been
established that simultaneous graphic recording of the fetal heart rate and uterine activity
can give an accurate picture of the status of the fetus .

INTERNAL MONITORING

Internal monitoring means the sensing devices are introduce directly into the uterus. The
contraction transducer is a special fluid filled catheter, which transmits exact pressure in
terms of cm of water to the minor. The fetal monitoring device is a pronged scalp electro,
which is applied to the fetal scalp over a bone by the physician and transmits the
electrocardiogram of the fetus to the graphic display.

In order to achieve this, the membranes must be ruptured and the cervix be at least 2-3cm
dilated. A small scalp would is inevitable but this really causes problems.

Internal monitoring is more comfortable for the patient in so far as breathing and position
are concerned. However, she must use a bedpan to empty her bladder when the
intrauterine catheter is used.

Evaluation of the progress of labor

The following items of information are used:

Contraction pattern, frequency, duration, intensity

Maternal behavior changes

Signs and symptoms of transition and impending second stage

Position of low back pain

Position of location of maximum intensity of fetal heat

Vaginal exam

Done to determine dilatation and effacement of cervix and the fetal station.

For the normal intrapartal woman, vaginal exam are indicated

Upon admission, to establish an informational baseline
Before administering medication,
As labor progresses,
After spontaneous rapture of membranes if a prolapsed cord is suspected
If the membranes have ruptured prematurely, vaginal exam is not done because of the
increase risk of introducing contaminants and the development of intrauterine infection