NORMAL LABOR;ESSENTIAL

FACTORS;ELEMENTS OF UTERINE
CONTRACTIONS & PHYSIOLOGY OF
1ST STAGE OF LABOR
 
SUBMITTED TO, SUBMITTED BY,
Dr. Sharda Rastogi Mrs. Aswathy M U
Assistant professor MN 1 st year
 INTRODUCTION
• Normal labor
• Signs of normal labor
• True and false labor
• Causes of onset of labor
• Stages of labor
• Factors affecting normal labor
• Elements of uterine contractions
• Physiology of first stage of labor
 LABOUR
Series of events that takes place in the
genital organs in an effort to expel the viable
products of conception (fetus, placenta and
the membranes) out of the womb through
the vagina into the outer world is called
LABOUR ( D C Dutta’s)
 LABOUR
• Normal labor is called EUTOCIA
• Abnormal labor is called DYSTOCIA
 CRITERIA OF 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),natural termination with minimal
aids, without complications to the mother, or
the foetus
 NORMAL LABOUR
• The period begins with the onset of regular
uterine contractions(UCs) and lasts until the
expulsion of the placenta; we called the
Intrapartum.
• Delivery is the birth of baby itself.
• Delivery can occur in two ways, vaginally or
by a cesarean delivery.
 Normal Labor Signs/Premonitary signs of
Labor
• 1.Pre-labor(1-4 weeks before labor ):
• Lightening
• Braxton Hick’s contractions
• Sudden burst of maternal energy/activity
• Increased back pain and cramps
• Abdominal pain
• Joints feel looser
• Diarrhea
• Cervix effacement and dilation
 Signs of lightening
• Increased frequency of voiding
• Increased amount of vaginal discharge
• Increased lordosis as the fetus enters the
pelvis and falls further forward
• Increased varicosities
• Shooting pains down the legs because of
pressure on the sciatic nerve
Cervix effacement and dilation
 Normal Labor Signs/Premonitary signs of
Labor
• 2.Early labor (Hours before labor):
• Bloody show
• Rupture of membranes
• Uterine contractions
 Phases of uterine contractions
• Increment/Crescendo –intensity of the
contraction increases
• Apex/Acme –the height or peak of the
contraction
• Decrement/Decrescendo–intensity of the
contraction decreases
 Characteristics of contractions
• Frequency of contraction
• Duration of contraction
• Intensity of contraction
 Mild contraction
 Moderate contraction
 Strong contraction
 True vs False Labor
• Parameters for comparison:
1.Regularity
2.Location
3.Changes in contractions
4.Absence/presence of contractions during
activity.
5.Cervical Changes
CAUSE OF ONSET OF LABOUR

•Hormonal factors
•Mechanical factors
 HORMONAL FACTORS
1. 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.
2. Progesterone withdrawal theory:
• Before labour, there is a drop in progesterone
synthesis leading to predominance of the excitatory
action of oestrogens
 HORMONAL FACTORS
3. Prostaglandins theory:
• PGF2α was found to be increased in maternal
and foetal blood as well as the amniotic fluid
late in pregnancy and during labour.
4. Oxytocin theory:
• The secretion of oxytocinase enzyme from the
placenta is decreased near term due to
placental ischemia leading to predominance of
oxytocin’s action.
 MECHANICAL FACTORS
1. 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
 STAGES OF LABOR
a).1st stage (cervix dilation): begins with onset of
labor and ends with complete cervical dilation.
b).2nd stage (baby delivery): begins with complete
dilation of cervix and ends with delivery of baby.
c).3rd stage (placenta delivery): begins after delivery
of baby and ends with delivery of placenta.
d).4th stage (post partum): begins after delivery of
the placenta and is completed 4hours later.
 Approximate time taken for each stage of
labour
  Primigravidae Multigravidae

Firststage 12–14hours 6–10hours

Second stage 60minutes Upto30minutes

Third stage 20–30mts or 5–15mts 20–30mts or5-15mts

with active management with active management

 
 FIRST STAGE
• THE LATENT PHASE : Last 6-8 hours in the first time
mothers; cervix dilates from 0cm to 3-4 cm
dilated;cervical canal shortens from 3cm long to less
than 0.5 cm long.
• THE ACTIVE PHASE :This begins when the cervix is 3-
4 cm dilated; in the presence of rhythmic
contractions, is complete when the cervix is fully
dilated.
• THE TRANSITIONAL PHASE : It is the stage of labor
when the cervix from around 8 cm dilated until it is
fully dilated
FIRST STAGE
 SECOND STAGE
• It starts when the cervix is completely
opened and ends with the delivery of the
baby.
• Often referred to as the "pushing" stage.
• When the baby's head is visible at the
opening of the vagina, it is called "crowning."
• It may take between 30 minutes to 1 hour for
a woman's first pregnancy
SECOND STAGE
 THIRD STAGE
• It is the delivery of the placenta
• Once the baby has been delivered, it may be
left for two to three minutes before cut the
umbilical cord.
• The mother may experience some bleeding.
• This stage usually lasts just a few minutes
upto a half-hour
THIRD STAGE
 FOURTH STAGE
• The hour to four hours after delivery,and
sometimes for about six weeks, or with the
stabilization of the mother.
• The baby should be assessed and the mother
should have regular assessments for uterine
contraction,vaginal bleeding, heart rate and
blood pressure, and temperature, for the first
24 hours after birth.
 FACTORS AFFECTING LABOR (5 P’S)

1.Passenger:the fetus
2.Passage way:the pelvis and birth canal
3.Powers:the uterine contractions
4.Position:maternal postures and physical
positions
5.Psyche:the response of the mother
 1.PASSENGER (THE FETUS)
• Presentation of the fetus (breech,
transverse).
• Position of the fetus (ROP, LOP).
• Size of the fetus
• Number of fetus
 1.PASSENGER (THE FETUS)
• FETAL LIE : It is the relationship between the
long axis of the fetus and the long axis of the
uterus. It may be longitudinal, oblique or
transverse lie. In the majority of cases the lie
is longitudinal owing to the ovoid shape of
the uterus.
 1.PASSENGER (THE FETUS)
• FETAL PRESENTATION : It refers to the part of
the fetus that lies at the pelvic brim or in the
lower pole of the uterus. Presentation can be
vertex, breech, shoulder, face or brow.
Vertex, face and brow are called cephalic
presentation. When the head is flexed the
vertex presents.
1.PASSENGER (THE FETUS)
 1.PASSENGER (THE FETUS)
• FETAL ATTITUDE : Attitude is the relationship
of the fetal head and limbs to its trunk. It
may be flexion (normal) or extension
(abnormal). The attitude should be one of
flexion. The fetus is curled up with chin on
chest, arms and legs flexed, compact mass,
which utilises the space in the uterine cavity
most effectively.
1.PASSENGER (THE FETUS)
 1.PASSENGER (THE FETUS)
• Denominator : It is an arbitrary bony fixed
point on the presenting part which comes in
relation with the various quadrant of the
maternal pelvis
Eg :-occiput in vertex, mentum(chin) in
face,sacrum in breech and acromian in
shoulder
 1.PASSENGER (THE FETUS)
• FETAL POSITION : The position is the
relationship between the denominator of the
presentation and six points on the pelvic
brim. Anterior positions are more favourable
than posterior positions
1.PASSENGER (THE FETUS)
 1.PASSENGER (THE FETUS)
• FETAL STATION: Position of the baby's head
relative to the lower bone of pelvis called the
ischial spines.
1.PASSENGER (THE FETUS)
 2.PASSAGE WAY (THE PELVIS)
• Parity of the woman, if she has ever
delivered before.
• Resistance of the soft tissues as the fetus
passes through the birth canal.
• Fetopelvic diameters.
2.PASSAGE WAY (THE PELVIS)
 2.PASSAGE WAY (THE PELVIS)
•The passage includes the bony pelvis,the soft
tissues of the cervix, and the vagina.
•The maternal pelvis is the greatest determinant
in the vaginal delivery of the fetus.
•During the first stage of labor, the cervix opens
(dilates) and thins out (effaces) to allow the
baby to move into the birth canal.
•The cervix must be 100 percent effaced and 10
centimeters dilated before a vaginal delivery.
2.PASSAGE WAY (THE PELVIS)
 3.POWERS
• Powers refer to the involuntary Uterine
Contractions (UCs) and voluntary pushing of fetus.
• Contractions are a tightening and relaxing of the
muscles in the abdomen and the back.
• Uterine Contractions have two major goals:
1.To dilate the cervix
2.To push the fetus through the birth canal
• After each contraction there is a uterine
relaxation that allows blood flow to the uterus.
4.POSITION
 5.PSYCHE
• Patient may be
anxious. We should
give her the support
and health care, and
allow the family to give
her the support
 ELEMENTS OF UTERINE CONTRACTIONS

a. actin
b. myosin
c. adenosine triphosphate (ATP)
d. The enzyme myosin light chain kinase
(MLCK)
e. Ca++
 ELEMENTS OF UTERINE CONTRACTIONS

• Structural unit of of a myometrium cell is

myofibril which contains the proteins—actin
& myosin. The interaction of actin and
myocin is essential for muscle contraction.
The key process in actin-myocin interaction is
myocin light chain phosphorylation. This
reaction is controlled by myosin light chain
kinase (MLCK).
 ELEMENTS OF UTERINE CONTRACTIONS

• Oxytoccin acts on myometrial receptors and

activates phospholipase C, which increase
intracellular calcium level. Calcium is
essential for the activation of MLCK and
binds to the kinase as calmodulin-calcium
complex.
 ELEMENTS OF UTERINE CONTRACTIONS

• Intracellular calcium levels are regulated by

two general mechanisms:
1. influx across the cell membrane and
2. release from intracellular storage sites
• Calcium is stored within the cells in the
sacroplasmic reticulum and in mitochondria.
 ELEMENTS OF UTERINE CONTRACTIONS

• Intracellular Ca++ calmodulin Ca++

MLCK phosphorylated myosin + actin
Myometrial contraction
• Decease of intracellular Ca++
dephosphorylation of myosin Light chain
inactivation of MLCK myometrial
relaxation
PHYSIOLOGY OF FIRST STAGE OF
LABOUR
PHYSIOLOGY OF FIRST STAGE OF LABOUR

1. Completion of effacement of the cervix and

dilatation of the os uteri caused by uterine
activity:
2. Formation of the bag of forewaters and the
hindwaters
3. Rupture of the membranes
4. Show
 UTERINE ACTIVITY
• Contraction and retraction of uterine muscles
• Fundal dominance
• Active upper uterine segment, passive lower
segment
• Formation of the retraction ring
• Polarity of the uterus
• Intensity or amplitude of contractions
• Resting tone
Cervical effacement and dilatation
• Effacement (taking up) of the cervix may start in
the latter 2 or 3 weeks of pregnancy and occurs as a
result of changes in the solubility of collagen
present in cervical tissue
• Dilatation of the cervix is the process of
enlargement of the uteri from a tightly closed
aperture to an opening large enough to permit
passage of the fetal head. It is measured in
centimetres and full dilatation at term equates to
about 10 cm.
Cervical effacement and dilatation
 Show
• The ‘show’ is the operculum from the cervical
canal passed per vaginam in labour, displaced
when effacement of the cervix and dilatation
of the os uteri occur. It is usually mucoid and
slightly streaked with blood due to some
separation of the chorion from the decidua
around the cervix.
 Uterine contractions
• Uterine contractions are responsible for
achieving progressive effacement and
dilatation of the cervix and for the descent
and expulsion of the fetus in labour.
Contractions of the uterus in labour are:
 involuntary
 intermittent and regular
 in almost all labours, painful.
 Coordination of contractions
• Contractions start from the cornua of the
uterus inwards and downwards. In normal
uterine action, the intensity is greatest in the
upper uterine segment and lessens as the
contraction passes down the uterus. This is
called fundal dominance. The upper segment
of the uterus contracts and retracts
powerfully, whereas the lower segment
contracts only slightly and dilates.
FUNDAL DOMINANCE
 RETRACTION
• Retraction is a state of permanent shortening of the
muscle fibres and occurs with each contraction.
• The muscle fibres gradually become shorter and
thicker, especially in the upper uterine segment
A.relaxed;B.contracted; C.relaxed but
retracted; D.contracted but shorter and thicker than those in B.
 POLARITY
• It is the term used to describe the
neuromuscular harmony that prevails
between the two poles or segment of the
uterus throughout labor.While the upper
segment contracts powerfully and retracts,
the lower segment contracts only slightly and
dilates.
 INTENSITY OR AMPLITUDE
• Contractions cause a rise in intrauterine
pressure – the intensity or amplitude of
contractions.
• It can be measured by placing a fine catheter
into the uterus and attaching it to a pressure-
recording apparatus.
 RESTING TONE
• The uterus is never completely relaxed, and
between contractions a measured resting
tone is usually 4–10mmHg.
• The period of relaxation between
contractions when the uterus has a low
resting tone is vital for adequate fetal
oxygenation.
Formation of the forewaters and hindwaters

• As the lower uterine segment stretches some

chorion becomes detached from the decidua
and both membranes form a small bag
containing amniotic fluid, which protrudes
into the cervix.
• When the fetal head descends onto the
cervix, it separates the small bag of amniotic
fluid in front, the Forewaters, from the
remainder, the Hindwaters
Formation of the forewaters and hindwaters

• The forewaters aid

effacement of the cervix
and early dilatation of
the os uteri
• The hindwaters help to
equalize the pressure in
the uterus during uterine
contractions, providing
some protection to the
fetus and placenta
 THE RETRACTION RING
• A ridge forms between the upper and lower
uterine segment; this is known as the
retraction, or Bandl’s ring.
• It becomes visible above the symphysis in
mechanically obstructed labor when the
lower segment thins abnormally
THE RETRACTION RING
MECHANICAL FACTORS
• General fluid
pressure
• Rupture of the
membranes
• Fetal axis pressure
 GENERAL FLUID PRESSURE
• While the membranes remain intact, the
pressure of the uterine contractions is exerted
on the fluid and the pressure is equalised
throughout the uterus and over the fetal
body; it is known as ‘general fluid pressure’
• Preserving the integrity of the membranes
optimises the oxygen supply to the fetus and
also helps to prevent intrauterine and fetal
infection,
GENERAL FLUID PRESSURE
 RUPTURE OF THE MEMBRANES
• The optimum physiological time for the
membranes to rupture spontaneously at the
end of the first stage of labor after the cervix
become fully dilated
• 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.
 FETAL AXIS PRESSURE
• During each contraction the uterus rises
forward and the force of the fundal
contraction is transmitted to the upper pole
of the fetus, down the long axis of the fetus
and applied by the presenting part to the
cervix. This is known as fetal axis pressure
FETAL AXIS PRESSURE
THAT’S ALL!
You are ready for the evaluation test
1.Normal labor is called
A) Dystocia
B) Eutocia
C) Paraesthesia

ANS:B
2.State True/False
True labor is associated with regular
uterine contractions
• Ans: TRUE
 3.Second stage of labor refers to
A) cervix dilates from 0cm to 3-4 cm dilated
B) cervix from around 8 cm dilated until it is
fully dilated
C) cervix is completely opened and ends with
the delivery of the baby.

ANS: C
4.The relationship between the long axis
of the fetus and the long axis of the uterus
is called
A) FETAL LIE
B) FETAL ATTITUDE
C) FETAL PRESENTATION

ANS: A
5.The term used to describe the
neuromuscular harmony that prevails
between the two poles or segment of the
uterus throughout labor

A) RESTING TONE
B) POLARITY
C) RETRACTION

ANS : B
6. A ridge forms between the upper and
lower uterine segment
ANS: RETRACTION
RING OR BANDL’S
RING
7. 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
ANS : CAUL
CONGRATULATIONS!
THANK YOU FOR PARTICIPATING!

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