PHYSIOLOGY OF LABOR

Department of Obstetrics
and Gynecology, number 1
KhNMU
Normal labor - these are the labor with
spontaneous onset and progression in
low-risk pregnant at 37-42 weeks of
gestation, the fetus in cephalic occipital
presentation ,with satisfactory condition
of mother and newborn after delivery.
 Childbirth - a complex multilinks
physiological act that occurs and
terminates as a result of interaction of
many organs and systems and
expulsion of fetus, placenta and fetal
membranes with amniotic fluid from the
uterus through the birth canal.
Theories of labor onset

 Hippocratic theory
 The theory of a "foreign body“
 Mechanical theory
 Immunological theory
 Placental theory
 Chemical theory
 Endocrine theory
 The causes of the labor onset
•Trigger release is accompanied by excitation of
acetylcholin by nerve terminal receptors , thereby
changing the balance inside the cell and in the
extracellular space, as well as by cell membranes;

• oxytocin, synthesized in the mother and fetus,

provides for the release of prostaglandins due to
ischemia of the myometrium and the release of
high concentrations tonomotor substances
(serotonin, prostaglandins , catecholamines , etc. ),
which was accompanied by decreasing the
concentration of their inhibitors and mediates
activation of the uterine receptors;
 Prostaglandins inhibit delay of calcium in the cells,
release of witch is accompanied by a reduction of
the myometrium;

 energy produced by the breath and glycolysis

against high level of enzymes and the mandatory
presence of calcium ions, potassium, sodium and
magnesium;

 uterine contractions provided by donators of energy

- macroergic phosphates, which store energy so
cold phosphocreatine and ATP;
 Physiological changes that
precede childbirth offensive
 Restructuring the CNS and the formation of
"the labor dominant.“
 Increased excitability of the myometrium
(hormones, neurotransmitters, electrolytes,
etc.).
 Relative oligohydramnion develops (fetal
growth outstrips formation of amniotic fluid).
 Fetal movement become more active.
 Lowered fetal presenting part (impact of
receptors).
 “Points" the cervix.
 Appear predictive contractions.
 Women’s weight loss.
 Labor forces
 Contractions - periodic involuntary
reduction of the uterus, are the process
of contraction and retraction
 Stadium incrementi – increase
 Acte - the highest degree of reduction

 Stadium decrementi - gradually

transformed into a relaxing break
 Bearing down-to involuntary
contractions of the smooth muscles of
the uterus joins a reflex contraction of
striated skeletal and abdominal muscles,
diaphragm, pelvic floor
 Stages of delivery
I stage – cervical
 contraction -reduction

 retraction - change in the relative

location
 distraction - stretching muscles in the
sides and top

II period - expulsion

III period –expulsion of the after-births

 Scale of levels of maturity of the cervix (By
E.H.Bishop)
Points
Index 0 1 2
Consistency of Thick Softened at the Soft
cervix periphery, in the
internal os

Cervical length More than 2 cm 1-2 cm Less than 1 cm

Patency of the External os closed, Cervical canal is Canal passable

cervical canal but misses the passable up to the for one or more
fingertip internal os fingers out of
internal os

Position of the Set back Between the Along the axis of

cervix relatively sacrum and pelvis the pelvis
to the axis of the axis
pelvis
 I stage of labor
 Latent phase - to 8 hours, the rate of opening of
0.3-0.5 cm per hour. Effacement and dilatation of
the cervix up to 3 - 3.5 cm
 Active phase - disclosure rate of 1.0 -1.5 cm /
hour, opening up to 8 cm
 deceleration phase -1 -1.5 hours lasts until full
disclosure of the uterine os, speed of opening-
0.8-1.0 cm / hour
 CERVICAL DISCLOSURE
Primigravida- complete effacement of the cervix occurs
at first (by opening the internal cervical os), then
dilatation of the cervical canal and only then - the
disclosure (owing to the external os).
 CERVICAL DISCLOSURE
• Multipara – ‘taking up’ and dilatation of the
external os occur simultaneously.
 Full cervical dilatation is considered
disclosure by 10 - 12 cm, the cervix is not
defined during vaginal examination, palpable
only presenting part of the fetus.
 The abutment head to the walls of the lower
uterine segment is called the contact zone
(ring of ingagement). It shared the amniotic
fluid in the fore-waters and hind-waters.
Labor tumor formed on the head below it.
Position of women in labor in the first stage
 ІI stage of labor
• This stage is соncerned with the descent and delivery of
the fetus through the birth canal
• The second period is determined by the totality of all the
successive movements, which carries the fetus during the
passage through the mother's birth canal and is
characterized as Biomechanisms of childbirth.
• Depending on the position, fetal presentation, view – type
of biomechanism delivery will be different.
• When descent the fetal presenting part (head) on the
pelvic floor there are bearing down. Duration of
contractions in the II period is 40 - 80 sec., after 1 - 2
minutes.
 Conducting of II stage of
labor
• Assessment of parturient woman: measurement of
blood pressure and heart rate every 10 minutes
• Monitoring the fetal heart rate every 10 minutes
 Conducting of II stage of
labor
• Monitoring the progress and
condition of the head of the
lower segment
 Conducting of II stage of
labor

If amniotic fluid is not escape in a timely

manner - spend amniotomy
Careful manual assistance at birth the baby's
head (preservation of the integrity of the
perineum and the prevention of intracranial
and spinal cord injury)
 Conducting of II stage of
labor

For the ensuring a woman's rights she will be

informed about opportunity to choose a
convenient position both for her and for the
medical staff
Episio-, or perineotomy held by a physician
on the testimony and providing preliminary
anesthesia
 5 maneuvers protect the
perineum

 Purpose:
 Prevent rupture of the perineum.
 Withdraw fetal head without damaging it.
 Maneuvers:
 Prevention of premature extension and rapid
advance of the head.
 Extruction of the fetal head out of pushing.
 Tension reduction and borrowing of perineal
tissues.
 Regulation of bearing down attempts.
 Extruction of the shoulders and the birth of the
fetus.
 Two tactics, III stage of
labor:

Expectant (physiological) approach and in

this case - only treatment of complications
should they arise;
Active management of the third period
with any uterotonic.
 Conducting of III stage of
labor

In order to prevent bleeding in the first

minute after the birth of the fetus as an
intramuscular injection of 10 IU oxytocin

Held control cord traction is an indication

only when the placenta have separated
from walls of the uterus
 The third stage of labor
 During this period there is a separation and
isolation of the placenta from the uterus.
 Successive period lasts an average of 15 - 30 min.
Blood loss should not exceed 0.5% by weight of a
woman's body, with an average of 250 - 300 ml.
 The uterus is immediately reduced in size
significantly after the birth of the fetus , so in a
few minutes the uterus is in a state of tonic
contraction, and then start “after birth“ contractions
 Placenta with membranes separates from
the walls of the uterus and is born out of
the uterus due to its contractions.
 Placenta with membranes separates from
the walls of the uterus and is born out of
the uterus due to this contractions.
 Types of placenta detachment

 Type I - centrall (by Schulze), when the placenta

separates from the center and its attachment
formed retroplacental hematoma, which promotes
the subsequent separation of the placenta. In this
case, the last born by fetal surface outward.

 Type II - peripheral (by Duncan), in which the latter

begins to separate from the edge of the placenta,
retroplacental hematoma is not formed, and the
last born my maternal surface outside.
 Signs of separation of the placenta:
Schroeder - change the shape and height of the
bottom.
Alfeld - extension of the external segment of the
umbilical cord (clip drops to 10 - 12 cm from the genital
slit).
-Kyustner- Chukalov’s Sign- when pressed edge of
the palm above the symphysis umbilical cord is
pulled, if the placenta separated from the uterine
wall. (Do not pull the cord, massage the uterus,
etc.!).
After the birth of placenta -subsequent
examine in detail to identify gaps and
damage.
INSPECTION OF
MEMBRANES
 Technique to separate the placenta

Method Abuladze
method Günter
By Crede-Lazarevich
•If within 30 min. no signs of
separation of the placenta -
start to manual removal and
separation of the placenta!
 Conducting of III
stage of labor
• Using ice packs inappropriate
• With no signs of placental separation and
external bleeding for 30 minutes after the
birth of the fetus is performed manual
removal of the placenta and the separation of
the placenta
 Conducting of III stage of
labor

Immediately after birth of the placenta

uterus is massaged through the abdominal
wall
Woman offers to urinate
Bladder catheterization performed on the
testimony
Indications for the inspection of
the cervix in the mirrors

 Instrumental delivery

 Bleeding
 Metrypercinesia(rapid
labor)
PRIMARY TOILET of NEWBORN
• At birth, the fetus and is called as newborn and
estimated by Apgar scores at 1 and 5 minutes for 5
features:
• HR - 2 points
• Breathing - 2 points
• Skin color - 2 points
• Muscle tone - 2 points
• Reflexes - 2 points
• After that the primary toilet of newborn: treatment
of upper respiratory tract, the processing of the
cord, weighing, measuring, processing eyes and
genitalia, as well as an assessment of its term and
maturity.
 Newborn care

When a satisfactory condition of the mother,

fetus is put on her abdomen after births,
rubbed by dry diaper and put the ​clamp on
the cord after 1 min and the intersection of
the umbilical cord.
 Newborn care

When needed - remove mucus from the mouth.

Worn hat, socks.
Provided "thermal chain": the child is placed on
the mother's abdomen and covered with her by
blanket. Contact "skin to skin" is conducted while
the implementation of sucking reflex, but not less
than 30 minutes.
 Newborn care
After 30 minutes, the cord being
processed.
Free baby swaddled and transfer from
the delivery room with his mother.
UP TO THIS MOMENT THE NEWBORNS
DOES NOT CARRY OUT FROM THE
LABOR ROOM
 Newborn care
Assessment of the newborn is made on the 1st and
5th minute of Apgar scores.
In the first 30 minutes the temperature of the
newborn is measured and recorded in the map
development of the newborn.
During the first hour of life is carried out preventive
of ophthalmia 1% tetracycline or erythromycin
ointment 0.5%.
• FIRST 2 HOURS AFTER DELIVERY
puerperas and the baby is in the
delivery room, then transferred to
the postnatal ward where evaluates
the status every 15 minutes. For 2
hours.
• PARTOGRAPH - (insert in history birth f.
096/0) is a graphical record flow of labor,
the mother and the fetus state, designed to
enter information on the results of
observations made during the birth ,state of
mother, fetus, processes of cervical
dilatation and fetal head advancement.
 Partograph
main components
I - the fetus - heart rate, the state of the amniotic sac
and amniotic fluid, the configuration of the head.
II - during birth - rate of cervical dilatation, descent of
the fetal head, uterine contractions, oxytocin mode.
III - the woman's condition - pulse, blood pressure,
temperature, urine (volume, protein, acetone),
drugs that are introduced during childbirth.
 The fetus condition

HEART RATE. TAB. 1

used to record the fetal heart rate, which in the I
stage of labor are calculated and recorded in the
partogram every 15 minutes, and in the II period
are heard every 5 min after attempts and recorded
in the partogram every 15 minutes. Each square in
the table are themselves time span of 15 minutes.
Fetal heart rate should be registered within 1 min
(before or after a contractions or attempts), the
woman then lies on her side.
 Amniotic fluid and fetal head
configuration
tab. 2 :
 integrity of membranes (H – hole a bag of waters) and water
condition at rupture of membranes ( T - transparent water ,
M - meconium stain water, B - water stained with blood),
which is determined for each internal OB exam.
 the power configuration of the fetal head (I st - skull bones
separated by connective tissue, joints easily palpated , II -
bone in contact with one single, seams are not detected,
ІІІst - bones are on one another, can not be separated ,
expressed configuration of the head) . indicated by: I. - (-) .
e II - (+) ІІІ - ( + +).
 During childbirth

Tab. 3 shows:

Dynamics of cervical dilatation and passing of

fetal head. These data are defined after internal
examination
Research conducted at
admission to the labor room ,after
escape of amniotic fluid or every 4 hours
during childbirth.
 During childbirth

Tab. 3 shows:

Dynamics of cervical dilatation and passing of

fetal head. These data are defined after internal
examination
Research conducted at
admission to the labor room ,after
escape of amniotic fluid or every 4 hours
during childbirth.
 LINE ALARM - begins at the point that
corresponds to the disclosure of 3 cm and
continues until the opening of the cervix
with the speed of opening of 1 cm / hour.

ACTION LINE - runs parallel to the alert

line, departing at 4hr right away.
 The woman's condition

tab. 6 fills in the case of using other medications.

tab. 7 shows the pressure (determined every 2

hours), heart rate (every 2 hours), body temperature
(every 4 hours), urine volume (every 4 hours),
protein, urine acetone (according to indications).
Factors causing pain during labor

• Dilatation of the cervix

• Compression of the nerves
Stretching of uterine ligaments
 Methods of pain relief in
labor:

• Medication
• Nonmedicamentous
 MEDICAL METHODS FOR
PAIN RELIEF IN LABOR
Requirements for them:
• Analgesic effect
• No negative impact on the mother and fetus
• No negative impact on the generic activities
• The simplicity and accessibility for all maternity
hospitals
Medical methods of pain relief in
labor
Drugs
Non-inhalant (systemic) anesthetics
Inhalation anesthetics
Regional Anesthesia
 Non-pharmacological
methods of pain relief in
labor
Psychological support by partner
Active behavior of mothers during 1-st
stage of childbirth
Music and aromatherapy by essential oils
Shower, bath, massage