OB Review

Normal and Abnormal

Labor
John Vincent A. Pagaddu

Parturition
Normal Pregnancy
Fetus
Fetus

Uterine quiescence
Immature fetus
Closed cervix

Parturition
Coordinated uterine
activity
Maturation of the fetus
Maternal lactation
Progressive cervical
dilation
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Placenta
Placenta
Membranes
Membranes

Mother
Mother

Parturition
Encompasses all physiologic processes
involved in birthing.

Phase
Phase
Phase
Phase

0:
1:
2:
3:

Prelude to Parturition
Preparation for Labor
Process of Labor
Parturition Recovery

Uterine Activity During Pregnancy

Inhibitors
Progesterone
Prostacycline
Relaxin
Nitric Oxide
Parathyroid
hormone-related
peptide
CRH
HPL

Quiescence

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Uterotrophins
Estrogen
Progesterone
Prostaglandins
CRH

Activation

Uterotonins

Involution

Prostaglandins
Oxytocin

Oxytocin
Thrombin

Stimulation

Involution

PHASE 0: Uterine QUIESCENCE

Uterine smooth muscles tranquility with
maintenance of cervical structural integrity
Unresponsive to natural stimuli, contractile
paralysis
Myometrium : quiescent state
Cervix : firm unyielding
Successful anatomical structural integrity
:essential for successful parturition
Some myometrial contractions occur but do not
cause cervix dilation = Braxton-Hicks contraction
/ false labor

PHASE 0: Uterine
QUIESCENCE
Braxton Hicks contraction or
false labor
myometrial contractions that do not
cause cervical dilatation
unpredictability in occurrence
lack of intensity
brevity of duration
discomfort confined to low abdomen &
groin

PHASE 1: PREPARATION FOR

LABOR
Uterine awakening or activation
Progression of change in uterus
during last 6-8 weeks of pregnancy
Cervical change
Myometrial change

PHASE 1: PREPARATION FOR

LABOR
CERVICAL CHANGE
Initiation of parturition: Cx soften, yield, more readily dilatable
Fundus transformed to produce effective contraction that
drive fetus through Cx & birth canal
Change of state of bundles of collagen fiber

Collagen breakdown & rearrangement of collagen fiber bundles

leading to decrease in the number and size of collagen bundles within
the Cx.

Chages in relative amount of glycosaminoglycans

increase in hyaluronic acid (assoc. w/ the capacity of Cx to retain

water)
Decrease in Dermatan sulfate (need for collagen fiber cross linking)
Increase production of cytokine (degrade collagen)

Cx thinning, softening relaxation= Cx initiate diatation

PHASE 1: PREPARATION FOR

LABOR
MYOMETRIAL CHANGE
Increase Uterine irritability &
responsiveness to uterotonins
Alterations in expression of key enzyme CAP
(contraction-associated proteins) - control
myometrium contractility
Myometrial oxytocin R
Myometrial cell gap junction protein (ex
connexin -43)

Formation lower Uterine segment

lightening

PHASE 2 : PROCESS OF LABOR

Labor is a physiologic process during
which a fetus is expelled.
Main
labor
force
is
uterine
contracion.
bring
about
progressive
dilatation and delivery.

cervical

Diagnosis of labor strictly defined is

regular uterine contractions that
cause cervical change.

TRUE LABOR
Presence
of
regular
uterine
contractions (duration 30-60 seconds,
every 2-5 minutes)
that lead to
progressive cervical effacement and
dilatation
Labor pain: fundal to lower back
(+/-) bloody show
(+/-) rupture of membranes
IE: cervix is 4cm dilated, fully effaced
(in active labor)

Initiation of Labor
Fetus
Fetal increased DHEA

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Placental conversion to estradiol

Increased decidual PGF2 and gap junctions
Increased oxytocin and PG receptors
Decreased progesterone receptors

12

Initiation of labor
Oxytocin
Peptide hormone
Hypothalamus-posterior pituitary
Fetal production
Maternal serum increase in second stage of labor

Oxytocin receptors
Fundal location
100-200 x during pregnancy

Actions
Stimulate uterine contractions
Stimulate PG production from amnion/decidua
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Mechanisms of labor
Effacement
Dilatation
Three Ps
Powers
Uterine activity

Passage
Passenger

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Powers
Uterine contractions
Normal labor
Duration 30-60 seconds
every 2-5 minutes
3-5 contractions / 10 minutes

Montevedeo units (intrauterine catheter)

Baseline to peak, sum of contractions in 10 minutes
Adequate: >200-250 MVU

Interventions
Induction
Augmentation
Oxytocin
AROM
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Passage

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Passenger
Size
4500gram =
macrosomia

Lie
Presentation
Attitude
Position
Station
Engagement
Widest diameter passes
inlet
0 station, vertex

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Cardinal Movements of
Labor

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Engagement
Descent
Flexion
Internal rotation
Extension
External rotation
Expulsion

18

NORMAL LABOR
Normal labor is divided into 3 stages by
Friedman.
The first stage is subdivided into the latent
phase and the active phase.

4c
m

Duration of Labor Stages

Multigravid
STAGE 1: Latent

4.8-14 hours

Primigravi
d
9-20 hours

STAGE 1: Active

1.5cm/hr

1.2cm/hr

STAGE 2

20-60min

50-120 min

STAGE 3

15-30min

15-30min

STAGE 4

2hrs

2 hrs

STAGE 4:

when the tone of the uterus is reestablished after delivery as the uterus
contracts again, expelling any remaining contents.
These contractions are hastened by breastfeeding, which stimulates
production of the hormone oxytocin.

Example:
A patient is a primigravid at 4cm
cervical dilation. How long until she
delivers the baby?
Stage 1: 6cm/1.2cm = 5hr
Patient needs 6cm to get to 10cm (full
dilatation)

Stage 2: 2hrs
Answer = Stage 1 + Stage 2 =

7hrs

Labor course
divided fuctionally on basis of expected
evolution of dilatation & descent curves
into 3 divisions:
PREPARATORY DIVISION
latent & acceleration phases

DILATATIONAL DIVISION
phase of maximum slope of cervical dilatation
most rapid rate of dilatation occur

PELVIC DIVISION
deceleration phase & second stage while concurrent
with phase of maximum slope of fetal descent

Third Stage of Labor

Goals: delivery of an intact placenta
and avoidance of uterine inversion or
post-partum hemorrhage
Signs of placental separation:

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Mechanisms of Placental
Extrusion

Mechanisms of Placental
Extrusion

Fourth Stage of Labor

Postpartum hemorrhage as the result
of uterine atony is more likely at this
time.
During this time, lacerations are
repaired
ACOG recommendation:
Maternal blood pressure and pulse be
recorded immediately after delivery and
q 15 minutes for the first 2 hours.

BIRTH CANAL LACERATION

1st degree
fourchette,
perineal
skin, vaginal mucous
membrane but not the
underlying fascia and
muscle

2nd degree
3rd degree
Skin,
mucous
membrane,
perineal
body
and
anal
sphincter

4th degree
Extends through the
rectal
mucosa
to
expose the lumen of
the rectum

Skin
and
mucous
membrane, fascia and
muscle of the perineal
body but not the anal
sphincter

PHASE 3: THE PUERPERIUM

The period of 6 weeks following
delivery of the fetus and placenta
Immediate: first 24hrs
Early: first week
Late: 2nd to 6th week

The period taken for the uterus and

other body systems return to the prepregnant condition.
Lactation is initiated during this period.

Fetal assessment in labor

External monitoring
Internal monitoring

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Patterns of fetal heart rate

monitoring
Baseline
Variability
Periodic changes
Accelerations
Decelerations
Variable
Early
Late

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Patterns of fetal heart rate

monitoring
Baseline
Variability
Periodic changes
Accelerations
Decelerations
Variable
Early
Late

Normal
110-160

Tachycardia
>160

Bradycardia
<110

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Patterns of fetal heart rate

monitoring
Baseline
Variability
Periodic changes
Accelerations
Decelerations
Variable
Early
Late

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Absent
undectable

Minimal
< 5bpm

Moderate
6-25bpm

Marked
>25bpm

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Patterns of fetal heart rate

monitoring
Baseline
Variability
Periodic changes
Accelerations
Decelerations

<32 weeks 10bpm over baseline

>32 weeks 15bpm over baseline

Variable
Early
Late

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Patterns of fetal heart rate

monitoring
Baseline
Variability
Periodic changes
Accelerations
Decelerations
Variable
Early
Late

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Patterns of fetal heart rate

monitoring
Variable decelerations
Umbilical cord compression
Variable in appearance
Processes
UV compression
Decreased cardiac return
Fetal hypotension
Fetal increased HR

UA compression
Increased SVR
Decreased fetal heart rate
protective
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Patterns of fetal heart rate

monitoring
Baseline
Variability
Periodic changes
Accelerations
Decelerations
Variable
Early
Late

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Vagal reflex
cervical compression on fetal head

40

Patterns of fetal heart rate

monitoring
Baseline
Variability
Periodic changes
Accelerations
Decelerations
Variable
Early
Late

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Uteroplacental insufficiency - hypoxia

Reflex late
low O2 in CNS, increased sympathetic
tone, increased BP, baroreceptor
medicated bradycardia
Myocardial depression

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Management of abnormal fetal heart rate

patterns

Remove potential etiologies

Hypotension
Maternal position left lateral recumbent
IVF hydration

Maternal O2 administration
Cessation of contractions
Discontinue oxytocin
Uterine relaxants

Expedite delivery

DYSTOCIA
=
DIFFICULT / ABNORMAL LABOR
Greek
'dys' = 'difficult, painful,
disordered, abnormal'
'tokos' = 'birth'.

Dystocia Incidence
Primiparous women ~25% have
dystocia
Most common indication for primary
CS

~50% of CSs are related to

dystocia

 Powers

Passage

Passenger

Contractions
Expulsive forces
Maternal pelvis

The fetus
(Malposition/
Malpresentation)

A combination of these factors

Dystocia Classification

Dystocia
Abnormalities of the passage

Inlet
Mid-pelvis
Outlet

Current Diagnosis & Treatment Obstetrics & Gynecology - 10th Ed. (2007)

Planes of the Pelvis

Pelvic Inlet
Plane of the Midpelvis
Pelvic Outlet

PELVIC INLET
Superior strait
Forms the brim of the true pelvis
Four diameters:
Anteroposterior
Transverse
2 obliques

PELVIC INLET
Anteroposterior
Diameters
Diagonal Conjugate
Distance between the lower
border of the symphysis
pubis to the midpoint on the
sacral promontory
12 cm
Only AP diameter that can be
measured clinically

ELVIC INLET
True or anatomic conjugate
Distance between the midpoint of the sacral promontory to
the upper margin of the inner border of the symphysis pubis
11 cm
Measured indirectly subtract 1.2cm from the diagonal
conjugate
Obstetric conjugate
Distance between the midpoint of the sacral promontory to
the midpoint of the inner surface of the symphysis pubis
10cm
Subtract 1.5 to 2cm from the diagonal conjugate or by
radiopelvimetry

ELVIC INLET
Transverse Diameter
Constructed at right angles to the obstetrical
conjugate
Greatest distance between thelineaterminalis
on either side (measures 13.5 cm)

Two oblique diameters

Extends from one sacroiliac synchondroses to
the iliopectineal eminence on the opposite side
Measures 13.5 cm

MIDPELVIS
Extends from the lower margin of the symphysis pubis
through the level of the ischial spines to the tip of the sacrum
Has the smallest area: most critical part of the pelvis
Anteroposterior Diameter
From Inferior Symphysis pubis to S4-S5

Transverse Diameter
Between 2 ischial spines
10.5cm

Posterior Sagittal Diameter

Extends from the midpoint of the bispinous diameter to the point of
the sacrum where the midpelvic plane meets
4.5cm

MIDPELVIS
Clinical assessment is not possible.
Suspect midpelvic contraction if:
Prominence of the ischial spines
Pelvic sidewalls are convergent
Concavity of the sacrum is shallow
Bi-ischial diameter of the outlet is less
than 8cm

PELVIC OUTLET
Consists of 2 triangular planes sharing a common base
formed by a line joining the 2 ischial tuberosities.
Boundaries:
Anteriorly: pubic arch
Laterally: ischiopubic rami, ischial tuberosity and
sacrotuberous ligament
Posteriorly: tip of the coccyx

ANTEROPOSTERIOR DIAMETER
9.5-11.5 cm

POSTERIOR SAGITTAL DIAMETER:

exceeds 7cm

INTERTUBEROUS OR TRANSVERSE DIAMETER:

11cm
Measured by placing a closed fist against the perineum at
the level of the tuberosities.

PELVIC OUTLET
THOMS RULE:
Transverse diameter + Posterior Sagittal
Diameters of the outlet = >15cm by
xraypelvimetry: BONY OUTLET IS ADEQUATE

Internal Pelvimetry

Internal Pelvimetry

Internal Pelvimetry

Dystocia
Abnormalities of the passage
Bony pelvis
- Gynecoid (50%)
- Android (33% white, 15% black)
- Anthropoid (50% black, 20% white)
-Platypelloid

(<3%)

Gynecoid: P>A, ideal type;

Android: P<A, found in males, poorest prognosis;
Platypelloid: P=A;
Anthropoid: P<A, if the baby is small, can still
maneuver in this type

Dystocia
Abnormalities of the passage
Classification:
Contraction of the pelvic inlet
Contraction of the mid-pelvis and pelvic
outlet
traumatic fracture,
rickets,
chondrodystrophic
dwarfism,
kyphosis & scoliosis,
exostosis, bone
neoplasia

General contraction of the pelvis

Pelvic deformities

BONY PELVIS
CONTRACTION

PELVIC INLET CONTRACTION

The pelvic inlet is regarded as contracted if:

Shortest AP
diameter
Transverse
diameter
Diagonal
Conjugate

< 10cm
< 12cm
<11.5

BONY PELVIS
CONTRACTION
MIDPELVIC
CONTRACTION

Midpelvis is assessed at the level of

the ischial spines (interspinous
AP diameter
11.5
diameter).
Interspinous diameter
Posterior sagittal

10.5
5.0

*if the sum ofInterspinous

IS (10.5) and PS (5.0) is Midpelvis
</= 13.5cm, then midpelvis
contraction is present.

diameter
If <10cm
If <8cm

Contraction is
inferred to be
present
Midpelvis is

BONY PELVIS
CONTRACTION
MIDPELVIC
CONTRACTION
Clues that may indicate midpelvic contraction:
Prominent ischial spines
Convergent Pelvic Sidewalls
Narrow SCN

*midpelvic contraction is frequently

associated with deep transverse arrest of the
head.
*Oxytocin induction is contraindicated
*Ceasarian section is the method of choice

BONY PELVIS
PELVIC CONTRACTION
OUTLET CONTRACTION

Interischial tuberous diameter of 8cm or

less
Perineal tears is more common with
narrowing of the subpubic arch with the
head being formed increasingly farther
down into the perineum = predisposed to
AP diameter
9.5-11.5 cm
lacerations
Transverse 11 cm
Intertuberous
Posterior sagittal
Anterior pubic
arch

7.0 cm
90-100

SOFT TISSUE DYSTOCIA

Causes:
Uterine Abnormalities
Cervical abnormalities
Vaginal abnormalities
Pelvic masses
Low-lying placenta

UTERINE ABNORMALITIES
Anatomic Position of Uterus
anteverted (cervix angles forward)
anteflexed (body is flexed forward)

Abnormal fusion of mullerian ducts or failure of

absorption of the septum malformations of the uterus
malpresentation or abnormal fetal lie.
Malformation of the uterus may lead to abnormalities of
uterine contraction. This results in hypotonic uterine
dysfunction, which leads to dystocia.
UTERINE TORSION: rotation of uterus along its long axis
(>45).
Manifestations: Pain, shock and obstructed labor.
Most serious complication: Uterine rupture

CERVICAL ABNORMALITIES
STENOSIS
Due to extensive cauterization
Dilatation and effacement does not take place
Stenosis may gradually yield during labor.
Otherwise, C-section is carried out.

AGGLUTINATION
Results from the use of silver nitrate
Presence of small external os that fails to dilate
after full effacement.
Digital mechanical dilatation to dilate cervical os.

 VAGINAL ABNORMALITIES
SEPTUM
Divides the vagina
Diagnosis is made when there is failure
of descent of the presenting part.
Excision is done to permit delivery.

PELVIC MASSES
GARTNER DUCT CYST
Protrudes into the vagina
May slip above presenting part during labor but may be
aspirated if it does not.

CYSTOCELE/RECTOCELE
Can block normal descent.
Proper evacuation or emptying to allow normal descent.

UTERINE MYOMAS
Not all myomas can cause dystocia

Mucous (inside of the uterus)

can cause malpresentation, such as transverse and breech.
Serous can allow the passage of the fetus.
Lower uterine segment myomas may obstruct labor with
associated higher incidence of cesarean section.

LOW-LYING PLACENTA
May prevent normal fetal descent
May give rise to abnormal bleeding
C-section may be required.

DYSTOCIA DUE TO
ABNORMALITIES OF POWERS

Abnormalities that may exist singly or

in combination and result to dystocia:
Abnormalities of expulsive forces
Uterine dysfunction uterine forces insufficiently strong or
not approximately coordinated to efface and dilate the
cervix.
Inadequate voluntary muscle effort during the second stage
of labor.

Abnormalities of presentation, position, or

development of the fetus.
Abnormalities of the maternal bony pelvis pelvic
contractions.
Abnormalities of the birth canal other than those of
the bony pelvis that form an obstacle to fetal descent.

Uterine dysfunctions
Failure of the cervix to dilate or the
presenting part to descend
Uterine dysfunction in any phase is
characterized by lack of progress.
The lower limit of contraction pressure
required to dilate the cervix is 15 mmHg.
Uterine contractions of normal labor are
characterized by a gradient of myometrial
activity; being greatest and longest at the
fundus and diminishing towards the cervix.

Types of Uterine
Dysfunction
Hypotonic Uterine Dysfunction
Absence of basal hypertonous , presence of normal
gradient pattern with fundal dominance, but the
slight rise in pressure during a contraction is
insufficient to dilate the cervix at a satisfactory rate.
Contractions: less frequent
Uterus: easily indentable at the height of a
contraction.
Occurs at active phase of labor after the cervix has
dilated to more than 4 cm.
Often responds to oxytocin.

Types of Uterine Dysfunction

Hypertonic Uterine Dysfunction
Basal hypertonous with distorted pressure
gradient because of absence of fundal
dominance or by complete asynchronism of the
impulses originating in each cornu, or in
combination of these two.
Contractions: painful but ineffective
Use of oxytocin will result in accentuation of
abnormal pattern of uterine contractions and
increase of uterine tone.
Respond to sedation

EFFECTS OF
DYSTOCIA

MATERNAL EFFECTS

Infection: due to early membrane rupture

Vesicocervical, vesicovaginal or rectovaginal
fistula: caused by excessive pressure on presenting
part to the sidewalls or prolonged second stage which
compromises circulation and results in necrosis.
Urinary and anal incontinence, pelvic organ
prolapse: due to stretching of pelvic floor by direct
compression from the fetal head.
Neurologic injury or footdrop: injury of the
lumbosacral root, plexus, sciatic or common peroneal
nerve.

EFFECTS OF
DYSTOCIA

FETAL EFFECTS

Deleterious if labor is more than 20 hours.

Infection: consequence of Early ROM
Large caput succedaneum: in the dependent portion
of fetal head.
fatal intracranial and subdural hemorrhage because of
severe molding or overlapping of bones of the skull
which causes tentorial tears.
Skull fracture because of forcible attempts at delivery.
Shallow groove fracture: not dangerous
Spoon-shaped depression: may lead to neonatal death