Labor
It is the act of expulsion of the fetus, placenta, and membranes from
the uterus.
Normal Labor:
Labor is considered normal when:
There is a single mature fetus, presenting by vertex, the process of
labor terminates spontaneously, through the birth canal, without fetal
and maternal complications, and within 24 hours.
Prolonged labor:
The course of labor is lasting more than 24 hours.
The causes of prolonged labor are:
1) Inefficient uterine contractions (inertia) are the commonest
causes.
2) Occipto posterior position.
3) Rigid perineum especially in elderly.
4) Full bladder and rectum.
Precipitate labor:
When the duration of labor lasting less than 3 hours, due to:
1) Strong uterine contraction, No obstruction in the birth canal,
lack of resistance of the soft tissues and usually the patient
does not feel expect the last contraction during the expulsion of
the fetus. It is more frequent in multiparas.
Post mature labor:
When the duration of pregnancy is 42 weeks or more, labor is
called post mature.
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SYMPTOMS OF ONSET OF LABOUR
1) Show
Discharge of mucous mixed with blood may occur. This is due to
the dilatation of the cervix.
2) True Lour pain:
The true labor pains are characterized by the following:
a. They are regular and increase gradually in amplitude,
frequency and duration.
b. They are accompanied by hardening of the uterus.
c. The discomfort is in both the back and the abdomen.
d. They are accompanied by progressive dilatation of the
cervix.
e. The contractions are not affected by sedation.
f. They are usually enhanced by an enema.
Rupture of membranes
•
Rupture of membranes associated by gush of amniotic fluid
(liquor aminii, about one liter)
•
The women should be admitted to the hospital immediately
because of danger of cord prolapsed.
The functions of liquor amnii are:
a) Protection of the fetus.
b) Medium for free movement of the fetus.
c) Keep the fetus temperature constant.
d) Medium of fetal exertion. After rupture of membranes the liquor
amnii act as antiseptic fluid for birth canal.
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False labor pain:
Many women may complain of painful uterine contraction, despite,
the contractions, progressive dilatation of the cervix falls to occur.
The false pains are characterized by:
a) The contraction occurs at irregular intervals.
b) The intensity of the contraction remains the same.
c) The discomfort is chiefly in the lower abdomen.
d) The contractions are usually relived and after stopped by
sedation.
e) The pains do not cause progressive dilatation of the cervix.
1st stage of labor
It begins with the onset of labor and ends when dilatation of the
cervix is complete (10 cm diameter or 5 fingers).
 It is the longest stage(8→12 hours in primigravida, 6→8 hours
in multigravida
It is divided into:
1) Quiet phase (when contractions are infrequent, short
duration.).
2) Active phase (when frequent of contractions ↑and strong.)
 Contraction that occur every 2-3 min. and last 30-45 sec.
indicates Significant dilatation or effacement of cervix and
decent of presenting part.
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 1st stage of labor may be less than one hour or more than 24
hours depending on:
a) The parity of the woman
b) The frequency, intensity and duration of the uterine
contractions.
c) The ability of the cervix to dilate.
d) The presentation and position of the fetus.
During the 1st stage of labor the uterine muscle fibers contract
and retract, they do not return to their original length after
contraction but remain shorter. Thickening also occur in the upper
uterine segment while lower uterine segment becomes thinner and
stretched.
2nd stage of labor
It starts from full dilatation of the cervix to complete birth of the
infant; it varies from a few minutes to several hours. Depending on
the following:
a) Fetal presentation and position.
b) Fetor pelvic relationship.
c) Resistance of maternal pelvic tissue.
d) Frequency, intensity, duration, and regularity of uterine
contraction.
e) Efficiency of maternal voluntary expulsive effort.
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3rd stage of labor
•
It starts from the birth of the infant to delivery of the placenta
and membranes. (By uterine contraction), it takes about
5min.tained If the placenta falls to be expelled within half
hour after delivery of the fetus, the condition called
retained placenta.
 The 3rd stage is composed of 3 phases:
a) Placental separation.
b) Placental decent.
c) Placental expulsion.
 Sings of placental separation:
a) Gush of blood.
b) Lengthening of the cord of the fetus passes though the cervix.
c) A rise of height of the fundus as the placenta reaches the
vagina.
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Management of the 1st stage of labor
When labor is established the uterine contractions will come at
intervals (from one hour or more to ten minutes).
 The mother should choose a position she prefer and relax
completely each time contraction begins.
 Breathe deeply (the key of relaxation.)
 No strain during 1st stage (will cause prolapsed and
unnecessary exhausts the mother).
 The mother may walk in the intervals between pains if the
membranes are intact.
Once the membranes rupture:
 The mother is asked to lie down to avoid leakage of liquor amnii.
 If the mother complains from backache:
Apply firm massage on lumber region to alleviate pain from
modified side lying position.
 The rectum should be empty by enema and the mother should
be asked to empty the bladder at 2 hours interval.
 Vaginal examination is performed when indicated
 Pulse, temp, and blood pressure are recorded every 2 hours in
normal cases and more frequently if any abnormality.
 The fetal heart rate should be listened every 15 minutes in the
1st stage of labor and every 5 minutes in the 2nd stage
especially towards the end of uterine contraction to detect any
abnormality.
 The normal variation of fetal heart ratio (F.H.R.) is between 120140 beats per minute. If the F.H.R. delayed to return after the
end of uterine contraction is an early sign of fetal distress.
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 Normally there is slowing of F.H.R. during uterine contraction,
and may return to normal after contraction F.H.R. above 160 or
below 100 is more dangerous.
When the cervix is fully dilated:
 The mother lies lithotomy position and ask her to bear down
during uterine contraction (there a reflex desire to bear down
during the contractions) and relax in between.
 Relaxation between contractions is important in the 2nd stage
of labor to enable the mother to regain her strength and to
recover from the effect of the last effort.
 Instruct the mother to take deep breath and bear down to
increase the power of expulsion of the fetus
 The attendant supports the perineum and press on it during
uterine contraction to prevent perineal laceration.
 At crowning the mother will be asked to stop bearing down and
pant in and out softly and easily with mouth open.
 If the perineum is much stretched and about to tear episiotomy
will be done.
As soon as the signs of separation and descent of the
placenta are detected:
 Massage the uterus to help it to contract to stop any bleeding.
 After delivery of the placenta
 Inspect the external genitalia and perineum (any laceration 1cm.
Or more should be repaired.
 Observe the mother carefully for one hour for fear of
postpartum hemorrhage.
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Prophylactic treatment
a) Diminish respiratory complications
b) Diminish vascular complications as thrombosis and embolism.
c) Guard against prolapsed and stress incontinence.
Curative
a) Restore the muscle tone (abdominal and pelvic floor).
b) Re-education of posture sense.
c) Help excretion (micturition and defecation).
d) Help involution of uterus.
Lactation
a) To aid lactation by improving the blood supply of the breast
and allowing free flow of milk.
b) Prevent sagging of the breast.
Contra – indications for postnatal exercises
1. Post partum hemorrhage.
2. Nephritis.
3. Puerperal fever.
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Post partum exercises
1st day
1. Breathing exercises.
2. Circulatory exercises.
3. Relaxation exercises.
4. Static abdominal exercises.
2nd day
1. Repeat the previous exercises and add the following exercises.
2. Leg exercises.
3. Pelvic floor exercises.
4. Arm exercises.
3rd day
1.
Repeat exercises of the second day and add the following:
2.
Pelvic rocking exercises.
4th day
1. Repeat exercises of the third day and add the following:
2. Hip shrugging.
3. Pelvic rotation.
4. Posture correction training.
5th day
1. Repeat exercises of the fourth day and add the following:
2. 1st step of trunk flexion.
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