INTRODUCTION

Pregnancy, the state of carrying a developing embryo or fetus within the female body. This condition can be indicated by positive results on an over-the-counter urine test, and confirmed through a blood test, ultrasound, detection of fetal heartbeat, or an X-ray. Pregnancy lasts for about nine months, measured from the date of the woman's last menstrual period (LMP). It is conventionally divided into three trimesters, each roughly three months long.

When gestation has completed, it goes through a process called delivery, where the developed fetus is expelled from the mothers womb. There are two options of delivery: Cesarean section and NSVD or normal spontaneous vaginal delivery. A cesarean section is a surgical incision through the mothers abdomen and uterus to deliver one or more fetuses. NSVD or normal spontaneous vaginal delivery is the delivery of the baby through vaginal route. It can also be called NSD or normal spontaneous delivery, or SVD or spontaneous vaginal delivery, where the mother delivers the baby with effort and force exertion.

Normal labor is defined as the gradual subjugation and dilatation of the uterine cervix as a result of rhythmic uterine contractions leading to the expulsion of the products of conception: the delivery of the fetus,

membranes, umbilical cord, and placenta. Laboring cannot that be easy; thereby implicating that there are processes and stages to be undertaken to achieve spontaneous delivery. Through which, Obstetrics have divided labor into four (4) stages thereby explaining this continuous process.

STAGE 1: It is usually the longest part of labor. It begins with regular uterine contractions and ends with complete cervical dilatation at 10 centimeters. This stage is broken down into three (3) phases: the Early phase, where the contractions are usually very light and maybe

approximately 20 minutes or more apart from the beginning, gradually becoming closer, possibly up to five minutes apart; the Active phase, where contractions are generally four or five times apart, and may last up to 60 seconds long. Cervix dilates with 4-7 cm and initiates a more rapid dilatation. It is known that to get through active labor, mobility and relaxations are done to increase contractions; and the Transition phase, where it is definitely known as the shortest phase but the hardest, contractions maybe two or three times apart, lasting up to a minute and a half, about approximately 810 cm of cervical dilatation. Some women will shake and may vomit during this stage, and this is regarded as normal. Most of the time, women would find a comfortable position to acquire complete dilatation.

STAGE II: This stage lasts for three or more hours. However, the length of this stage depends upon the mothers position (e.g.; upright

position yields faster delivery). Once the cervix has completely dilated, the second stage had begun. This stage ends with the expulsion of the fetus.

STAGE III: This stage focuses on the expulsion of the placenta from the mother. Placenta exclusion is much more easier than the delivery of the baby because it includes no bones, and this is during this stage that the baby is placed on top of the mothers womb.

STAGE IV: No more expulsions of conception products for this stage as this is generally accepted as POST PARTUM juncture. This phase is from the placental delivery to full recovery of the mother.

Labor and delivery of the fetus entails physiological effects both on the mother and the fetus. In the cardiovascular system, the mothers

cardiac output increases because of the increase in the needed amount of blood in the uterine area. Blood pressure may also rise due to the effort exerted by the mother in order expel the fetus. There could also be a development of leukocytes or a sharp increase in the number of circulating white blood cells possibly as a result of stress and heavy exertion. Increased respiratory may also occur. This happens as a response to the increase in blood supply in order to increase also the oxygen intake.

Braxton Hicks contractions, or also known as false labor or practice contractions. Braxton Hicks are sporadic uterine contractions that actually start at about 6 weeks, although one will not feel them that early. Most women start feeling them during the second or third trimester of pregnancy. True labor is felt in the upper and mid abdomen and leads to the cervical changes that define true labor.

With delivery imminent, the mother is usually placed supine with her knees bent (ie, the dorsal lithotomy position). An episiotomy (an incision continuous with the vaginal introitus) may be performed at this time. Episiotomy may ease delivery of the fetal head and allow some control over what may otherwise be an uncontrolled perineal laceration. However, many providers no longer perform routine episiotomy, since it may increase the risk of rectal injury and are larger than the spontaneous laceration.

The labor and birth process is always accompanied by pain. Several options for pain control are available, ranging from intramuscular or intravenous doses of narcotics, such as Meperidine (Demerol), to general anesthesia. Regional nerve blocks, such as a pudendal block or local infiltration of the perineal area can also be used. Further options include epidural blocks and spinal anesthetics.

PROCEDURES
A vaginal examination is done to determine position and station of the fetal head; the head is usually the presenting part (see Fig. 2: Normal Pregnancy, Labor, and Delivery: Sequence of events in delivery for vertex presentations.). When effacement is complete and the cervix is fully dilated, the woman is told to bear down and strain with each contraction to move the head through the pelvis and progressively dilate the vaginal introitus so that more and more of the head appears. When about 3 or 4 cm of the head is visible during a contraction in nulliparas (somewhat less in multiparas), the following maneuvers can facilitate delivery and reduce risk of perineal laceration.

The clinician, if right-handed, places the left palm over the infant's

head during a contraction to control and, if necessary, slightly slow progress.

Simultaneously, the clinician places the curved fingers of the right

hand against the dilating perineum, through which the infant's brow or chin is felt.

To advance the head, the clinician can wrap a hand in a towel and,

with curved fingers, apply pressure against the underside of the brow or chin (modified Ritgenmaneuver). Thus, the clinician controls the progress of the head to effect a slow, safe delivery.

Fig. 2 Sequence of events in delivery for vertex

presentations.

Forceps

or

vacuum

extractor (see Abnormalities

and

Complications of Labor and Delivery: Operative vaginal delivery) is often used for vaginal delivery when the 2nd stage of labor is likely to be prolonged (eg, because the mother is too exhausted to bear down

adequately or because regional epidural anesthesia precludes vigorous bearing down). If anesthesia is local (pudendal block or infiltration of the perineum), forceps or a vacuum extractor is usually not needed unless complications develop; local anesthesia may not interfere with bearing down. Indications for forceps and vacuum extractor are essentially the same. An episiotomy is not routine and is done only if the perineum does not stretch adequately and is obstructing delivery, usually only for first deliveries at term. A local anesthetic can be infiltrated if epidural analgesia is inadequate. Episiotomy prevents excessive stretching and possible tearing of the perineal tissues, including anterior tears. The incision is easier to repair than a tear. The most common type is a midline incision made from the midpoint of the fourchette directly back toward the rectum. Extension into the rectal sphincter or rectum is a risk, but if recognized promptly, the extension can be repaired successfully and heals well. Tears or extensions into the rectum can usually be prevented by keeping the infant's head well flexed until the occipital prominence passes under the symphysis pubis. Another type of episiotomy is a mediolateral incision made from the midpoint of the fourchette at a 45 angle laterally on either side. This type usually does not extend into the sphincter or rectum, but it causes greater postoperative pain and takes longer to heal than midline episiotomy. Thus, for episiotomy, a midline cut is preferred. However, use of episiotomy is

decreasing because extension or tearing into the sphincter or rectum is a concern. Episioproctotomy (intentionally cutting into the rectum) is not recommended because rectovaginal fistula is a risk. When the head is delivered, the clinician determines whether the umbilical cord is wrapped around the neck. If it is, the clinician should try to unwrap the cord; if the cord cannot be rapidly removed this way, the cord may be clamped and cut. After delivery of the head, the infant's body rotates so that the shoulders are in an anteroposterior position; gentle downward pressure on the head delivers the anterior shoulder under the symphysis. The head is gently lifted, the posterior shoulder slides over the perineum, and the rest of the body follows without difficulty. The nose, mouth, and pharynx are aspirated with a bulb syringe to remove mucus and fluids and help start respirations. The cord should be double-clamped and cut between the clamps, and a plastic cord clip should be applied about 2 to 3 cm distal from the cord insertion on the infant. If fetal or neonatal compromise is suspected, a segment of umbilical cord is doubly clamped so that arterial blood gas analysis can be done. An arterial pH > 7.l5 to 7.20 is considered normal. The infant is thoroughly dried, then placed on the mother's abdomen or, if resuscitation is needed, in a warmed resuscitation bassinet. After delivery of the head, the infant's body rotates so that the shoulders are in an anteroposterior position; gentle downward pressure on the head delivers the anterior shoulder under the symphysis. The head is

gently lifted, the posterior shoulder slides over the perineum, and the rest of the body follows without difficulty. The nose, mouth, and pharynx are aspirated with a bulb syringe to remove mucus and fluids and help start respirations. The cord should be double-clamped and cut between the clamps, and a plastic cord clip should be applied about 2 to 3 cm distal from the cord insertion on the infant. If fetal or neonatal compromise is suspected, a segment of umbilical cord is double-clamped so that arterial blood gas analysis can be done. An arterial pH > 7.l5 to 7.20 is considered normal. The infant is thoroughly dried, then placed on the mother's abdomen or, if resuscitation is needed, in a warmed resuscitation bassinet. Placenta: After delivery of the infant, the clinician places a hand gently on the abdomen over the uterine fundus to detect contractions; placental separation usually occurs during the 1st or 2nd contraction, often with a gush of blood from behind the separating placenta. The mother can usually help deliver the placenta by bearing down. If she cannot and if substantial bleeding occurs, the placenta can usually be evacuated (expressed) by placing a hand on the abdomen and exerting firm downward (caudal) pressure on the uterus; this procedure is done only if the uterus feels firm because pressure on a flaccid uterus can cause it to invert. If this procedure is not effective, the clinician holds the umbilical cord taut while placing the other hand on the abdomen and pushing upward (cephalad) on the firm uterus, away from the placenta; traction on the umbilical cord is avoided because it may invert the uterus. If the placenta has not been

delivered within 45 to 60 min of delivery, manual removal may be necessary; the clinician inserts an entire hand into the uterine cavity, separating the placenta from its attachment, then extracts the placenta. In such cases, an abnormally adherent placenta (placenta accretasee Abnormalities of

Pregnancy: Placenta Accreta) should be suspected. The placenta should be examined for completeness because fragments left in the uterus can cause hemorrhage or infection later. If the placenta is incomplete, the uterine cavity should be explored manually. Some

obstetricians routinely explore the uterus after each delivery. However, exploration is uncomfortable and is not routinely recommended. Immediately after delivery of the placenta, an oxytocic drug (oxytocin

10 units IM or as an infusion of 20 units/1000 mL saline at 125 mL/h) is given to help the uterus contract firmly. Oxytocin should not be given as an IV bolus because cardiac arrhythmia may occur. Postdelivery: The cervix and vagina are inspected for lacerations, which, if present, are repaired, as is episiotomy if done. Then if the mother and infant are recovering normally, they can begin bonding. Many mothers wish to begin breastfeeding soon after delivery, and this activity should be encouraged. Mother, infant, and father should remain together in a warm, private area for an hour or more to enhance parent-infant bonding. Then, the infant may be taken to the nursery or left with the mother depending on her wishes.

For the first hour after delivery, the mother should be observed closely to make sure the uterus is contracting (detected by palpation during abdominal examination) and to check for bleeding, BP abnormalities, and general well-being. The time from delivery of the placenta to 4 h postpartum has been called the 4th stage of labor; most complications, especially hemorrhage (see Abnormalities and Complications of Labor and Delivery: Postpartum Hemorrhage), occur at this time, and frequent observation is mandatory.