OG 2.

2
Anatomy of the Female Pelvis

OG 1.4 Normal Labour and Delivery

Class Senior Cycle 1

Course Obstetrics and Gynaecology
Code SC1 Obs
Title Normal labour and Delivery
Date Department
Decemberof 2014
Obstetrics & Gynaecology
Department of Anatomy
Royal College of Surgeons in Ireland
 Learning Objectives
To understand the initial assessment
of the labouring patient.
To understand the stages and
mechanisms of normal labour and
delivery.
To be familiar with methods of
monitoring mother, baby and
progress of labour.
To be aware of options for analgesia
in labour.Department of Obstetrics &
Gynaecology, RCSI
 Skill objectives
Observe normal labour and delivery and
participate in at least three normal deliveries
during the Delivery Suite attachment
Complete partogram forms for all patients in the
Delivery Suite with whom you have interacted
To perform intermittent fetal heart auscultation
To describe CTG characteristics in detail
To assist in the placental assessment following
each delivery in which you have participated
To observe at least one perineal tear repair
To follow-up all mothers and babies on the
postnatal ward for deliveries in which you have
participated
Department of Obstetrics &
Gynaecology, RCSI
 LABOUR
Diagnosis: Progressive effacement and
dilatation of the cervix in the presence of uterine
contractions.

Effacement occurs when the entire length of the cervical canal has
been taken up into the lower segment of the uterus. In a
Primigravid patient, dilatation will not begin until full effacement is
complete.

A show (blood-stained mucous discharge) or spontaneous

rupture of membranes (SROM) provide further evidence that a
woman is in labour provided she is experiencing regular uterine
contractions.

Spontaneous / induced / term / preterm

Department of Obstetrics &
Gynaecology, RCSI
Department of Obstetrics &
Gynaecology, RCSI
Progressive cervical dilatation shown on
a model

Department of Obstetrics &

Gynaecology, RCSI
Labour
Continuous process; three stages:
First stage: From establishment of labour until
full dilatation.

Second stage: Full dilatation to delivery of the

fetus.

Third stage: Delivery of the placenta

Department of Obstetrics &
Gynaecology, RCSI
 Labour assessment:
Standard procedures:
General examination, assessment of uterine
contractions and fetal wellbeing.
FBC, blood type and Rh status.
Partogram.
Minimal vaginal examinations following initial
assessment.

Department of Obstetrics &

Gynaecology, RCSI
 LABOUR
Fetal assessment:
Amniotic fluid (volume & colour).
Fetal heart rate monitoring: continuous vs
intermittent.
Maternal assessment:
BP / HR / temp charting
Uterine contractions Cardiotocography Doptone

Department of Obstetrics &

Gynaecology, RCSI
 FIRST STAGE OF LABOUR
Progress is measured in terms of dilatation of the cervix
and descent of the presenting part.
Progress is recorded by means of a partogram.
The average rate of cervical dilatation in primigravidae
is 1cm per hour.

Department of Obstetrics &

Gynaecology, RCSI
 FIRST STAGE OF LABOUR
Descent of the fetal head is measured in labour by:
Abdominal examination. If only 2-fifths or less of the fetal head is
palpable abdominally then the head is engaged.
Vaginal examination, the station of the fetal head with respect to
the ischial spines is recorded. The ischial spines are designated
station zero. When the head is above the spines, it is said to be
at -1, -2, -3, -4 -5cm. When the head is below the spines it is +1,
+2, +3, +4 and +5cm , with +5cm representing crowning of the
head.

Department of Obstetrics &

Gynaecology, RCSI
 Modes of Analgesia in Labour:
TENS machine:
Simple analgesia-
Paracetamol
Opiods:
IM Pethidine
Morphone PCA
Fentanyl PCA
Remifentanil PCA
Epidural
Combined Spinal-
epidural

Department of Obstetrics &

Gynaecology, RCSI
 SECOND STAGE OF LABOUR
Begins with full dilatation.

Progress is measured in terms of descent and rotation of

the fetal head on vaginal examination.

Two phases:
Passive phase: From full dilatation until the head reaches the
pelvic floor.
Active phase: When fetal head reaches pelvic floor. Usually
associated with strong desire to push.

Department of Obstetrics &

Gynaecology, RCSI
Department of Obstetrics &
Gynaecology, RCSI
 MECHANISM OF LABOUR

Engagement
Flexion
Descent
Internal rotation (Head has now rotated from a lateral(occipito-
transverse) position at the pelvic brim to an antero-posterior position
at the pelvic outlet.) The position of the head as it traverses the canal
is described according to the position of the occiput. The head usually
rotates from an occipitotransverse to an occipitoanterior position.
Extension (as the head delivers).
External rotation (back to transverse position, allows rotation of
shoulders to anteroposterior position.)
Expulsion

Department of Obstetrics &

Gynaecology, RCSI
Department of Obstetrics &
Gynaecology, RCSI
Department of Obstetrics &
Gynaecology, RCSI
EPISIOTOMY & PERINEAL TEARS

An episiotomy is a surgical
procedure in which the perineum is
cut with a scissors with the intention
of widening the soft tissue diameter
of the introitus in order to prevent a
severe perineal tear or accelerate
delivery.

There is little evidence to support

routine use of episiotomy. Indications
include: A rigid perineum, if it is felt
that a perineal tear is imminent and
shoulder dystocia.

Department of Obstetrics &

Gynaecology, RCSI
EPISIOTOMY & PERINEAL TEARS
First degree:
Injury to the vaginal epithelium & vulval skin only.
Second degree (equivalent to episiotomy):
Injury to the perineal muscles, but not the anal
sphincter.
Third degree:
Injury to the perineum involving the anal sphincter.
Fourth degree:
Injury involving anal sphincter and rectal mucosa.

Department of Obstetrics &

Gynaecology, RCSI
 THIRD STAGE OF LABOUR
Signs of placental separation:
Lengthening of umbilical cord
Gush of blood per vaginam
Rising up of the fundus

The third stage of labour is actively managed to minimise the risk of

postpartum haemorrhage. Active management involves administration of
Syntocinon (oxytocin) or Syntometrine (oxytocin and ergometrine) and
delivery of the placenta via controlled cord traction. The uterine fundus is
rubbed up to ensure that it is well contracted and the placenta is
examined to ensure that it is complete.

Department of Obstetrics &

Gynaecology, RCSI