Normal Birth The Mechanism of Normal labour KATIE ADAMS Midwifery Practice Facilitator / Labour Suite Manager April 2015

Normal Birth Where labour is spontaneous at full term, not induced or augmented and where normal progress is made without the use of pharmacology. The infant delivers with maternal effort, no episiotomy or intervention with instruments or caesarean section What is Normal?

Signs of labour -Latent phase The body starts to prepare for labour. Varies between individuals Irregular painful contractions, period type pain, back pain Sleeplessness, nausea, hunger / cravings, constipation, diarrhoea Excitement / Nesting Lasts for several hours / days Emotional support and reassurance

When the waters break or Spontaneous rupture of the membranes Waters can break at any time – does not mean labour or childbirth is imminent Clear in colour Meconium stained liquour Umbilical cord Presenting part When the waters break or Spontaneous rupture of the membranes

Three stages of labour First Stage: The onset of regular painful uterine contractions accompanied by progressive dilatation of the cervix through the transitional phase to full cervical dilation of 10 cm. Second Stage: Full cervical dilatation to the delivery of the baby.   Third Stage: Time of birth to the delivery of the placenta and control of bleeding. Three stages of labour

Bishops score

Pain Relief Natural Endorphines Immersion in Water Breathing Techniques Hypnosis Reflexology Massage TENS N2O+O2 Simple Analgesia (Paracetamol) Narcotics (Pethidine) Epidural Spinal GA Pain Relief

Occurs towards the end of 1st stage, leads into 2nd stage the Ferguson reflex: as pressure on the cervix increases, the Ferguson reflex increases uterine contractions so that the second stage can go ahead. Behavioural changes Loss of control; panic Negative thoughts Nausea and vomiting Slowing of contractions Heavy show, bowels opened Restful stage – don’t jump in! Urge to bear down Purple Line 'Push Off' stage Transitional phase

The strength of the pushing urge varies in intensity but will become more consistent Characteristic grunting noise Thinks she needs to empty her bowels / bowels open Signs of full dilatation: heavy show, anal dilatation, perineum bulges and stretches. The presenting part will become progressively more visible Expulsive phases

Labour will progress if The fetus is of average size With a normally positioned head In a normal labour In a woman with an average sized gynaecoid pelvis If contractions are adequate Labour will progress if

Mechanisms of Normal Labour Descent Flexion Internal rotation of head Crowning Extension Restitution -Internal rotation of the shoulders External rotation of the head Lateral flexion Mechanisms of Normal Labour

The fetal head engages and descends into the pelvis in an OT (occiput transverse) position. The widest part of the fetal skull into the widest diameter of the pelvis. Descent

Descent

As the fetus descends the head flexes so that the fetal chin is touching the fetal chest. Thereby creating the smallest diameter to pass through the pelvis. Flexion

Internal rotation of the head With good uterine contractions and maternal expulsive effort the occiput reaches the pelvic floor. As it reaches the resistance of the pelvic floor, it rotates forward through 45 degrees into OA (occiput anterior) position. The head emerges through the widest diameter of the pelvic outlet – anteroposterior diameter.

As head descends it meets the muscles of the pelvic floor and rotates anteriorly Internal rotation

The occiput escapes under the pubic arch and the head is crowned. The head no longer recedes between contractions. Crowning

The forehead, face and chin sweep the perineum and the head is born. Extension

Extension

When the head is born it will turn right or left righting itself with the shoulders. The shoulders rotate internally to lie in the AP diameter of the pelvis. Rotation follows the same direction as restitution. Restitution

External rotation

The Anterior shoulder is born under the pubic arch first The posterior shoulder passes over the perineum The natural curve of the birth canal causes the baby to flex sideways Lateral flexion

Complete Expulsion or Delivery

Placenta Physiological Do nothing Active Breast feed Observe blood loss Maternal observations Can take one hour or more Pass urine Sit up right Placenta Active Clamp and cut cord Oxytocic drugs Signs of separation CCT Contracted uterus? Average 5 minutes

Skin to skin & Breast feeding 4th Stage of labour Promotes bonding / Feelings of wellbeing Thermoregulat ion Comforts baby Promotes early breast feeding Expels placenta

UHCW Lucina Birth Centre Division of B2B training Birthing Pools Dedicated supervisor of Midwives Team Specialist Midwives Roles Birthing outside of Guidance Low Risk Policies and Guidelines Large birthing rooms UHCW

CAN WE IMPROVE ? ? CEASAREAN SECTION RATE ? NORMAL BIRTH RATE ? WATERBIRTH RATE ? INSTRUMENTAL CAN WE IMPROVE ?

Any Questions?