LABOUR Labour can be defined as involuntary coordinate uterine constraction. Cause cervical effacement and dilataion. Follow up by expulsion of products of conceptio. DELIVERY Delivery is the expulsion of products of conception after viability of the fetus(which is around 22 weeks of gestation).

LIE OF THE FETUS Is the relation between the long axis of the fetus to the long axis of the mother (longitudinal, transverse, oblique)

POSITION Is the relation between arbitrary chosen portion of the presenting part and the right or left side of the pelvic, it also can be anterior, transverse or posterior. (Occiput, chin and sacrum) in vertix, face and breech respectively.

ONSET OF LABOUR - Estrogen - STATION OF THE HEAD it is part of the pelvic assessment to Evaluate the relation between the Presenting part and the pelvis. It can be determined by the amount of the head felt above the pelvic brim expressed as fifth or more accurate by the vaginal examination of the presenting part in relation to the ischial spines and expressed as centimeters above(-) or below + the ischial spines.

PRESENTATION Is the portion of the fetus that is Foremost within the birth canal or closest toil. It is head or breech in longitudinal lie, shoulder in transverselie. Cephalic presentation is classified according to the degree of head flexion occiput, Sinciput, below, face presentation. usually sinciput and brow or transient position changes with the progress of labour. Breech presentation is classified according to the thigh and leg extension, frank, complete footling. -

CLINICAL EVALUATION OF LIE PRESENTATION AND POSITION OF THE FETUS The examiner should first determined The fundal height of the uterus. First the Uterus Maneuver gentle palpitaion of the fundus of the uterus with the tip of the fingers of both heads, to determine the fetal part that occupy the fundus.] Second Maneuver the palm of the examiner’s hands are placed on either side of the uterus and press to exert deep pressure (hard resistant structure is felt, the back,) numerous nodulation is felt in the side (the extremities).

Third Maneuver By applying the thumb and fingers on the presenting part of the lower portion of the maternal abdomen, above the symphysis pubis. This maneuver is to determine the presenting part, careful palpitation may help to evaluate the degree of head flexion and engagement of the presenting part.

Fourth Maneuver The examiner faces the mother’s feet and with the lip of three fingers of both hands palpate the presenting part of vertex presentation. One hand will first feel the prominent part while the other will descent more vertex presentation, or in the side of the back in face presentation. When the head is clearly enlarged the shoulder is felt by this maneuver.

■ IN THE FIRST STAGE OF LABOUR C ervical changes is the result of two factors: ■ Passive stretching as an effect of the pressure of the presenting part and hydrostatic pressure of the amniotic sac – early rupture of the membranes does not prolonged labour as far as the presenting part is will apply to the cervix. ■ Contraction of the longitudinal muscle fires of the uterus.

THE STAGES OF LABOUR First is the stage of effacement and dilatation of the cervix. Second stage is for the expulsion of the fetus. Third stage is for the expulsion of the placenta and membranes. Fourth stage is for the early recovery.

IT IS DIVIDED INTO TWO PHASES 1. Lateral phase – start with the regular uterine contraction till the cervix is cm dilated and its mean duration is around 7 hours (Friedman’s sters). 2.Active phase – from the end of latent phase until full cervical dilatation.

SECOND STAGE Cervix is fully dilated and uterine contraction every 2-3 minutes. It has 2 component: Phase I – head begins to descent and patient feels abdominal lightening (normal to encourage patient to push at this phase). Phase II – head reaches the pelvic floor And patient starts to bear down.

IT IS THE THREE COMPONENTS ●Acceleration phase – it usually predict the outcome of labour during which cervix dilate most rapidly. ●Maximum slope – it reflects the efficacy of uterine contraction. ●Deceleration phase – it reflect the fetopelvis relationships the dilatation rate normally is 1.2 cm/hr in nulliparous women and 1.5 cm/hr in multiparous women.(practically 1 cm/hr).

THIRD STAGE Placenta separation happen through spongiosa layer. The stage rarely exceeds 5 minutes. ■Separation is the result of : ●Contraction and refraction of uterine muscle ●Reduction of uterine volume and area of placenta site ■Retroplacenta haematoma

If the leading part separate first (Mathews Duncan mechanism) the raw surface (maternal) will be exposed. If the centre separate first Schultse mechanism. The fetal surface will be seen first. Signs of placenta separation: ■Rising of the uterine fundus ■Blood show ■Lengthening of the umbilical cord

THE FOURTH STAGE OF LABOUR The immediate recovery phase following the third stage where patient needs close observation for any signs of bleeding.

MECHANICAL OF NORMAL LABOUR IN OCCIPUT PRESENTATION Flexion: Complete flexion of head take place in vertex presentation and the occiput used to indicate. Position : LAO,LOP,LOT,ROA,ROP and ROT Engagement of the head – when the largest diameter of the head (Biparietal) passes the pelvic brim. The sagittal sure is in the transverse diameter of the pelvis so the occiput is lateral.

Descent is Limited until the second stage of labour. Internal rotation – the largest diameter of the pelvic outlet in anteroposterior. So the occiput rotate anteriorly. Restitution and external rotation – the occiput rotate back to its lateral position.

Extension and delivery of the Head When the vulva is distended over the largest diameter of the head the occiput remain below the public arch and the sinciput sweeps forwards as the neck extended (tearing of the perineum should be avoided at the stage).

ONSET OF LABOUR - Estrogen - Progesterone - Prostaglandin appears in the myometrium. - Prostaglandin resistance in the cervix. Management Delivering Labor - Admission NPO IV line Fetal monitoring Pinard stethoscope every 15-20min Continous CTG High risk Patient Internal scalp electrode Fetal blood scalp sampling Monitoring of Labour

-Comport of the patient Explain what is likely to happen in labor presence of relative Discuss with her pain killer Material assessment/ 2 hours abdominally/ 4 hours vaginally Support of the perium at crowing Episiotomy Midline Mediolateral Lateral Delivery of the placenta by CCT Third stage Oxytocin Ergometrin

Abdominal examination during labour can be done between contractions. It provides important information (retraction ring in obstructed labour)