1. Normal Labour
No pain,No gain

2. Labour
Labour is the act of expulsion of the foetus, placenta, and membranes from the uterus.
Types of Labor:

3. Normal Labour: Labor is considered normal When:
There is a single mature foetus, presenting by vertex, the process of labour terminates spontaneously, through the birth canal, without foetal and maternal complications, and within 24 hours.
Post Mature labour:
When the duration of pregnancy is 42 weeks or more.
Prolonged labour:
The course of labour lasting more than 24 hours.
The causes of prolonged labour are:
Inefficient uterine contractions (inertia) is the commonest cause.
Occipto posterior position.
Rigid perineum especially in elderly women.
Full bladder and rectum of the pregnant woman.

4. Precipitate labour:
When the duration of labour lasting less than 3 hours, due to:
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 foetus.
It is more frequent in multiparas.

5. THE ONSET OF LABOUR
SYMPTOMS OF ONSET OF LABOUR:
1) Show
Discharge of mucous mixed with blood may occur. This is due to dilatation of the cervix.
2) True Lbour pain:
The true labour pains are characterized by the follwing:
They are regular and increase gradually in amplitude, frequency
and duration.
They are accompanied by hardening of the uterus.
The discomfort is in both the back and the abdomen.
They are accompanied by progressive dilatation of the cervix.
The contractions are not affected by sedation.
They are usually enhanced by an enema.

6. The functions of liquor amnii are:
3. 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:
Protection of the fetus.
Medium for free movement of the fetus.
Keep the fetus temperature constant.
Medium of fetal exertion. After rupture of membranes the liquor amnii act as antiseptic fluid for birth canal.
False labor pain:
Many women may complain of painful uterine contraction, despite, the contractions, progressive of the cervix falls to occur.

7. The false pains are characterized by:
The contraction occur at irregular intervals.
The intensity of the contraction remain the same.
The discomfort is chiefly in the lower abdomen.
The contractions are usually relived and after stopped by sedation.
The pains do not cause progressive dilatation of the cervix.

8. Forces of labour 1) Uterine force: The values of retraction are:
It is the most important force of labor, It consists of contractions and retraction of the uterus. (Retraction means incomplete relaxation or sustained partial contraction)
The values of retraction are:
Assist in dilatation of the cervix.
Assist in expulsion of the fetus .
Assist of separation of the placenta.
To control post-partum bleeding.
2) Auxiliary forces of labor:
By strong contraction of the diaphragm and abdominal muscles. When the head stretches the pelvic floor, bearing down occurs involuntary by a reflex mechanism, which is needed for expulsion of the fetus and placenta (in 2nd stage and 3rd stages of labor.)

9. Stages of labour

10. Stages of labour

11. 1st Quiet phase 2nd Active phase
1st stage:
Begins with the onset of labour and ends when dilatation of the cervix is complete(10 cm diameter or 5 fingers).
It is the longest stage(8→12 hours in primi-gravida, 6→8 hours in multi-gravida.
It is divided into :
1st Quiet phase nd Active phase
when contractions are when contractions are
infrequent, short duration frequent,↑and strong.
Contraction that occur every 2-3 min. and last sec. indicates
Significant dilatation or effacement of cervix and decent of presenting part.
1st stage of labour may be less than one hour or more than 24 hours depending on:
The parity of the woman
The frequency, intensity and duration of the uterine contractions.
The ability of the cervix to dilate.
The presentation and position of the fetus.

12. 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.

13. 2nd stage
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:
Fetal presentation and position.
Feto pelvic relationship.
Resistance of maternal pelvic tissue.
Frequency, intensity, duration, and regularity of uterine contraction.
Efficiency of maternal voluntary expulsive effort.

14. 3rd stage The 3rd stage is composed of 3 phases: Placental separation.
From the birth of the infant to delivery of the placenta and membranes. (by uterine contraction), it takes about 5min.
If the placenta falls to be expelled within half hour after delivery of the
foetus ,the condition called retained placenta.
The 3rd stage is composed of 3 phases:
Placental separation.
Placental decent.
Placental expulsion.
Sings of placental separation:
Gush of blood.
Lengthening of the cord of the fetus passes though the cervix.
A rise of height of the funds as the placenta reaches the vagina.

15. The progress of labour can be observed by:
4th stage
Postpartum hemorrhage due to uterine atony. It may be primary (when bleeding occur during the 3rd stage
or within24 hours) or secondary (when it occurs after the 1st 24 hours.
The progress of labour can be observed by:
The rate of cervical dilatation.
Descent of the presenting part.
The strength and frequency and duration of uterine contraction

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18. Management of the frist stage of labour Management of the
When labour 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.
Breath deeply (the key of relaxation.)
No strain during 1st stage (will cause prolapse 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.

19. 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 foetal heart rate should be listened every 15 minutes in the 1st stage of labour and every 5 minutes in the 2nd stage especially towards the end of uterine contraction to detect any abnormality.
The normal variation of foetal heart ratio (F.H.R.) is between beats per minute. If the F.H.R. delayed to return after the end of uterine contraction is an early sign of foetal disress.
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.

20. Woman‘s positions during normal labour

21. Management of the second stage of labour
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 contraction is important in the 2nd stage of labour 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 foetus
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.

22. Management of the 3rd stage of labour
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.

23. Post Partum Exercises
Post partum exercises should start with shorter duration which consists of:
Warm up period.
Gentle stretching exercises.
Postural correction exercises.
Specific strengthening exercises.
Relaxation techniques.
Avoid strenuous exercises (cause significant ↑ of lactic acid concentration in breast milk which affect the taste and acceptance of milk by the infant.
Exercises program at 60-70% of the maximum heart rate for 45 minutes a day., Five times a week for 12 weeks, will significantly improve the cardiovascular fitness of post natal woman.

24. Values of Post Partum Exercises Prophylactic: Curative: Lactation:
Diminish respiratory complications
Diminish vascular complications as thrombosis and embolism.
Guard against prolapse and stress incontinence.
Curative:
Restore the muscle tone (abdominal and pelvic floor.
Re-education of posture sense.
Help excretion (micturition and defecation).
Help involution of uterus.
Lactation:
To aid lactation by improving the blood supply of the breast and allowing free flow of milk.
Pervent sagging of the breast.

25. Contra-indications for
postnatal exercises
Post partum heamorrhage.
Nephritis.
Puerperal fever.

26. Post partum exercises 1st day 2nd day 3rd day 4th day 5th day
Breathing exercises.
Circulatory exercises.
Relaxation exercises.
Static abdominal exercises.
2nd day
Repeat the previous exercises and add the following exercises.
Leg exercises.
Pelvic floor exercises.
Arm exercises.
3rd day
Repeat exercises of the second day and add the following:
Pelvic rocking exercises.
4th day
Repeat exercises of the third day and add the following:
Hip shrugging.
Pelvic rotation.
Posture correction training.
5th day
Repeat exercises of the fourth day and add the following:
1st step of trunk flexion.

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