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Labour

Labour is a normal physiological function in pregnant women to deliver the neonate through the vagina. Being a very painful procedure, it is it is a physiological and psychological experience for women. And that experience differs from woman to woman. For convenience of understanding the process of labour is divided three stages.

A woman's pain during labour occurs due to the uterine muscles' contraction and the cervix's pressure.  Pain can also be felt around the sides and thighs. During labour pain, the muscles of the uterus tighten and then relax.

The strong to very strong contraction of the uterine muscle and the consequent pressure exerted on the cervix produces pain which gradually increases in intensity depending up on the strength of the contractions. The progress of the labour depends on the strength and frequency of contractions and so does the pain. After each contraction, the uterus relaxes intermittently, and pain reduces during relaxation.

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As the due date is approaching, the body sometimes gives out false signals of labour, known as "false labour". False labour is characterized by mild contractions that are not very painful, lasts for a short duration of time, does not occur at regular intervals of time, and is not accompanied by bleeding, leakage of amniotic fluid, or reduced fetal movements. It is also known as Braxton Hicks contractions.

Beginning a few days before actual labour pregnant women experience intermittent and irregular contractions which are mild in nature and are generally referred to as false pains. These mild contractions are not accompanied by any significant vaginal discharge or bleeding.  As the time for delivery approaches, these contractions become more regular, frequent and grow stronger in force. Usually, there will not be any watery discharge or bleeding from the vagina.

Stages

The process of human labour is specifically divided into three stages:

Stage 1: Uterine contractions become regular in frequency, increasingly more powerful with pain reaching a crescendo. This is the stage of dilatation of the cervix which admits one finger to begin with and reaches a width of 10 centimeters. Intensity of contraction, pain and dilation of cervix varies form individual to individual and between first pregnancy and succeeding pregnancy.

During this stage women get exhausted due to the severity of contractions of uterus and accompanying pain. It calls for good nutritional support in the form of beverages and fruit juices liberally while avoiding solid foods to prevent accumulation of food residue in the stomach.

Stage 2: With complete dilatation of the cervix the descent of the fetus starts marking the beginning of second state. The fetus under the contraction of uterus and with the yielding of birth canal, maneuvers its descent in a well-known pattern to get delivered resulting in birth. Uterine contractions continue but with much reduced severity and force. Pain also gets correspondingly reduced. Several postures are practiced during the second stage depending upon the prevailing practices. The umbilical cord is double ligated and severed between the knots to prevent bleeding.

Stage 3: During this stage the placenta and the fetal membranes get delivered known as ‘after birth’. The normal duration of the third stage is between 5 to 30 minutes. Placenta need to be carefully examined for being complete in order to prevent post-partum bleeding.

Symptoms

Labour pain varies among individuals and among women with birth order. However, some common symptoms of labour are:


  • Uterine contractions accompanied by pain on the lower abdomen to begin with.

  • Pain occurs all over the abdomen, in the hips and thighs. The intensity of pain may vary in these locations.

  • Discharge of cervical thick mucous plug stained with blood indicates beginning of cervical dilatation.

  • With the increasing frequency and intensity of contractions pain arises from the front of abdomen and radiates to the back of the abdomen and thighs

  • Clear watery discharge per vagina appears and gradually increases indicating the rupture of fetal membranes and dilatation of cervix.

  • With progression of contractions pressure builds up in the lower pelvic regions.

Diagnosis

Onset of active labour may be diagnosed with the help of the following findings:


  • Uterine contractions become increasingly frequent and with the correspondingly increasing intensity of pain.

  • On examination progressive cervical dilatation > 2 Cm indicates the beginning of labour.

  • Also, cervical rim of the cervix progressively becomes thin and soft known as effacement of cervix.

Pain Management Without Medications

Generally, labour pain could be managed to make the parturient comfortable though labour is a temporarily painful physiological condition. Unless the parturient is high strung and apprehensive there is no need for medication for pain during labour. General measures are:


  • Repeated reassurance and comforting will psychological prepare the parturient to look forward for a relatively easy delivery.

  • Hydration during labour with clear fluids like water and fruit juices will help in circumventing dehydration which leads to exhaustion and irritability.



  • Mild and comfortable massaging the back, lower abdomen and upper thighs will relieve stiffness in these regions. Mild fomentation with soft towels dipped in hot water will be comfortable.

  • Early in the labour, lukewarm water bath or shower will cheer up the mood but extreme care must be exercised while moving about in the bathroom to guard against loosing balance.

  • Walking around early in the labour and changing position while on bed will help in reducing discomfort while the labour progresses.

  • If the parturient had practiced meditation and relaxation exercises prior to and during antenatal period would be helpful during labour.

Pain Management With Medications

The following are some of the pharmacological options for managing labor pain:

Analgesics: Pain killers in normal therapeutic doses have no virtually no role in reducing the pain during labour as in labour the uterine contractions are neurological mediated and controlled. If higher doses of analgesics alone and in combination with other pharmacological agents is known to have deleterious effect on the vital functions of the parturient and the fetus. Some of the drugs used for to hasten the cervical ripening, for example have sever impact on the fetal central nervous system. No place for analgesics.

Anaesthesia in Labour: Since labour is a neurologically controlled physiological process there is a definite role for Anaesthesia in reducing the pain during labour. This can be achieved either by the application of anaesthetics locally or through a regional block anaesthesia. Certain amount of experience is required in the case of local block anaesthesia and more expertise is required in regional anaesthetic block.


  • Local Nerve Block: Is commonly known as pudendal block. Plain solution of long-acting local anaesthetic is in injected into the vicinity of pudendal nerves which control the transmission of pain impulses from the uterus during contraction. This nerve block will not affect the contractile function of the uterine muscle. Thus, delivery will proceed normally and without pain.  It will ease in episiotomy and its repair.

  • Regional Anaesthesia: Classical example of regional anaesthesia in labour is epidural anaesthesia or epidural block. Again, a long-acting anaesthetic solution is injected into the epidural space of the lower spinal column of the parturient. The is left in situ to replenish the anaesthetic should a need arise later. Epidural anaesthesia blocks the sensory impulses from the lower part of the body corresponding to the level of injection of anaesthetic without affecting the motor activity and the uterine contraction function. Thus, aiding delivery without much pain and discomfort.


The regional anaesthesia needs certain expertise in the placement of epidural needle and followed by a cannula at a more or less precise level in the spinal column. Also, there is a risk of epidural anaesthetic gravitating upwards either by sheer pressure of anaesthetic solution in the limited dural space or by chance the parturient is placed in a tilted position during delivery. It requires specific technique and good care. Postoperative episodes of hypotension, giddiness, and headaches are known uncommon complications of epidural anaesthesia.

During normal labour spinal anaesthesia and general anaesthesia have little role, first, because of technical expertise and specialized equipment is required. Secondly, it will seriously interfere with the normal delivery and hence reserved for occasional instrumental and often used Caesarian deliveries.

Complications

Several complications can arise during labour. Some of them are as follows:

Pregnancy and childbirth are normal physiological process which proceeds to labour in a normal well-known pattern almost always. Yet rarely there could be instances that complicate the normal progression of labour and childbirth these include:


  • Slow progress in labour: As an occasional instance cervical dilatation may become slow for a variety of reasons leading to delay in delivery. Such delays will affect the parturient physically and mentally and the impact will be more pronounced on the fetus as the fetal circulation and oxygenation are compromised. In cases of failure of efforts of cervical priming Caesarean section might become imperative to save the fetus.

  • Perineal Tears: Insufficient stretching of the pudendal tissues or an oversized large fetal head forced through the region of vagina and perinium may give way leading to tears in the vagina extending often into anal region. A liberal episiotomy will most likely obviate such tears and repaired properly episiotomy is a better alternative to ragged tears which increase morbidity and need more efforts to repair.

  • Fetal malpresentations: Is the leading cause prolonged labor and delayed delivery with consequent on the parturient and the fetus. Current practice is to designate the fetal malpresentation as high-risk condition and refer such cases to centers with facilities to mange such cases. Breech, footling, and shoulder presentations should be diagnosed and referred to appropriate facilities. However, lesser unexpected conditions could develop during apparently normal labour. Uterine inertia and dystocia may occur during apparently normal labour and should be competently managed or referred at the earliest instance.

  • Retained Placenta: Delivery of the placenta is spontaneous and usually complete within a time range of 5 to 30 minutes after the birth of the baby. It is relatively rare event and If it occurs it could be one of the causes of postpartum bleeding. Should be managed carefully managed by manual extraction and the cavity of the uterus after such extraction be carefully inspected.


Up on delivery the maternal surface of the placenta must inspected closely to account for the intactness of all the cotyledons as any retained cotyledon could be a cause of postpartum bleeding and puerperal infections.

  • Postpartum Haemorrhage: Vaginal Bleeding following birth of the baby and the placenta is a serious condition. Immediately after the delivery of the placenta by its inherent character uterus contract firmly thus obviating any bleeding from the raw internal surface of the uterus.  Any condition that does not allow complete and firm contraction of the uterus following delivery will lead to postpartum bleeding. Prolonged labour, uterine inertia unexpected rupture of uterine muscle and retained whole or part of placental tissue are the leading cause of postpartum bleeding. Occasionally puerperal infections could also cause Postpartum bleeding. Each instance must be managed vigorously on individual merit and on the basis time of tis occurrence.

  • Perinatal Fetal Asphyxia: Prolonged labour and improper delivery of the baby could reduce the oxygen in the new-born. Amniotic fluid aspiration and / or meconium  aspiration could compromise the neonatal fetal oxygen exchange. Also, rapid fetal extraction could lead to aspiration of amniotic fluids choking the neonate. There would be sufficient time after the head is born to clear the respiratory passages of the neonate in preparation for breathing freely by the neonate. Generally, a good Apgar Score could be possible by conducting a delivery properly. Amniotic fluid or meconium aspiration needs careful succession / spiration of the tracheobronchial passage which demands expertise.

References

 


  1. March of Dimes. Contractions and signs of labor [Internet] [Updated on December, 2018] Available at: https://www.marchofdimes.org/pregnancy/contractions-and-signs-of-labor.aspx. Accessed on March 10, 2021.

  2. Labor S, Maguire S. The pain of labour. Reviews in pain. 2008 Dec;2(2):15-9.

  3. Cleveland Clinic. Pregnancy: Epidurals and Pain Relief [Internet] [Updated on January 12, 2018] Available at: https://my.clevelandclinic.org/health/articles/4450-pregnancy-epidurals--pain-relief-options-during-delivery. Accessed on March 10, 2021.

  4. Medline Plus. Am I in labor? [Internet] [Updated on March 31, 2020]Available at: https://medlineplus.gov/ency/patientinstructions/000508.htm#:~:text=Leaking%20amniotic%20fluid,10%20minutes%20for%2060%20minutes. Accessed on March 10, 2021.

  5. Birth Injury Help Center. The Stages of Labor [Internet] Available at: https://www.birthinjuryhelpcenter.org/labor-stages.html. Accessed on May 6, 2021.

  6. Womens Health. Labor and Birth [Internet] [Updated on June 6, 2018] Available at: https://www.womenshealth.gov/pregnancy/childbirth-and-beyond/labor-and-birth. Accessed on March 10, 2021.

  7. Chirldbirth connection. Labor Pain Basics [Internet] Available at: http://www.childbirthconnection.org/giving-birth/labor-pain/basics/. Accessed on March 10, 2021.

  8. Ragusa A, Mansur M, Zanini A, Musicco M, Maccario L, Borsellino G. Diagnosis of labor: a prospective study. Medscape General Medicine. 2005;7(3):61.

  9. John Hopkins Medicine. Labor [Internet] Available at: https://www.hopkinsmedicine.org/health/wellness-and-prevention/labor. Accessed on March 10, 2021.

  10. NWH. Nonpharmacologic Labor Pain Management [Internet] Available at: https://www.nwh.org/patient-guides-and-forms/maternity-guide/maternity-chapter-3/comfort-measures-during-labor-and-delivery-non-pharmacological-methods. Accessed on March 10, 2021.

  11. NWH. Pharmacologic Labor Pain Management [Internet] Available at: https://www.nwh.org/patient-guides-and-forms/maternity-guide/maternity-chapter-3/comfort-measures-during-labor-and-delivery-pharmacologic-methods. Accessed on March 10, 2021.

  12. Pregnancy Birth and Baby. Labour Compliccations [Internet] [Updated on May, 2018] Available at: https://www.pregnancybirthbaby.org.au/labour-complications. Accessed on March 10, 2021.

  13. NIH. What are some common complications during labor and delivery? [Internet] Available at: https://www.nichd.nih.gov/health/topics/labor-delivery/topicinfo/complications. Accessed on March 10, 2021.


 

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