Normal labor and physical therapy role

Physical Therapy for Women's Health - 4th Year Students SVU

4. -Laboris defined as the process by which
a Viablefetusis expelledfrom the uterus. More
specifically, labor requires regularContractions
that lead to dilationand effacementof the cervix.
-Laboris a physiologicprocess during which
the fetus, membranes, umbilical cord, and placenta
are expelledfrom the uterus.
-Normal labor describes the process of spontaneousexpulsion of single, full
term, living fetus, presenting by the vertex, in occipito anterior position through normal
birth canal (Vagina), in not less than 3 hours and within 24 hours, withoutinterference
rather than episiotomyand withoutany complicationsto the motheror the fetus.

5. -Precipitate deliveryrefers tochildbirthafter an
unusually rapid labor (combined1st stage and second stage duration
is less than two hours) and culminates in the rapid, spontaneous
expulsion of the infant with a total time less than 3hours. It can cause
maternal perineal laceration, PPHand intracranialfetal hemorrhage.
-Prolonged labor also known as failure to
progress, occurs when the (combinedduration of the first
and second stageis more than the arbitrary time limit of
18 hours. It is not synonymous with inefficient uterine
contraction. As inefficient uterine contraction can be a
causeof prolonged labor, butlabor may also be prolonged
due to pelvicor fetal factor.

6. Signs & symptoms of onset of labor:
*Lightening
Lightening is a term used to denote the descentof the
fetal head into the pelvisas labor approaches. It can occur
up to two weeks prior to the onset of labor, or it may not
occur at all. This diminishesthe fundal height and hence minimizesthe pressureon the
diaphragm. The mother experiences a sense of relieffrom the mechanical cardiorespiratory
embarrassment. Many women find it easier to breathe after lightening occurs because upward
pressure on thediaphragmdiminishes butThere may be frequencyof micturitionor
constipationdue to mechanical factor—pressure by the engaged presenting part.
*Mucus plug
Release of the "mucusplug" can be another sign that labor is near. It is produced by
cervical glands normally blocks the entrance to the cervix and helps prevent infection. When
the fetal headimpinges on the cervix, mucus plug stained with blood (Show) is expelled.

7. *Rupture of membranes
With the dilatationof the cervical canal, the lower pole of the fetal
membranesbecomes unsupportedand tends to bulgeinto the cervical
canal. As it contains liquor, which has passed below the presenting
part, it is called “bag of waters”. During uterine contraction with
consequent riseof intra-amniotic pressure, Spontaneous ruptureof
the fetal membranes and clearamniotic fluid is often expelledfrom the vagina at that time.
Once this occurs, labor will generally ensue spontaneously. If it does not, induction of labor
may be necessary to avoid infection ascending upward through the vagina into the uterus.
*Contractions
Throughout pregnancy, painless Braxton Hicks contractions with simultaneous
hardening of the uterus occur. These contractions change their character, become more
powerful, intermittentand are associated with pain. Pain more often felt in frontof the
abdomenor radiating toward the thighs. Butthese contractions are called false labor pain
which is significantly different from the true labor pain that is associated with labor.

9. True Labor PainFalse Labor Pain
Regular Irregular
Increase progressively in frequency,
duration and intensity
Do not
Pain is felt in the abdomen and
radiating to the back
Pain is felt mainly in the abdomen
Progressive dilatation and effacement
of the cervix
No effect on the cervix
Membranes are bulging during
contractions
No bulging of the membranes
Notrelieved by antispasmodicsor
sedatives
Can be relieved by antispasmodics and
sedatives

10. Causes of onset of labor:
Estrogen theory:
Promotesthe synthesisof myometrial receptors for oxytocin (by 100–200 folds),
prostaglandins, increasein gap junctions in myometrial cells and increasethe
excitabilityof the myometrial cell membranes.
Progesterone withdrawal theory:
Before labor, there is a dropin progesterone synthesis, butthere is alterationinestrogen :
progesterone ratio rather than the fallin the absoluteconcentration of progesterone.
Prostaglandins theory:
PGE2and PGF2α inamnion& myometriumare powerful stimulators of uterine activity.
Oxytocin theory:
Oxytocinis a powerful stimulator of uterine contraction.
Fetal cortisol theory:
Increasedcortisolproduction from the fetal adrenal gland before labor may influence its
onset by increasing estrogen production from the placenta.

12. Forces of labor
1-Uterine force:
It is the most important force of labor. It consists of contractionsand retractionof the uterus
(Retraction means incomplete relaxation). The values of retraction are to: assistin dilatation
of the cervix, expulsionof the fetusand placentaalso controlof postpartum hemorrhage.
2-Auxiliaryforce:
It is the secondary force of labor. It consists of maternal voluntary bearing down through
strong repeated contractions of diaphragmand abdominal muscles, but these contractions
become involuntarywhen the fetal head stretch the pelvic floor.
3-Fetal axis pressure:
In labor with longitudinal lie and with flexed fetal head on the cervix, fetal vertebral column
is straightened by the contractionsof the circular muscle fibers of the body of the uterus. This
causes mechanical stretching of the lower segment and dilatationof the cervical canal.

13. STAGES OF LABOR
-The First stage:It starts from the onset of true labor painand ends with
full dilatation of the cervix. It is, in other words, the “cervical stage” of labor.
-The Second stage:It starts from the full dilatation of the cervix(notfrom the ruptureof the
membranes) and ends with expulsion of the fetus from the birth canal. It has got two phases:
*Propulsive phase-from full dilatation up to descentof the presenting part to the pelvic floor.
*Expulsive phase-is distinguished by maternal bearing down efforts and ends with delivery
of the baby.
-The Third stage:It begins after expulsion of the fetus and ends with expulsion of the
placenta and membranes(afterbirths).
-The Fourth stage:It is the stage of observation for at least 1-2 hour after expulsion of the
after births. During this period maternal vitals and any vaginal bleeding are monitored.

14. The first stage (Cervical effacement and dilation)
-The first stage of labor and birth occurs with beginningof feeling
regular contractions, which cause the cervix to open(dilate) and
soften, shortenand thin(effacement). Initially, pains are not strong
enough to cause discomfort and come at varying intervalsof
15–30 minutes with durationof about 30 seconds. Butgradually
the interval becomes shortened with increasing intensity and
durationso that in late first stage the contraction comes at intervals
of 3–5 minutes and lasts for about 45 seconds.
-Effacement:is the process by which the muscular fibers of the cervixare pulled upward
and mergeswith the fibersof the lower uterine segment. The cervix becomes thin during
first stage of labor or even before that in primigravidae. In primigravidae, effacement
precedes dilatationof the cervix, whereas in multiparae, bothoccur simultaneously.

15. -LOWER UTERINE SEGMENT: Before the onset of labor, there is no complete
anatomicalor functional division of the uterus. During labor, the demarcationof an
activeupper segmentand a relatively passivelower segmentis more pronounced. The
wall of the upper segment becomes progressively thickened with progressive thinning of the
lower segment. This is pronounced in late first stage, especially after rupture of the
membranes and attains its maximum in second stage. A distinct ridge is produced at the
junction of the two, called physiological retraction ring.

16. -The first stageis the longestof the labor stages. It's divided into two phases of its own:
early labor (latent phase) and active phase.
*Thelatent phase →which is defined as period between the start of labor up until the
cervix is 4cm dilated. This latent phase tends to be slow, lasting an average of around 6
hours for primigravidae, and 4 to 5 hours for multiparouswomen.
*Theactive phase →is from 4cm of cervical dilation until the cervix is fully dilated
(10cm). During the active phase, it is expected that the cervixshould dilateat least 1cm
an hourin women who are primigravidae. The cervix in multiparouswomen tends to
dilate more quickly (about 2cm/hr.).
-During the first stage of labor, the Midwifeor Obstetricianwill regularlydo a vaginal
examinationto assess how dilated the cervix is, how the baby is descending, and the
color of the amniotic fluid.

18. The Second Stage (Delivery of the fetus)
-The second stage begins with the complete dilatation of
the cervix and ends with the expulsion of the fetus.It can
last from 20 minutes to 2 hours in Primiparouswhile
less than 1 hour in multiparous women.
-With the full dilatationof the cervix, the membranes
usually ruptureand there is escapeof good amount of
liquor amni. The volume of the uterine cavity is thereby
reduced. Simultaneously, uterine contraction and retraction
become stronger. The uterusbecomes elongatedduring
contraction, while the anteroposteriorand transverse
diameters are reduced.

19. -The Second stage has two phases:
(1) Propulsive phase→ from full dilatation until headtouches the pelvic floor.
(2) Expulsive phase→ since the time mother has irresistible desire to “bear down”
and push until the baby is delivered.
Cardinal Movements of Labor
Delivery of the head
*Descent:
It is continuousthroughout labor particularly during the second stage and caused by:
-Uterinecontractionsand retractions.
-The auxiliary forces which is bearing down brought by contractionof the diaphragmand
abdominalmuscles
-The unfoldingof the fetusi.e., straightening of body especially after rupture of membranes.
*Engagement:
The head normally engagesin the transverse diameter (70%) or obliqueof the inlet.

20. *Flexion:
As the fetal chin is placed on the thorax & the occiputwill meet the
pelvic floor. Flexionis essentialfor descent, since it reduces
the shapeand sizeof the plane of the advancing diameter of the head.
*Internal rotation:
It is a movement of great importance withoutwhich there will be no further descent. Two
halves of levator ani form a gutterand viewed from above,
the direction of the fibers is backward and toward the midline.
-Thus, during each contraction, the head, occiput in particular,
in well-flexed position, stretchesthe levator ani, particularly
that half which is in relation to the occiput.
-After the contraction passes off, elastic recoil of the levator ani
occurs bringing the occiput forward toward the midline. The process
is repeated until the occiput is placed anteriorly. This is called rotationby law ofpelvic floor.

21. Crowning→After internal rotation of the head, further descent occurs
until the subocciputlies underneaththe pubic arch. At this stage, the
maximum diameter of the head(biparietal diameter) stretchesthe
vaginal orificewithoutany recessionof the head(does not retract or
go back in) even after the contraction is over, This is called
“crowning of the head”, If the obstetrician decided to do episiotomy,
it should be done just before crowning.
*Extension:
The suboccipital region lies under the symphysis pubis then by head extension
the vertex, foreheadand facecome out successively.
The head is acted upon by 2 forces:
-The uterine contractions acting downwardsand forwards.
-The pelvic floor resistance acting upwardsand forwards,
so, the net result is forward direction i.e., extensionof the head.

22. (Expulsion) Delivery of the shoulder and body
-The anterior shoulderhinges below the symphysis pubis and with further descent takes
place until the anterior shoulder escapesbelow the symphysis pubis first. By a movement
of lateral flexion of the spine, the posterior shoulder sweeps over the perineum.
Rest of the trunk is then expelled outby lateral flexion.
*Restitution:
After delivery, the headrotates1/8 of a circlein the opposite
directionof internal rotation to undo the twist produced by it.
*External rotation:
The shouldersenter pelvis in opposite oblique diameter to that
previously passed by the head. When anterior shoulder meets
pelvic floor, it rotatesanteriorly 1/8 of a circle. This movement is
transmittedto the head, so it rotates 1/8 of a circle in the same direction of restitution.

26. The third Stage (Delivery of the placenta)
-The third stage is the deliveryof the placentawith its membranes.
-It is the shorteststage. The timeit takes to deliver the
placenta can range from 5to 30 minutes.
-It is composed of 3 phases: *Placental separation.
*Placental descent.
*Placental expulsion.
-The most reliable sign of Placental separation is the lengtheningof the umbilical cord
as the placenta separates and is pushed into the lower uterine segment by uterine activity.
-The uterustakes on a more globular shapeand becomes firmer.
-The uterus (fundal height)risesin the abdomen.
-A gushof bloodoccurs.

27. Management of the first stage of labor (in the hospital,
after admission)
*Monitoring of the fetal well-being (CTG, amnioscopy)
-Normalfetal heart rateranges from 110to 160per minute
*Uterine contractions(by handand/or by CTG)
as evaluation of the frequency, duration, and intensity
-Normal:5 or fewer contractions in 10 minutes, averaged over a 30-minute window.

28. *Maternal vital signs (BP, Pulse, Temperature, Respiration)
*Subsequent vaginal examinations
*Oral intake butFoodshould be withheld
*Intravenous fluids (not necessary in all cases)
*Maternal positionduring labor
*Analgesia(intramuscular, TENSand/or epidural)
*Amniotomy
*Urinary bladder function

29. Management of the second stage of labor
*Spontaneous delivery
*Deliveryof the head
*Crowning
*Episiotomy: If it is needed.
*Ritgen maneuver
*Controlleddelivery of the head

30. *Deliveryof the shoulders
*Gentle downwardtractionof the head
*The rest of the body almost always
followsthe shoulder
*Clearingthe nasopharynx
*Clampingand ligatureof the umbilical cord
-Delayin clampingfor 2–3 minutes or till
cessationof the cord pulsation facilitates
transfer of 80–100 mL blood from the
compressed placenta to the baby.

31. -Episiotomy,also known as
perineotomy.
*It is a surgical incisionof the
perineumand the posterior vaginal
wall duringchildbirthgenerally done
by a midwifeor obstetrician.
*Episiotomyis usually performed
during second stage of labor to
quickly enlarge the openingfor the
babyto pass through.
*Its types: midlineand mediolateral
approaches.

32. Management of the third stage of labor
*Spontaneous separation and descentof the placenta
*Gentle uterine massage during deliveryof the placenta
*Manual removal of the placenta
*Controlledcord traction
*Active management of the third stage
*Oxytocin

33. Physical
Therapy
Role
During
Childbirth

34. Relaxation techniques:
*Relaxation techniques may relieve tension
and relaxthe involved muscle. These
techniques may also help relieve anxiety.
During labor it allowsthe body to function with
minimum energy and increasesthe pain
threshold.
*Diversion drill technique is one of the
best techniques that the mother actually
educated it during antenatal care is used during
the first stage to avoid bearing down to
prevent mother’s exhaustion.

35. Positions for first stage
Upright positions
-Standing: Leaningonto a bench top, ballor similar surface,
or the back of a chair, or leaning on a husbandwith hands
around their neck or waist for contractions may be helpful.
-Sitting:usually with the legs wide apart, leaning forward
with elbows on thighs. Alternatively, straddling a chair,
resting forward on pillows on the backrest, may be helpful,
especially to relieve back pain. Rocking chairs, or swaying
with the bottom on a large ball, may provide comfort.

36. -Kneeling:possibly with a pillow between the bottom and the feet and
leaning forwards onto a bed(hospital beds may have the head raised to lean
against) or chair seat.
-Walking around:it is helpfulin-between uterine contractions although it
is importantthat the womanconserves her energy, so taking rests regularly
are encouraged and it is preventedif there is rupture of membranes.
Non-upright positions
-Four-point kneeling:in which the abdomenis hanging freely, and the
hips are over the shoulders. Weight may be taken alternately between the
hands and the forearms resting on a raised surface. This position has been
found to be appropriatefor most women with epidural anesthesia.
-Side-lying:it is advisedonce the rupture of membranes is started
especially in hypertensive women, pillows between the legs for comfort.

37. Positions for second stage
Upright positions
-Partial sitting / half-lying:Itis the most common position used during
childbirth; Trunk tilted backwardsapproximately thirty degrees to the vertical.
Pillows may be behind the knees, arms and back. During contractions, the
woman may brace by holding her knees and pulling up. The benefitof this
position is that the perineumcan be easily visualized.
-Sitting:such as on a birth stool, with the legs wide apart and leaning forwards
with the arms supported on the thighs.
-Kneeling:on the bedor floor, leaning against a large pile of pillows, or
supported by the husbandor catchingthe side rails of the hospital bed.

38. -Squatting:supportedby the husbandbehind or a chairagainst the wall. The
woman should stand to rest between contractions. This may not be appropriate
for women who have had epidurals. This position helpsthe babymove into an
optimal position as gravity encourages movement, butit requires a strongand
elasticpelvic floor to decreasestresson the perineumfrom this position.
-Supported kneeling: It will openthe pelviswider than sittingor lying down,
and it may be a good position also through the 3
rd
stageto deliver the placenta.
Non-upright positions
-Side lying: also known as the lateral, or ‘Sims’ position, with an attendant
supporting the top leg. This is a good position for precipitate labor, as it is
gravity-neutral.
-Lithotomy position: Easy to check fetal heart rateand it makes assisted
delivery using forceps or vacuum extractor easier.

39. Breathing exercises
Benefits of breathing exercises:
*The mother remains in a more relaxed state and will respond more
positivelyto the onset of pain.
*The steady rhythm of breathing is calmingduring labor.
*Provides a sense of well being and control.
*Increased oxygenprovides more strength and energyfor both the motherand baby.
*Brings purpose to each contraction, making contractions more productive.
*Breathing exercises should be deep diaphragmatic breathing during the first stage
(during Uterine contractions) as a key for relaxation, deep intercostal breathing in the
Propulsive Phase of the second stage (Assisted with bearing down) to assist in expulsion of
fetus, then shiftedto be shallow Painting sternal breathing at Crowningto prevent
bearing downto avoid perineal lacerations.

40. TENS
-When TENSis used for pain relief during labor, the electrodes are
applied to the lower backor to acupuncture points.
-It is an effective non-pharmacological, non-invasive adjuvant pain
relief modality for use in labor and delivery.
TENSapplication reducedthe duration of the first stage of labor and
the amount of analgesic drug administered. There were no adverse
effectson mothersor newborns (Kaplan et al., 1998).
Kaplan et al., 1998: Transcutaneous electrical nerve stimulation
(TENS) for adjuvant pain-relief during labor and delivery. International
Journal of Gynecology and Obstetrics. 60(3):251-5.

41. APPLICATION of TENS during labor:
*During the first stage→the electrodes are frequently positioned on
the lower back on both sides of the spine at vertebral positions T10-L1
and S2-S4, corresponding to nerve pathways through which painful
impulses from contracting uterus are believed to enter the spinal cord.
The TENS apparatus emits low voltage impulses, frequency and
intensity of which can be controlledby womanin labor.
*During the 2
nd
stage→the distal electrodes (S2-S4) will be
transferredto anterior aspect of lower abdomen in a V-shaped
placementto relieve supra pubic pain.
*Frequency:80-120HZ
*Pulse width: 150 microseconds.
*Mechanism:Gate control theory

42. -Results from 17 studies show that there was little
difference in pain ratings between TENS and
control groups, although women receiving TENS
to acupuncture points were lesslikely to report
severe pain. There was some evidence (Low to
Moderate) that women using TENS were less
likely to rate their pain as severe.
(Dowswell et al., 2009): Transcutaneous electrical
nerve stimulation (TENS) for pain management in
labor. Cochrane Database Syst Rev.
-TENSproduces a significant decrease in pain
during laborand postponestheneed for
pharmacological analgesiafor pain relief
(Santana et al., 2016).

43. Kinesio taping
-Kinesiotapingcombined with deep breathing exerciseis an effective
method in reducing labor pain and shortening the duration of the first
stageof labor(El-Refayeet al., 2016).
-Kinesio tape is a non‐pharmacological resource, significant
positive effects on pain sensation with no negative effects on perinatal
and neonatal variables would justify KT application during labor on
the vertebral regions corresponding to uterine dermatomes –from
T10 to L1 and from S2 to S4. Among the advantages of this technique
are its non‐invasiveness and its easy application; there is also no need
for constant monitoring, and it can be used concomitantly with other
alternative pain‐relief approaches (Miquelutti and Cecatti, 2017)

44. Heat and Cold therapy
-Intermittentlocalheat and cold therapy is a non-pharmacological,
safeand effectivemethod to relief labor pain, The pain was significantly
lowerin intervention group during the firstand second phases of labor. Durationof the first&
third phases of labor was shorter in the intervention (heat & cold) group (Ganji et al., 2017).
-During the first stage, participants of intervention group received warm water pack with a
temperature of 38-40°Cand covered with towel on their lowerabdomen, and low back for 30
min. throughout contractions. Afterward, they received icepackcovered with towel on the
same parts of the body for 10 m.Then, heat was used once more after 30 m, and this process
was repeated.
-During the second stage, these timeswere decreased to half, so warm water pack covered
with sterile towel was placed on patients’ perineum for 15 m.followed by icepackfor 5 m.

45. -Localized heat and cold therapy are non-pharmacological, non-invasive, satisfactory
for the primiparous females, and effectivemethods to control and relieve pain during
labor withoutadverse effectson maternal and fetal outcomes (Yazdkhasti et al., 2018).
-Acupuncturemay increase satisfaction with pain relief compared to
sham acupuncture (one trial, moderate-certainty evidence).
-It slightly reduced the use of pharmacological analgesia compared to
sham acupuncture (2 trials, 261 women, moderate-certainty evidence).
-Use of acupressurewas associated with a reductionin pain intensity
in laborwhen compared to a combined control (2 trials, 322 women,
moderate-certainty evidence).
Smith et al., 2020: Acupunctureor acupressurefor painmanagement
during labor. Cochrane Database of Systematic Reviews, Issue 2.
Acupuncture and Acupressure