Original Editor - Esraa Mohamed Abdullzaher
Definition of Labour
Labour is defined as the process by which the products of conception are expelled from the uterus after the 24th week of pregnancy.
Stages of Labour
There are three stages of Labour
The first stage of labour is from the commencement of regular uterine contractions effecting dilatation (opening) of the cervix, culminating when the cervix is fully dilated, allowing the passage of the fetus into the birth canal. It can be further subdivided into the latent phase (early labour), where contractions are short and irregular, and the active phase (established labour), where contractions become intense and regular . Contractions (tightening) and retraction (shortening) of myometrial muscle fibres increase in length, strength and frequency as labour progresses. The mucous plug (show) is expelled as the cervix opens and the membrane sac (amnion and chorion) often spontaneously ruptures, allowing amniotic fluid to drain. Various changes can be observed in women adapting to the intensity of contractions. Expenditure of energy increases the need for hydration and food, although as labour progresses appetite is often suppressed. Women may appear hot, flushed and agitated as intense contractions may cause pain, fear and distress. Endorphin release in response to pain provides an analgesic and euphoric bolster, which may cause some women to appear calm, quiet and withdrawn. Many women find relief through their own instinctive behaviour, such as mobility, change of position and posture , warm baths or compresses, massage, relaxation and distraction techniques. As the cervix nears full dilatation further changes can be observed in the woman as she enters the ‘transition’ into second stage. The intensity of contractions increases, exacerbating pain and stress, although the contractions may be less frequent. The woman is exhausted and often expresses defeat. She may appear agitated and overwhelmed by the effort of labour, or conversely calm and removed. Increased vocalisation, spontaneous shaking, rapid movement of the legs, nausea and vomiting may be seen, and she may express an urge to bear down or push.
The second stage of labour is the expulsive stage culminating in the birth. Commonly defined as commencing from full dilatation of the cervix which was thought to herald the urge to push, it has been suggested that second stage labour commences ‘when the presenting part has passed through the cervix and is below the ischial spines’. When the presenting part distends the genital tract and pelvic floor a surge of oxytocin is released, known as the fetal ejection or Ferguson reflex, whereby strong expulsive contractions facilitate the birth. Throughout the second stage women should be encouraged to instinctively bear down as the urge occurs with a contraction, adopting positions which increase the pelvic outlet . Prolonged breath holding and overzealous pushing should be avoided, as this interferes with placental perfusion and may compromise the fetus. The environment should feel safe and nonthreatening,with minimal intrusion from staff, and the midwife should be confident in her skill to support normal labour .
The third stage is defined as the period from the birth of the baby to complete expulsion of placenta and membranes, and control of haemorrhage from the placental site. It can be managed physiologically or actively with the use of drugs. The placenta and membranes are examined for completeness and occasionally part, or all, of the placenta and/or membranes may be retained, requiring anaesthetic and manual removal.
Relaxation techniques may relieve tension and relax the involved muscle. These techniques may also help relieve anxiety. During labour it allows the body to function with minimum energy and it is said that pain threshold is increased.
Mothers should do patterned breathing exercise cause it benefits in:
- Breathing becomes an automatic response to pain.
- The mother remains in a more relaxed state and will respond more positively to the onset of pain.
- The steady rhythm of breathing is calming during labor.
- Provides a sense of well being and control.Increased oxygen provides more strength and energy for both the mother and baby.
- Brings purpose to each contraction, making contractions more productive.
- Patterned breathing and relaxation can become techniques for dealing with life’s every day stressors.
How It can help in Labour:
Rhythmic breathing during labour will maximise the amount of oxygen available to you and your baby. Breathing techniques can also help you to handle contractions and be more satisfied with how you've coped with your labour. Using relaxation techniques, including breathing, has also been linked to a reduced risk of assisted birth. Exploring what happens when you lose control of your breathing can help you to understand why rhythmic breathing can help in labour. 
Physical like transcutaneous electrical nerve stimulation (TENS) and acupuncture can be used to reduce the pain.
TENS IN LABOUR:
TENS is one of the most common non-pharmacological medium available for relieving pain in various conditions like dysmenorrhea and back pain. It has been used in childbirth since 1970s. Although the precise mechanism whereby TENS relieves pain is unkown , there are number of theories that have been proposed:
- The "gate control theory" pf pain which suggests that pathway for painful stimuli is closed by the operation of gate in the spinal cord that controls transmissions to the brain.
- TENS is believed to complement the chemical process (release of endorphins due to painful stimuli) in the brain.
During labour the electrodes are frequently positioned on the lower back on both sides of the spine at vertebral positions T10 and S2, corrosponding to nerve pathways through which painful impulses from contracting uterus are believed to enter the spinal cord. The TENS appartus emits low voltage impulses, frequency and intensity of which can be controlled by woman in labour.
Other complimentary like aromatherapy, water immersion.Psychological like hypnosis. besides the many pharmacological analgesia too.
During labor and delivery, massage can dramatically relax a woman's muscles, ease her pain and improve her sense of overall well-being. The response to massage varies widely, however, from one individual to the next. The chief concern when providing massage is to carefully track and quickly respond to the new mother's feedback, both verbal and non-verbal. Just as massage can bring exceeding benefit, an improperly executed massage can create discomfort or even dangerous medical complications.
The best position for women to adopt during labour and birth varies depending on which stage of labour she is in.
Women instinctively use a variety of positions and movements to cope with the pain of the first stage of labour. These include walking, leaning forward, gentle lunging, four-point kneeling (kneeling on hands and feet), rocking and swaying. The act of changing positions may give women a sense of control by providing something active they can do to relieve the sense of feeling overwhelmed during labour.
Positions for first stage
Common options for positions to try during the first stage of labour include:
- Standing: Leaning onto a benchtop or similar surface, or the back of a chair, or leaning on a partner with hands around their neck or waist for contractions may be helpful. Some women find asymmetrical positions reduce discomfort, such as having one leg bent with the foot on a stool;
- 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. Again, asymmetrical positions may be helpful, with one leg up on the lounge and the other on the floor. Rocking chairs, or swaying with the bottom on a large ball, may provide comfort;
- 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), beanbag or chair seat;
- Walking around, although it is important that the woman conserves her energy, so taking rests regularly are encouraged.
- Four-point kneeling, in which the abdomen is 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 appropriate for most women with epidural anaesthesia;
- Side-lying for rest, with pillows between the legs for comfort; and
- Recumbent or semi-recumbent, though the impact on blood supply to the baby needs to be taken into account. Positions for second stage Examples of positions that may be assumed for second stage include: Upright positions
- Partial sitting / half-lying: Trunk tilted backwards approximately thirty decrees 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 partner may sit behind the woman to assist with pulling her knees up. The benefit of the semi-sitting position is that the perineum can be easily visualised and is accessible if necessary, though in one study this position was associated with an increased risk of perineal tears;
- Sitting, such as on a toilet or birth stool, with the legs wide apart and leaning forwards with the arms supported on the thighs, or by a partner;
- Kneeling, on the bed or floor, leaning against a large pile of pillows, or supported by a partner. Some women may feel more comfortable with one knee up; or
- Squatting, supported by partner behind, or holding onto a bar. The woman should stand to rest between contractions. This may not be appropriate for women who have had epidurals. Non-upright positions
- Lying on the side, also known as the lateral, or ‘Sims’ position, with an attendant supporting the top leg. This is a good position when delivery is rapid, as it is gravity-neutral;
- Four-point kneeling, which may reduce the effect of gravity on delivery as the head is crowning, reducing the risk of perineal tears, and be more comfortable for women who are experiencing significant back pain.
- Stuart Porter,Tidy's Physiotherapy.14th ed,1991.
- Pregnancy, Childbirth and the Newborn: The Complete Guide Simkin, Penny, P.T., et al, Ch. 7. Birthing from Within. England, Pam, CNM, MA, and Rob Horowitz, PhD, Ch. 38.
- Dowswell T, Bedwell C, Lavender T, Neilson JP. Transcutaneous Electrical Nerve Stimulation for pain mangement in labour (Cochrane Review). Cochrane Database Sys Rev 2015; (2) : CD007214