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📘 Chapter 7 – Labour (Williams Obstetrics)

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1. Definition of Labour

• Cervical effacement (thinning of cervix)
• Cervical dilation (opening of cervix)
• Or both

Note: Labour onset is sometimes hard to pinpoint — hospital admission may underestimate how long early labour has been going on.

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2. Stages of Labour

First Stage is Further Divided:

• Latent phase: Cervix dilates from 0 → 6 cm (slow)
• Active phase: Cervix dilates from 6 → 10 cm (faster, ≥1 cm/hr expected)

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3. True vs. False Labour

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4. Cardinal Movements of Labour (Mechanisms)

1. Engagement – Head enters the pelvic inlet (biparietal diameter at level of ischial spines)
2. Descent – Head moves downward through the pelvis
3. Flexion – Chin tucks to chest (presents smallest diameter)
4. Internal Rotation – Head rotates from transverse → anterior-posterior
5. Extension – Head extends as it passes under the pubic symphysis → delivery of head
6. External Rotation (Restitution) – Head rotates back to align with shoulders
7. Expulsion – Anterior then posterior shoulder delivered → rest of body follows

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5. Uterine Contractions

• Originate from pacemaker cells near the uterine cornua
• Spread downward (fundal dominance)
• Normal contractions: 3–5 per 10 minutes, lasting 45–60 seconds
• Pressure: 50–80 mmHg during contraction

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6. Cervical Changes

• Effacement: Cervix thins and shortens (0–100%)
• Dilation: Cervix opens (0–10 cm)
• In primigravida: effacement usually occurs before dilation
• In multigravida: effacement and dilation occur together

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7. Fetal Monitoring in Labour

• CTG (Cardiotocography) is used to monitor fetal heart rate
• Normal fetal heart rate: 110–160 bpm
• Key features: baseline rate, variability, accelerations, decelerations

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8. Management of Each Stage

First Stage:

• Monitor contractions and cervical dilation (partogram)
• Assess fetal well-being (CTG)
• IV access, analgesia if needed
• Encourage ambulation in latent phase

Second Stage:

• Push with contractions (active pushing)
• Support perineum
• Deliver head slowly to avoid tears
• Check for nuchal cord

Third Stage:

• Active management is preferred:
  • Give oxytocin 10 IU IM after delivery of baby
  • Controlled cord traction
  • Uterine massage

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9. Complications of Labour

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10. Key Terms to Remember

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These notes cover the core concepts of Chapter 7 — Labour from Williams Obstetrics. For exam preparation, focus especially on stages of labour, cardinal movements, and active management of 3rd stage.

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👶 Positions of the Baby in the Uterus

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Key Terms (Must Know First)

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1. Fetal LIE

MRI showing all four lies:

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2. Fetal PRESENTATION

A. Cephalic (Head-First) — Most Common ✅

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B. Breech (Bottom/Feet First) — ~3–4% of term pregnancies

Usually managed by caesarean section or External Cephalic Version (ECV) to turn baby head-down before labour.

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C. Transverse Lie / Shoulder Presentation

• Baby lies horizontally across the uterus
• Shoulder is the presenting part
• Cannot deliver vaginally — caesarean section required
• Associated with: prematurity, high parity, placenta previa, polyhydramnios
• Risk of cord prolapse if membranes rupture — obstetric emergency!

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3. Fetal POSITION

Common Positions in Vertex Presentation:

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4. Fetal ATTITUDE

• Good flexion (chin on chest): presents the smallest head diameter → easy delivery
• Deflexion (head extended): presents a larger diameter → difficult delivery

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5. Causes of Abnormal Fetal Position

• Placenta previa (blocks normal head engagement)
• Polyhydramnios (too much fluid → baby floats freely)
• Uterine abnormalities (fibroids, bicornuate uterus)
• Multiple pregnancy
• Grand multiparity (lax uterine muscles)
• Pelvic tumours
• Prematurity

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6. How Position is Assessed

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Quick Summary Table

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The ideal baby position for delivery is Left Occiput Anterior (LOA) with vertex presentation — head down, chin on chest, occiput pointing to the left-front of the mother's pelvis.

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🤲 Leopold's Maneuvers — Easy Notes

What Are They?

• What part of the baby is at the top (fundus)
• Where the baby's back is
• What part is presenting at the pelvis
• How far the baby has descended / degree of head flexion

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The Four Maneuvers

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🅐 1st Maneuver — Fundal Grip

"What is in the fundus (top of the uterus)?"

• Doctor faces the mother's head
• Both hands placed on top of the uterus (fundus)
• Feel what part is there

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🅑 2nd Maneuver — Lateral / Umbilical Grip

"Where is the baby's back?"

• Hands slide down the sides of the uterus
• One hand steadies, the other palpates each side

• Back on left side = Left position (LOA, LOT, LOP)
• Back on right side = Right position (ROA, ROT, ROP)

💡 Fetal heart tones are best heard through the back — this helps confirm position!

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🅒 3rd Maneuver — Pawlik's Grip (Lower Pole Grip)

"What is presenting at the pelvis?"

• Use one hand (thumb and fingers) just above the symphysis pubis
• Gently grip the presenting part

• If the part moves freely → not yet engaged
• If fixed/immovable → engaged in pelvis

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🅓 4th Maneuver — Pelvic / Pawlik's Second Grip

"How far is the head descended? Is it flexed or extended?"

• Doctor turns to face the mother's feet
• Both hands placed on lower sides of uterus, fingers pointing downward toward the pelvis
• Feel for the cephalic prominence (brow/forehead)

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Quick Summary Table

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Memory Trick 🧠

"Fundus → Flanks → Front-low → Flip & Feel"

1. Top 2. Sides 3. Lower front 4. Flip around & deep pelvic

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Clinical Importance

• Helps diagnose malpresentation (breech, transverse)
• Guides decision for normal delivery vs. caesarean section
• Helps locate best place to listen to fetal heart sounds
• Assesses engagement of the presenting part before labour