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 N ernando , Msss.Ms\o&G)
Or (Mrs) TR . . nd naeco\og1st,
Consultant obste tn c.1an a gy
1-1 m a's C.:1p1tal Hospital,
Thdl wothugoda.
 MBBS and beyond
Pregnancy and labour

By Dr (Mrs)TRN Fernando. MBBS, MS(O&G)

Senior Lecturer in obstetrics and gynaecology, Faculty of Medicine, Rajarata

University of Sri Lanka

MBBS and beyond, Pregnancy and labour by Dr(Mrs) TRN Fernando 1

 Table of contents

Chapter page

1. Normal pregnancy ...................... 6

2. Physiological changes in pregnancy ......... 10

3. Normal labour ...................... 30

4. Abnormal labour 42
·····················•·
s. Drugs used in labour ...................... 47

6. Induction of labour ....................... 60

7. Mai-position and ma I-presentation .......... 69

MBBS and beyond, Pregnancy and labour by Dr(Mrs) TRN Fernando 5

 Chapter 1: ~ • Evidence e
ethnicity. A
. mal pregnancy? . . with single
what 1s nor f m conception to giving birth to a •
. I process ro
It is a physiolog1ca
1 i~, concludes t
weeks in BI
~~ ?
. fa normal pregnancy. • This research
What is the duration o Black and As
days (40 weeks) after the onset of th
. . lculate d as 28 0 e1 and that feta
• This 1s ea . d (approximately about 266 days fro
last menstrual perio ~
(n=16 000
conception).
30
•• lation (Nagele's rule) of expected date 0
Trad1t1ona 1 ea 1CU . 25
• . . b dding g months and 7 days to the first day of th
delivery 1s Y a ~ 20
last regular menstruation.
f 15

• Nagele's rule is based on a 28-day me_nstrual cycle wit\ i

>A.. 10

ovulation occurring on the 14th day. An adjustment should bi 5

made if the patient's cycle is shorter or longer than 28 days. 0 L-----,-

30

• The discrepancies caused by 31-day months and the 29-da

1.1: Length of human
variation in February of leap year are not correctable bi
Nagele's rule. 100

• Almost all pregnancies occur when intercourse occurs durin! 80

the 2 days preceding or on the day of ovulation . Thus the post

ovulatory and post-fertilization developmental ages are similar
Yet only 5% of women deliver at 280 days and only 85 % delive
within 10 days of their estimated due date even when the dat 1

is calculated with the help of ultrasound. ,

20

• A re~ent st udy found that the length of human gestation varie

~onsiderably among healthy pregnancies even when ovulatio
1s accurately measured1. '
Figure 1.2:

MBBS and beyond p

' regnancy and labour by Dr(Mrs) TRN Fernando t1
 • Evidence exists that normal gestational length varies with
ethnicity. A study comprised with 122,415 nulliparous women
with singleton live fetuses at the time of spontaneous labour,
concludes that the median gestational age at delivery was 39
weeks In Blacks and Asians and 40 weeks in white Europeans 2 •

• This research suggests that normal gestational length is shorter in

and Asian women compared with white European women
nd that fetal maturation may occur earlier.

e OI Spontanaoua
fth, lnd.-d

WiU
aid b1
s.
•o L-...---~-0...-.-~--,---......---,-----===;:t:,,,o.....,._
• n M • • ~ a ~ ~
w..ara Gf gaatatlon R1ure
!9-da\
1. ofhuman gestation (16000 pre1nancles).
le b\

fjuring
100

1==E__,,
---· Aalan
~ post·
imilar.
tleliver
e date

varies
U 25 28 27 28 28 30 31 32 33 34 315 38 37 38 - ,o ,1 ,2 '8
ulatior o-tatlonal age at delivery (w-lca)

R,ure 1.2: Gestational age at delivery by ethnicity.

ond, Pre111ancy and labour by Dr(Mrs) TRN Fernando 7

 f pregnancy?
·mesters o
What are tn . to three trimesters, each tri
. divided in l'l"leste
• Pregnancy is ·t·c fetal developments . r
k d by speCI I
mar e . to l2 weeks of period of arne
. ester 1s up d norr
The first tnm esponds to the eveloprnent
• . time corr of
(POA). This . ) and initiation of maternal physiol .
organogenes1s og1
embryo (
changes.
. traditionally from 12 weeks+ 1 day up t
nd trimester 1s d o
• The 2 ond trimester correspon s to the f
k Of POA. 5ec . . et
wee s t maternal phys1olog1cal changes acceler t
growth and _mos a1
during this trimester.

. · from 28 weeks + lday up to delivery of tl

• Third trimester is . . .
~~m 40 ~
eks . For further reading see phys1olog1cal chang,
in pregnancy (see page 4).

What is term?
A woman
From 37 weeks to 42 weeks (for Asian ethnicity this may be 01
trimester
week less).

What is gravidity (G) and parity (P)?

• The terms gravidity and parity are often applied to women

A mothe
pregnancy. Gravidity refers to a pregnancy of any gestatioi
ectopic
including miscarriages, ectopics, H'moles and twin pregna ncie!

• A woman who is pregnant for the first time is a primigravida.

Figure 1:3. lllust

• Parity refers to having given birth to a viable (>24 weeks) live

born or a stillborn child.

MBBS and beyond Pre

' gnancy and labour by Dr(Mrs) TRN Fernando 8 MBBS and beyond
 h tr;flle
Stet I

afllenortti
rrtent of
@ EJ
Physio1 t
Ogj

day up to
to the f
Q- ~
s e
accelerate

elivery of th
gical chang,
Q• +
----+ I G2P1C1 I

A woman Is 14 weeks pregnant. She had previous first

may be on
trfmester miscarriage and Is having a child 3 years old.

to women i A mother with 2 children (twins) with a previous

ny gestatior ectopic pregnancy, now she is 9 weeks pregnant.
pregnancies

igravida.
fllure 1:3. Illustrations of gravidity and parity

MBBS IDd beyond, Pregnancy and labour by Dr(Mrs) TRN Fernando 9

 Chapter 2:

Intended learning outcomes:

Understan
•
Understand the physiological changes in pregnancy,
The main cha
• • proactive. :ha
Describe the hormonal changes in pregnancy .
physiology ,s t
• delivery.
Understand how the above changes affect the uterine rnuSd,
and cervix during pregnancy.
• At the ti
• proactive_
Describe the cardiovascu lar changes during pregnancy, labour implantat,
and peuparium.
taking plac
• proactive
Describe the Respiratory tract changes during pregnancy . and peupa
•
Describe haematological and coagulation changes in pregnancy
and peuparium. • Endometri
Decidualiz
• Describe the renal system changes in pregnancy .
endometri
estrogen
implantin

• Progester
pregnanc
initially a
leuteal ph

• CL is mai
chorionic
syncytiot

• CL is m~
progeste

• The aver
ng/ml I fo
300 n g/
of cycle of an ovum.
Figure 2.1: d1acram
· matlc represent.atlon a.nes
..a an d b eyon d • P
MBBS and beyond. Pregnancy and labour by Dr(Mrs) TRN Fernando
 Undentand the physlologlcal changes In pregnancy

• The main characteristic of physiological changes in pregnancy is

,woactlve. That is the every change during pregnancy in maternal
physiology Is to adapt to nourish the growing fetus and prepare for
delivery.

.the time of ovulation the endometrlum has undergone

pt'Oflf.'tlve changes in its secretary phase in preparation for
ncy, labour J~lantation of the blastocyst. Therefore the changes start
takfn1 place at the leuteal phase of the menstrual cycle and the
proodlt,e changes continue throughout the pregnancy, labour
ancy, and peuparium.

n Pregnancy Endometrlum is called the decidua at the time of implantation.

- - ~~1clduallzation Is the transformation of secretory
endometrium to decidua, is dependent on the action of
estro1en and progesterone and factors secreted by the
lanttng blastocyst during trophoblast Invasion.

rone is the main hormone which maintains the

presnancy. Progesterone is produced by corpus luteum {CL)
lally and then by the placenta. CL is formed during the
phase of the menstrual cyde fol ing ovulation.

reaaamv,,by human
by the

is maintained by hCG until placenta starts producing

progesterone around 10-12 weeks of POA.

-[J
e average levels during the first trimester are 9 ng/ml to 47
.,,./ml, for the second trimester 17 ng/ml -146 ng/ml and 49 to
300 ng/ml for the third trimester.

10 t.,ond. Prepancy and labour by Dr(Mrs) TRN Fernando 11

 ted tissue, whi ch is the only tissu
. n,ultinuc Iea 'd ) e that
hoblast ,s a . ithelium (dee, ua and irnp1
Syncytiotrop h uterine ep ant t~I OeCI"dual Structur
trate t e '"
able to pene (Figure 2.2) .
developing embryo Embryo b l ast

0. •...............,..------~"-"--:J...~
,ff") • •
\(_/
t\:))
'· .~~
r,
/ Endometr1a1 gland
Uterine c:Jecldual 5 iroma and caplllarles

Figure 2.2: The process of .imp 1an tation of the

. b/astocyst where cytotrophob/asts syncytia/ly
fuse with maternal cells giving rise to syncyt1otrophoblast.

• At day 7-8 post-conception, the blastocyst has complete!)

crossed the decidua and is embedded within the endometriurn.
At day 12 post-conception, the process of implantation ii
complete. Figure 2.3: Thre

• The developing embryo is totally embedded in the decidua and

the syncytio-trophoblast surrounds the whole surface of the
Endometrium du
conceptus.
portions:

• The syncytio-trophoblast is a multinucleated layer wit hout cell 1. Decidua

membranes, hence there is a single syncytio-trophoblast
covering all villi of a placenta. The absence of cell borders 2. Decidua
facilitates transport across the syncytio-tropho blast. implante

3. Decidua

Fusion of the d
the uterine cavit
MBBS and beyond Pre
' gnancy and labour by Dr(Mrs) TRN Fernando MBBS and beyond, p
12
 oecidual Structural changes in early pregnancy

Figure 2.3: Three portions of the decidua shown in a diagram.

a and
,f the Endometrium during pregnancy is called the decidua which has three
portions:

t cell 1. Decidua basalis is the site of placental development.

blast
2. Decidua capsularis is the part of the decidua covering the
ders
implanted ovum.

3. Decidua parietalis (Vera) lines the rest of the uterine cavity.

Fusion of the decidua capsularis and parietalis, functionally obliterate

the uterine cavity by 14 weeks of gestation (figure 2.38).

MBBS and beyond, Pregnancy and labour by Dr(Mrs) TRN Fernando 13

 Formation of the Placenta
. dependent on the pla centa for PUI
• The fetus 1s . . rnona
and renal functions .during t he intrauterine ry, hePat
lish these functions placenta has a un· Period
accom P . ique ·l
·ation with the maternal circul ation . anato .
~00 ~
syncyti
• Human placenta is a "haemo-chorial " typ e. Feta ! nd
a mater~.
bloods are not mixed in this hemo-chorial t yp e of Placent
a.
• In the human placenta, maternal and feta! t issu es are
in such a way that there are three-dimensional .11 0 arrang~ Villous-syncyti
5
fetal tissues that float in a lake of maternal blo~~ ~ trees ,
The maternal-feta! barrier composed of villou s t (figure 2.4
direct contact with maternal blood . rophoblasts ,

• Human placenta also has an endocrine functi on .

Penetrat
spir

Umlicalmd

Decidual Spir
Basal
plate •

Artery • Failu re
Vein Endometnurn' cond iti
decidua restrict,

Figure 2.4·. maternal and fetal tl

ssue arrangement of haemo-chorial placenta. • Extra-vi
matern
endoth

MBBS and beyond, pregnancy

and labour by D 14 MBBS and beyond,
. r(Mrs) TRN Fernando
 Diffe~ntiation of Trophoblast cells

syncytiotrophoblast Cyto-trophoblasts

angec Villous trophoblast

Villous-syncytiotrophoblast
rees c
e 2-4
asts 1r Extra villous trophoblasts

Penetrates the lumen of the spiral arteries and transform maternal

spiral arteries in to large non-resistant capacitance vessels

Decidual Spiral Artery Invasion

• During human placental development is the extensive

modification of the maternal vasculature by trophoblast cells.

• Failure of the above modification gives rise to pathological

conditions like pre- eclampsia and intrauterine growth
restriction.

• Extra-villous trophoblast which enters the lumen of the

maternal spiral arteries, proceeds to destroy the vascular
endothelium and invade and modify the vascular media, where

~
MBBS and beyond, Pregnancy and labour by Dr(Mrs) TRN Fernando 15
 . places the smooth muscle and
. atena 1 re Conn
fibrino1d rn ett1v
. f th is layer. i • severa l features
tissue 0
narrow-lumen, muscular spiral art survival of th
nging t he enes · environment.
• Thus cha . ta nce utero-p lacenta I vessels. Thes in~
d low-res1s . e cha
dilate ,
12 weeks of gestation are described . ng~
initiated before 1n ty,.
stages: Umbilical Cord and Relate
. f · al arteries of th e decidua {<12 weeks)
1. Invasion o sp1r Embryological ori
•
. f rther in to the intra-myometrial parts of th . allantois and yolk
2. Invasion u e sp1r1
arteries (12-16 weeks) • The cord at t erm
umbilical vein us
• In the first trimester, growth of t he placenta is more rapid tha leaving only the
that of the fetus, but by approxim ate ly 17 weeks, placental an, diameter than th
fetal weights are approximately equal. At term, the placent; t o fetus, while
weight may be roughly one sixth t hat of feta I weight. pla centa .

Immunological Considerations of the Fet al- Maternal Interface • The umbilical co

which protects t
• The ability of mother and fetu s to coexist as two distinc cord is 0 .8 to 2.0
30 t o 100 cm .
immunological systems results from endocrine, paracrine, a111
abnormally sho
immunological modification of fet a I and maternal tissues in i
manner not seen elsewhere. • Within the fetus
fissure of the liv
• The lack of transplantation immunity manifest in the uterusf hepatic portal v
unique compared with that of othe r tissues. Th erefore, th1 bran ch (ductus
acceptance and the survival of the co nceptus in the materna ven a cava, whic
uterus must be attributed to an im munological peculiarity o
the trophoblasts, not the decidua .
• The two umbilic
pa ss on either
completing the
• The trophoblasts are the only cells of the conceptus in dired
contact with maternal tissues or blood and th ese tissues art • The blood flow
genetically identical with feta I tissues.
' at 20 weeks an

• After delivery
close up, and d
MBBS and beyond, Pregnan 16 MBBS and beyond, Pregna
cy and labour by Dr(Mrs) TRN Fernando
 • Several features of trophoblast cells are likely contribute to the
survival of these ce lls in an immunologically hostile
environment.

umbilical Cord and Related Structures

• Embryological ori gin of the umbilical cord is from the remna nts of the
allantois and yolk sac w hich inhabits the connecting stalk.

• The cord at term normally has two arteries and one vein . The right
umbilical vein usually disappears early during fetal development,
ore rapid thar leaving only the original left vein. The two arteries are smaller in
s, placental a diameter than the vein . Vein carries oxygenated blood from placenta
nc
, the placent to fetus, while arteries carry de-oxygenated blood from fetus to
. h
! lg t.
a
placenta .

I Interface • The umbilical cord contains Wharton 's jelly, a gelatinous substance
which protects the blood vessels inside. Diameter of the umbilical
as two distino cord is 0.8 to 2.0 cm, with an average length of 55 cm and a range of
paracrine, anc 30 to 100 cm. Generally, cord length <30 cm is considered
1nal tissues in,
abnormally short.

• Within the fetus, the umbilical vein continues towards the transverse
fissure of the liver, where it splits into two. One branch joins with the
in the uterus i! hepatic portal vein which carries blood into the liver. The second
Therefore, thf branch (ductus venosus) bypasses the liver and flows into the inferior
n the materna vena cava, which carries blood towards the heart.
ii peculiarity of
• The two umbilical arteries branch from the internal iliac arteries, and
pass on either side of the urinary bladder into the umbilical cord,
completing the circuit back to the placenta.
:eptus in direct
ese tissues arE • The blood flow through the umbilical cord is approximately 35ml/min
at 20 weeks and 240ml/min at 40 weeks of gestation .

• After delivery of the neonate, umbilical vein and ductus venosus

close up, and degenerate into fibrous remnants known as the round

l6 MBBS and beyond, Pregnancy and labour by Dr(Mrs) TRN Fernando 17

 oncentration normall
hCG C ·
ancv during the 1 trim
preg n

Rate of production (mg/24 hours)

·,ons of hCG are:
Fune t
Non pregnant pregnant
Maintain corpus lute
1.
0.1 - 0.6 15 - 20
z. Stimulate secretion o
0.02 - 0.1 so - 150

0.1 40 250 - 600

o.05-0.1 0.25 - 0.6

Aldesterone
0.05 - 0.5 1 - 12
oeoxycorticosterone

10 -30 10 - 20
cortisol

'd h rmone production during non-pregnant and pregnant state.

Table 2.1: Sterot 0

Pla cental Hormones o / , 2 3 •

Month• afl•r beglnnln

Human placenta produces steroid an~ protein hormones greater· FertlllzaUon

amount and diversity than that of any single human end0 crine orgar Figure 2.5: placental hormones leve

Human Chorlonlc Gonadotropin (hCG)

The so-called pregnancy hormone is a glycoprotein with bioloi, Estrogen and progesteron
activity very similar to luteinizing hormone (LH), both of which act
the plasma membrane LH-hCG receptor. Their actions balance eac
body.
hCG is produced almost exclusively in the pla centa but also
synthesized in fetal kidney, and a number of feta I tissues may proi1
the P-subunit. The a-subunit is common to: hCG, LH, FSH and TSH.

MBBS and beyo nd•Pregnancy and labour by Dr(Mrs) TRN Fernando 18 ¼BBS and beyond, Pregnancy an
 osurn
. res Pec
g into Wh th,.e1
at a r i
re I\ hCG concentration normally doubles within 48hrs in a hea lt hy
st
pregnancy during the 1 trimester (figure 2.4).

Functions of hCG are:

1. Maintain corpus luteum of pregnancy

2. Stimulate secretion of testosterone in XY embryos

Human Dlacental lactoRen (hPll

0 I 1 2 3 4 5 II 7 8 9
Month• after beginning of laat rn•n•tru•I period
t
\
10

Fertlllzation Delivery
1ormones greater ·
n endocrine orgar Figure 2.s: placental hormones levels in plasma during pregnancy .

)tein with biolog, Estrogen and progesterone are endogenous steroid hormones.
Joth of which act . .
Their actions balance each hormone's physiological functions in the
body.

tace nta but also

tissu es may proo.
I
FS H and TSH.

18 MBBS and beyond, Pregnancy and labour by Dr(Mrs) TRN Fernando 19

 Estrogens
corpus luteum of pregnancy and Place • Regulates maternal
• secreted by l'lta
that glucose will al
• de· stimulate growth of rny 0 ..... mother is malnouris
. ns me 1u ,
10 ",etn
• Funct . ases the sensitivity of oxytocin a1 s
les mere · rec
muse '. during the pre-labour period. eptor • Reduces maternal
myometrrum increase maternal b
mammary glands for lactation (t
• Also prepare d prolactin). ogether • Increased lipolysis
progesterone an acids become avail
also stimulate the hepatic synthesis of Pr . that relatively mor
• Estrogens . C oteins ketones formed fr
bone marrow synthesis of WB . ,,
and be used by the

Progesterone hPL also promotes

•
• Secreted by corpus luteum of pregnancy and placenta. hPL can be det
•
pregnancy, and it'
• Progesterone i~ the key hormone for the rnaternal chang~
placenta . hPL rea
adaptation during pregnancy.
pregnancy.
• Progesterone causes relaxation of smooth rnuscles this atti
many systems during pregnancy.

• Also has a Na retention property. P1

• It also inhibits the uterine contractility and relaxes smo

muscles.

Human placental lactogen (hPL)

• hPL is a polypeptide hormone with homology to prolactin1

growth hormone (GH). This hormone has lactogenic
growth-promoting properties.

• hPL Is present only during pregnancy, with ma ternal ser

levels rising in relation to the growth of the fetu s and placent
Figure 2.6: schematic represen

~M:B~~~-~--------l!l!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!~!!!!!!'!~ZO
nd MBBS and beyond, Pregnancy
BS a beyond , Pregnancy and labour by Dr(Mrs) TRN Fernando
 • Regulates maternal glucose, protein and fat metabolism, so
that glucose will always be available to the fetus even if the
mother is malnourished .

• Reduces maternal insulin sensitivity at cellular level and

increase maternal blood glucose levels.

on (togeth • Increased lipolysis with the release of free fatty acids. Free fatty
er ~
acids become available for the maternal organism as fuel, so
that relatively more glucose can be utilized by the fetus. Also,
is of Prate· ketones formed from free fatty acids can cross the placenta
lrts, c
and be used by the fetus.

• hPL also promotes mammary gland growth.

lacenta. • hPL can be detected in the serum at the 6th week of

pregnancy, and it's levels continue to rise with growth of the
ternaf changes placenta. hPL reaches the peak at around the 23rd week of
pregnancy.

scles this afff

..
--.- , ._
llmrllllblood PI-* F9111blood Fetal adrenal cortex

Cholllllrol- -Cholllllrol- ~Challllnl- I---. Chollltlrol

relaxes smoc
l
to prolactin a
Pn,jjillaCIIII P,ogwlliCIIII

DHEA

l
DHEA- Dlhydroepl1ndr01terone
(DHEA)
I
lactogenic a Eltroge,I Ellrogen

Fetoplacental unit

Figure 2.6: schematic representation of steroid hormone synthesis in pregnancy.

MBBS and beyond, Pregnancy and Jabour by Dr(Mrs) TRN Fernando 21

 the abo ve hormonal chan
derstand hoW . during pregnanc'l
Un and cervix
oath museIe ..
sm lays 2 f un damental qualities :
• Uterus disp
• The cervix, on
Receive and nu rture th e pregnancy.
1. f upper vaginal
the nurtured etus. the other ute
2. Give birth to and the intern
• Uterus has 2 structures : • There is also
1. Uterine Corpus considerably I
the Cervix corn
2. Uterine Cervix
• covering the
Uterine smooth muscle: el astic fibers a
form ed of hyd
Bundles of smoo th muscle united by con nectivehtissue in Wh·ten ke ep the calla
elastic fibers. During pregnancy smoot muscles oftL
are many
of the uterus undergoes mar e
k dh rt phy .
ype ro 1
1e1
•
fibrils in t o ri
The uterine musculature during pregnancy is arranged in three st~ 'tensile stren

l. An outer hood like layer which arches over the fundui •

extends into the various ligaments.

2. A middle layer composed of a dense network of inteni • During pregna u

does not expa
muscle fibers between which extend the blood vessels.
becomes very ,
3. An internal layer consisting of sph incter-like fibers arou~ seal off the re
orifices of the fallopian tubes ·and th e internal os of the ceri,

The main portion of the uterine wall is fo rmed by the middlei)escrib_e th e ca, iov<
d
Each smooth muscle cell in this layer has a double curve, so t~~>euparium
interlacing of any two gives approximately the form of a figure OfNhy ea rd io-vascular (
As a result of this arrangement, when the ce ils contract afterdel,ro aid optimal growth
they constrict the penetrating blood vessels an d thus act as liga"nother from the risks,
MBBSandbeyond, Pregnancy and labour by Dr(Mrs) TRN Fernand o
1) "188S and beyond, Pregnan
s:
• The ce rvi x, only about 4cm long, projects about 2 cm into the
upper vaginal cavity. It is densely fib rous and more rigid than
the other uterine tissue. During pregnancy the cervix is rigid
and the internal os is tight ly closed.

• There is also some smooth muscle ti ssue, but t he quantity is

considerably less than in the rest of the uterus (- 10% muscle in
the Cervix compared to uterus).

• Covering the mucous membrane is a thick layer of collagen and

elastic fibers arranged in helical structures. Ground substance
formed of hydrophobic dermatan sulphate acts like a gum t o
keep the collagen fibers glued together.
ve tissue in wh· h
IC th,
oth muscles of th ' • Ground substance act like a glue binding individual collagen
e bo
fibrils in to rigid bundles . This binding gives the tissue its
'tensile strength' during pregnancy.
ranged in t hree strat,
• Increased vascularity, hypertrophy and hyperplasia of the
over th e fundus a cervical glands during pregnancy soften its consistency.

• During pregnancy the cervix is the only part of the uterus that
netwo rk of interlac1 does not expand; the mucus inside the endo-cervical canal
blood vessels. becomes very thick at this time and acts as a plug that helps to
seal off the rest of the uterus from infection.
- like fibers around t
rn a l os of the cervix
. Describe the cardiovascular changes during pregnancy, labour and
b y the middle 1a~ peuparium
bl e curve, so that t
rm of a figure eight Why cardio-vascular (CV) changes during pregnancy?

·ont ract after delive· To aid optimal growth and development of the fetus and to protect the
hu s act as ligaturei mother from the risks, such as primary post partum haemorrhage .

22 MBBS and beyond, Pregnancy and labour by Dr(Mrs) TRN Fernando 23

Jndo
 . normal pregnan cy?
CV changes in
what are th e o o what are the
resistance by 30%-70% of its P
·c vascu Iar . . rec 0
Fall in system1 f gestation. This is due to extravillous t nt·~
1. b 8 weeks o ) roph 1,
value Y . rterioles (page 8 . or
invasion of sp1ra 1a Uterine cont
2.
until mid- pregnancy, gradually returning back into the
2. Arterial BP fa:lslate in the 2"d trimester. to
pregnancy feve s 3. The sympath
te (HR) is minimal - 10 - 20 bpm rise . and blood pr
3. Change in heart ra
. . cardiac out put (CO) by 50% to a peak betwee What are the
4. The increase tn n 2~
weeks. 1. Following de
systemic circ
In late pregnancy when lying in the supine position, pressure of
5
· 'd terus on inferior vena cava (IVC) reduces venous return 1 In the third s
gravr u . f 25% 300/ . k o 2.
heart, amounting to a reduction o o- /o I~ stro e volume (SV)i due to the r
CO. These in turn will reduce placental perfusion and increased risl
fetal hypoxia. 3. Cardiac bloo
by a rapid d
What are the normal CVS findings in pregnancy?
4. SV, HR and
1. Loud first heart sound.
5. Rapid IV vol
2. Exaggerated splitting ofthe second heart sound. revert quite
following 6
3. A physiological third heart sound at the apex.

4. A systolic ejection murmur at the left sternal edge .

Those women
5. ECG - Small Q-waves and T-wave inversion in the right precor( risk, of pulmon
leads. immediate pas
6· Atrial and ventricular ectopics are both commo n.
7
· Che5t X-rays should never be withheld if clinical ly indicatea
pregnancy.

IIBBS IJld bey MBBS and beyond,

ond, Prtgnanc.y and I b 24
a our by Dr(Mrs) TRN Fernando
 of its p What are the CVS Changes during labour?
reco
:ravillou ncep
s troph 1ii st
1. Labour increases CO by 15% in the 1 stage and by 50% in the 2 nd stage .
Obi
2. Uterine contractions lead to auto transfusion of 300ml - 500 ml of blood
returning back into the circulation .
to Pr
3. The sympathetic response to pain and anxiety further elevate heart rate
se. and blood pressure .

What are the CVS changes following delivery?

1. Following delivery of the placenta, the return of uterine blood into the
systemic circulation results in a further increase in cardiac output.
n, pressure of ~
enous return to ~ 2. In the third stage up to a 1L of blood may be returned to the circulation
ke ~olume (SV) a· due to the relief of IVC obstruction and contraction of the uterus.
nd increased risl
3. Cardiac blood volume rise, cardiac output increases by 60-80%, followed
by a rapid decline to pre-labour values within about 1 hour of delivery.

4. SV, HR and CO remains high for 24 hours post delivery.

s. Rapid IV volume shifts in the first 2 weeks postpartum. All the changes
revert quite rapidly during the first week and more slowly over the
following 6 weeks .

Those women with cardiovascular compromise are therefore most at

he right precord risk, of pulmonary oedema, during the second stage of labour and the
immediate post-delivery period.

ically indicated

MBBS and beyond, Pregnancy and labour by Dr(Mrs) TRN Fernando 25

 1

2.

3
e ra~e of i crease 1s
heart rate and stro e olu e.
Figure 2.6:cha;~
compared to H
~arty pregnancy.
re -

- 1400 s.
120 BP

" ~
1 100 l
6.

~ TPVR $. 7. µreg~
~ "'O
I
re5:::i
I
m I .JI 800 e eT·
0 20 38

Figure 2.7: change in total penp

. heral vascular resistance (TPVR) during pregnancy.

Figure 2.8: changes in cardiac output in pregnancy.

Mees and beyond, Pregnancy and labour by Dr(Mrs) TRN Fernando

 Describe the Respiratory tract changes during pregnancy

1. Tidal volume rises by -30% in early pregnancy to 40-50% above non-

pregnant values by term. The rise in tidal volume is largely driven by
progesterone, which appears to decrease the threshold and increase
the sensitivity of the medulla oblongata to carbon dioxide .

2. A fall in expiratory reserve and residual volume.

3. Respiratory rate does not change .

. ase is more in sv 4. Neither FEV1 nor peak expiratory flow rate are affected by pregnancy,
even in women with asthma .

5. The Pc 02 is lowest in early gestation Carbon dioxide production rises

sharply during the third trimester, as fetal metabolism increases.

6. There is an increase of -16% in oxygen consumption by term, due to

increasing maternal and fetal demands.

7. Pregnancy places greater demands on the cardiovascular than the

respiratory system. This is shown in the response to moderate
exercise .

......... ,ory
aapaclty
2500

J!
Rwla.idual
fl••ldual wolurna
Wlluffle SOO
1000 I _ _ _...__ _ __.__ _ _ _ _.L-_.
f f Elevation of dlopf\r09"' f
Nonp,e9nant Grawido ot Term

Figure 2.9: respiratory changes during pregnancy.

MBBS and beyond, Pregnancy and labour by Dr(Mrs) TRN Fernando 27

do
 ulation chan
coagulation chan
Qfillpariu,m
1. Several of
ical changes in pregnancy end of the
Haemato Iog
doubles
. reases by 20-30% during pregnancy, With ,
d cell mass inc . .
1. The re b and size. It is more in women with m, 2. Anti-throm
. both cell num er .h .
in . d ubstantially more wit iron supplemenia
pregnancies, an s
3. The ESR ris
(- 2g%compared with 17%).
other phys
. entration falls 1 the• absorption of iron from the
2 serum iron cone •
4. Protein C,
· rises
. d ·
an iron- b'
i nd'
i ng capacity rises in a normal pregnancy i
in pregnan
increased synthesis of transferrin. fall during
3. Plasma folate concentration halves by term, because of greatern· An estima
5.
clearance but red cell folate concentrations fall less. during pla
4. Even a relatively mild maternal anaemia is associated decreased ~· 6. Plasma fib
weight. but return
placenta.
5. The plasma volume increases more than the red cell mass, wi
leads to physiological haemo-dilution during pregnancy. 1' 7. Pregnancy
haematocrit, the haemoglobin concentration and the red cell c0u prevent p
falls. The fall in packed cell volume from -36% in early pregnancy· labour.
-32% in the third trimester.
Renal chan es in re

6. Neutrophil numbers rise with oestrogen concentrations and pea.I

33 Renal changes In
- weeks. St abilize after that until labour and the early puerpentf Increased renal siz
when they rise sharply.
Dilatation of pe
7 (more marked on
· Platelet count a d I d in f11C GFR increases by -
pregna t n P atelet volume are largely unchange
n Women, al th ough their survival is reduced.
Renal bicarbonat
progesterone
center
Altered osmo regu

Ol\d, Prun•• __ MBB anti hevond P

--~-, •nd labo11r .._
"'7 Dr(Mn) TRN Pemando
 coagulation changes in pregnancy

1. Several of the potent pro-coagulatory factors start rising from the

end of the first trimester: Factors VII, VIII, X and plasma fibrinogen
doubles
cy, With rr
With ll1Ult1 2. Anti-thrombin Ill, an inhibitor of coagulation falls.
plementat10,
3. The ESR rises early in pregnancy due to the increase in fibrinogen and
other physiological changes.
from the g
regnancy a 4. Protein C, which inactivates Factors V and VIII, is probably unchanged
in pregnancy, but concentrations of Protein S, one of its co-factors,
fall during the first two trimesters.
f greater rer.
5. An estimated 5-10% of the total circulating fibrinogen is consumed
during placental separation in the third stage of labour.
ecreased bir?
6. Plasma fibrinolytic activity is decreased during pregnancy and labour,
but returns to non-pregnant values within an hour of delivery of the
placenta.

7. Pregnancy is a hyper coagulable state; this is a proactive change to

prevent primary post-partum haemorrhage in the third stage of
labour.

Renal changes In pregnancy

Renal chan1es In pre1nancy Cllnlcal relevance

Increased renal size Post partum decrease in size is normal.
Dilatation of pelvi-calysis and ureters Not obstructive uropathy.
(more marked on right) UTI is more virulent.
anged in GFR increases by -s0% BU & serum creatinine decrease
Increase clearance of glucose, prot,ens.

Renal bicarbonate threshold decrease. HCO ) decreued by SmE/L

progesterone stimulates respiratory pC0 2 decreased by 10mm Hg
tenter
Altered osmo , . .ulltlon Serum osmolallty decreases by 10
mmoVL and Na bv -s mE/L

29
Chapter 3: Normal labour What is labour?

Intended learning outcomes : It is the process of chil

placenta . It is divided in
• Describe the onset of labour and triggers of onset of noni
total time between con
labour • is confirmed only retros

• Understand the physiology of pre-labour and labour Definition of onset of

demonstrable effacem
• Define the stages of labour
What are the signs of on
• Understand the stages of labour
"show" (per-vagi
• Describe the benefits of the partogram and its use in labour
• Spontaneous rup
• Outline the management of labour
Painful uterine c

What is false labour?

21!0
0.llve,y - - -
A pregnant woman
effacement or dilata~
positional change and
for a few minutes.

Understand the h sia

Cervical effacement i
depends on the softe
PGE2 is the importa
changes at term .

MBBs and b ~~~:::::::~~~--------!!!'!~e"'

eyond, Pre
gnancy and labour by D
r(Mrs) TRN Fernando 3o
MBBS a11d beyo11d , Pregn,,n
 What is labour?

It is the process of childbirth from the onset of labour to delivery of

iggers of onset of placenta. It is divided in to three stages. Labour is only a fraction of the
norm, total time between conception and birth. Diagnosis of onset of labour
is confirmed only retrospectively.
urandlabour
Definition of onset of labor: Uterine contractions that bring about
demonstrable effacement and dilatation of the cervix.

What are the signs of onset of labour?

"show" (per-vaginal, blood stained, mucous discharge)

and its use in labour
Spontaneous rupture of membranes (SROM)

Painful uterine contractions at regular intervals

What is false labour?

A pregnant woman, having abdominal pain but no progressive

effacement or dilatation of the cervix. This pain disappears with
positional change and does not occur at regular intervals. Pain may last
for a few minutes.

Understand the physiology of labour

Cervical effacement is a prerequisite to its dilatation. This change

depends on the softening and ripening of cervical connective tissues .
PGE2 is the important prostaglandin (PG) for initiation of cervical
changes at term.

regnancy and labour.

MBBS and beyond, Pregnancy and labour by Dr(Mrs) TRN Fernando 31

Fernando
30
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Titel: De
Nederlandsche
stads- en dorp-
beschrijver; III.
deel
Auteur: Lieve van Info
Ollefen (1749– https://viaf.org/viaf/54397564/
1816)
Aanmaakdatum 2023-11-18
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IV, 4, 16,
3, 16, 2,
2, 8, 10,
3, 3, 8,
16, 16, 8 [Niet in bron] . 1
V eders elders 1
VII, 18, 3,
2, 2, 1, 4,
6, 10, 9 [Niet in bron] , 1
IX vier-en negentig vier-en-negentig 1
IX, 4 [Niet in bron] - 1
X, 13, 12 [Niet in bron] „ 1
XII [Niet in bron] : 1
XV Sicht Sticht 1
6 zjin zijn 2
8, 9, 2,
14 , [Verwijderd] 1
11 Huitzitten Huiszitten 1
14 Keizersgaft Keizersgraft 1
19, 15, 8,
2, 5, 16,
1, 4 , . 1
19 [Niet in bron] ’s 3
26 de die 1
28 te ze 1
35 tegenwêer tegenweêr 2/0
36, 36 . 1
1, 1 ’d d’ 2
1 reedsbijna reeds bijna 1
5 geemenlijk gemeenlijk 2
5 vee veel 1
6 Histerie Historie 1
10, 10 baterijen batterijen 1
10 twaafponder twaalfponder 1
11, 11 Collonel Colonel 1
13 leewen leeuwen 1
15 Patriooten Patriotten 1
15 zie ( (zie 3
15 gegenomd genoemd 3
16 Elisabethts Elisabeths 1
16, 4, 4,
7, 7 . , 1
3, 14 - 1
6 geteiteisterd geteisterd 3
6 merktenen merktekenen 2
1 Ambachtsheerlijk Ambachtsheerlijkheid 4
2 aangenam aangenaam 1
7 Seretarij Secretarij 1
10 geappropieerd geapproprieerd 1
15 Collonels Colonels 1
2 Lutersch Luthersch 1
8 erhalven derhalven 1
1 ? , 1
9 Amsterveen Amstelveen 1
9, 16 . [Verwijderd] 1
13 warmoesstraat Warmoesstraat 1
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16 baterij batterij 1
16 bezorgen de bezorgende 1
2 naaamlijk naamlijk 1
5 ligggen liggen 1
6 geplaast geplaatst 1
6 voor Voor 1
9, 12 Ontewaaler Outewaaler 1
12 ; : 1
14 innudatie inundatie 2
14 Mathys Matthys 1
1 Anstelland Amstelland 1
4 toortjen torentjen 3
7 Postorij Pastorij 1
11 [Niet in bron] van 4
16 was waren 3
20 niette enstaande niettegenstaande 1
20 Ouder Amstel Ouder-Amstel 1
2 Narden Naarden 1
11 oerde voerde 1
11 waar uit waaruit 1
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14, 15 gekwest gekwetst 1
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15 zettede zetteden 1
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3 ) [Verwijderd] 1
7 . : 1
10 rijd rijdt 1
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3 Eersteliijk Eerstelijk 1
1 naa naar 1
1 als sal 2
2 derzelve derzelver 1
3 to tot 1
4 suijdellijksten suijdelijksten 1
8 gtoote groote 1
8 ” [Verwijderd] 1
8 t’ ’t 2
3 onvertsaagheid onversaagdheid 2
3 erfpracht erfpacht 1
4 anmerking aanmerking 1
4 en den 1
5 nag nog 1
5 vau van 1
5 overredig overreding 1
8 rste eerste 2
9 pla ten plagten 1
13 [Niet in bron] – 1
13 100739 5–:0 100739–5–0 2
14 ordinarire ordinaire 1
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3 vriendljke vriendlijke 1
6 - [Verwijderd] 1
7 eenstemming eenstemmig 1
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12 Abbama Abbema 1
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9 welden welken 1
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