NORMAL PHYSIOLOGY OF LABOR

Pregnancy is generally characterized by smooth muscle myometrium activity relative

calm that enables the growth and development of fetal intrauterine pregnancy until term.
Before delivery, the uterine smooth muscle contraction is starting to show activity in a
coordinated manner, interspersed with a period of relaxation, and reached its peak before the
birth, and gradually disappeared in the postpartum period. Regulatory mechanisms that
regulate contraction activity of myometrium during pregnancy, labor and birth, until now stay
unclear.
Physiological processes of pregnancy in humans, leading to the initiation of
parturition and the onset of labor is not certain. Until now, generally accepted opinion that the
success of pregnancy in all mammalian species depend on the activity of progesterone to
maintain the tranquility of the uterus until near the end of pregnancy.
This assumption is supported by the findings that the majority of mammalian
pregnancy nonprimata studied, disarmament progesterone (progesterone breakthrough) either
naturally occurring, induced by surgical or pharmacological turns may precede the initiation
of parturition. In many species, the decline in progesterone levels in maternal plasma which
sometimes occurs suddenly usually begins after approaching 95 percent of pregnancies. In
addition, experiments with progesterone administration on the species-spesie this late in
pregnancy can slow the onset of labor.
However in pregnancy primates (including humans), disarmament progesterone did
not precede the onset of parturition. Progestron levels in the plasma of pregnant women
throughout pregnancy increases precisely, and only declined after the birth pasenta, which is
the network location of progesterone synthesis in human pregnancy.
NORMAL PHASES OF LABOUR
The last few hours of pregnancy characterized by thinning causing contractions,
cervical dilation, and push out the fetus through the birth canal. Many the energy released at
this time. Therefore, the use of the term "in labor" (hard work) is intended to illustrate this
process. Contraction of the myometrium during labor pain labor pain so the terms used to
describe this process.

THIRD STAGE OF LABOR

Active labor when labor is divided into three distinct. The first stage of labor begins
when it has reached a uterine contraction frequency, intensity, and duration sufficient to
produce cervical effacement and dilation are sufficient. Completed first stage of labor when
the cervix is opened completely (about 10cm) so as to allow the fetal head through.
Therefore, when one persalina called staging effacement and dilation of the cervix. Second
stage of labor begins when cervical dilation is complete and ends when the fetus is born.
Second stage of labor is also called the expulsion of the fetus stage. The third stage of labor
begins immediately after fetus is born, and ends with the birth of the placenta and fetal
membranes. The third stage is also referred to as stage separation and expulsion of the
placenta.
DIFFERENTIATION ACTIVITY UTERUS
During labor, the uterus transformed into two distinct parts. Segments on the
berkontaksi actively becomes thicker as direct labor. The bottom of the relatively passive
compared with the upper segment, and it evolved into a part of the birth canal is much
thinner-walled. Lower uterine segment analaog with uterine isthmus is widened and thinned
to women who are not pregnant; the lower segment is gradually formed when gestational age
and later became lime once at the time of delivery. By abdominal palpation, both segments
can be distinguished when the contractions, though not ruptured membranes. Upper segment
uterine fast enough or loud, while the consistency of the lower uterine segment is much less
tight. Upper segment of the uterus is contracted uterus active part, the bottom part is
stretched, normally much more passive,
If all the muscle wall of the uterus, including the cervix and lower uterine segment to
contract simultaneously and with the same intensity, then a thrust labor will clearly decline.
Herein lies the importance of the division of the uterus into contracting segmena atsa active
and passive segments more under different not only anatomical but also physiologically.
Segments on contract retracted and push the fetus out in response to the contraction of the
upper segment dodrong power; while the lower uterine segment and cervix will be soft
dilated; and thereby forming a muscular line and fibromuscular thinned so that the fetus can
stand out.

Myometrium in the upper segment uterine relaxation to return to its original length
after contraction; but being relatively settled on a shorter length. However, the voltage
remains the same as before kontaksi. The top of the uterus, or active segment berkontaksi
down even when it is reduced, so that the pressure remains konatan myometrium. The end
effect is to tighten the slack, by maintaining favorable conditions obtained from the expulsion
of the fetus and maintain uterine muscles still clung to the contents of the uterus. As a
consequence retraction, each kontaksi next start in the space left by the previous contraction,
so that the top of the uterine cavity be slightly smaller on each subsequent contraction. Due to
the shortening of the muscle fibers are continuous at each contraction, the upper segment of
the uterus becomes progressively more active along the first and second stage of labor and
becomes very thick right after delivery of the fetus.
The phenomenon of retraction of the upper segment of the uterus depends on the
reduced volume of the contents of the uterus, especially in early labor when the entire uterus
is really a sealed bag with only a small hole in the cervical os. This allows more isis
intrauterine fill the lower segment, and the segment above only in so far as the expansion
beretraksi lower segment and cervical dilation.
Relaxation of the lower uterine segment is not a perfect relaxation, but rather a
retraction opponent. Fibers become stretched in the lower segment of each segment kontaksi
above, and thereafter did not return to the previous long but relatively retaining a longer
length; but the voltage remains essentially the same as before. The muscles are still showing
tone, still hold the stretch, and still contracting slightly during the last stimulus. When the
delivery of advanced, pemanjangn successively lower uterine segment followed by
shortening, normally only a few millimeters at the thinnest part. As a result of the depletion of
the lower uterine segment and together with thickening the upper segment of the boundary
between the two is marked by a circle on the surface of the uterus, called the physiologic
retraction ring. If the shortening of the lower uterine segment is too thin, as in obstructed, this
ring is very prominent so forming pathological retraction ring. This is an abnormal condition
is also referred to as ring Bandl. The existence of a gradient of the physiological activity of
the shrinking of the fundus to the cervix can be seen from the measurement of the top and
bottom of the uterus in normal labor.

AMENDMENT FORM UTERUS

Figure 1: uterine vaginal deliveries. Segments on the active beretraksi uterus around the
fetus because the fetus down through the birth canal. In the lower segment of the passive tone
of myometrium much smaller
Each contraction produces ovoid shaped uterus elongation accompanied by a
reduction in horizontal diameter. With this shape change, no important effects on labor. First,
the reduction of the horizontal diameter cause fetal vetebralis rectification column,
emphasizing the pole it tightly against the fundus, while the lower pole is pushed further
down and toward the pelvis. Ovoid-shaped elongation of the resulting fetus is estimated to
have reached between 5 to 10 cm: the pressure exerted in this way is known as fetal stress
axis. Second, with prolonged uterus, longitudinal fibers pulled taut and because of the lower
segment and cervix is the only portion of the uterus flexible, this section is pulled up in the
lower pole of the fetus. This effect is an important factor for cervical dilatation in the muscles
of the lower segment and cervix.
ADDITIONAL FORCES IN LABOR
Once fully dilated cervix, the most important force in the process of expulsion of the
fetus is the force generated by the intra-abdominal pressure rises mother. This style is formed

by the contraction of the muscles of the abdomen simultaneously through efforts pernapasa
forced to closed glottis. This force is called push.
The nature of the force created in the same style that happens to defikasi, but the
intensity is usually larger. The importance of intra-abdominal pressure on the expulsion of the
fetus is most clearly seen in patients with paraplegia labor. Women like this do not suffer
pain, although it may contract the uterus strong. Cervical dilatation which largely is the result
of uterine contractions acting on the cervix to soften proceeds normally, but ekpulsi baby can
be accomplished more easily if she was asked to push, and can perform the command during
a uterine contraction.
Despite the high intra-abdominal pressure required to complete spontaneous labor,
this labor would be in vain until the full opening of the cervix. Specifically, this power is the
additional assistance needed by contractions of the uterus in the second stage of labor, but
pushing it only helped slightly in the first stage besides causing sheer exhaustion.
Intaabdominal pressure may also be important in the third stage of labor, especially when the
mother who gave birth unsupervised. After the placenta separated, spontaneous expulsion of
the placenta may be assisted by the mother increased intra-abdominal pressure.
CHANGES IN CERVICAL
Power effective in the first stage of labor are uterine contractions, which in turn will
generate a hydrostatic pressure to the rest of the membranes of the cervix and lower uterine
segment. When the membranes have ruptured, the presenting part is forced directly urged the
cervix and lower uterine segment. As a result of the thrust of this activity, there are two
fundamental changes-effacement and dilation of the cervix-which already softened. For the
passage of an average head aterem fetus through the cervix, cervical canal to be widened to
about 10 cm in diameter; at this time the cervix is said to have a complete open. Perhaps there
is no impairment of the fetus during cervical effacement, but most often the presenting part
tururn sediki start when it comes to the second stage of labor. Decrease the presenting part be
typically a little slow on the nulliparous. But in multiparas, especially those of high parity, a
decline usually takes place very rapidly.
Cervical effacement
Obliteration or effacement of the cervix is shortening of the cervical canal along
approximately 2 cm into the estuary just a nearly circular with a paper-thin edge. This process

is referred to as a flattening (effacement) and going from top to bottom. Muscle fibers as high
as cervical os internum is pulled up, or shortened, to the lower uterine segment, while the
condition os eksternum temporarily remain unchanged. The edge of the os internum ditaraik
to the top few centimeters to be a part (both anatomic and functional) of bawaj uterine
segment. Shortening can be compared with a bunch of a tunneling process that changes the
whole length of a narrow tube into a funnel that is very blunt and expands with small circular
exit holes. As a result of the myometrium activity increased throughout the preparation of the
uterus for childbirth, perfect effacement of the cervix that sometimes software has been
completed before the start of active labor. Leveling cause expulsion of mucus plugs when the
cervical canal shortened.

Cervical dilatation
When compared with the uterine corpus, cervix and lower uterine segment is an area
of resistance is smaller. Therefore, during the contraction of these structures in the process to
stretch the cervix undergoes a centrifugal pull. When the contractions of the uterus puts
pressure on the amniotic membrane, amniotic bag hydrostatic pressure will dilate the cervix.
When the membranes have ruptured, the pressure at the bottom of the fetus against the cervix
and lower uterine segment as well as effective. Premature rupture of the membranes that do
not reduce cervical dilation during the presenting part is in a position to continue the pressure
on the cervix and lower uterine segment. The process effacement and dilation of the cervix
this causes the formation of pockets of amniotic fluid in the front of the head.

PATTERNS OF CHANGES IN LABOR

Pattern cervical dilatation
Friedman, in his treatise on labor states that; clinical characteristics of uterine
contractions ie frequency, intensity, and duration can not be relied upon as a measure of the
progress of labor and childbirth as an index of normality. In addition to cervical dilatation and
fetal descent, there are no clinical characteristics at birth mother seems to be beneficial to
assess the progress of labor. Cervical dilatation patterns that occur during normal labor to
have a sigmoid curve. Two phases of cervical dilatation is the latent phase and an active
phase. The active phase is further divided into acceleration phase, the phase of maximum
slope and deceleration phase. The duration of the latent phase is more variable and
susceptible to change by external factors, and by sedation (prolongation of the latent phase).
The duration of the latent phase little to do with the trip next delivery process, while the
characteristics of accelerated phase typically have greater predictive value of the results of
the late labor. Friedman considers the maximum ramp phase as a good gauge of the efficiency
of this machine as a whole, while the deceleration phase properties better reflect the
relationships fetopelvik. The full cervical dilation in the active phase of labor produced by
retraction of the cervix around the presenting part. After cervical dilation is complete, the
second stage of labor begins; after that only the progression of the decline in the presenting
part is the only measure available to assess the progress of labor,

DECREASE IN FETAL PATTERNS

In many nulliparous, the entry of the head of the fetus into the pelvic persalianan has
been reached before the start, and further descent will not occur until the onset of labor.
Meanwhile, in multiparas entry of the fetal head to the pelvic initially not so perfect, further
decline will occur in the first stage of labor. In a declining pattern in normal labor, the
formation of a typical hyperbolic curve when the fetal head station plotted on a function of
the duration of labor. In the current declining pattern typically occurs after cervical dilatation
has been developed for some time. In nulliparous, speed down usually increases rapidly
during the phase of maximum lerang cervical dilation. At this time, the speed drops increases
to a maximum, and the maximum decline rate is maintained until the presenting part reaches
the bottom of the perineum.

NORMAL LABOR CRITERIA

Friedman also tried to choose the criteria that will give the limits of normal delivery,
so that abnormalities significant labor can be immediately identified. This group of women
studied were nulliparous and multiparous not have dispoporsi fetopelvik, no multiple

pregnancy, and no treated with heavy sedation, analgesia conduction, oxytocin, or operative
intervention. All had normal pelvis, term pregnancies with vertex presentation, and averagesized babies. From this research, friedman develop the concept of three functional parts,
namely childbirth preparation, dilatation, and pelvik- to find that part of the preparation for
labor might be sensitive to sedation and analgesia conduction. Despite the little cervical
dilation at this time, a big change in the extracellular matrix (collagen and components of
other connective tissue) in the cervix. Part dilatation childbirth, when dilatation with the most
rapid pace, in principle, not affected by sedation or analgesia conduction. Part of the pelvic
labor begins simultaneously with cervical deselarasi phase. Classic delivery mechanisms,
involving the major movements of the fetus, especially so during the pelvic part of this labor.
The early part of this quaint clinically rarely be separated from the dilatation of labor. In
addition, the speed of cervical dilation is not always reduced when it has reached full
dilatation; perhaps even sooner.

Spontaneous rupture of membranes most often occur at any time in active labor.
Rupture of membranes typical secra apparent as the liquid jet that is normally clear or slightly
cloudy, virtually colorless varying amounts. The membranes intact until after the baby is born
is more rare. If by chance the membranes intact until delivery is completed, the fetus is born
is wrapped by membranes, and the part that wraps a newborn baby's head is sometimes
referred to as caul. Rupture of membranes before labor begins at any stage of pregnancy is
referred to as membrane rupture.
Disposal Placenta
Third stage labor begins after the birth of the fetus and involve the release of and
expulsion of the placenta. After delivery of the placenta and fetal membranes, active labor
was completed. Because the baby is born, spontaneously contracting uterine hard to fill the
empty. Normally, when the baby has been born almost obliterated the uterine cavity and
Reviews These organs form an almost solid mass of muscle, with some thick lower segment
above sentimerer thinner. Fundus now under the height limit of the umbilicus.
The sudden depreciation uterine size is always accompanied by a reduction in the
field of placental implantation site. So that the placenta can accommodate themselves to the
surface of this shrinking, this organ enlarges its thickness, but the limited elasticity of the
placenta, the placenta was forced to bend. The resulting voltage causes the decidua weakest
layer of spongy layer, or decidua spongiosa relented, and separation occurred at this place.
Therefore, the release of the placenta and shrinking beneath the implantation site. In cesarean
section this phenomenon may be observed directly when the placenta implants in the
posterior.
The separation of the placenta is very easy by the structural properties of the decidua
spongiosa loose. When the separation took place, formed a hematoma between separate
placenta and decidua were tersisisa. Hematoma formation is usually a consequence and not
the cause of the separation. However hematoma can accelerate the process of separation.
Due to the separation of the placenta through the spongy layer of the decidua, part of
the decidua disposed of with the placenta, while the rest remain attached to the myometrium.
Number of decidua tissue left in the placenta varies. Placental separation usually occurs
within a few minutes after delivery. Because the peripheral part of the placenta is the most
attached, separation usually begin anywhere. Sometimes a few degrees of separation initiated

before the third stage of labor, which may explain the occurrence of cases of fetal heart rate
decelerations just before the expulsion of the fetus.
EXTRUSION PLACENTA
After the placenta separates from the implantation, the pressure exerted on it by the
wall of the uterus causing this organ was sliding down the slope to the lower uterine segment
or the top of the vagina. In some cases, the placenta can be pushed out as a result of
heightened abdominal pressure. Artificial methods are used to complete the delivery plasneta
is alternately pressing and raising the fundus, while doing a light traction on the center.

MECHANISM OF LABOR
Ongoing Normal Delivery
Parturition is divided into 4 time
1. Kala I, called kala opening.
2. Kala II, called kala expenditure.
3. Kala III, or when the placenta.

4. Kala IV, called kala supervision.

The First Stage

Parturition begins when raised his and the woman blushed blood mucus (bloody
show). Bloody show is derived from the cervical canal because cervical mucus began to open
or flat. While the blood comes from capillaries that are around canal srvikalis was broke
because of the shifts due to cervical opening.
The first stage is divided into two phases:
1. latent phase, lasts for 8 hours with the opening of 3 cm.
2. The active phase: divided into three phases, namely:
a. Accelerated phase, opening to 4 cm within 2 hours.
b. Phase of maximum dilation, opening takes place very rapidly from 4 cm to 9 cm within 2
hours.
c. Deceleration phase, opening from 9 cm to complete within 2 hours.
These phases were found in primigravida. In multigravida, latent phase, active phase and the
deceleration phase becomes shorter.
The mechanism is different between the cervical opening and multigravida
primigravidae. In primigravida, os internum will open first, so that the cervix opens and thins.
Then os eksternum open. In multigravida os internum already slightly open. Os internum and
eksternum well as thinning and flattening of the cervix occur in the same time.
Membranes will be broken by itself if the opening is almost or already complete. Not
infrequently the membranes have to be solved when the opening is almost or already
complete. When the membranes have ruptured before reaching the opening of 5 cm is called
premature rupture of membranes. When I have finished, if the opening of the cervix is
complete. On pda primigravidas first stage lasts approximately 14 hours, whereas in
multiparas approximately 7 hours.

The Second of stage

In his second stage to be stronger and faster, about 2-3 minutes. In this case the head
of the fetus is already entered in the pelvic area and on his perceived pressure on the pelvic
floor muscles that reflektoris cause a sense of straining, increased pressure on the rectum and
about to defecate. Then perineum start to stand out and be the width of the anal opening.
Labia begin to open and soon the head of the fetus appears in the vulva in his time. At the
time of holding the head of deflection, hold the left hand behind your head (so that deflection
is not too fast), the right hand hold the perineum. By slowly starting born head of Uub,
forehead, nose, mouth, chin until the entire head passes through the perineum. After a brief
rest, his began again to pull out bodies and members of the baby. In primigravidas second
stage lasts an average of 1 hour and in multiparas lasts an average of half an hour.
The third of stage
After the baby is born, the uterus palpable hard with fundus somewhat above the
center. A few minutes later the uterus to contract again to release the placenta from the wall.
Usually the placenta separated in 6 to 15 minutes after the baby is born and come out
spontaneously or with pressure on the uterine fundus. Expulsion of the placenta is
accompanied by vaginal bleeding. When more than 30 minutes palsenta unborn, called a
retained placenta.

The fourth of stage

Fourth stage lasted until 1 hour after delivery of the placenta. At this time conducted
surveillance of postpartum hemorrhage. Even given oxytocin, postpartum hemorrhage due to
uterine atony most likely to occur at this time. Similarly, the perineal area should be inspected
to detect bleeding that much.

NORMAL DELIVERY MECHANISM

3 factors that play a role in labor, namely: 1). The forces that exist in the mother as his
strength and the strength of straining; 2). The birth canal; and 3). Fetus itself.

His is the power of the mother that cause cervical opening and push the fetus down.
At the presentation of his head when strong enough, will head down and started to get into
the pelvic cavity.
The entry of the head across the pelvic inlet can be in a state of sinklitismus is when
the fetal head axis direction perpendicular to the plane of the pelvic. Can also head into the
state asinklitismus, ie towards the axis of the fetal head tilted to the field of the pelvic inlet.
Asinklitismus anterior according to Naegele is when the head axis direction to make acute
angle to the front with the door on pnggul. Can also asinklitismus posterior according to
Litzman; the situation is the opposite of the anterior asinklitismus.
Asinklitismus anterior circumstances more favorable than the decline in the head with
a mechanism for asinklitismus posterior pelvic space in the posterior region wider than the
space pelvs in daerh anterior. It is important asinklitismus pelvis when the power of
accommodation is rather limited.
As a result of the eccentric axis of the fetal head or not symmetrical with the axis
closer subocciput, then the detainee in the underlying tissue of the head that will decrease
mengakibatkn head held flexion in the pelvic cavity. With flexion of the fetal head into the
pelvic cavity with the smallest size, the diameter suboccipito-bregmatica (9.5 cm) and with
sirkumferensia suboccipito-bregmatica (32 cm). reached the pelvic floor fetal head in a state
of maximum flexion. Head from the fall meet pelvic diaphragm that runs from top to bottom
rear forward. As a result of the elasticity combination pelvic diaphragm and intrauterine
pressure caused by his repeated, holding the head of the rotation, called the rotation axis
inside. In the case of holding round occiput axis will rotate towards the front so that the
pelvic floor occiput under the symphysis. After the fetal head to the bottom of the pelvis and
occiput under the symphysis, then by subocciput as hipomoklion, head deflection maneuver
to be born. In each of his vulva is more open and more visible fetal head. Perineum becomes
increasingly wide, thin wall rectum anus opening. With his strength along with strength
straining, successively appear bregma, forehead, face and finally the chin. After the head is
born, the head immediately entered rotation, called the pivot round the outside.

Pivot round the outside this is a movement back before the rotation axis in the case, to adjust
the position of the head with the back of the child.
Shoulder across the inlet in an oblique. In the pelvic cavity shoulder will conform to
the shape of the pelvis in its path, resulting in pelvic floor, when the head has been born, the
shoulder will be in a position behind the front. Similarly, the front trochanter was born first,
then trochanter behind. Then the baby is born entirely.

When the baby was born, soon airway cleared. The umbilical cord is clamped
between the two pliers at a distance of 5 and 10 cm. then cut between the two pliers, and then
tied up. Umbilical cord stump given antiseptic. Generally, when it has a complete birthday,
baby soon draw breath and cry. Resuscitation with street cleaning and sucking lenders in the

airway should be promptly undertaken. Similarly liquid in the bubble about to inhaled to
prevent aspiration into the lungs when the baby vomits.
If the baby is born, the uterus shrink. Parturition are in the third stage. Although the
baby was born, when uri is no less important than the first stage and second stage. Maternal
death due to bleeding when the placenta is not uncommon because the leadership of the third
stage less carefully done. As has been stated, immediately after the baby is born, his having
amplitude that is approximately the same height reduced frequency only. As a result of this
his, the uterus will shrink so that the attachment of the placenta to the uterus wall of
separation. Remove the placenta from the uterine wall can be started from 1). Central (central
according to Schultze); 2). The edge (marginal according to Mathews-Duncan); 3). A
combination of 1 and 2. The most is according to Schultze. Uri kala generally lasts for 6-15
minutes. High fundus after the third stage of approximately two fingers below the center.

REFERENCES
Garry Cunningham F, Leveno, K J et al. Normal labor and delivery;. Williams Obstetrics 21st
Edition. Book Medical Publishers EGC. It 272-318, 2006
Keman K. Physiology and mechanisms of normal deliveries in the book of Obstetrics. Bina
Library Sarwono Prawiwohardjo, Jakarta. The third mold fourth edition, p 296-314, 2010
W. Power Hanifa labor and delivery mechanisms, in the book of obstetrics surgery. Bina
Library Sarwono Prawiwohardjo, Jakarta. The eighth edition of the mold first, p 19-29,
2010