Normal Labor and Delivery

Labor : a coordinated effective sequence of

involuntary uterine contractions that result in
effacement and dilatation of the cervix and a
voluntary bearing down effort leading to the
expulsion per vaginum of products of
conception after 28 weeks of gestation
Delivery : the mode of actual expulsion of
the fetus and the placenta
It`s the period from the onset of regular
uterine contractions until expulsion of the
placenta.
 Labor is a clinical diagnosis, classically defined
by the triad of regular painful uterine
contractions, progressive cervical
effacement and dilatation, and show
(bloody discharge).
Labor is a physiological event involving a
sequential, integrated set of changes
within the myometrium, decidua, and
uterine cervix that occur gradually over a
period of days to weeks.
Hormonal control of myometrial contractions
Oxytocin
Receptors increase from early to late pregnancy and labor
Oxytocin receptor concentration is increased by estrogen
and decreased by progesterone
Its stimulation leads in release of IC Ca++
PG
Increased in labor
PG mediated contraction is achieved by increased IC Ca ++:
Increasing Ca ++ by influx across the cell membrane and release
from IC stores
Enhancing formation of GJ
Effect depends on type of PG
Contraction: PGF2, Thromboxane, PG E3
Inhibition of contraction: PG D, PG E2, PG I
 Endothelin:
Receptors found in chorion, endometrium, and
myometrium, Receptors increase during labor
Enhances uterine contraction by:
Increasing Ca ++ influx
Stimulating PG production
Epidermal growth factor (EGF)
Receptors present in endometrium and
myometrium
Induced by estrogen
Increases Ca++
 PHYSIOLOGICAL PHASES OF
MYOMETRIAL ACTIVITY
Phase 0 Quiescence/Prelude to
parturition
Phase 1 Activation/Preparation for labor
Phase 2 Stimulation/Process of labor
Phase 3 Involution/Parturient recovery
Myometrial contraction pattern

Quiescence Activation Stimulation Involution

Inhibitors Uterotrophins Uterotonins
Progesterone Estrogen PG Oxytocin
PGi2 GJ Oxytocin
Relaxin Ion channels
Uterine contractility

NO etc

Phase 0 Phase 1 Phase 2 Phase 3

 Phase of uterine activity
Phase 0 Phase 1 Phase 2 Phase 3
Quiescence Activation Stimulation Involution
Preparation for Process of Parturient
Prelude to parturition
labor labor recovery
Uterine preparedness Active labor Uterine involution
Contractile unresponsiveness
for labor Breast feeding

conception Initiation of Onset of Delivery of Fertility

parturition labor conceptus restored

Progesterone Estrogen Prostaglandins Oxytocin

Prostacycline Progesterone Oxytocin
Relaxin withdrawal ?CRH
Nitric oxide Uterine stretch
?CRH Prostaglandins
?CRH
?cortisol
 Phase 0 of Parturition: Uterine
Quiescence and Cervical Softening
Uterine Quiescence
Comprises 95 percent of pregnancy
Uterine smooth muscle tranquility with maintenance of
cervical structural integrity
Uterine muscle is rendered unresponsive to natural
stimuli.
Braxton Hicks contractions or false labor may be noted
Unpredictability, low intensity, and brief duration.
Lower abdomen and groin discomfort.
More common Near the end of pregnancy, especially in
multiparous women
 Cervical Softening
xized by an increase in tissue compliance, yet
the cervix remains firm and unyielding.
Results from increased vascularity, stromal
hypertrophy, glandular hypertrophy and
hyperplasia, and compositional or structural
changes of the extracellular matrix
Mediated by Progesterone, Prostacyclin (prostaglandin
I 2), Relaxin, Parathyroid hormone-related peptide,
Nitric oxide, Calcitonin gene-related peptide,
Adrenomedullin, Vasoactive intestinal peptide
Phase 1 of Parturition: Preparation for
Labor, uterine awakening or activation
Represents a progression of uterine changes
during the last 6 to 8 weeks of pregnancy
Myometrial Changes during Phase 1
Increase in myometrial oxytocin receptors,
numbers and surface areas of gap junction,
increased uterine irritability and
responsiveness to uterotonins
Formation of the lower uterine segment from
the isthmus and occurrence of lightening
 Cervical ripening
Involve connective tissue changes that results
in physical softening and distensibility of the
cervix, ultimately leading to partial cervical
effacement and dilation.
Involves enzymatic dissolution of collagen
fibrils, increase in water content, and chemical
changes.
Induced by hormones (estrogen, progesterone,
relaxin), as well as cytokines, prostaglandin, and
nitric oxide synthesis enzymes
 Phase 2 of Parturition: Labor
Synonymous with active labor, that is, uterine
contractions that bring about progressive
cervical dilatation and delivery.
Clinically, phase 3 is customarily divided into the three
stages of labor.
The 1st stage
The stage of cervical effacement and dilatation
The 2nd
The stage of fetal expulsion
The 3rd stage
The stage of placental separation and expulsion.
 First Stage of Labor: Clinical Onset of Labor
The initiation of labor is heralded by spontaneous release
of a small amount of blood-tinged mucus from the
vagina referred to as "show" or "bloody show.
Uterine Labor Contractions
Uterine smooth muscle during labor are painful
Hypoxia of the contracted myometriumsuch as
that with angina pectoris
Compression of nerve ganglia in the cervix and
lower uterus by contracted interlocking muscle
bundles
Stretching of the cervix during dilatation
Stretching of the peritoneum overlying the
fundus
 Uterine contractions are involuntary and for the most
part, independent of extrauterine control.
Mechanical stretching of the cervix enhances
uterine activity the Ferguson reflex
Manipulation of the cervix and "stripping" the fetal
membranes is associated with an increase in blood
levels of prostaglandin F2 metabolite (PGFM).
The interval between contractions diminishes gradually from
about 10 minutes at the onset of the first stage of
labor to as little as 1 minute or less in the second
stage.
In active-phase labor, the duration of each contraction
ranges from 30 to 90 seconds, averaging about 1 minute.
There is appreciable variability in contraction intensity
during normal labor. Average approximately 40 mm Hg,
but with variations from 20 to 60 mm Hg
Formation of distinct Lower and Upper
Uterine Segments
During active labor, the uterine divisions that
were initiated in phase 2 of parturition become
increasingly evident
The lower segment thinning and concomitant
upper segment thickening, a boundary between
the two is marked by a ridge on the inner uterine
surface- the physiological retraction ring.
When the thinning of the lower uterine
segment is extreme, as in obstructed labor, the
ring is prominent and forms a pathological
retraction ring (the Bandl ring)
Cervical Changes during
First-Stage Labor
Cervical effacement multiparous primigravida
is "obliteration" or "taking
up" of the cervix.
It is manifest clinically by
shortening of the cervical
canal from a length of about
2 cm to a mere circular
orifice with almost paper-
thin edges
A centrifugal pull is
exerted on the cervix
leading to distension, or
cervical dilatation
 Cervical dilatation is divided into latent and
active phases
The duration of the latent phase is more variable
and sensitive to changes by extraneous factors.
For e.g., sedation may prolong the latent
phase, and myometrial stimulation shortens
it.
The active phase is subdivided further into the
acceleration phase, the phase of maximum
slope, and the deceleration phase
The characteristics of the accelerated phase are usually
predictive of a particular labor outcome.
 Second Stage of Labor: Fetal Descent
In the descent pattern of normal labor, a
typical hyperbolic curve is formed when
the station of the fetal head is plotted as a
function of labor duration.
In nulliparas, increased rates of descent
are observed ordinarily during cervical
dilatation phase of maximum slope.
 Third Stage of Labor
Period following the completed delivery of the newborn
until the completed delivery of the placenta and its
attached membranes.
Mechanism of placental separation and expulsion
Myometrial contractions & retraction reduction in
the surface area of the placental site shearing of the
placenta.
Hematoma formation due to venous occlusion and vascular
rupture in the placental bed caused by uterine contractions.
The Schultze mechanism - separation of the placenta from its center
leading to concealed bleeding behind the placenta & membranes
until placental delivery.
Matthews duncan method - separation of the placenta from its edge
leading escape of blood from the implantation site to the vagina
immediately
Phase 3 of parturition: process of labor
Immediately after delivery & for 1hr or so
thereafter, myometrium in state of rigid &
persistent contraction & retraction
Effect compression of large Uterine vessels
Severe PPH prevented
Involution of Uterus & reinstitution of ovulation
Complete Uterus involution: 4~6 wks
Infertility persist as long as breast feeding is
continued (lactation anovulation &
amenorrhea).
 Mechanisms of Labor
Cardinal movements of labor
Engagement, descent, flexion, internal
rotation, extension, external rotation, and
expulsion
During labor, these movements not only are
sequential but also show great temporal overlap. For
example, as part of engagement, there is both
flexion and descent of the head.
 Engagement
The mechanism by which the biparietal diameter
passes through the pelvic inlet is designated
engagement.
Cephalic presentation with well-flexed head:
biparietal diameter (9.5 cm).
Breech: bitrochanteric diameter
In nulliparous women, engagement occurs during
the last few weeks of pregnancy but multiparous it
occurs after labor commencement.
The fetus enters the pelvis in the left occiput transverse
(LOT) position in 40 % of labors and in the right occiput
transverse (ROT) position in 20 %.
 Owing to the angle of inclination between the
maternal lumbar spine and pelvic inlet, the fetal
head engages in an asynclitic fashion. Leading
parietal eminence descends and is 1st to engage
the pelvic floor.
Presenting part at 0 station (ischial spines)
The pelvic inlet is sufficiently large to allow
descent
Head normally enters pelvis in the transverse
or oblique diameter of the inlet.
More than 2/5th palpable abdominally, the head
is not engaged"floating."
8/24/2017 Eyaya M. 27
Descent
Descent is brought about by one or
more of four forces:
Pressure of the amnionic fluid,
Direct pressure of the fundus upon
the breech with contractions,
Bearing-down efforts of maternal
abdominal muscles, and
Extension and straightening of the
fetal body.
Greatest rates of descent:
In nulliparas, descent may not follow Deceleration phase and
until the onset of the second stage. Second stage

In multiparous women, descent

usually begins with engagement.
 Flexion
As soon as the descending
head meets resistance,
Complete flexion presents the
smallest diameter of the fetal
head (the suboccipitobregmatic
diameter) for optimal passage
through the pelvis.

whether from the cervix,

walls of the pelvis, or pelvic
floor, then flexion of the
head normally results.
Shorter suboccipito -
bregmatic diameter (9.5cm)
is substituted for the longer
occipitofrontal diameter
(11.5cm)
 Internal Rotation Rotation of the presenting part from
its original position as it enters the
Turning of the head in such a pelvic inlet (usually OT) to the AP
manner that the occiput position as it passes through the
pelvis.
gradually moves toward
the symphysis pubis
anteriorly
Head now in occipito-
anterior (OA) position
Shoulders is in left oblique
of the brim
Approximately two thirds,
internal rotation is completed
by the time the head reaches
the pelvic floor; in about another
fourth, internal rotation is
completed very shortly after the
head reaches the pelvic floor
 Extension
Head is delivered by
Occiput is below symphysis pubis.
extension and rotates
The head is acted upon by 2 forces: around the symphysis pubis
The uterine contractions acting by the downward force
downwards and forwards exerted on the fetus by the
uterine contractions along
The pelvic floor resistance acting with the upward forces
upwards and forwards so the net exerted by the muscles of
result is forward direction i.e. the pelvic floor.
extension of the head
The well flexed head now extends and
the occiput escapes from underneath
the symphisis pubis and distends the
vulva.
Crowning
That stage of childbirth when the fetal
head has negotiated the pelvic outlet
and the largest diameter of the head
is encircled by the vulvar ring.
Occiput is delivered followed by
bregma, brow and face.
External Rotation
If the occiput was originally directed
toward the left, it rotates toward
the left ischial tuberosity.
If it was originally directed toward
the right, the occiput rotates to the
right.
Restitution of the head to the
oblique position is followed by
completion of external rotation to
the transverse position. This
movement corresponds to rotation of
the fetal body and serves to bring
its bisacromial diameter into
relation with the anteroposterior
diameter of the pelvic outlet.
 Lateral flexion
(Expulsion)
Shoulders will be in the
anterior-posterior
position
Anterior shoulder is
under symphysis pubis,
delivers first and
subsequently posterior
shoulder.
Aided by lateral
movement:
The rest of the body is
born by lateral flexion
with arms folded on the
chest and hands under
the chin.
 FACTORS THAT INFLUENCE
PROGRESS OF LABOUR
The ability of the fetus to successfully
negotiate the pelvis during labor and
delivery depends upon a complex interaction
of three variables:
Power (uterine contractions)
Passenger (fetus)
Passage (both bony pelvis and pelvic
soft tissues).
 POWER Contractions + Maternal pushing
Uterine contractions:
1. Initiate by pacemakers ~ uterotubal junction
2. Contraction waves meet at the fundus
3. Contraction waves progress downward Additional force

maternal pushing
Shortening of muscle fibres
Retractions Intra abdominal pressure
Intra uterine pressure

EXPULSION OF THE FETUS

8/24/2017 Eyaya M. 35
 UTERINE CONTRACTION

Uterine contractions

ADEQUATE CONTRACTION
1. Frequency ~ one in every 2 3 min with at least 1 minute
interval
2. Intensity ~ strong (> 50 mmHg)
3. Duration ~ 45 60 sec 36
Methods of uterine activity assessment
Simple observation,
Manual palpation,
External tocodynamometry:
Contractions Abdominal shape change
Graphic uterine activity
Correlates FHR with uterine activity BUT NOT contraction
intensity or basal inauterine tone.
Internal tocodynamometry via internal uterine pressure
catheter
Most precise method
Performed with indication
Risks: uterine perforation, placental disruption, intrauterine
infection (HIV)
37
Contraction measurement
Montevideo unit: most common objective
measure
Measures average frequency and amplitude above basal
tone
Average strength of contractions in mmHg multiplied
by number of contractions per 10 minutes
Adequate labor in the active phase of labor: 200 to 250
MU
Abnormal uterine activity
Tachysystole: < 5 contractions in 10 minutes for at
least 20 minutes
Hyperstimulation: tachysytole accompanied by
abnormal FHR 38
The Fetus (Passenger):
Fetal variables influence course of labor & delivery
Fetal size: abdominal palpation or ultrasound
Macrosomia: actual birth weight > 4,000g
Lie: longitudinal axis of the fetus relative to the
longitudinal axis of the uterus
Longitudinal, transverse, or oblique
Presentation refers to the fetal part that directly
overlies the pelvic inlet.
Malpresentation: any presentation other than vertex
5% of all term labors
39
 Attitude: position of head with fetal spine
Flexion facilitates engagement
Chin optimally flexed onto the chest:
suboccipitobregmatic diameter (9.5 cm)
Deflexed (extended) head: brow and face
Position: relationship of the fetal presenting part
to the maternal pelvis
Malposition refers to any position in labor that is not
ROA, OA, or LOA
Station: measure of descent of the bony presenting
part of the fetus through the birth canal
Classification (-5 to +5) based on a quantitative
measure in cm of the distance of the leading bony
edge from the ischial spines
Descent using remaining part of head above pubis.
40
The Maternal Pelvis (Passage)
Consists:
Bony pelvis (composed of the sacrum, ilium,
ischium, and pubis)
Soft tissues

8/24/2017 Eyaya M. 42
 The obstetric pelvis is divided into false (greater) and true
(lesser) pelvis by the pelvic brim or inlet
The female pelvis provides the basic framework of the birth canal.
The true pelvis is important, for it is through this confined space
that the fetus must pass on its journey through the birth canal.
The true pelvis is composed of inlet, cavity and outlet

* Pelvic brim is demarcated by:

sacral promontory
anterior ala of sacrum
arcuate line of ilium
pectineal line of pubis
pubic crest
8/24/2017 43
 Caldwell-Moloy Classification
P
P
A
A

Gynecoid Anthropoid

P
P
A
A

Platypelloid Android
8/24/2017 Eyaya M. 44
 The ideal normal female gynaecoid pelvis:
1. The brim is slightly oval transversely.
2. The sacral promontory is not prominent.
3. The transverse diameter is slightly longer than
the anteroposterior.
4. The sidewalls are parallel and straight.
5. The ischial spines are not prominent.
6. The sacrosciatic notches are wide.
7. The sacrum has a good curve.
8. The pubic arch angle are wide, i.e. more than 90
9. Intertuberous diameter is wide

Favorable pelvic shape for vaginal delivery:

Favorable: gynecoid, anthropoid
Less favorable: android, platypelloid
Many pelvis of women fall into intermediate categories
8/24/2017 Eyaya M. 45
Shape of bony pelvis
Gynecoid pelvis:
Classic female shape
Oval-shaped inlet,
Diverging midpelvic sidewalls,
Far-spaced ischial spines
Anthropoid pelvis:
Exaggerated oval shape to the inlet
Largest diameter being anteroposterior
Limited anterior capacity to the pelvis
More often associated with occiput posterior
position
 Android pelvis:
Male in pattern
Heart-shaped inlet
Prominent sacral promontory
Prominent ischial spines
Shallow sacrum
Converging midpelvic sidewalls
Increased risk of CPD.
Platypelloid pelvis:
Broad, and flat pelvis
Exaggerated oval-shaped inlet
Largest diameter being transverse diameter
Theoretically predisposing to transverse arrest
Management of labor and Delivery
Labor is considered normal when the
following conditions are fulfilled.
Parturient without any risk (eg. Pre-eclampsia,
Previous scar),
Labor should start spontaneously and at term,
Fetal presentation must be by vertex,
Delivery should be by spontaneous vertex
delivery
All stages of labor are lasting normal duration
The neonate is alive, normal and the
woman has uncomplicated pueperium.
Diagnosis of labor
One defines onset as the clock time when
painful contractions become regular
False labor may develop at any time & often
stops spontaneously, or it may proceed
rapidly into effective contractions.
A woman experiencing contractions is in
true labor unless a physician certifies that
after a reasonable time of observation the
woman is in false labor."
TRUE LABOUR PAIN FALSE LABOUR PAIN
Regular Irregular.
Increase progressively in frequency, Do not.
duration and intensity
Pain is felt in the abdomen and Pain is felt mainly in the
radiating to the back. abdomen.
Progressive dilatation and No effect on the cervix.
effacement of the cervix.
Membranes are bulging during No bulging of the
contractions. membranes.
Not relieved by Can be relieved by
antispasmodics or sedatives. antispasmodics and
sedatives.
 Diagnostic criteria
Painful uterine contractions accompanied by any one of
the following:
Ruptured membranes,
Bloody "show", or
Complete (100%) cervical effacement.
Admission Criteria
High-risk mothers should be admitted with the diagnosis
of latent or active phase of labor
Mothers with ruptured membranes should be admitted
irrespective of the stage of Labor
For a woman without known risk and intact membrane-
cervix dilation is 4 cms with complete effacement
(Active phase of labor)
Women admitted during latent-phase labor had more
active-phase arrest, need for oxytocin labor
stimulation, and chorioamnionitis.
Admission procedure
Warm and friendly acceptance
Immediate assessment of the general conditions of the
mother and fetus including assessment of whether delivery is
imminent or not, and to act accordingly
Appropriate history, physical examination and laboratory
investigations as indicated.
Lab. tests: - blood group and Rh, Hct, U/A, VDRL (if no
previous documentation or no ANC)
For those with ANC record, update Hct and U/A
Review ANC record and present evaluation and plan a scheme of
management during labor and immediate postpartum.
*All admission information should be transferred to a partograph.
Preparation of the vulva and perineum
Clipping of pubic hair if and when needed
Shower: if mobile and wishes
Clothing: loose hospital gown preferably
 General examination of the mother
a. General conditions evaluate the mother general
health condition. Look for pallor, edema, abdominal
scar (LSCS) and maternal height.
b. Vital signs Blood pressure, pulse, respiration and
temperature are taken and recorded
c. Heart and lungs
Abdominal examination:
a. A detailed abdominal examination should be carried out and
recorded.
b. Determine the presentation and position of the fetus and also
the engagement
c. Auscultate the fetal heart
d. Evaluate the uterine contraction
 Vaginal examination the purpose is to
a. To make a positive diagnosis of labour.
b. To make a positive identification of
presentation.
c. To determine whether the fetal head is
engaged in case of doubt.
d. To ascertain whether the fore waters have
ruptured or to rupture them artificially.
e. To exclude cord prolapse after rupture of the
fore waters.
f. To confirm the degree of cervical dilatation
and position of the presenting part.
g. To assess progress of labour.
h. To assess the adequacy of the pelvis.
 Bowel preparation:
If there has been no bowel action for 24 hours or the rectum feels loaded on
vaginal examination an enema is given.
Bladder care
A full bladder may initially prevent the fetal head from entering
the pelvic brim and later impede descent of the fetal head. It
will also inhibit effective uterine action.
The woman should be encouraged to empty her bladder every
1 - 2 hours during labor.
The quantity of urine passed should be measured and recorded
and a specimen obtained for testing.
Nutrition in early labour
When labour is established no oral feeding is allowed, but sips
of water.
15 ml magnesium trisilicate is given every 2 hours as an oral antacid to
guard against bronchospasm occurs if the acid vomitus is inhaled
during general anaesthesia "Mendelsons syndrome". Antacid injections
may be used instead.
If labour is delayed more than 8 hours, IV drip of glucose
5% or saline-glucose solution is given
 Position of labouring mother:
As long as the patient is healthy, the presentation
normal, the presenting part engaged, and the fetus in
good condition, the patient may walk about or may be
in bed, as she wishes.
Avoid supine position
Monitoring the progress of labour
Once labour has become established, all events during
labour should be recorded on a partogram.
a) The well-being of the fetus
b) The well-being of the mother
c) The progress of the labour
Pain relief
When the pains are severe an analgesic preparation
may be given.
Opiate drugs e.g. Pethidine given IM every 4 hour
Inhalational analgesia e.g. Entonox
Epidural analagesia
 Monitoring Fetal Well-Being during Labor
In the absence of any abnormalities, the FHR
should be checked immediately after a
contraction at least every 30 minutes and then
every 15 minutes during the second stage.
30 min for low risk and Q 15 min for high risk
Continuous electronic FHR monitoring for high risk
Uterine Contractions
Evaluate the frequency, duration, and intensity
of uterine contractions.
Maternal Vital Signs
Temperature, pulse, and blood pressure are
evaluated at least every 4 hours.
Management during 1st stage
All observations and findings should be recorded on the partograph.
Maternal wellbeing monitoring
Vital signs:
Maternal position - avoid supine position
Nutrition - In general encourage oral intake of liquid diet (tea, juice) but not hard
foods Consider fluid diet as a source of water and energy for those mothers staying
longer before delivery (e.g. small sips of sweetened tea or water )
Companionship in labor: encourage partner to accompany the spouse who is in
labor. Partner support and education should start during ante-natal care and
continue through delivery
Pain management - provide continuous emotional support
Inform laboring mothers about the procedures to which they will be subjected during
labor and delivery
The selected analgesia should be simple to administer, safe to the mother and fetus, no
undue effect on progress of labor, and available in the unit.
Timing, route, dosage and frequency of administration should be based on the
anticipated interval of time till delivery
Pethidine injection: 50 mg im initially. Assess after hr and if not adequate and side
effects not troublesome, repeat 50 mg . Onset of action within 10 -20 min and lasts for
2-4 hours
Fetal Well - being monitoring
FHR - use Pinnard stethoscope for a women with no
known problem
Immediately after a contraction for 1 min
Every 30 min for a parturient without any risk and every 15 min for
with a risk condition
Continuous electronic FHR monitoring for Known problem (
external/internal)
FHR 100-180 BPM is normal for term normal fetus. If FHR is
less than 100 or higher than 180 manage as Non reassuring
fetal heart pattern (NRFHRP)
Status of liquor for meconium
Grades of meconium
Grade I - good volume of liquor, lightly meconium stained
Grade II - Reasonable volume with a heavy suspension of meconium
Grade III - Thick meconium which is undiluted
NB a newly appearing meconium is quite significant
Monitoring of progress of labor
Uterine contraction - frequency in 10 minutes, duration
and intensity of each contraction determined by
palpation and or toco-dynamometer,
Monitored every 1 hr. for latent phase and every 30 min. for
active phase
Descent of fetal head: should be done by abdominal
palpation before vaginal examination
Vaginal examination to see:
Rate of cervical dilation at least 1 cm./hr.
Station, position, degree of moulding
The frequency of vaginal examination is every 4 hrs unless
the following condition occur
After spontaneous rupture of membranes
When there is abnormal FHR pattern
Before giving analgasia
Symptoms suggesting 2nd stage (to confirm the diagnosis)
The WHO partograph
Principles
The active phase commences at 4 cm cervical
dilation
During active phase, the rate of cervical dilation
should not be slower than 1cm/hr
Vaginal examination- infrequently as compatible
with safe practice (Q 4 hrs is recommended)
Midwives and other personnel managing labor
may have difficulty in constructing alert and
action line pre-drawn lines
61
Modified WHO partograph

62
The WHO partograph (ctd.)

Components
- Patient information
- Fetal condition
- Progress of labor
- Maternal condition

63
Information required upon admittance

Mrs. X 3 2
12.12.07 04.35 am 03.10
Dilatation of cervix
Cervical dilatation

Cervical dilatation of 1 cm/hour= progress

of labour follows the alert line standard
progress
> 1 cm/hour = progress line moves to the left
of the alert line = speedy progress

< 1 cm/hour = progress line moves to the right

of the alert line, moving towards or passing the
action line slow or prolonged progress
Cervix dilatation speedy vs. normal
vs. slow progress

08.00

10.00

15.00
67
Descent of foetal head determined by
abdominal examination

Head is Head is one hand

loose over width over the
the pelvic pelvic brim
brim = 5/5

Head is Head is two finger

moulding = width over the pelvic
2/5 brim

68
 Vaginal examination to see:
Rate of cervical dilation at least 1 cm./hr.
Station, position, degree of moulding

Assessing descent of head by vaginal examination

The frequency of vaginal examination is every 4 hrs unless the following condition occur
After spontaneous rupture of membranes
When there is abnormal FHR pattern
Before giving analgasia
Symptoms suggesting 2nd stage ( to confirm the diagnosis )
Descent of foetal head

08.00

70
Recording the contractions strength i.e. duration
in seconds

< 20 secs duration

20-40 secs duration

> 40 secs duration 71

Information about foetal status in labour
FHR 100-180 BPM is normal for term normal fetus. If FHR
is < 100 or > 180 manage as Non reassuring fetal heart
pattern (NRFHRP)
Mrs X 3 2
12.12.07 04.35 am 03.10

Amniotic
liqour

I, CM
B, A
73
 Amniotic fluid

I membranes intact
C clear amniotic fluid
blood-stained amniotic fluid
A absence of amniotic fluid
M meconium-stained amniotic fluid
Grades of meconium
Grade I - good volume of liquor, lightly meconium
stained
Grade II - Reasonable volume with a heavy suspension
of meconium
Grade III - Thick meconium which is undiluted
74
Information about foetal status in labour

Mrs X 3 2
12.12.07 04.35 am 03.10

Moulding
0 : no configuration (CONJUNCTIVE
TISSUE CAN EASILY be palpated)
+ : the bones are SLIGHTLY adjoined
75
++ : the bones overlap
+++: the bones overlap significantly
 Information about maternal status in labour

Pethidine 2% 2 ml

Maternal 36,7
temperature

50 ml

76
Abnormal progress of labor
Second Stage of Labor
Full dilatation of the cervix (10 cm) in between
uterine contractions is the most imminent sign
A woman typically begins to bear down & develops
the urge to defecate.
Uterine contractions and the accompanying
expulsive forces may now last 1 minutes and recur
at an interval no longer than 1 minute.
Rupture of membranes, although this is not specific as
it may occur earlier even before start of labor "prelabour
rupture of membranes" or later even to the degree
that the foetus is delivered in an intact sac.
The median duration of the second stage is 50
minutes in nulliparas and 20 minutes in multiparas
 Maternal care and wellbeing evaluation in 2nd stage of labor
Vital signs : continued as 1st stage but more frequently
Bp Q 30 min ( if indicated more frequently)
PR, temp., RR Q 1hr
Evaluate general condition fatigue , pain, physical depletion and
state of hydration
Evaluate the presence of the urge to push and / or effort
Avoid early push; it should start spontaneously.
LLP till head is visible and preparation
The woman should be encouraged to empty her Bladder before
delivery
FHR Monitoring in second stage of labor
Every 15 min for low-risk fetus
Every 5 min for high-risk fetus or continuous electronic
monitoring
Labor progress evaluation in second stage of labor
Evaluate the degree of descent every 1 hr.
 Diagnosis of prolonged 2nd stage
Nullipara- 2 hrs without or 3hrs with epidural
anesthesia
Multipara- 1 hrs without or 2hrs with epidural
anesthesia
Management of Prolonged 2nd stage
Reevaluate maternal and fetal condition
Rule out inefficient uterine contraction and
maternal expulsive effort, malposition,
malpresentation and CPD
Act accordingly
Factors affecting duration of the second stage
Epidural analgesia,
Nulliparity,
Older maternal age,
Longer active phase,
Larger birth weight,
Excess maternal weight gain
Maternal position
Allowing women to choose alternate positions
may be beneficial, especially in nulliparas
Delayed pushing
Preparation for delivery
General
Notify nursing staff that delivery is imminent.
Move the woman to the delivery room if its is separate.
Make sure all the equipment for delivery and newborn care are
available at the delivery room.
There should be a pre-warmed neonatal corner for neonatal care
Position the mother to semi-sitting (back up and leg down)
Attendant should be dressed and gloved appropriately (gloves,
gowns, apron, masks, caps, eye protection)
Sterile draping in such a way that only the immediate area about
the vulva is exposed.
Perineal care:-
Cleaning of the vulva and perineum with antiseptic (downward
and away from the introitus).
If pieces of faeces get expelled, wipe them downward.
Assistance of spontaneous delivery
Goal:-
Reduction of maternal trauma
Prevention of fetal injury
Initial support of the newborn
Episiotomy: individualization is important. Routine
performance of episiotomy should be avoided
Do episiotomy when there is
Threat for a perineal tear
Perineal resistance for fetal head descent
Fetal/maternal distress to expedited delivery
Timing of episiotomy performed when fetal head has
distended the vulva 2-3cms unless early delivery is
indicated.
Types- median or mediolateral
Use analgesia/anesthesia for making episiotomy and repair.
Delivery of the Head
Prevent rapid delivery and assist extension of the head.
Assist using modified Ritgens maneuver if extension
does not occur with ease i.e., hand protected with
sterile towel placed on the perineum and the fetal chin
palpated and pressed up ward gently effecting
extension.
After delivery of the head, wipe the face; aspirate
mucus from fetal mouth, oropharynx 1st and then
nares (use suction catheter in the presence of thick
meconium).
Check for cord around the neck
Disentangle the cord from around the neck and slip it
over the head or clamp at two sites and cut in
between if not reducible.
 The main aim during delivery of
the head is to prevent perineal
lacerations through the following
instructions
Support of the perineum
Delivery of the shoulders
Gentle downward traction is
applied to the head till the anterior
shoulder slips under the symphysis
pubis. The head is lifted upwards
to deliver the posterior
Delivery of the remainder of the
body
Usually slips without difficulty
otherwise gentle traction is applied
to complete delivery.
Clamping the cord
This may be enhanced by milking
the cord towards the baby, to add
about 100 ml of blood to its
circulation.
The cord is divided between 2
clamps to avoid bleeding from a
possible 2nd uniovular twin.
Immediate newborn care
Prevent heat loss: -
Use warm towel
Change moist/wet towel
Care for the newborn on a table in a thermo-neutral room
Evaluate using APGAR score
Neonatal resuscitation using the Melbourne Chart
Tie the cord and label the baby
Take weight, head circumference and length
Give neonatal eye prophylaxis: - 1% TTC eye ointment, 0.5%
erythromycin
Vitamin K 1mg IM.
Immunization
Handover the newborn to the mother
 Third stage: Delivery of baby until delivery of
the placenta
Median duration:
6 minutes
Exceeded 30 minutes in 3% of women
Duration not affected by parity
30 minutes associated increased risk of:
> 500-ml blood loss,
> 10% drop in post-delivery hematocrit
Need for D&C
Manual removal and or extraction of the placenta
is indicated after 30 minutes (or earlier in PPH)
Signs of placental separation
Lengthening of the umbilical cord
the most reliable sign.
The uterus takes on a more globular shape and
becomes firmer
This occurs as the placenta descends into the lower
segment and the body of the uterus continues to retract.
The uterus rises in the abdomen.. Fundus rises to level
of umbilicus
The descent of the placenta into the lower segment, and
finally into the vagina, displaces the uterus upward.
A gush of blood occurs.
is not a reliable indicator of complete separation.
Management of 3rd stage
1. Physiologic/conservative/expectant management
of third stage
Waiting for signs of placental separation & allowing
spontaneous delivery of the placenta by gravity and/or
nipple stimulation.
2. Active management of third stage of labor
(AMTSL)
Administration of uterotonic agent after the delivery of
the neonate,
Early cord clamping,
Controlled cord traction &
Uterine massage after the delivery of the placenta.
Components of AMTSL
1. Administration of prophylactic uterotonic agents
The fundus is assessed immediately following delivery
of the baby, thus excluding an undiagnosed twin and
giving a baseline fundal height.
Administer uterotonic agent with in 1 min of the
completed delivery of the newborn.
Promotes strong uterine contractions and
Leads to faster retraction and placental delivery.
Decreases the amount of maternal blood loss and the
rate of PPH.
Leads to a reduction in the incidence of retained
placenta.
Uterotonic agents
Oxytocin
The preferred and 1st line choice for AMTSL
10 IU of oxytocin is administered intramuscularly.
In patients with intravenous access in place, 10-20 IU is
placed in 500-1000 mL of crystalloid and run quickly.
Ergot preparations
The usual dose of ergonovine is 0.2-0.25 mg IM
Increased rates of manual removal of the placenta
Increases in nausea, vomiting, and blood pressure
Avoid ergot preparations in patients with hypertension, history
of migraine.
Misoprostol
Misoprostol 400-600mg po
Its low cost, pill form, and heat stability make it a potentially excellent agent
in low resource settings.
Inferior to injectable uterotonics in effectiveness
Adverse effects, such as shivering, fever, nausea, vomiting, and diarrhea
 Oxytocine Ergot preparations Misoprostol
Site of action Specific for uterine Systemic smooth
smooth muscle muscle
Uterine Increased strength and Tetanic contraction
contraction frequency
Heat stability Relatively stable (15 Not stable (28C and Stable (room
30C, protect from protect from light and temperature, in a
freezing) from freezing) closed container)
Duration of Short long
action
Cost cheap Costy Most cheap
Effectiveness +++ +++ ++
Need skilled yes yes no
provider

Contraindication 0% 15% 0%

Serious side rare common rare

effects
2. Early cord clumping
Early cord clamping may be indicated in order to facilitate
newborn assessment or resuscitation.
Delaying cord clamping until the cord is pulseless, usually 1-
3 minutes, results in higher hemoglobin and hematocrit
values in the newborn and, possibly, lower levels of early
childhood anemia and greater iron stores.
Holding the newborn below the level of the placenta or
"milking" the cord toward the baby to exaggerate this
transfer is discouraged
The cord should be singly clamped; a 2nd clamp should then
be placed after the blood has been milked from the segment
of cord between the 2 clamps.
The cord is then divided between the clamps in a relatively
bloodless manner.
Place the clamps a reasonable distance from the newborn
so that the newborn caregivers can place the cord tie or
disposable cord clamp at the appropriate place
3. Controlled cord traction (CCT)
Clamp the cord close to the perineum & hold in one hand
Place the other hand just above the womans pubic bone & stabilize the
uterus by applying counter pressure during CCT
Keep slight tension on the cord & await a strong uterine contraction (2-3min)
With the strong uterine contraction encourage the mother to push & very
gently pull down ward on the cord to deliver the placenta. Continue to apply
counter pressure on the uterus.
If the placenta doesnt descend during 30-40 sec of CCT do not continue to
pull on the cord.
Gentle cord traction is only applied when the uterus is well contracted, and
the uterus is manually controlled above the level of the symphysis with
counter traction (Brandt-Andrews maneuver).
Cord traction must never be applied in the absence of counter traction
Traction is applied in the axis of the birth canal initially downward, then
parallel to the floor, and finally upward as the placenta delivers.
Do not perform uterine massage before delivery of the placenta, and never
apply downward fundal pressure.
Placental delivery
The placenta usually presents with the cord insertion and the fetal
side of the placenta.
The membranes trail the placenta, and measures to prevent them
from tearing include slowly rotating the placenta about the
insertion site as it descends or grasping the membranes with a
clamp.
Following delivery of the placenta, make sure that the uterus is well
contracted and bleeding is minimal.
After delivery, the placenta, umbilical cord, & fetal membranes should be
examined
- Weight:
- Placental weight (without membranes, cord) varies with NB weight
- Ratio of approximately 1 : 6
- Large placentae: hydrops fetalis, congenital syphilis etc
- Inspection of fetal & maternal sides
- Adherent clots
- Cord & placental abnormalities
 Examine fetal and maternal surfaces:
Fibrosis, infarction, calcification
extensive lesions prompts histologic examination
Adherent clots: recent placental abruption
absence does not exclude abruption
Missing placental cotyledon or a membrane defect
Missing succenturiate lobe prompts further clinical
evaluation
No routine manual exploration of uterus unless suspicion of
retained products of conception or PPH
The site of insertion of the umbilical cord into the
placenta should be noted.
Abnormal insertions include
Marginal insertion (in which the cord inserts into the edge of the
placenta)
Membranous insertion (in which the vessels of the umbilical cord
course through the membranes before attachment to the placental
disk).
 The cord itself should be inspected for:
Length: average cord length is 50 to 60
cm
Correct number of umbilical vessels
(normally two arteries and one vein);
A single umbilical artery is associated with
other fetal structural anomalies in 27% of
cases: need for thorough examination of NB
True knots,
Hematomas,
Strictures
4. Uterine massage
Immediately massage the fundus of the uterus
until its contracted
Palpate for a contracted uterus every 15min &
repeat uterine massage as needed during the
first 2hrs
Ensure that the uterus doesnt become relaxed
(soft) after you stop uterine massage.
PERINEAL INJURY
Perineal injuries, either spontaneous or with episiotomy,
are the most common complications of spontaneous or
operative vaginal deliveries.
Classification:
First-degree tear: superficial tear confined to the
epithelial layer
Second-degree tears extend into the perineal body but
not into the external anal sphincter
Third-degree tears involve superficial or deep injury to
the external anal sphincter
Fourth-degree tear extends completely through the
rectal mucosa
Significant morbidity is associated with 3rd- and 4th-degree
tears, including risk of flatus and stool incontinence, rectal
vaginal fistula, infection, and pain
 Following delivery of the placenta, the cervix,
vagina, and perineum should be carefully
examined for evidence of injury.
If a laceration is seen, its length and position
should be noted and repair initiated.
Adequate analgesia (either regional or local) is
essential for repair
Special attention should be paid to repair of the
perineal body, the external anal sphincter, and the
rectal mucosa.
Primary approximation of perineal laceration
affords the best opportunity for functional repair,
especially if there is evidence of rectal sphincter
injury
Episiotomy
Incision into the perineal body made during the second stage of
labor to facilitate delivery.
It is a second-degree tear.
Classified:
Median (midline)
Mediolateral
No role for routine episiotomy except indicated episiotomy to
expedite delivery in:
NRFHR
Relief of shoulder dystocia
Adequate analgesia, either local or regional
Avoid direct injury to anal sphincter
Complications:
Increased blood loss, especially if the incision is made too early, fetal injury,
and localized pain
May lead to 3rd and 4th degree tear
Benefits of AMTSL
Shortens duration of third stage
Less maternal blood loss (60% reduction in the
occurrence of PPH greater than or equal to 500 mL
and 1000 mL)
Less anemia in postpartum (hemoglobin conc. of
less than 9 g/dL at 24-48 hours after delivery)
Less need of blood transfusion
An 80% reduction in the need for therapeutic
uterotonic agents postpartum
Less need for manual removal
 CARE FOR THE NEWBORN BABY AT THE
TIME OF BIRTH
In Ethiopia Most neonates die mainly from three
causes:
Neonatal infection (47%) : Sepsis, Tetanus, Diarrhea and
pneumonia
Birth Asphyxia (23%)
Preterm delivery/ Low birth weight (17%)
We should mainly focus on the triads of activities that
should be carried out routinely:
Ensure the provision of Essential newborn care to all babies
Early detection and management of common newborn
problems particularly Birth asphyxia, and neonatal infection.
Provision of extra care and creation of an environment of
thermal comfort to all preterm and low birth weight babies
Steps of Essential Newborn Care
Deliver baby onto mothers abdomen
Dry baby with a warm and clean towel
Remove the wet towel and wrap the baby with dry
towel and for preterm babies you wrap them with
double towels
Assess the babys breathing while drying - make sure
that there is not second baby
Clamp and cut the umbilical cord
Put the baby between mothers breasts for skin-to
skin-care
Cover mother and baby with warm cloth
Place and identity label on baby
Put a hat on the babys head and put socks also
Start breastfeeding within one hour of life.
Resuscitation of Asphyxiated newborn
If the baby is not breathing, gasping or
breathing < 30/minute and if drying the baby
does not stimulate him to breathe, the first
step of resuscitation should be started
immediately.
CALL FOR HELP!
Cut cord quickly, transfer to a firm, warm surface
[under an over head heater source]
Inform the mother that baby has difficulty
breathing and you will help the baby to breathe
Start newborn resuscitation
Opening the airway
POSITIONING
Lay the baby on its back on a hard warm surface
Position the babys head so that is slightly
extended
Place a folded piece of cloth under the babys
shoulders
SUCTION
Routine suctioning may not be required. Do it
when there is Meconium stained liquor
Ventilating the baby
If the baby is still not breathing, VENTILATE.
Components of postpartum care
Early detection and management of
complications
Promoting health and preventing disease
Providing woman-centered education and
counseling
Specific postpartum care and treatment
Nutrition:
A regular diet should be offered as soon as the woman
requests food and is conscious.
Intake should be increased by 10% (not physically active)
to 20% (moderately or very active) to cover energy cost
of lactation.
Women should be advised to eat a diet that is rich in
proteins and fluids.
Eating more of staple food (cereal or tuber)
Greater consumption of non-saturated fats
Encourage foods rich in iron (e.g., liver, dark green leafy
vegetables, etc.)
Avoid all dietary restrictions
Breastfeeding
Early skin to skin contact of mother and baby and immediate initiation of
breast feeding
Initiate breastfeeding within 2-3 hours of CS; when the mother is conscious
Incase breast feeding cant be started due to either maternal or newborn
illness, feeding the baby has to be initiated if possible by milk sucked from the
mother herself.
Rooming in throughout the hospital stay of mother and baby
Women should be encouraged to maintain exclusive breast feeding for six
months and should be educated about effective breastfeeding practices, as
well as common breastfeeding problems, how to continue breast feeding
for two years and to start complementary feeding after six months. See
PMTCT section on breast feeding advice regarding HIV infected women.
Postpartum education and counseling includes:
Correct positioning of the baby at the breast
Exclusive breast feeding.: No other fluids e.g. herbs, glucose, or sugar water
should be given
Encouraging breast feeding on demand
- If there is a medical contraindication to breastfeeding, firm support of the
breasts can suppress lactation. For many women, tight binding of the breasts,
cold packs, and analgesics followed by firm support effectively control
temporary symptoms while lactation is being suppressed
Postpartum family planning
All postpartum women should receive family planning
education and counseling before discharge.
Ideally, counseling for postpartum contraception should start
during the antenatal period, and should be an integral part of
antenatal care
Women who had no antenatal care and those who did not
receive counseling during the ante natal period, should be
counseled for family planning in the immediate post partum
period, after their own and their babys condition have
stabilized.
Women should be informed about the advantages of birth
spacing for at least two years before getting pregnant again
and about different family planning options.
Women should also be given a choice of receiving a family
planning method in the labor ward before discharge from
hospital or at a family planning clinic within the first 40 days
postpartum.
 Advise against use of combined oral contraceptives
in breastfeeding women in the first 6 months after
childbirth or until weaning, whichever comes first
Women who are interested in immediate initiation
of contraception should be offered a family
planning method before discharge.
Women who were counseled during antenatal care
and who had indicated a desire for postpartum IUD
insertion or tubal ligation could have an IUD
inserted at delivery (postplacental IUD insertion) or
have minilap for tubal ligation. Other women could
have an IUD inserted before discharge or receive
any other method depending on their needs.
Sexual activity
Intercourse may be resumed after cessation of
bleeding and discharge, and as soon as desired and
comfortable to the woman.
However, a delay in sexual activity should be
considered for women who need to heal from
lacerations or episiotomy repairs.
Sexual activity after childbirth may be affected due
to decreased sexual desire (due to fatigue and
disturbed sleep patterns, genital lacerations/
episiotomy), hypoestrogenization of the vagina,
and power issues in marriage.
Pain management
Common causes: after-pain and episiotomy
Episiotomy pain: immediately after delivery, ice packs may help
reduce pain and edema at the site of an episiotomy or repaired
laceration; later, warm sitz baths several times a day can be used.
Analgesics are used if not relieved.
Contractions of the involution uterus, if painful (after-pains), may
require analgesics.
Commonly used analgesics include:
Aspirin 600 mg,
Acetaminophen 650 mg
Ibuprofen 400 mg orally every 4 to 6 hours
Rh-negative blood group
Women with Rh-negative blood group, who have an infant
with Rh-positive blood and are not sensitized, should be
given Rh0(D) immune globulin 300 g IM, as soon as possible
(preferably within 72 hours of delivery) to prevent
sensitization.
Follow-up visit:
Women should be informed that they should make
a follow up visit to the hospital or to a health unit
on 6th day and at six weeks postpartum. The
schedule should not be rigid. It should incorporate
maternal (family) convenience and medical
condition.
They should also be informed to come back to
hospital if they feel any symptoms that worry
them. The education regarding complication and
preparedness includes:
Danger signals for woman
Sudden and profuse blood loss, persistent or increased
blood loss
Fainting, dizziness, palpitations
Fever, shivering, abdominal pain, and/or offensive
vaginal discharge
Painful or hot breast(s)
Abdominal pain
Calf pain, redness or swelling
Shortness of breath or chest pain
Excessive tiredness
Severe headaches accompanied, visual disturbances
Edema in hands and face
 DANGER SIGNS IN NEWBORNS
Unable to breastfeed (Unable to suck or sucking poorly)
Convulsions
Drowsy or unconscious
Apnea (cessation of breathing for >20 secs)
Breathing 30 or 60 breaths per minute, grunting, severe chest
in drawing, blue tongue & lips, or gasping
Grunting
Severe chest in drawing
Central cyanosis
Feels cold to touch or axillary temperature < 35C
Feels hot to touch or axillary temperature 37.5C
Red swollen eyelids and pus discharge from the eyes
Jaundice /yellow skin: at age < 24 hours or > 2 weeks Involving
soles and palms
Pallor, bleeding from any site
Repeated Vomiting, swollen abdomen, no stool after 24 hour