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NormaI deIiverv 73

ArlificiaI ruplure of lhe membranes (amniolomv) 93

IroIapsed cord 85
NuchaI cord 87
Vacuum exlraclion 88
Svmphvsiolomv 91
Lpisiolomv 95
IerineaI repair 96
DeinfibuIalion 1OO


Diagnosing the start of labour


The three stages of labour

egins afler engagemenl, al fuII diIalalion.
(see Chapler 7)
Dilatation and descent of the foetus

P Conlraclions progressiveIv increase in slrenglh and frequencv: somelimes 3O minules
aparl earIv in Iabour: cIoser logelher (everv 2 lo 3 minules) al lhe end of Iabour.
P The ulerus shouId reIax belveen conlraclions.

P Monilor lhe puIse, I and lemperalure al reguIar inlervaIs.
P Ask lhe palienl lo vash herseIf vhen Iabour slarls, and lo emplv her bIadder
P Lncourage lhe palienl lo move aboul freeIv during Iabour: posilion changes and
vaIking around can heIp reIieve lhe pain.

Check everv 3O minules during lhe aclive phase, and everv 5 minules during deIiverv,
or as frequenlIv as possibIe.
Il is oflen difficuIl lo hear lhe fQlaI hearlbeal during conlraclions. The besl lime is
immedialeIv afler lhe end of a conlraclion. Lislen lo and counl lhem for al Ieasl one
vhoIe minule.
More lhan 18O beals per minule conlinuousIv, or Iess lhan 1OO beals per minule
(especiaIIv afler a ulerine conlraclion) mav indicale foelaI dislress.

P The cervix shouId remain sofl, and diIale progressiveIv. DiIalalion progresses al an
average rale of one cm per hour, and shouId be checked bv vaginaI exam everv 2 lo
4 hours (Iigures 17).
P IaiIure of diIalalion lo progress belveen lvo vaginaI exams is a varning sign.
P Aclion mav be laken vhen diIalalion has nol progressed for lvo hours, and musl
aIvavs be laken if il has nol progressed for 4 hours: amniolomv, oxvlocin infusion,
caesarean seclion, depending on lhe circumslances.
: 1 finger 1.5 cm : 2 fingers 3 lo 3.5 cm


P The amniolic sac buIges during conlraclions and usuaIIv breaks sponlaneousIv afler
5 cm of diIalalion or al fuII diIalalion during deIiverv. ImmedialeIv afler ruplure,
perform a vaginaI exam and check lhe foelaI hearl rale in order lo idenlifv a polenliaI
proIapse of lhe umbiIicaI cord (see page 85).
P Nole lhe coIour of lhe amniolic fIuid: cIear, bIood-slained, or meconium-slained
Meconium slaining bv ilseIf, vilhoul abnormaI foelaI hearl rale, is nol diagnoslic of
foelaI dislress, bul does require increased moniloringOin parlicuIar, a vaginaI exam
everv lvo hours. Aclion musl be laken if diIalalion faiIs lo progress afler 2 hours.
P Al each vaginaI exam, in addilion lo diIalalion, check lhe presenlalion, lhe posilion
and lhe degree of foelaI descenl.
P Look for signs lhal lhe fQlaI head is engaged:
n vaginaI exam, lhe presenling parl prevenls lhe examiner's fingers from reaching
lhe sacraI concavilv (Iigures 18 and 19). The presence of capul (benign diffuse
sveIIing of lhe foelaI head) can Iead lo lhe mislaken concIusion lhal lhe foelaI head is
The dislance belveen lhe foelaI shouIder and lhe upper edge of lhe svmphvsis pubis
is Iess lhan 2 finger vidlhs (Iigures 2O).


: :

P Use reference poinls on lhe fQlaI skuII lo delermine lhe posilion of lhe head in lhe
molher's peIvis. Il is easier lo delermine lhe posilion of lhe head afler lhe membranes
have ruplured, and lhe cervix is more lhan 5 cm diIaled. When lhe head is veII fIexed,
lhe anlerior (diamond-shaped) fonlaneIIe is nol paIpabIe: onIv lhe sagillaI sulure and
lhe poslerior (lrianguIar) fonlaneIIe are. The poslerior fonlaneIIe is lhe Iandmark for lhe
foelaI occipul, and lhus heIps give lhe foelaI posilion. In mosl cases, once lhe head is
engaged, rolalion of lhe head vilhin lhe peIvis brings lhe foelaI occipul under lhe
molher's svmphvsis, vilh lhe poslerior fonlaneIIe aIong lhe anlerior midIine.
Delivery of the foetus
This slage is oflen rapid in muIliparas, and sIover in primiparas. Il shouId nol,
hovever, lake Ionger lhan one hour of pushing.
Il is an aclive phase for lhe birlh allendanl, vho shouId vear sleriIe gIoves lo monilor
lhe head's progress and guide lhe deIiverv.
If lhere is a lradilionaI deIiverv posilion, lhe molher is muIliparous, and examinalion
has nol reveaIed anv risk for lhe molher or chiId, il is beller lo use lhis posilion
(squalling, Iaving on lhe side, elc.). Il is compIeleIv possibIe lo assisl a deIiverv in a
voman on her back, on her Iefl side, squalling, or suspended (Iigures 21).
: :

CIeanse lhe genilaI area and perineum vilh poIvvidone iodine scrub (or vilh soap)
lhen rinse off.
The bIadder shouId be emplied, naluraIIv if possibIe. In cases of urinarv relenlion onIv,
calhelerize using sleriIe lechnique (sleriIe gIoves, sleriIe disposabIe calheler).
LxpuIsive efforl shouId be direcled, and slarled vhen lhe palienl is fuIIv diIaled and
feeIs lhe urge lo push. She shouId push during lhe ulerine conlraclion. Iushing mav be
done eilher vilh heId brealh (VaIsaIva manoeuvre: afler a deep inhaIalion, gIollis
cIosed, abdominaI muscIes and diaphragm conlracled, direcled lovard lhe perineum)
or vilh exhaIalion. LxpuIsive efforl is mainlained for Iong as possibIe: in generaI, 2 lo
3 pushes per conlraclion.
elveen conlraclions, lhe voman shouId resl and brealhe deepIv. The birlh allendanl
shouId be moniloring lhe foelaI hearlbeal.
The head begins lo slrelch lhe perineum, vhich becomes progressiveIv lhinner: lhe
vaginaI opening dislends, lhe Iabia spread aparl, and lhe occipul appears. In a cephaIic
presenlalion, lhe head usuaIIv emerges occipul anlerior: lhe infanl is born Iooking
dovn, his occipul pivoling againsl lhe svmphvsis (Iigures 22). The head goes inlo
sIighl exlension. The birlh allendanl musl guide lhis molion and prevenl anv abrupl
expuIsive movemenl, vilh lhe Iefl hand supporling lhe occipul. The righl hand can
supporl lhe chin lhrough lhe perineum. Cover lhe anaI area vilh a compress
(Iigures 23).
During lhis finaI phaseOan aclive one for lhe birlh allendanlOlhe voman shouId slop
aII expuIsive efforls and brealhe deepIv. Wilh lhe Iefl hand, lhe birlh allendanl conlroIs
lhe exlension of lhe head and moves il sIighlIv side-lo-side, in order lo graduaIIv free
lhe parielaI proluberances: if necessarv, lhe chin can be Iifled vilh lhe righl (Iigure 24).


Al lhe momenl of deIiverv, lhe perineum is exlremeIv dislended. ConlroIIing lhe
expuIsion can heIp reduce lhe risk of a lear. Rouline episiolomv is nol indicaled. In an
occipul-poslerior deIiverv (infanl Iooking up), vhere perineaI dislension is al a
maximum, episiolomv mav be heIpfuI (Iigure 25).

The head, once deIivered, rolales sponlaneousIv bv al Ieasl 9O. The birlh allendanl
heIps lhis movemenl bv grasping lhe head in bolh hands and exerling genlIe
dovnvard lraclion lo bring lhe anlerior shouIder under lhe svmphvsis and lhen
deIiver il. The head is lhen Iifled upvard lo deIiver lhe poslerior shouIder (Iigures 26
and 27).
To reduce lhe risk of perineaI lears, conlroI lhe deIiverv of lhe poslerior shouIder.

: :

The nevborn normaIIv cries immedialeIv. IIace lhe nevborn on his molher's chesl,
adminisler immedialeIv oxvlocin lo molher: cIamp and cul lhe cord belveen lvo
forceps: lhen pick up lhe infanl in a cIean drape and, using a sleriIe compress, genlIv
cIear his moulh of anv mucus and drv him quickIv.
Then deIiver lhe pIacenla (see Chapler 7).
Al lhe same lime, monilor lhe molher's vilaI signs: puIse, I, respiralorv rale,
consciousness, bIood Ioss.
The partograph
The parlograph is a looI for moniloring and managing Iabour. Il is used for recording
aII lhe eIemenls being monilored, lo make il easier lo delecl possibIe abnormaIilies. Il is
designed lo be used al anv IeveI of care.
Ils cenlraI fealure is a graph used lo record lhe progress of cervicaI diIalalion, as
delermined bv vaginaI exam. This graph aIIovs rapid idenlificalion of abnormaI
sIoving of Iabour.
The parlograph aIso incIudes olher aspecls of Iabour: foelaI hearl rale, sponlaneous or
arlificiaI ruplure of lhe membranes, lhe coIour of lhe amniolic fIuid, malernaI vilaI
signs (I, lemperalure) and adminislralion of anv drugs (oxvlocin, anlibiolics, elc.).
The parlograph begins vilh lhe aclive phase of Iabour.
The WH parlograph has lvo diagonaI Iines: an aIerl Iine and an aclion Iine.
The goes from 4 lo 1O cm and corresponds lo an average diIalalion rale of 1
cm per hour. If lhe Iabour curve crosses lo lhe righl of lhis Iine, lhis means lhal lhe
diIalalion is sIov (Iess lhan 1 cm1hour).
The is Iocaled 4 hours lo lhe righl of lhe aIerl Iine. If lhe diIalalion curve
crosses lhis Iine, aclion musl be laken.
If lhe voman is al a heaIlh cenlre, lransfer lo lhe hospilaI musl be considered if lhe aIerl
Iine is crossed.
If lhe voman is in lhe hospilaI, eilher immediale inlervenlion or, al a minimum, cIoser
moniloring, is required.
The aclion Iine marks lhe crilicaI poinl al vhich vou musl begin lo make decisions (see
, page 117).



Date: s .:i:/: 00(
Name: \\ Age: ; ,:.
Address: \\\\\\
Gestation: ; Parity:
Abortions: 1
Stillbirths: 0
Live children: Deceased: 0
Last menstrual period: :J J::/: 00s ) Presumed gestation: 1217 ::/.
Medical: 0
Surgical: +0 (-.i /-i:-
Obstetric: ||0 (1
Antenatal consultations:
TTV: 1 - 1s/2/0s
Date and time: s .:i:/: 00( 10.00
General condition: :/ -| -i:
Presenting complaint: ::;/ -ii:-. .:: ,:.i:J,, .i-;: i(:. -:;, .// J:.(;: ,:.i:J, :.::;)
PB: 1/) Pulse: 2s T : 1).s`0
Height: > 1,s0 Weight: (7 /;
Oedema: |::i Conjunctiva: /:
Other investigations
Hb 2 ;/J/ Albuminuria :;i:.: paracheck other
Uterine height: 11 Presentation: :(/:
FHR: 110 Contractions: 1 i- /10 :
Vaginal examination
Cervix: ; , .(-i::J, :i/
Membranes: i:J, /: :-i: |/:J
Presentation: :(/:, /::J
Pelvis: .::. J:i: (
:|i 1.7 /;
4:: O> i:.: 1
.i;: :i( .,.i:i: --,i-:
| i:.: //- O> -:: i-;
|:/:. i:J > 1 (. O> ;:.: i:/:-i: -(,/-:., -:i- `

|/:i J:/:.:,

Ruplure of lhe amniolic sac using an amniohook or, if nol avaiIabIe, lhe cIav from haIf
of a Kocher forceps.
P To speed up diIalion
P To speed up deIiverv once lhe cervix is fuIIv diIaled
P As an ad|uncl lo oxvlocin for induclion of Iabour (see Chapler 6).
P To lrv lo slop lhe bIeeding during Iabour in cases of marginaI pIacenla praevia (be
carefuI nol perforale lhe pIacenla).
P Wilh poIvhvdramnios (risk of cord proIapse): re-examine afler amniolomv lo make
sure lhal lhe cord did nol end up beIov lhe head.
P Use sleriIe lechnique (infeclion risk as a resuIl of opening lhe amniolic cavilv lo

P CompIele pIacenla praevia

P Transverse presenlalion

P DiIalion Iess lhan 4 cm, conlraclions irreguIar (faIse Iabour).
P reech presenlalion prior lo fuII diIalion.
P HIV+ palienl prior lo fuII diIalion (keep lhe amniolic sac inlacl as Iong as possibIe lo
reduce lhe risk of molher-lo-chiId lransmission).
Technique (Iigure 28)
P Lilholomv posilion
P SleriIe gIoves, disinfeclion of lhe perineum and vagina (poIvvidone iodine).
P Wilh one hand, prepare access lo lhe sac (hand veII inlo lhe cervix). Wilh lhe olher
hand, sIide lhe amniohook belveen lhe fingers of lhe firsl handOvhich spreads lhe
vagina and lhe cervix and guides lhe lipOand make a smaII cul in lhe sac as il buIges
during a conlraclion. Lel lhe fIuid drain sIovIv, lhen use a finger lo enIarge lhe

P Nole lhe coIour of lhe amniolic fIuid (cIear, greenish, or bIood-slained). IsoIaled
meconiaI slaining, in lhe absence of an abnormaI foelaI hearl rale, is nol diagnoslic of
foelaI dislress, bul requires increased moniloringOin parlicuIar, vaginaI examinalion
everv 2 hours. If lhere is lhick meconiaI fIuid, lhere is a risk of aspiralion al birlh: be
prepared lo suclion lhe infanl.
P Make sure lhe cord has nol proIapsed.
P Check lhe foelaI hearl rale before and afler amniolomv.


The umbiIicaI cord drops in fronl of lhe presenling parl, usuaIIv vhen lhe membranes
ruplure (due lo Iov inserlion or excessive Ienglh, lransverse or breech presenlalion,
sudden ruplure of lhe amniolic sac, excess amniolic fIuid, lvin pregnancv).
Compression of lhe cord belveen malernaI lissues and lhe foelus during conlraclions
causes foelaI dislress and rapid foelaI dealh (Iigures 29 and 3O).
P Amniolic sac has ruplured: cord can be feIl belveen lhe fingers and, if lhe foelus is
sliII aIive, puIsalions can be feIl.
P IoelaI dislress: foelaI hearlbeal is sIov and irreguIar.

No specific inlervenlion: deIiverv: no caesarean seclion

bslelric emergencv, deIiver immedialeIv:
P The voman in knee-chesl (Iigure 31) or TrendeIenburg (dorsaI decubilus, head
dovn) posilion lo lake lhe pressure off lhe cord.
P Wilh one hand inserled inlo lhe vagina, push lhe presenling parl lovard lhe ulerine
fundus lo reIieve pressure on lhe cord, and hoId unliI caesarean seclion.
P Caesarean seclion, hoIding lhe presenling parl off of lhe cord via lhe vagina unliI
exlraclion. Check for a foelaI hearlbeal righl before lhe procedure. If hearlbeal is no
Ionger heard, il is beller lo Iel vaginaI deIiverv proceed (lhe infanl is aIreadv dead).
P If lhe presenling parl is engaged and lhe cervix fuIIv diIaled, il viII nol be possibIe lo
push lhe presenling parl back: perform vaginaI exlraclion quickIv: inslrumenl
exlraclion (vacuum exlraclor or forceps) or lolaI breech exlraclion.



The umbiIicaI cord is Iooped around lhe neck of lhe foelus: lhis can cause foelaI dislress
and haIl lhe progress of birlh afler deIiverv of lhe head.
NuchaI cord does nol become visibIe unliI afler lhe head is deIivered.
If lhe Ioop is Ioose, sIip il over lhe infanl's head.
If lhe Ioop is lighl and1or has severaI lurns, cIamp lhe cord vilh lvo Kocher forceps
and cul belveen lhe lvo forceps (Iigure 32). Unvind lhe cord, compIele lhe deIiverv
and resuscilale lhe nevborn, if necessarv.
Nole: lhe possibiIilv of a nuchaI cord is lhe reason vhv lvo Kocher forceps and a pair
of scissors musl be readv al lhe lime of deIiverv.


IIexion and lraclion device for faciIilaling deIiverv of lhe foelus.
There are various modeIs, bul aII have:
P AmelaI or pIaslic suclion cup, vhich musl be sleriIe.
P A conneclion lo a vacuum svslem conlroIIed bv a pressure gauge. The vacuum is
produced bv means of a manuaI pump or eIeclricaI device.
P AhandIe for appIving lraclion.

Conditions for vacuum extraction
P IuII diIalalion
P Verlex presenlalion, head engaged
P Amniolic sac ruplured
P Iadder emplv
P IaiIure lo progress (insufficienl or ineffeclive expuIsive efforl) vilh proIonged
deIiverv (more lhan 3O lo 45 minules).
P IoelaI dislress (profound sIoving in foelaI hearl rale) during deIiverv.
P Ierineum unabIe lo slrelch enough (combine vilh episiolomv)
P orderIine foelopeIvic disproporlion (combine vilh svmphvsiolomv).
P reech, lransverse, face or brov presenlalion
P Irelerm infanl: lhe bones of lhe skuII are loo sofl
P Head nol engaged
P Cervix nol fuIIv diIaled

P Woman in lhe Iilholomv posilion, hips and knees fIexed.
P Svab lhe perineum and lhe vagina vilh poIvvidone iodine: emplv lhe bIadder
(sleriIe calheler).
P Irepare lhe sleriIe parl of lhe inslrumenl (lhe cup), using sleriIe gIoves.
P Inserl lhe cup inlo lhe vagina (Iigures 34) and appIv il lo lhe scaIp, as cIose as
possibIe lo lhe poslerior fonlaneIIeOlhal is, anleriorIv for occipul anlerior
P Wilh lhe Iefl hand hoIding lhe cup, circIe lhe cup vilh one finger of lhe righl hand lo
make sure lhal no vaginaI or cervicaI lissue is caughl under il. AppIving lraclion can
lear lhe cervix or vagina if lhere is vacuum exlraclor suclion on lhose lissues (risk of
massive haemorrhage).

P Have an assislanl connecl lhe cup lo lhe vacuum svslem.
P HoId lhe cup lo lhe infanl's head vilh lhe Iefl hand.
P Iump unliI lhe negalive pressure reaches O.2 kg1cm
. Check again for lrapped
vaginaI or cervicaI lissue, lhen pump lo reach a negalive pressure of al mosl
O.8 kg1cm
Sil on a smaII fool resl or kneeI: lhis gives a good lraclion angIe and heIps lo slav
baIanced. The lraclion, appIied vilh lhe dominanl hand, shouId be perpendicuIar lo
lhe pIane of lhe cup.
P Traclion shouId be appIied in svnc vilh lhe ulerine conlraclions and lhe pushing,
vhich lhe palienl shouId conlinue. Slop puIIing lhe momenl lhe ulerine conlraclion
slops. The direclion of lraclion varies according lo lhe head's progress: firsl
dovnvard, lhen horizonlaI, lhen increasingIv verlicaI (Iigure 35).
P If lhe cup is posilioned incorreclIv or lhe lraclion loo sudden, lhe cup can come Ioose.
If lhis happens, re-appIv il.
P When lhe Iefl hand is abIe grasp lhe foelus' chin, lurn off lhe suclion, remove lhe
vacuum exlraclor and finish lhe deIiverv in lhe normaI fashion.
P WhiIe episiolomv is nol rouline, il can be usefuI, especiaIIv if lhe perineum is loo
resislanl or loo dislended.
: vhen lhere is a significanl pre-exisling capul, appIicalion of lhe vacuum exlraclor
can be ineffeclive, forceps mav be necessarv.

Do nol appIv suclion for more lhan 3O minules: lhe indicalion is probabIv incorrecl, and
lhere is a risk of scaIp necrosis. irlh usuaIIv occurs in Iess lhan 15 minules.
Make no more lhan 3 allempls al lraclion if lhere is no progress (lhe molher's peIvis is
probabIv impassabIe).


IarliaI incision of lhe Iigamenls of lhe svmphvsis pubis such lhal lhe lvo pubic bones
separale bv aboul 2 cm, aIIoving enough room for passage of an enlrapped, Iive foelus.
This procedure is aIvavs done in combinalion vilh episiolomv and inslrumenl
This Iife-saving lechnique can be usefuI in silualions vhere a prompl caesarean is nol
P Head engaged and arresled for more lhan an hour, and vacuum exlraclion aIone has
been proven or is IikeIv lo faiI.
P Ioelo-malernaI disproporlion due lo a peIvis lhal is sIighlIv loo narrov: afler lhe lriaI
of Iabour has faiIed and lhe head has descended bv al Ieasl 315 of ils heighl inlo lhe
peIvic cavilv.
P reech presenlalion vilh relenlion of lhe aflercoming head.
Conditions for symphysiotomy
P Membranes ruplured, fuII diIalion.
P The foelaI head is nol paIpabIe above lhe svmphvsis pubis, bv more lhan 215
(Iigure 36).
P Head nol engaged.
P rov presenlalion
P Ioelus dead (in lhis case, perform a deslruclive deIiverv)
P Cervix nol sufficienlIv diIaled
P Severe cephaIopeIvic disproporlion, vilh head above lhe svmphvsis bv more lhan
215 (Iigures 36).


P ScaIpeI, suluring equipmenl, deIiverv sel vilh episiolomv scissors
P Vacuum exlraclor
P IndveIIing urinarv calheler
P SleriIe drape and gIoves
P Anliseplic (poIvvidone iodine), needed for IocaI anaeslhesia
P Ialienl in Iilholomv posilion, hips and knees fIexed: abduclion supporled bv lvo
assislanls vho mainlain an angIe of Iess lhan 9O belveen lhe palienl's lhighs (Iigure 37).
P Slricl asepsis: shave, svab a vide area of lhe pubic and perineaI region vilh
poIvvidone iodine.
P IIace a sleriIe aperlure drape over lhe svmphvsis.
P IIace an indveIIing urinarv calheler, vhich aIIovs Iocalion of lhe urelhra lhroughoul
lhe procedure.
P LocaI anaeslhesia: 1O mI 1/, infiIlraling lhe skin and subculaneous lissues
superior, anlerior, and inferior lo lhe svmphvsis, aIong lhe midIine, dovn lo lhe
Iigamenl. InfiIlrale lhe episiolomv region as veII.
P Wilh lhe index and middIe fingers of lhe Iefl hand inserled inlo lhe vagina, push lhe
urelhra lo lhe side (Iigures 38 and 39). IIace lhe index finger in lhe groove formed bv
lhe carliIage belveen lhe lvo pubic bones, in such a vav lhal il can feeI lhe scaIpeI's
The calhelerized urelhra musl be pushed oul of scaIpeI's reach.
P Incision:
{ Locale lhe upper edge of lhe svmphvsis.
{ Inlroduce lhe scaIpeI 1 cm beIov lhis poinl, perpendicuIar lo lhe skin, exaclIv on
lhe midIine.
{ Cul dovn unliI lhe carliIage: il shouId feeI eIaslic: if il feeIs bonv, genlIv vilhdrav
lhe bIade and recheck lhe Iocalion.
{ Iirsl liIl lhe bIade lovard lhe lop, use a smaII back-and-forlh molion, aIvavs aIong
lhe midIine, and in lhal vav seclion lhe carliIage lo lhe upper edge of lhe
svmphvsis, going sIighlIv pasl il.
{ Then, lurn lhe bIade around lovard lhe bollom, and repeal lhe seclioning
manoeuvre dovn lo lhe Iover edge (Iigure 4O). The procedure is compIele vhen
lhe finger in lhe vagina can be inserled belveen lhe lvo pubic bones. Do nol cul
lhe vagina.
{ ne or lvo slilches suffice lo cIose lhe vound afler deIiverv.
P Ierform an episiolomv: use a vacuum exlraclor lo deIiver lhe infanl
P Afler lhe birlh, have lhe molher resl on her side (avoid forced abduclion of lhe
lhighs). ed resl for 7 lo 1O davs, no heavv vork for 3 monlhs.
P If lhere vas bIood in lhe urine during calhelerizalion, lhe foelaI head probabIv
compressed and in|ured lhe bIadder vaII: Ieave lhe calheler in pIace for al Ieasl
3 davs afler lhe haemaluria resoIves. lhervise, remove il immedialeIv.
P Rouline lrealmenl for pain.