CONDUCTION OF

LABOUR
Dr. BWIRE INNOCENT
 Important definitions
1. Labor: regular painful uterine contractions
progressively stronger & more frequent
effacement and progressive dilatation of the
cervix & descent of the presenting part of the
fetus.
2. Normal labor/delivery: Spontaneous
expulsion of a single mature fetus presented by
vertex through the birth canal within a
reasonable time (not < 3 or > 18 h), without
complications to the mother or the fetus.
 Important definitions
True labor False labor
cervical changes+++: No cervical changes, if any >>>
effacement and dilatation minimal
Regular Contractions, more No regular contractions and
frequent, intense & longer not progressive Increase
Labor pain usually begins in the Pain may be located in the
back and radiates to the front fundus, lower abdomen or
in a band groin

Ambulation increases Rest, position changes, warm

contraction but rest won't bath/shower, hydration or
decrease it ambulation may relieve false
labor

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 Management and monitoring of a normal labor

Aims:
• To Achieve delivery of a normal healthy child with minimal
physical and psychological maternal effects.

• To Earlier anticipate, recognize and manage any

abnormalities during labor course.

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Preparation for a normal vaginal delivery
1. Antenatal preparation: maternal Education

• The physiology of labor & symptoms of

impending Labor

• Breathing exercise: teach the mother breathing

technic during labor to prevent respiratory
alkalosis caused by hyperventilation.
 Preparation for a normal vaginal delivery
2. Preparation at the admission
• Patient care: a shower or bath is recommended, wears laundered gown and
stays mobile. Shaving or hair clipping of the vulva is done. The vulva and the
perineum are washed (soap & water) and then with 10% Dettol solution or
chlorhexidine.

• Medical equipment and consumables to be checked sufficient and functional:

delivery set material for resuscitation,…
• Standard precautions (gloves, glasses, mask, gown, clogs) are mandatory
 First stage
It concerns dilatation of the cervix and descent of the fetus
• Latent phase: from the beginning of the labor to 4 cm of cervix
dilatation. The duration varies to the parity
• Active phase: from 4 cm to complete cervix dilatation. The
cervix dilates 1.5 cm/h in average. The duration is max 6-8 h in
multipara and 12 h in nullipara
 First stage
First assessment:
1. Assess the mother’s status:
- Clinical interview: gravidity, parity, age, gestational age, Past medical, surgical,
gynecological and obstetrical history, information about the current pregnancy
(record of ANC)
- Vital parameters and others: BP (each 1h), pulse (each 30 min), temperature
(each 2h), urine output, weight
- Lab investigation: urine strip (glucose and proteins), Hct blood groups, syphilis,
Hep B, counseling for HIV test if not done yet

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 First stage
2. Obstetrical assessment
• Abdominal palpation: conducted systematically employing
the four maneuvers described by Leopold in 1894. Determines
the presentation, the position, the level of engagement (just
indicative), the descent (indicative)

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 First stage
2. Obstetrical assessment
• Fundus Height: with an average of 33 cm

• Assess the contractions: the tocography is the reference methods to assess and
monitor the contractions. By the way, the palpation is still efficient. Assess:
frequency (Nb/10 min: earlier in the labor, we may have 1 contraction every 30
min, later on up to 1 contraction every 2-3 min), the duration in sec (may go up to
1 min) and the intensity (details in the partograph section). Watch the shape of the abdomen in order to spot
an Bandl’s ring.

• Assessment of the perineum: herpes lesions, scares, congenital abnormalities

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 First stage
2. Obstetrical assessment
• Vaginal examination: The standard precautions are mandatory. Information
captured:
 The assessment of the bony pelvic and soft parts
 The diagnosis of the presentation and the station or level: as the presenting fetal
part descends from the inlet toward the ischial spines, the designation is –5, –4,
–3, –2, –1, then 0 station (at the a=ischial spines). Below the spines, as the
presenting fetal part descends, it passes +1, +2, +3, +4, and +5 stations to
delivery. Station +5 cm corresponds to the fetal head being visible at the
introitus
 • The status of the membranes intact or ruptured and Color of
the amniotic fluid: clear ,meconium, blood or absent

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 First stage
2. Obstetrical assessment
 The status of the cervix:
Progressive shortening (effacement): length of the cervical canal compared
with that of an uneffaced cervix. When the cervix is reduced by one half, it is 50
% effaced. When the cervix becomes as thin as the adjacent lower uterine
segment 100 % effaced.

The position of the cervix: by the relationship of the cervical os to the fetal
head and is categorized as posterior, mid-position, or anterior. Along with
position, the consistency of cervix: soft, firm, or intermediate between these
two.
 First stage
2. Obstetrical assessment
 The status of the cervix:
Dilatation of the cervix: estimating the average diameter (cm) of the cervical opening
by sweeping the examining finger from the margin of the cervical opening on one side
to that on the opposite side
 First stage
2. Fetal wellbeing
• Fetal heart monitoring: done Pinard’s or ordinary stethoscope or electronically
(direct: echo Doppler; or indirect methods: scalp electrodes). The information: Fetal
heart rate & amplitude.

• Normal range of FHR: 110-160 bpm

Amplitude: 5-25 bpm
• Frequency of the monitoring: every 30 min
 First stage: additional recommendations
Rest and ambulation If the membranes are intact, the patient is
allowed to walk about. This attitude prevents vena caval
compression and encourages descent of the head
Diet: food is withheld, Adequate Fluid intake as plain water, hot tea
or fruit juice
Bladder care: encourage to pass urine (as full bladder often inhibits
uterine contraction and may lead to infection). Give a bed pan where
nedded. If the patient fails to pass urine specially in late first stage,
catheterization is to be done with strict aseptic precautions.
 Second stage
• Definition: This stage begins with complete cervical dilatation and ends with fetal
delivery. Usually, the patient feels the desire to defecate, the Reflex desire
to bear down during the contractions.
• Duration: The median duration is approximately 50 minutes for nulliparas and about
20 minutes for multiparas, but it is highly variable.
• FHR monitoring: each 15 minutes (each 5 minutes in high risk pregnancy)

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 Second stage

• Delivery room:
• The patient is transferred on a wheel or trolley to the delivery
room.
• Put her in the lithotomy position.
• The lower abdomen, upper parts of the thighs, vulva and
perineum are swabbed with antiseptic lotion
• Sterile towels is applied.
 Second stage
• Bearing down:Ask the patient to bear down during contractions and
relax in between
1 Delivery of the head: The main aim during delivery of the head is to
prevent perineal lacerations through the following instructions:
i) Support of the perineum:
• When the labia start to separate by the head, a sterile pad is
placed over the perineum and press on it with the right hand
during uterine contractions. This is continued until crowning
occurs to maintain flexion of the head.
 Second stage
• Crowning:is the permanent distension of the vulval ring by the
fetal head like a crown on the head.

DR BAVBIKIR RAJAB
ii) Episiotomy:
• It is done at crowning when the perineum is stretched to the
degree that it is about to tear.

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iii) Coils of the umbilical cord :
• if present around the neck are slipped over the head but if tight
or multiple they are cut between 2 clamps
2 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 shoulder first then downwards to
deliver the anterior shoulder.
DR BAVBIKIR RAJAB
3 Delivery of the remainder of the body:
Usually slips without difficulty otherwise gentle traction is
applied to complete delivery.
4 Clamping the cord:
Delay clamping the cord to reduce the risk of neonatal anemia but
if resuscitation is needed clamp and cut the cord immediately
• New born care : Clearance of the air passages, Apgar score , Congenital
anomalies , Weight , Dressing ,Care of the eyes:
 Third stage
• Immediately after the birth of the baby, palpate the abdomen to
rule out the presence of an additional baby(s).
• In the absence of an additional baby(s), give oxytocin 10 units
IM. If oxytocin is not available, give oral misoprostol 600
mcg OR ergometrine (0.2 mg IM)
• The most important intervention to reduce postpartum
hemorrhage is the immediate postpartum administration of
a uterotonic within one minute of birth.
 Third stage
• Delivery of the placenta
– 3 classic signs of placental separation:
– 1- Lengthening of the umbilical cord
– 2- Gush of blood from vagina
– 3- Change in shape of the uterine fundus to a
more globular appearance
 Active management of 3rd stage.

• Brandt-Andrews Maneuver: The palmar surface of the

fingers of the left hand is placed above the symphysis pubis
The body of the uterus is pushed upwards and backwards,
toward the umbilicus while by the right hand steady tension
(but not too strong traction) is given in downward and
backward direction holding the clamp until the placenta comes
outside. "control cord traction”

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• Fundal pressure the fundus is pushed downwards and
backwards after placing four fingers behind the fundus and the
thumb in front using the uterus as a sort of piston
Inspect the placenta and membrane
by exploring it under light or running water to be sure that it is
complete. If there is missed part, exploration of the uterus is done
under general anaesthesia
Explore the genital tract: For any lacerations that should be
immediately repaired