UNIVERSITY OF

HARGEISA
Normal labour and
birth
Edna Dahir

RN MSc SRH
 Normal labour
Onset of regular involuntary coordinated,
painful uterine contractions associated
with cervical effacement and dilatation
Delivery is the expulsion of the product of
the conception after fetal viability.
With in a reasonable time (not less than 3
hours or not more than 18 hrs)
With out complication to the mother or
fetus
 Care of the women
during labour
Most women find the first stage of labour very difficult.
They need midwives/nurses and other attendants who are
kind and respect them
At first, its exciting for a woman to feel labour
contractions. They are little more than menstrual cramps.
However. If the woman is not concentrating on controlling
breathing exercise, the contraction becoming strong she is
becoming more and more uncomfortable.
 Cont…

A couple can begin to worry that something is going wrong.

So give couples frequent progress reports and emotional
support during labour. So they do not become discouraged
of fearful
A woman wants to feel that she has some control over her
situation during labour, breathing with contraction and
changing position to the one that makes them most
comfortable.
 Cont…

Some women handle the stress of labour by

becoming extremely quiet other feels most
comfortable when they can show their
emotions by shouting or crying. Help women
express her feelings in her own way one that
works the best for her
 Respect contraction time
Do not interrupt a woman who is the middle of
breathing exercise during labour because once
her concentration is disrupted, she will feel the
extent of contraction. Instead of interrupting,
allow her to finish breathing with her
contraction, then ask questions or announce
what procedure needs to be done next, or ask
the questions but wait patiently for the answer
 Promote change of
positions
Most women assume that they are expected
to lie quietly in bed during labour. In early
labor, how woman may be out of bed walking
or sitting up in bed or in a chair, kneeling,
squatting or in whatever position she prefers.
Encourages the woman in labour to move
around and be active.
 Cont…

A women whose membrane have ruptured

should lie on her side until a fetal monitor
shows good baseline variability and no
variable decelerations, because unless the
head of the fetus is well engaged the umbilical
cord may prolapse into the vagina if she
walks.
 Cont…

Left side position causes the heavy uterus to tip

forward. Away from the vena cava, allowing
free blood return from the lower extremities,
adequate placental filling and circulation. Most
women are comfortable in this position.
Walking, sitting and squatting help the baby’s
descend into the pelvis.
 Promote voiding and
bladder care
A full bladder can prevent fetal decent so encourage
the women to void, at least every 2 to 4 hours. You
need to remain the woman to do this during labour,
because she may mistakenly interpret the discomfort
of a full bladder as part of sensations of labour.
Assess for a full bladder by percussion. If she cannot
void and the bladder becomes distended, she may
need to be catheterized
 Respect and promote the
support person’s activities
Admit a woman’s support to the birth
area and allow him or her to remain
with the woman throughout the birth.
Having someone with her during labour
is important.
 Prevent dehydration
Encourage the woman to drink nourishing
fluids or water during labour. Fluid provide
energy and prevent dehydration.
Dehydration can exhaust a mother and slow
down or make her contractions more
irregular.
 Bowel care

•A full rectum slows the baby’s descend and cause discomfort to

the mother. Give enema if she is constipated when she begins
labor.
never give enema
•More than 6 hours
•When membranes are ruptured
•When the woman is bleeding
•When she is high blood pressure
 Prevention of infection

Infection that start during labour and childbirth may

cause the death or illness of mother or baby.
A woman should bath and wear clean clothes during
labour.
You should wash your hands and use disinfectant
solution to clean the area during vaginal examination
Use sterile instrument during labour
 NORMAL LABOUR:
Definitions
Onset of regular involuntary coordinated,
painful uterine contractions associated with
cervical effacement and dilatation
Delivery is the expulsion of the product of the
conception after fetal viability.
With in a reasonable time (not less than 3
hours or not more than 18 hrs)
With out complication to the mother or fetus
 The following criteria should be
present to call it normal labour

1. Spontaneous
expulsion
2. Mature fetus
3. Presented by vertex
4. Through the birth
canal
 STAGES OF LABOUR

First stage cervical dilatation and effacement

Second stage is the expulsion of the fetus

Third stage is the delivery of the placenta

Fourth stage is the early recovery

Causes of onset of labour
There are some factors which take part onset
of labour
Hormonal factors (e.g)
Estrogen, progesterone, prostaglandin, oxytocin,
fetal cortisol
Uterine muscles stretching, which results in release
of prostaglandins Pressure on the cervix, which
stimulates the release of oxytocin form the posterior
pituitary.
Oxytocin stimulation, which works together with
prostaglandins to initiate contraction
Change in the ratio of estrogen to progesterone
(increasing estrogen in relation to progesterone
stimulates uterine contraction)
 Prodromal (pre-labour)
stage
The following clinical manifestation may occur in the
last week of pregnancy.
1. Shelfing: it is falling forwards of the uterine fundus,
making upper abdomen looks like a shelf during standing
position
2. Lightening: It’s the relief of upper abdominal pressure
symptoms as dyspnea, dyspepsia and palpitation due to:
descent in the fundal level after engagement of the head
and shelfing of uterus.
 Cont…
Pelvic pressure symptoms: with
engagement of the presenting
part the following symptoms may
occur: frequency of micturition,
difficult in walking.
Increasing vaginal discharge
False labour pain
 Signs of Labor

Experience lightening (baby drops lower into

the pelvis)
Can occur a few weeks before labor or it may not happen until
just before labor
Few weeks before birth, the cervix (lower part
of the uterus) becomes thinner – effacement
Opening of cervix begins to widen – dilate
 Signs of Labor

May notice a pinkish discharge from vagina – show

Results from a loosening of the mucus plug that sealed the cervix
during pregnancy
Amniotic sac ruptures when labor begins –
breaking of the waters
Labor begins – contractions – a tightening of the
uterus muscles, followed by relaxation of the
muscles
 Differentiation between the true and
false labor contractions
False contractions True contractions

Begin and remain irregular Begin irregularly but become regular and predictable

Felt first abdominally and remain confined to the Felt first in lower back and sweep around to the abdomen in a wave
abdomen

Often disappear with ambulation Continue no matter what the women’s level of activity

Do not increase in duration, frequency or intensity increase in duration, frequency, and intensity.

Do not achieve cervical dilatation Achieve cervical dilatation

 The Stages of Labor

First Stage
Contractions cause the cervix to
dilate
Second Stage
The baby is born
Third Stage
The placenta is expelled from the
mother’s body
MECHANISM OF
LABOUR
Edna Dahir
 Lie, presentation, attitude, &position
FETAL LIE

The relation of the long axis of the fetus to that of the mother

1-Longitudinal lie -99% of labors at term

2-transverse lie  multiparty, placenta previa, hydramnious, & uterine

anomalies

3-oblique lie -maternal & fetal axes cross @ 45 angle

-most unstable & become longitudinal Or transverse at labor.

 ATTITUDE or posture.

In later months posture of the fetus folded on

itself to accommodate the shape of the uterus
(flexed head, thighs, knees &feet ,the arms
crossed over the chest)

Change from this flexed attitude can cause

abnormal presentations
.
'
"
'

I
!
1\

1
1

A
B
ii

c
D vertex )A( sinciput )B( brow )C( face )D(
 Lie, presentation, attitude, &position
CEPHALIC PRESENTATION
• Head is flexed sharply  vertex / occiput presentation
• Head is extended sharply  face presentation
• Partially flexed  bregma presenting (sinciput
presentation)
• Partially extended  brow presentation
BREECH PRESENTATION
• Frank breech
• Complete breech
• Footling breech (incomplete breech)
.
 MECHANISM OF LABOUR WITH OCCIPUT
PRESENTATIONS
THE CARDINAL MOVEMENTS OF LABOUR

1-ENGAGEMENT
The greatest transverse diameter Biparietal
diameter passes through the pelvic inlet
It may occur in the last few weeks of
pregnancy or only in labour especially in
multipara
THE CARDINAL MOVEMENTS OF
LABOUR

2-DESCENT
• In nullipara engagement takes place before the onset of
labour & further descent may not occur till the 2nd stage
• In multipara descent begins with engagement
• It is gradually progressive till the fetus is delivered
• It is affected by the uterine contractions & thinning of the
lower segment
 3-flexion

• The descending head meets resistance of pelvic

floor, Cx & walls of the pelvis   flexion

• The shorter suboccipito-begmatic is substituted

for the longer occipito-frontal
 4-INTERNAL ROTATION
Turning of the head from the Occiput transfer position 
anteriorly towards the symphysis pubis ie. Occiput moves from
transverse to anterior 45º

Less commonly Occiput transfer  posteriorly towards the

sacrum 135º

It is not accomplished till the head has reached the spines

The levator ani muscles form a V shaped sling that tend to rotate
the vertex anteriorly
 5-EXTENSION
• When the flexed head reaches the vulva it undergoes
extension  the base of the occiput will be in direct
contact with the inferior margin of the symphysis pubis

• Crowning  the largest diameter of the fetal head is

encircled by the vulvar ring

• The head is born by further extension as the occiput,

bregma (ant.fontanelle), forehead, nose, mouth & chin
pass successively over the perineum
 6-EXTERNAL ROTATION
After delivery of the head it returns to the position it occupied
at engagement , the natural position relative to the shoulders
(oblique position)

Then the fetal body will rotate to bring one shoulder anterior
behind the symphysis pubis ( biacromial diameter into the APD
of the pelvic outlet)

The anterior shoulder slips under the pubis

By lateral flexion of the fetal body the posterior shoulder will be

delivered & the rest of the body will follow
3
0
2

2.Engagement;descent, flexion 6. Restitution (external rotation)

3. Further descent, internal rotation

4. Complete rotation, beginning

extension
,
.

,
0

Mechanism of labor for right occiput

posterior position, anterior rotation.
Commonest presentation during labor is

1. left occiput anterior position (LOA)

2. right occiput anterior (ROA)
3. occiput transverse (OT)
4. left occiput posterior (LOP)

breach presentation which is correct

1-beech presentation is the more common in primeparous
2-incomlete breach can’t be delivered vaginally
Cont….

1-engagment occur when

Biparietal diameter reach the
pelvic outlet
2-engagment always occur
before onset of labor in prime.
Essential factors of labour

•A successful labor depends on

five integrated concepts these
are more easily remembered as
the five P’s
Cont…

1. passenger: size, presentation and position of

the passenger or fetus.
2. Passage way
A. Daimeter of the maternal pelvis
B. Distensibility of the lower uterine segment,
cervical dilatation and capacity for distention of
vaginal canal and introitus.
 Cont…

3. power: strength, duration and

frequency of uterine contraction ( so
called primary power of labor)
4. Placenta: site of insertion of the
placenta
5: psychology: psychology state of the
women
Terminology

• Gravida - number of pregnancies

• Para - number of pregnancies carried to viability
and delivered
• Primigravida - pregnant for first time
• Multigravida - pregnant more than once
• Viability - able to survive outside the womb (24+
weeks gestation)
• Nulliparous - never carried a pregnancy to viability
• Multiparous - has had two or more deliveries that
were carried to viability
Adna Dahir
Duration of pregnancy

• Average 280 days or 40 weeks (9 lunar

months)
• Estimated Date of Confinement (EDC)
• Nagele’s rule
• Date of first day of LMP
• Subtract 3 months
• Add 7 days
• Accurate to plus or minus 2.5 week

Adna Dahir
First stage of labour

•Begins with onset of coordinated

contractions leading to dilation of
cervical os and ends with complete
dilation (10 cm) of the cervical os.
•False Labor (Braxton Hicks contractions)
• Cervix fails to dilate greater than 2 cm

Adna Dahir
First stage of labour

• The length of labour varies widely and is

influenced by parity birth interval,
physiological state, presentation and position
of the fetus, maternal pelvic shape and the
character of uterine contraction. The
duration of first stage labour is 10-14 hours in
primigravida, the longest of prim para is 17
hours and duration of multipara is 6-8 hours
the longest of multipara is 13 hours

Adna Dahir
Uterine action

• Each uterine contraction starts in the fundus and

spreads across and downwards.
• The contraction lasts longest in the fundus where its
also most intense but the peak is reached
simultaneously over the whole uterus and the
contraction fades from all parts together. This
pattern permits the cervix to dilate and strongly
contracting fundus to expel the fetus

Adna Dahir
Contraction and retraction
• Uterine muscle has unique properly during
labour muscle fibers remain some of the
shortening of contraction instead of
becoming completely relaxed. By the end of
the first stage contraction occur at 2-3
minutes intervals, last for 50-60 seconds and
are very powerful.

Adna Dahir
Cont…

• By the end of pregnancy the body of the

uterus is divided into two segment, upper
and lower uterine segments, the upper
segment is formed from the body of the
fundus. The lower segment is formed of the
isthmus and cervix

Adna Dahir
Cervical effacement

• Effacement is shortening and thinning of the

cervical canal normally the canal is approximately 1-
2 cm long. With effacement that can disappears,
this occurs because of longitudinal traction from the
contracting uterine fundus. In primipara,
effacement is accomplished before dilatation begins
in multipara effacement and dilatation may occur
simultaneously

Adna Dahir
Cervical dilatation

•The dilatation of the cervix is the

process of enlargement of the cervix
canal from an opening a few millimeters
wide to one large enough
(approximately 10cm) to permit passage
of the fetus

Adna Dahir
Show

• As a result dilatation of the cervix operculum which

forms the cervical plug during pregnancy is lost. The
women may see blood staining mucous discharge
few hours before or with in few hours after labour
starts. The blood comes from the ruptured
capillaries in the parietal decidua's where the
chorion has become detached from the dilating
cervix

Adna Dahir
Formation of the forewaters

•As the lower uterine segment forms and

stretches the chorion becomes
detached from it and the increased
intrauterine pressure causes this
loosened part of the sac of fluid to bulge
downwards into the internal OS.

Adna Dahir
Management of 1st Stage of Labour

• Is the care given through out the 1st stage of labour

• A. Admission procedure
• Well coming the mother and her partner On Arrival
• - Greet the mother
• - Introduce your self
• - Inform relative to wait
Cont..

• B. Admission criteria
• - Check- show.
• - rupture of membrane.
• - regular uterine contraction with progressive cervical
dilatation.
• Fetal Heart Rate should be between 120 - 160 BPM
• History
• - Information from the mother.
• - Ask the mother on set of contraction.
• - Rupture of membranes / passage of liquor.
• - Show or any other bright red bleeding.
 Physical examination
• - The general condition. Exhausted, anemic, pain, dehydrated,
general edema.
• Vital sign: Blood Pressure, Temperature, pulse, respiration
• Abdominal examination
• 1. Inspection
• 2. Palpation lie, presentation, attitude, engagement
• 3. Fundal height
• 4. Auscultation fetal heart rate & rhythm.
• Vaginal examination To check if the mother is in labor .
cervical dilatation .
• Membrane intact or not.
• To assess progress of labor - Station, Position - presenting part;
molding, caput.
Investigations

• Hematology: Hemoglobin, Blood Group, Rh, cross-

match, Urine analysis, Protein (Albumin), Sugar,
Ketone Write on patient chart and inform relatives.
• Use partograph and record on it.
• Emotional support
• 1. A good nurse/midwife will give comfort, relieve
pain, make strength, prevent exhaustion, Maintain
cleanliness, asepsis & antisepsis during labor.
Prevent complications, recognize early & promptly
act when complication occurs until the arrival of the
doctor.
Cont..
• These principles are not kept to labor only, for the
management of labor begins during the Antenatal
period, by building woman's heath gaining her
confidence, promoting encourage & supervise.
• Detect abnormalities which may adversely affect
labor.
• The nurse/midwife must handle child birth with
sensitivity and compassion because the emotions of
the woman in labor deeply influence her reaction to
discomfort & pain with are a factor in determining
the amount of physical and mental exhaustion she
will experience.
Relief of pain & promotion of comfort

• Pain exhausts the woman physically & emotionally so it

must be reviled by every obstetrically safe means.
• The midwife/Nurse by her kindly confident bearing &
professional proficiency has an assuring beneficent
influence.
• Back rub and explanation of the labour process is very much
important in pain relieving.
• Fewer drugs are now being prescribed during labour.
• E.g. pethedine, analgesia. Drug choice - if anxious a
tranquilizer, if tired/hypotonic, for discomfort & pain an
analgesic & sedative.
Diet during labour

• Avoid dehydration. Prolonged labour can present serious

problem.
• If dehydration present give I.V infusion 5 or 10 % Dextrose in
water and also Glucose 40%.
• Attention to the bladder A full bladder will prevent the head
from engaging, empty bladder every 2 hours.
• Recordings:-
• 1. Half hourly- maternal pulse, contractions for length, strength
and frequency, FHB
• 2. Every 1 1/2 - 2 hours check bladder
• 3. Every 4 hours – B/P. Temperature, abdominal examination
for descend, V.E, urine test acetone, albumin.
Vaginal Examination in Labour

When Doing Vaginal Examination Always Remember:-

• The vaginal is not a sterile cavity.
• Every vaginal examination increases the danger of
intrauterine infection, if carelessly performed.
• A vaginal examination is uncomfortable and
embarrassing for the patient.
• Careful abdominal examination gives a lot of
information. Do it always before vaginal examination.
• When doing a vaginal examination, find out all the
information you can, this may save it having to be
repeated.
 Cont..
When you perform a vaginal examination, look and feel
to decide
• Dilatation of the cervix,
• Status of the membranes,
• Presenting part and position,
• Moulding of the vertex presentation and
• Descent of the presenting part.
Cont

• The vaginal examination must be performed with care to

prevent the risk of infection to the vagina, cervix or uterus.
Often this examination is very uncomfortable for a woman in
labor.
• Never perform vaginal examination if the woman is
bleeding
Indications

• When in doubt about the presentation, dilatation, or position

and to assess progress.
• To assess the shape and size of the pelvis.
• To know the cause in fetal or maternal distress.
• When the membranes rupture and the head is high or there is
Malpresentation, to make sure there is not prolapsed cord.
Information: To be got on Vaginal Examination
• Presenting Part - Presentation - Level of presenting Part
• Caput - Sutures and Fontanels. - Overlapping or molding
Cont..

• Membranes Intact - Bulging or flat? Ruptured - Color of

liquor.
• Cervix: READY - firm or soft EFFACEMENT - long or
short - taken up. OEDEMATOUS- thick or thin APPLIED to
the presenting part- Loose or well applied.
• DILATION- Measure in cm.
• Vagina: Lax or tight, Warm or hot, Moist or Dry
• Pelvis: Cavity, sacral promontory Curve of the sacrum,
ischeal spine Lateral pelvic side walls- parallel or convergent
Now Co-relate your findings, after recording them and
determine the stage of labour.
Equipment

• Soup, water and towel

• Gloves
• Antiseptic solution
• Gauze
• Lubricant
 Procedure
• Make sure , the mother has emptied her bladder
• Collect your equipment
• Provide privacy
• Reassure and explain each step to the mother
• Wash your hands
• Wear gloves
• Ask woman to lie on her back with her knees bent and
her legs spread apart. Cover her as much as possible
• Look for discharge ( blood, liquor or meconium) on her
vulva. Inspect any abnormality
• Wash the genital area with antiseptic. Wash from front
to the back of the genital area until clean
 Cont..
• Hold the woman’s labia apart with your non examining
hand
• Look at the vaginal opening for discharge blood,
liquor, meconium, sores or warts inspect any
abnormality. Lubricate your fingers.
• Gently put the index and middle finger of your
examining hand into the vagina. Once your fingers are
in the vagina, do not take them out until the exam is
complete.
During the vaginal exam feel for:

• Dryness and temperature of the vagina: A hot and

dry vagina may mean prolong labour, dehydration or
infection
• Thickness( effacement) and dilation of cervix: the
cervix is thin, soft and open during labour
• Bag of water (membranes): the bag of waters often
does not break until the cervix is more than half way
dilated. Look at the color of the amniotic fluid if the
bag is broken. Feel for presence of the umbilical
cord.
•
Cont..

• Presenting part: check if the head is engaged and

moving downs through the pelvic compare the
descent with the abdominal exam for progress. If the
head can be reached, feel the fontanelles and sutures
for molding and overlap decide the position of the
baby.
Cont..

• If the bag of water is broken, feel for prolapsed of

the umbilical cord. It will feel soft and pulsating.
Prolapsed umbilical cord needs immediate
management.
• Most babies deliver occiput anterior (face looking
down). When baby delivers occiput posterior (face
looking up ) the labour is longer and usually more
painful decide the position of the baby you must
know difference between the baby’s anterior and
posterior fontanelles.
Partograph
Parthograph
• The partograph is a tool the midwife uses to
record the information from the history and
physical examination of the women in labour
• It helps you to follow and interpret the
progress of a woman’s labour through
recording of
1. Cervical dilatation
2. Descent of the fetal head
3. Contractions
Cont…

• The partograph also helps you to monitor

maternal and fetal well being by recording
• The fetal heart rate
• Condition of amniotic fluid
• Mothers temperature, pulse and blood
pressure
Parts of partogragh

Progress of labour
1. Cervical dilatation
2. Descent of the presenting fetal head
3. Uterine contraction
Fetal condition
4. Fetal heart rate
5. Color of amniotic fluid if it ruptured
6. Molding of the fetal skull
Maternal condition

• Pulse and blood pressure

• Temperature
• Urine tests and volume
• Medications given
• Fluid intake
How to use partograph

• When a woman is admitted in labour, you must to

evaluate her condition of her baby. Ask, listen, look,
feel. Start labour record (partograph) by writing the
woman’s name and other admission information
• Find out when contractions began, if the membrane
ruptured and when membrane ruptured.
• Listen to the fetal heart rate and feel contraction
• Perform an admision physical examination.
Including vaginal examination (if there is no
bleeding)
Progress of labour

1. Cervical dilatation is divided into the latent and

active phase.
the latent phase is 0-3cm dilatation
The active phase is from 3-10cm
Along the bottom of the graph are number 0-24 for
the hours and time in labour. Each number/square
represents one hour. The time of admission is written
in front of the first square.
To record dilatation
•Look at the partograph. Find th area
along the left side labeled. Cervix (cm)
(plot x)
•Also along the left side are the numbers
0-10 each number/ square represents
1cm dilatation and represents the
number of cm the cervix is dilatated.
Descent of fetal head

•On the left side of the graph near where

the dilation of the cervix is recorded,
find the words: descent is head (plot 0).
They printed on the graph near 0-5.
descent is plotted with an ‘0’ because
the head is round like an 0
Descent of fetal head

•Place your hands on the abdomen over

the baby’s head. If all five of your fingers
can cover the baby’s head we can say
the head is 5/5 above the pelvic prim.
The baby’s head is not engaged (not on
the pelvis)
Uterine contractions
• Effective uterine contraction are necessary for
progress of labour. Normally contraction become
more frequent and last longer as labour pregresses
• Look at the left side of the partograph below time.
Find where contractions per 10min is printed
Cont…

• There are five squares numbered from 1-5

each square represents one contraction, so
that if two contractions are felt in 10 minutes
two square will be shaded, there is special
way to mark the squares so that you can
show how long each contraction lasts.
Contractions

• Palpate the number of contractions in 10 minutes and their duration

in second

•.…… Dots are for mild contraction less than 20 second duration
•///// diagonal lines indicates moderate contraction between 20-40
seconds duration
• solid color represent strong contractions of longer than 40
seconds
 Fetal heart rate
• As reliable way to know that the baby is well.
To listen and record the fetal heart rate
(beat). It should be taken at least every 30 to
60 minutes in the first stage of labour. The
normal rate is between 120 and 160. record
the rate at the top of the partograph with a
dot.
Membrane and liquor

Membrane liquor (amniotic fluid) condition of

the liquor after membrane ruptured gives you
more information about the fetal condition.
Normal liquor is clear. Observations are made
at each vaginal examination and recorded on
the partograph under the section for fetal
heart rate at liquor as follows
Symbols to record membranes and
liquor status
C: clear liquor
B: bloody liquor
M: meconium stained liquor
A: absent liquor
I: intact membranes
Listen to the fetal heart rate every 15
minutes
• If liquor is green or black meconium stained
because this may be a sign of fetal distress
• If liquor absent at the time membranes
rupture because membranes may have
ruptured a long time ago or the baby is over
due
• During stage two labour
Moulding of fetal skull bones
• Molding indicates how well the baby’s head
is fitting into the mothers pelvis. The amount
that the bones of the baby’s head slide over
each other (overlap) tells you the fit between
the baby and the mother’s pelvis.
Cont…

• If you feel overlapping, the fit is tight

this may be a sign that the baby cannot fit
through the mother’s pelvis
Symbols to record molding

0: bones are separted, sutures can be felt

easily (no molding)
+: bones are just touching
++: bones are overlapping but can be
separated easily pressure by your fingers
+++: bones are overlapping but can not be
separted.
Protocols for labour management with the WHO
Partogram

EXCLUSIONS

Don’t complete the partogram in case of:

• Prematurity (<34/40)

• Cervical dilatation 9 -10 cm on admission

• Elective CS

• Emergency CS on admission
MANAGEMENT OF LABOUR
BETWEEN ALERT AND ACTION LINES

• Known as Alert or Referral zone

1. Health facilities with Basic EmOC

• Transfer the woman to hospital unless the cervix is
almost fully dilated
• ARM may be performed if membranes are still
intact and first stage of labour is advanced and
delivery is expected soon.
MANAGEMENT OF LABOUR
BETWEEN ALERT AND ACTION
LINES
Health Facility with Comprehensive EmOC

• Perform ARM at vaginal examination

• Continue routine monitoring
• Repeat vaginal examination 4 hrs or earlier if
delivery is expected sooner
• Do not intervene or augment – unless complications
develop.
MANAGEMENT OF LABOUR AT OR
BEYOND THE ACTION LINE
1. Full medical and obstetric assessment
2. Consider IV infusions/ catheterization/ analgesics
(pethidine)
3. Options
• Perform CS - if fetal distress or obstructed labour or
operative vaginal delivery if in 2nd stage without
severe fetal distress and/or obstructed.
• Oxytoxin – if no contraindications
• Supportive therapy only – if satisfactory progress is
established and dilatation could be anticipated at
1cm/hr or faster.
ABNORMAL PARTOGRAPM

Include the following

1. Prolonged latent phase
2. Prolonged dilatation of cervix
3. Arrested dilatation of cervix
4. Protracted descent of the presenting part
5. Arrested descent of the presenting part
6. Prolonged second stage of labour
CAUSES OF ABNORMAL
PARTOGRAPM
Divided into 3 Ps
1. Passenger related
o Refers to the fetus: Big baby, hydrocephaly,
2. Power related
o Refers to the expulsive efforts of the uterus and
mother: Poor uterine contractions etc
3. Passage related
o Refers to the bony and soft tissue of the pelvis, vagina
and perineum: Contracted pelvis - CPD
The Second Stage of Labour

• Definition: It is the stage from full dilatation of the

cervix (i.e no cervix felt on V.E) until the Baby is
born:-
• Duration o f labour: first stage of labour Starts
with the onset of true labour pain and ends with full
dilatation of the cervix i.e. 10 cm in diameter.
• It takes about 10-14 hours in prim gravida
and about 6-8 hours in multipara.
•
Cont..

• Duration: Prim gravida 45 min – 1 hour, as long as 2

hrs Multigravida 1/2 hour can be as little as 5
minutes.
• N.B. there should always be advance or descent in
this stage
Signs of Second Stage:
• No cervix felt on Vaginal examination.
• Contractions are much stronger, and last 30-50 seconds.
• The patient wants to push (Urge to push).
• Sometimes head can be seen at the vulva.
Preparation for Delivery

• A. Equipment: Set with 2 clamps, scissors, sterile towels, cord

tight, Bowl and kidney dish oxytocin: 0.5mgs. in a syringe
with swab ready to be given SUCTION APARATUS, READY
AND WORKING SAVLON 1 – 80 or any antiseptic lotion.
• IDENTIFICTIONS: with name and number of mother
EMPTY CONTAINER
• B. Patient: - Position the mother, watch descent of head fetal
heart and mothers condition. - Encourage the mother & place
her in position - Explain to her what is happening - Gloves on.
- Arrange and check equipment,
• - Keep constant contact with mother.
• Perform episiotomy
Episiotomy
• An episiotomy is surgical incision made in the
perineum, the area between the vagina and
anus. Episiotomies are done during the
second stage of labour to expend the
opening of vagina to prevent tearing of the
area during the delivery.
 Types of episiotomy
two cuts of episiotomy are
• A mediolateral cut is angled down away from the vagina and into the
muscle
• A midline cut is made straight down between the vagina and anus.
Midline episiotomy
• A midline episiotomy may be performed after
adequate anesthesia has been confirmed, protecting
the fetal head during the procedure is importance.
Generally, the index and middle fingers are inserted
into the vagina between the fetal head and
perineum. This maneuver provides space for making
the incision. A vertical incision is made in the midline
of the perineum from the posterior fourchette
toward the anus. Most commonly the incision is
made just before delivery of the fetal head, at the
time when the perineum is thinned and stretched.
Mediolateral episiotomy
• As with a midline episiotomy, most surgeons
recommend making the incision immediately before
delivery. The index and middle fingers are placed
into the vagina between the fetal head and the
perineum. The incision can be performed on either
side and is generally 3-4cm in length. The anatomic
structures involved in a mediolateral episiotomy
include the vaginal epithelium, transverse perineal
muscle. Bulbocavernosus muscle and and perineal
skin
Indication of episiotomy

• When a women has undergone FGM and she prima

• When baby is very large
• When baby is breech position
• When perineal muscles are excessively rigid
• When instrumental delivery is indicated (forcep,
vacuum)
• The baby’s shoulders are stuck (shoulder dystocia)
Repair of episiotomy
• Immediately after the expulsion of placenta
assesses the episiotomy area check any
laceration and any bleeding when you finish
your assessment, start the repairing
procedure. Early repair prevents sepsis and
eliminate patients prolonged apprehension
Cont…

Repair of any perineal laceration, including

episiotomy, serves the following two
important function:-
1. Hemostasis
2. Tissue re-approximation for lacerated
vaginal mucosa, soft tissue and muscle
Procedure
• Explain procedure to the patient
• Check your equipment
• Privacy
• Patient is placed in lithotomy position or
dorsal position, with a good light source
• Patient is draped properly and repair should
be done under strict aseptic precautions
contt…

• Blood clots are removed from vagina, the

uterus and other injuries including genital
tear
• The perineum and the wound area is
cleansed with antiseptic solution
• Put on new gloves or wash gloved hands with
antiseptic, place a sterile or very clean towel
or cloth under the buttocks
Cont…

• A vaginal pack may be inserted in high up to prevent

oozing of blood (do not forget to remove back after
the repair is completed)
• Check to see if the local anesthetic is working well
• Touch the cut areas with the sharp point of the
needle
Cont…

• If she feels sharp pain, give her some more

anesthesia before the repair
• Sit down and make yourself comfortable
• Perform complete vaginal, cervical and perineal
inspection
• Open the suture and gently stretch it out straight
• Place the needle in the needle holder at the right
angle
Cont…

• Clamp the teeth of the holder firmly shut

• Run your fingers through the whole wound
• See clearly where the top of the wound is
• Place your first suture about 1cm above the top of
the wound in the vagina
• Pull it through with your forceps
• Tie it off with a square knot and trim of the short
thread to about 1cm
Cont…

• Suture the vaginal mucosa by using a continuous stitch

• Put the needle through vaginal mucosa behind the hymenal
ring and bring it out on the wound of the perineum
• Continue using the suture sparing continous method to
suture all the way to the bottom of the wound
• Always use forceps to pull the needle through. Don’t try to
pull the needle your fingers (be careful for the needle)
• Suture the skin and subcutaneous tissue by using
interrupted sutures
Cont….

• Remove vaginal pack, double check the wound to

not left any gouze or instrument in the women’s
vagina
• Clean the area with antiseptic
• Put the patient comfortable position
• Wash the equipment and your hands
• Documentation
Advices to the patient

• The perineal area should be kept clean and dry,

clean water or soap water can be used
• Do not strain too much in defecation or urination
(to avoid constipation, patients is advised to drink
plenty of water and eat high fiber diet like beans,
whole grains, papaya, bananas)
• Tell patient if any discharge occurs come to the
hospital without delay
Remember

• Do not tie the sutures too tightly

• The last stitches are important for they prevent
excessive scar.
• Press firmly on suture line with a pad to see if
bleeding has stopped.
• Remove perineal pad or suture pack from vagina.
Rub up fundus put clean pad on perineum
• Put gloved finger in to the rectum – to make suture
that no stitch has one through the rectum
• Make the women comfortable, clean and dry
Normal delivery procedure

• Assess mother general condition

• Explain the mother what will happen during the second stage of
labour
• Assess safety, appropriateness and privacy of the environment
• Check the vital sign of the mother every 30 min and record findings
on the pantograph
• Palpate her bladder and empty her bladder by self-catheter if she
cannot urinate
Cont..

• Continue giving liquid to prevent her from becoming

dehydration
• When the mother is fully dilated and starts pushing
be ready for delivery put the mother good position
for delivery
• Prepare your equipment
• Wash your hand and wear gloves and other
protective things like apron
• Cleanse the women’s perineum, pubic area and
inner tights with soapy cleansing solution
Cont…
• Tell the women to push when there is contraction and the
baby head is near
Instruct the assistant to:
• Check fetal heart rate every contraction
• Check maternal pulse every 10 minutes
• Wipe sweat from the women's face
• When the head is crowning the vaginal outlet is
stretched. Place fingers of your dominant hand
on the baby’s head to keep it flexed. Its important
that the fetal head is only controlled and not held
back
Cont…

• Put your right hand support the perineum as the

baby’s head delivers
• if perineum is tight infiltrate with local anesthesia
• performed episiotomy during crowning
• Once the baby’s head delivers tell the women not to
push and check around babies neck for the
umbilical cord:
• If the cord is around the neck but is loose, slip it
over the baby’s head
• If the cord is tight around the neck, double clamp
and cut it immediately before another contraction
Cont…
• Wipe the baby’s face and suction the nasal and oral passages
of the baby
• After the head turns, place a hand on each side of the baby’s
head
• Reduce the tears by delivering anterior shoulder at a time
move the baby’s head posterior to deliver the shoulder that
is anterior
• Lift the baby’s head anteriorly to deliver the shoulder that is
posterior
• Support the rest of the baby’s body with one hand as it
slides out
• Place the baby on the mother’s abdomen or chest and climb
and cut the umbilical
Cont…

• Assess the Apgar score of the baby, wrap the baby

in towel and dry, tie umbilical cord, cover with
blanket, and ensure that the head is covered to
prevent heat loss
• Assess mother and palpate the abdomen to rule out
the presence of and additional baby and give the
active management of the third stage oxytocin 10
unit. Don’t give ergometrine to the women with
pre-eclampsia, eclampsia because it increase the
risk of convulsion and cerebrovascular accidents.
Cont…

• To deliver placenta use control cord traction hold the

clamped cord one hand and place the other hand just above
the women’s pubis bone supporting the uterus upward
gently guide the cord of the placenta down ward
• Keep slight tension and wait a strong uterine contraction
when the uterus become rounded or the cord lengthens,
very gently pull down ward on the cord to deliver the
placenta continue to apply counter traction to the uterus
with the other hand.
Signs of placenta separation

• A sudden gush of blood

• Lengthening of the visible portion of the umbilical
cord (elongated cord)
• The uterus which is usually soft and flat
immediately after delivery becomes round and firm
Cont….

• Never apply cord traction (pull) without applying

counter traction, above the pubic bones with the
other hand
• As the placenta delivers the thin membranes can
tear off, hold the placenta in two hands and gently
turn it until the membranes are twisted. Slowly pull
to complete the delivery
• If the membrane tears gently examine the upper
vagina and uterus wearing long gloves and use
sponge forceps to remove any pieces of membrane
that are present
• Look carefully at the placenta to be sure none of its missing, if
portion of the maternal surface is missing or there are torn
membrane with vessels, suspect retained placental fragments.
• Check for clots and massage the uterus
• Examine the women carefully and repair if any tear is present or
repair the episiotomy
• Clean the genital area with disinfectant solution
• Observe any postpartum bleeding, monitor mother’s vital signs
and monitor the condition of the baby
• Assess the mother and baby and put comfortable position
• After one hour transfer maternity ward if her condition is stable
• Documentation
Placenta
The Oxytocic Drugs
• These drugs stimulate the uterus to contract.
• It is used before, during & after the third stage of labour.
Advantages:
• 1. It speeds up the delivery of the placenta
• 2. Lessen the blood loss
• 3. Contract the uterus
• The oxytocin drugs are:-
• 1. oxytocin one ampule contains 5 or 10 units
• 2. Ergometrine ampules – 0.5 mg or 0.25mg Ergometrine 0.25
or 0.5mg tablet form
 Cont..
Indications-
• To prevent or treat PPH
• To prevent bleeding in inevitable complete or incomplete abortion - To
treat sub involution during the puerperium.
Contraindications:
• It should not given for pre-eclampsia, cardiac and hypertensive mothers.
• oxytocin Actions: - To contract the smooth muscle.
• Advantages – It can be given before or at any stage of labour (1st, 2nd
or 3rd of labour) It has a rapid action.
• Indication:
• To induce /start/ labour
• To accelerate /increase/ the contractions in labour
• To prevent or treat post partum hemorrhage
Cont..

• Caution – The uterine contractions and fetal heart are

continuously monitored.
• Contraindications- In the presence of malpresentation or
C.P.D do not start.
• Danger - Rupture of the uterus - Tachycardia & an increased
stroke volume increases the cardiac out put. - Fetal distress.
Bleeding before placental delivery

Bleeding before placental delivery is due to:- - Partial

separation of the placenta
• Uterine relaxation Prolonged third stage is due to:- -
Weak uterine contraction which causes failure of the placenta
to separate
- Adherent placenta
- Full bladder
- Danger: - Post partum hemorrhage and shock If the fundus is
more than 2.5cm above the umbilicus
Cont…

four cases must be considered.

• There is another baby in uterus, Palpate for fetal
parts, auscultate for a fetal heart beat
• The placenta is unduly large. causes- Rh negative
• Blood clot is present in the uterus This will
prevent strong contraction of the uterus and cause
post partum hemorrhage (contraction of oblique
muscles of myometrium).
• Full bladder.
The fourth stage of labour

• The fourth stage of labour is the first two or three

hours after birth.
• During this time you might experience tremors and
chills, as well as discomfort from after-pains,
episiotomy or tears, and hemorrhoids.
• You may also feel dizzy or faint if you stand up
Immediate Care of Mother and Baby

• The mother and the baby has to remain in the delivery room
for an hour after delivery.
• Immediate care of mother: Give oxytocin, massage the
uterus and expel the clot.
• The vulva is swabbed and a sterile pad placed in position
Buttocks should be dray and any wet sheet is removed the
sterile towel is lain over the lower abdomen and thighs and
cover with warm blanket.
Cont..

• Careful observation - Check the maternal pulse

/60-70/minute is the normal range - Take body temperature –
subnormal due to loss of body heat, as high as 37.20 C due to
reactions of prolonged labour.
• - Encourage her to pass urine
• - Blood pressure is taken ½ hourly.
• Immediate care of baby Observe: The general well being of
the baby Check the security of the cord clamp Check
APGAR score Promote bonding and breast feeding Put on ID
(identification) band Check weight, height, head
circumference and any drug (s) given to the baby.
Record keeping

• Record your observations during labour

• Method of delivery- spontaneous or accelerated, forceps, caesarian
section or vacuum.
• Anesthetic – General, epidural, local
• Blood loss- amount
• Placenta and membranes- complete, incomplete
• Perineum- laceration, episiotomy
• Drugs given for the mother
• Baby – Sex, weight, APGAR score, alive or stillbirth.
• Date and time of delivery N.B .The chart should present a clear,
concise, reliable record.
• The legal aspect of record keeping is also important during labour.
Discharge Planning

• (Instructions) Before the post partum discharge, the women

will be given instructions by her physician or nurse midwife
concerning her care at home.
• These instructions are summarized as follows.
AREA INSTRUCTIONS
Work All women should avoid heavy work for
at least the first three weeks following
birth
Rest The women should plan at least one rest
period a day and try to get a good night
sleep

Exercise The women should limit the number of

exercises
Hygiene The women may take either tub baths or
shower.
Contraception The women should begin contraception
measures, this may be fitted immediately
following delivery or at the first postnatal
check up.
Follow up The women should notify her physician or
nurse midwife if she has any abnormal
sign
Neonatal care
• Reassess Airway and Respirations
• Keep warm and dry
• Eye drops (1% silver nitrate or Neosporin)
• Allow for maternal bonding
• Stimulation of nipples during attempts at
breastfeeding will aid in release of oxytocin
by posterior pituitary gland resulting in
uterine contraction and hemorrhage control

Adna Dahir
Apgar score

• Taken at 1 minute and 5 minutes after

delivery
• Score of zero to two is given for each
category
• The higher the score, the more vigorous and
“healthy” the child is considered to be

Adna Dahir
Scoring

•7 to 10 provide supportive care

•4 to 6 indicates moderate depression
•< 4 requires aggressive resuscitation