MANAGING LABOUR

SAFE AND CLEAN CHILD BIRTH

Labour: Initial Management

Rapid evaluation or Rapid Initial Assessment

(RIA
Complete history- estimate POG
(both obstetric and medical/ surgical) and
examination of records to note important
information including medical disorders,
obstetric complications and high risk factors.
General and systemic examination – G.C.,
consciousness, pallor, oedema, cyanosis,
jaundice, neck veins, pulse, BP, temperature,
respiration, examination of CVS and
respiratory system.
Abdominal Examination

 Fundal height, foetal size, liquor volume

(corroborate gestational age )
 Lie, presentation, position
 Engagement, head station.
 FHS
P/V Examination during Labour

Cervical dilatation (cm) and effacement

 Membrane / liquor
 Presentation, position, station
 Pelvis and foeto-pelvic relation
 Caput, moulding
P/V Examination during Labour
(Cont..)
 Initial assessment
 Then 4 hourly if in active phase (or very near it)
at initial assessment and after 6 hours if not in
active labour ( if indicated)
 Every hour in 2nd stage.
 When membrane ruptures; and from symptoms
and abdominal findings patient appears to be in
2nd stage.
 Any special indication, e.g. foetal distress - to
decide intervention
On Completing History and
Examination

Ascertain gestational age

Identify presentation, engagement,
position, foetal life
Identify medical and obstetric abnormality
or complication if any
Diagnosis of Labour
Anticipate labour

If the woman in third trimester of

pregnancy has
 Painful intermittent uterine contraction with
increasing frequency and intensity
 Show
 Watery vaginal discharge / sudden gush of
water
Confirm onset of labour

If there is
 Regular, painful uterine contractions of >
20 secs duration and at least once every
10 mins.
 Progressive cervical dilatation and
effacement or
 Cervical dilatation of >/= 4 cms
Stages and Phases of Labour

First Stage:
 Active phase: Cervix ≥ 4 cm : 4-6 hours
Dilatation rate ≥ 1 cm/
hour

Second Stage: Cervix : 10 cms/fully

dilated
Stages and Phases of Labour
(Cont..)
If cervix is not dilated at initial
examination and pain persists:
reexamine after 6 hours.
 If there is effacement and dilatation –
diagnose labour.
 If still no cervical change – diagnose false
/ pre-labour.
If pain subsides – observe for 24 hours.
Labour: General Care
General Care

Ensure good communication, counseling

and support by staff
Ensure dignity and privacy
Honour woman’s rights
Ensure mobility in first stage
Allow posture of her choice as far as
possible
Encourage breathing techniques
Allow to drink liquids in early labour :
ensure nutrition & hydration
General Care

Maintain cleanliness/sterility
 Vulva/perineum
 Hands/gloves
 Birthing area
 Cord tie
 Instruments/consumables
General Care

Encourage to empty bladder

Catheterization only on indication
No routine enema
No need for shaving
Help / provide verbal support for the
anxious / fearful and those in pains
Use non pharmacological pain relief as
far as possible and use analgesics as
needed
Labour : Obstetric Care and
Management
Obstetric Care

Careful monitoring of
▪ Progress of labour
▪ Foetal wellbeing
▪ Maternal wellbeing

Early identification of
abnormality/complication

Timely intervention.
Monitoring Progress of labour
Latent phase – Cervical dilatation and
– Effacement
Active phase – Cervical dilatation
– Foetal descent
Second stage – Foetal descent
Increasing frequency and duration of uterine
contraction also indicates progress of labour.
Latent phase – Infrequent, short
Active phase – At least 3 in 10 mins, >=
40 secs
Second stage – every 1-2 mins, > 40 secs
Monitoring Foetal wellbeing

Foetal heart rate and regularity

– Count for one minute just after
contraction
– Note FHS half hourly in active phase

Colour and amount of liquor

Degree of moulding indirectly provides

idea of foetal wellbeing
Monitoring Maternal Wellbeing

Pulse
Temperature
B.P.
General condition and state of hydration
Urine output
Protein and Ketone in urine
Care during Latent Phase
Note
▪ Pulse : 2 hourly
▪ Respiration, temperature and B.P.: 4 hourly
▪ Uterine contraction: 1-2 hourly
▪ F.H.S.: hourly
▪ Descent: by abdominal palpation.
▪ Cervical dilatation and effacement, station of head
and character of liquor (if membranes ruptured) at
each P/V examination (6 hours after initial
assessment)
▪ Protein and acetone in urine when passed
▪ DO NOT INDUCE LABOUR UNNECESSARILY
Care during Active Phase

Start plotting on partograph all events of

labour once the woman is in active phase.
The WHO partograph is modified by
excluding the latent phase and beginning
plotting at 4 cm cervical dilatation in
active phase to make it simpler and easier
to use.
Simplified Partograph – Partograph case
study and hands-on .
Labour care guideline
Labour care guideline
Labour care guideline
 Management of second stage of
labour

Diagnosis of Second Stage:

Urge to defaecate.
Urge to bear down.
Membranes spontaneously rupture.
Cervix is no longer palpable i.e. fully
dilated.
Conduct of Delivery

Shift the patient to the delivery table, if

such transfer is needed, when second
stage is diagnosed
Monitor FHR every 5-10 minutes.
Put her on the position of her choice –
preferably in dorsal or semi-recumbent
position.
Maintain cleanliness.
Wash perineal area with an antiseptic
solution and use sterile/clean drapes.
SBA training AV on conduction of
normal labour

Click
Active Management of third
stage of labour
Active Management of third stage
of labour (AMTSL)
Inj. Oxytocin 10 units IM after delivery of
foetus (within 1 min)(after excluding 2nd
foetus).
Deliver placenta by controlled cord
traction while raising the uterus gently
upward by abdominal hand.
Massage the uterus (after delivery of
placenta) to keep it contracted
AMTSL (Cont..)

Inspect the placenta & membranes for

completeness
Inspect vagina and perineum for any
tears
Repair tears / episiotomy if any
AMTSL (Cont..)

Look for placental separation after delivery

of baby
Place the left hand on lower abdomen to
detect the contraction of uterus. (After
delivery, uterus is at or just below the level
of umbilicus.)
Signs of placental seperation

Uterus becomes contracted, hard and

globular
Uterus rises just above umbilicus
Extra vulval lengthening of umbilical cord
A gush of blood may appears
On pushing the uterus up in the abdomen,
the cord does not recede back
 Oxytocics for third stage management
OXYTOCIN ERGOMETRINE/ PROSTAGLANDIN MISOPROSTOL
METHYL 15-Methyl PGF2α
ERGOMETRINE
Cheap Cheapest Costly Cheap

No contra- Important contra- Some contra- No significant

indication Indications indications contraindication

Safe – no side Side effects – Some side effects No significant side

effects sometimes -effect
serious
Effective – quick Effective Effective
action Effective

Less heat labile Highly heat labile Highly heat stable

Heat labile
10 units IM 125-250 mcg IM 600 mcg orally
Oxytocics (Cont..)
Oxytocin - first choice (but never give IV bolus)
Misoprostol - has its place
Prostaglandin – effective but costly
Ergometrine/Methyl ergometrine – has
contraindications & side effects

Use other oxytocic if oxytocin is not available.

Exclude contraindications if using methyl
ergometrine & remain cautious about its side
effects
Exclude second foetus before giving oxytocic
Immediate Postpartum Care

Closely monitor for first 6 hours.

 Pulse, respiration, temperature, BP, GC
 Vaginal bleeding.
 Uterine hardness.
@ Every 15 mins. for 2 hours.
@ Every 30 mins. for 2 hours.
@ Every hour for 2 hours.
Immediate Postpartum Care

Massage the uterus every 15 mins. to

maintain contraction.
If stable (and there is no contraindication)
give her something to drink when she
feels thirsty and something to eat when
she is hungry.
Keep the baby in skin contact with mother.
Initiate exclusive breast feeding within 1
hour.
 Prolonged Labour

COUNSEL & KEEP THE PATIENT’S RELATIVES INFORMED ABOUT PROGRESS &
Thank You