Normal Labour

Objectives

The goal of care during Labour and delivery is to

promote the most positive outcome, i.e. a healthy
mother and baby.
The specific objectives are:
• Proper management of the four stages of labour and

• Early identification and proper management (treatment

and /or referral) of complications.
Fetus in the utero at the beginning of labour
 Definition

Labour is the process by which fetus, placenta and

membranes are expelled through the birth canal
• Normal Labour is called Eutocia
• Abnormal Labour (difficult Labour) is Dystocia
 Characteristics of normal Labour

Spontaneous in onset
2. The Fetus is born alive at term and presents by
vertex
3. The process is completed spontaneously.
4. Lasting less than 24 hours
5. No complication.
 Causes of the onset of Labour:

• What initiates Labour is not known,

• but appears to be the result of a combination of factors
in hormonal and mechanical elements predominate.
Theories have been offered
a. Labour started at term because of the
overstretching and over distension of the uterus.
b. This explains why patients with multiple pregnancy
or hydramnious tend to go into premature Labour.
 Cont.

c. The placental efficiency is diminished towards term,

resulting in reductions in the level of estrogen and
progesterone.
d. The uterus becomes sensitive to the effect of
oxytocin from the posterior pituitary gland and the
patient goes into Labour.
 Cont.

e. There is an increased contractibility of the uterus

towards term. The Braxton hick’s contractions
increase in amplitude and may bring about the onset
of labour
f. Prostaglandins: synthesized in deciduas at term, local
release of prostaglandins from the uterus cause the onset
of labour.
g. Pressure of the presenting part on the cervix and
lower uterine segment
 Premonitory sign of labour
• Predict the approach of labour,
• useful where the gestational age of pregnancy is not definite.

1. Lightening: is sinking of the uterus down wards occurs 2to3

weeks before term.

- Breathing is laser because the funds no longer crowd the

lungs.

- The heart and stomach can function better.

- The symphysis pubes widens, softened, the uterus descends into

the true pelvis.
 CONT
2. Frequency of micturition :- due to pressure of the
fetal head on bladder
3. False pains: these are erotic and irregular, causing
the uterus to contract and relax, whereas in true
labour the uterus contracts and retracts.
4. Taking up of the cervix Occurs because it is being
dram up and merged into lower uterine segment
shortening of the cervix.
 cont

Types of labour
• True labour
• False labour

Signs of true labour:

A. painful rhythmic uterine contraction
B. Dilation of cervix
C. show
 A. Painful rhythmic uterine contraction

• Uterine contraction are involuntary

• Controlled by the nervous system & by endocrine
• Palpable between the two poles
• Contractions rarely lasts 60 to 70 seconds
 Cont.

• There is polarity between uterine contraction

- The upper pole contracting strongly and retract to

expel the fetus
-The lower pole contracting slightly and dilating to
allow expulsion to take place
 B. Dilatation of the cervix

• Enlargement of the external os from a circular

opening.
• Up ward traction, exerted by the retracted muscle
fibers
• Pull on the margin of the weekend area
 C. Show

This is the blood-stained mucoid discharge seen a few

hour before, or with in a few hours after labour has
started.
• The mucus is thick cervical plug of the operculum-
during pregnancy
• The blood comes from the ruptured capillaries of the
deciduas Vera
 False labour

False Labour pains are

painful, irregular contraction of uterus which
does not cause
dilation of the cervix
 cont
True Labour False labour
Show is present mostly No show
Cervix, become effaced and dilated No change in cx.
Descent of presenting part No descent
Sedation will not stop true labour pain sedation stop labour pain
Head is fixed between pains Head remain free
 Stages of Labour

• First stage of labour

• Second stage of labour
• Third stage of labour
• Fourth stage of labour
The stages of Labour
A. First stage of labour: From the onset of true labour
to complete dilation of the cervix.
B. Second stage: from the complete dilation of the
cervix to the birth of the baby
C. Third stage: from the birth of the baby to the
delivery of the placenta
D. Fourth stage from the birth of the placenta until one
hour postpartum
 The duration of labour
There are wide variations in duration of labour
depends on
• The primigravida or multipara

• The time that has elapsed of the last child

• The type of pelvis

• Size and presentation of the fetus.

• The strength and frequency of uterine contractions

• Note: The greater part of labour is taken up with in the 1 st

stage. It is about 18 hours in prime and 7hours in multi.
 The average time of duration of labour
1st stage 2nd stage 3rd stage Total

11 Hours 45 Minutes 15 Minutes 12 Hours

Prime
gravida

6 and ½ 15 Minutes 15 Minutes 7 Hours

Multi Hours
gravida
 Cont.

The relation ship of the fetus to the uterus and pelvis

1. Lie
2. Presentation
3. Presenting part
4. Altitude
5. Position
6. Denominator
 Physiology of First stage

1. Contraction with retraction of the uterine muscle

2. Formation of the upper and lower segment

3. Development of the Retraction Ring

4. Taking up of the cervix

5. Dilation of cervix

6. Show

7. Formation of the bag of water

8. Rupture of membranes
1. Contraction with retraction of the uterine muscle

- Contraction = Temporary shortening of muscle fibers

- Retraction = Permanent shortening of muscle fibers

- Upper segment arises from the corpus uteri

- Lower segment arises from the isthmus uteri and

the cervix.
• Note: The upper segment shortens and thickens
and the lower segment relax and distend.
 cont

Characteristic of normal uterine action in labour

1. Onset every 15-20 mints. Lasting 30 seconds at first.

2. Increases as labour progresses in length strength and

frequency.
3. Usually pain is felt after the contraction starts and
passes off before it finished.
 cont

4.There is always relaxation between the contraction

5. Each contraction starts: at the tubes and spreads

down over the uterus.

6. Contraction is strongest at the fundus as it

passes down wards it decreases in strength.

The fundus and mid zone remain hardest during the

contraction.
 cont

7. Polarity is the harmonious action between

upper and lower uterine segments there is no

polarity before labour starts.
8. Contraction is left by the midwife before the
woman feels the pain.
 cont

Function of contraction:
• Descent of head into pelvis
• Flexion of head
• Dilation of the cervix
Note Most, but not all women, experience labour in this
manner.
2. Formation of the upper and lower segment

• The lower uterine segment has begun to form during

the end of pregnancy & continues during labour.
• The upper segment is the thick muscular contractile
part, and the lower segment is the thin distensible
7.5 to 10 cm developed from the isthmus of the uterus.
• For uterus to expel its contents the upper segment
must contract strongly and the lower segment remain
passive.
 cont

• Failure to achieve this fundal dominance means that

labour dies not progress.
e.g. 1) Contraction of late pregnancy and of false labour
2) In coordinate uterine action in prolonged labour.
 3. Development of the Retraction Ring

- Ring or ridge (Retracting ring) forms at the edge of

the upper segment just where it meets the thin lower
segment. It is present always but is not seen.
- In obstructed labour, when the lower segment
becomes very thin, It then becomes visible, and can be
seen rising in the abdomen, this is known as Bandls’
Ring and is a sign that the uterus is about to rupture.
 4. Taking up of the cervix

•The cervix is shortened, or effaced or taken up.

•In a primigravida this happens before dilatation, but in
a multipara they usually happen together.
•Some shortening of the cervix has already taken place
at the end of pregnancy (ripped).
 5. Dilation of cervix

This is the opening up of the cervix or neck of the

uterus, and it occurs as the lower segment and cervix
are pulled up by the retracting.
Uterus the canal widens from above to form a
funnels, through which the fetus will eventually pass.
The well flexed head will, when closely applied to
cervix, aid dilation.
 6. Show

•This is the blood-stained mucous discharge seen a few

hours before (some time days) or with in a few hours
after labour has started
•The mucus is thick substance which formed the
cervical plug-the operculum-during pregnancy
•The blood comes from the ruptured capillaries of the
deciduas Vera where the chorion attaches.
 7. Formation of the bag of water

• As the head descends into the pelvis, some of the

liquor becomes separated, some is behind the head,
and is known as the hind-water, and
• the liquor in front is known as the fore-water.
• This is nature’s method of keeping the membranes
intact during the first stage.
 8. Rupture of membranes

• This occurs most often of full dilation,

• but can occur at any stage in about, and
• even before it starts.
 psychological/emotional support/ pain relief

How?
• with care of the mother by giving
pharmacological or non pharmacological pain
relief and appropriate care.
 psychology/emotional support/ pain relief

Care of the mother

1. General
- The mother should not be left alone
- If the rectum is full give suppository
- Shower can make her refresh.
2. Diet
- Fluid diet
- Avoid dehydration
3. Observation
4. Assess the progress of labour
5. Analgesia is given as required
 The second stage of labour

Def. it is the stage of descent and delivery of

the baby.
• From the full dilatation of the cervix (i.e. No
cervix felt on v.e) until the baby is born.
• N.B. there should always be advance or descent in
this stage.
 Cont.

Signs of second stage:

1. No cervix felt on vaginal examination.
2. Contractions are much stronger and last 30-50
seconds.
3. The patient wants to push
4. Sometimes head can be seen at the vulva.
 Mechanism of the second stage

•Before we deliver a baby, we must understand the

mechanics or mechanisms of how the baby passes down
through the pelvis.
•We also must know the pelvis and certain definitions.
•Mechanism: is the series movements of the fetus in his
passage through the birth canal
 Cont.

All relations must be included E.g.

Mechanism in labour in a normal vertex presentation
(L.O.L)
Lie ------------- Longitudinal
Presentation --------Vertex
Attitude --------- Flexion
Position--------- LOL
The head enters the pelvis with the sagittal suture in the
transverse diameter of the pelvic brim engagement takes
place.
 cont

Mechanism of the second stage

1. Flexion of the head

2. Internal rotation of the head

3. Crowning of the head

4. Extension of the head

5. Restitution of the head

6. Internal rotation of the shoulders

7. External rotation of the head

8. Lateral rotation of the head

 Cont.

• Notes: the mechanism in any other position

follows the same principles of Engagement,
Descent, Internal rotation, birth and
external rotation.
 Management of the second stage

Do not leave her alone, and look for

1. General condition
2. Maternal pulse
3. Fetal heart after second contractions
4. Descent of the presenting part and progress is seen.
 preparation for delivery
A. Equipment : have ready
- Delivery set with clamps, scissors, sterile towel, cord
ligature, swabs, bowl and kidney dish.
- Ergometrine : 0.5mg. in a syringe with swab on top.

- Suction: apparatus a ready and working

- Savlon: 1-80 or any antiseptic lotion.

- Identifications: with name and number of mother.

- Empty container
 Cont.
B. patient: watch descent of head. fetal heart and mother’s
condition.
- Encourage mother

- Lie her flat

- Legs drawn up

- Explain to her what is happening

- Gloves on

- Arrange and check equipment

‘’ WELLEGA”
 Delivery

When the head bulges the perineum

• If tight perform an episiotomy
• Place one hand over the head
• The other hand is on a pad or gauze over the rectum
• After the head is born wipe the eyes with the right
hand
• Look for cord around neck if it is there and tight
 Cont.

• Wait for rotation of the shoulders

• When the baby down clear the air way
• Then upwards slides hand over the body and left him
out.
• Clamp cord in two places and cut in between
• place him in a cot and label properly
• Continue with the third stage of labour
 Episiotomy

Is a cut made in the perineum when the baby’s head is

crowning.
Reasons for an episiotomy:
1. To prevent a perineal tear or overstretching of perineal
tissues as in the case of a very large baby.
2. To speed the birth in case there is fetal distress, or to
protect the baby from damage as in the case of a
premature infant whose head is being repeatedly
pressed against the thick, firm perineum.
 Cont.

3. To prevent damage to both mother and baby in the

case of an abnormal presentation (breech, face,
occipital posterior position) by providing more space
for a safe delivery.

4. To decrease the length of the second stage for

women who are ill with heart disease, Eclampsia,
sickle cell disease etc.
 There are 3 types of episiotomy
Types of epi. Advantage Disadvantage

Midio lateral -Less risk of extension to Takes longer time repair

anal sphincter Slower to heal
-Avoid damage to More blood loss
bartholi’n glands Post-operative pain great.
-Easy to do
-Reasonably easy to repair.

Median Incis. -Faster healing process Extension to anal sphinct.

-Easy to repair
-Bleeding will be less(less
vessels)
-Less bruising
-intercourse resumed earlier

J-shaped Inc. -No danger to anal More difficult to do

sphincter More difficult to repair
 Cont.
Note: choose, a mediolateral episiotomy to prevent recto
vaginal fistula (r.v.f).
Episiotomy must be done neither too soon nor too late.
- Too early, bleeding

- Too late, developing tear (objectives of epi defeated)

- Make the episiotomy when the perineum is thin

- Bulging and about 4 to 5cm of the baby’ head is visible.

 Third stage of labour (placenta stage)

• In order to prevent post partum hemorrhage in 3rd stage of

labour,
• the physiology and management of the third stage of labour
must be well understood
Relative position of the uterus
– In front of uterus lies on bladder and utero vesicle pouch

– The closeness of the bladder to the uterus explains why

a full bladder will interfere with the ability of the
uterus to contract after delivery.
 cont.

The uterus has three layers

1. The endometrium

2. The myometrium

3. The perimetrium
 1. The endometrium

• Inner most where fertilized ovum embeds

• During pregnancy referred to as the deciduas.
• The part that underneath the placenta is deciduas
basalis.
• The remainder of uterus is the deciduas vera
(parietals).
 Cont.

• The placenta normally embeds as far as the deciduas

• But some times the whole placenta or more

frequently certain segments of the placenta
imbedded in the myometrium: in this case the
placenta or placenta fragments are left behind the
uterus as they will not separate from the
endometrium in the normal way called placenta
accreta.
 2 The myometrium

• Very expansile muscle coat

By the name Oblique,Crisscross and Living ligature

muscle
• Constrict strongly and compress during 3 rd stage of
labour
• Mostly found in the upper segment of the uterus

* Perimetrium is a layer of peritoneum that covers the

uterus except, at the sides where it extends to form the
broad ligaments.
 Mechanism of placental separation

1. Separation of placenta:(by the contraction &

retraction)
2. placenta area becomes smaller (placenta not
contract)
3. When placenta separate a retro placental clot forms.
4. When placenta completely detach push out through
the vagina along the membranes and retro placental
clot.
 cont

• There are two method of expelling the placenta which

are not under the control of the attendant.
1.The SCHULTZ method
2.The MATHEOWS DUNCUN. method
 Types of separation of the placenta
(A) Schultze method (B) Mathews-Duncan
method
 1. The SCHULTZ method

- More common
- Detaches from central point and slips down into
vagina
- Fetal surface appears at vulva with the membranes

- The maternal surface of the placenta is not seen

- Blood clot is inside the inverted sac.

 2. MATHEWS DUNCAN method

- The placenta slide down side ways with lateral

border 1st
- Like a button through a button hole.

- The maternal surface is seen and the blood escapes

- Parts of membranes left behind in Matthews

Duncan method
 Cont.

- Are not peeled off as completely as in the Schultz

method
- May be associated with a placenta lying lower in the
uterus
- The process of separation takes longer and blood loss
is greater (because there are fewer oblique fibers in
the lower segment).
 Signs of placental separation

1. The fundus feels hard and globular

2. Rises abdominally to the levels of the

umbilicus

3. The cord lengthens at the vulva

4. A trickle of blood appears when the placenta

separates.
 cont

Control of bleeding
- 500 to 800 ml of blood flow at placental site each
minute.
- Quick: She would bleed to death in a matter of minutes.

- The contraction and retraction of the uterine muscle also

Compress the blood vessels strongly to control bleeding.
 Cont.

– A full bladder or any thing left behind in the

uterus after delivery such as placental tissue,
– membranes or blood clots interfere with the ability
of the uterus to contract and
– will cause the woman to bleed excessively.
Method of placenta expulsion (management of
3rd stage of labour)

Active management of third stage of labour:

•is a steps series of procedures, conducted during the third
stage of labour are collectively called active management.
•It consists of interventions designed to speed up the
delivery of the placenta enhancing uterine contractions
and prevent Post partum hemorrhage by avoiding uterine
atoney.
 Components active management of third stage of
labour (AMSTL)

1. Giving uterotonic drug (Oxytocin within 1minutes birth

of baby)

2. Clamping and cutting the umbilical cord soon

3. Applying controlled cord tension (controlled cord

traction)

Applying simultaneous counter-pressure to the uterus just

above the pubic bone and

4. Massaging the fundus of the uterus through abdomen until

the uterus is contracted.
Expulsion of the placenta by controlled cord
traction
 Giving Oxytocin
• Palpate abdomen and rule out the presence of an
additional baby(s)
• Give oxytocin 10 units IM with one minute of
delivery of the baby.
• Oxytocin is preferred because

a. it is effective 2-3 minutes after injection

b. has minimal side effects
c. can be used in all women.
 • If oxytocin is not available, give ergometrine
0.2mg IM.
Note: do not give ergometrine to women with
preeclampsia, Eclampsia, high blood pressure or
cardiac diseases because it increases the risk of
convulsion and cerebrovascular accidents.
Clamping and cutting the umbilical cord
 Clamp and cut the umbilical cord immediately after
birth.
 Please note that the timing of cord cutting after the
delivery of the controlled cord traction
Examination of the placenta and membranes

A. Completeness after the birth of the baby

B. Checking weather the placenta is normal or not
C. The type of the cord insertion must be checked.
D. Amniotic fluid and the other concepts material
must be removed completely
 Perennial laceration

Perennial laceration:
- Is a tear into the perineum.
- They can not always be avoided
- Is better to have a laceration than a damaged
perineum
- Which would lead to prolapse of the uterus later.
Signs of imminent tearing in 2nd stage of labour
1. Fresh bleeding from the vagina due to mucosal
tearing
2. Thin and shiny perennial skin.
 Causes of perennial tears
1. Precipitate labour

2. Big baby

3. Face to pubis

4. Face Presentation

5. After coming head of breach

6. Instrumental delivery

7. Old scar tissue-which doesn't stretch

8. Android pelvis where-the head forced posterior part of

pelvis
 Types of perennial lacerations

1.First degree: Damage to the skin and underlying

muscle exposed.
2. Second degree: the posterior wall and the perennial
muscles are torn, in some cases the anal sphincter can
be damaged.
3. Third degree: also called complete tear.
This is when the skin, muscle, and inner lining of
rectum are torn so that there is one opening or canal.
 Fourth stage of labour

• It is the stage of observation for at least 1 hour

after expulsion of the placenta afterbirths.
• During this period maternal vitals, uterine
retraction and any vaginal bleeding are
monitored.
• Baby is examined. These are done to ensure
that both the mother and baby are well.
 Partograph

Best practices in managing labor using partograph.

Session Objectives:
• Discuss the importance of using a partograph

• Understand how to fill in a partograph

• Understand how to use a partograph in decision

making
 cont

Usefulness of partograph
• Assessment of fetal well-being

• Assessment of maternal well being

• Assessment of progress of labour

1. Measuring fetal well being during Labour

- Fetal heart rates and pattern

- Degree of molding, caput.

- Color of amniotic fluid

2. Measuring maternal well-being during labour
- pulse, temperature, blood pressure, respiration

- Urine out put, ketones, protein

- Measuring progress of labors

- Cervical dilatation

- Descent of presenting part

- Contractions: duration, frequency

- Alert and action lines

Using the partograph
• Patient information: Name, gravida, Para, hospital
number date and time of admition and time of
ruptured membranes.
• Fetal heart rate: Record every half hour
• Amniotic fluid: Record the color at every vaginal
examination.
Amniotic fluid
I: membranes intact
C: membranes ruptured, clear fluid
M: meconium stained fluid
B: blood stained fluid
• Molding
• 1. Sutures apposed
• 2. sutures overlapped but reducible
• 3. sutures overlapped and not reducible
• Cervical dilatations

Assess at every vaginal examination, mark with cross (x)

• Alert line: Line starts at 4cm of cervical dilatation to
the point of expected full dilatation at the rate of 1 cm
per hour.
• Action line : parallel and 4 hours to the right of the
alert line
• Using the partograph (Descent) –Descent assessed by
abdominal palpation: Part of head (divided into 5 parts)
• Palpable above the symphysis pubis recorded as a circle
(O) at every vaginal examination.
• At 0/5, the sinciput (5) is at the level of the symphysis
pubis
• Using the partograph (timing)
- Hours time elapsed since onset of active phase of labour
(observed or extrapolated)
- Time record actual time
- Contractions chart every half hour palpate the number of
contractions in 10 minutes and
1. Less than 20 seconds
2. Between 20 and 40 seconds
3. More than 40 seconds
• Using the partograph (Drugs)
- oxytocin: Recorded amount per volume, Iv fluids in
drops/minutes every 30 minutes, when used
- Drugs given: Record any additional drugs given
 Using the partograph (vital signs and urine)
- Temperature: Record every 2 hours
- Pulse Record every 30 minutes and mark with a dot (.)
- Blood pressure: Record every 4 hours and mark with arows
- Protein, acetone and volume: Record every time urine is
passed
 Management of normal newborn

Immediate management
1. Lie flat head on side of down dry and deep warm.
2. Make sure the baby is breathing (clear the airway)
3. Check Apgar score at one minute and 5 minute.
4. Identification ties on arm bands before cutting cord
-Wrap him in warm towels after cord clamped and cut
- Use rubber band applied to the cord
- Check the cord for bleeding
6. Physical examination.
 • Apgar score: is a method of assessing the condition
of the body at one minute and 5 minutes after birth.
Sign 0 1 2

Appearance Blue-pale Body pink limbs blue pink

Heart beat Absent -100 + 100

Response to stimuli Absent Grimace Cry

Muscle tone Absent Some flexion Good

extremities

Respiration Absent Slow, irregular Regular

 cont
0-3 severe Asphyxia
4-5 Moderate
6-7 Mild
8-10 No Asphyxia
• Apgar score is important because it guides one as to
how to treat the baby if distressed.
• Allow score on the second count is more serious
than on the first count as this show lack of response
 Inspection of the new born baby

Daily care (daily inspection of the new born baby)

 The eye-for the risk of
- Ophthalmic neonatorum
- Inflammation
- Discharge
 The mouth-thrush
 The umbilical cord
- Infection
- Inflammation
- Discharge
- Offensive odor.
 Cont.

 The temperature - To detect neonatal hypothermia

- To detect infection.
 Bathing, handling and dressing
 Crying – high pitch cry is sustained intracranial
injury.
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