For Under and Postgrad Medical students

1. Management of
Normal Labor
Prof. Dr. Iram Chaudhry
FCPS (Obs & Gynae) MHPE
Bahawalpur, Pakistan

2. OUTLINE
• Definition of Labor
• Stages of Labor
• Mechanism of Labor
• Management of Normal Labor

3. Labour
• It is a physiological process by which the
fetus, placenta and membranes are expelled
out through the birth canal after twenty four
week of pregnancy
• Parturition isthe process of givingbirth

4. Normal labour
• Normal labour is physiological process by
which the fetus ,placenta and membrane are
expelled through the birth canal after full
term pregnancy (37-42 weeks ofgestation)

5. • Labour is called normal when it fulfills
the following criteria :
 Spontaneous onset at term
 With vertex presentation
 Without prolongation
 Natural termination with minimal
aids

6. NORMAL LABOUR
FIRST STAGE
SECOND STAGE
THIRD STAGE
LATENT PHASE: 0-6cm
ACTIVE PHASE: 6-10cm
FULL DILATION TO EXPULSION OF FETUS
BIRTH TO EXPULSION OF PLACENTA
Expectant (physiological) vs Active (CCT + OT)

7. Mechanism of Labor
19
In the normal labor; there are series of changes in position
and attitude of the fetus to accommodate himself to the
pelvic to pass easily through the birth canal:
1. Engagement
2. Descent
3. Flexion
4. Internal rotation
5. Extension
6. External rotation
7. Expulsion

8. Fetal Station 12

9. 1. Engagement
20
of the fetal head passes
The greatest diameter
through the pelvic inlet.
2. Descent
Movement of the fetus through the birth canal
during the first and second stages of labor
3. Flexion
The chin of the fetus moves toward the fetal chest
which reduce the fetal head diameter from nearly 12
to 9.5 cm.

10. 10

11. 4. Internal rotation
The rotation of the fetal head until the longest diameter
of the fetal head match the longest diameter of the
maternal pelvic.
11

12. 5. Extension
The fetal head passes beneath the symphysis pubis and
passes out of the birth canal making the crowning.
12

13. 6. Restitution & External rotation
After the head has delivered, the shoulders
rotate internally to fit the pelvis.
13

14. 7. Expulsion
The shoulders and remainder of the body are
delivered
14

15. Management of Normal Labor:
• Birthing should be recognized as a normal
physiological process that most women
experience without complications
• Intrapartum complications, often arising
quickly and unexpectedly, should be
anticipated.

16. 1st Stage of Labour
I. Assessment
II. Preparation and care
III. Partogram

17. 1- Regular Uterine Contractions
2- Show
3- Leaking

18. HISTORY
Woman’s antenatal record is
reviewed
Previous births and size of babies.
Previous caesarean section.
Onset, frequency, duration, strength of contractions.
Membranes have ruptured and, if so, colour
and amount of amniotic fluid.

19.  Presence of abnormal vaginal discharge
or bleeding.
Fetal movements.
Medical or obstetric issues of note (e.g. diabetes,
hypertension, fetal growth restriction [FGR]).
Anyspecial requirements
(an interpreter or particular emotional/psychological
needs).
Maternal expectations of labour and delivery?

20. GENERAL & PHYSICAL
EXAMINATION
Identify women with a raised BMI
Pallor, edema etc.
Vital signs: BP, pulse, RR and Heart
Lungs

21. Abdominal examination
Abdominal examination:
Presentation, position and engagement
Auscultate fetal heart
Evaluate uterine contractions

22. Vaginal examination
Presentation
Engagement,
station
Position, attitude and the presence of caput or
moulding.
Position can be determined by locating occiput.
Membranes Intact or absent: exclude cord
prolapse
Cx: Consistency, Position Dilatation Effacement
Pelvis Adequacy

23. • No vaginal examination:
• In case of vaginal bleeding (before
placenta previa is excluded)
• Sterile speculum examination: suspected
ROM, if the woman is not in labour.

24. Admission to labour ward: In Active
labour:
less time in the labor ward
less intrapartum oxytocics, less analgesia
Investigation:
• Urine: Protein Sugar ketones
• Blood: CBC
• RBS
• Grouping cross match for high risk

25. Preparation and care
Bowel preparation: Indication: No bowel
action for 24 h or Rectum loaded
Bladder care: Encourage to empty bladder
/1½ -
A full bladder inhibits fetal head descent and
effective uterine action.
Nutrition.

26. Position of the woman:
Walk about or in bed,
As long as the patient is healthy, presentation is
normal, presenting part has engaged and fetus
in good condition.
Pain relief:
Opiates. e.g. Pethidine (IM/4 h b)
Inhalational analgesia (Entonox)
Epidural analagesia

27. Factors affecting Labor (5 P’s)
In every labor; there are five essential factors affect the
process. 5 P’s:
1. Passenger: the fetus
2. Passageway: the pelvis and birth canal
3. Powers: the uterine contractions
physical
4. Position: maternal postures and
positions
5. Psyche: the response of the mother
7

28. 1.Passenger (The Fetus):
The fetus relationship to the passageway is the major
factor in the birthing process. The relationship includes:
• Fetal skull and size
• Number of fetuses
• Position of feus
– Fetal lie: relationship of fetal spine to maternal spine;
longitudinal (vertical) or transverse (horizontal)
– Fetal presentation: part of fetus that enters pelvis first
– Fetal attitude: relationship of fetal body parts to each other;
flexion (normal) or extension (abnormal)
– Fetal position: fetal direction in the pelvis
– Fetal station: position of the baby's head relative to the lower
bone of pelvis called the ischial spines 8

29. MANAGEMENT OF FIRST STAGE
OF LABOUR:
First stage: Interval from diagnosis of labour to
full dilatationof the cervix.
 One-to-one midwifery care.
 Additional emotional support from a birth partner.
 Obstetric and anaesthetic care.
 Maternal and fetal wellbeing should be
monitored.
 Vaginal examinations are performed 4 hourly or
as clinically indicated.
 Progress of labour, using a partogram.
 Appropriate pain relief.
 Adequate hydration and light diet to prevent
ketosis.

30. 30

31. Condition of the fetus
FHR: every half hour.
Intermittent auscultation using a Pinard
stethoscope or a Doppler ultrasound.
 Continuous external electronic fetal monitoring
(EFM) using CTG.
 Membranes & Liquor: On every vaginal
examination.
 Moudling: 0 (separated) + (touching)
++(overlap) +++ (severe overlap)
 Continuous internal electronic fetal monitoring
using a fetal scalp electrode (FSE) and CTG.
 Fetal scalp blood sampling (FBS).

32. PROGRESS OF LABOUR
Monitoring the progress of labour :
All events during labour should be recorded on a
PARTOGRAM.
a) Well-being of the fetus
b) Well-being of the mother
c) Progress of the labour
d) Patient information: name, gravida, para,
hospital number, date and time of admission
and time of ruptured membranes.

33. PARTOGRAM
• A graphic record of labour
• An instant visual assessment of theprogress of labour
based on the rate of cervical dilatation compared with
an expected norm, according to the parity of the
woman.
• frequency and strengthof contractions
• Descent of the head in fifths palpable, station, the
amountand colour of the amniotic fluid
• Basic observations of maternal wellbeing (blood
pressure, heart rate and temperature)

35. Secondstage of labour:
stage of delivery of the fetus.
Definition:
the second stage refers to the period from complete
cervical dilatation to the birth of thefetus.
Duration:
primigravida =2h
multigravida =1h
However the duration of second stage is
controversial

36. 36

37. Management during second stage
First sign of the second stage is anurge to push.
Full dilatation of the cervix: Confirm by vaginal
examination if the head is not visible.
Use of regional analgesia (epidural or spinal) may
interfere with the normal urge to push and pushing can
be delayed for 1 to 2 hours.
In all cases the baby should be delivered within 4 hours
after full dilatation.
Descent and delivery of the head
Delivery of the shoulders and rest of the body

38. 34
clamp and cut of the umbilical cord

39. Third stage of labour:
The stage of expulsion of placenta and
membranes.
Duration:
upto30minutes,averagetimeis10 minutes

40. Management of third stage
Interval between delivery of the baby and the
complete expulsion of the placenta and membranes.
Takes between 5 and 10 minutes
Considered prolonged after 30 minutes
SIGNS OF PLACENTAL SEPARATION:
• Apparent lengthening of the cord.
• A small gush of blood from the placental bed.
• Rising of the uterine fundus above the
umbilicus
• Uterus feels firm globular mass on palpation.

41. 41

42. Active management of the third
stage
• Recommended for all women, as it reduces the
incidence of PPH from 15% to 5%.
• Intramuscular injection of 10 IU oxytocin, given
immediately after delivery of the baby.
• Delayed cord clamping between 1 and 3 minutes.
• Controlled cord traction
• Uterine massage after the placenta is delivered
After completion of the third stage, the placenta should
be inspected.
The vulva should be inspected for any tears or
lacerations.

43. Immediate care of the neonate
• Head should be kept dependent to drain mucus
• Oropharyngeal suction: only if really necessary.
• Calculate Apgar score at 1 minute and 5 minutes after
cutting the cord.
• Immediate skin-to-skin contact between mother and
baby
• The baby should be dried and covered with a warm
towel
• Initiation of breastfeeding: within the first hour of life,
• Newborn measurements of head circumference,
birthweight and temperature.
• The first dose of vitamin K.
• General examination for abnormalities and a wrist label
for identification.

44. KEY LEARNING POINTS
 Features of normal labour:
• Spontaneous onset at 37–42 weeks’
gestation.
• Singleton pregnancy.
• Cephalic vertex presentation.
• No artificial interventions.
• Spontaneous vaginal delivery.
 Cervical dilatation of at least 1 cm every 2 hours in
the active phase of firststage.
 Active second stage no more than 2 hours in
primiparous and 1 hour inmultiparous.
 Third stage lasting no more than 30 minutes with
active management.

45. Stage of labour
Definition Duration
StageI latent
phase
(affacment)
•Beginsfrom the onset of regularcontractions.
•Endswith acceleration of cervicaldilatation
•Prepares cervix for dilatation.
<20hours in PG
<14hours MG
Stage1 active
phase
(dilatation)
•Beginswith acceleration of cervicaldilatation.
•Endsat 10 cmdilatation
•Rapid cervical dilatation
<2/hours in PG
<1.5/ hrs inMG
Stage2
(descent)
•Beginsfrom 10cmdilatation
•Endswith delivery of thebaby
•Descent of the fetus
<2hours in PG
<1hours in MG
Add 1 hour inepi
Stage3
(expulsion)
•Beginswith delivery of thebaby.
•Endswith delivery of theplacenta
•Delivery of the placenta
<30min.

46. Thank you
THANK YOU