stages and management of laborPresentation Transcript
is the process that begins with
repeated, forceful uterine contractions.
Uterine contractions supply the power that
makes birth possible. Contractions cause the
cervix to dilate and help move the baby
through the birth canal3.
as effective onset of uterine
contractions leading to progressive
effacement and dilatation of cervix resulting
in expulsion of fetus, placenta and
Labor is called normal if it fulfils the following
in onset at term
With vertex presentation
Without undue prolongation
Natural termination with minimal aids
Without having any complication
Any deviation from the definition of Normal Labor is
called Abnormal Labor.
It starts from the onset of true labor pain, and ends with
the full dilatation of the cervix. Its average duration is 12
hrs. in primigravidae and 6 hrs in multiparae1.
FIRST STAGE comprises of 3 phases
phase : is prior to active first stage of labor
and may last 6-8 hrs. in first time mothers when the
cervix dilates from 0 cm to 3-4 cm dilated and
cervical canal shortens from 3 cm to less then 0.5
phase : is the time when cervix undergoes
more rapid dilatation. This begins when the cervix
is 3-4 cm dilated2.
phase : is the stage of labor when the
cervix is around 8cm dilated until it is fully dilated2.
second stage is that of expulsion of
the fetus. It begins when the cervix is fully
dilated and the women feels urge to expel
the baby. It is complete when baby is
It has got two phases :
Propulsive phase : starts from full dilatation
up to the descent of the presenting part to
the pelvic floor.
Expulsive phase : is distinguished by maternal
bearing down efforts and ends with the delivery
of baby. Its average duration is 2 hours in
primigravida and 30 min utes in muliparae.
third stage is that of separation and
expulsion of placenta and membranes ; it
also involves control of bleeding. It lasts
from the birth of the baby until the placenta
and membranes have been expelled2.
is the stage of observation for at least one
hour after expulsion of the after-births.
During this period, general condition of the
patient and the behaviour of the uterus are
to be carefully watched1.
of spontaneous labor is not
always easy. Both the woman midwife being
aware of the latent phase of the labor and
allowing this time to pass with no
Spurious labor: many woman experience
contractions before the onset of labor
, causing the women to think that labor has
The 2 features of true labor that are
2} Cervical dilatation
(a) Fundal dominance
(c) Contractions and retraction
(d) Formation of upper and lower uterine
(e) The retraction ring
(f) Cervical effacement
(g) Cervical dilatation
(a) Formation of the forewaters
(b) Rupture of the membranes
(c) Fetal axis pressure
of labor is influenced by parity, birth
interval, psychological state, presentation
and position, maternal pelvic shape and size,
character of uterine contractions.
primipara women, average duration is 12
multipara women it is 6 hrs.
Each uterine contraction starts in the fundus
near one of the cornua and spreads across
and downwards. contraction lasts longest in
the fundus where it is also more intense and
contraction fades from all parts together.
Polarity is the term used to describe the
neuromuscular hormony that prevails
between the two poles or segments of the
uterus through out the labor.
polarity disorganized = labor inhibited
Contraction is the
temporary reduction in
the length of the fibers
Uterine muscles have unique property. During
labour the contraction does not pass off entirely
,but muscle fibers retain some of the shortening
of contraction instead of becoming completely
relaxed, this termed as retraction .
: gradually increases with
advancement of labor until it become
maximum in the second stage during delivery
of the baby.
Intrauterine pressure raised to 40-50 mm Hg
in first stage.
Duration : In the first stage the, the
contraction last for about 30 sec., but
gradually increase in duration with the
progress of labour.
Frequency : in early stage, the contraction
come at intervals of 10-15 mints. By the end
of the second stage they occur at 2-3 mints.
Intervals, last for 50-60 seconds and are very
the phenomenon of the uterus in labour in
which the muscle fibers are permanently
Effects of retraction
in formation of lower segment
Maintains advancement of presenting part
Favouring separation of placenta
the end of the pregnancy body of the
uterus is described as having divided in to
The upper segment, have been formed from
the body of fundus, and is mainly concerned
with concerned with contraction and
retraction, it is thick and muscular.
The lower segment is formed of the isthmus
and cervix, about 8-10 cm.
The lower segment is prepared for distention
wall of the upper segment become
progressively thickened with progressive
thinning of the lower segment.
Distinct ridge is produced at the junction of
two, called physiological retraction ring.
Physiological retraction ring should not be
confused with pathological retraction ring
also called as Bandl’s ring1 .
Once the cervix is fully dilated and the fetus
can leave the uterus, the retraction ring rises
no further 2
cervix is drawn up and gradually merges
in to the lower uterine segment.
In the primiparous women it may result in
In multiparous women perceptible canal may
Effacement is the gradual thinning, shortening, and drawing up of
the cervix, This is measured in
percentages from 0 to 100
EFFACEMENT OF CERVIX
No changes to cervix
Cervix is half of the normal
Cervix is completely thinned
dilation (or cervical dilatation) is
the opening of the cervix, the entrance to
uterus, during childbirth, miscarriage, induce
d abortion, or gynaecological surgery.
Cervical dilation may occur naturally, or may
be induced by surgical or medical means .
General guidelines for cervical dilation:
Latent phase: 0-3 centimeters
Active Labor: 4-7 centimeters
Transition: 8-10 centimeters
Complete: 10 centimeters. Delivery of the
infant takes place shortly after this stage is
phase: 0-3 centimeters
Active Labor: 4-7 centimeters
Transition: 8-10 centimeters
Complete: 10 centimeters. Delivery of the
infant takes place shortly after this stage is
pregnancy, the os (opening) of the
cervix is blocked by a thick plug of mucus to
prevent bacteria from entering the uterus.
During dilation, this plug is loosened. It may
come out as one piece, or as thick mucus
discharge from the vagina. When this
occurs, it is an indication that the cervix is
beginning to dilate.
Bloody show : is another indication that the
cervix is dilating. Bloody show usually comes
along with the mucus plug, and may continue
throughout labor, making the mucus tinged
pink, red or brown.
The sac of amniotic fluid is described as having
two sections – the forewaters (in front of baby’s
head) and the hind waters (behind baby’s head).
During labor forewaters are formed as the lower
segment of the uterus stretches and the chorion (the
external membrane) detaches from it4.
The well flexed baby’s head fits into the cervix
and cuts off the fluid in front of the head
(forewaters) from the fluid behind (hind waters)4.
from contractions cause the
forewaters to bulge downwards into the
dilating cervix and eventually through into
the vagina. This protects the forewaters from
the high pressure applied to the hind waters
during a contraction and keeps the
membranes intact 4.
forewaters transmit pressure evenly over
the cervix which aids further dilatation 4 .
a contraction the pressure is
equalised throughout the fluid rather than
directly squeezing the baby, placenta and
protects the baby and his/her oxygen
supply from the effects of the powerful
uterine contractions .
optimum physiological time for the
membranes to rupture spontaneously is at
the end of the first stage of labor after the
cervix become fully dilated and no longer
supports the bag of forwaters 2.
When the baby is in an OP position the head
may not flex as well to block off the hind
waters = pressure is able to move into the
forewaters and they may rupture. Early
rupture of membranes if often a feature of
an OP labour 2.
longitudinal lie, there is a tendency of
straightening out of fetal vertebral column.
allow the fundal contraction to transmit
through the podalic pole in to the fetal axis
and hence allow mechanical stretching of
lower segment and opening up of cervical
transverse lie fetal axis pressure is absent
Non interference with watchful expectancy
so as to prepare the patient for natural birth.
To monitor carefully – the progress of labour,
maternal conditions, and fetal behaviour so as to
detect any intrapartum complication early.
of normal labor aims at
maximal observation with minimal
intervention. The idea is to maintain the
normalcy and to detect any deviation from
the normal at the earliest possible moment.
consist of basic evaluation of the
current clinical condition.
Enquiry is to be made about the onset of
labor pains or leakage of liquor, if any.
Thorough general and obstetrical
examinations including vaginal examinations
are to be carried out and recorded.
Records of antenatal visits, investigation
reports and any specific treatment given, if
available, are to be reviewed.
Women may choose to give birth in their own home
where they control the environment and feel
comfortable in their own surroundings or they
wish the security of a hospital birth where
facilities are readily available for prompt and
efficient action should an emergency occurs.
A trusting atmosphere between a women and her
caregivers, a feeling of being among friend’s and
a knowledge of the skills required to cope with
the stresses of labor set the scene for a positive
Emotional support consist of helping the mother
to feel in control of herself to feel accepted
whatever her reactions and behaviour may be
and to complete her labor feeling that she is
success, even if the outcome was not what she
Consent and information giving
Any individual who puts herself in the hands
of professional attendants deserves to be
kept fully informed about their actions and
The Midwife must takecare not only to talk to
the mother but to ask for her consent to
what she plans to do and to invite her
comments and questions.
The very nature of the care given during labor
may expose both mother and fetus to the risk
This is the responsibility of midwife to
acquaint herself with the risks, prepare the
woman physically during the antenatal
period and to maintain hygiene and asepsis in
order to prevent infection occuring, this
: The haemoglobin level should be
adequate and anemia should be corrected if
necessary. WBCs are needed to fight invading
organism and usually their ability to do so
correlates with the general health and
absence of fatigue.
status: poverty may lead to
malnurition. Education in using economic yet
nutritious food, including how to prepare
them may be an invaluable contribution from
and membranes :
An intact skin provides an excellent barrier to
organisms and it is important to protect its
integrity. This involves the aviodance of
surgical wounds whenever possible including
how to prepare them may be an invaluable
contribution from the midwife.
A clean body and environment will reduce
the organisms which have assess to
mother. This implies the need for barrier
methods to be used.
A tired, exausted women will not be able to
combat infection and if the mother has been
deprived of sleep and rest prior to admission of
during labor, the widwife may need to create an
opportunity for sleeping if necessary by mild
health and care of
A modern maternity unit should be constructed
so as to limit the spread of infection. It should
be sighted from a distance from any source of
pathogenic organisms and should be designed for
easy and effective cleaning and in a way which
will reduce the transfer of air born organisms.
is the responsibility of midwife to ensure
that high standards of cleanliness are
maintained even if she does not have
managerial control over domestic services.
The midwife must always use sterile
equipments and aseptic technique in
order to avoid introduction foreign
organism in to the genital tract.
several consideration govern the choice of
position during the first stage of labor, of these
the most important is that of maternal
preference. In early labor, ambulation can be
encouraged and during a contraction the woman
often finds it comforting to lean forward,
supporting her weight on a table or on her
lateral position will be the best as this avoids
compression of the inferior venacava and
changing position not only improves comfort but
also help progress.
upright and leaning
forward reduces this pressure
while allowing your baby’s head to
constantly bear down on your
cervix. The result? Dilation tends
to occur more quickly.
Advice prior to admission : the women’s need in
labor is for energy and it is carbohydrates which
provide. She should choose food that are light
and easily digested such as bread and
butter, fluids may be taken freely, although fizzy
and very sweet drinks may induce vomiting.
Intake in early labor : in some centers, no food is
permitted after labor is established, on the basis
that anesthesia could be needed.
Policies in advance labor : most obstetric units
withhold food in advanced labor. Some also
discourage drinking but allow the women to have
sips of water to keep her mouth comfortable.
Bladder care :
The woman should be encouraged to empty
her bladder every 1-2 hrs during labor.
The quantity of urine passed should be
If the bladder remains full, the bladder neck
can become nipped between the fetal head
and the symphysis pubis. This may give rise
to bruising which can slough during the
perineum leaving a vesico-vaginal fistula.
Pulse rate : A steady pulse rate is an
indication that the women is in good
condition. If the rate increases mare than
100 beats/min. it may indicative of
infection, haemorrhage, ketoacidosis.
Temperature : this should remain with in the
normal range. It should be recorded every 4
Blood pressure : the effect of labor may be
to further elevate a raised blood pressure.
or PV examinations are performed
for a number of clinical reasons e.g.
problems relating to menstruation, irregular
bleeding, dyspareunia, abnormal vaginal
discharge, pelvic pain, and here we are going
to examine for early detection of any
abnormality in labor process.
– hands and forearms should be
washed, a scrubbing brush should be used for
Sterile pair of gloves is to be put on.
Vulval toileting should be performed and
same solution is poured over the vulva by
separating the labia minora by the fingers of
Gloved middle and index finger of the right
hand smeared with antiseptic cream
introduced in to vagina after separating the
labia by two fingers of the left hand.
examination should be done before
fingers are withdrawn.
examination should be kept as
minimum as possible.
of cervical dilatation in centimeters
Degree of effacement of cervix
Status of membranes and if ruptured –color
Presenting part and its position by noting the
fontanelles and sagittal suture in relation to
to the quadrants of the pelvis.
Caput and moulding of head
Station of the head in relation to ishchial
condition during labor can e assessed
by obtaining information about the fetal
heart rate and patterns. The pH of the fetal
blood and the amniotic fluid.
doppler ultrasound apparatus can be
used for measuring fetal heart rate and rate
should be between 120-160 beats/min.
pharmacological methods :
Transcutaneous electrical nerve
stimulation (TENS) : It work be interrupting
pain transmission along the sensory pathway.
Hypnosis : Is also a pain relieving technique.
Women are usually taught self hypnosis and
in suitable subject it may be successful.
Sedative and analgesics :
The sedative given were usually the chloral
derivatives. Analgesics which are used in early
labor are in mild to moderate analgesic range
Narcotics : A narcotic is a strong analgesic drug
with some sedative properties. These include
pethidine, morphine, naloxone, pentazocine.
Inhalation analgesia : They offer effective
pain relief for the majority, of women with the
adnvantage that all their effects are short
lived and they donot give rise to any
complication in the neonate. The agent used is
Entonox. Entonox is the trade name used to
describe an equal mixture of oxygen and
Physiology in the
second stage of labor
stage of labor begins when the cervix
is fully dilated and ends with the baby’s
birth, it is a time when the whole tempo of
activity changes. The mother’s passive
control during the long hours of the first
stage is replaced by intense physical effort
and exertion for a comparatively short
stamina, courage and confidence in the skill
of attendant midwife.
2 hours in Primi-gravida
30 minutes in multi- gravida
1) Uterine action
2)Soft tissue replacement
Uterine actions :
contractions becomes stronger and longer
but may be less frequent affording mother
and fetus a recovery period during the
contractions and retractions of the upper
uterine segment while the lower segment
and cervix passively dilate and thin. The
membrane often rupture spontaneously at
the onset of second stage.
The consequent drainage of liquor allows the hard
, round fetal head to be directly applied to the
vaginal tissues and aid distension.
Fetal axis pressure increases flexion of the head
which results in smaller presenting
diameters, more rapid progress and less trauma to
both mother and fetus
The nature of the contraction changes. They
become more expulsive as pressure is exerted on
the rectum and pelvic floor.
2) Soft tissue replacement :
As the fetal head descends, the soft tissue of the
pelvic become displaced. Anteriorly the bladder
is pushed upwards in to the abdomen where it is
at less risk of injury during descent .
Posteriorly the rectum becomes flattened in to
the sacral curve and the pressure of the
advancing head expels any residual fecal matter.
The fetal head become visible at the vulva,
advancing with each contraction and receding
during the resting phase untill crowing takeplace
and the head is born
Expulsive uterine contractions : it is possible
for a women to feel a strong desire to push
before the cervix is fully dilated, specially if
the fetus is in an occipto-posterior position.
Rupture of the fore-water : this may occur
at anytime during labor.
Dilation and gaping of the anus: Deep
engagement of the presenting part and
premature maternal effort may produce this
Appearance of the presenting part :
Excessive moulding may result in the
formation of a large caput succedaneum
which can protrude through the cervix prior
to the full dilatation . Similarly a breech
presentation may be visible when the cervix
only 7 to 8 cm dilated.
Show : This must be distinguished from
bleeding due to partial separation of the
placenta or that caused by ruptured vasa
Congestion of the vulva : Enthusiastic
premature pushing may also cause this.
the fetus descends soft tissue and bony
structures exert pressure which force fetus
to negotiate the birth canal by a series of
passive movements. Collectively these
movements are called the mechanism of
Principles common to all are :
Descent take place throughout.
Whatever part leads and first meets the
resistance of the pelvic floor will rotate forward
untill it comes under the symphysis pubis
Whatever emerges from the pelvis will pivot
around the pubic bone.
the mechanism of normal labor the
fetus turns slightly to take advantage of the
widest available space in each plane of the
The lie is longitudinal.
The presentation is cephalic
The position is right or left occipitoanterior
Attitude is good flexion
Denominator is occiput
The presenting part is the posterior part of
the anterior parietal bone
a first-time pregnancy descent is usually
slow but steady; in subsequent pregnancies
descent may be rapid. Progress in descent of
the presenting part is determined by
abdominal palpation until the presenting part
can be seen at the introitus.
Descent refers to the progress of the presenting part
through the pelvis. Descent depends on at least four
Pressure exerted by the amniotic fluid.
Direct pressure exerted by the contracting fundus on
Force of the contraction of the maternal diaphragm
and abdominal muscles in the second stage of labor.
Extension and straightening of the fetal body.
The effects of these forces are modified by the size
and shape of the maternal pelvic planes and the size
of the fetal head and its capacity to mold.
degree of descent is
measured by the station of
the presenting part As
mentioned, little descent
occurs during the latent
phase of the first stage of
labor. Descent accelerates in
the active phase when the
cervix has dilated to 5 to 7
cm. It is especially apparent
when the membranes have
the bi-parietal diameter of the head
passes the pelvic inlet, the head is said to
be engaged in the pelvic inlet .
In most nulliparous pregnancies this occurs
before the onset of active labor because the
firmer abdominal muscles direct the
presenting part into the pelvis.
In multiparous pregnancies, in which the
abdominal musculature is more relaxed, the
head often remains freely movable above the
pelvic brim until labor is established.
: The head usually engages in
the pelvis in a synclitic position, one that is
parallel to the anteroposterior plane of the
pelvis. Frequently asynclitism occurs (the
head is deflected anteriorly or posteriorly in
the pelvis), which can facilitate descent
because the head is being positioned to
accommodate to the pelvic cavity. However,
extreme asynclitism can cause cephalopelvic
disproportion, even in a normal-size pelvis,
because the head is positioned so that it
soon as the descending head meets resistance
from the cervix, pelvic wall, or pelvic floor, it
normally flexes so that the chin is brought into closer
contact with the fetal chest Flexion permits the
smaller suboccipito-bregmatic diameter (9.5 cm)
rather than the larger diameters to present to the
Flexion has advantage of bringing the shortest
diameter of the head into descent.
maternal pelvic inlet is widest in the
Therefore the fetal head passes the inlet into
the true pelvis in the occipito-transverse
The outlet is widest in the antero-posterior
Therefore, for the fetus to exit, the head
Internal rotation begins at the level of the
ischial spines but is not completed until the
presenting part reaches the lower pelvis.
the occiput rotates anteriorly, the face
rotates posteriorly. With each contraction
the fetal head is guided by the bony pelvis
and the muscles of the pelvic floor.
Eventually, the occiput will be in the midline
beneath the pubic arch. The head is almost
always rotated by the time it reaches the
Both the levator ani muscles and the bony
pelvis are important for achieving anterior
rotation. A previous childbirth injury or
regional anesthesia may compromise the
function of the levator sling.
which explains the anterior rotation
of occiput are :
# Slope of pelvic floor
# Pelvic shape
# Law of unequal flexibility
Slope of pelvic floor :
two halves of levator ani form a gutter &
viewed from above, the direction of fibres is
downwards, backwards and towards the
midline. Thus with each contraction, the
head, occiput in particular, in a well flexed
ani, particularly that half which is in relation
# after contraction passes off, elastic recoil of
the levator ani occur, bringing the occiput
forwards toward the midline. The process is
repeated untill the occiput is placed
anteriorly “this is called rotation by Law of
shapes : forward inclination of the side
walls of the cavity, narrow bispinous
diameter and ant.-Post. Diameter of the
outlet results in putting the long axis of the
head to accommodate in the maximum
Law of unequal flexibility : the internal
rotation is primarily due to inequalities in
the flexibility of the component parts of the
O.T. position ,there will be anterior
rotation by 2/8 of a circle of the occiput.
In oblique anterior position ( O. A.), the
rotation will be 1/8 of a circle
forward, placing the occiput behind the
There is always accompanying movement of
descent with internal rotation
of internal rotation :
Well flexed head
Efficient uterine contractions.
Favourable shape of pelvis
Good tone of levator ani mucles.
is when baby’s head remains visible
at vaginal outlet without slipping back in as
mother is pushing continuously during birth
is the torsion because of the internal
rotation, and it depends upon the location of
the occiput in-relation to pelvis.
In LOA or ROA torsion will be of 1/8th of
In LOT or ROT torsion will be of 2/8th of the
And torsion is corrected on restitution.
the fetal head reaches the perineum
for birth, it is deflected anteriorly by the
perineum. The occiput passes under the
lower border of the symphysis pubis
first, then the head emerges by extension:
first the occiput, then the face, and finally
the head is born, it
rotates briefly to the position
it occupied when it was
engaged in the inlet. This
The 45-degree turn realigns
the infant's head with her or
his back and shoulders. The
head can then be seen to
external rotation occurs as the shoulders
engage and descend in maneuvers similar to
those of the head.
Bisacromial diameter had rotated into the
anterio-posterior dimeter of the pelvis
posterior shoulder is guided over the
perineum until it is free of the vaginal
downward traction : ant. shoulder under the
upward movement: post. shoulder is delivered
the trunk of the baby is born by flexing
it laterally in the direction of the symphysis
emerged, birth is complete, and the second
stage of labor ends.
onset: full dilatation of the cervix
bear down :
descent of the presenting part
the urge of defecate
contraction & expulse force
- 50 min in nulliparous
- 20 min in multiparous
-become abnormally long if
A contracted pelvis
A large fetus
expulsive effort from
conduction analgesia or intense
-low risk: 15 min
-high risk: 5 min
-slowing of the FHR
: due to fetal head compression
: reduce placental perfusion
: recovery after the contraction and
expulsive effort cease
Descent of the fetus obstruct umbilical
cord blood flow (tighten loop or cord neck)
->uninterrupted maternal expulsive effort
can be dangerous to the fetus
Maternal tachycardia in second stage
:common, must not be mistaken for a
leg : half-flexed deep breath & breath
held exert downward pressure
She should not be encouraged to “push”
beyond the time of completion of each
In increasing bulging of the perineum
encouragement is very important.
FHR is likely to be slow
Feces is frequently expelled perineum
begins to bulge , tense and glistening
scalp may be visible
-The dorsal lithotomy position
: increase the diameter of the pelvic
: using leg holder and stirrup
-> result in spontaneous tear or
-vulvar and perineal cleansing
: sterile drape and gowning, gloving
of the head : crowning
encirclement of the largest head
diameter by the vulval ring.
- one hand: a towel-draped, gloved hand
may be exert forward pressure on the
chin of the fetus through the perineum
just in front of the coccyx
- with other hand: exerts pressure
superiorly against the occiput.
The occiput : Turns toward one of the
Fetal head: Transverse position
sucking the nasopharynx or checking for a
the nasopharynx :
fluid, debris, blood
The face: quickly wiped
Nares and mouth : aspirated
after head dilevered, ascertain the umbilical
-occur 25%, ordinarily do no harm
-drawn down or cut (too tightly)
two clams: 4 or 5cm and later 2
or 3cm from the fetal abdomen
of cord clmaping
After delivery, the infant is placed at the level of
vagina for 3 min, the fetoplacental circulation is
80 ml of blood – shift to the fetus (50mg of Fe)
After first clearing the airway (30 second)
-> then clamps the cord
the baby has been born the placenta,
which has sustained baby throughout
pregnancy, is no longer needed; mother need
to push it out along with the remaining part
of the umbilical cord that runs between the
placenta and baby.
With no intervention the normal process is
that baby is born and you can greet and
hold her while she remains attached to the
umbilical cord. The cord supplies
oxygenated blood which supports her until
she starts to breathe on her own. The cord
runs from her tummy to the placenta,
which is still attached to the inside of the
womb until the placenta detaches and
mother push it out.
after delivery of the infant, the
height of the uterine fundus and its
consistency are ascertained.
As long as the uterus remains firm and there
is no unusual bleeding, watchful waiting until
the placenta is separated is the usual
No massage is practiced; the hand is simply
rested on the fundus frequently, to make
certain that the organ does not become
atonic and filled with blood behind a
< 500 mL
< 1000 mL
the placenta has separated, it should
be ascertained that the uterus is firmly
The mother may be asked to bear down, and
the intra-abdominal pressure so produced
may be adequate to expel the placenta.
If these efforts fail, or if spontaneous
expulsion is not possible
In 2010 ICM/FIGO formed a Multidisciplinary
expert taskforce to define the components of
physiological management. ICM conducted a
survey of current best practice and 39 ICM
Member Association Countries responded.
There was consensus on;
1) Signs of separation
2) How to support women to expel
3) The first two hours after the birth
Signs of separation
Change in the size, shape and position of
– A small gush of blood
– The cord lengthens
– The woman becomes uncomfortable, get
contractions or feel that she wants to
change position or bear down
Most placentas will be delivered in one
2) Supporting women to expel the
placenta, after signs of separation
Encourage woman into upright position
The placenta may be expelled spontaneously
Encourage maternal effort to expel placenta
The birth attendant catches the placenta in
cupped hands or a bowl
If the membranes are slow then assist by
holding the placenta in two hands and gently
turning it until the membranes are twisted
then exert gentle tension
Oxytocics are not used
Placenta is delivered by gravity and maternal
Cord is clamped after delivery of the placenta
Oxytocic is given
Cord is clamped
Placenta delivered by controlled cord traction
(CCT) with counter-traction on the fundus
Fundal massage or pressure
Within 1 minute of birth, palpate abdomen to
rule out presence of another baby
Await strong uterine contraction (2–3 minutes)
Apply controlled cord traction while applying
counter-traction above pubic bone
If placenta does not descend, stop traction and
await next contraction
not to give oxytocic
Try not to use CCT or any manual
interference with uterus at fundus
Try to encourage mother to concentrate on
feeling for next contraction or urge to push
When mother feels contraction or urge or
there are signs of separation, encourage
mother and help her change posture
If placenta does not deliver spontaneously,
wait, try putting baby to breast and
encourage maternal effort
to give one ampule of oxytocic (5 units
oxytocin and 0.5 mg ergometrine routinely or
10 units synthetic oxytocin if mother has high
BP) immediately after delivery of anterior
Clamp cord 3 mints. after delivery of baby
When uterus has contracted, try to deliver
placenta by CCT with protective hand on
abdomen helping to shear off placenta and
preventing uterine inversion
Try not to give any special instructions about
None or after placenta With delivery of
anterior shoulder or
Assessment of size
Assessment of size
and tone after delivery and tone after delivery
traction when uterus
oxytocin, when available:
If oxytocin is not available, use syntometrine
If oxytocic drugs are not available, use nipple
not use ergometrine in women with
hypertension or heart disease
Store oxytocics in refrigerator (2–8ºC) and
away from light
Misoprostol rectally has advantages.
Causes uterus to contract
Acts within 2.5 minutes when given IM
Generally does not cause side effects
More expensive than ergometrine
IM or IV preparations only
Not heat stable
Effect lasts 2–4 hours
Takes 6–7 minutes to become effective when
given IM; oral form insufficiently effective
Causes tonic uterine contraction
Increased risk of hypertension, vomiting,
Contraindicated in women with hypertension
or heart disease
Not heat stable
stimulation has not been shown to
reduce risk of PPH
Randomized controlled trial of suckling
immediately after birth with over 4,000 subjects
in Malawi showed no significant difference in
frequency of PPH, mean blood loss or retained
oxytocics are not available, CCT and
fundal massage should be performed
Advantages of early breastfeeding and nipple
Stimulates natural production of oxytocin
May maintain tone of contracted uterus
Bullough, Msuku and Karonde 1989.
the fundal position and size of the
Ensure that the uterus is contracted (can be
enhanced with oxytocin and uterine massage).
Examine the placenta for completeness and
detection of abnormalities.
Suturing of lacerations.
- Is justified in patients with bleeding
originating high in the genital tract.
- No longer recommended for normal
deliveries or those following
previous cesarean delivery.
- Is justified in patients with
bleeding originating high in the
- The cervix should be visualized
after all forceps deliveries
Observe the vital signs.
the abdomen to assess and monitor
uterine tone and size.
Do uterine massage.
Ensure continuous infusion of oxytocin.
Encourage early breastfeeding to promote
endogenous oxytocin release.
assess the lower genital tract for bleeding.
repair of an episiotomy or any lacerations.
Close observation every 15 minute for the next
Dutta DC textbook of obstetrics. edition
Normal labour is the process by which
contractions of the gravid uterus expel the
fetus and the other products of conception
A-between 37 and 42 weeks from the last
B- Before 37 weeks gestation
C-After 42 weeks gestation
D- After 24 weeks gestation
Fetal lie refers to ???
longitudinal axis of the fetus in relation
to the oblique axis of the maternal
longitudinal axis of the fetus in relation
to the transverse axis of the maternal
longitudinal axis of the fetus in relation
to the long axis of the maternal uterus
longitudinal axis of the fetus in relation
to the long axis of the maternal pelvis
True onset of labor is defined by
which one of the following
Passage of bloody show
Occurance of uterine contraction
Excessive fetal movement
Cervical dilation and effacement
Gush of vaginal fluid
False contractions characteristics
(Braxton-Hicks) all true Except
Occur At Irregular Intervals
Intensity doesn't change
Pain primarily in lower abdomen
Pain usually relieved with sedation
Which is true about retraction
Relaxion after uterine contraction
Intensity of uterine contraction in upper
and lower segment
The myometrium of the upper uterine
become shorter after contraction
the pacemaker in the right cornu of the