2. CASE 1
• A 23-year-old primegravida with her LMP on 23/02/2021 presents to
the hospital because she is experiencing abdominal pain every 2 to 3
minutes. On examination, afebrile, not pale, her blood pressure (BP)
is 110/70 mm Hg and heart rate (HR) is 80 beats per minute (bpm).
The FH 36cm, 3 uterine contractions lasting for 30 to 40 secs fetus
longitudinal cephalic 4/5 and FHR 146bpm. On pelvic examination,
the cervix is 6 cm dilated the pelvis is adequate.
• WHAT IS A DIAGNOSIS?
3. CASE 2
• A 26-year-old primegravida at 38 weeks’ gestation
presents to the hospital because she is experiencing
abdominal pain every 2 to 3 minutes. On examination,
afebrile, not pale, her blood pressure (BP) is 110/70
mm Hg and heart rate (HR) is 80 beats per minute
(bpm). The FH 36cm, 3 uterine contractions lasting for
30 to 40 secs fetus longitudinal cephalic 4/5 and FHR
146bpm. On pelvic examination, the cervix is 2 cm
dilated the pelvis is adequate.
4. CASE 2….
What is a diagnosis?
What is the next step in management of this patient?
6. TRUE LABOUR
• A process characterized by regular and progressive
painful uterine contractions associated with cervical
changes leading to delivery of the fetus and placenta
7. Characteristics
• Regular uterine contractions which increases in
frequency, duration and strength over time
• Significant cervical changes: effacement and dilation
• Rupture of membranes
• Descent of the presenting part
• Deliver of the baby
• Delivery of the placenta and membranes
8. Normal labour
Characteristics:
• Spontaneous expulsion,
• of a single,
• mature fetus (37 completed weeks – 42 weeks),
• presented by cephalic vertex,
• through the birth canal (i.e. vaginal delivery),
• within a reasonable time (not less than 3 hours or more
than 18 hours),
• without complications to the mother, or the fetus
9. Mechanism of labour
• Engagement and descent
• Flexion of the fetal head
• Internal rotation to occipitoanterior position
• Extension of the fetal head
• Crowning
• Restitution
• External rotation
• Delivery of the anterior shoulder
• Delivery of the posterior shoulder
10. CASE 3
A 28-year-old gravida 2 para 1 at 38 weeks’ gestation is
admitted at 08:00 in labour complaining of abdominal
pain. On abdominal examination the fundus is 36 cm,
single fetus with a longitudinal lie, head is 4/5 palpable
above the brim of the pelvis. 3 contractions in 10
minutes, each lasting 25 seconds are noted. On vaginal
examination the cervix fully effaced and 6 cm dilated.
The presenting part is in the left occipito-posterior
position.
12. Stages of labour
First stage of labour
• Latent phase is a period of first stage of labor
characterized by some degree of cervical effacement
and slower progression of dilatation up to 5 cm.
• Active phase is a period of first stage of labor
characterized by substantial degree of cervical
effacement and more rapid cervical dilatation from 5
cm until full dilatation.
13. Stages of labour..
Second stage of labour
• A period of labor which begins with a complete
cervical dilatation to a complete delivery of the fetus.
Third stage
• It is the period of labor between the delivery of the
fetus and the delivery of the placenta and fetal
membranes
16. Initial evaluation
• Admission in labor ward should be considered in women in
active phase of first stage of labor.
• Review antenatal visit records for medical or obstetrical
conditions that need to be addressed intrapartum
• Check for development of new disorders since the last
antenatal visit
• Enquire for a recent history of membrane rupture, vaginal
bleeding or bloody show (vaginal discharge of a small
amount of blood and mucus)
17. Initial evaluation….
• Initial assessment should include general condition of the patient,
check for vital signs; i.e. pulse rate, blood pressure; heart and
respiratory rates; temperature.
• Obstetric assessment should include; frequency, quality and duration
of uterine contractions; fetal size estimation, lie, presentation, level
and position; and fetal heart rate (FHR) should be performed.
• Initial pelvic assessment to establish baseline cervical status so that
subsequent progress can be determined; fetal position and station;
and assessment of adequacy of the pelvis except for patients with
placenta previa and PPROM for expectant management
18. Investigations
The following laboratory results should be available at the
time of delivery
• Hemoglobin
• ABO grouping and Rhesus (Rh) factor
• Human immunodeficiency virus (HIV)
• Hepatitis B surface antigen
• Syphilis test
19. CASE 4
A 28-year-old gravida 2 para 1 at 38 weeks’ gestation is
admitted at 08:00 in labour complaining of abdominal pain.
On examination: temperature 36.5C, pulse 70bpm and BP
110/70mmHg. On abdominal examination the fundus is 36
cm, single fetus with a longitudinal lie, head is 4/5 palpable
above the brim of the pelvis. 3 contractions in 10 minutes,
each lasting 30 seconds are noted and FHR 140bpm. On
vaginal examination the cervix fully effaced and 6 cm
dilated. The presenting part is in the left occipito-anterior
position and the membranes are intact
20. CASE 4…
• WHAT IS A DIAGNOSIS?
• WHAT IS THE MANAGEMENT?
22. CASE 4…..
• At 12:00. Pulse rate 80bpm, temperature 37C, BP 115/75 mmHg,,
head is 2/5 palpable above the brim of the pelvis. 4 contractions
in 10 minutes, each lasting more than 40 seconds are noted. On
vaginal examination the cervix fully dilated (10 cm). The
presenting part is in the occipito-anterior position, moulding +,
no caput and the membranes are intact and bulging.
Plot the findings
What is the diagnosis?
What is the management?
23. Monitoring (recorded on the partogram)
Active First Stage of labour
• Fetal heart rate: Intermittent auscultation with Pinard fetal stethoscope or
Doppler scan every 15- 30 minutes or Continuous electronic FHR
monitoring e.g. CTG
• Uterine contractions every 30 min: Uterine contractions should be
monitored and documented by the duration of each contraction (in sec)
and number of contractions per 10 minutes.
• Labor progress
• Perform vaginal examinations on admission and subsequently at four-hour intervals
in the first stage
• When the woman feels the urge to push to determine whether the cervix is fully
dilate
24. Monitoring ……
First stage…
• Pulse rate hourly
• Bp and temperature 4 hourly
• Maternal should be checked for ketones and protein
4hourly
25. Second stage of labour
Prepare delivery kit and oxytocin
Monitoring
• Fetal heart rate monitoring should be every five minutes
• The maximum duration of the second stage of labour should not be
more than 2 hours, in the absence of fetal distress
• Shortening of the second stage should be considered based on the
obstetric indications including maternal illness (e.g. Severe anaemia,
Cardiac diseases, Eclampsia) and fetal distress, when appropriate with
the use of vacuum extraction
26. Second stage of labour…..
Toilet the perineum
Empty the bladder
Pushing position and technique
• Pushing is encouraged after confirmation a fully
dilated cervix
• A woman should bear down when she feels the need
to do so
An episiotomy may be performed whenever indicated
27. Second stage of labour…….
Perineal care
• Perineal massage should be performed during and between
pushes with two fingers of the lubricated gloved hand
moving from side to side just inside the patient’s vagina and
exerting mild, downward pressure.
• Perineal support should be performed during delivery of the
fetus
28. Third stage of labour
Active management of third stage of labour include:
• Prophylactic administration of oxytocin or other uterotonics
(prostaglandins or ergot alkaloids)
• Oxytocin 10IU I.M
• Or ergometrine 0.5mg
• Or misoprostol 600mcg orally single dose
• Cord clamping/cutting
• Controlled traction of the umbilical cord
• Uterine massage
29. Care immediately after delivery (4th stage)
• The 1st 2hours after delivery
• Most third stage complications occurs in the 1st 2
hours
• Postpartum Haemorrhage
• Uterine inversion
• Haematoma formation
30. Care immediately after delivery (4th stage)..
• Keep the woman in labour for 2 hours for observations of:
• Pulse
• BP
• Temperature
• Uterine size and contraction
• Massage of the uterus every 15 minutes for two hours to
prevent post-partum haemorrhage.
• Make sure the woman is left clean and comfortable
31. Immediate care of the newborn
• Make sure the baby breathes normal, that is has cried
during delivery
• Observe at the cord stump to make sure is well tied
and there is no bleeding
• Cover the baby well and give the baby to the mother
immediately to be attached on breast for
breastfeeding.
• Breastfeeding should be initiated with the first hour
