Conduct of labor

1. CONDUCT OF I & II
STAGE LABOR
- DHANA NADEESHWARAN
(INTERN)

2. STAGES OF
LABOR
DESCRIPTION CHARACTERISTICS DURATION IN
PRIMIGRAVIDA
DURATION IN
MULTIGRAVIDA
STAGE I Onset of True labor
pain to Full dilatation
of cervix
Latent phase:
Upto 4cm
Active phase:
From 4cm to 10cm
(Full dilatation)
PRIMI – 1cm/hr
MULTI – 1.5cm/hr
8 – 20hrs
6 – 12hrs
6 – 14 hrs
3 – 6 hrs
STAGE II Full dilatation of
cervix to Expulsion of
fetus from Birth
canal
Propulsive (head
touches pelvic floor)
& expulsive phase
(bear down)
1 – 2 hrs 0.5 – 1 hr
STAGE III Full dilatation of
cervix to expulsion of
placenta &
membranes.
15 min 15 min
STAGE IV 1hr after expulsion
of placenta
1 hr 1 hr
LABOR - STAGES

3. CONDUCT OF IST STAGE OF LABOR

4. I ST - STAGE LABOR
IMPORTANT EVENTS IN 1ST STAGE OF
LABOR:
Formation of Lower Uterine segment
Dilatation and Effacement of cervix
Formation of bag of membranes
Rupture of membranes at the end
LUS forms from isthumus…
• Non pregnant  0.5cm
• At term  5cm
• In labor  10cm

5. The Fibers of Cervix thin out and are pulled up
into the Lower uterine segment  Shortening of
cervix  Effacement of cervix

6. Increase in COX-2Increased PG’s PGF2 α  stimulates GAG synthesis
PGE2  vasodilatation increase in hyaluronic acid, chemoxtaxis for leucocytes  increased collagen
degradation + IL-8 release cervical ripening by Rearrangement & realignment of collagen molecules
Cervical Extracellular connective tissue - Type 1 & 3 collagens
intercalated with GAG’s + Proteoglycans + Fibronectin + Elastin
[GAG’s - heparin sulphate, dermatan sulphate, Hyaluronic
acid]
Increased hyaluronic acid content  increased water molecules that intercalate among collagen fibres 
decreased collagen fiber alignment  decreased collagen fiber strength & diminished tensile strength of
extracellular cervical matrix + Increase in cervical dermatan sulphate & proteoglycan collagen fibre
separation  decrease in cervical firmness.

8. PHASES OF IST STAGE:
CLASSIFICATION
ACOORDING TO
LATENT PHASE ACTIVE PHASE
o ACOG Upto 6cm From 6-10cm
o WHO Upto 5cm From 5-10cm
o PARTOGRAM Upto 4cm From 4-10cm

9. WHO – MODIFIED
PARTOGRAM (2000)

10. MANAGEMENT OF IST STAGE LABOR:
o Ambulation in Early labor & left
lateral position is advised in labor.
o Bladder care – Nelaton catheter
o Diet
o Constant supervision
o Monitoring of maternal and fetal
heart rate
o Assessment of progress of labor
oEpidural analgesia on demand
Continuous electronic FHR montoring
Or intermittent auscultation of FHR can be
done (Hand held doppler)

11. DURING PROGRESS OF IST STAGE OF LABOR:
 Uterine contractions checked every 30min – 1hr.
 CTG Monitoring done. (Pre and post induction CTG)
 PV examinations done every 4th hrly.
 Inform Paediatrician about the case.
 Maternal Pulse, BP – Hourly
Temp – 4th hrly (if membranes ruptured or febrile)
Under certain cases Watch for….
- Scar tenderness - Imminent Signs of eclampsia,
- Bleeding PV

12. Indications for Vaginal Examination
during Labor:
 At onset of labor – to detect cervical changes
and to assess pelvis.
 To assess progress of Labor – Cervical
dilatation, Effacement, Station of Fetal head
 Following rupture of membranes – To Exclude
cord Prolapse
 To confirm IInd stage labor – When Pt starts
bearing down

13. Modified Bishop’s
Score:
PARAMETERS SCORE

14. CRICHTON’S
SCORE
In this method...
- The fetal head above pelvic brim is assessed in
fingerbreadths by placing fingers above the pubic
symphysis.
- A freely mobile head will accommodate the full width of
five fingers.
- As the head descends, the portion of head remaining
above brim will be represents as 4/5th or 3/5th ,etc.
- The head is said to be engaged when <2/5th is palpable.
- ASSESMENT OF DESCENT
BY ABDOMINAL FIFTH
METHOD

15. MOLDING OF FETAL SKULL:
Grade 1:
Bones are touching each other, but
not overlapping.
Grade 2:
Bones are overlapping, but can be
seperated.
Grade 3:
Bones are overlapping and cannot
be seperated.

16. LABOR INDUCTION:
INDICATIONS:
o Post term pregnancy
o Uncontrolled GDM
o Rh isoimmunization
o IUGR, IUD
o Pre-eclampsia
o PROM, APH
METHODS OF INDUCTION:
 Foley’s cather (22F)
 Sweeping of membranes
Dinoprostone gel (PGE2) 0.5mg intracervically.
(can be repeated after 6hrs)
 Misoprostol 25mcg Vaginally or 50mcg Orally.
(can be repeated after 4hrs) Max - 6doses
 ARM with Kocher’s Forceps.
Oxytoxin 2.5U in 500ml RL
(8drops/min  2.5mU/min)
Oxytocin augmentation (escalating dose) if Cx dilatation <1cm/hr.

17. OXYTOCIN DRIP
 Started with Oxytocin 5U for Primi and
2.5U for Multigravi patients.
 1U  1000 milliUnits of oxytocin.
 1ml = 16drops.
 If 2.5U Oxytocin is added to 500ml RL and
if flow rate is started at 8 drops/min, it
means that the dose of oxytocin is
2.5mU/min.
 Oxytocin drip is titrated every 30min with
escalating 2.5U oxytocin upto
64drops/min max. until effective
contractions achieved.

18. CONDUCT OF IIND STAGE OF LABOR

19. IIND STAGE LABOR
IMPORTANT EVENTS IN 2ND STAGE OF
LABOR:
 Bearing down efforts by mother to
expel fetus.
 Propulsion and expulsion of fetus. CLINICAL FEATURE INDICATING 2ND
STAGE ONSET:
 Increase in intensity & duration of
Uterine contractions
 Urge to defecate with descent of
presenting part
Cervical rim cannot be palpated
around fetal head (full dilatation)

20. CARDINAL STEPS OF LABOR
ENGAGEMENT – Biparietal diameter crosses the pelvic brim
DESCENT
FLEXION – When the fetal head touches the
pelvic floor muscles & resistance occurs
INTERNAL ROTATION – By 1/8th of a circle in occipito-
anterior position due to gutter shaped fibres of levator ani
muscle Occiput under pubic symphysis  neck sustains
1/8th torsion
CROWNING – BPD stretches vulval outlet &
does not recede back b/w contractions

21. Continued…
Delivery of the Head by EXTENSION  Baby’s chin in close
proximity to mother’s anus
RESTITUTION – Head untwists 1/8th of circle
in opp. Direction of int.rotation
Head aligns back to its original position &
aligns along long axis of fetus
EXTERNAL ROTATION - Anterior shoulder rotates 1/8th of circle
towards pubic symphysis & both shoulder engages in Antero-
posterior direction of pelvis.
DELIVERY OF SHOULDERS (Anterior followed by
Posterior), & DELIVERY OF TRUNK by Lateral flexion

22. MANAGEMENT OF 2ND STAGE LABOR:
 The Patient is put in dorsal position with Thighs flexed
(WHO – any position)
 External genitalia & perineum cleaned with antiseptic
solution and Bladder is emptied
 Patient is encouraged to bear down with uterine contractions
 FHR monitored every 15min (low risk) or 5min (high risk)
once
 Perineum bulges & fetal head distends the vulval outlet &
does not recede back in b/w (crowning)  shifted to 2nd
stage room.

23.  Mediolateral episiotomy given after injecting 1% lignocaine
 Controlled delivery of head by placing 1 hand over pubic
symphysis and 1 hand over perineum (Ritgen maneuver)
 Delivery of head by extension & Baby’s mouth and nose are
suctioned
 Cord around neck: If Loose  Slipped over head.
 Following fetal head delivery, Restitution & external rotation
occurs.

24. Delivery of anterior shoulder followed by
posterior shoulder.
 Rest of trunk slides out of introitus and is
supported by clinicians hand.
 Umbilical cord is then clamped, cut, and the
baby is handed over to paediatrician.

25. THANK YOU…