Normal labour for nursing students

1. BIRTH PROCESS

2. Categories of labor
First Stage:
from labor onset until full dilation
– Latent phase:
 period from onset till labor becomes active
 Usually, it is defined by the initiation of regular painful contractions.
 The onset of labor is difficult to identify objectively.
 Identification of latent labor usually depends on patient memory
– Active phase:
 From accelerating slope of cervical dilation till full dilatation (Beginning
diagnosed retrospectively)
 Diagnosis:
– ≥80 percent effacement
– ≥4 cm dilation of the cervix
 Cervical dilatation rates (5th percentile):
– Multiparous: 1.5 cm
– Nulliparous: 1.2 cm
– Generally: at least 1 cm per hour

3. Categories of labor
Second stage:
Full dilation until delivery of the baby
Factors affecting duration of the second stage
 Epidural analgesia*,
 Nulliparity,
 Older maternal age,
 Longer active phase,
 Larger birth weight,
 Excess maternal weight gain
 Maternal position*
– Allowing women to choose alternate positions may be beneficial,
especially in nulliparas
 Delayed pushing*
* Modifiable factors

7. Categories of labor
Third stage:
Delivery of baby until delivery of the placenta
• Median duration:
• 6 minutes
• exceeded 30 minutes in 3% of women
• Duration not affected by parity
• 30 minutes associated increased risk of:
• > 500-ml blood loss,
• > 10% drop in post-delivery hematocrit
• need for D&C
• Manual removal and or extraction of the placenta is
indicated after 30 minutes (or earlier in PPH)

8. SPONTANEOUS VAGINAL DELIVERY
 Goals of assistance at spontaneous delivery:
– reduction of maternal trauma,
– prevention of fetal injury,
– initial support of the newborn, if required

10.  Don’t just stand
there.
 Do nothing!”

11. Prolonged second stage
 ????????????????
 Maternal morbidity, including perineal trauma, PPH, and
chorioamnionitis, is higher in second stage lasting longer than
2 hours but instrumental delivery does not prevent perineal
trauma and morbidities

12. Third stage of labor
 Quickly dry and wrap the baby and give to
mother if appropriate.

13. Signs of placental separation
 Fundus rises to level of umbilicus, getting
contracted
 The cord lengthens in the vulva
 Trickle or gush of blood

14. Management of 3rd
stage of labour

15. Selecting Management
 EXPECTANT
- no oxytocin
- waiting for signs of
separation and placenta is
delivered by gravity and
woman’s effort
- cord is clamped when
pulsation ceases or after
delivery of placenta
 ACTIVE
- Oxytocin im
- Early cord- clamping
- controlled traction of cord
and counter traction on
uterus

16. Active management of third stage of labour
 Give oxytocin immediately:
– Palpate uterus to rule out the possibility of an
additional baby
– Administer oxytocin 10 units im (within one minute
after delivery)

17. Active management of third stage of labour
 Deliver the placenta by controlled cord
traction:
Clamp the cord
– Clamp the cord close to the perineum using sponge
forceps.
– Hold the clamped cord and the forceps with one
hand.
– Keep slight tension on the cord and await a strong
uterine contraction (2-3 minutes).

18.  Deliver the placenta by controlled cord
traction:
Controlled cord traction
When the uterus becomes rounded or the cord
lengthens:
– Very gently pull downwards on the cord.
AND
– Place the other hand just above the woman’s pubic
bone and stabilize the uterus by applying counter
traction during controlled cord traction.

20. Controlled cord traction:
 Never pull on the cord without pushing the uterus up with
the other hand.
 CCT helps prevent inversion of the uterus.

21.  Deliver the placenta by controlled cord
traction:
Controlled cord traction
– If the placenta does not descend during 30-40 sec of controlled
cord traction (i.e. there are no signs of placental separation), do
not continue to pull on the cord.
– Gently hold the cord and wait until the uterus is well contracted
again. If necessary, use a sponge forceps to clamp the cord
closer to the perineum as it lengthens.
– With the next contraction, repeat controlled cord traction with
counter traction.

22. Slowly pull to complete
the delivery:
– Receive placenta in cupped
hands
– Gentle up-and down-
movements with placenta to
deliver membranes

23. Placenta, umbilical cord, and fetal
membranes examination:
 Placental weight (without membranes, cord) varies with NB weight
– ratio of approximately 1 : 6
– Large placentae: hydrops fetalis, congenital syphilis etc
 Examine fetal and maternal surfaces:
– Fibrosis, infarction, calcification
 extensive lesions prompts histologic examination
– Adherent clots: recent placental abruption
 absence does not exclude abruption
– Missing placental cotyledon or a membrane defect
 missing succenturiate lobe prompts further clinical evaluation
 No routine manual exploration of uterus unless suspicion of retained
products of conception or PPH

24. Examine the placenta
routinely
lobules. membranes, cord, weight, clot
– If a portion of the maternal surface is
missing or there are torn membranes
with vessels, suspect retained
placental fragments
– Check for excessive bleeding
– Make sure no clot in vagina and uterus
is well controlled

25. Management of incomplete placenta
 Membranes – inspection of vagina and
cervix, gentle removal with a non-sharp
instrument
 Lobules – manual revision of uterus
– Be gentle
– Communicate with the woman throughout the
procedure

26. Oxyticics
Why oxytocin?
 Effective (2-3 minutes)
 No side effects
 Can be given to all women
If oxytocin is unavailable ?
 Ergometrin 0.2 mg IM
– NOT in pre-eclampsia, eclampsia, high blood pressure
Prostaglandines – some advantages
– Inexpensive,
– Stable at room temperature,
– Administered orally, rectally,
– Hypertension is not a contraindication

27. Why choose active management?
 Reduced risk of PPH
– by over 60% (relative risk 0.38, 95% confidence
interval 0.32-0.46)
 Reduced incidence of prolonged third stage
 Decreased need for blood transfusion or
additional uterotonic drugs
 Should be offered by all skilled birth attendants
at every childbirth.

28. Fourth stage of labor
– Massage the uterus
– Immediately massage the fundus of the uterus through
the woman’s abdomen until the uterus is contracted.
– Repeat the uterine massage every 15 min for the first
two hours.
– Ensure that the uterus remains hard after you stop
uterine massage.

29. PERINEAL INJURY
 Perineal injuries, either spontaneous or with episiotomy, are the most
common complications of spontaneous or operative vaginal
deliveries.
 Classification:
– First-degree tear: superficial tear confined to the epithelial layer
– Second-degree tears extend into the perineal body but not into the
external anal sphincter
– Third-degree tears involve superficial or deep injury to the external
anal sphincter
– Fourth-degree tear extends completely through the rectal mucosa
 Significant morbidity is associated with third- and fourth-degree tears,
– Including risk of flatus and stool incontinence,
– Rectal vaginal fistula,
– Infection, and pain

30. Episiotomy
 Incision into the perineal body made during the second stage of labor to
facilitate delivery.
– It is a second-degree tear.
 Classified:
– Median (midline)
– Mediolateral reading assignment
 No role for routine episiotomy except indicated episiotomy to expedite
delivery in:
– NRFHR
– relief of shoulder dystocia
 Adequate analgesia, either local or regional
 Avoid direct injury to anal sphincter
 Complications:
– increased blood loss, especially if the incision is made too early, fetal injury,
and localized pain
 May lead to 3rd and 4th degree tear