STAGES OF LABOR

1. STAGES OF LABOR
Dr.Puneeth Kumar
[Intern] 2K15
MMCRI

2. Definition
• Labor
Series of events that take place in genital organs in an effort to expel the
viable products of conception out of the womb through vagina into the outer
world.
Basically it is characterised by
* Uterine Contractions.
* Cervical effacement and dilatation.
* Fetal descent.

3. Normal Labor
Normal labor is expulsion of healthy mature foetus presented by vertex through the vagina followed by
expulsion of placenta & membranes where the whole process is spontaneous,uncomplicated without
delay minimal aid like episiotomy included .
It is also called EUTOCIA
Abnormal labor is DYSTOCIA which doesnot fulfill the above criteria.

4. Stage 1st stage 2nd stage 3rd stage 4th stage
Definition From True Labor Pain to Full
dilatation of Cervix.
PHASES
From Full
dilatation of
Cervix to
Delivery of
BABY
From Delivery of foetus to
Delivery of Placenta &
Membranes.
2 hour of
observation after
placenta delivery
LATENT
(Cx:3-5cm)
ACTIVE
(Cx:>6cm)
Normal
Duration
PRIMI
MULTI
10-12hr
6-8hr
1.2cm/hr
1.5cm/hr
01hr
30min
PASSIVE
15-30min
ACTIVE
5-10min
2hr

5. 1st Stage
Diagnosis
1. SYMPTOMS
CHARACTERISTICS TRUE LABOR PAIN FALSE LABOR PAIN
CONTRACTIONS
• Rhythm
• Intervals
• Intensity
Regular
Gradually Shorten
Gradually Increase
Irregular
Unchanged
Unchanged
DISCOMFORT
• Location
• Sedation/Rest/Enema
Back & Abdomen
No effect
Lower abdomen
Usually relieved
CERVICAL CHANGES Present Absent
A.

6. B. SHOW-Blood Stained Mucous:Bleed PV
C. Spontaneous Rupture of Membranes:Leak PV
2. SIGNS
A. Palpable Uterine Contractions
B. Cervical dilatation and effacement
C. Formation of forewater-Bag of Waters
Management
• History and clinical examination
Risks present No risk,Normal labor expected
• POSITION: Any non-supine position and movement throughout latent phase
Supine with knees flexed in active phase and delivery.
• ORAL INTAKE: ACOG recommends only sips of clear liquids.
• RECTUM: Routine enema has no beneficiary evidence.

7. • BLADDER: Encourage patient to empty her bladder regularly.
Use urinary catheter only woman is unable to void.
• PAIN: Psychoprophylaxis
Sedatives & Analgesics
Inhalational agents
Transcutaneous Electric Nerve Stimulation
Regional Anaesthesia
General Anaesthesia
• PARTOGRAPH
1. FHR Monitoring
Not in labor In labor
4th hourly
* Normal FHR: 110-160 bpm
1st stage 2nd stage
Low Risk 30 min 15 min
High Risk 15 min 05 min

8. 2. CERVICAL DILATATION
& FETAL DESCENT
A. FRIEDMAN CURVE
B. Philpott and Castle gave the concept of ALERT & ACTION
LINE.
C. MODIFIED WHO PARTOGRAPH
• Latent phase is absent
• Active phase from 4cm
• Time b/w Alert & Action line- 4hr
• Slope of Alert line=Slope of Action line=MINIMAL
DILATION OF ACTIVE PHASE= 1cm/hr
• NORMAL LABOR=Cervicograph is on the Alert line or
left to it.
FRIEDMAN CURVE

9. 3. UTERINE TOCOGRAPHY
• Adequate Uterine contractions
1. Frequency- 3 contractions/10min 200-220 Montevideo units
2. Intensity of 65-75mm Hg
3. Duration- 45 sec.
• * Tachysystole is >5contractions/10min
4. MATERNAL VITALS
1. Pulse - Every 30 min
2. BP – 4th hourly
If PIH – hourly monitoring
3. Temperature – 4th hourly
5. DRUGS & IV FLUIDS
• Oxytocin – concentration of U/litre of RL administered
rate as drops/min are recorded
• Any other drugs and IV fluids are recorded in partograph

10. ABNORMALITIES OF 1ST STAGE & THEIR ACTIVE MANAGEMENT
1. PROLONGED LATET PHASE
CAUSES & MANAGEMENT
A. Poor Cervical Conditions
Uneffaced and Undilated Cervix – Unripen Cervix
Treatment- PGE2 Dinoprostone gel induction of labor
B. False Labor
Management- Rest
C. Excessive sedation or Epidural Analgesia
Latent Phase Normal Prolonged
Primi 12 hr >20 hr
Multi 8 hr >14 hr

11. 2. PROTRACTED ACTIVE PHASE
NORMAL ACTIVE PHASE
Dilatation Descent of Fetal head
Primi: 1.2 cm/hr 1cm/hr
Multi: 1.5 cm/hr 2cm/hr
WHO MINMAL RATE FOR BOTH: 1cm/hr
Rate of Cervical dilatation or Rate of Fetal descent < 1cm/hr is
Protracted Active Phase.
Management
1. Rule out Cephalopelvic disproportion
Pelvis Adequate CPD Present
Wait & Watch LSCS
2. Rule out Occipitoposterior Position
If present- Wait & Watch

12. 3. Occipito Anterior positon
Management- Augment labor
A. ARM
B. Oxytocin Infusion
3. ACTIVE PHASE ARREST
Cervix is ≥ 6 cm + Membranes ruptured
Contractions present Oxytocin given for not having contractions
No dilatation for 4 hr still no dilatation for 6 hr
Management: LSCS

13. 2nd STAGE
Begins from full dilatation of cervix to delivery of foetus
MANAGEMENT
Onset of 2nd stage is characterised by
Full dilatation of cervix
Ruptured Membranes
Involuntary bearing down efforts
Obstetrician role
Encourage mother to bear down only during contractions.
Prevent & Manage tears.
Maintain asepsis.
Position
Dorsal lithotomy with half flexed legs
FHR Monitoring
Slowing down of FHR may occur due to head compression

14. Delivery of Head
To prevent tears
• Ritgen’s maneuver
• Restricted Episiotomy
Ritgen maneuver
Delivery of shoulders
is followed by delivery
of trunk

15. ABNORMALITIES & THEIR MANAGEMENT
2ND STAGE
NORMAL PROLONGED ARREST=OBSTRUCTED LABOR
WITHOUT EPIDURAL WITH EPIDURAL WITHOUT EPIDURAL WITH EPIDURAL
PRIMI 1 hr 2 hr 3 hr 3 hr 4 hr
MULTI 30 min 1 hr 2 hr 2 hr 3 hr
MANAGEMENT Station
≥+2= Forceps or Vacuum assisted
delivery
<+2= LSCS
LSCS at the earliest
Never WAIT & WATCH
Never give Oxytocin.

16. 3RD STAGE
From Delivery of foetus to Delivery of Placenta & Membranes.
MANAGEMENT
Signs of separation of Placenta
1. Uterus becomes globular,firm and ballottable.
2. Fundal height is reduced
3. Slight bulging of Suprapubic region
4. Gush of Vaginal bleeding
5. Permanent lengthening of cord
EXPECTANT MANAGEMENT
Wait & Watch for spontaneous expulsion of Placenta with the aid of uterine
contractions & gravity
Duration: 15-25 min

17. ACTIVE MANAGEMENT OF THIRD STAGE OF LABOR
1. Inj.Oxytocin 10 units IM to the
mother within 1 minute of delivery
2. Controlled Cord Traction using
Modified Brandt-Andrews method
3. Uterus is massaged to make it hard
and pressure given to push back &
down
4. Examination of Placenta, Membranes & Cord so that it is completely expelled and
no abnormalities seen.
Duration:- 5-10 min

18. ABNORMALITIES
1. RETAINED PLACENTA
Expulsion of Placenta ≥30 min
Management
1. Inj.Oxytocin 5/10 units slowly IV/IM
2. Manual removal of placenta
3. Rule out abnormal adherence of placenta to uterus.
Placenta increta,accreta,percreta.
2.PPH
3.UTERINE INVERSION

19. 4th STAGE
Post labor 1 hour monitoring of maternal vitals
Physiological Thrills & Shivering are usually seen in the mother.

20. ನಿಂದಕರಿರಬ ೇಕು ಇರಬ ೇಕು ನಿಂದಕರಿರಬ ೇಕು
ಹಿಂದಿ ಇದದರ ಕ ೇರಿ ಹ್ಯಿಂಗ ಶುದಿಿಯೊ ಹ್ಿಂಗ
ಅಿಂದಿಂದು ಮ್ಡಿದ ಪ್ಪದ ಮ್ಮಲ
ತಿಂದು ಹ ೇಗುವರಯ್ಯ ನಿಂದಕರು
ವಿಂದಿಸಿ ಸ್ುುತಸ್ುವ ಜನರ ಲಲರ ನಮಮ
ಹ ಿಂದಿದ ಪುಣ್ಯವನ ಯ್ುಯವರಯ್್ಯ
-ಪುರಿಂದರದ್ಸ್ರು.
Thank You.