management of labor

1. Management of 1st , 2nd and 3rd stage of labor

2. Labor
• Labor is a sequence of uterine contractions that results in
effacement and dilatation of the cervix and voluntary bearing-
down efforts leading to the expulsion per vagina of the products
of conception.

3. Normal labor
• 1. Spontaneous expulsion
• 2. Singleton
• 3. Term fetus
• 4. Presentation by the vertex
• 5. Through the birth canal
• 6. With reasonable time
• 7. Without any maternal and fetal complications.

4. Diagnostic criteria
• Painful contractions at least 2 contractions in 10minute
•Rupture of the membranes or
• Cervical dilatation after 100% effacement.

5. Stages of labor
 First stage- interval between the onset of labor and full cervical
dilatation.
 Second stage - the interval between full cervical dilatation and delivery
of the infant
 Third stage- the time from delivery of the baby to expulsion of the
placenta.
 Fourth stage- one to two hours after the expulsion of the placenta

6. Management of 1st stage labor
• MATERNAL WELLBEING MONITORING
• (a) Vital signs:
• pulse- every ½ hourly
• Temperature and BP - every 4 hourly or more frequently if indicated

7. • (b) Maternal position –
• Should not be confined to bed unless contraindicated
• Can assume any position comfortable to her
• (c) Nutrition - oral intake
• (d) Companionship in labor

8. • (e) Pain management
• The selected analgesia should be
 simple to administer,
safe to the mother and fetus,
no undue effect on progress of labor, and
available in the unit.
• Emotional Support…

9. • FETAL WELL - BEING MONITORING
• a) FHR
• Immediately after a contraction for 1 min
• every 30 min for a parturient without any risk and
• every 15 min for with a risk condition
FHR 100-180 BPM is normal for term normal fetus.

10. • (b) Status of liquor for meconium
• Grades of meconium
• Grade I - good volume of liquor, lightly meconium stained
• Grade II - Reasonable volume with a heavy suspension of meconium
• Grade III - Thick meconium which is undiluted

11. • (C)MONITORING OF PROGRESS OF LABOR
• 1. Uterine contraction –
• frequency in 10 minutes,
• duration and
• intensity of each contraction determined by palpation
 Monitored every 1hr. for latent phase and
 every 30 min. for active phase

12. 3. Vaginal examination to see:
• Rate of cervical dilation at least 1 cm./hr.
• Station, position, degree of molding
• The frequency of vaginal examination is every 4 hrs.
2. Descent of fetal head: should be done by abdominal palpation

13. Management of 2nd stage
 From 10 cm of Cervical dilatation to delivery.
The second stage of labor in a normal labor stays for
• 1 Hour in Primi and 20 minutes in Multi.
• Rate of Descent is 1cm/hr in primi and 2cm/hr for multi.
Diagnosis of prolonged 2nd stage
• Nulliparous - 2 hrs. without or 3hrs with epidural anesthesia
• Multipara- 1 hrs. without or 2hrs with epidural anesthesia

14. • MATERNAL CARE AND WELLBEING EVALUATION
• Vital signs :
• Bp : Q 30 min ( if indicated more frequently)
• PR, temp., RR : Q 1hr

15. • Evaluate general condition fatigue , pain, physical depletion and state
hydration
• Evaluate the presence of the urge to push and / or effort
• Avoid early push
• FHR MONITORING
• Every 15 min for low-risk fetus
• Every 5 min for high-risk fetus or continuous electronic monitoring
• LABOR PROGRESS EVALUATION
• Evaluate the degree of descent every 1 hr.

16. • Preparation for delivery
• Notify nursing staff that delivery is imminent.
• Move the woman to the delivery room if its is separate.
• Make sure all the equipment for delivery and newborn care are
available.
• There should be a pre-warmed neonatal corner for neonatal care
• Position the mother to semi-sitting (back up and leg down)
• Sterile draping
•Perineal care:- cleaning of the vulva and perineum with antiseptic .If
pieces of feces get expelled, wipe them downward.

17. • Episiotomy:
• Do episiotomy:-
• Threat for a perineal tear
• perineal resistance for fetal head descent
• fetal/maternal distress to expedited delivery
• Timing of episiotomy – performed when fetal head has distended the
vulva 2-3cms
Types-median or mediolateral

18. •Delivery of the Head
• Prevent rapid delivery and assist extension of the head.
• Assist using modified Ritgen’s maneuver if extension does
not occur with ease
• Check for cord around the neck
• After delivery of the head, wipe the mouth, oro-pharynx

19. • Complete delivery of the rest of the body
• Cord clamping:-
• 4-5 cm from fetal umbilicus
• It should be with in the 1st minute.

20. Management of 3rd stage labor
• ACTIVE MANAGEMENT OF THIRD STAGE OF LABOR
(AMTSL):
• AMTSL is the administration of uterotonic agents
• controlled cord traction and uterine massage
• Uterine massage
• • Immediately massage the fundus of the uterus until the uterus is well contracted.
• • Palpate for a contracted uterus every 15 minutes
• • Ensure that the uterus does not become relaxed (soft) after you stop uterine
massage. and repeat uterine massage as needed during the first 2 hours of the
postpartum period.

21. • Benefit of AMTSL
• • Duration of third stage of labor will be short
• • Less maternal blood loss
• • Less need for oxytocin in post partum
• • Less anemia in the post partum

22. References-
-FMOH on protocol of management of labor
- Williams Gynecology and Obstetrics 24th Edition
- Uptodate21.2
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