Management of labor

1. MANAGEMENT OF
NORMAL LABOUR
PREPARED BY: DR MEHWISH
IQBAL
BEMS 4TH YEAR (2010-2014)
LECTURER: DR WAJEEHA MOIN

2. Management of labor:
• The care in labor is aimed at achieving 2 goals:
i. Delivery of a normal healthy child with minimal
physical discomfort to the mother
ii. To recognize potentially abnormal conditions &
treat them before any significant danger develop
for the mother or the baby.

3. Admission:
Generally the patients are asked to seek
Admission when the pain starts or liquor
drains following rupture of membranes.
Examination of patient in labor:
The first examination of a patient in labor,
when admitted is the recognition of the
following 3 points:
• The lie, presentation and position of fetus
• The attitude & the level of the presenting
part & its relationship to the pelvis.
• The presence & character of the fetal heart
sounds.

4. Abdominal palpations:
The palpations is done in b/w uterine contractions (UC,s). the
part of the fetus which can be recognized by palpations, are
the head, the breech, the back & the anterior shoulder.
• The size of the uterus & height of the fundus are also noted.
• The lower pole of the fetus is palpated by placing the hands
on the lower abdomen just above the pubis & this is called
pelvic grip.

5. Engagement:
In primigravida the presenting part is said to be engaged.
It is fixed & cannot be moved from side to side.
In multigravida the head is usually not engaged in early
labor & can be readily move from side to side
Vaginal examination in labour:
A vaginal examination is performed as soon as it is
convenient after admission. It is done immediately if
there is a history of ruptured membranes

6. Procedure:
• Sterile gloves are worn and the vulva is
cleaned with a swab soaked in a mild
antiseptic lotion (Dettol 5% or cetavlon).
The index & the middle fingers of the
gloved right hand are negotiated carefully
in the vagina after being moistened with
an antiseptic cream (dettol
cream/lubricant jelly).
• The following features are recorded during
vaginal examinations:
 Cervix: its effacement, dilation &
consistency are checked
 Membrane: intact or ruptured
 Liquor: the color of liquor if membranes
have ruptured
 Fetus: the presenting part, & its
position,
station in relations to the ischial spines.
 Pelvis: assessment of the pelvis mainly

7. Management of the 1st stage of labor:
• It starts with the onset of labor till cervix is fully dilated
• Once labor is established, the mother needs constant
super vision & support.
• It is best not to leave her alone.
• Give her lots of encouragement & reassurance.
• Shave the vulval region because she may need
episiotomy later
• Give IV fluid during labor to avoid dehydration
i. 0.9% NaCl solution at 80-125ml/hr
ii.5% dextrose to prevent hypoglycemia

8. +. General Management
#.Ambulation:-
Walking about during labor intensifies the UC,S.
The duration of labor is short in ambulant patients.
The need for analgesia is less & the incidence of
abnormalities of the fetal heart is lower than in
recumbent women.
#.Oral intake:-
1.oral fluid intake is permitted (such as fruit juices etc)
2.solids are better avoided as there is delayed emptying of the
stomach.
3.Antacids are given orally to combat lowering
gastric pH
4.Give anti emetics such as
Metoclopromide(5-10mg) I/M
.
She is encouraged not to lie straighten her back as it
may cause venacaval compression.

9. #.Care of the bladder and bowel:-
1.The mother is encourage to pass
urine every 2 hours.
2.Catheterization may be necessary
in some mothers if they are unable to
pass urine voluntarily, commonly seen
in epidural blockage.
3.On admission it is traditional to
give a soap and water enema, with the
idea that it will enhance UC,S & prevents
soiling of the perineum in the 2nd stage

10. +. Assessment:-
*. Maternal well being:-
Normal labor is an exhausting experience for the
mother. The maternal condition is checked at
intervals to detect early evidence of maternal
distress.
1.Her pulse rate is recorded every 30 minutes or
whenever the FHR is checked.
2.B.P is recorded after every one hour or more
especially when the female is hypertensive.
3.Temperature is recorded every 4 hours
unless the mother is pyrexial, when it should
be checked more frequently.

11. 4.Take blood for grouping & cross match for high risk
patients.
5.Consider augmentation with synto if progress of labor is
slow.
_ 1000ml hartmanns solution or normal saline+10
units synto (pitocin)
_ Or begin with 15 drops/min & increase the rate by
10 drops every 30 min until adequate contractions.
For 3rd and 4th gravida 5 unit synto is given usually.

12. *.Fetal well being:-
1.Fetal heart is auscultated every 30 min in every
patient & for about 30 seconds.
2.Doppler ultra sonic pulse detector should be used
freely.
3.High risk patients should have continuous electronic
fetal heart monitoring. If normal, to be followed by
intermittent auscultation:
+.First stage every 15 mins
+.second stage every 5 mins
*. Colour of the liquor:-
1.Meconium stained amniotic fluid when the
presentation is cephalic may be a sign of fetal
distress.
2.The passage of meconium may represents nothing
more than fetal maturity.
3.Meconium is believed to result from relaxation of
the rectal sphincter and increased peristalsis

13. + Analgesia: Give analgesia as
required:
(a) Pethidine & dimorphine
(b) entonox
(c) epidural analgesia
(d) General anesthesia.
%. Maintains the Partogram of
patient & record the strength
duration and frequency of
uterine contractions.
%. observations of the
contractions are made every
half hour.
%. Usually at the end of 1st stage
the duration of contractions
will be 60 sec & the interval
will be 1-2mins

14. Management of the 2nd stage of labour:-
*. From the full dilatation of cervix to
delivery of the baby.
*. The onset of the 2nd stages
recognized by the bearing down
efforts of the patient.
*. Vaginal examination should be done
to confirm full dilatation of the
cervix, to note the position &
station of the head.
The clinical indications that the
2nd stage has started are:
(1) There is an increase in blood
show.
(2) The patient wants to bear
down with each contraction.

15. (3) The patient feels pressure on the
rectum accompanied by the desire to
pass stool.
(4) Nausea and retching occurs
frequently as the cervix reaches full
dilatation.
#. FHR is checked every 5 to 10 minutes.
#. The patient is transferred from the first
stage room to the labor table when the
bearing down pain starts.

16. +.Delivery procedure:-
$. Delivery of the head:-
*. A sterile vulval pad is placed over the
anus with the right hand when the head
starts stretching the perineum.
*.Advancing head is controlled with the
palm & fingers of the left hand.
*.Episiotomy is performed if there is under
stretching of the perineum.
*.The head is best delivered towards the
end of a contraction or in b/w
contractions.
*.The for head, nose, mouth & chin are
now delivered over the stretched
perineum by extension.
*.When the chin is free, the pad over the
rectum is discarded.
*.The face should be wiped gently &
mucus aspirated from the mouth &
throat.

17. *. In case where meconium is present the
following steps should be taken:
(1)After delivery is complete in a patient with
meconium in the liquor, laryngoscope is
employed to check if there is meconium at or
below the level of the vocal cords.
(2) Meconium should be removed by suction
$. Delivery of the shoulders:-
*. It is best to wait for the next UC,S to
deliver the anterior shoulder, which
appears behind the symphysis pubis.

18. *.When the anterior shoulder is delivered the head is guided
upwards towards the mother’s abdomen to allow the posterior
shoulder to deliver out of the perineum.
*. Intravenous ergometrine may be given during this period by the attending
nurse.
$. Clamping of the cord:
*. The umbilical cord is clamped approximately 5cm away from the fetal
abdomen.
*.The time of the cord clamping is not critical
if the baby is born at term & is of average size.
*. Early clamping of the cord should be done if
the baby is small, depressed at birth or
in case of Rh isoimmunization to
prevent antibody transfer.
The head should be pulled gently to avoid injury to the brachial plexus &
the clavicle.

19. Management of the 3rd stage of labor:
*.All obstetricians now prefer a more active
method of management of the 3rd stage,
because it is safer for the patient &
minimizes blood loss.
*.The delivery of the placenta occurs in two
stages:
+. Separation of the placenta from the wall of
the uterus & its advancement into the lower
uterine segment.
+. Actual Expulsion of the placenta out of the
vagina.

20. @.Separation of placenta:-
Placental separation takes place within 3
to 5 minutes of the end of the 2nd stage.
$. The signs of placental separation
includes:
1.Gush of blood from vagina.
2. Lengthening of the umbilical cord
outside the vulva
3.Uterine fundus becomes firm &
globular.
@. Expulsion of placenta:-
$. When these signs have appeared the
placenta is ready for expression.
$. The patient is asked to bear down
while gentle traction is made on the
umbilical cord.

21. %. Active Management :-
*.After vaginal delivery of the baby,administer injection
0.125mg of PGF2 deep I/M forthwith.This shortens the
duration of 3rd stage to 2-5 mins and reduces blood
loss to <100 ml.
*.It has been common practice to give an intra muscular
injection of 0.5 mg ergometrine as the shoulder are
being delivered.
*.Ergometrine causes prolonged contractions of the
uterus without any relaxation & as such is very
effective in the control of excessive bleeding in the 3rd
stage.

22. *. Oxytocin 5 units may also be given by I/M or I/V
injection with delivery of the anterior shoulder, but
its action Is not as strong as that of ergometrine.
*. Controlled cord traction after ensuring that the
uterus is contracted, to deliver the placenta.
*. Inspect the placenta & the membranes for
completeness.
*. Examine the patient for any injury to the birth canal
& watch for any abnormal vaginal bleeding.
*. If placenta is not delivered within 15 minutes,
arrange for manual removal of placenta.

23. Active management of 3rd stage

24. @ PARTOGRAM:
The graphical representation of the
progress of labor & all the events in
labor are charted on a record sheet
designated as the PARTOGRAM.
The partogram is used in the following
manner:
1.Identification Data of the patient:- Name,
Age, Parity and hospital identification
data are entered here.
2.Fetal heart rate:-
*The FHR is recorded half hourly
*Basal FHR (rate b/w 2 contractions) is
charted.
3.Liquor Amnii:- When the membranes are
intact, mark ‘’I’’ if the liquor is clear, mark
‘’C’’,
if the liquor is meconium stained, mark

25. 4.Moulding: Degree of molding is
recorded as + or ++
5. Cervical dilatation: It is measured in
centimeters and recorded at the start
of chart. Examination are made every
2 hours in the active stage of labou
until full dilatation is reached.
6. Station of the head:
*.Station of the fetal head is estimated
in 5th s during abdominal palpation.
*.Engagement of the head is equivalent
to two fifths of the head palpable
above the brim
*. In the 2nd stage of labor, it is
important that less than 1/5th of the
head is palpable abdominally.

26. 7. Oxytoxins: Concentration of synto is noted
on the upper line. Rate of infusion in drops per
minute on the bottom line.
8. Uterine contractions: There are vertical
column of 5 squares on the Partograph for the
graphical recording of contractions. The
squares are shaded according to the duration
of contractions.
9. B.P pulse and temperature: B.P is recorded
every hour and pulse every 30mins
10.Urine: *Urine sample is checked for the
presence of ketones & protein.
*If catheterization is performed,
it is recorded as ‘’C’’

27. PARTOGRAM

28. +.Alert line & Action line:
*.The straight line on partogram is called the Alert
line. This line indicated the mean rate of
progress in terms of cervical dilatation.
*.The 2nd line was drawn 2 hours to the right &
parallel to alert line is called ACTION LINE.
*.All the patients whose partograms cross the
action line should be closely monitored; some
of these patients would successfully deliver
vaginally but a fair number of these would
require to be delivered by C-section.
*The action line helps to identify dystocic
labours,in case of mechanical dystocia a
decision for C.section does not get unduly
delayed.
@.Importance of Partogram: Partography provides
a clinical method for early diagnosis of
dysfunctional labor & helps to improve obstetric

29. Obstetric Anesthesia/ Analgesia

30. Obstetric Anesthesia/Analgesia:-
* Pain pathways:
In the 1st step of labor the pain is visceral, produced by
the intension of the lower uterus & cervix &
ischemia of the uterine & cervical tissues.
The 2nd stage involves both visceral & somatic pain
due to the distension of the vagina, perineum &
pelvic floor. Somatic pain signals transverse the
pudendal nerve(S2-S4) & enter into the anterior
spinal cord.
Types of Obstetric Analgesia:
1. Local injection (field block):
 Used before cutting or repairing episiotomies or
lacerations during and after delivery
 Common agents include lidocaine(1% to 2%)
or 2-choloroprocaine (1% to 3%), which provide
anesthesia for 20 to 40 minutes. The maximum
allowed dose of injected lidocaine is 4.5 mg/kg.

31.  Hypotension, arryhthmias, and seizures are
rare complications.
 Paracervical block is used for the first stage
of labor in patient for whom an epidural or
spinal is contraindicated, unavailable, or
undesired.
 Pudendal block may be used as
supplemental analgesia during the second
stage of labor or before operative deliveries
if an epidural has not provided adequate
relief.
 Intravascular injection can result in systemic
effects, hematoma formation, and pelvic
infection; these are recognized
complications.
 Fetal bradycardia is a known side effect of
paracervical block, occurring in
approximately 15% of cases. Direct fetal
injection is also a risk with paracervical
block, resulting in fetal cardiac toxicity.

32. OPIATES:
 Such as pethidine & dimorphine, are
still used in most obstetrics units.
 But they provide only limited pain
relief.
 Side effects including:
1. Nausea & vomiting.
2. Maternal drowsiness & sedation.
3. Delayed gastric emptying.
4. Short term respiratory depression of
the baby.
 Opiates tend to be given as IM
injection.
 An alternative is a subcutaneous
patient controlled analgesic device.

33. INHALATION ANALGESIA:
 Nitrous oxide in
the form of
entonox.
 It has quick onset.
 Short duration of
effect.
 More effective
than pethidine.
 It is not suitable
for prolonged use.

34. EPIDURAL ANALGESIA:
 Epidural analgesia is the
most reliable analgesia in
labor.
 Women may temporarily
lose sensation & movement
in her legs.
 Some indications for
epidural analgesia are:
1. Prolonged labor.
2. Maternal hypertensive
disorders.
3. Multiple gestation.

35. COMPLICATION OF REGIONAL ANALGESIA:
1. Accidental dural puncture
leads to leakage of CSF
results in spinal headache.
2. Accidental total spinal
anesthesia.
3. Drug toxicity.
4. Hypotension.
5. Respiratory failure.
6. Backache after pregnancy
7. Bladder dysfunction.

36. SPINAL ANESTHESIA:
 Spinal block is
considered more
effective than epidural.
 It has faster onset.
 Used in caesarian
sections, instrumental
deliveries repair of
perineal & vaginal tears.
 Not used for routine
analgesia in labor.

37. NATURAL MANAGEMENT
OF LABOUR

38. Ginger (Rhizoma Zingiberis officinalis)
Ginger is one of the best anti-nauseants
available, for pregnant women with
severe nausea and vomiting, 250 mg of
powdered ginger root taken four times a
day significantly reduced their
discomfort. The root and rhizomes dispel
gas, indigestion, morning sickness,
nausea and vomiting, and hot flashes.
Ginger stimulates circulation, cleanses
the colon, and reduces cramps and
spasms.
Dosage: Mix one to three 1/8-inch pieces
with one pint boiled water and steep for
20 minutes. Drink this tea as often as
needed.

39. Peppermint (Mentha piperita)
A long held favorite flavoring for
everything from chocolate to
mouthwash, peppermint helps
relieve nausea, particularly
morning sickness, as well as
flatulence. It is especially good for
treating heartburn
Dosage: For a beverage tea, mix
one-half ounce of herb in one pint of
boiled water. Double the quantity of
herbs to create a medicinal dose
(check with your herbalist or doctor
before taking a medicinal dose
while pregnant). Drink up to three
¾ cups daily.

40. Raspberry Leaf (Rubus idaeus)
It is extremely valuable in preventing
postpartum hemorrhage and
improves blood supply, aiding
contractions during labor. It is a
rich in vitamins A, B-1, C, and E, in
addition to calcium, iron,
potassium, and phosphorus.
Raspberry leaf also eases morning
sickness and improves digestion (it
is also a galactagogue—increasing
breast milk production—and
restores vitality postpartum).
Dosage: Mix one ounce loose herb in
one pint of boiled water and steep
for 20 minutes. The tincture can be
used in dosages of two tablespoon

41. LICORICE (GLYCYRRHIZA GLABRA):
Licorice, real licorice
candy, the black kind,
is thought to also
stimulate the
production of
prostaglandins. This is
due to the chemical,
glycyrrhizin. Eating lots
of licorice might also
result in mild diarrhea,
which causes intestinal
contractions that may
lead to sympathetic
uterine contractions.
This type of licorice
can also be found in
tablet form.

42. Blue cohash(papoose root):
Blue cohosh does not increase contractions. It
is an antispasmodic. Because it is an
antispasmodic, women often use it when a
miscarriage threatens. It relaxes the uterus
and keeps it from contracting when it isn't
time for birth. In much the same way, blue
cohosh can be taken to help stop the hard
Braxton Hicks contractions often referred
to as false labor.
Blue Cohosh contains powerful qualities for
reducing child birth pains and aiding in a
quick and painless delivery. An herb used
widely by Native Americans, it is also
popular for treating menstrual cramps.
Because of its emmenagogue properties
(inducing or hastening menstrual flow),
blue cohosh should not be used until the
last month of pregnancy.

43. Black cohash(snake root):
Black cohosh seems to
work on the body in the
same way as estrogen does.
Using black and blue
cohosh to induce labor is
especially effective if you
are already having weak or
irregular contractions.
These two herbs work
together to strengthen and
regulate uterine
contractions

44. Side Effects
Generally you won't be taking black and blue cohosh long enough to
experience any side effects. Herbalists agree that these herbs are
safe to take at 40 weeks gestation and will not harm your baby.
There have been some concerns that blue cohosh could cause
heart problems in a baby when used during pregnancy, however
this was one isolated incident and there is no evidence that it was
the blue cohosh that caused the problem.
Black cohosh, and blue cohosh should work in a twelve hour
period if taken properly. These herbs are dangerous to used for
inducing labor before the forty week mark

45. REFERENCES:-
1.Manual of obstetrics by shirish N daftary &
sudip chakravarty 3rd edition.
2.Manual of emergency obstetrical care UNICEF
Pakistan.
3.John Hopkins Manual of Gynaecology &
Obstetrics.
4.Ten teachers 19th edition.
5.Herbal encyclopedia.

46. Caution!!
• The natural management in
this presentation is for
information purpose only,
few of the herbal
treatments have scientific
evidences while few do not,
so don’t prescribe or
suggest anything to
pregnant women without
having strong educational
background.

47. THANK
YOU