Child birth and labor process

Fetus in utero
2
• The Head Is The Most Important
Part Of The Fetus ; If It Can Pass
Through The Pelvis Canal Safely
• There Is Usually No Difficulty In
Delivering The Rest Of The Body

Fetal lie
Lie:
is the relationship
between the long
axis of the fetus
and the long axis
of the uterus.
Type :
1. Longitudinal lie
2. Oblique lie
3. Transverse lie

Fetal lie
longitudinal lie :
99.5% of cases is
longitudinal lie.
the remainder are o
blique or transverse.
Oblique lie:
when the fetus lies
diagonally across th
e long axis of the ut
erus.

Fetal lie
 Obliquity of the ute
rus: when the whole
uterus is tilted to the
one side( usually the
right) and the fetus
lies longitudinally
within it.
 Transverse lie: the
fetus lies at right
angles across the
long axis of the
uterus.

Attitude
Attitude: is the relationship of the feta
l head and limbs to its trunk.
 The attitude should be one of flexion.
 The fetus is curled up with chin on
chest and arms and legs flexed,
forming a snug, compact mass which
accommodates itself to the uterine
cavity.
 Progress of labour depends partly
on increased flexion.

Attitude
Flexion of fetal head enables the
smallest diameters to present to
the pelvis and results in an easier
labour ( the posture of the fetus)

Presentation
 Presentation: refers to the part of the
fetus which lies at the pelvic brim or
in the lower pole of the uterus.
 Presentations can be:

Presentation
head or cephalic presentations are :
Vertex, Face And Brow .
 When head is flexed the
Vertex Presents.
 When head is Deflexed the
Vertex Present
 When the head Fully Extended
the Face Present.
 When head partially extended
the Brow Present.

Denominator
 Denominator: is the name of the part
of the presentation , which is used when
referring to fetal position.
 Denominator may be found anteriorly or
posteriorly.
 In the vertex presentation it is the
occiput.
 In the breech presentation it is the
sacrum.
 In the face presentation it is the
mentum.
 In the shoulder presentation it is the
acromion process.

Position
Position: is the relationship
between the denominator of the
presentation and six points on the
pelvic brim.
Anterior position are more
favorable than posterior position.
Positions in vertex presentation
are:
1-LOA 2-ROA
3-LOL 4-ROL
5-LOP 6-ROP
7-DOA 8-DOP

Bony landmarks of the Pelvis Brim

POSITION IN VERTEX
 Left Occipitolateral (LOL) 40%
 Left Occipitioanterior (LOA) 15%
 Left OccipitoPosterior (LOP) 3%
 Right OccipitoLateral (ROL) 24%
 Right OccipitoAnterior (ROA) 10%
 Right OccipitoPosterior(ROP) 8%*
 Direct occipitoanterior (DOA)
 Direct occipitoposterior (DOP)

POSITION IN VERTEX
 LOA: the occiput points
to the left iliopectineal
eminence, the sagittal
suture is in the right
oblique diameter of the
pelvis.
 ROA: the occiput points
to the right iliopectineal
eminence, the sagittal
suture is in the left obliq
ue diameter of the pelvis
.

Engagement
Engagement: occurred when the
widest presenting transverse
diameter has passed through the
brim of the pelvis.
In Cephalic presentation the widest
diameter is the biparietal diameter.
In Breech presentation the widest di
ameter is the bitrochanteric diamete
r.

Engagement
• Primigravid woman engagement at any time
between about 36 weeks and 38 weeks of
pregnancy. if the head remains unengaged
in PG ,the possibility of Cephalopelvic
disproportion should be born in mind.
• Multipara women engagement may not
occur until after the onset of labour .
 Engagement of the fetal head is usually
measured in fifths palpable above the
pelvic brim.

Engagement
• If the head is engaged ,
the finding on clinical
examination are:
1-Less than half of the
head is palpable above
the pelvic brim.
2-The head is not mobile.
3-The Sinciput is felt less
than 5cm above the brim.
4-The anterior shoulder is
little more than 5 cm
above the brim.

Engagement
• If the head is not engaged
(high or floating head) ,the
finding on clinical examination are:
1. More than half of the head is palpable
above the pelvic brim.
2. The head may be high and freely
movable but it can also be partly settled
in the pelvic brim and consequently
immobile.
3. The sinciput may be 7. 5 cm above the
brim.
4. Not engaged or high head

Engagement
Causes of a non-engaged head at
term include:
1. Occipitoposterior position
2. Full bladder
3. Wrongly calculated gestational age
4. Polyhydramnios
5. Placenta praevia
6. Multiple pregnancy
7. Pelvic abnormalities
8. Fetal abnormality

 Descent of the fetal
head estimated in fifths
palpable above the pelvic brim:
5/5:
Sinciput and occiput above
the brim(not engaged)
4/5:
Sinciput prominent , occiput
descending (not engaged).
3/5:
Sinciput rising, occiput can
be tipped.
2/5:
Sinciput not so prominent.
1/5:
Sinciput and occiput not felt
(engaged).
0/5:
Head on pelvic floor (deeply
engaged).

Descent (station)
 The level or station of the
presenting part is estimated
in relation to the ischial
spines.
 When the presenting part at
level of ischial spine known
as zero( 0 )station.
 If Head 1-2cm above ischial
spines known as minus 1 st
ation, minus 2 station, minus
3 station.
 If head below the ischial
spines known as +1,+2,+3,+4
station.

Normal labour
 Labour:
is described as the process by which the
fetus, placenta, and membranes are
expelled through the birth canal.
 A human pregnancy is considered to
last approximately 40 weeks.
 Normal labour occurs between
37and 42 weeks gestation.

LABOUR PROCESS
The WHO define Normal labour as:
low risk throughout, spontaneous in
onset with the fetus presenting by
the vertex, culminating in the mother
and infant in good condition followin
g birth.

Normal Labour
• Occurs at term,single baby and is
spontaneous in onset with the fetus
presenting by the vertex, Through
The Birth Canal .
The process is completed within
18 hours and no complication arise.
• Prolonged Labor:- Lasting > 18 Hours
• Precipitate Labor :- Lasting < 3 Hours

Components Of Normal Labor “ Five Ps”
• A successful labour depends on five
integrated concepts:(5 P)
1. The Passage
( The pelvis & maternal soft parts)
2.Passenger (fetus)
3.Powers (uterine contraction)
4.Psyche
(maternal psychological status)
5.Position (maternal)

Involuntary uterine contraction
assisted by maternal pushing
efforts during the second stage
must be adequate strength with
coordination of muscle activity
( BEARRING DOWN)

• The body part of the a fetus that
has the widest diameter is the
head.
• A fetal skull can pass depends on
both its structure and its alignment
with the pelvis.

 The woman pelvis is
of adequate size and
contour.
 Refers to the route the
fetus must travel from
the uterus through the
cervix and vagina to
the external perineum.
Passage Way “ The Birth Canal “

The maternal
psychological
response may
affect the
women progress d
uring labor and p
ossibly weaken
the forces .

39
The Process Of Labor Is
Divided Into Four Stages
1- The First Stage Of Labor
2- The Second Stage Of Labor
3- The Third Stage Of Labor
4-The Fourth Stage Of Labor

First stage of labor
40
Dilatation of the cervix.
It begins With regular
rhythmic Contractions And
is complete when the cervix
is fully dilated.

Second stage of labour
• Is that of expulsion of the fetus.
• It begins when the cervix is fully
dilated, in physiological labour the
woman usually feels the urge to
expel the fetus.
• it is complete when the baby is
born.

Third stage of labour
• Is that of separation and expulsion
of placenta and membranes.
• It also involves the control of
bleeding.
• It lasts from the birth of the baby
until the placenta and membranes
have been expelled.

The Fourth Stage Of Labor
• Recovery stage .
• The first 1 to 4 hours after birth
of the placenta.
• Emphasis the importance of the
close observation needed at this
time.

Signs of labour
• Preliminary signs of labour:
before labour, the woman often
experiences subtle signs that
can signal the onset of labour.
1-lightening
2-Increase in level of activity
3-Braxton Hicks Contractions
4-Ripening of cervix

Signs of labour
Signs of true labour:
Signs of true labour involve uterine
and cervical changes.
1-Uterine contractions
2-Show
3-Rupture of the membranes
4-Cervical dilatation

True labor
1. Progressive Cervix Dilation And effacement
2. felt first in lower back and sweep around
to the abdomen.
3. Regular Contraction ,Progressive Increase
In Frequency And Intensity Of Contractio
ns , Intervals Between Contraction
Gradually Shorten
4. Contractions Intensity Increased By
Walking

False Labor:
1-Begin and remain irregular
2-Felt first abdominally and remain confined to
the abdomen and groin.
3-No cervical dilatation.
4-Irregular Contraction , No Increase In Frequ
ency And Intensity Of Contraction ,Interval
Between Contraction Remain Long
5-Disappear with ambulation and sleep

The onset of labour
1- Pre-labour: is the term given to
the last few weeks of pregnancy
during which time a number of
changes occur.
2-lightening.
3-frequency of maturation.
4-cervical effacement
(taking up of the cervix):
The cervix is drawn up and
gradually merges into the lower
uterine segment.

The onset of labour
4-Spurious labour(false labour):
Braxton Hicks Contractions
( Intermittent Uterine Contrition ):
Many women experience
contractions before the onset of
labour, these may be painful and
may even be regular for a time ,
causing a woman to think that
labour has started.

Cervical Effacement
Refers to the inclusion of the
cervical canal into the lower
uterine segment.
is the shortening of the cervical
canal from a structure 2- 3 cm in
length to one .
Expect a circular orifice with
almost paper thin edges.

Cervical Effacement
 The cervix is drawn up and
gradually merges into the lower
uterine segment.
In primiparous woman, this may
result in complete effacement of
the internal and external cervical os.
In the multiparous woman a
perceptible canal may remain.

Cervical Effacement
The cervix thins from the external os
upwards, leaving the internal os to b
e affected last.
May occur late in pregnancy or may
not take place until labour begins.
In primigravida the cervix will not dil
ate until effacement is complete.
In the multigravida effacement and
dilatation may occur simultaneously.

Physiology of the first stage of labour
• The dilating stage begins with the onset
of regular labor contractions and ends with
the complete dilation of the end cervix .
• First Stage Of Labor Divided Into “
Three Phases”:
1-Latent phase (preparatory phase)
2-Active first stage
3-Transitional phase

• Is the process of enlargement of
the cervix os from a tightly
closed aperture to an opening
large enough to permit passage
of the fetal head.
• Dilatation is measured in
centimeters (cm)
• Full dilatation at term equates to
about 10 cm
Dilation of the cervix

Dilatation occurs as a result of
1. Uterine action
2. The counter pressure applied by
either the intact bag of membranes
or the presenting part or both.
3.The pressure applied evenly to the
cervix causes the uterine fundus to
respond by contraction and
retraction.

The Latent Phase
• Is prior to active first stage of labour .
• Contractions are mild and short, lasting
20 to 40 second.
• Last 6-8 hrs in first time mothers.
• Last 4.5 hrs in a multipara.
• The cervix dilate from 0 cm to 3-4 cm dilated.
• The cervical canal shortens from 3cm long
to < o.5 cm long.

The Active Phase
Is the time when the cervix undergoes more
rapid dilatation. (Or from 4cm to 7cm).
This begins when the cervix is 3-4cm dilated
.
Presence of rhythmic contractions and
strong, lasting 40 to 60 second and
occurring approximately every 3-5 minutes.
This phase lasts 3 hrs in a nullipara and
2 hrs in a multipara.
Is complete when the cervix is (8cm) dilated

The Transitional Phase
Is the stage of labour when the cervix is from
around 8cm dilated until it is fully dilated.
Or until the expulsive contractions during se
cond stage are felt by the woman.
Contraction reach their peak of intensity,occ
uring every 2 to 3 minutes with a duration of
60 to 90 seconds.

Physiology of first stage of labour
• Duration: the length of labour varies
widely.
• is influenced by:
1- parity 2- psychological state
3-presentation 4- position of fetus
5-maternal pelvic shape and size
6-Character of uterine contractions.

Maternal And Fetal Adaptation To Labor
60
 Duration of labor usually the normal
duration of each stage of labor is
shown in table
Multi Para
Primigravida
Stage Gravida
6-8 Hours
12-16 Hours
First Stage
5miute – 1hr
30min-2 Hours
Second Stage
5-15minute
5- 15 Minute
Third Stage
1-4 Hours
1-4 Hours
Fourth Stage

show
 As a result of the dilatation of the cervix.
 The operculum, which formed the cervical
plug during pregnancy, is lost.
 The woman may see a bloodstained
mucoid discharge a few hours before,
or within a few hours after labour starts.
 As the first stage ends, there is often a
small loss of bright red blood which
heralds the second stage. both are referred
to as a show.

Formation of the forewaters
As the lower uterine
segment stretches
The chorion becomes
detached from it
-the increased
intrauterine pressure
causes this loosened
part of the sac of fluid
to bluge downwards
into the internal os ,to
the depth of 6-12mm.
62

Formation of the forewaters
The well flexed
head fits snugly
into the cervix.
This cuts off the
fluid in front of
head from that
which surrounds
the body.
-the former is
known as the
forewaters and
the latter the
hindwaters.
63

General fluid pressure
The membranes
remain intact
The pressure of
the uterine
contraction is
exerted on the
fluid.
-As fluid is not
compressible, the pressure
is equalized throughout the
uterus and over the fetal
body and is known as
general fluid pressure.
64

General fluid pressure
When the membranes rupture:
1- A quantity of fluid emerges.
2-The fetal head, and the placenta an
d umbilical cord are
compressed between the uterine wal
l.
3-The fetus during contraction and
oxygen supply to the fetus is
diminished.

Rupture of membranes
 The optimum physiological time for the
membranes to rupture spontaneously
is at the end of the first stage of labour
after the cervix becomes fully dilated.
 The uterine contraction are also applying
increasing expulsive force at this time.
 Occasionally the membranes do not
rupture even in the second stage and
appear at the vulva as a bulging sac
covering the fetal head as it is born, this
is known as the (caul).

Early rupture of membranes may
lead to an increased incidence of
variable deceleration on CTG.
Which may lead to an increase in
caesarean section rate.

Augmentation of labour
Intervention to correct slow progress
in labour.
Is the stimulation of spontaneous
uterine contraction.
Assisting labour that has started spont
aneously to be more effective.
Augmentation of labour done
according to Bishops score.
Augmentation by:
1. Amniotomy
2. Oxytocin (pitocin).
3. Sweeping of cervix.

Bishops score
Score of between 0 and 3.
When a total of 6 or over is reached
the prognosis for induction is good.
The key elements in the assessment are
1. Dilatation Of Cervix
2. Effacement Or Cervical Canal Length In
Cm
3. Position Of Cervix
4. Station Of The Presenting Part
5. Consistency Of Cervix.

Amniotomy
 Amniotomy: routine Artificial Rupture 0f
Membranes (ARM) may decrease the overall
length of labour by 60-120min.
 ARM used to induce and augment the
labour .
 Prior to the ARM or induce the labour, the
Bishops score is measured.
 This is an objective method of assessing
whether the cervix is favorable for induction
of labour.

 artificial rupture of membranes
(ARM) does not reduce the
caesarean section rate.
All women need to give consent
for this intervention.
The practitioner should have
a positive indication for
performing ARM, which should be
recorded in the notes.

Amniotomy
ARM : is performed to induce lab
our when cervix is favorable or durin
g labour to augment contractions.
A well fitting presenting part is
essential ,to prevent cord prolapsed.
ARM may also be carried out to
visualize the color of the liquor and
amount..

Amniotomy
 may be low, involving rupture of the
forewaters, or, less commonly, high,
which requires the hindwaters to be
ruptured.
Hazards of ARM:
1-intrauterine infection, from
instrument or vaginal examination.
2-early deceleration of fetal heart rate
3-cord prolapse,abruptio placenta.
4-bleeding .the friable vessels in the
cervix.

 If the head not engaged and the
mother complain of polyhydraminous
the membranes should ruptured
under control to prevent cord prolapsed
and abruptio placenta.
 The midwife should monitor the fetal
heart rate during ARM because FHR
may become bradycardia during ARM.

Oxytocin(syntocinon)
 Is a hormone released from the
posterior pituitary gland.
 It acts, at cell level, on smooth muscle
and is released in a pulsed manner
in response to stimulation.
 Receptors to oxytocin are found in
myometrium .
 Oxytocin is used in conjunction with
ARM and may be commenced at the
same time as ARM or after a delay of
several hours.(2hrs)

Administration Of Oxytocin To Induce Labour
 Slow intravenous infusion using an infusion pump.
 Diluted in an isotonic solution such as normal saline.
 The dose according to doctor order and according to
parity.
 The midwife may need to reduce the infusion rate as
labour becomes established because uterus becomes
more sensitive to oxytocin as labour progresses.

Administration Of Oxytocin To Induce Labour
 The midwife should aim to administer
the lowest dose required to maintain
effective, well-spaced uterine
contractions, typically occurring every
3 minutes, lasting 45-50 seconds.

Oxytocin Protocol
Usually after either spontaneous or
artificial rupture of the membranes.
Dose:
 according to Mentioventeo unit.
5 - Number of Para =oxytocin unit.
Example: 5 - para 4 = 1 unit the
woman need.

Oxytocin protocol
 Administer oxytocin in 500ml of Ringer Lactate or
Saline.
 5 IU in 500ml =10 mU/mL = 5,000 mU.
 If an infusion pump is available, start with 0.5mU/
min to 1mU/min .
 Increase the dose gradually every 15 min to 60
min by small increment of 1 to 2 mU until
contraction begin.
 The rate should not be increased to more than
20 mU/min.
 500ml over 4hrs.

Oxytocin protocol
If no infusion pump is available,
start with 12 drops/min (8mU/min)
and increase the dose every 15min
by 4 drops/min, until satisfactory
uterine contraction have been
established or to a maximum of 64
drops/min.

Side effect of oxytocin
1. Uterine hyper stimulation
2. Fetal hypoxia and asphyxia.
3. Uterine rupture.
4. Fluid retention as a result of the antidiuretic effect
of oxytocin, water intoxication.
5. Postpartum hemorrhage.
6. Amniotic fluid embolism.
7. Prolonged use may contribute to uterine atony pos
tpartum.
8. Systemic side effect include
• Direct vascular smooth muscle relaxation leading
to transient vasodilatation and hypotension.
• Hyponatremia.
• Neonatal hyperbilirubinemia.

Side Effect of Oxytocin
1- Uterine hyper stimulation :
which could cause fetal hypoxia and
uterine rupture.
This is a tonic contraction .
The uterus contract strongly, with
the contraction lasting longer than
60 seconds, and more frequently
than every 2 minutes.
Relaxation between contraction is
inadequate.

Side effect of oxytocin
1- uterine hyper stimulation :
 The midwife should turn off the infusi
on and inform the doctor.
 Salbutamol may be administered, as an
inhalation or infusion ,to counteract
the effect of oxytocin.
 Oxytocin should not be given as a bol
us injection during labour because of
the risk of hyper stimulation.

Oxytocin
 Be very cautious regarding the use
of oxytocin, in the following:
1. The presence of CPD.
2. C /S.
3. High parity.
4. Breech presentation.
5. Marked uterine over distention as in a
multiple pregnancy or hydramnios.

Midwifes care during administration of oxytocin
1. Monitor Fetal Heart Rate
2. Monitor Uterine Contraction
3. Observe Any Sign Of Hyper Stimulation
4. Assessment Of Pain
5. Observation Of Maternal Pulse Rate, blood
pressure , and Temperature Rate.
6. Observe Any Sign Of Rupture Uterus
7. Vaginal Examination.

Pre-labour Rupture of
Membranes at term

Pre-labour Rupture Of Membranes At Term
 The incidence of (PROM) at term (>37 weeks) is b
etween 8-10% of all pregnancies.
 Most women with PROM will labour spontaneou
sly within 24 hrs.
 If midwife not sure about ROM by PV and the
diagnosis of ROM is ambiguous, sterile speculu
m should be performed to try and visualize
pooling of liquor in the posterior fornix of vagin
a (Endocervical swab may be taken)

PROM
 Management of rupture of membranes:
1. Reduce maternal infectious morbidity
2. Use of vaginal prostaglandins or via intravenous
oxytocin to induce the delivery.
3. Admission of baby to neonatal intensive care if
ROM last 24 hrs and more to give the baby
antibiotics according to doctor order.
4. Monitore of temperature , women may need
antibiotic according to doctor order
5. Monitore fetal heart rate to exclude fetal
tachycardia or other signs of fetal compromise
associated with infection(if mother complain of fever
the fetal heart rate tachycardia).

Prolonged Pregnancy
• Prolonged pregnancy and post-term
pregnancy are used synonymously and
refer to a specific gestation of the pregnancy
and not the fetus or neonate.
• WHO : as a pregnancy equal to or more than
42 completed weeks (294 days from the first
day of the last menstrual period, LMP).
• Post-maturity refers to a description of the ne
onate or condition of baby with peeling of the
epidermis, long nails, an alert face and loose
skin suggestive of recent weight loss .
• Incidence : from 5–10%
4/10/2023

Prolonged pregnancy
• Associated risks and implication for
mother, fetus and baby :
1. Large for gestational age or macrosomic
infant such as shoulder dystocia.
2. Genital tract trauma, postpartum
haemorrhage and operative birth.
3. Risk of neonatal morbidity and mortality
• Small for gestational age baby
• Suffering hypoxia, asphyxia.
• Meconium aspiration
• Stillbirth.
4/10/2023

Predisposing factors :
• Factors that might predispose a
woman to a prolonged pregnancy
include :
1. Nulliparity .
2. Previous prolonged pregnancy .
3. Male fetus .
4. Pre-pregnancy BMI of 25 kg/m2 or
more .
5. Anencephaly previous prolonged
pregnancy .
4/10/2023

Management of prolonged pregnancy :
 The expectant approach involves
increased antenatal surveillance including:
1. A non-stress test (NST) and ultrasound
2. Estimation of amniotic fluid volume
(AFV)
3. The active approach involves Induction
of labour (IOL) at 41 or 42 completed
weeks . there is evidence of a reduction i
n perinatal mortality.
4/10/2023

The midwife’s role
 the interventions necessary when labo
ur is induced also pose a potential risk
to mother, fetus and neonate.
 The woman and her partner should be
fully informed of the risks and benefits
of any management to enable her to
make an informed choice.
4/10/2023

Induction of labour
• IOL is an intervention to initiate the process of
labour by artificial means , is the stimulation
of uterine contractions before the onset of
spontaneous labour.
• a full assessment must be made to ensure
that any intervention planned will confer more
benefit than risk for the mother and her baby.
4/10/2023

The contraindications for IOL are
1. Placenta praevia .
2. Transverse lie or Compound presentation .
3. HIV-positive women not taking highly active
4. Antiretroviral therapy .
5. Active genital herpes .
6. Cord presentation or cord prolapse .
7. Known cephalopelvic disproportion .
8. Severe acute fetal compromise.
4/10/2023

Methods of induction
1.Membrane Sweep
2.Prostaglandin E2 (PGE 2 )(Dinoprostone)
•An active ingredient in Prostin E 2 vaginal tablets, gel, and pessaries
•It replicates prostaglandin E2 produced by the uterus in early labour
to ripen the cervix.
•Where the membranes are intact or ruptured, the recommended initial
dose for all women whether it is a first or subsequent pregnancy is
PGE 3 mg tablet.
•There should be a break of no less than 6hrs from the last PGE 2 to
commencement of an oxytocin infusion.
•Side effects of Prostin include nausea, vomiting and diarrhoea
3. PGE1 (misoprostol)
•can be given by the oral, sublingual, or vaginal route for IOL .
•The dosage of tablets currently available is 200 mg and for use in IOL
a much smaller dose would need to be available .
•The use of PGE2 can be unpredictable and may lead to hypertonic
uterus, placental abruption, fetal hypoxia, pulmonary or amniotic
fluid embolism .
4. Artificial rupture of membrane
5. Oxytocin
4/10/2023

Alternative approaches to initiating
labour
• The ingestion of castor oil,
• Nipple stimulation,
• Sexual intercourse,
• Acupuncture
• The use of homeopathic methods.
• The midwife must ensure that any
advice given on alternative therapies
is in line with the sphere of practice .
4/10/2023

1. Welcoming The Mother
2. Taking History ( Present Labor , Past Hi
story )
3. General Abdominal Examination (
)
4. Assessment Of Contraction ( Frequency
, Intensity , Duration Of Contraction , Int
erval)
5. Vaginal Examination
6. Birth plan

7-General Physical Condition And Vital Sign
( Pulse ,Temperature , Blood Pressure , Respir
ation)
8- Fetal Evaluation ( To Establish Fetal Well Be
ing)
9- Physical Preparation
10- Records ( Partogram ) : Labor Progress Sh
eet

General and abdominal examination
• Inspection
• Skin changes
• Palpation
• Fundal palpation
• Lateral palpation
• Pelvic palpation
• Pawliks manoeuvre
• Leopold's manoeuvers
• Auscultation

• Prior to touching the woman,
a sound explanation of the
proposed examination and their
significance should be given.
• Verbal consent should be obtain
ed and recorded in the notes.

106
 Indication
1. To Make Positive Diagnosis Of Labor
2. To Identify Presentation
3. To Determine Head Engagement
4. To Assess Whether Membrane Is Ruptured Or
Not
5. To Assess Progress Or Delay In Labor
6. To Confirm Full Dilation Of Cervix
7. Exclude cord prolapse after rupture of
membrane
8. Confirm the axis of the fetus and presentation
of the second twin in multiple pregnancy

Vaginal examination
• Method:
Vaginal examination during labo
ur is an aseptic procedure.
Explain the procedure and give
woman opportunity to ask quest
ion.
Ask the woman to lie on her
back( lithotomy position)

Vaginal examination
• Method:
 Provide privacy, the woman can be
asked to move and uncover herself w
hen the midwife is ready to begin.
 There is no increased risk of infection
to mothers and babies if the midwife
does not swab the vulva with antiseptic
solution or use sterile vaginal packs.
 What is important is using a good han
d washing technique and wearing
sterile gloves.

109
Finding :-
1.Condition Of Vagina for any sign of varicosities,
oedema,warts or sores.
2.Notes the perineum is scarred from a previous tear
or episiotomy.
3. Cervical Effacement And Cervical Dilation,
position and consistency)
4. note any discharge or bleeding from the vaginal
orifice.
5-Fore Water Intact Or Rupture (color and odor)
Indicates the presence of infection or meconium.
6-Level Of Presenting Part “ Station”
7- Presentation , Position Of Fetus,lie,attitude.
8- Moulding (by feeling the amount of overlapping of
the skull bones, it can also give additional
information as to position, Pelvic Capacity

Cleanliness and comfort
1-Bowel preparation: asked the woman
if she would like an enema or
suppositories.
This is never done as a routine
procedure.
2-perineal shave.
3-Bath or shower.
4-Clothing : if in hospital she may
prefer to wear the loose gown offered
or she may feel more comfortable
wearing her own choice of clothing.

Records(Partogram or partograph)
 Defined As Labor Progress Sheet
 The midwife record of labour is a legal document
 The maternity record is shared between the mid
wife and the obstetrician.
 An accurate record during labour provides the
basis from which clinical improvement ,progress
or deterioration of the mother or fetus can be
judged.(indicate if prolonged labour, or precipitat
e, or if failure to progress).

Component Of Partogram
The charts are usually designed to allow
for recordings at 15 min interval and incl
ude:
1.Fetal Heart Rate
2-Vital Sign ( Bp,temperature,pulse,respiration)
3-Detail of vaginal examination
4-Strength Of Contractions
5- frequency , Duration In 10 Minute
6-Urine Analysis
7-Drugs Administered
8-fluid balance
9-record if membrane rupture and color of fluid

Management of first stage of labour
1. Communication and environment
2. Emotional support
3. Explanation
4. Privacy
5. consent and information giving
6. prevention of infection:
7. Position and mobility
8. Analgesia:
9. monitoring the fetus
10. Nutrition
11. Bladder care
observation:(mother),vital signs:

12- observation:(mother)
vital signs:
1- pulse rate : if increases to more
than 100 b.p.m.it may be indicative
of infection,anxiety,ketosis,or
hemorrhage.
It usual to record the pulse rate
every 1-2 hrs during early labour
and every 30 min when labour is
more advanced.

 vital signs:
2-respiratory rate:
 It should be recorded at least every 4 hrs
.
3-Temperature:
 This should remain within normal range.
 Pyrexia is indicative of infection or ketosis
, or may be associated with epidural anal
gesia.
 In normal labour,should be recorded at l
east every 4hrs.

vital signs:
4-B /P: is measured every 2-4hrs
unless it is abnormal.
More frequent recording will be nece
ssary depending on the individual
situation like HTN,pre-eclampsia.
The BP must also be monitored very
closely following epidural or spinal an
esthetic.
Hypotension may be caused by the
supine position, shock or as a result
of epidural anesthesia.

Observation:(mother)
Urinalysis: should be tested for gl
ucose,ketones,and protein.
Measurement of I&O chart.
Abdominal examination.
Vaginal examination
Assessment contraction

Assessment contraction
• Frequency, length, and intensity ,
and duration.
The duration of a contraction is timed
from the moment the uterus first tens
es until it has relaxed again.

Intensity or strenght Of Contractions.
• Estimate the intensity or the
strength of the contraction.
• Contractions are rated as mild
(the uterus is contracting but
does not become more than mini
mally tense)
• Moderate (the uterus feels firm)
• Strong (the contraction is so inten
se the uterus feels as hard as a wo
oden board at the peak of the con
traction).

Frequency of Contractions.
• Time the frequency of contractions.
• The frequency is timed from the
beginning of one contraction to the begi
nning of the next (interval).

Observation:(fetus):
 Fetal heart rate
Amniotic fluid: should be remain clear.
If meconium indicate fetal hypoxia.
Meconium in breech normal.
In the rare case of a fetus that is
severely affected by Rhesus
isoimmunization, the amniotic fluid
may be golden-yellow owing to an
excess of bilirubin.
Bleeding of sudden onset at the time
of rupture of the membranes may be
result of ruptured vasa praevia and is
an acute emergency(bloody liquor).

The physiology of pain
Perception of pain:
Factor affect the perception of pa
in:
1-fear and anxiety: a previous bad ex
perience will also increase anxiety.
2-personality.
3-fatigue.
4-culture and social factor.
5-expectation.

The second stage of labour
• Begins With Full Dilatation Of Cervix
,Ends With Delivery Of The Fetus .
• This is typically characterized by
maternal restlessness, discomfort,
desire for pain relief, a sense that
the process is never ending, and
demands to attendants to end the
whole process.

The second stage of labour
 Some women may experience an
urge to push before the cervical os
is fully dilated.
 others may experience a Full before
the onset of strong expulsive second
stage contraction this phenomenon
has termed the resting phase of the
second stage of labour.

Recognition of the commencement
of the second stage of labour.
 Presumptive signs and differential
diagnosis:
1-expulsive uterine contractions: woman
feel a strong desire to push before full
dilatation occurs, especially if the fetus
is in an occipitoposterior position, the re
ctum is full or the woman is highly
parous.
 Early urge to push will lead to maternal
exhaustion and cervical oedema or
trauma.

Recognition of the commencement of the second stage
of labour.
diagnosis:
2-rupture of the forewaters: this may
occur at any time of labour.
3-dilatation and gaping of the anus: dee
p engagement of the presenting part m
ay produce this sign during the latter pa
rt of first stage.
4-congestion of the vulva: premature pus
hing cause this.

Recognition of the commencement of the
diagnosis:
5-anal Cleft Line: (the purple line) as a
pigmented mark in the cleft of the buttocks
which creeps up the anal cleft as the labour
progresses.
6-appearance of the rhomboid of Michaelis:
 Its noted when a woman in a position wher
e her back is visible.
 It present as dome shaped curve in the
lower back, and is held to indicate the
posterior displacement of the sacrum and
coccyx as the fetal occiput moves into the
maternal sacral curve.

Recognition of the commencement of the
Presumptive signs and differential dia
gnosis:
6-upper abdominal pressure
7-show: due to rapid dilatation of cervix,
must be distinguished from bleeding.
8-appearance of the presenting part:
excessive moulding may result in the
formation of a large caput succedaneum
which can protrude through the
cervix prior to full dilatation.

Phases and duration
The latent phase: full dilatation of
cervix os is recorded, but the pres
enting part may not yet have
reached the pelvic outlet.
She may not experience a strong
expulsive urge until the head has
descended sufficiently to exert
pressure on the rectum and
perineal tissues.

Phases and duration
Active phase:
Once the fetal head is visible(crown
ing), the woman will usually experien
ce a compulsive urge to push.
Duration of second stage:
In multi Para from 5min-30min.
In multiPara with spinal anesthesia
take 1 hr.
Primigravida may take 1- 2 hrs
But if the fetal heart is bradycardia
deliver the baby as soon as possible.

Maternal response to transition and the secon
d stage
Pushing: if the maternal urge to push
occur before confirmation of full dilatatio
n of the cervix ,the mother is encourage
d to avoid active pushing at this stage.
ask woman to push after full dilatation t
o cervix.

Maternal response to transition and the second
stage
Position of woman:
1-Semi-recumbent or supported sittin
g position, with the thighs abducted.
2-left Lateral Position.
3-upright Position, Squatting ,Kneeli
ng , All Four Standing ,using a birth
ing ball.
4-used of Birthing Chairs Position.

Observation during the second stage
1-uterine contraction.
2-descent,rotetion,and flexion
of the presenting part.
3-fetal condition .
4-maternal condition.

Uterine contraction
• They are usually stronger and long
er than during the first stage.
• The progress of descent : is obse
rved by noting the descent of the
fetal head as it advances during
contractions and recedes after war
ds.

Fetal condition
• As fetus descends, fetal oxygenation
may be less efficient to cord cause fet
al Brady cardia.
• compression on head occurs and may
cause deceleration in fetal heart rate.
• Monitor fetal heart rate immediately
after each contraction by sonicade.
• Observe the liquor if clear or meconi
um if ruptured in second stage of
labour.

Maternal condition
• Assessment of vital signs.
• Emotional support.
• The mother lips may dry ,using
sips of water to refreshing the
lips.
• Empty bladder to prevent bladder
injury, due to compression of
bladder between the pelvic brim
and the fetal head.
• IVF.

Maternal condition
• Pushing: ask mother to push
when vertex is visible.
• Ask the woman to push or
bearing down with contraction.
• Ask woman to take long breathin
g(inspiration) and then pushing
accompanied by prolonged breat
h-holding.

Maternal condition
• Maternal comfort and position:
• Allow Freedom In Position And
Movement Throughout Labor And
Childbirth
1-the semi recumbent or supported
sitting position.
2-squatting, kneeling or standing
position.
3- the birthing chair.
4-left lateral position.

Preparation for the birth
Once active pushing commences,
the midwife should prepare for the
birth:
1-the room should be warm with a
spotlight available.
2-A lean area prepared to receive the
baby.
3-waterproof cover provided to prote
ct the bed and floor.
4-sterile cord clamp
5-sterile gloves
6-a clean apron

Once active pushing commences,
the midwife should prepare for t
he birth:
7-sterile gown
8-delivery set ,episiotomy set.
9-stavlon to clean the vagina.
10-suture.
11-follys catheter
12-oxytocin, syntometrine.
13-IVF

Once active pushing commences, the
midwife should prepare for the birth:
14-sonicade
15-a warm baby cot.
16-clothes for baby and woman.
17-identification band.
18- stump.
19-neonatal resuscitation equipment.
20- syringe
21-delivery towel.

Conducting the delivery
• The midwife skill and judgments
are crucial factors in minimizing
maternal trauma and ensuring
an optimal birth for both mothe
r and baby.
• These qualities are refined by exp
erience but certain basic principl
es should be applied.

Conducting the delivery
The principles are:
1-observation of progress.
2-prevention of infection.
3-emotional and physical comfort of
the mother.
4-anticipation of normal event, and
support for the normal process of
labour.
5-recognition of abnormal development
s, and appropriate response to them.

Asepsis
 During delivery both mother and
baby are particularly vulnerable to
infection.
 Use sterile equipment and sterile proc
edure during delivery.
 Clean the perineum of mother to
prevent infection, the delivery area
draped with sterile towels and a pad
used to cover the anus,a clean towel
placed on or near the mother for
receipt the baby.

Asepsis
the equipment used in cleaning
of perineum:
1. Warm antiseptic solution
(diluted stavlon)
2. Cotton wool and pads(use
7 swab).
3. Cord scissors and clamps.

The mechanism of normal labour
The fetus descend through birth ca
nal by a series of movements , thes
e movements are called the mecha
nism of labour.
 The Presenting Part Of The Fetus Under
goes Certain Positional Changes Called “
Cardinal Movement “ That Constitute T
he “ Mechanism Of Labor”

Cardinal Movements:
• Also called the “mechanisms of labor”
.
• A series of adaptations the fetus mak
es as it moves through the maternal
bony pelvis during the process of lab
or & birth.
• Influenced by the size and position of
the fetus, the powers of labor, the siz
e and shape of the maternal pelvis, a
nd the mother’s position.

The mechanism of normal labour
• The Following Characteristics Should Be
Available In The Fetus :
1. Longitudinal Lie
2. the presentation is cephalic
3. the position is RT Or LT
Occipitoanterior
4. the attitude is one of Good Flexion
5. the denominator is the Occiput.
6. the presenting part is the posterior
part of the anterior parietal bone.

Main movement of the fetus
1-descent
2-flexion
3-internal rotation of the head
4-extension of the head
5-restitution
6-internal rotation of the shoulder
at same time external rotation of
the head.
7-lateral flexion and expulsion

Internal rotation of the head
(head rotates from occiput transverse to
occiput anterior.)

Internal rotation of the shoulder
The shoulder undergo a similar
rotation to that of the head to lie
in the widest diameter of the
pelvic outlet ,namely
anteroposterior.
The anterior shoulder rotate
anteriorly to lie under the symphy
sis pubis.
This movement can be seen with
external rotation of the head.
head returns to its' occiput
transverse orientation)

Lateral flexion, Expulsion
• The shoulder are usually born sequentially.
• The anterior shoulder is usually born first.
 Immediately After External Rotation ,
The Anterior Shoulder Appears Under The
Symphysis Pubis ,Then Posterior Shoulder
Is Born , Assisted By An Up Ward.
 The remainder of the body is born by late
ral flexion as the spine bends sideways thr
ough the curved birth canal.

Expulsion(shoulders and torso of
the baby are delivered).

• The third stage is defined
as:
 the period from the birth of the
baby to complete expulsion of
the placenta and membranes.
 involving the separation, descent a
nd expulsion of the placenta
and membranes and control of
hemorrhage from the placenta site.

• The third stage is defined as:
During the third stage, separation
and expulsion of the placenta and
membranes occur as the result of
mechanical and haemostatic factors.
The third stage usually lasts between
5 and 15 min, up to 30 min
if no bleeding.

164
2- Duncan
Mechanism
1- Schultze’s
Mechanism
Two Mechanism
Of Placental
Separation

Evident 80% Of
Delivers
Placenta Starts
Separation
Centrally
Delivered Liked
Inverted Umbrella
With The Fetal
Surface Presenting
Following By
Membranes
Containing Small
Retro Placental
Clots
There Is Less
Blood Loss ,Less
Liability To
Retention Of
Fragment
165

166
Evident 20% Of
Deliveries
Placenta Starts
Separation At Its
Lower Pole And Is
Delivers Side
Ways Presenting
By Its Lower Edge
There Is More
Liability Of
Bleeding And
Retained Part Of
Fragments

Haemostasis factors
• The normal volume of blood flow
through the placental site is 500–8
00 mL/min.
• At placental separation, this has
to be arrested within seconds, or
serious hemorrhage will occur.

Delivery of the placenta
and membranes
• Controlled cord traction (CCT):
1-This maneuvers is believed to reduce
blood loss.
2-shorten the third stage of labour and
3-minimize the time during which the
mother is at risk from hemorrhage.
4-It is designed to enhance the normal
physiological process.

and membranes
• If CCT is to be used, there are
several checks to be made before pr
oceeding:
1- that a uterotonic drug has been adm
inistered.
2-that it has been given time to act.
3- that the uterus is well contracted.
4-that counter-traction is applied.
5- that signs of placental separation
and descent are present.

and membranes
• At the beginning of the third stage,
a strong uterine contraction results
in the fundus being palpable below
the umbilicus .
• It feels broad as the placenta is still
in the upper segment.
• As the placenta separates and falls
into the lower uterine segment

Signs of placental separation
1-is a small fresh blood loss (gush of
blood).
2- the cord lengthens .
3- the fundus becomes rounder, small
er and more mobile as it rises in
the abdomen above the level of the
placenta.(globular shape of uterus).
 There is however debate about
whether CCT should be applied
before or after the signs f placental
separation have been noted.

and membranes
It is important not to manipulate the
uterus in any way as this may
precipitate in coordinate action.
 No further step should be taken
until a strong contraction is palpable.
If tension is applied to the umbilical
cord with-out this contraction, uterin
e inversion may occur.
 This is an acute obstetric emergency
with life-threatening implications for
the mother

Summary of fundal heights during third stage
A- at the beginning of third stage :
2.5 cm below the umbilicus.
15 cm above the symphysis pubis.
B-placenta in lower segment
(separated) :
1.5 cm above the umbilicus.
19cm above the symphysis pubis.
C-end of third stage (placental expelled):
4cm below the umbilicus.
14cm above the symphysis pubis.

Blood loss estimation
• Normal delivery= about 500mL.
• C /S delivery=The average blood loss is a
pproximately 1000 ml during cesarean d
elivery.
 It should also be remembered that any
amount of blood loss that causes a physi
cal deterioration such as feeling faint, su
dden onset of tachycardia, drop in blood
pressure should be immediately investiga
ted.

Immediate care
• It is advisable for mother and baby to re
main in the midwife’s care for at least 1
hr after birth, regardless of the birth setti
ng.
• Much of this time will be spent in clearin
g up and completion of records but care
ful observation of mother and infant is v
ery important.
• If an epidural cannula is in situ it is usual
ly removed and checked at this time.

Immediate care
• Most mother appreciate being able to eit
her wash or shower at this stage, which c
an do much to restore comfort and incre
ase a sense of well-being.
• Cleaning the teeth and the application of
lip salve or cream can help relieve the di
scomfort of a dry mouth and sore lips, e
specially in inhalational analgesia has be
en used during labour.

Immediate care
• Early physiological observations includin
g:
• 1- ensuring a well contracted uterus,
• 2-assessment of vaginal blood loss and a
gentle inspection of the genital tract to i
nspect for trauma should be undertaken
• 3-The woman should be encouraged to
pass urine because a full bladder may im
pede uterine contraction.

Immediate care
• Early physiological observations includin
g:
She may not actually feel an urge to do
so,
especially if she has passed urine immediat
ely prior to giving birth or an effective e
pidural has been in progress, but she sh
ould be asked to try.
4-Uterine contraction and blood loss shou
ld be checked on several occasions durin
g this first hour.

Immediate care
• 5-Most women intending to breastfeed
will wish to put their babies to the breast
during these early moments of contact.
• This is especially advantageous, as babie
s are usually very alert at this time and t
heir sucking reflex is particularly strong.
• There is also evidence to suggest that w
omen who breastfeed soon after birth su
ccessfully breastfeed for a longer period
of time.

Immediate care
• An additional benefit lies in the reflex rel
ease of oxytocin from the posterior lobe
of the pituitary gland, which stimulates t
he uterus to contract.
• This may result in the mother experienci
ng a sudden fresh blood loss as the uter
us empties and she should be pre-warne
d and reassured that it is a normal respo
nse.

Immediate care
• The desire to feed a newborn baby is a
warm, loving and instinctive response.
• While breastfeeding should be actively e
ncouraged, a formula feed should be ava
ilable for those who do not wish to brea
stfeed.

Immediate care
• The mother is left warm and resting com
fortably with good pillow support and in
a dry bed.
• there is no evidence to suggest that restr
iction of food or fluids is necessary.

Immediate care
The midwife should pay regard to the ba
by general well-being.
She should check the security of the cor
d clamp and observe general skin color,
respirations and temperature.
Put baby in safety area and warm.

records
A complete and accurate account of the lab
our,
including the documentation of all drugs, p
hysical
examination and observations, is the midwif
e’s
responsibility.
 This should also include details of examina
tion of the placenta, membranes and cord
with attention drawn to any abnormalities.
The volume of blood loss is particularly imp
ortant.

records
This record not only provides informatio
n that may be critical in the future care o
f both mother and infant but is a legal d
ocument that may be used as evidence o
f the care given.
The completed records are a vital comm
unication link between the midwife respo
nsible for the birth and other caregivers,
including the community midwife.

Transfer from the birth room
• The midwife is responsible for seeing that a
ll observations are made and recorded prior
to transfer of mother and baby to the postn
atal ward or before the midwife leaves the
home following the birth.
• The postnatal ward midwife should verify th
ese details prior to transfer of mother and
baby.
• Following a domiciliary birth, the midwife s
hould leave details of a telephone number
where she may be contacted should the par
ents feel any cause for concern.

Child birth and labor process

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