This document outlines the management of the three stages of labor. The first stage involves monitoring the mother's vital signs and positioning, providing nutrition and pain management, as well as fetal heart rate monitoring and assessing cervical dilation. The second stage focuses on monitoring the mother's vitals and pushing efforts, as well as fetal descent. Procedures like episiotomy and delivery of the baby are also described. The third stage involves active management with uterotonic drugs, controlled cord traction, and uterine massage to achieve a quick delivery and reduce bleeding.

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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