The document describes the stages of labor and delivery. It discusses the first stage from onset of labor to full dilation, the second stage from full dilation until delivery of the baby, and the third stage from delivery of the baby until delivery of the placenta. It provides details on managing each stage, including administering oxytocin during the third stage and controlled cord traction to deliver the placenta. Complications like postpartum hemorrhage are also addressed.

1. BIRTH PROCESS

2. Categories of labor
First Stage:
from labor onset until full dilation
– Latent phase:
 period from onset till labor becomes active
 Usually, it is defined by the initiation of regular painful contractions.
 The onset of labor is difficult to identify objectively.
 Identification of latent labor usually depends on patient memory
– Active phase:
 From accelerating slope of cervical dilation till full dilatation (Beginning
diagnosed retrospectively)
 Diagnosis:
– ≥80 percent effacement
– ≥4 cm dilation of the cervix
 Cervical dilatation rates (5th percentile):
– Multiparous: 1.5 cm
– Nulliparous: 1.2 cm
– Generally: at least 1 cm per hour

3. Categories of labor
Second stage:
Full dilation until delivery of the baby
Factors affecting duration of the second stage
 Epidural analgesia*,
 Nulliparity,
 Older maternal age,
 Longer active phase,
 Larger birth weight,
 Excess maternal weight gain
 Maternal position*
– Allowing women to choose alternate positions may be beneficial,
especially in nulliparas
 Delayed pushing*
* Modifiable factors

7. Categories of labor
Third stage:
Delivery of baby until delivery of the placenta
• Median duration:
• 6 minutes
• exceeded 30 minutes in 3% of women
• Duration not affected by parity
• 30 minutes associated increased risk of:
• > 500-ml blood loss,
• > 10% drop in post-delivery hematocrit
• need for D&C
• Manual removal and or extraction of the placenta is
indicated after 30 minutes (or earlier in PPH)

8. SPONTANEOUS VAGINAL DELIVERY
 Goals of assistance at spontaneous delivery:
– reduction of maternal trauma,
– prevention of fetal injury,
– initial support of the newborn, if required

10.  Don’t just stand
there.
 Do nothing!”

11. Prolonged second stage
 ????????????????
 Maternal morbidity, including perineal trauma, PPH, and
chorioamnionitis, is higher in second stage lasting longer than
2 hours but instrumental delivery does not prevent perineal
trauma and morbidities

12. Third stage of labor
 Quickly dry and wrap the baby and give to
mother if appropriate.

13. Signs of placental separation
 Fundus rises to level of umbilicus, getting
contracted
 The cord lengthens in the vulva
 Trickle or gush of blood

14. Management of 3rd
stage of labour

15. Selecting Management
 EXPECTANT
- no oxytocin
- waiting for signs of
separation and placenta is
delivered by gravity and
woman’s effort
- cord is clamped when
pulsation ceases or after
delivery of placenta
 ACTIVE
- Oxytocin im
- Early cord- clamping
- controlled traction of cord
and counter traction on
uterus

16. Active management of third stage of labour
 Give oxytocin immediately:
– Palpate uterus to rule out the possibility of an
additional baby
– Administer oxytocin 10 units im (within one minute
after delivery)

17. Active management of third stage of labour
 Deliver the placenta by controlled cord
traction:
Clamp the cord
– Clamp the cord close to the perineum using sponge
forceps.
– Hold the clamped cord and the forceps with one
hand.
– Keep slight tension on the cord and await a strong
uterine contraction (2-3 minutes).

18.  Deliver the placenta by controlled cord
traction:
Controlled cord traction
When the uterus becomes rounded or the cord
lengthens:
– Very gently pull downwards on the cord.
AND
– Place the other hand just above the woman’s pubic
bone and stabilize the uterus by applying counter
traction during controlled cord traction.

20. Controlled cord traction:
 Never pull on the cord without pushing the uterus up with
the other hand.
 CCT helps prevent inversion of the uterus.

21.  Deliver the placenta by controlled cord
traction:
Controlled cord traction
– If the placenta does not descend during 30-40 sec of controlled
cord traction (i.e. there are no signs of placental separation), do
not continue to pull on the cord.
– Gently hold the cord and wait until the uterus is well contracted
again. If necessary, use a sponge forceps to clamp the cord
closer to the perineum as it lengthens.
– With the next contraction, repeat controlled cord traction with
counter traction.

22. Slowly pull to complete
the delivery:
– Receive placenta in cupped
hands
– Gentle up-and down-
movements with placenta to
deliver membranes

23. Placenta, umbilical cord, and fetal
membranes examination:
 Placental weight (without membranes, cord) varies with NB weight
– ratio of approximately 1 : 6
– Large placentae: hydrops fetalis, congenital syphilis etc
 Examine fetal and maternal surfaces:
– Fibrosis, infarction, calcification
 extensive lesions prompts histologic examination
– Adherent clots: recent placental abruption
 absence does not exclude abruption
– Missing placental cotyledon or a membrane defect
 missing succenturiate lobe prompts further clinical evaluation
 No routine manual exploration of uterus unless suspicion of retained
products of conception or PPH

24. Examine the placenta
routinely
lobules. membranes, cord, weight, clot
– If a portion of the maternal surface is
missing or there are torn membranes
with vessels, suspect retained
placental fragments
– Check for excessive bleeding
– Make sure no clot in vagina and uterus
is well controlled

25. Management of incomplete placenta
 Membranes – inspection of vagina and
cervix, gentle removal with a non-sharp
instrument
 Lobules – manual revision of uterus
– Be gentle
– Communicate with the woman throughout the
procedure

26. Oxyticics
Why oxytocin?
 Effective (2-3 minutes)
 No side effects
 Can be given to all women
If oxytocin is unavailable ?
 Ergometrin 0.2 mg IM
– NOT in pre-eclampsia, eclampsia, high blood pressure
Prostaglandines – some advantages
– Inexpensive,
– Stable at room temperature,
– Administered orally, rectally,
– Hypertension is not a contraindication

27. Why choose active management?
 Reduced risk of PPH
– by over 60% (relative risk 0.38, 95% confidence
interval 0.32-0.46)
 Reduced incidence of prolonged third stage
 Decreased need for blood transfusion or
additional uterotonic drugs
 Should be offered by all skilled birth attendants
at every childbirth.

28. Fourth stage of labor
– Massage the uterus
– Immediately massage the fundus of the uterus through
the woman’s abdomen until the uterus is contracted.
– Repeat the uterine massage every 15 min for the first
two hours.
– Ensure that the uterus remains hard after you stop
uterine massage.

29. PERINEAL INJURY
 Perineal injuries, either spontaneous or with episiotomy, are the most
common complications of spontaneous or operative vaginal
deliveries.
 Classification:
– First-degree tear: superficial tear confined to the epithelial layer
– Second-degree tears extend into the perineal body but not into the
external anal sphincter
– Third-degree tears involve superficial or deep injury to the external
anal sphincter
– Fourth-degree tear extends completely through the rectal mucosa
 Significant morbidity is associated with third- and fourth-degree tears,
– Including risk of flatus and stool incontinence,
– Rectal vaginal fistula,
– Infection, and pain

30. Episiotomy
 Incision into the perineal body made during the second stage of labor to
facilitate delivery.
– It is a second-degree tear.
 Classified:
– Median (midline)
– Mediolateral reading assignment
 No role for routine episiotomy except indicated episiotomy to expedite
delivery in:
– NRFHR
– relief of shoulder dystocia
 Adequate analgesia, either local or regional
 Avoid direct injury to anal sphincter
 Complications:
– increased blood loss, especially if the incision is made too early, fetal injury,
and localized pain
 May lead to 3rd and 4th degree tear