NORMAL LABOUR

1. CHAPTER 12
Normal Labour
DEFINITIONS
Labour - series of events that take place in the genital organs in an effort to expel the viable products of
conception out of the womb through the vagina into the outer world.
Delivery - the expulsion or extraction of a viable fetus out of the womb.
Normal Labour (Eutocia) - Labour is called normal if it fulfils the following criteria:
1. delivery of a single baby
2. by vertex presentation
3. vaginally
4. at or near term
5. with spontaneous onset
6. the whole process of delivery getting over within 24 hours
7. with minimal intervention
8. leaving behind a healthy mother and a healthy fetus.
Abnormal Labour (Dystocia) — any deviation from the definition of normal labour.
CAUSE OF ONSET OF LABOUR
It is unknown but the following theories were postulated:
(I) Hormonal factors:
1. Oestrogen theory: During pregnancy, most of the oestrogens are present in a binding form. During the last
trimester, more free oestrogen appears increasing the excitability of the myometrium and prostaglandins
synthesis.
2. Progesterone withdrawal theory: Before labour, there is a drop in progesterone synthesis leading to
predominance of the excitatory action of oestrogens.
3. Prostaglandins theory: Postaglandins E2 and F2 are powerful stimulators of uterine muscle activity.
PGF2 was found to be increased in maternal and fetal blood as well as the amniotic fluid late in
pregnancy and during labour.
4. Oxytocin theory: Although oxytocin is a powerful stimulator of uterine contraction, its natural role in onset
of labour is doubtful. The secretion of oxytocinase enzyme from the placenta is decreased near term due to
placental ischaemia leading to predominance of oxytocin’s action.
5. Fetal cortisol theory: Increased cortisol production from the fetal adrenal gland before labour may
influence its onset by increasing oestrogen production from the placenta.
(II) Mechanical factors:
1.Uterine distension theory: Like any hollow organ in the body, when the uterus in distended to a certain limit,
it starts to contract to evacuate its contents. This explains the preterm labour in case of multiple pregnancy
and polyhydramnios.
2.Stretch of the lower uterine segment: by the presenting part near term.
CLINICAL PICTURE OF LABOUR
Prodromal (pre - labour) stage:
The following clinical manifestations may occur in the last weeks of pregnancy-
1.Shelfing: It is falling forwards of the uterine fundus making the upper abdomen looks like a shelf during
standing position. This is due to engagement of the head which brings the fetus perpendicular to the pelvic
inlet in the direction of pelvic axis.
2.Lightening: It is the relief of upper abdominal pressure symptoms as dyspnoea, dyspepsia and palpitation due
to :
a. descent in the fundal level after engagement of the head and
b. shelfing of the uterus.
3.Pelvic pressure symptoms: With engagement of the presenting part the following symptoms may occur:
a. frequency of micturition,
b. rectal tenesmus, and
c. difficulty in walking.
4.Increased vaginal discharge.
5.False labour pain:

2. False labour pains are differentiated from true labour pain as follows:
True Labour Pain False Labour Pain
Regular Irregular
Increase progressively in frequency, duration and
intensity
do not
Pain is felt in the abdomen and radiating to the
back
is felt mainly in the lower abdomen and groin
Progressive dilatation and effacement of the
cervix
No effect on the cervix
Associated with ‘show’ Not associated with ‘show’
Formation of “bag of waters” No formation of “bag of waters”
Not relieved by antispasmodics or sedatives
Can be relieved by antispasmodics and
sedatives
Onset of Labour:
It is characterised by:
1.True labour pain.
2.The show: It is an expelled cervical mucus plug tinged with blood from ruptured small vessels as a result of
separation of the membranes from the lower uterine segment. Labour usually starts several hours to few
days after show. Expulsion of cervical mucus plug, mixed with blood, is called “show.”
3.Dilatation of the cervix: A closed cervix is a reliable sign that labour has not begun. In multigravidae the
cervix may admit the tip of the finger before onset of labour.
4.Formation of the bag of fore-waters: Due to stretching of the lower uterine segment, the membranes are
detached easily because of its loose attachment to the poorly formed decidua. With the dilatation of the
cervical canal, the lower pole of the fetal membranes becomes unsupported and tends to bulge into the
cervical canal. As it contains liquor which has passed below the presenting part, it is called bag of waters.
During uterine contraction with consequent rise of intra-amniotic pressure, this bag becomes tense and
convex. After the contractions pass off, the bulging may disappear completely. This is almost a certain sign of
onset of labour.
STAGES OF LABOUR
Labour is divided into four stages:
(I) First stage:
- It is the stage of cervical dilatation.
- Starts with the onset of true labour pain and ends with full dilatation of the cervix i.e.10 cm in diameter.
- It takes about 12 hours in primigravida and about 6 hours in multipara.
(II) Second stage:
- It is the stage of expulsion of the fetus.
- Begins with full cervical dilatation and ends with the delivery of the fetus.
- Its duration is about 2 hours in primigravida and ½ an hour in multipara.
(III) Third stage:
- It is the stage of expulsion of the placenta and membranes.
- Begins after delivery of the fetus and ends with expulsion of the placenta and membranes.
- Its duration is about 15 minutes in both primi and multipara.
(IV) Fourth stage:
- It is the stage of early recovery.
- Begins immediately after expulsion of the placenta and membranes and lasts for one hour.
- During which careful observation of the patient, particularly for signs of postpartum haemorrhage is
essential.
EVENTS IN FIRST STAGE OF LABOUR
The first stage is chiefly concerned with the preparation of the birth canal so as to facilitate expulsion of the
fetus in the second stage.
The main events that occur in the first stage are:

3. 1. Dilatation and effacement of the cervix
• Causes of cervical dilatation:
1. Contraction and retraction of uterine musculature.
2. Mechanical pressure by the forebag of waters, if membranes still intact, or
have ruptured. This in turn will release more prostaglandins which stimulate uterine contractions and
cervical effacement.
3. Softness of the cervix which has occurred during pregnancy facilitates dilatation and effacement of the
cervix.
• Mechanism of cervical dilatation:
In primigravidae, the cervical canal dilates from above downwards i.e.
the external os. So its length shortens gradually from more than 2 cm to a thin rim of few millimetres
continuous with the lower uterine segment. This process is called effacement and expressed in percentage
so when we say effacement is 70
2. Full formation of lower uterine segment
• Before the onset of labour, there is no comp
the demarcation of an active upper s
wall of the upper segment becomes progressively thickened with progressive thinning of the lower segment
• This is pronounced in late first stage, especially after rupture of the memb
second stage.
• A distinct ridge is produced at the junction of the two, called
confused with pathological retraction ring (a feature of obstructed la
superiorly by physiological retraction ring, and inferiorly by the fibromuscular
vix
uterine musculature.
orebag of waters, if membranes still intact, or
ill release more prostaglandins which stimulate uterine contractions and
has occurred during pregnancy facilitates dilatation and effacement of the
anal dilates from above downwards i.e., from the internal
hortens gradually from more than 2 cm to a thin rim of few millimetres
ne segment. This process is called effacement and expressed in percentage
0% it means that 70% of the cervical canal has been taken up.
ment
no complete anatomical or functional division of the uterus. During labour,
segment and a relatively passive lower segment is more pronounced. The
progressively thickened with progressive thinning of the lower segment
, especially after rupture of the membranes and attains its maximum in
nction of the two, called physiological retraction ring, which
n ring (a feature of obstructed labour). The lower segm
n ring, and inferiorly by the fibromuscular junction of cervix and uterus.
the presenting part, if they
ate uterine contractions and
ation and effacement of the
he internal os downwards to
thin rim of few millimetres
and expressed in percentage
been taken up.
f the uterus. During labour,
nt is more pronounced. The
nning of the lower segment.
d attains its maximum in
n ring, which should not be
er segment is limited
tion of cervix and uterus.

4. • Clinical Significance
1. The phenomenon of receptive relaxation enables expulsion of the fetus by formation of complete birth c
along with the fully dilated cervix
2. Implantation of placenta in lower segment gives rise to placenta praevia
3. Caesarean section is performed through this segment
4. Because of poor retractile property, there is chance of PPH if placen
5. Poor decidual reaction facilitates morbid adherent placenta
6. In obstructed labour, the lower segment is very much stretched and thinned out and is likely to give way,
especially in multiparae.
• In normal presentation and position, the head is applied well to the lower uterine segment dividing the
amniotic sac by the girdle of contact into a hindwaters above it containing the fetus and a forewaters below it.
This reduces the pressure in the forewaters preventing
cervix the hind and forewaters become one sac with increased pressure in the bag of forewaters leading to its
rupture.
EVENTS IN SECOND STAGE OF LABOUR
• The second stage begins with the complete dil
• This stage is concerned with descent and delivery of the fetus through the birth canal.
• With the full dilatation of the cervix, the membranes usually rupture and there is escape
liquor amnii. The volume of the uterine cavity is thereby reduced. Simultaneously, uterine contraction and
retraction become stronger.
• Delivery of the fetus is accomplished by the downward thrust offered by uterine contractions supplemented by
voluntary contraction of abdominal muscles against the resistance offered by bony and soft tissues of the birth
canal.
• The expulsive force of uterine contractions is added by voluntary contraction of the abdominal muscles called
“bearing down” efforts.
EVENT
• Comprises of placental separation and it’s expulsion with membranes
deep spongy layer of decidua basalis.
• Mechanism:
1.Marked retraction reduces effectively the surface area at the placental s
2.As it is inelastic, it undergoes buckling
3.A shearing force is initiated between the placenta and placental site
4.Plane of separation runs throug
• There are two ways of separation:
1.Central separation (Schultze): S
2.Marginal (Mathews-Duncan): S
T
xation enables expulsion of the fetus by formation of complete birth c
segment gives rise to placenta praevia
rough this segment
y, there is chance of PPH if placenta is implanted over the area
morbid adherent placenta
gment is very much stretched and thinned out and is likely to give way,
n, the head is applied well to the lower uterine segment dividing the
into a hindwaters above it containing the fetus and a forewaters below it.
ewaters preventing early rupture of membranes. After full dilatation of the
me one sac with increased pressure in the bag of forewaters leading to its
NTS IN SECOND STAGE OF LABOUR
mplete dilatation of the cervix and ends with the expulsion of the fetus.
and delivery of the fetus through the birth canal.
the membranes usually rupture and there is escape
ine cavity is thereby reduced. Simultaneously, uterine contraction and
by the downward thrust offered by uterine contractions supplemented by
muscles against the resistance offered by bony and soft tissues of the birth
ctions is added by voluntary contraction of the abdominal muscles called
ENTS IN THIRD STAGE OF LABOUR
nd it’s expulsion with membranes.The plane of separation runs through
ctively the surface area at the placental site to about half
buckling
tween the placenta and placental site
gh deep spongy layer of decidua basalis.
Separation starts in the centre collection of blood behind placenta
(retroplacental hematoma) whole placenta separates
Separation starts at margin and progressively involves more &
Then there is separation of membranes.
• Expulsion of Placenta
separation of the placenta, it is forced down into
the flabby lower uterine segment or u
of the vagina by effective contraction and
retraction of the uterus. Thereafter, it is
expelled out by either voluntary contraction of
abdominal muscles (bearing down efforts) or by
manipulative procedure.
• Signs of placental separation:
1. Fresh gush of blood
2. Extra-vulval lengthening of the cord
3. Suprapubic bulge with a depression above it
ion of complete birth canal
ed over the area
and is likely to give way,
erine segment dividing the
us and a forewaters below it.
s. After full dilatation of the
g of forewaters leading to its
e expulsion of the fetus.
nal.
scape of good amount of
uterine contraction and
ntractions supplemented by
and soft tissues of the birth
abdominal muscles called
separation runs through
about half
blood behind placenta
separates
nvolves more & more area.
acenta - After complete
acenta, it is forced down into
erine segment or upper part
effective contraction and
uterus. Thereafter, it is
her voluntary contraction of
(bearing down efforts) or by
dure.
separation:-
od
thening of the cord
with a depression above it.

5. Definition - series of movements that occur on the head in the process of adaptation, during its journey
through the pelvis.
The principal movements are:
1. Engagement
• The head normally engages in the oblique or transverse diameter of the inlet.
• When the fetal head is not engaged at the onset of labour, and the fetal
inlet, the head is said to be floating
• Engagement may take place during the last few weeks of pregnancy, or it may not occur until labour begins.
2. Descent
• It is continuous throughout labour particularly during the second stage and caused by:
a. Uterine contractions and retractions.
b. The auxiliary forces which is bearing down brought by contraction of the diaphragm and abdominal
muscles.
c. The unfolding of the fetus i.e. straightening of its body due to contractions of the circular muscles of the
uterus.
3. Flexion
• The descending head meets resistance
from either the cervix, the walls of the
pelvis, or the pelvic floor, flexion of the
fetal head normally occurs.
• This movement causes a smaller
diameter of fetal head to be presented
to the pelvis than would occur i
head were not flexed.
4. Internal rotation
• The movement involves the gradual
turning of the occiput from its original
position anteriorly toward the
symphysis pubis.
• The main purpose of internal rotation is
to place the occiput behind the pubic
symphysis.
• Theories which explain the anterior
rotation of the occiput:
1. Hart’s rule: The part of the fetal
skull which presses on the levator
ani muscle is pushed anteriorly with
each recoil.
2. Pelvic shape: Pelvic outlet is greater
in AP diameter. Hence, the head
tries to accommodate in the
maximum available diameter.
5. Crowning
• After internal rotation of the head,
further descent occurs until the
subocciput lies underneath the pubic
arch.
• At this stage, the maximum diameter of
the head (BPD) stretches the vulval
outlet without any recession of the head even after the contraction is over
6. Extension
• The suboccipital region lies under the symphysis then by head extension the vertex, forehead and face come
out successively.
• The head is acted upon by 2 forces:
MECHANISM OF LABOUR
t occur on the head in the process of adaptation, during its journey
oblique or transverse diameter of the inlet.
d at the onset of labour, and the fetal head is freely mo
g.
g the last few weeks of pregnancy, or it may not occur until labour begins.
particularly during the second stage and caused by:
ions.
aring down brought by contraction of the diaphragm and abdominal
raightening of its body due to contractions of the circular muscles of the
tance
of the
of the
maller
ented
if the
adual
iginal
the
ion is
pubic
terior
fetal
evator
y with
reater
head
the
bic
ter of
al
head even after the contraction is over - called “crowning of the head”.
the symphysis then by head extension the vertex, forehead and face come
n, during its journey
eely mobile above the pelvic
t occur until labour begins.
ed by:
ragm and abdominal
e circular muscles of the
“crowning of the head”.
ex, forehead and face come

6. - the uterine contractions acting downwards and forwards.
- the pelvic floor resistance acting upwards and forwards
extension of the head.
7. Restitution
• After delivery, the head rotates 1/8
produced by it.
8. External rotation
• The shoulders enter the pelvis in the opposite oblique diameter to that previously passed by the head.
• When the anterior shoulder meets the pelvic floor it rotates anteriorly 1/8
• This movement is transmitted to the head so it rotates 1/8
9. Expulsion of the trunk
• The anterior shoulder hinges below the symphysis pubis and with continuous descent the posterior shoulder
is delivered first by lateral flexion of the spines followed by anterior shoulder.
• After delivery of the shoulders, the rest of the infant's body is extruded quickly
Cervical dilatation is expressed in terms of fingers (1, 2, 3 or fully dilated); or better, in terms of centimeters
(10 cm when fully dilated). It is usually measured with fingers
average.
MAN
Aims:
1. To achieve delivery of a normal healthy child with minimal physical and psychological maternal effects.
2. Early anticipation, recognition and management of any abnormalities during labour course.
First Stage of Labour:
(I) History:
(1) Complete obstetric history.
(2) History of present pregnancy:
- Duration of pregnancy.
- Medical disorders during this
pregnancy.
- Complications during this
pregnancy such as antepartum haemorrhage.
(3) History of present labour:
- Labour pains: onset, frequency and duration.
- Passage of “show", fluid or blood per vaginum.
- Sensation of fetal movement.
(II)Examination:
(1) General examination:
- Height and build.
- Maternal vital signs: pulse, temperature and blood pressure.
- Chest and heart examination.
- Lower limbs for oedema.
(2) Abdominal examination:
downwards and forwards.
g upwards and forwards, so the net result is forward direction i.e.
th of a circle in the opposite direction of internal rotation to undo the twist
he opposite oblique diameter to that previously passed by the head.
the pelvic floor it rotates anteriorly 1/8th of a circle.
he head so it rotates 1/8th of a circle in the same direction of restitution.
w the symphysis pubis and with continuous descent the posterior shoulder
of the spines followed by anterior shoulder.
rest of the infant's body is extruded quickly.
CERVICAL DILATATION
rms of fingers (1, 2, 3 or fully dilated); or better, in terms of centimeters
lly measured with fingers but recorded in cms. 1 finger =
ANAGEMENT OF NORMAL LABOUR
althy child with minimal physical and psychological maternal effects.
d management of any abnormalities during labour course.
haemorrhage.
y and duration.
ood per vaginum.
erature and blood pressure.
ward direction i.e.,
al rotation to undo the twist
y passed by the head.
rcle.
e direction of restitution.
cent the posterior shoulder
r, in terms of centimeters
1 finger = 1.6 cm on
ogical maternal effects.
our course.

7. - Fundal level. - Fundal grip. - Umbilical grip. - Pelvic grips.
- FHS. - Scar of previous operations (e.g. CS, myomectomy or hysterotomy).
(3) Pelvic examination:
a. Cervix:
- Dilatation: the diameter of the external os is measured by the finger(s) during P/V examination and
expressed in cm, one finger = 2 cm, 2 fingers = 4 cm and the distance resulted from their separation is
added to the 4 cm in more dilatation.
- Effacement.
- Position (posterior, midway, central).
b. Membranes: ruptured or intact. If ruptured exclude cord prolapse and meconium stained liquor.
c. Presenting part and its position.
d. Station: of the presenting part.
e. Pelvic capacity.
(4) Investigations:
If not done before or if indicated:
1. Blood grouping & Rh typing.
2. Urine for albumin and sugar.
3. Hb%.
4. Ultrasonography.
(III) Active procedures:
(1) Evacuation of the rectum by enema to;
i) avoid uterine inertia,
ii) help the descent of the presenting part,
iii) avoid contamination by faeces during delivery.
(2) Evacuation of the bladder:
Ask the patient to micturate every 2-3 hours, if she cannot use a catheter.
It prevents uterine inertia and helps descent of the presenting part.
(3) Preparation of the vulva:
Shave the vulva, clean it with soap and warm water from above downwards, swab it with antiseptic lotion
and apply a sterile pad.
(4) Nutrition:
When labour is established no oral feeding is allowed, but sips of water allowed in early labour.
If labour is delayed more than 8 hours, IV drip of glucose 5% or saline-glucose solution is given.
(5) Posture:
Patient is allowed to walk during the early first stage particularly with intact membranes.
If rest is needed the patient lies on her left lateral position to prevent IVC compression and hence
placental insufficiency and fetal distress.
(6) Analgesia:
- Pethidine 100 mg IM,
- Trilene inhalation, or
- Epidural anaesthesia is the most commonly used.
(7) The partogram:
It is the graphic recording of the course of labour.
Second Stage of Labour:
(1) Its beginning is identified by:
1. The patient feels the desire to defecate.
2. The contractions become more prolonged and painful.
3. Reflex desire to bear down during the contractions.
4. Rupture of membranes, although this is not specific as it may occur earlier even before start of labour
“premature rupture of membranes" or later even to the degree that the fetus is delivered in an intact sac.
5. Full dilatation of the cervix (10 cm) in between uterine contractions is the surest sign.
(2) Delivery room:
The patient is transferred on a wheel or trolley to the delivery room.

8. Put her in the lithotomy position.
The lower abdomen, upper parts of the thighs, vulva an
Sterile leggings and towels are applied.
(3) Bearing down:
Ask the patient to bear down during contractions and relax in between.
(4) Delivery of the head:
The main aim during delivery of the head is to prev
instructions:
i) Support of the perineum: When the labia start to separate by the head, a sterile pad is placed over the
perineum and press on it with the right hand during uterine contractions. This is conti
occurs to maintain flexion of the head.
Crowning is the permanent distension of the vulval ring by the fetal head like a crown on the head. The
head does not recede back in between uterine contractions.
vulval ring and the occipital prominence escapes under the symphysis pubis.
After crowning, allow slow extension of the head so the vulva is distended by the suboccipito
diameter 10 cm. If the head is allowed to extend before crowning
frontal diameter 11.5 cm increasing the incidence of perineal lacerations.
Ritgen manoeuvre:
upward pressure on the
perineum by the right
hand and downward
pressure on the occiput
by the left hand to
control the extension of
the head.
ii) Episiotomy: It is done
at crowning when the perineum is stretched to the degree that it is about to tear.
iii) Swab and aspirate: the mouth and nose
liquor, meconium or blood is inhaled.
iv) Coils of the umbilical cord: if present around the neck are slipped over the head but if tight or multiple
they are cut between 2 clamps.
(5) Delivery of the shoulders:
Gentle downward traction is applied to the
head till the anterior shoulder slips under
the symphysis pubis. The head is lifted
upwards to deliver the posterior shoulder
first then downwards to deliver the anterior
shoulder.
(6) Delivery of the remainder of the body:
Usually slips without difficulty oth
gentle traction is applied to complete
delivery.
(7) Clamping the cord:
The baby is held by its ankles with the head downwards at a lower level than its mother for few seco
This is contraindicated in:
i) Preterm babies.
ii) Erythroblastosis fetalis.
iii) Suspicion of intracranial haemorrhage.
This may be enhanced by milking the cord towards the baby, to add about 100 ml of blood to its circulation.
The cord is divided between 2 clamps to a
of the thighs, vulva and perineum are swabbed with antiseptic lotion.
plied.
ng contractions and relax in between.
he head is to prevent perineal lacerations through the following
the labia start to separate by the head, a sterile pad is placed over the
right hand during uterine contractions. This is conti
head.
nsion of the vulval ring by the fetal head like a crown on the head. The
ween uterine contractions. This means that the BPD ha
inence escapes under the symphysis pubis.
nsion of the head so the vulva is distended by the suboccipito
owed to extend before crowning the vulva will be distended by the occipito
ng the incidence of perineal lacerations.
m is stretched to the degree that it is about to tear.
and nose, once the head is delivered before respiration is initiated and the
haled.
resent around the neck are slipped over the head but if tight or multiple
plied to the
slips under
ad is lifted
or shoulder
the anterior
body:
herwise
lete
h the head downwards at a lower level than its mother for few seco
aemorrhage.
the cord towards the baby, to add about 100 ml of blood to its circulation.
mps to avoid bleeding from a possible 2nd uniovular twin.
with antiseptic lotion.
ugh the following
le pad is placed over the
s continued until crowning
e a crown on the head. The
he BPD has just passed the
by the suboccipito- frontal
be distended by the occipito-
ear.
piration is initiated and the
ad but if tight or multiple
mother for few seconds.
ml of blood to its circulation.
ular twin.

9. Third Stage of Labour:
(I) Delivery of the placenta:
i) Conservative method:
• Put the ulnar border of the left hand just above the fundus at the level of the umbilicus to detect any
bleeding inside the uterus known by rising level of the atonic uterus.
• Wait for signs of placental separation and descent but do not massage the uterus.
• As soon as they are detected massage the uterus to induce its contraction, ask the patient to bear down
and push the uterus downwards to deliver the placenta.
• Hold the placenta between the two hands and roll it to make the membranes like a rope in order not to
miss a part of it.
• Give ergometrine 0.5 mg or oxytocin 5 units IM after delivery of the placenta to help uterine
contraction and minimise blood loss. These may be given be
• Signs of placental separation and descent
1. The body of the uterus becomes smaller, harder and globular.
2. The fundal level rises as the upper segment overrides the lower uterine segment which is now
distended with the placenta.
3. Suprapubic bulge due to presence of the placenta in the lower uterine segment.
4. Elongation of the cord particularly on pressing on the uterine fundus and it does not recede back into
the vagina on relieving the pressure.
5. Gush of blood from the vagina.
ii) The active method (Brandt- Andrews method):
1. Principle:
To excite powerful uterine contractions
following birth of the anterior shoulder by
parenteral oxytocin which facilitates early
separation of the placenta and produces
effective uterine contractions following its
separation.
2. Advantages:
a. to minimize blood loss in third stage
approximately to one-fifth
b. to shorten the duration of third stage to half
3. Disadvantages:
a. increased incidence of retained placenta
b. increased incidence of manual removal of
placenta.
4. Procedures:
a. Injection ergometrine 0.25 mg or methergin 0.20 mg is given IV following the birth of anterior
shoulder. If administered prior to this, there is chance of imprisonment of the shoul
symphysis pubis.
b. This is followed by slow delivery of the baby taking at least 2
c. The placenta is expected to be delivered following delivery of the buttocks. If the placenta is not
delivered instantaneously, it should be delivered by controlled cord traction after clamping the cord
while the uterus still remains contracted .If the first attempt fails, another attempt is made after 2
3 minutes failing which another attempt is made at 10
d. If this still fails, manual removal is to be done.
5. Limitation:
a. To be effective, it should be administered at
followed by rapid delivery of the placenta.
b. It should not be used in cardiac cases or s
in cardiac cases, and aggrava
(II) Routine examinations:
(1) Examination of the placenta and membranes: by explori
complete. If any part is missing
(2) Explore the genital tract: For any lacerations that should be immediately repaired.
(III) Repair of episiotomy
eft hand just above the fundus at the level of the umbilicus to detect any
nown by rising level of the atonic uterus.
paration and descent but do not massage the uterus.
massage the uterus to induce its contraction, ask the patient to bear down
ards to deliver the placenta.
he two hands and roll it to make the membranes like a rope in order not to
xytocin 5 units IM after delivery of the placenta to help uterine
od loss. These may be given before delivery of the placenta.
and descent:
omes smaller, harder and globular.
he upper segment overrides the lower uterine segment which is now
a.
resence of the placenta in the lower uterine segment.
ticularly on pressing on the uterine fundus and it does not recede back into
pressure.
gina.
drews method):
ontractions
or shoulder by
acilitates early
nd produces
s following its
third stage
f third stage to half.
ained placenta
nual removal of
5 mg or methergin 0.20 mg is given IV following the birth of anterior
prior to this, there is chance of imprisonment of the shoul
elivery of the baby taking at least 2-3 minutes.
to be delivered following delivery of the buttocks. If the placenta is not
, it should be delivered by controlled cord traction after clamping the cord
ains contracted .If the first attempt fails, another attempt is made after 2
nother attempt is made at 10 minutes.
removal is to be done.
be administered at proper time followed by slow delivery of the baby and
y of the placenta.
ardiac cases or severe pre-eclampsia. It may precipitate cardiac overload
ravate blood pressure in severe pre-eclampsia.
and membranes: by exploring it on a plain surface to be sure that it is
ng, exploration of the uterus is done under general anaesthesia.
any lacerations that should be immediately repaired.
e umbilicus to detect any
terus.
sk the patient to bear down
es like a rope in order not to
a to help uterine
the placenta.
egment which is now
gment.
d it does not recede back into
g the birth of anterior
of the shoulder behind the
ks. If the placenta is not
ion after clamping the cord
er attempt is made after 2-
w delivery of the baby and
ecipitate cardiac overload
ace to be sure that it is
eral anaesthesia.
paired.

10. Fourth Stage of Labour:
Observation for the patient particularly atony of the uterus and vaginal bleeding.
Care of The Newborn
(1) Clearance of the air passages: The newborn is placed in supine position with the head lower down. A plastic
catheter is used to aspirate the mucus from the pharynx and mouth. Crying of the baby usually occurs
within seconds, if delayed slapping its soles, flexion and extension of the legs and rubbing the back usually
stimulate breathing.
(2) Apgar score: is calculated at 1 and 5 minutes and further steps of resuscitation are arranged according to it.
(3) The umbilical cord: A disposable plastic umbilical cord clamp is applied about 5 cm from the umbilicus to
avoid the possibility of tying an umbilical hernia then cut about 1.5 cm distal to the clamp. Inspect for
bleeding and paint it with alcohol. If the plastic umbilical clamp is not available, 2 ligatures of silk are
applied instead of it.The umbilical stump is painted daily with an antiseptic till its fall within 10 days.
(4) Congenital anomalies: The newborn is examined for injuries or congenital anomalies such as imperforate
anus, hypospadias (not to be circumscised as the cut skin will be used in the repair later on), cyanotic heart
diseases etc.
(5) Weight: Weigh the newborn and record it.
(6) Dressing: Dressing as well as all previous procedures should be done in a warm place better under radiant
warmer to prevent heat loss which occurs rapidly after delivery increasing the metabolism and acidosis.
(7) Care of the eyes: An antibiotic eye drops such as chloramphenicol are instilled into the eyes as a
prophylaxis against ophthalmia neonatorum.
(8) Identification: of the baby by a plastic bracelet on which its mother’s name is written.
PREVIOUS EXAMINATION QUESTIONS FROM THIS CHAPTER
LONG
ESSAY
1. Define full term normal delivery. Describe how you conduct normal labour.
2. Write the diagnosis of term pregnancy and management of normal labour in a primi.
3. Describe the duration and stages of labour.
SHORT
ESSAY
1. Write in brief physiology of 3rd stage of labour. How will you conduct 3rd stage? List the
complications.
2. Management of Maternal Distress.
3. What are the differences between true and false labour?
4. What is lower segment and write its obstetric importance?
5. Second stage of labour.
6. Third stage of labour and its management.
7. Signs of placental separation.
8. Changes in third stage of labour.
9. Partogram.
10. Gravidogram.
11. Brandt – Andrew’s technique.
12. Management of first stage of labour.
SHORT
ANSWERS
1. Mention the three complications of first stage of labour.
2. Active management of third stage of labour.
3. Signs of placental separations.
4. What is crowning and its clinical importance?
5. Describe moulding of fetal head and its importance
6. Differentiate false from true labour pains.
7. Conduct of third stage of labour.
8. Define active management of 3rd stage of labour.