This document defines labor and its stages, describes the characteristics of normal labor versus false labor pains, and outlines the mechanism and clinical course of labor. It provides details on the three stages of labor, criteria for normal labor, and management of each stage. This includes monitoring the progression of labor, administering pain relief, conducting vaginal exams, and techniques for delivering the baby including managing the head, shoulders, and trunk.

2. Definition
 Series of events that take place in the
genital organs in an effort to expel the
viable products of conception (fetus,
placenta and membranes) out of the
womb through the vagina into the outer
world

3. Criteria of normal labor
 Spontaneous in onset and at term
 With vertex presentation
 Without undue prolongation
 Natural termination with minimal aids
 Without having any complications
affecting the health of the mother or the
baby

4. True labor pain
 Uterine contractions at regular intervals
 Frequency of contractions increase gradually
 Intensity and duration of contractions increase
progressively
 Associated with “show”(expulsion of cervical
mucus mixed with blood)
 Progressive effacement and dilatation of cervix
 Descent of the presenting part
 Formation of “bag of forewaters”
 Not relieved by enema or sedatives

5. False labor pain
 Dull in nature
 Confined to lower abdomen and groin
 Not associated with hardening of uterus
 No other features of true labor pain
 Relieved by sedatives or enema

6. Stages of labor
 First stage: from onset of true labor pain to full
dilatation of cervix(10 cm)
12 hrs:primi 6hrs:multi
 Second stage: full dilatation to the expulsion of
fetus from the birth canal
1. propulsive phase: full dilatation of cervix to
descent of presenting part to the pelvic floor
2. expulsive phase: maternal bearing down
efforts to delivery of baby
2 hrs:primi 30 mins: multi

7.  Third stage: expulsion of fetus to expulsion
of placenta and membranes
15 mins in both primi and multi
5 mins in active management
 Fourth stage: stage of observation for at
least 1 hour after expulsion of placenta

8. Mechanism of normal labor
 DEFINITION:
The series of movements
that occur on the fetal head in the
process of adaptation during its journey
through the pelvis

9. Mechanism of normal labor
 Engagement-
The mechanism by which the biparietal
diameter—the greatest transverse diameter in an
occiput presentation—passes through the pelvic inlet
is designated engagement
 Descent-A continuous process in absence of
obstruction.
 Flexion- flexion is achieved either due to the
resistance offered by the unfolding cervix, the walls
of the pelvis or by the pelvic floor

10.  Internal rotation-
This movement consists of a turning
of the head in such a manner that the occiput
gradually moves toward the symphysis pubis
anteriorly from its original position
 Crowning-
the maximum diameter of the head
(biparietal diameter) stretches the vulval outlet
without any recession of the head even after the
contraction is over— called “crowning of the head”.
 Delivery of head by extension

11.  Restitution- It is the visible passive
movement of the head due to untwisting of
the neck sustained during internal rotation
 External rotation - It is the movement of
rotation of the head visible externally due
to internal rotation of the shoulders
 Delivery of shoulder and trunk by lateral
flexion

13. Clinical course of labor
1st stage
 Pain with simultaneous contraction of uterus
Initially, interval: 15-30 mins
duration: 30 secs
late stage, interval: 3-5mins
duration: 45 secs
 Dilatation and effacement of cervix
 General maternal condition:
pulse- increased by 10-15 bpm
SBP- raised by 10 mmHg
 Fetal effect : increase in heart rate of the fetus by 10-
20 bpm.

14. 2nd stage
 Pain : increase in intensity
Interval : 2-3 min
Duration : 1-1.5 mins
 Bearing down efforts : additional voluntary expulsive
efforts that appear during the 2nd stage of labour
(expulsive phase) , which is initiated by Ferguson
Reflex (a reflex contraction of uterus caused by
stretching of vagina by the presenting part)
 Membrane status :
Spontaneous rupture with a gush of liquor per
vaginum

15. Descent of fetus:
assessed per abdomen using fifth
formula(Crichton)

16.  Vaginal signs:
-scalp hair are visible through slit like
vagina
-perineum is distended with overlying
tense and glistening skin.
-crowning

17.  Maternal signs :
-features of exhaustion
-respiration slowed down
- increased perspiration
-face become congested
 Fetal effects : slowing of FHR during contractions

18. 3rd stage :
 Pain: intermittent discomfort in lower abdomen after a short
period of relief
 P/A examination:
Before separation of placenta :
 Uterus: discoid , firm and non ballotable
 Fundal height : slightly below the umbilicus
After separation :
 Uterus : globular, firm , ballotable
 Fundal height : slightly raised as the separated placenta comes
down in the lower segment and contracted uterus rests on top of
it
 Slight bulging in the suprapubic region.

19.  Per vaginal examination
Before separation :
 Slight trickling of blood
 Length of umbilical cord remain static
After separation :
 Slight gush of vaginal bleeding
 Permanent lengthening of cord
 Expulsion of placenta or membranes
 Maternal signs : chills and occasional shivering

20. Management of normal
labor
 Preliminaries :
 Toileting : hand wash with soap and water for at
least 3 min.
 Sterile pair of gloves should be worn
 Vulval toileting : forward to backwards with 10%
dettol
 Smear gloved index and middle fingers of the right
hand with antiseptic cream and introduce into
vagina

21. Following information to be noted and recorded
carefully :
 Degree of cervical dilatation in cm
 Degree of effacement
 Status of membrane if rupture- colour of liquor
 Presenting part and its position
 Caput or moulding of head
 Station of head
 Assessment of pelvis

23. Management of first stage of labor
 General :
I. Antiseptic dressing
II. Encouragement , emotional support and assurance
III. Constant supervision
 Rest and ambulation
 Diet : Food is withheld during active labour ; plain
water , ice chips or fruit juice may be given
 Bladder care : encourage to pass urine
 Relief of pain : Pethidine 50-100mg im +
metoclopramide 10 mg im

24. Assessment of progression of labor and
partograph recording :
 Pulse : every 30min
 Bp : every 1 hr
 Temperature : every 2 hr
 Urine output : for volume, protein or
acetone
 Any drug : Oxytocin or other

25.  Abdominal palpation :
 Uterine contractions : frequency, intensity and duration
 No. of contractions in 10 min and duration of each
contraction in sec
 Pelvic grip: for descent of head in fifths
 Note fetal well being :
FHR with its rhythm and intensity (n : 110-160 bpm)
every ½ hr : 1st stage
every 15 min : 2nd stage

26.  Vaginal examination :
 Dilatation of cervix in cm
 Position of head
 Degree of flexion
 Station of head
 Color of liquor
 Degree of moulding of head
 Caput formation

27. Management of 2nd stage of labour :
 General:
 complete bed rest
 constant supervision
 FHR is recorded every 5 min
 Per vaginal: to detect accidental cord
prolapse

28.  Preparation for delivery :
 Position : dorsal position with 15 degree left
lateral tilt
 Scrub , put on sterile gown , mask and gloves
 Stand on rt. Side of the patient
 Toilet the external genitalia and inner side of
thigh
 Catheterize the patient if it is full

29. Conduction of delivery :
 Delivery of head :
 Encourage the pt for bearing down efforts
during uterine contractions
 When scalp visible for about 5 cm in diameter
maintain the flexion during contractions
 Push the occiput downwards and backwards
using thumb and index finger of the left hand ;
at the same time press the perineum by the
right palm with the sterile vulval pad

30.  Repeat the process until subocciput is
placed under the symphysis pubis
 Now slow delivery of head is conducted a/c
to Ritzen manoeuvre:
 Push the chin with a sterile towel covered
fingers of the rt hand placed over
anococcygeal region
 Exert the pressure on the occiput by left
hand

31.  Delivery of shoulder :
 Wait for movements of restitution and external
rotation of head
 Anterior shoulder is born behind the pubic
symphysis
 If delay grasp the head by both hands
 Gently draw posteriorly until the anterior
shoulder is released from under the pubis
 Draw the head upwards
 Deliver the posterior shoulder out of perineum

32.  Delivery of trunk :
 Place the forefingers of each hand
under the axillae
 Deliver trunk gently by lateral flexion

33. Management of third stage :

34. REFERENCES
1. D C Dutta’s Textbook of obstetrics,7th
edition
2. Williams obstetrics, 24th edition

35. THANK YOU