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STAGES OF LABOR
Dr.Puneeth Kumar
[Intern] 2K15
MMCRI
Definition
• Labor
Series of events that take place in genital organs in an effort to expel the
viable products of conception out of the womb through vagina into the outer
world.
Basically it is characterised by
* Uterine Contractions.
* Cervical effacement and dilatation.
* Fetal descent.
Normal Labor
Normal labor is expulsion of healthy mature foetus presented by vertex through the vagina followed by
expulsion of placenta & membranes where the whole process is spontaneous,uncomplicated without
delay minimal aid like episiotomy included .
It is also called EUTOCIA
Abnormal labor is DYSTOCIA which doesnot fulfill the above criteria.
Stage 1st stage 2nd stage 3rd stage 4th stage
Definition From True Labor Pain to Full
dilatation of Cervix.
PHASES
From Full
dilatation of
Cervix to
Delivery of
BABY
From Delivery of foetus to
Delivery of Placenta &
Membranes.
2 hour of
observation after
placenta delivery
LATENT
(Cx:3-5cm)
ACTIVE
(Cx:>6cm)
Normal
Duration
PRIMI
MULTI
10-12hr
6-8hr
1.2cm/hr
1.5cm/hr
01hr
30min
PASSIVE
15-30min
ACTIVE
5-10min
2hr
1st Stage
Diagnosis
1. SYMPTOMS
CHARACTERISTICS TRUE LABOR PAIN FALSE LABOR PAIN
CONTRACTIONS
• Rhythm
• Intervals
• Intensity
Regular
Gradually Shorten
Gradually Increase
Irregular
Unchanged
Unchanged
DISCOMFORT
• Location
• Sedation/Rest/Enema
Back & Abdomen
No effect
Lower abdomen
Usually relieved
CERVICAL CHANGES Present Absent
A.
B. SHOW-Blood Stained Mucous:Bleed PV
C. Spontaneous Rupture of Membranes:Leak PV
2. SIGNS
A. Palpable Uterine Contractions
B. Cervical dilatation and effacement
C. Formation of forewater-Bag of Waters
Management
• History and clinical examination
Risks present No risk,Normal labor expected
• POSITION: Any non-supine position and movement throughout latent phase
Supine with knees flexed in active phase and delivery.
• ORAL INTAKE: ACOG recommends only sips of clear liquids.
• RECTUM: Routine enema has no beneficiary evidence.
• BLADDER: Encourage patient to empty her bladder regularly.
Use urinary catheter only woman is unable to void.
• PAIN: Psychoprophylaxis
Sedatives & Analgesics
Inhalational agents
Transcutaneous Electric Nerve Stimulation
Regional Anaesthesia
General Anaesthesia
• PARTOGRAPH
1. FHR Monitoring
Not in labor In labor
4th hourly
* Normal FHR: 110-160 bpm
1st stage 2nd stage
Low Risk 30 min 15 min
High Risk 15 min 05 min
2. CERVICAL DILATATION
& FETAL DESCENT
A. FRIEDMAN CURVE
B. Philpott and Castle gave the concept of ALERT & ACTION
LINE.
C. MODIFIED WHO PARTOGRAPH
• Latent phase is absent
• Active phase from 4cm
• Time b/w Alert & Action line- 4hr
• Slope of Alert line=Slope of Action line=MINIMAL
DILATION OF ACTIVE PHASE= 1cm/hr
• NORMAL LABOR=Cervicograph is on the Alert line or
left to it.
FRIEDMAN CURVE
3. UTERINE TOCOGRAPHY
• Adequate Uterine contractions
1. Frequency- 3 contractions/10min 200-220 Montevideo units
2. Intensity of 65-75mm Hg
3. Duration- 45 sec.
• * Tachysystole is >5contractions/10min
4. MATERNAL VITALS
1. Pulse - Every 30 min
2. BP – 4th hourly
If PIH – hourly monitoring
3. Temperature – 4th hourly
5. DRUGS & IV FLUIDS
• Oxytocin – concentration of U/litre of RL administered
rate as drops/min are recorded
• Any other drugs and IV fluids are recorded in partograph
ABNORMALITIES OF 1ST STAGE & THEIR ACTIVE MANAGEMENT
1. PROLONGED LATET PHASE
CAUSES & MANAGEMENT
A. Poor Cervical Conditions
Uneffaced and Undilated Cervix – Unripen Cervix
Treatment- PGE2 Dinoprostone gel induction of labor
B. False Labor
Management- Rest
C. Excessive sedation or Epidural Analgesia
Latent Phase Normal Prolonged
Primi 12 hr >20 hr
Multi 8 hr >14 hr
2. PROTRACTED ACTIVE PHASE
NORMAL ACTIVE PHASE
Dilatation Descent of Fetal head
Primi: 1.2 cm/hr 1cm/hr
Multi: 1.5 cm/hr 2cm/hr
WHO MINMAL RATE FOR BOTH: 1cm/hr
Rate of Cervical dilatation or Rate of Fetal descent < 1cm/hr is
Protracted Active Phase.
Management
1. Rule out Cephalopelvic disproportion
Pelvis Adequate CPD Present
Wait & Watch LSCS
2. Rule out Occipitoposterior Position
If present- Wait & Watch
3. Occipito Anterior positon
Management- Augment labor
A. ARM
B. Oxytocin Infusion
3. ACTIVE PHASE ARREST
Cervix is ≥ 6 cm + Membranes ruptured
Contractions present Oxytocin given for not having contractions
No dilatation for 4 hr still no dilatation for 6 hr
Management: LSCS
2nd STAGE
Begins from full dilatation of cervix to delivery of foetus
MANAGEMENT
Onset of 2nd stage is characterised by
Full dilatation of cervix
Ruptured Membranes
Involuntary bearing down efforts
Obstetrician role
Encourage mother to bear down only during contractions.
Prevent & Manage tears.
Maintain asepsis.
Position
Dorsal lithotomy with half flexed legs
FHR Monitoring
Slowing down of FHR may occur due to head compression
Delivery of Head
To prevent tears
• Ritgen’s maneuver
• Restricted Episiotomy
Ritgen maneuver
Delivery of shoulders
is followed by delivery
of trunk
ABNORMALITIES & THEIR MANAGEMENT
2ND STAGE
NORMAL PROLONGED ARREST=OBSTRUCTED LABOR
WITHOUT EPIDURAL WITH EPIDURAL WITHOUT EPIDURAL WITH EPIDURAL
PRIMI 1 hr 2 hr 3 hr 3 hr 4 hr
MULTI 30 min 1 hr 2 hr 2 hr 3 hr
MANAGEMENT Station
≥+2= Forceps or Vacuum assisted
delivery
<+2= LSCS
LSCS at the earliest
Never WAIT & WATCH
Never give Oxytocin.
3RD STAGE
From Delivery of foetus to Delivery of Placenta & Membranes.
MANAGEMENT
Signs of separation of Placenta
1. Uterus becomes globular,firm and ballottable.
2. Fundal height is reduced
3. Slight bulging of Suprapubic region
4. Gush of Vaginal bleeding
5. Permanent lengthening of cord
EXPECTANT MANAGEMENT
Wait & Watch for spontaneous expulsion of Placenta with the aid of uterine
contractions & gravity
Duration: 15-25 min
ACTIVE MANAGEMENT OF THIRD STAGE OF LABOR
1. Inj.Oxytocin 10 units IM to the
mother within 1 minute of delivery
2. Controlled Cord Traction using
Modified Brandt-Andrews method
3. Uterus is massaged to make it hard
and pressure given to push back &
down
4. Examination of Placenta, Membranes & Cord so that it is completely expelled and
no abnormalities seen.
Duration:- 5-10 min
ABNORMALITIES
1. RETAINED PLACENTA
Expulsion of Placenta ≥30 min
Management
1. Inj.Oxytocin 5/10 units slowly IV/IM
2. Manual removal of placenta
3. Rule out abnormal adherence of placenta to uterus.
Placenta increta,accreta,percreta.
2.PPH
3.UTERINE INVERSION
4th STAGE
Post labor 1 hour monitoring of maternal vitals
Physiological Thrills & Shivering are usually seen in the mother.
ನಿಂದಕರಿರಬ ೇಕು ಇರಬ ೇಕು ನಿಂದಕರಿರಬ ೇಕು
ಹಿಂದಿ ಇದದರ ಕ ೇರಿ ಹ್ಯಿಂಗ ಶುದಿಿಯೊ ಹ್ಿಂಗ
ಅಿಂದಿಂದು ಮ್ಡಿದ ಪ್ಪದ ಮ್ಮಲ
ತಿಂದು ಹ ೇಗುವರಯ್ಯ ನಿಂದಕರು
ವಿಂದಿಸಿ ಸ್ುುತಸ್ುವ ಜನರ ಲಲರ ನಮಮ
ಹ ಿಂದಿದ ಪುಣ್ಯವನ ಯ್ುಯವರಯ್್ಯ
-ಪುರಿಂದರದ್ಸ್ರು.
Thank You.

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STAGES OF LABOR

  • 1. STAGES OF LABOR Dr.Puneeth Kumar [Intern] 2K15 MMCRI
  • 2. Definition • Labor Series of events that take place in genital organs in an effort to expel the viable products of conception out of the womb through vagina into the outer world. Basically it is characterised by * Uterine Contractions. * Cervical effacement and dilatation. * Fetal descent.
  • 3. Normal Labor Normal labor is expulsion of healthy mature foetus presented by vertex through the vagina followed by expulsion of placenta & membranes where the whole process is spontaneous,uncomplicated without delay minimal aid like episiotomy included . It is also called EUTOCIA Abnormal labor is DYSTOCIA which doesnot fulfill the above criteria.
  • 4. Stage 1st stage 2nd stage 3rd stage 4th stage Definition From True Labor Pain to Full dilatation of Cervix. PHASES From Full dilatation of Cervix to Delivery of BABY From Delivery of foetus to Delivery of Placenta & Membranes. 2 hour of observation after placenta delivery LATENT (Cx:3-5cm) ACTIVE (Cx:>6cm) Normal Duration PRIMI MULTI 10-12hr 6-8hr 1.2cm/hr 1.5cm/hr 01hr 30min PASSIVE 15-30min ACTIVE 5-10min 2hr
  • 5. 1st Stage Diagnosis 1. SYMPTOMS CHARACTERISTICS TRUE LABOR PAIN FALSE LABOR PAIN CONTRACTIONS • Rhythm • Intervals • Intensity Regular Gradually Shorten Gradually Increase Irregular Unchanged Unchanged DISCOMFORT • Location • Sedation/Rest/Enema Back & Abdomen No effect Lower abdomen Usually relieved CERVICAL CHANGES Present Absent A.
  • 6. B. SHOW-Blood Stained Mucous:Bleed PV C. Spontaneous Rupture of Membranes:Leak PV 2. SIGNS A. Palpable Uterine Contractions B. Cervical dilatation and effacement C. Formation of forewater-Bag of Waters Management • History and clinical examination Risks present No risk,Normal labor expected • POSITION: Any non-supine position and movement throughout latent phase Supine with knees flexed in active phase and delivery. • ORAL INTAKE: ACOG recommends only sips of clear liquids. • RECTUM: Routine enema has no beneficiary evidence.
  • 7. • BLADDER: Encourage patient to empty her bladder regularly. Use urinary catheter only woman is unable to void. • PAIN: Psychoprophylaxis Sedatives & Analgesics Inhalational agents Transcutaneous Electric Nerve Stimulation Regional Anaesthesia General Anaesthesia • PARTOGRAPH 1. FHR Monitoring Not in labor In labor 4th hourly * Normal FHR: 110-160 bpm 1st stage 2nd stage Low Risk 30 min 15 min High Risk 15 min 05 min
  • 8. 2. CERVICAL DILATATION & FETAL DESCENT A. FRIEDMAN CURVE B. Philpott and Castle gave the concept of ALERT & ACTION LINE. C. MODIFIED WHO PARTOGRAPH • Latent phase is absent • Active phase from 4cm • Time b/w Alert & Action line- 4hr • Slope of Alert line=Slope of Action line=MINIMAL DILATION OF ACTIVE PHASE= 1cm/hr • NORMAL LABOR=Cervicograph is on the Alert line or left to it. FRIEDMAN CURVE
  • 9. 3. UTERINE TOCOGRAPHY • Adequate Uterine contractions 1. Frequency- 3 contractions/10min 200-220 Montevideo units 2. Intensity of 65-75mm Hg 3. Duration- 45 sec. • * Tachysystole is >5contractions/10min 4. MATERNAL VITALS 1. Pulse - Every 30 min 2. BP – 4th hourly If PIH – hourly monitoring 3. Temperature – 4th hourly 5. DRUGS & IV FLUIDS • Oxytocin – concentration of U/litre of RL administered rate as drops/min are recorded • Any other drugs and IV fluids are recorded in partograph
  • 10. ABNORMALITIES OF 1ST STAGE & THEIR ACTIVE MANAGEMENT 1. PROLONGED LATET PHASE CAUSES & MANAGEMENT A. Poor Cervical Conditions Uneffaced and Undilated Cervix – Unripen Cervix Treatment- PGE2 Dinoprostone gel induction of labor B. False Labor Management- Rest C. Excessive sedation or Epidural Analgesia Latent Phase Normal Prolonged Primi 12 hr >20 hr Multi 8 hr >14 hr
  • 11. 2. PROTRACTED ACTIVE PHASE NORMAL ACTIVE PHASE Dilatation Descent of Fetal head Primi: 1.2 cm/hr 1cm/hr Multi: 1.5 cm/hr 2cm/hr WHO MINMAL RATE FOR BOTH: 1cm/hr Rate of Cervical dilatation or Rate of Fetal descent < 1cm/hr is Protracted Active Phase. Management 1. Rule out Cephalopelvic disproportion Pelvis Adequate CPD Present Wait & Watch LSCS 2. Rule out Occipitoposterior Position If present- Wait & Watch
  • 12. 3. Occipito Anterior positon Management- Augment labor A. ARM B. Oxytocin Infusion 3. ACTIVE PHASE ARREST Cervix is ≥ 6 cm + Membranes ruptured Contractions present Oxytocin given for not having contractions No dilatation for 4 hr still no dilatation for 6 hr Management: LSCS
  • 13. 2nd STAGE Begins from full dilatation of cervix to delivery of foetus MANAGEMENT Onset of 2nd stage is characterised by Full dilatation of cervix Ruptured Membranes Involuntary bearing down efforts Obstetrician role Encourage mother to bear down only during contractions. Prevent & Manage tears. Maintain asepsis. Position Dorsal lithotomy with half flexed legs FHR Monitoring Slowing down of FHR may occur due to head compression
  • 14. Delivery of Head To prevent tears • Ritgen’s maneuver • Restricted Episiotomy Ritgen maneuver Delivery of shoulders is followed by delivery of trunk
  • 15. ABNORMALITIES & THEIR MANAGEMENT 2ND STAGE NORMAL PROLONGED ARREST=OBSTRUCTED LABOR WITHOUT EPIDURAL WITH EPIDURAL WITHOUT EPIDURAL WITH EPIDURAL PRIMI 1 hr 2 hr 3 hr 3 hr 4 hr MULTI 30 min 1 hr 2 hr 2 hr 3 hr MANAGEMENT Station ≥+2= Forceps or Vacuum assisted delivery <+2= LSCS LSCS at the earliest Never WAIT & WATCH Never give Oxytocin.
  • 16. 3RD STAGE From Delivery of foetus to Delivery of Placenta & Membranes. MANAGEMENT Signs of separation of Placenta 1. Uterus becomes globular,firm and ballottable. 2. Fundal height is reduced 3. Slight bulging of Suprapubic region 4. Gush of Vaginal bleeding 5. Permanent lengthening of cord EXPECTANT MANAGEMENT Wait & Watch for spontaneous expulsion of Placenta with the aid of uterine contractions & gravity Duration: 15-25 min
  • 17. ACTIVE MANAGEMENT OF THIRD STAGE OF LABOR 1. Inj.Oxytocin 10 units IM to the mother within 1 minute of delivery 2. Controlled Cord Traction using Modified Brandt-Andrews method 3. Uterus is massaged to make it hard and pressure given to push back & down 4. Examination of Placenta, Membranes & Cord so that it is completely expelled and no abnormalities seen. Duration:- 5-10 min
  • 18. ABNORMALITIES 1. RETAINED PLACENTA Expulsion of Placenta ≥30 min Management 1. Inj.Oxytocin 5/10 units slowly IV/IM 2. Manual removal of placenta 3. Rule out abnormal adherence of placenta to uterus. Placenta increta,accreta,percreta. 2.PPH 3.UTERINE INVERSION
  • 19. 4th STAGE Post labor 1 hour monitoring of maternal vitals Physiological Thrills & Shivering are usually seen in the mother.
  • 20. ನಿಂದಕರಿರಬ ೇಕು ಇರಬ ೇಕು ನಿಂದಕರಿರಬ ೇಕು ಹಿಂದಿ ಇದದರ ಕ ೇರಿ ಹ್ಯಿಂಗ ಶುದಿಿಯೊ ಹ್ಿಂಗ ಅಿಂದಿಂದು ಮ್ಡಿದ ಪ್ಪದ ಮ್ಮಲ ತಿಂದು ಹ ೇಗುವರಯ್ಯ ನಿಂದಕರು ವಿಂದಿಸಿ ಸ್ುುತಸ್ುವ ಜನರ ಲಲರ ನಮಮ ಹ ಿಂದಿದ ಪುಣ್ಯವನ ಯ್ುಯವರಯ್್ಯ -ಪುರಿಂದರದ್ಸ್ರು. Thank You.