CONDUCT AND MONITORING

OF LABOUR
135-140
NORMAL LABOR
DEFINITION:
The process by which the fetus gets expelled from the genita tract after the period
of viability.
Labor can be called normal if:
1. It is spontaneous in onset
2. Term gestation
3. Vertex presentation
4. Uncomplicated
5. Vaginal delivery
6. Natural expulsive forces
NORMAL LABOR
The normal progress of labor depends upon :

1. Passage
2. Passenger
3. Powers
PASSAGE
1. BONY PASSAGE
A. Inlet
B. midpelvis
C. outlet
2. SOFT TISSUES
A. Lower uterine segment
B. cervix
C. vagina
D. pelvic muscles
PASSENGER
1. Average fetal weight
2. Longitudinal lie
3. Vertex presentation
4. LOA or Occipitotransverse position
5. Well flexed attitude
POWERS
UTERINE CONTRACTIONS:
They are the most important force which helps in the progress of labor.
They are intermittent, this helps in the uteroplacental reperfusion.
As labor progresses, intensity increases, interval between the contraction reduces.
Normal: 3-5 contractions in ten minutes.
Uterine contractions are measured in Montevideo units.
Uterine contractions increases the hydrostatic pressure of the amniotic fluid and
Physiology of labour
 Features and mediators of phase 2 of labor
Features : Mediators
● Changes in myometrium
1. Increase in contactility
● Estrogen
2. Increase in uterine responsiveness ● Progesterone
3. Increase in gap junctions ● CAPs
● Changes in cervix Cervical
● Glycosaminoglycans
ripening caused due to changes in
collagen structure , increase in ● Proteoglycans
collagen solubility and infiltration ● pCRH
● Prostaglandins
● Cortisol
● Interleukin-8
● MMP
ROLE OF HORMONES
Events happening before onset of labor
● Lightening / welcome sign Adequate uterine contractions

● 3 contractions in 10 min (frequency)

(at 36 weeks height of uterus
● each contraction lasts for 45 seconds
comes below xiphisternum ) ● pressure of 65 to 75 mm Hg
● Cervical ripening 1st stage of labor
● False labor pains
Uterine contractions are regular, painful
● Retraction - uterine muscle fibre
and progressive increase in
on relaxation becomes shorter
than original length 1. intensity
2. duration
It leads to cervical ripening. 3. frequency
 STAGES OF LABOR
First stage of labor :-

Begins with onset of true labor pain and ends with full cervical dilatation.

● Show /mucosanguineous discharge

● Uterine contractions
● Cervical changes

-dilatation

-effacement

● Formation of LUS
● Descent of presenting part
● Formation of bag of membranes
● Rupture of bag of membranes
 FIRST STAGE OF LABOR
ACTIVE PHASE
LATENT PHASE
Ends by full dilatation of cervix . It has 3 phases
-UPTO 4CM (PARTOGRAM)

NORMAL DURATION : - acceleration phase

- phase of maximum slope
● NULLIPAROUS < 20h - deceleration phase
● MULTIPAROUS <18h
Rate of dilatation : 1.2cm/hr (nulli) ; 1.5cm/hr (multi)
PROLONGED DUE TO:

- fetal malposition
- unfavourable cervix
- deflexion
- inadequate pelvic contractions
- large baby
 SECOND STAGE OF LABOR
BEGINS ->FULL DILATION OF CERVIX

ENDS-> DELIVERY OF FETUS

MAIN EVENTS :-

1. Pelvic phase/ phase of descent

- maternal bearing down efforts
- uterine contractions
2. Perineal phase /phase of expulsion
- cardinal movements of labor
- crowning
- expulsion of fetus
- duration is 30 mins(multi) , 1 hr in nulliparous
 THIRD STAGE OF LABOR
● BEGINS AFTER DELIVERY OF BABY, ENDS WITH DELIVERY OF PLACENTA
● HUMAN PLACENTA IS DECIDUATE
● SIGNS OF PLACENTAL SEPERATION
-gush of blood per vaginally
-suprapubic bulge
-lengthening of cord
- height of uterus increases slightly
● Placental seperation methods
-schlutz
- duncan
 FOURTH STAGE OF LABOR

● 1 to 2 hr period after delivery of placenta (arrest of bleeding)

● Uterine contraction and retraction
● Occlusion of arterioles by myometrium - living ligatures
● Formation of clots and thrombosis of vessels

MONITOR - uterine tone, pulse, BP every 15mins

-void within 4hrs after delivery
- temperature every 4th hourly
- start oral intake by 2hrs in NVD

WATCH FOR COMPLICATIONS

MANAGEMENT OF LABOR
GENERAL MANAGEMENT:

● Laboring women must be provided with support and encouragement

from husband,family, and other trained person
● Cleanliness and sterile precautions have to be maintained in the labor
room
● On admission, woman has to assume a position comfortable to her
● Walking is encouraged in uncomplicated cases
● Distended bladder interferes with descent and after delivery. It can
cause atonicity
● In early labor oral fluids given. Adequate hydration has to be
maintained
MANAGEMENT OF FIRST STAGE
1. MATERNAL MONITORING:
● Temperature - every 2 hrs
● Pulse - evey 30 mins
● BP - every 4 hrs and in G.HTN every hour
● Urine - checked for acetone protein and volume

2. UTERINE CONTRACTIONS:
● Monitored by placing palm of hand on the abdomen
● Duration and interval between contractions frequency and intensity
are noted
.
3. MONITERING FETAL HEART RATE:
● Low risk women - FHR monitored every 30 mins and after every
contraction
● High risk woman - FHR monitored every 15 mins
4. PAIN CONTROL IN LABOR:
● Systemic opioids - pethidine, tramadol, fentanyl ( meperidine 50 mg
IM)
● Inhalational agents - Entonox ( 50% o2 and 50& nitrous oxide)
● Epidural anesthesia
5. AMNIOTOMY:
● Artificial rupture of membranes
● Promotes labor by inducing release of PG and stretching cervix by fetal
head
PARTOGRAPH
Composite graphical record of maternal and fetal data during labor, plotted against
time

Modified WHO Partograph

PARTOGRAPH
The components of a partograph are

a. Patient identification
b. Time- recorded at hourly interval
c. Fetal heart rate
d. State of membranes and colour of liquor { I- intact membrane ;C- clear M-
meconium stained liquor, B- blood stained}
e. Cervical dilatation and descent of head
f. Uterine contractions
g. Drugs and fluids
h. BP, Urine analysis, Temperature
i. Oxytocin[mIU/L]
COMPLICATIONS OF FIRST STAGE:
MANAGEMENT OF SECOND STAGE
 MANAGEMENT OF
THIRD STAGE OF LABOUR
STEPS OF MANAGEMENT:
There are 2 methods of management
● Expectant management:
The placental separation and its descent into the vagina is allowed to occur
spontaneously.

● Active management:
Done to excite powerful uterine contractions within 1 minute of delivery of the
baby (WHO) by giving parenteral oxytocin.
EXPECTANT MANAGEMENT:
● After the delivery of the baby, delayed cord clamping (90-120 sec) and
ligation is done.
● Wait for spontaneous separation of placenta.
● Once separated, wait for spontaneous expulsion within 20 minutes with
the aid of gravity or bearing down effort.
● If there is failure of expulsion, assisted expulsion is done.
● Assisted expulsion includes controlled cord traction and fundal
pressure.
EXPECTANT MANAGEMENT:

● Fundal pressure: ● Modified Brandt-Andrews maneuver:

The fundus is pushed downward and Placenta is delivered by controlled cord

backward after placing four fingers behind traction wherein the uterus is pushed upward
the fundus and the thumb in front using the with the left hand and gentle, steady traction
uterus as a sort of piston. is applied with the right hand.
COMPONENTS OF ACTIVE MANAGEMENT:
● Administration of uterotonic agent:
Oxytocin 10 units IM is administered with the anterior shoulder or within 1
minute of delivery of the baby.
● Delivery of placenta by controlled cord traction:
Controlled cord traction following oxytocin administration prevents postpartum
hemorrhage.
● Assessment of uterine tone and size:
The uterus is assessed intermittently to see if it is well contracted by placing the
left hand on the fundus, abdominally.
EXAMINATION OF PLACENTAL MEMBRANES & CORD:

● Weight: One-sixth the baby's weight (500-600

g)
● Cord length: 50-60 cm
● Vessels in the cord: Two arteries, one vein
● Look for

- Missing cotyledons

- Completeness of membranes

- Other abnormalities
 COMPLICATIONS OF
THIRD STAGE OF LABOUR
COMPLICATIONS OF THIRD STAGE OF LABOUR
● Postpartum hemorrhage:
- Primary (within 24 hours) - 4 Ts
- Tonicity: Uterine Atony
- Trauma to reproductive tract
- Tissue: Retained placenta
- Thrombin: DIC
- Secondary (after 24 hours and before 12 weeks)
● Adherent placenta - Accreta, Percreta, Increta
● Uterine inversion
POSTPARTUM HEMORRHAGE:
● PPH is defined as bleeding that occurs after the birth process and
results in blood loss of >500 ml following a vaginal delivery and
of >1000 ml following a cesarean section.
● Most common cause: Uterine Atony (80%)
● Clinical features:
- Profuse bleeding
- Uterus flabby, filled with blood
- Fundus palpable above the umbilicus
- Signs and symptoms of blood loss, shock
MANAGEMENT OF
ATONIC PPH
OTHER COMPLICATIONS OF THIRD STAGE:

● Retained placenta:

The placenta is said to be retained, when it is not expelled out even after 30 minutes of the
birth of the baby.
● Causes:

-Placenta completely separated but is retained due to poor voluntary expulsive efforts.

-Simple adherent placenta is due to uterine atonicity in cases of grand multipara,

overdistension of uterus, prolonged labor and uterine malformation or due to bigger placental
surface area.
-Morbidly adherent placenta—partial or rarely, complete.

-Placenta incarcerated
● The commonest cause of retention of non-separated placenta is atonic uterus.
OTHER COMPLICATIONS OF THIRD STAGE OF
LABOUR:
● ADHERENT PLACENTA:

It is an abnormality of placental implantation wherein part or all of the placenta is

attached to or infiltrates the myometrium.
OTHER COMPLICATIONS OF THIRD STAGE OF
LABOUR:
● UTERINE INVERSION:

Uterine inversion is the prolapse of the uterine fundus into the uterine cavity.