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 oxytocins 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 pregnancy1. 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:

False labour pains are differentiated from true labour pain as follows:
True Labour Pain
Regular
Increase progressively in frequency, duration and
intensity
Pain is felt in the abdomen and radiating to the
back
Progressive dilatation and effacement of the
cervix

False Labour Pain

Irregular
do not
is felt mainly in the lower abdomen and groin
No effect on the cervix

Associated with show

Not associated with show

Formation of bag of waters

No formation of bag of waters

Can be relieved by antispasmodics and
sedatives

Not relieved by antispasmodics or 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 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:

1. Dilatation and effacement of the cervix

vix
Causes of cervical dilatation:
1. Contraction and retraction of uterine musculature.
2. Mechanical pressure by the forebag
orebag of waters, if membranes still intact, or the presenting part, if they
have ruptured. This in turn will
ill release more prostaglandins which stimulate
ate uterine contractions and
cervical effacement.
3. Softness of the cervix which has occurred during pregnancy facilitates dilatation
ation and effacement of the
cervix.
Mechanism of cervical dilatation:
In primigravidae, the cervical canal
anal dilates from above downwards i.e.,
i.e. from the
he internal os downwards to
the external os. So its length shortens
hortens gradually from more than 2 cm to a thin rim of few millimetres
continuous with the lower uterine
ne segment. This process is called effacement and expressed in percentage
so when we say effacement is 70
0% it means that 70% of the cervical canal has been taken up.
2. Full formation of lower uterine segment
ment

Before the onset of labour, there is no complete

comp
anatomical or functional division off the uterus. During labour,
the demarcation of an active upper segment
s
and a relatively passive lower segment
nt is more pronounced. The
wall of the upper segment becomes progressively thickened with progressive thinning
nning of the lower segment.
segment
This is pronounced in late first stage,, especially after rupture of the memb
membranes and
d attains its maximum in
second stage.
A distinct ridge is produced at the junction
nction of the two, called physiological retraction
n ring, which should not be
confused with pathological retraction
n ring (a feature of obstructed labour).
la
The lower
er segment
segm
is limited
superiorly by physiological retraction
n ring, and inferiorly by the fibromuscular junction
tion of cervix and uterus.

 Clinical Significance
1. The phenomenon of receptive relaxation
xation enables expulsion of the fetus by formation
ion of complete birth canal
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
rough this segment
4. Because of poor retractile property,
y, there is chance of PPH if placenta
placen is implanted
ed over the area
5. Poor decidual reaction facilitates morbid adherent placenta
6. In obstructed labour, the lower segment
gment is very much stretched and thinned out and is likely to give way,
especially in multiparae.
n, the head is applied well to the lower uterine
erine segment dividing the
In normal presentation and position,
amniotic sac by the girdle of contact into a hindwaters above it containing the fetus
us and a forewaters below it.
This reduces the pressure in the forewaters
ewaters preventing early rupture of membranes.
s. After full dilatation of the
cervix the hind and forewaters become
me one sac with increased pressure in the bag
g of forewaters leading to its
rupture.
EVENTS
NTS IN SECOND STAGE OF LABOUR
The second stage begins with the complete
mplete dil
dilatation of the cervix and ends with thee expulsion of the fetus.
This stage is concerned with descent and delivery of the fetus through the birth canal.
nal.
With the full dilatation of the cervix, the membranes usually rupture and there is escape
scape of good amount of
liquor amnii. The volume of the uterine
ine cavity is thereby reduced. Simultaneously, uterine contraction and
retraction become stronger.
ntractions supplemented by
Delivery of the fetus is accomplished by the downward thrust offered by uterine contractions
voluntary contraction of abdominal muscles against the resistance offered by bony and soft tissues of the birth
canal.
ctions is added by voluntary contraction of the abdominal muscles called
The expulsive force of uterine contractions
bearing down efforts.
EVENT
ENTS IN THIRD STAGE OF LABOUR
Comprises of placental separation and
nd its expulsion with membranes.The
membranes
plane of separation runs through
deep spongy layer of decidua basalis.
Mechanism:
ctively the surface area at the placental site
s to about half
1. Marked retraction reduces effectively
2. As it is inelastic, it undergoes buckling
3. A shearing force is initiated between
tween the placenta and placental site
4. Plane of separation runs throug
gh deep spongy layer of decidua basalis.
There are two ways of separation:
S
starts in the centre
collection of blood behind placenta
1. Central separation (Schultze): Separation
(retroplacental hematoma)
whole placenta separates
2.Marginal (Mathews-Duncan): Separation
S
starts at margin and progressively involves
nvolves more & more area.
T
Then
there is separation of membranes.
acenta - After complete
Expulsion of Placenta
separation of the placenta,
acenta, it is forced down into
the flabby lower uterine
erine segment or upper
u
part
of the vagina by effective contraction and
retraction of the uterus. Thereafter, it is
expelled out by either
her voluntary contraction of
abdominal muscles (bearing down efforts) or by
manipulative procedure.
dure.
Signs of placental separation:
separation:1. Fresh gush of blood
od
2. Extra-vulval lengthening
thening of the cord
3. Suprapubic bulge with a depression above it.
it

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

- the uterine contractions acting downwards and forwards.

- the pelvic floor resistance acting
g upwards and forwards,
forwards so the net result is forward
ward direction i.e.,
i.e.
extension of the head.
7. Restitution
al rotation to undo the twist
After delivery, the head rotates 1/8th of a circle in the opposite direction of internal
produced by it.
8. External rotation
he opposite oblique diameter to that previously
y passed by the head.
The shoulders enter the pelvis in the
When the anterior shoulder meets the pelvic floor it rotates anteriorly 1/8th of a circle.
rcle.
This movement is transmitted to the
he head so it rotates 1/8th of a circle in the samee direction of restitution.
9. Expulsion of the trunk
w the symphysis pubis and with continuous descent
cent the posterior shoulder
The anterior shoulder hinges below
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.
quickly
CERVICAL DILATATION
Cervical dilatation is expressed in terms
rms of fingers (1, 2, 3 or fully dilated); or better,
r, in terms of centimeters
(10 cm when fully dilated). It is usually
lly measured with fingers but recorded in cms. 1 finger = 1.6 cm on
average.

MAN
ANAGEMENT OF NORMAL LABOUR
Aims:
1. To achieve delivery of a normal healthy
althy child with minimal physical and psychological
ogical maternal effects.
2. Early anticipation, recognition and
d management of any abnormalities during labour
our 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:
y and duration.
- Labour pains: onset, frequency
- Passage of show", fluid or blood
ood per vaginum.
- Sensation of fetal movement.
(II)Examination:
(1) General examination:
- Height and build.
- Maternal vital signs: pulse, temperature
erature and blood pressure.
- Chest and heart examination.
- Lower limbs for oedema.
(2) Abdominal examination:

- Fundal grip.
- Umbilical grip.
- Pelvic grips.
- Fundal level.
- 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.

Put her in the lithotomy position.

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

Third Stage of Labour:

(I) Delivery of the placenta:
i) Conservative method:
eft hand just above the fundus at the level of thee umbilicus to detect any
Put the ulnar border of the left
bleeding inside the uterus known
nown by rising level of the atonic uterus.
Wait for signs of placental separation
paration and descent but do not massage the uterus.
terus.
As soon as they are detected massage the uterus to induce its contraction, ask
sk the patient to bear down
and push the uterus downwards
ards to deliver the placenta.
Hold the placenta between the
he two hands and roll it to make the membranes
es like a rope in order not to
miss a part of it.
xytocin 5 units IM after delivery of the placenta
a to help uterine
Give ergometrine 0.5 mg or oxytocin
contraction and minimise blood
od loss. These may be given before
be
delivery of the placenta.
Signs of placental separation and descent:
descent
1. The body of the uterus becomes
omes smaller, harder and globular.
2. The fundal level rises as the
he upper segment overrides the lower uterine segment
egment which is now
distended with the placenta.
a.
3. Suprapubic bulge due to presence
resence of the placenta in the lower uterine segment.
gment.
4. Elongation of the cord particularly
ticularly on pressing on the uterine fundus and
d it does not recede back into
the vagina on relieving the pressure.
5. Gush of blood from the vagina.
gina.
ii) The active method (Brandt- Andrews
drews method):
1. Principle:
To excite powerful uterine contractions
ontractions
following birth of the anterior
or shoulder by
parenteral oxytocin which facilitates
acilitates early
separation of the placenta and
nd produces
effective uterine contractionss following its
separation.
2. Advantages:
a. to minimize blood loss in third stage
approximately to one-fifth
b. to shorten the duration off third stage to half
half.
3. Disadvantages:
a. increased incidence of retained
ained placenta
b. increased incidence of manual
nual removal of
placenta.
4. Procedures:
5 mg or methergin 0.20 mg is given IV following
g the birth of anterior
a. Injection ergometrine 0.25
shoulder. If administered prior to this, there is chance of imprisonment of the shoul
shoulder behind the
symphysis pubis.
b. This is followed by slow delivery
elivery of the baby taking at least 2-3
2 minutes.
c. The placenta is expected to be delivered following delivery of the buttocks.
ks. If the placenta is not
delivered instantaneously,, it should be delivered by controlled cord traction
ion after clamping the cord
while the uterus still remains
ains contracted .If the first attempt fails, another
er attempt is made after 22
3 minutes failing which another
nother attempt is made at 10 minutes.
d. If this still fails, manual removal is to be done.
5. Limitation:
w delivery of the baby and
a. To be effective, it should be administered at proper time followed by slow
followed by rapid delivery
y of the placenta.
b. It should not be used in cardiac
ardiac cases or ssevere pre-eclampsia. It may precipitate
ecipitate cardiac overload
in cardiac cases, and aggrava
ravate blood pressure in severe pre-eclampsia.
(II) Routine examinations:
(1) Examination of the placenta and membranes: by explori
exploring it on a plain surface
ace to be sure that it is
complete. If any part is missing
ng, exploration of the uterus is done under general
eral anaesthesia.
(2) Explore the genital tract: For any lacerations that should be immediately repaired.
paired.
(III) Repair of episiotomy

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 mothers name is written.

LONG
ESSAY

SHORT
ESSAY

SHORT
ANSWERS

PREVIOUS EXAMINATION QUESTIONS FROM THIS CHAPTER

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.
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 Andrews technique.
12. Management of first stage of labour.
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.