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STAGES OF LABOUR

DR. A.RATHNA M S ( O&G)


MMC &RI
Normal Labor

Process by which regular


uterine contractions
progressive effacement and
dilatation of the cervix delivery
of the fetus and the placenta at or
beyond age of fetal viability.
Labour can occur at:

Term
Labour
PTL prolonged

24 W 28 W 37 W 40W 42W
1 LNMP
Stages of labor
Stage 1st 2nd 3rd 4th

Onset Onset of Full cx Fetal Placental


true dilatation expulsion delivery
uterine
contractio
ns
End Full cx Fetal Placental
2h
dilatation expulsion deliveryobservatio
ns for
Time oPG =12-14 oPG = 1-2 h PG &MG PPHge
h oMG = - 1
oMG = 6-8 h h = 10-30 and any
min complicati
ons
Management of stages of labor

Diagnosis

How to deal

Preparations
Monitoring
Procedures
Management of the
First Stage of Labour
Diagnosis {made within one hour of admission}
A. symptoms:
1. True labour pains colicky pain in the abdomen and
back are characterized by:
character True labour pain False labour pain
contractions regular Irregular
Interval between Progressive Short duration, not
contractions and (increase in progressive
intensity frequency and
intensity)
Changes in the Associated with Not associated with
cervix effacement and effacement and
dilation of the dilation of the cervix
cervix
Membranes Associated with Not associated with
bulging of bulging of
membranes membranes
Response to Not relieved by Relieved by sedation
analgesia sedation
Labour Followed by labour Not followed by labour
Patient preparations:
Full history and clinical
examination
Position: Encourage any non-
supine position and movement
throughout labor and childbirth.
Diet: nothing by mouth, IV fluid, or
light diet but fat ,proteins are not
allowed at all.
IV line : recommended.
Patient preparations:
Rectum: no evidence that routine
enema is beneficial .
Bladder:
Encouraged patient to empty her bladder
regularly.
Urinary catheter only when woman is
unable to void.
Pain Control: antenatal women education
about pain relief techniques- epidural anesthesia
satisfaction.
2. Show blood stained mucous.
3. SROM

B. Signs:
o palpable or recorded uterine
contraction
o effacement and dilation of the cervix
o formation of forewater
What is a partogram
(partograph) ?
PARTOGRAM
Def: diagrammatic record of the
events of labour.
Advantages:
Monitoring
the progress of labour,
maternal and fetal wellbeing
Early detection and management of
labour abnormalities.
Fetal

cervical

Descent

Uterine

Materna
l
Timing observations of different parameters
of partogram in the the1st stage of labor

Ideal Minimum acceptable


Parameter in both Latent Active
phases phase phase
)hrs(

Vaginal examination 4 8 4
Descent of head 4 8 4
Contractions 4 2
Fetal heart beats 4 1
Temperature, PR, BP, urine 4 4 4
Phases of cervical dilatation
The alert line:
Drawn from 3 cm dilatation ( at rate of dilatation
of 1 cm / hour).
Represents the rate of dilatation of the slowest 10 % of
labours in primigravidae.
Crossing the alert line suggests that the patient should be
transferred to a hospital for extra care.
The action line :
parallel and 2 (4) hours to the right of the alert line;
crossing the action line suggests the need for intervention
(eg, artificial rupture of the membranes, administration of
oxytocics.
Vaginal examination:
single individual to minimize
interobserver variations
Indications:
On admission
At one to four hour intervals in the first stage
At rupture of membranes to evaluate for cord prolapse
Feeling the urge to push to determine whether the
cervix is fully dilated
If the FHR falls, to evaluate for conditions such as cord
prolapse or uterine rupture.
Vaginal examination:

Disadvantages:
Increases womans anxiety.

Increasing numbers vaginal examinations in

(PROM) increases neonatal sepsis


Effacement and dilation of the cervix
Assessing descent of the fetal head by
vaginal examination;
0 station is at the level of the ischial
spine (Sp).
Palpate number of contraction in ten
minutes and duration of each contraction in
seconds

Less than 20 seconds:

Between 20 and 40 seconds:

More than 40 seconds:


Fetal heart rate
Intermittent auscultation of the fetal heart ( for low
risk patients): after a contraction should occur for at
least 1 minute, at least every 15 minutes.
Method : Doppler ultrasound or Pinard stethoscope.
Continuous intrapartum FHR monitoring for :
(External and Internal)
High-risk patients ,
When FHR below 110 or over 160 BPM
Active management of
labor

Amniotomy

Oxytocin

administration

for dilation rates

of <1 cm/hour
Management of second stage

of labour
Onset of second stage
Full cervical dilatation (sure)
Involuntary Bearing down
The urge to defecate and urinate.
Contractions becomes more prolonged.
Expiratory grunting with expulsive efforts.
Rupture of membranes (suggestive)
Preparation for delivery
Position: Patient is put in dorsal Lithotomy position and
the legs are half-flexed
Patient is properly draped
Asepsis:
Diet
Bladder and rectum
Pain relief
Patient is asked to take deep breath & breath held then
exerts downward pressure at the time of uterine
contraction and relax in between
Fetal heart rate monitoring

Low risk: every 15 min


High risk: every 5 min

Slowing of the FHR may occur due to


fetal head compression
Obstetrical role
Bearing down only during contraction.
Delivery of the head
Crowning
The main role of obstetrician is the
prevention of perineal tears
Before crowning
After crowning) Ritgen maneuver )

Episiotomy

Once head delivered clear upper air way.


Ritgen maneuver
Delivery of shoulder
Anterior shoulder Posterior shoulder

The rest of the body almost always follows the shoulder


without difficulty
Management of third stage of

labour
Management of third stage of labour
aimed at:

1-Complete delivery of the after birth

(placenta and membranes).

2-Prevention of acute inversion of the

uterus.

3-prevention of postpartum

haemorrhage
Delivery of the placenta and membranes: uterus should
be examined for the presence of second baby
a-Conservative method:
The left hand is placed just above the fundus to detect any
change in the fundal level, shape and consistency of the
uterus which indicate atony.
Wait for signs of placental separation and decent,
Massage uterus to contract
The patient is asked to bear down to deliver the placenta
spontaneously.
Ergometrine 0.5mg or Syntometrine(5 units syntocinon +
0.5mg Ergometrine) to be given intravenouslly.
Signs of separation and decent of the
placenta:
1. -The body of the uterus becomes smaller, harder, and
globular.
2. -The fundal level rises in the abdomen because the
lower segment becomes distended by the placenta.
3. -Suprapubic bulge may appear due to presence of the
placenta in the lower segment.
4. -Elongation of the cord out side the vulva.
5. -Sudden gush of blood from the vagina.
b-Active methods (prophylaxis against postpartum haemorrhage)
1-Give Methargine 0.5 mg IM or Syntometrine (5units
oxytocin+0.5mg Methargine), at the time of the anterior
shoulder is free from symphysis pubis or as soon as possible
thereafter.
2-Deliver the placenta and membranes by control cord traction by
right hand, and the left hand is placed on the suprapubic
region, pushing the uterus upwards.

N.B. USE SYNTOCINON RATHER THAN METHARGINE


IN CARDIAC AND HYPERTENSIVE CASES.
Controlled Delivery of
cord traction the placenta
IV-Post Delivery:
1-examine the placenta for their completeness,

anomalies, length, and number of vessels in the

cord and record the placental weight.

2-Suture the episiotomy or any laceration.

3-Estimate blood loss, count swabs, and take cord

blood for Hb, blood group, Rh, bilirubin, and

coombs test for Rh negative mother.


IV-Post Delivery:
4-Check BP, P, T, Lochia and firmness of the uterus

before transferring the patient.

5-Continue an infusion of syntocinon through the first

hour if necessary.

6-Allow no food during the first hour, sips of water

may be taken, encourage nursing.


Seven Cardinal
Movements
Engagement
descent of BPD to a level below the plane of
the pelvic inlet

Descent
Flexion
Internal rotation
Extension
Restitution
External rotation
Expulsion
Induction

Assess adequacy of pelvis and


cervical exam
Bishop score
Bishop score