Normal Labour,

Delivery
and
Postnatal Care
 AIMS
• Understand the process of normal labour

• Understand what Active Management of

the Third Stage of Labour (AMTSL) is and
it’s importance

• Knowledge of evidence based practices

 When is a Woman in
Labour?
• Diagnosis of Labour

 2-3 uterine contractions in 10mins

 Progressive shortening and thinning of the
cervix during labour and
 Cervical dilatation
 4cm or more dilated
 Normal Labour
• Stages of Labour
 First Stage: onset of labour pains to full
dilatation of the cervix
 Second Stage: full dilatation of the cervix to the
delivery of the baby
 Third Stage: starts after the delivery of the baby
ending with the delivery of the placenta
 Immediate postpartum (‘Fourth Stage’):
frequent monitoring in the one hour following
delivery
 Supportive Care

• Many providers continue to use,

untimely, inappropriate and/or
unnecessary interventions, leading to
complications

• Example: immobilising women, not

allowing eating and drinking
 Supportive Care

• Supportive care during labour is the

most important thing to help the
woman tolerate labour pains and
facilitate the progress of labour
 Supportive Care
• Support from a birth partner or companion.

• Good communication and building trust

with staff.
• Encourage walking around and changing
positions frequently.
• Encourage adequate intake of food and
drinks
• Monitor maternal and fetal wellbeing using
the partograph
Care that is of no proven
benefit

• Routine shaving of the pudendal

area.
• Giving an enema.
• Routinely cutting episiotomy for
delivery.
• Application of fundal pressure
Management of
Labour
• Not in active labour
(cx 0-3cm, contraction <2/10)

- Monitor every hour: contractions, FHR

- Monitor every 4 hours: HR, BP, temp
• In active labour
(cx 4cm or more)

- START partograph
- Monitor every 30 min: contractions, FHR,
presence of any danger signs
- Monitor every 4 hours: cervical
dilatation, HR, BP, temp
 Assessing Progress in
Labour
- Assessing changes in cervical dilatation
and effacement (PV examination)

- Foetal descent (PV and Abdominally)

5ths of Head palpable above symphysis pubis
 Second Stage
• Once the cervix is fully dilated, encourage
the woman to assume the position she
prefers to push only with a contraction.
 Squatting, sitting and standing positions
may make pushing easier
 Avoid routine catheterization which may
lead to infections.
 When delivery is imminent the women may
be put in dorsal lithotomy position for the
actual conduct of delivery
 Second Stage
Delivery of the head:
 Control birth of the head to keep it flexed.
 Gently support the perineum as the baby’s head
delivers.
 Feel around the baby’s neck for the umbilical cord:
- if the cord is loose, slip it over the baby’s head
- if the cord is tight clamp and cut it.
[!] NO routine episiotomy
 Second Stage
Completion of delivery :
• Allow the baby’s head to turn
spontaneously.
• Deliver one shoulder at a time - anterior
then posterior.
• Support the rest of the baby’s body as it
slides out.
• Dry and wrap baby, assess breathing
• Ensure the baby is kept warm and in skin-
to-skin contact on the mother’s
chest/abdomen.
Third stage of labor
 The classical expectant
management
• Wait for the natural forces of labor to
bring about 3rd stage contraction and
placental separation
• Look for the signs of placental
separation
• Controlled cord traction to expel the
placenta and membranes
• Optional administration of Oxytocics
 Active management of 3rd
stage
• Oxytocic administration immediately after
delivery of the baby so that the uterine
contractions and placental separation is not left
to the natural uncertain forces of labor
• Controlled cord traction on perception of a
strong uterine contraction with out waiting for
the actual signs of placental separation
• Uterine massage to maintain the contraction
 Active Management of
the Third Stage
As practiced
• Palpate the abdomen to rule out the presence of an additional baby(s)
• Give Oxytocin: 10 units
• Clamp and cut the umbilical cord
•  Controlled cord traction on perception of a strong uterine contraction with
out waiting for the actual signs of placental separation
• Uterine massage to maintain the contraction
 Controlled Cord Traction
• Should be done only when the
uterus is felt to have contracted
strongly
• Make sure the bladder is empty
• Hold the clamped cord in one
hand and with the other hand
apply counter traction on the
uterus. Keep slight tension on the
cord and await a contraction.
Controlled Cord Traction
Cont
• Pull downward on the cord to deliver
the placenta, applying counter traction
to the uterus with the other hand
• If it does not succeed at first attempt
wait for some more time for a stronger
uterine contraction
• Stress on a complete examination of
the placenta for any retained placental
fragments
 Third Stage
• As the placenta delivers, gently turn it until
the membranes are twisted and slowly pull
to complete the delivery.

• Check the placenta to be sure none of it is

missing.

• Examine the woman carefully and repair any

tears to the cervix or vagina or repair the
episiotomy.
[!] NO routine packing of vagina while attempting a repair.
 Immediate PNC - Mother

• Routine observations
• Regular checks for vaginal bleeding and contraction of
uterus.
• Examine perineum for tears.
• Pain relief
• Encourage the mother to eat, drink and rest
• Consider IUD insertion
• Identify any signs of complications, stabilise and REFER
 Observations

• 1-2 hours: every 15 minutes

• 3-5 hours: every 30 minutes
• >5 hours: every 4 hours

• Length of stay in health facility:

Advise observation for 24hours
 Immediate PNC - Newborn

• Encourage early breastfeeding

• Keep warm, check temp every 15min by feeling the feet
• Examine for any malformation or abnormality > REFER
• Care of the cord, check for bleeding
• Give VIT K 1mg IM.
• Delay baby’s first bath to beyond 24 hours of birth

[!] Avoid separating mother from baby whenever possible. Do not

leave mother and baby unattended at any time.
[!] NO routine suction of throat and nose