NORMAL LABOUR

Dr Otara A.
Learning Objectives

The learner should be able to

• Describe the course of labour
• Describe the factors that influence normal labour
• Describe the mechanisms of labour
• Demonstrate the mechanisms of labour
• Describe the stages of labour
• Demonstrate proficiency in managing a mother with normal
labour
• Conduct a delivery in normal labour
Topic Outline

• Introducton
• Definitions
• Course of labour
• 4Ps of Labour
• Mechanisms of labour
• Signs and symptoms
• Stages of labour
• Management of normal labour
• Preparation
• Partograph
• Dos and DONTs in labour
• Delivery
Introduction

Rachel

• Genesis 35:17 "And when she was in hard labour,

the midwife said to her "Fear not, for now you will
have another son."

• Genesis 35:18 “And it came to pass, as her soul was

in departing, (for she died)......”
Introduction

Maternal mortality : Strategies by

International organizations to reduce MM
Goals
•Improved access to ante/intra/postnatal
care
•Skilled care attendance
•Access to basic and comprehensive
obstetric care including referral; AMTSL,
MgSO4
•Community involvement
Definitions

• Labour is the process through which a baby

placenta and membranes are expelled fro the
uterus
• Normal labour occurs after 37completed weeks and
no complications occur
• True labour occurs when uterine contractions are
accompanied by cervical effacement and dilatation
• False labour occurs when uterine contraction do not
change the cervix
Definitions
• Lie: The relation of the long axis of the fetus to that of the
mother: longitudinal, transverse
• Attitude: Posture of the fetus:
• Flexed: head flexed over the chest, arms/hands flexed
over the chest, thighs/legs flexed over abdomen
• Extended
• Presenting part: the portion of the body of the fetus that
leads at the maternal pelvis: Vertex, shoulder, face
• Position: the relation of an arbitrary chosen point of the
fetal presenting part to the left or right side of the maternal
pelvis: ROA, LOP
4 Ps of Labour
Progress of labour must be determined by examining
the patient using the ‘Rule of the 4 Ps’. The 4 Ps are:
• The patient.
• The powers
• The passenger.
• The passage.
(Six P's: passage, passenger, power, position, psyche
or perception and parity)
Patient

Patient factors
• Psyche or perception

• Parity

• Posture
Powers
Contractions: There are 2 Powers
• Force of the uterine contractions.

• Frequency of the uterine contractions.

.
Powers
With continuing uterine contractions, the upper uterus
(active segment) thickens, the lower uterine segment
(passive segment) thins, and the cervix dilates. In this way,
the fetus is moved downward, into, and through the
vaginal canal.
Passenger
Passenger

• Size of passenger

• Number of passengers

• State of passenger
• Presentation and Lie
• Position
• Attitude - relationship of fetal body part
Passage

• Bony Pelvis:
• The bony pelvis consists of:
• The two hip bones (innominate or pelvic bones),
• The sacrum
• The coccyx.
• There are four articulations within the pelvis:
• Sacroiliac joints (x2) – between the ilium of the hip bones, and the
sacrum
• Sacrococcygeal symphysis – between the sacrum and the coccyx.
• Pubic symphysis – between the pubis bodies of the two hip bones.
• Uterine Cervix
• Vagina
• Perineum
Passage
Passage
Pelvis Varieties
Mechanisms of Labour

The positional movements that the fetus undergoes

to accommodate itself to the maternal pelvis

https://youtu.be/2kM35XMMiPk

Labor and delivery occurs in a continuous fashion,

but the Cardinal Movements are described as 7
discrete sequences
Mechanisms of Labour
Cardinal Movements
• Engagement: BPD of fetal head has passed through the pelvic inlet to ischial
spines.
• Descent; uterine contractions, maternal pushing efforts, abdominal muscles.
• Flexion: due to resistance from the pelvic walls and floor. The flexion brings
the shortest longitudinal diameter of the head Sub-occiput-bregmatic, 9.5cm
to pass through the pelvis
• Internal rotation: the occiput meets the pelvic floor and rotates anteriorly1/8
of a circle OT-OA.
• Extension: the fetal head is pivot under under the symphysis pubis and the
sinciput, face and chin sweep over the perineum.
• Restitution: baby head realigns with body
• External rotation.: Occiput moves 1/8 circle towards the side where it
started
• Expulsion of the body
Stages of labour

First Stage
• Latent phase
• Cervix effacing and dilating but less than 4cm
• Rate of dilation not as predictable
• Active phase
• 4-9cm
• Rate of dilation about 1cm/hour typically
• Foetal descent begins
Stages of labour
Second stage
• Early (non-expulsive)
• Cervix fully dilated
• Foetal descent continues
• No urge to push
• Late (expulsive)
• Cervix fully dilated
• Presenting part reaches the pelvic floor
• Urge to push
• In nulliparous women, 2nd stage should be considered prolonged if
it exceeds 3 hours if regional anesthesia is administered or 2 hours
in the absence of regional anesthesia
• In multiparous women, the 2nd stage should be considered
prolonged if it exceeds 2 hours with regional anesthesia or 1 hour
without it
Stages of labour

• Third stage: Period from delivery of the baby to

delivery of placenta and fetal membranes
• Delivery of the placenta often takes less than 10
minutes, but the third stage may last as long as
30 minutes

• Fourth stage: Period of up to 2 hours after delivery

of the placenta
Management of Labour

Sign and symptoms

• Uterine contractions; Intermittent

• Cervical effacement and dilation

• Bloody mucus discharge (show)

• Drainage of liquor
Management of 1st Stage of Labour

History
• Duration since onset of labour
• Drainage of liquor
• Bleeding
• Presence of foetal movements
• LMP/EDD/Gestation
• ANC and any events
• ANP
Management of 1st Stage of Labour

Physical examination
• General condition
• Vital signs
• Pallor, oedema
• Thyroid
• Breasts
• RS/CVS
• Obstetric examination
Management of 1st Stage of Labour

Obstetric examination
• Fundal height
• Lie
• Presentation
• Descent
• Frequency and duration of contractions
• Foetal heart tone
Management of 1st Stage of Labour

Pelvic Examination
Inspection of vulva: fluid, blood, swellings, FGC
Per vaginal examination
• Cervical effacement
• Dilation
• Colour of liquor
• Moulding
• Caput
Management of 1st Stage of Labour

• FHR every ½ hour

• Frequency and duration of contraction every ½ hour
• PR every ½ hour
• Cervical dilation every 4hours
• Descent every 4hours
• BP and Temperature every 4hours
• Urine output/Acetone/Protein every 4hours
Partograph

• The partogram is graphical method of assessing the progress

of labour
•It is intended to provide an accurate record of the progress
in labour, so that any delay or deviation from normal may be
detected quickly and treated accordingly.
• Commence at 4 cm of cervical dilatation

•Components of The Partograph

• The fetal condition
•The progress of labour
•The maternal condition
WHO Partograph
Plotting descent of the fetal head
Management of 1st Stage of Labour

Other action that may be needed include;

• Rehydrate
• Analgesia
• Ambulate

• Oxytocin augmentation
• Caesarian section
Management of 2nd Stage of Labour

Conduct of Labour

5 Minute Vaginal Delivery Video - The Brookside Associates.html

Management of 2nd Stage of Labour

• Infection Prevention

• Use position of her choice

• Prepare for newborn resuscitation

• Control birth of the head and support the perineum

• Wipe the baby’s mouth and nose

• Feel around the neck for the cord

Management of 2nd Stage of Labour

• Allow head to rotate spontaneously and apply

gentle downward traction to deliver the anterior
shoulder with next contraction

• When axillary crease appear, use upward curve to

deliver the posterior shoulder

• Deliver the rest of the trunk by grasping the baby by

the chest and lifting it to the mothers abdomen
Management of 2nd Stage of Labour

• Place clamps over the cord and cut using sterile scissors
or blade

• Apply gauze to avoid blood sluttering

• Note the time of delivery

• Dry the baby, wipe the eye and asses breathing

• If breathing does not start in30s, ask for help and start
resuscitation
Management of 3rd Stage of Labour
Expectant management involves spontaneous delivery of the
placenta
• The third stage of labor is considered prolonged after 30
minutes, and active intervention is commonly considered
Active management of third stage of labour (AMTSL)
• Prophylactic Uterotonics: Oxytocin 10u/Cabertocin/Ergometrine
0.5mg/Prostaglandins
• Within 1minute of delivery, palpate for possible twin
• Give oxytocin 10u(im) of ergometrine 0.5mg
• Cord clamping/cutting and Controlled cord traction: Clump cord
close to the perineum and support uterus with the other hard.
Perform controlled cord traction with next contraction

• Uterine massage: Massage the uterus as soon as the uterus is

delivery until it is well contracted. Ensure that it does not relax
after stopping massage
Management of 3rd Stage of Labour

• Examine the placenta and membranes for completeness and

retroplacental clots

• Examine the cervix, vagina and perineum for tears

• Suture episiotomy or tears if any

• Gently clean the perineum, apply fresh pad and make mother
comfortable
Management of 3rd Stage of Labour: E-
MOTIVE
• Early Detection: emphasison early and accurate detection
of PPH using a calibrated blood-collection drape. This helps
to identify PPH early, allowing for timely intervention and
potentially preventing more severe complications.
Immediate Treatment Bundle: The "first response" bundle:
• Uterine massage: help contract the uterus and reduce
bleeding.
• Oxytocic drugs: Medications like oxytocin to stimulate
uterine contractions.
• Tranexamic acid: To help clot the blood.
• Intravenous fluids: To maintain blood volume and address
dehydration.
• By implementing E-MOTIVE, healthcare providers can
improve their ability to detect and treat PPH, potentially
leading to improved maternal health outcomes.
Management of 4th Stage of Labour

• Take BP, RR, Temp. every 15min for first 1hour then 30min for the
next 1hour

• Check uterine contraction and vaginal bleeding every 15minutes for

first 1hour and every 30minutes for the next 1hour
Summary

Dos in labour
• Labour companion of patient choice
• Allow client to walk around
• Adequate fluid intake
• Pass urine frequently
• Deliver in position of choice
Don’ts in labour
• Routine catheterization
• Routine episiotomy
• Routine shave
• Routine induction without medical indication
• Routine enemas
Provider, Respectful Care

Providers/Support Persons
• Patience

• Persistance

• Practice

• Psyche
 Respectful Care in Maternity
Category of Disrespect and Abuse Corresponding Right
1 Physical abuse Freedom from harm and ill treatment
2 Non-consented care Right to information, informed consent
and refusal, and respect for choices and
preferences, including companionship
during maternity care
3 Non-confidential care Confidentiality, privacy
4 Non-dignified care (including verbal Dignity, respect
abuse)
5 Discrimination based on specific Equality, freedom from discrimination,
attributes equitable care
6 Abandonment or denial of care Right to timely healthcare and to the
highest attainable level of health
7 Detention in facilities Liberty, autonomy, self-determination,
and freedom from coercion
ASSIGNMENT
 Case Scenario 1
A primigravida was admitted in the latent phase of labour at 5 AM:
• - fetal head 4/5 palpable;
• - cervix dilated 2 cm;
• - 3 contractions in 10 minutes, each lasting 20 seconds;
• - normal maternal and fetal condition.
Note:This info is not plotted on partograph

At 9AM:
• Fetal head is 3/5 palpable
• Cervix 5cm dilated
Note:The woman was in the active phase of labour and this information is
Plotted on the partograph.Cervical dilation is plotted on the alert line.
-4 contractions in 10 minutes, each lasting 40 seconds;
- cervical dilatation progressed at the rate of 1 cm per hour
 Case Scenario 1(continued)
• At 2 PM:
• - fetal head is 0/5 palpable;
• - cervix is fully dilated;
• - 5 contractions in 10 minutes each lasting 40 seconds;
• - spontaneous vaginal delivery occurred at 2:20 PM.
Partogram For Case Scenario 1
 Case Scenario 2
• The woman was admitted in active labour at 10 AM:
• - fetal head 3/5 palpable;
• - cervix dilated 4 cm;
• - three contractions in 10 minutes, each lasting 20–40 seconds;
• - clear amniotic fluid draining;
• - first degree moulding.

· At 2 PM:
- fetal head still 3/5 palpable;
- cervix dilated 6 cm and to the right of the alert line;
-improvement in contractions (three in 10 minutes, each lasting 40 sec)
- second degree moulding.
 Case Scenario 2(continued)
At 5PM
• - fetal head still 3/5 palpable;
• - cervix still dilated 6 cm;
• - third degree moulding;
• - fetal heart rate 92 per minute.
•· Caesarean section was performed at 5:30 PM.

Arrest of cervical dilation & descent in active phase of labour noted.

Fetal distress and third degree moulding together with arrest of dilation
&
descent of in active phase of labour in presence of adequate uterine
contractions indicates obstructed labour
Partogram for Case scenario 2
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