Management Of 1 ,2 &3

st nd rd

Stages Of Labour

Prepared By:
Mercy Parneetha K.A.
Definition

• Labour : Regular involuntary coordinated, painful uterine

contractions associated with cervical effacement and dilatation
• • Regular frequent uterine contractions
• •cervical changes (dilatation & effacement) ,or
• • SROM
• Delivery: Expulsion of the product of the conception after fetal
viability.
MECHANISMS OF NORMAL LABOUR
 MECHANISMS OF NORMAL LABOUR
• The following criteria should be present to call it normal labour
 Spontaneous expulsion,
 of a single,
 mature fetus (37 completed weeks – 42 weeks),
 presented by vertex,
 through the birth canal (i.e. vaginal delivery),
 within a reasonable time (not less than 3 hours or more than 18 hours),
 without complications to the mother,
 or the fetus
What are the stages of labour?
 The first stage:
 begins when start having contractions that cause progressive changes in
the cervix and ends when the cervix is fully dilated. This stage is divided
into two phases:
 Latent phase (~8H): Point at which woman perceives regular uterine
contractions until 4cm dilatation. Prolonged if >20H in a nulliparous;
>16H if multipara.
 Active phase (~8H nullipara, 6H multipara): 4cm dilatation to fully dilated
and regular contractions. Rate of dilatation should be >1cm per hour if
nulliparous; >1.5cm per hour if multipara.
• The second stage of labor begins when the cervix is fully
dilated and ends with the birth of the baby. This is
sometimes referred to as the "pushing" stage.

• The third stage: begins right after the birth of the baby
and ends with the delivery of the placenta. This is the
shortest stage, lasting up to 30 minutes, with an average
length of 5 to 10 minutes. There is no difference in
duration for nulliparous and parous.
Stages Of Labour
Aims in the management of labour

To achieve delivery of a normal healthy child

To anticipate, recognize and treat potential abnormal conditions

before significant hazard develops for the mother or the fetus.
MANAGEMENT Of 1st STAGE OF LABOUR

I. Assessment
II. Preparation and care
III. Partogram
• I. Assessment
 1. History:
• 1. Woman’s antenatal record is reviewed 2. No records
of antenatal care: complete history .
 2. Examination
 General
Pallor, edema, abdominal scar
Vital signs: BP, pulse, RR and Temp.
 Abdominal examination:
• a. Presentation and position and engagement
• b. Auscultate the fetal heart
• c. Evaluate the uterine contraction
 Vaginal examination
• Presentation, Engagement, Position
• Membranes: Intact or absent: exclude cord prolapse after ROM
• Cervix: Consistency, position Dilatation Effacement,
• Assess the adequacy of the pelvis.

• 3. Investigation
Urine: Protein, Sugar, ketones
Blood: CBC ,RBS, Grouping ,cross match for high risk
patients.
• II. Preparation and care
1. Bowel preparation: Indicated when there is
No bowel action for 24 h or Rectum feels loaded on vaginal
examination .
2. Bladder care: Encourage to empty bladder1½ - 2 h. (A full
bladder: prevent the fetal head from entering the pelvic brim impede
descent of the fetal head. inhibit effective uterine action).
The quantity of urine should be measured and recorded and a
specimen obtained for testing.
 3. Nutrition : No food is permitted after labour is established
{prevent regurgitation and aspiration} , Small amount of clear fluid or
frozen pineapple, Ice chips to moisten the mouth , Maintain adequate
hydration via intravenous routes
 4.Position of labouring mother:
As long as the patient is healthy, the presentation normal, the
presenting part engaged, and the fetus in good condition, the patient may
walk about or may be in bed, as she wishes.

 5. Pain relief :for Severe pain :

 Opiate drugs: e.g. Pethidine IM/4 h
 Inhalational analgesia: e.g. Entonox
 Epidural analagesia .

 III. Monitoring the progress of labour :

 Once labour has become established, all events during labour should be
recorded on a partogram.
 a) fetal Well-being. b) maternal Well-being. c) Progress of the labour .
Partogram:
 MONITORING FETAL HEART

•
How To Monitor The Fetal Heart Rate?

 Auscultation methods

 Electronic monitoring ~ CTG } === To detect fetal hypoxia

 Progress of labour

 I. Cervical dilatation (cm).every vaginal examination.

Causes of cervical dilatation:

Contraction and retraction of uterine musculature.
Mechanical pressure by the bulging membrane .
The descend of the presenting part.

Phases of cervical dilatation

Latent phase – the first 3 cm of dilatation; a slow process (8 hours in nulliparous and 3 hours in multiparous

Active phase – this is active process of cervical dilatation; the normal rate is 1 cm/hour

 II. Descend:
• every vaginal examination (amount of head palpable above pelvic brim).
 III. Contractions:

1: Regular
2: Increasing in frequency
3: Stronger
MANAGEMENT 2nd STAGE OF LABOUR

I. Preparation
II.Observation
III.Conduct of delivery
I. Preparation

1. Maternal position:
With the exception of avoiding supine position, the mother may
assume any comfortable position for effective bearing down.
Semi-recumbent or
Supported sitting position, with the thighs abducted
2. PERINEAL CLEANSING
When delivery is imminent skin over the lower abdomen, vulva, anus
and upper thigh is cleansed with antiseptic solution.
PERINEAL CLEANSING
Need 6 swab balls
Clean sequentially as shown by the numbers
Clean according to the direction shown by the
Arrows
II. Observation
1.Maternal conditions
•Emotional condition
• pulse quarter-hourly
•bloods pressure hourly
2.Fetal conditions
FHR: either continuously or after each contraction.
Liquor: meconium staining.
3.Uterine contractions: Strength, Duration, Frequency, assessed continuously.

4.The progress of descent: every 30 minutes

III. CONDUCTING THE DELIVERY
• 1. DELIVERY OF THE HEAD
Control the delivery of the head to prevent laceration that occur
when the head born suddenly,& the head must be flexed until the
largest diameter has passed vulval outlet.
Once the head has crowned , the women should be discouraged
from bearing down by telling her to take shallow breaths.
The head now delivered by pressure through perineum on to the
forehead , the fingers & thumb placed on each side of the anus ,
pushing the head forward slowly before it is allowed to extend and
complete its delivery, & control the rate of escape with the other
hand.
 place the fingers of one hand against the baby’s head to keep it flexed (bent),
Continue to gently support the perineum as the baby’s head delivers
• •Instruct the mother to focus on her breathing. Have
her “breathe heavily” to help her stop pushing and
prevent a forceful birth.
Once the baby’s head delivers, ask the woman not to push
Suction the baby’s mouth and nose
CORD AROUND THE NECK
Feel around the baby’s neck for the umbilical cord..
If the cord is around the neck, attempt to slip it over
the baby’s head
If the cord is tight around the neck, doubly clamp
and cut it before unwinding it from around the neck
As the head emerges, the baby will turn to one side (for
easier passage of shoulders through birth canal)
Note the time, if possible
Allow the baby’s head to turn spontaneously.
•After the head turns, place a hand on each side of the
baby’s head.
•Tell the woman to push gently with the next contraction.
•Reduce tears by delivering one shoulder at a time
DELIVERY OF FETAL HEAD WITH ROL POSITION
2. Delivery of the anterior shoulder
by gentle downward traction on the head.
In the direction of the axis of the body
3. DELIVERY OF POSTERIOR SHOULDER by elevating the
head. Support the rest of the baby’s body with one hand
as it slides out
Delivery Of Shoulders
4. DELIVERY OF THE TRUNK

After the delivery of the shoulders the baby is grasped around

the chest to aid the birth of the trunk.
Finally, the body is slowly extracted by traction on the
shoulders and lifts the baby towards the mother’s abdomen.
 The time of delivery is noted.
5. CLAMING AND CUTTING THE UMBILICAL CORD
After delivery .. wait 15 to 20 seconds before clamping
and cutting the umbilical cord.
After cutting the cord a plastic crushing clamp is placed
on the cord 1 to 2 cm from the umbilicus and the cord
is cut again 1 cm beyond the clamp.
Clamping, cutting and tying Of umbilical cord
EPISIOTOMY
Surgical incision into the perineum to enlarge the
diameter of vulval outlet & assist childbirth.
Benefits:
1.Speed up the birth
2.Prevent Tearing
3.Protects against incontinence
4.Protects against pelvic floor relaxation
5.Heals easier than tears
No decrease of :
perineal damage
future vaginal prolapse
urinary incontinence
Increase:
3rd & 4th degree tears
anal sphincter muscle dysfunction.
Indications :

1. Sizeable babies with anticipation of shoulder dystocia.

2. Shoulder dystocia.
3. Instrumental delivery (according to judgement)
4. Breech
5. Scarring from female genital mutilation or poorly healed third or
fourth degree tears
6. Fetal distress.
7.Prevent perineal tear or excessive stretching of muscles ,tear may
involve anal sphincter and stretching may lead to prolapse in later
years
8.Prevent damage from abnormal presenting part e.g face
presentation .
Complications
1.haemorrhage
2.infection
3.dyspareunia
4.extension to anal sphincter(third ,fourth degree tears)
Types Mediolateral rather than midline (less 3rd and 4th
degree perennial tear).
 IMMEDIATE CARE OF THE NEW BORN

Once the baby is breathing normally he should be dried and warmly

wrapped to prevent cooling and handle to the mother to hold, cuddle
and enjoy.
If spontaneous respiration is not established soon after birth,
resuscitation is the immediate priority.
The Apgar’s score of the baby should be noted and recorded.
 MANAGEMENT 3nd STAGE OF LABOUR

I. Delivery of placenta

II. Examination of placenta
& perineum
 III. Repair of episiotomy
I. Delivery OF THE PLACENTA :
two stages:
1)Separation of the placenta from the wall of the uterus and into the lower uterine
segment and/or the vagina, and
2) Actual expulsion of the placenta out of the birth canal.

MECHANISM OF PLACENTA SEPARATION:

1 Mathews-Duncan mechanism
The leading edge of the placenta separates first and the placenta is delivered with its raw
surface exposed.
2 Schultz mechanism :
If the placenta is inserted at the fundus and central area separates first, the placenta
inverts and draws the membranes after it, covering the raw surface (inverted umbrella)
• SIGNS OF PLACENTAL SEPARATION

• within 5 minutes after the delivery of the infant.

1. The uterus becomes globular and hard. =earliest to appear.
2. Sudden gush of blood
3. The uterus rises in the abdomen because the placenta, having separated
passes down into the lower segment and vagina, where its bulk pushes the uterus
upward.
 4. Cord lengthening. =most reliable clinically.
 ACTIVE MANAGEMENT OF THE THIRD STAGE

• Helps prevent postpartum haemorrhage. includes:

 1. use of oxytocin
 2. controlled cord traction,
 3. uterine massage.
• Once the signs of placental separation have occurred the obstetrician
assists delivery of the placenta by controlled cord traction as
described by Brandt- Andrews’ method. If the patient is awake, she is
asked to bear down while gentle traction is made on the umbilical
cord.
• II. EXAMINATION
• 1. OF THE PLACENTA : The placenta, membranes, and umbilical cord
should be examined for completeness and for anomalies.
• 2. OF THE PERINEUM :At the same time, the perineal region, vulva
outlet, vaginal canal, and the cervix should be carefully examined for
lacerations.
• If the perineum has been torn or an episiotomy made, tear or
incision should be repaired immediately.
• III. REPAIR OF EPISIOTOMY
• Suture as soon as possible after delivery to avoid bleeding and
infection.