Assessment and

management of intra-
natal period

Mrs. Joealin Mariam James

Nursing Tutor
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INTRODUCTION
 Labour is described as the process by which the foetus, placenta, &
membranes are expelled through the birth canal.
 It may occur prior to 37 completed week is called “Preterm Labour”.
 Labour is characterized by the presence of regular Uterine contraction with
Effacement & Dilation of the cervix & Foetal decent

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• A Parturient :- Mother who is in labour.

• Parturition :- Process of giving birth.

• Delivery :- is the expulsion or extraction of viable foetus out of the womb.

Delivery both included LSCS & Elective C.S without labour. It is

either spontaneous or aided or it may be abdominal.

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DEFINITION

Series of events that takes 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 is called Labour.

Normal labour or Eutocia

Abnormal Labour or Dystocia (any deviation from the normal Labour)

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 Normal labor (eutocia)

Labor is called normal if it fulfills following criteria:

• Spontaneous in onset and at term
• With vertex presentation
• Without undue prolongation
• Natural termination with minimal aids
• Without having any complications affecting the health of the mother
and /or the baby.

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Abnormal labor (dystocia): Any deviation from the definition
of normal labor is called abnormal labor

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 Causes of onset of Labour

The precise mechanism of initiation of labour is still obscure.

 Uterine distension

 Feto placental contribution

 Oestrogen

 Progesterone

 Prostaglandins

 Oxytocin

 Neurological
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 Uterine distension:- Stretching effect on the myometrium by the growing
foetus & liquor amnii can explain the onset of labour.

Feto placental Contribution:- foetal hypothalamic-pituitary-adrenal axis (HPA)

prior to onset of labour Increased CRH (Cortisone Releasing Hormone)
Increased release of ACTH (Adrenocorticotropic hormone) Fetal adrenals
Increased cortisol secretion Accelerated production of Oestrogen &
Prostaglandins from the placenta.

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Oestrogen :-
Increases the release of Oxytocin from maternal pituitary and increases
excitability of the myometrial cell membranes.
Promotes the synthesis of myometrial receptors from oxytocin in the
myometrium & decidua.
Accelerates lysosomal disintegration in the decidual & amnii cells resulting in
increased prostaglandin synthesis.
Stimulates the synthesis of myometrial contractile protein.

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Progesterone:-Increased foetal production of Dehydroepiandrosterone
sulphate & cortisol inhibits the conversion of foetal pregnenolone to
progesterone this progesterone level decreases before labour.
Prostaglandins:-are the important factor which initiate & maintain
labour. The major sites of synthesis of prostaglandins are amnion chorion
decidual cell & myometrium.
Oxytocin:-Large no of oxytocin receptor present in fundus than lower
segment & cervix.

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Neurological factors:- both α & β adrenergic receptors are present in the
myometrium oestrogen causing the α receptors & progesterone the β
receptors to function predominantly. The contractile response in initiated
through the α receptors of the postganglionic nerve fibres in & around the
cervix & lower part of the uterus.

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FALSE PAIN: It is found more in primigravidae than in parous women. It
usually appears prior to the onset of true labor pain by 1 or 2 weeks in
primigravidae and by a few days in multipara. Such pains are probably due
to stretching of the cervix and lower uterine segment with consequent
irritation.
PRELABOUR :- the premonitory signs of labour(i.e. lightening, cervical
ripening, taking up of the cervix & false labour pain) that occur prior to the
onset of the true labour pains, is called Pre-labour. It maybe last from few
days to few weeks & associated with increased oxytocin receptors in
myometrium. The premonitory stage may begin 2–3 weeks before the
onset of true labor in primigravidae and a few days before in multiparae.

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• The features of prelabor are inconsistent and may consist of the
following:
 “Lightening”: A few weeks prior to the onset of labor especially in
primigravidae, the presenting part sinks into the true pelvis. It is due
to active pulling up of the lower pole of the uterus around the
presenting part. This diminishes the fundal height and hence
minimizes the pressure on the diaphragm. The mother experiences a
sense of relief from the mechanical cardiorespiratory embarrassment.
There may be frequency of micturition or constipation due to
mechanical factor—pressure by the engaged presenting part. It is a
welcome sign.

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05/03/22 14
 Cervical changes: A few days prior to the onset of labor, cervix
becomes ripe.
A ripe cervix is
(a) soft,
(b) 80% effaced
(c) Admits one finger easily, and
(d) Cervical canal is dilatable.
 Appearance of false pain

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 True labour pain is characterized by:
i. Painful uterine contractions at regular intervals
ii. Frequency of contractions increase gradually
iii. Intensity and duration of contractions increase progressively
iv. Associated with 'show
v. Progressive effacement and dilatation of the cervix
vi. Descent of the presenting part
vii. Formation of the 'bag of forewaters’
viii.Not relieved by enema or sedatives.

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False labor pain is:
(i) Dull in nature
(ii) confined to lower abdomen and groin
(iii) not associated with hardening of the uterus
(iv) they have no other features of true labor pain
(v) usually relieved by enema or sedative.

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 Labor pain: Throughout pregnancy, painless Braxton Hicks
contractions with simultaneous hardening of the uterus occur. These
contractions change their character, become more powerful,
intermittent and are associated with pain. Pain more often felt in front
of the abdomen or radiating toward the thighs.
 Show: With the onset of labor, there is profuse cervical secretion.
Simultaneously, there is slight oozing of blood from rupture of
capillary vessels of the cervix and from the raw decidual surface
caused by separation of the membranes due to stretching of the lower
uterine segment. Expulsion of cervical mucus plug mixed with blood is
called “show”.

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 Dilatation of internal os: With the onset of labor pain, the cervical
canal begins to dilate more in the upper part than in the lower, the
former being accompanied by corresponding stretching of the lower
uterine segment.

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 STAGES
OF
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STAGES OF LABOR:
 First stage: It starts from the onset of true labor pain and ends with full
dilatation of the cervix. It is, in other words, the “cervical stage” of labor.
Its average duration is 12 hours in primigravidae and 6 hours in
multiparae.
 Second stage: It starts from the full dilatation of the cervix and ends
with expulsion of the fetus from the birth canal.
It has got two phases:
(1) The propulsive phase starts from full dilatation up to the descent of the
presenting part to the pelvic floor.
(2) The expulsive phase is distinguished by maternal bearing down efforts
and ends with delivery of the baby. Its average duration is 2 hours in
primigravidae and 30 minutes in multiparae.
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 Third stage: It begins after expulsion of the fetus and ends with
expulsion of the placenta and membranes. Its average duration is about
15 minutes in both primigravidae and multiparae.
 Fourth stage: It is the stage of observation for at least 1 hour after
expulsion of the afterbirths. During this period maternal vitals, uterine
retraction and any vaginal bleeding are monitored. Baby is examined.
These are done to ensure that both the mother and baby are well.

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 PHYSIOLOGY OF NORMAL LABOR
• During pregnancy there is marked hypertrophy and hyperplasia of the
uterine muscle and the enlargement of the uterus.
• At term, the length of the uterus measures about 35 cm including cervix.
• The fundus is wider both transversely and antero posteriorly than the
lower segment.
• The uterus assumes pyriform or ovoid shape.
• The cervical canal is occluded by a thick, tenacious and mucus plug.
Uterine Contraction In Labor: Throughout pregnancy there is
irregular involuntary spasmodic uterine contractions which are painless
(Braxton Hicks) and have no effect on dilatation of the cervix. The
character of the contractions changes with the onset of labor.

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 Tonus: It is the intrauterine pressure in between contractions. During
pregnancy, as the uterus is inactive, the tonus is of 2–3 mm Hg. During the
first stage of labor, it varies from 8 mm Hg to 10 mm Hg.
 Intensity: The intensity of uterine contraction describes the degree of
uterine systole. The intensity gradually increases with advancement of
labor until it becomes maximum in the second stage during delivery of the
baby. Intrauterine pressure is raised to 40–50 mm Hg during first stage and
about 100–120 mm Hg in second stage of labor during contractions.
 Duration: In the first stage, the contractions last for about 30 seconds
initially but gradually increase in duration with the progress of labor. Thus
in the second stage, the contractions last longer than in the first stage.
 Frequency: In the early stage of labor, the contractions come at intervals
of 10–15 minutes. The intervals gradually shorten with advancement of
labor until in the second stage, when it comes every 2–3 minutes
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 First stage of labour
First stage of labour (Cervical Stage)

It starts from the onset of true labour pain & ends with full dilatation of
the cervix. It has long duration. It will take 12hrs for Primi 6-8hrs for Multi.

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The first stage divided in to three phases
Latent phase
Active phase
Transition phase

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• Latent phase
It is defined as the period between the onset of true labour pains & ends
with cervical dilatation of 3-4cm.
Duration:- in Primigravida – 8hrs & Multi 5hrs
Frequency & interval:- contraction comes at interval of 15-30mts with duration
of about 30secs. But gradually the interval shortened with increasing intensity
& duration.

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Active phase
The active phase of labour begins when the cervix is 3-4cm dilated & ends
when cervical dilation is of 8cm. During this phase, contraction occurs every 3-
5mts & lasts up to 60secs.
Duration:- in Primi 6hrs & Multi 4hrs

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Transition phase
The last & shortest part of 1st phase of labour is transition; it is more
intense phase of a labouring woman. Contraction occurs every 2-3mts lasting
60-90secs. Its starts with 8cm to 10cm.
• Duration:- in Primi it last for 2hrs & in Multi 1hr.

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 EVENTS IN FIRST STAGE OF LABOR
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—
(a) Dilatation and effacement of the cervix
(b) Full formation of lower uterine segment.

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 DILATATION OF THE CERVIX: Prior to the onset of labor, in
the prelabor phase there may be a certain amount of dilatation of
cervix, especially in multipara and in some primigravidae

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Actual factors responsible to dilatation of the cervix are:
• Uterine contraction & retraction
• Fetal axis pressure
• Bag of membranes
• Vis-a-tergo

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Contraction & Retraction of the uterine muscles
Contractions (tightening) and retraction (shortening) of myometrial muscle
fibers increase in length, strength and frequency as labour progresses.

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Fetal axis pressure: this is the force transmitted by the uterine
contractions down the fetal spine to its head

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Bag of membranes: The membranes are attached loosely to the decidua
lining the uterine cavity except over the internal os. In vertex presentation, the
girdle of contact of the head (that part of the circumference of the head which
first comes in contact with the pelvic brim) being spherical, may well fit with
the wall of the lower uterine segment. Thus, the amniotic cavity is divided into
two compartments. The part above the girdle of contact contains the fetus with
bulk of the liquor called hindwaters, and the one below it containing small
amount of liquor called forewaters.

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Vis-a-tergo: The final phase of dilatation and retraction of the cervix is
achieved by downward thrust of the presenting part of the fetus and upward
pull of the cervix over the lower segment.

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 EFFACEMENT OR TAKING UP OF CERVIX: Effacement is the
process by which the muscular fibers of the cervix are pulled upward and
merges with the fibers of the lower uterine segment. The cervix becomes
thin during first stage of labor or even before that in primigravidae. In
primigravidae, effacement precedes dilatation of the cervix, whereas in
multiparae, both occur simultaneously. Expulsion of mucus plug is
caused by effacement.

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 LOWER UTERINE SEGMENT: Before the onset of labor, there
is no complete anatomical or functional division of the uterus. The wall
of the upper segment becomes progressively thickened with progressive
thinning of the lower segment.

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EVENTS IN SECOND STAGE OF
LABOR
• The second stage begins with the complete dilatation of the cervix
and ends with the expulsion of the fetus.
• This stage is concerned with the descent and delivery of the fetus
through the birth canal.

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Second stage has two phases:
(1) Propulsive—from full dilatation until head touches the pelvic floor.
(2) Expulsive—since the time mother has irresistible desire to “bear
down” and push until the baby is delivered.

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With the full dilatation of the cervix, the membranes usually
rupture and there is escape of good amount of liquor amnii.

The volume of the uterine cavity is thereby reduced.

Simultaneously, uterine contraction and retraction become

stronger.

The uterus becomes elongated during contraction, while the

anteroposterior and transverse diameters are reduced.

The elongation is partly due to the contractions of the

circular muscle fibers of the uterus to keep the fetal axis
straight.
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Delivery of the fetus is accomplished by the downward thrust offered by uterine
contractions supplemented by voluntary contraction of abdominal muscles
against the resistance offered by bony and soft tissues of the birth canal.

There is always a tendency to push the fetus back into the uterine cavity by the
elastic recoil of the tissue of the vagina and the pelvic floor.

This is effectively counterbalanced by the power of retraction.

Thus, with increasing contraction and retraction, the upper segment becomes
more and more thicker with corresponding thinning of lower segment.

Endowed with power of retraction, the fetus is gradually expelled from the
uterus against the resistance offered by the pelvic floor.
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After the expulsion of the fetus, the uterine cavity is permanently reduced in
size only to accommodate the afterbirths.

The expulsive force of uterine contractions is added by voluntary contraction

of the abdominal muscles called “bearing down” efforts.

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 EVENTS IN THIRD STAGE OF LABOR
The third stage of labor comprises the phase of placental separation; its
descent to the lower segment and finally its expulsion with the membranes.

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PLACENTAL SEPARATION
• At the beginning of labor, the placental attachment roughly corresponds to
an area of 20 cm (8") in diameter.
• There is no appreciable diminution of the surface area of the placental
attachment during first stage.
• During the second stage, there is slight but progressive diminution of the
area following successive retractions, which attains its peak immediately
following the birth of the baby.
• After the birth of the baby, the uterus measures about 20 cm (8") vertically
and 10 cm (4") antero posteriorly, the shape becomes discoid.
• The wall of the upper segment is much thickened while thin and flabby
lower segment is thrown into folds. The cavity is much reduced to
accommodate only the afterbirths.
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Mechanism of separation:
• Marked retraction reduces effectively the surface area at the placental
site to about its half.
• A shearing force is instituted between the placenta and the placental
site which brings about its ultimate separation.

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There are two ways of separation of placenta.
(1) Central separation (Schultze): Detachment of
placenta from its uterine attachment starts at the
center resulting in opening up of few uterine sinuses
and accumulation of blood behind the placenta
(retroplacental hematoma). With increasing
contraction, more and more detachment occurs
facilitated by weight of the placenta and
retroplacental blood until whole of the placenta gets
detached.
(2) Marginal separation (Mathews-Duncan):
Separation starts at the margin as it is mostly
unsupported. With progressive uterine contraction,
more and more areas of the placenta get separated.
Marginal
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separation is found more frequently. 47
SEPARATION OF THE MEMBRANES:
The membranes, which are attached loosely in the active part, are thrown
into multiple folds. Those attached to the lower segment are already
separated during its stretching. The separation is facilitated partly by uterine
contraction and mostly by weight of the placenta as it descends down from
the active part.

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EXPULSION OF PLACENTA:
• After complete separation of the placenta, it is forced down into the
flabby lower uterine segment or upper part of the vagina by effective
contraction and retraction of the uterus.
• Thereafter, it is expelled out either by voluntary contraction of
abdominal muscles (bearing down efforts) or by manual procedure.

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 MECHANISM OF NORMAL
LABOR
DEFINITION
The series of movements that occur on the head in the process of adaptation
during its journey through the pelvis is called mechanism of labor. It should
be borne in mind that while the principal movements are taking place in the
head, the rest of the fetal trunk is also involved in it, either participating in
or initiating the movement.

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MECHANISM:
The principal movements are:
(1) Engagement
(2) Descent
(3) Flexion
(4) Internal rotation
(5) Crowning
(6) Extension
(7) Restitution
(8) External rotation
(9) Expulsion of the trunk

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Engagement:
Passage of widest diameter of presenting part to the level beyond the plane
of pelvic inlet.

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Descent:
• Provided there is no undue bony or soft tissue obstruction, descent is a
continuous process.
• It is slow or insignificant in first stage but pronounced in second stage.
• It is completed with the expulsion of the fetus.
• In primigravidae, with prior engagement of the head, there is practically
no descent in first stage; while in multiparae, descent starts with
engagement.
• Head is expected to reach the pelvic floor by the time the cervix is fully
dilated.
Factors facilitating descent are—
(1) Uterine contraction and retraction
(2) Bearing down efforts
(3) Straightening of the ovoid fetal especially after rupture of the
membranes.
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Flexion:
While some degree of flexion of the head is noticeable at the beginning of
labor. As the head meets the resistance of the birth canal during descent, full
flexion is achieved. Thus, if the pelvis is adequate, flexion is achieved either
due to the resistance offered by the unfolding cervix, the walls of the pelvis
or by the pelvic floor.

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Internal rotation:
Well flexed head descends and occiput will touch the slopping floor gutter
and rotates anteriorly to come to lie just beneath pubis symphysis

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Crowning:
After internal rotation of the head, further descent occurs until the sub
occiput lies underneath the pubic arch. At this stage, the maximum
diameter of the head (biparietal diameter) stretches the vulval outlet
without any recession of the head even after the contraction is over—
called “crowning of the head”.

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Extension:
The driving force pushes the head in a downward direction while the pelvic
floor offers a resistance in the upward and forward direction. The downward
and upward forces neutralize and remaining forward thrust helping in
extension. The successive parts of the fetal head to be born through the
stretched vulval outlet are vertex, brow and face. Immediately following the
release of the chin through the anterior margin of the stretched perineum, the
head drops down, bringing the chin in close proximity to the maternal anal
opening.

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Restitution:
It is the visible passive movement of the head due to untwisting of the neck
sustained during internal rotation. Movement of restitution occurs rotating
the head through one-eighth of a circle in the direction opposite to that of
internal rotation. The occiput thus points to the maternal thigh of the
corresponding side to which it originally lay.

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External Rotation:
It is the movement of rotation of the head visible externally due to internal
rotation of the shoulders. As the anterior shoulder rotates toward the
symphysis pubis from the oblique diameter, it carries the head in a
movement of external rotation through one-eighth of a circle in the same
direction as restitution. The shoulders now lie in the anteroposterior
diameter. The occiput points directly toward the maternal thigh
corresponding to the side to which it originally directed at the time of
engagement

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Birth of Shoulders and Trunk:
After the shoulders are positioned in anteroposterior diameter of the outlet,
further descent takes place until the anterior shoulder escapes below the
symphysis pubis first. By a movement of lateral flexion of the spine, the
posterior shoulder sweeps over the perineum. Rest of the trunk is then
expelled out by lateral flexion.

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05/03/22 61
 CLINICAL COURSE OF FIRST STAGE
OF LABOR
The first symptom to appear is intermittent painful uterine contractions
followed by expulsion of bloodstained mucus (show) per vagina. Only
few drops of blood mixed with mucus is expelled and any excess should
be considered abnormal.

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• PAIN: Pains are felt more anteriorly with simultaneous hardening of the
uterus. Initially, pains are not strong enough to cause discomfort and
come at varying intervals of 15–30 minutes with duration of about 30
seconds. But gradually the interval becomes shortened with increasing
intensity and duration so that in late first stage the contraction comes at
intervals of 3–5 minutes and lasts for about 45 seconds.
• DILATATION AND EFFACEMENT OF THE CERVIX:
Progressive anatomical changes in the cervix, such as dilatation and
effacement, are recorded following each vaginal examination. Cervical
dilatation is expressed either in terms of fingers—1, 2, 3 or fully dilated
or better in terms of centimeters (10 cm when fully dilated). It is usually
measured with fingers but recorded in centimeters. One finger equals to
1.6 cm on average. Simultaneously, effacement of the cervix is expressed
in terms of percentage, i.e. 25%, 50% or 100% (cervix less than 0.25 cm
thick).
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• STATUS OF THE MEMBRANES: Membranes usually remain
intact until full dilatation of the cervix or sometimes even beyond in the
second stage. However, it may rupture any time after the onset of labor
but before full dilatation of cervix—when it is called early rupture.
When the membranes rupture before the onset of labor, it is called
premature rupture.

• MATERNAL SYSTEM: General condition remains unaffected;

although, a feeling of transient fatigue appears following a strong
contraction. Pulse rate is increased by 10–15 beats per minute during
contraction, which settles down to its previous rate in between
contractions. Systolic blood pressure is raised by about 10 mm Hg
during contraction. Temperature remains unchanged.
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• FETAL EFFECT: As long as the membranes are intact, there is
hardly any adverse effect on the fetus. However, during contraction,
there may be slowing of fetal heart rate by 10–20 beats per minute
which soon returns to its normal rate of about 140 per minute as the
intensity of contraction diminishes provided the fetus is not
compromised.

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 CLINICAL COURSE OF SECOND STAGE OF
LABOR
Second stage begins with full dilatation of the cervix and ends with
expulsion of the fetus.
• PAIN: The intensity of the pain increases. The pain comes at intervals of
2–3 minutes and lasts for about 1–1½ minutes. It becomes successive with
increasing intensity in the second stage.
• BEARING-DOWN EFFORTS: It is the additional voluntary
expulsive efforts that appear during the second stage of labor (expulsive
phase). It is initiated by nerve reflex set up due to stretching of the vagina
by the presenting part. Along with uterine contraction, the woman is
instructed to exert downward pressure as done during straining at stool.
Sustained pushing beyond the uterine contraction is discouraged.
Premature (in the first stage) bearing-down efforts may suggest uterine 66
05/03/22
• MEMBRANES STATUS: Membranes may rupture with a gush of
liquor per vaginam. Rupture may occasionally be delayed till the head
bulges out through the vagina.
• DESCENT OF THE FETUS: Features of descent of the fetus are
evident from abdominal and vaginal examinations. Abdominal findings
are—progressive descent of the head, assessed in relation to the brim,
rotation of the anterior shoulder to the midline and change in position of
the fetal heart rate— shifted downward and medially. Internal
examination reveals descent of the head in relation to ischial spines and
gradual rotation of the head evidenced by position of the sagittal suture,
and the occiput in relation to the quadrants of the pelvis

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05/03/22 68
• VAGINAL SIGNS: As the head descends down, it distends the perineum,
the vulval opening looks like a slit through which the scalp hair is visible.
During each contraction, the perineum is markedly distended with the
overlying skin tense and glistening and the vulval opening becomes circular.
The adjoining anal sphincter is stretched and stool comes out during
contraction. Ultimately, the maximum diameter of the head stretches the
vulval outlet. This is called “crowning” of the head. The head is born by
extension. After a little pause, the mother experiences further pain and
bearing-down efforts to expel the shoulders and the trunk
• MATERNAL SIGNS: There are features of exhaustion. Respiration is,
however, slowed down with increased perspiration. During the bearing-down
efforts, the face becomes congested with neck veins prominent. Immediately
following the expulsion of the fetus, the mother heaves a sigh of relief.
• FETAL EFFECTS: Slowing of FHR during contractions is observed,
which
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comes back to normal before the next contraction. 69
 CLINICAL COURSE OF THIRD STAGE OF
LABOR
Third stage includes separation, descent and expulsion of the placenta with its
membranes.
• PAIN: For a short time, the patient experiences no pain. However,
intermittent discomfort in the lower abdomen reappears, corresponding
with the uterine contractions.
• BEFORE SEPARATION:
Per abdomen: Uterus becomes discoid in shape, firm in feel and
nonballottable. Fundal height reaches slightly below the umbilicus.
Per vaginam: There may be slight trickling of blood. Length of the
umbilical cord as visible from outside remains static.
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• AFTER SEPARATION: It takes about 5 minutes in conventional
management for the placenta to separate.
Per abdomen:
1. Uterus becomes globular, firm, and ballotable.
2. The fundal height is slightly raised as the separated placenta comes
down in the lower segment and the contracted uterus rests on top of
it.
3. Slight bulging in the suprapubic regiondue to distension of the lower
segment by the separated placenta.
Per vaginum:
4. Slight gush of vaginal bleeding.
5. Permanent lengthening of the cord is established.
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• EXPULSION OF PLACENTA AND MEMBRANES: The
expulsion is achieved either by voluntary bearing down efforts or more
commonly aided by manipulative procedure. The afterbirth delivery is
soon followed by slight to moderate bleeding amounting to 100–250
ml.
• MATERNAL SIGNS: There may be chills and occasional
shivering. Slight transient hypotension is not unusual.

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05/03/22 73
Partograph is a composite graphical record of key data (maternal and
fetal) during labor, entered against time on a single sheet of paper.
The components of a partograph are:
(a) Patient identification
(b) Time
(c) Fetal heart rate — recorded at every 30 minutes
(d) State of membranes and color of liquor : to mark ‘I’ for intact membranes, ‘C’ for
clear and ‘M’ for meconium stained liquor
(e) Cervical dilatation and descent of the head
(f) Uterine contractions — the squares in the vertical columns are shaded according to
duration and intensity
(g) Drugs and fluids
(h) Blood pressure (recorded in vertical line) at every 2 hours and pulse at every 30
minutes
(i) Oxytocin
(j) Urine analysis
(k)05/03/22
Temperature record. 74
Advantages of a partograph:
(i) A single sheet of paper can provide details of necessary information at a
glance
(ii) No need to record labor events repeatedly
(iii) It can predict deviation from normal progress of labor early. So,
appropriate steps could be taken in time
(iv) It facilitates handover procedure
(v) Introduction of partograph in the management of labor has reduced the
incidence of prolonged labor and cesarean section rate. There is
improvement in maternal morbidity, perinatal morbidity and mortality.

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05/03/22 76
 MANAGEMENT OF NORMAL LABOR
General considerations:
• Labor events have got great psychological, emotional and social impact
to the woman and her family. She experiences stress, physical pain and
fear of dangers.
• The caregiver should be tactful, sensitive and respectful to her.
• The woman is allowed to have her chosen companion (family member).
• Continuous emotional support during labor may reduce the need for
analgesia and decrease the rate of operative delivery.
• Privacy must be maintained.
• She is explained about the events from time to time.
• Comfortable environment, skill and confidence of the caregiver and
appropriate support are essential.
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• ANTISEPTICS AND ASEPSIS: Scrupulous surgical cleanliness and
asepsis on the part of the patients and the attendants involved in the
delivery process are to be maintained.
Patient care: Shaving of the vulva is done. The woman should take a
shower or bath, wear laundered gown and stay mobile. Throughout labor
she is given continued encouragement and emotional support. Antiseptic
and aseptic precautions are to be taken during vaginal examination and
during conduction of delivery.

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• VAGINAL EXAMINATION IN LABOR: First vaginal examination
should be done by a senior doctor to be more reliable and informative. The
examination is done with the patient lying in dorsal position.
PRELIMINARIES:
(1) Toileting—Hands and forearms should be washed with soap and
running water, a scrubbing brush be used for the finger nails. The
procedure should take at least 3 minutes.
(2) Sterile pair of gloves is donned.
(3) Vulval toileting is performed.
(4) Gloved middle and index fingers of the right hand smeared liberally
with lubricant are introduced into the vagina after separating the labia
by two fingers of the left hand.
(5) Complete examination should be done before fingers are withdrawn.
(6) Vaginal examination should be kept as minimum as possible to avoid
risks of infection.
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The following information's are to be noted and recorded carefully:
 Degree of cervical dilatation in centimeters
 Degree of effacement of cervix
 Status of membranes and if ruptured—color of the liquor.
 Presenting part and its position
 Lambda or Posterior fontanel
 Bregma or anterior fontanel
 Caput or molding of the head
 Station of the head
 Assessment of the pelvis

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INDICATIONS OF VAGINAL EXAMINATION:
Vaginal examination should be restricted to a minimum.
• At the onset of labor: Confirm the onset of labor, to detect precisely the
presenting part and its position.
• The progress of labor can be judged on periodic examinations noting the
dilatation of the cervix and descent of the head in relation to the spines.
Generally, it is done at an interval of 3–4 hours.
• Following rupture of the membranes to exclude cord prolapse especially
where the head is not yet engaged.
• Whenever any interference is contemplated.
• To confirm the actual coincidence of bearing down efforts with complete
dilatation of the cervix and to diagnose precisely the beginning of second
stage.
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 MANAGEMENT OF THE FIRST STAGE
PRINCIPLES:

(1) Noninterference with watchful expectancy so as to prepare the patient

for natural birth.
(2) To monitor carefully the progress of labor, maternal conditions and fetal
behavior so as to detect any intrapartum complication early.

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PRELIMINARIES: This consists of basic evaluation of the current
clinical condition. Enquiry is to be made about the onset of labor pains or
leakage of liquor, if any. Thorough general and obstetrical examinations
including vaginal examination are to be carried out and recorded. Records
of antenatal visits, investigation reports and any specific treatment given, if
available, are to be reviewed.

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ACTUAL MANAGEMENT:
 General:
(a) Antiseptic dressing is as described before.
(b) Encouragement, emotional support and assurance are given to keep up
the morale.
(c) Constant supervision is ensured.
 Bowel: An enema with soap and water or glycerin suppository is
traditionally given in early stage.
 Rest and ambulation: If the membranes are intact, the patient is allowed
to walk about. This attitude prevents venacaval compression and
encourages descent of the head. Ambulation can reduce the duration of
labor, need of analgesia and improve maternal comfort. If, however, labor
is monitored electronically or drugs is given, she should be in bed.
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 Diet: There is delayed emptying of the stomach in labor. So food is withheld
during active labor. Fluids in the form of plain water, ice chips or fruit juice
may be given in early labor. Intravenous fluid with ringer solution is started
where any intervention is anticipated or the patient is under regional
anesthesia.
 Bladder care: Patient is encouraged to pass urine by herself as full bladder
often inhibits uterine contraction and may lead to infection. If the patient
fails to pass urine especially in late first stage, catheterization is to be done
with strict aseptic precautions.
 Relief of pain: For practical purposes, the common analgesic drug used is
pethidine 50–100 mg intramuscularly when the pain is well established in
the active phase of labor. The drug should not be given if delivery is
anticipated within 2 hours
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 Assessment of progress of labor and partograph recording
To note the fetal well-being:
 Fetal heart rate (FHR) along with its rhythm and intensity should be
noted every half hour in the first stage and every 15 minutes in second stage
or following rupture of the membranes. To be of value, the observation
should be made immediately following uterine contraction. The count
should be made for 60 seconds.

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Evidence of maternal distress are:
 Anxious look with sunken eyes
 Rising pulse rate of 100 per minute or more
 Dehydration, dry tongue
 Hot, dry vagina often with offensive discharge
 Acetone smell in breath
 Scanty high coloured urine with presence of acetone

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 MANAGEMENT OF THE SECOND
STAGE
The transition from the first stage to the second stage is evidenced by the
following features:
• Increasing intensity of uterine contractions
• Bearing-down efforts
• Urge to push or defecate with descent of the presenting part
• Complete dilatation of the cervix as evidenced on vaginal examination

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PRINCIPLES:
(1) To assist in the natural expulsion of the fetus slowly and steadily
(2) To prevent perineal injuries.

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GENERAL MEASURES:
• The patient should be in bed.
• Constant supervision is mandatory and the FHR is recorded at every 5
minutes.
• To administer inhalation analgesics, if available, in the form of gas to
relieve pain during contractions.
• Vaginal examination is done at the beginning of the second stage not
only to confirm its onset but to detect any accidental cord prolapse.
• The position and the station of the head are once more to be reviewed
and the progressive descent of the head is ensured.

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PREPARATION FOR DELIVERY
• Position: Positions of the woman during delivery may be lateral,
squatting or partial sitting (45°).
• The accoucheur scrubs up and puts on sterile gown, mask and gloves and
stands on the right side of the table.
• Toileting the external genitalia and inner side of the thighs is done with
cotton swabs soaked in Savlon or Dettol solution. One sterile sheet is
placed beneath the buttocks of the patient and one over the abdomen.
Sterilized leggings are to be used. Essential aseptic procedures are
remembered as three Cs: (a) Clean hands, (b) Clean surface and (c) Clean
cutting and ligaturing of the cord.
• To catheterize the bladder, if it is full.

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Care following delivery of the head:
• Immediately following delivery of the head, the mucus and blood in
mouth and pharynx are to be wiped with sterile gauze piece on a little
finger. Alternatively, mechanical or electrical sucker may be used. This
simple procedure prevents the serious consequence of mucus blocking
the air passage during vigorous inspiratory efforts.
• The eyelids are then wiped with sterile dry cotton swabs using one for
each eye starting from the medial to the lateral canthus to minimize
contamination of the conjunctival sac.
• The neck is then palpated to exclude the presence of any loop of cord.
If it is found and if loose enough, it should be slipped over the head or
over the shoulders as the baby is being born. But if it is sufficiently
tight enough, it is cut in between two pairs of Kocher’s forceps placed
1 inch apart.
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PREVENTION OF PERINEAL LACERATION:
More attention should be paid not to the perineum but to the controlled
delivery of the head.
• Delivery by early extension is to be avoided.
• Spontaneous forcible delivery of the head is to be avoided by assuring
the patient not to bear down during contractions.
• To deliver the head in between contractions.
• To perform timely episiotomy (when indicated).
• To take care during delivery of the shoulders as the wider biacromial
diameter (12 cm) emerges out of the introitus.

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 EPISIOTOMY
DEFINITION: A surgically planned incision on the perineum and the
posterior vaginal wall during the second stage of labor is called
episiotomy (perineotomy).

OBJECTIVES
• To enlarge the vaginal introitus so as to facilitate easy and safe delivery
of the fetus: spontaneous or manipulative.
• To minimize overstretching and rupture of the perineal muscles and
fascia; to reduce the stress and strain on the fetal head.

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INDICATIONS:
 In elastic (rigid) perineum: Causing arrest or delay in descent of the
presenting part as in elderly primigravidae.
 Anticipating perineal tear:
(a) Big baby
(b) face to pubis delivery
(c) breech delivery and
(d) shoulder dystocia.
 Operative delivery: Forceps delivery, ventouse delivery.
 Previous perineal surgery: Pelvic floor repair, perineal
reconstructive surgery.

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Timing of the episiotomy: The timing of performing the episiotomy
requires judgment.
• If done early, the blood loss will be more.
• If done late, it fails to prevent the invisible lacerations of the perineal
body and thereby fails to protect the pelvic floor

Bulging thinned perineum during contraction just prior to crowning

(when 3–4 cm of head is visible) is the ideal time.

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ADVANTAGES
• Maternal:
The suggested benefits are:
(a) a clear and controlled incision is easy to repair and heals better than a
lacerated wound that might occur otherwise
(b) reduction in the duration of second stage and
(c) reduction of trauma to the pelvic floor muscles—that reduces the
incidence of prolapse and perhaps urinary incontinence.
• Fetal:
It minimizes intracranial injuries, especially in premature babies or after-
coming head of breech.

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TYPES
The following are the various types of episiotomy
• Mediolateral
• Median
• Lateral
• ‘J’ shaped

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 Mediolateral: The incision is made downwards and outwards from the
midpoint of the fourchette either to the right or to the left. It is directed
diagonally in a straight line which runs about 2.5 cm away from the anus
(midpoint between anus and ischial tuberosity).
 Median: The incision commences from the center of the fourchette and
extends posteriorly along the midline for about 2.5 cm.
 Lateral: The incision starts from about 1 cm away from the center of the
fourchette and extends laterally. It has got many drawbacks including
chance of injury to the Bartholin’s duct. It is totally condemned.
 ‘J’ shaped: The incision begins in the center of the fourchette and is
directed posteriorly along the midline for about 1.5 cm and then directed
downwards and outwards along 5 or 7 O’clock position to avoid the anal
sphincter. Apposition is not perfect and the repaired wound tends to be
puckered. This is also not done widely.
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05/03/22 100
STEPS
 STEP I: Preliminaries—The perineum is thoroughly swabbed with
antiseptic (povidone-iodine) lotion and draped properly. Local anesthesia:
The perineum, in the line of proposed incision is infiltrated with 10 mL of
1% solution of lignocaine.
 STEP II: Incision—Two fingers are placed in the vagina between the
presenting part and the posterior vaginal wall. The incision is made by a
curved or straight blunt pointed sharp scissors, one blade of which is placed
inside, in between the fingers and the posterior vaginal wall and the other
on the skin.

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 STEP III: Repair
Timing of repair: the repair is done soon after expulsion of placenta.
Preliminaries: The patient is placed in lithotomy position. A good light
source from behind is needed. The perineum including the wound area is
cleansed with antiseptic solution. Blood clots are removed from the vagina
and the wound area. The patient is draped properly and repair should be
done under strict aseptic precautions. If the repair field is obscured by
oozing of blood from above, a vaginal pack may be inserted and is placed
high up. Do not forget to remove the pack after the repair is completed.
Repair: The repair is to be done in the following order: (1) Vaginal
mucosa and submucosal tissues (2)perineal muscles and (3) skin and
subcutaneous tissues.

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05/03/22 103
 IMMEDIATE CARE OF THE
NEWBORN
Soon after the delivery of the baby, it should be placed on a tray covered with
clean dry linen with the head slightly downward. It facilitates drainage of the
mucus accumulated in the tracheobronchial tree by gravity. The tray is placed
between the legs of the mother and should be at a lower level than the uterus
to facilitate gravitation of blood from the placenta to the infant.
• Air passage (oropharynx) should be cleared of mucus and liquor by gentle
suction.
• Apgar rating at 1 minute and at 5 minutes is to be recorded.
• Clamping and ligature of the cord: The cord is clamped by two Kocher’s
forceps, the near one is placed 5 cm away from the umbilicus and is cut in
between.
• Quick
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 MANAGEMENT OF THE THIRD STAGE
• Third stage is the most crucial stage of labor. Previously uneventful first
and second stage can become abnormal within a minute with disastrous
consequences.
• The principles underlying the management of third stage are to ensure
strict vigilance and to follow the management guidelines strictly in
practice so as to prevent the complications, the important one being
postpartum hemorrhage.

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 STEPS OF MANAGEMENT:
Two methods of management are currently in practice.
• Expectant management
• Active management

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Expectant management: In this management, the placental separation and its descent
into the vagina are allowed to occur spontaneously. Minimal assistance may be given for
the placental expulsion if it needed.
• Constant watch is mandatory and the patient should not be left alone.
• If the mother is delivered in the lateral position, she should be changed to dorsal position
to note features of placental separation and to assess the amount of blood loss.
• A hand is placed over the fundus—
(a) to recognize-the signs of separation of placenta
(b) to note the state of uterine activity—contraction and relaxation and
(c) to detect, though rare, cupping of the fundus which is an early evidence of inversion
of the uterus.
• Expulsion of the placenta: Only when the features of placental separation and its descent
into the lower segment are confirmed, the patient is asked to bear down simultaneously
with the hardening of the uterus. The raised intra-abdominal pressure is often adequate to
expel the placenta. If the patient fails to expel, one can wait safely up to 10 minutes if
there is no bleeding. As soon as the placenta passes through the introitus, it is grasped by
the hands and twisted round and round with gentle traction so that the membranes are
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stripped intact.
Assisted expulsion:
(a) Controlled cord traction (modified Brandt-
Andrews method) The palmar surface of the
fingers of the left hand is placed (above the
symphysis pubis) approximately at the junction of
upper and lower uterine segment. The body of the
uterus is pushed upward and backward, toward the
umbilicus while by the right hand steady tension
(but not too strong traction) is given in downward
and backward direction holding the clamp until the
placenta comes outside the introitus. It is thus more
an uterine elevation which facilitates expulsion of
the placenta. The procedure is to be adopted only
when the uterus is hard and contracted.
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(b) Fundal pressure The fundus is
pushed downward and backward after
placing four fingers behind the fundus
and the thumb in front using the uterus
as a sort of piston. Pressure must be
given only when the uterus becomes
hard. If it is not, then make it hard by
gentle rubbing. The pressure is to be
withdrawn as soon as the placenta
passes through the introitus. If the baby
is macerated or premature, this method
is preferable to cord traction as the
tensile strength of the cord is much
reduced in both the instances.
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Active Management of Third Stage of Labor (AMTSL)
• The underlying principle in active management is to excite powerful
uterine contractions within 1 minute of delivery of the baby (WHO) by
giving parenteral oxytocic.
• This facilitates not only early separation of the placenta but also produces
effective uterine contractions following its separation.
The advantages are—
a) to minimize blood loss in third stage approximately to one-fifth and
b) to shorten the duration of third stage to half.
The disadvantage is
c) slight increased incidence of retained placenta (1–2%) and
consequent increased incidence of manual removal.

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Procedures: Injection oxytocin 10 units IM (preferred) or methergine 0.2
mg IM is given within 1 minute of delivery of the baby (WHO). The placenta
is expected to be delivered soon following delivery of the baby. If the
placenta is not delivered thereafter, it should be delivered forthwith by
controlled cord traction (Brandt-Andrews) technique after clamping the cord
while the uterus still remains contracted. If the first attempt fails, another
attempt is made after 2–3 minutes failing which another attempt is made at 10
minutes. If this still fails, manual removal is to be done. Oxytocic may be
given with crowning of the head, with delivery of the anterior shoulder of the
baby or after the delivery of the placenta. If the administration is mistimed as
might happen in a busy labor room, one should not be panicky but conduct
the third stage with conventional watchful expectancy.

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FOURTH STAGE OF LABOR
Pulse, blood pressure, tone of the uterus (well retracted) and any abnormal
vaginal bleeding are to be watched at least for 1 hour after delivery. When
fully satisfied that the general condition is good, pulse and blood pressure
are steady, the uterus is well retracted and there is no abnormal vaginal
bleeding, the patient is sent to the ward.

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INDUCTION OF LABOR
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Induction of labor (IOL) means initiation of uterine
contractions (after the period of viability) by any method
(medical, surgical or combined) for the purpose of vaginal
delivery.

The patient and the family members are informed about the benefits,
potential complications and the possibility of cesarean delivery.

Augmentation of labor is the process of stimulation of uterine

contractions (both in frequency and intensity) that are already
present but found to be inadequate.

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05/03/22 115
05/03/22 116
Methods of induction of labor

 Medical

 Surgical

 Combined

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 Medical induction drugs used:
 Prostaglandins (PGE2, PGE3)
• Cervical ripening
• Myometrial contraction
• Sensitizes myometrium to oxytocin
 Oxytocin
• Stimulate uterine contraction
• To produce prostaglandin
 Mifepristone
• Blocks progesterone

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 SURGICAL INDUCTION
METHODS:
• Artificial rupture of the membranes (ARM)
• Stripping the membranes
Low rupture of the membranes (LRM)
Effectiveness depends on:
(1) State of the cervix
(2) Station of the presenting part.
Induction delivery interval is shorter when amniotomy is combined with
oxytocin than when either method is used singly.

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Advantages of amniotomy:
(a) High success rate
(b) Chance to observe the amniotic fluid for blood or meconium
(c) Access to use fetal scalp electrode or intrauterine pressure catheter or
for fetal scalp blood sampling.

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Limitation:
• It cannot be employed in an unfavorable cervix (long, firm cervix with
os closed).
• The cervix should be at least one finger dilated.
Indications:
• Abruptio placentae
• Chronic hydramnios
• Severe pre-eclampsia/ eclampsia
• In combination with medical induction
• To place scalp electrode for electronic fetal monitoring

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Contraindications:
• Intrauterine fetal death
• Maternal AIDS
• Genital active herpes infection.

Immediate beneficial effects of ARM

• Lowering of the blood pressure in pre-eclampsia-eclampsia.
• Relief of maternal distress in hydramnios.
• Control of bleeding in APH.
• Relief of tension in abruptio placentae and initiation of labor.

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HAZARDS OF ARM
• Once the procedure is adopted, there is no scope of retreating from the
decision of delivery.
• Chance of umbilical cord prolapse — The risk is low with engaged
head or rupture of membranes with head fixed to the brim.
• Amnionitis — Careful selection of cases with favorable preinduction
score will shorten the induction delivery interval.
• Accidental injury to the placenta, cervix or uterus, fetal parts or vasa
previa. Care taken during rupture of the membranes minimizes the
problem.
• Liquor amnii embolism (rare).

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 LOW RUPTURE OF THE MEMBRANES (LRM)
• The membranes below the presenting part overlying the internal os are
ruptured to drain some amount of amniotic fluid.
Contraindication:
• It is preferably avoided in chronic hydramnios, as there is risk of
sudden massive liquor drainage.
Procedures:
Preliminaries: It is an indoor procedure. The patient is asked to empty her
bladder. The procedure may be conducted in the labor ward or in the
operation theater if the risk of cord prolapse is high.

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Actual steps
• FHR status is monitored before and after the procedure.
• The patient is in lithotomy position.
• Full surgical asepsis is to be taken.
• Two fingers are introduced into the vagina smeared with antiseptic
ointment. The index finger is passed through the cervical canal beyond
the internal os. Th e membranes are swept free from the lower segment
as far as reached by the finger.
• With one or two fingers still in the cervical canal with the palmar
surface upwards, a long Kocher’s forceps with the blades closed or an
amnion hook is introduced along the palmar aspect of the fingers up to
the membranes.
• Th e blades are opened to seize the membranes and are torn by twisting
movements. Amnihook is used to scratch over the membranes. Th is is
followed by visible escape of amniotic fluid.
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126
 After the membranes rupture, the following are to be
assessed:
(a) Color of the amniotic fluid
(b) Status of the cervix
(c) Station of the head
(d) Detection of cord prolapse if any
(e) FHR pattern is again checked. In high-risk cases scalp electrode
for fetal monitoring is applied.
(f) A sterile vulval pad is placed. Prophylactic antibiotic may be
prescribed.

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Hazards:
(1) Cord prolapse
(2) Uncontrolled escape of amniotic fluid and placental abruption
(3) Injury to the cervix or the presenting part
(4) Rupture of vasa previa leading to fetal blood loss
(5) Amnionitis.

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 STRIPPING THE MEMBRANES
Stripping (sweeping) of the membranes means digital separation of the
choriamniotic membranes from the wall of the cervix and lower uterine
segment.
Sweeping of the membranes is done prior to ARM. It is simple, safe and
beneficial for induction of labor. As an isolated procedure, stripping the
membranes off from its attachment from the lower segment is an effective
procedure for induction provided cervical score is favorable. It is used as a
preliminary step prior to rupture of the membranes. It is also used to make
the cervix ripe.

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Criteria to be fulfilled for membrane stripping are:
(a) The fetal head must be well applied to the cervix
(b) The cervix should be dilated so as to allow the introduction of the
examiner’s finger.

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 COMBINED METHOD
The combined medical and surgical methods are commonly used to increase the efficacy
of induction by reducing the induction-delivery interval. The oxytocin infusion is started
either prior to or following a rupture of the membranes depending mainly upon the state
of the cervix and head brim relation. With the head nonengaged, it is preferable to induce
with prostaglandin gel or to start oxytocin infusion followed by ARM.

The advantages of the combined methods are:

(1) More effective than any single procedure

(2) Shortens the induction-delivery interval

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 Thank
you
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