Management of labor stages

MANAGEMENT OF LABOR STAGES

1. Management of
1
st
,2
nd
and 3
rd
stages of
labor
DR. Ahmed Walid Anwar Morad
Assistant Professor of OBS&GYN
FACULTY OF MEDECINE
BENHA UNIVERISITY
2014

2. Normal LaborNormal Labor
Process by which …… Process by which …… regular regular
uterine contractionsuterine contractions —›—› progressive progressive
effacement and dilatationeffacement and dilatation of the of the
cervix cervix —›—› delivery delivery of theof the fetus fetus and and
the the placentaplacenta at or beyond age of at or beyond age of
fetal viability.fetal viability.

3. 1 LNMP
24 W28 W37 W40W42W
PTL
Term
Labour
Labour can occur at:Labour can occur at:
prolongedprolonged

4. Stages of laborStages of labor
Stage Stage 11
stst
22
ndnd
33
rdrd
44
thth

Onset Onset Onset of Onset of
true true
uterine uterine
contractiocontractio
nsns
Full cx Full cx
dilatationdilatation
Fetal Fetal
expulsionexpulsion
Placental Placental
deliverydelivery
End End Full cx Full cx
dilatationdilatation
Fetal Fetal
expulsionexpulsion
Placental Placental
deliverydelivery
2h 2h
observatioobservatio
ns for ns for
PPHge PPHge
and any and any
complicaticomplicati
onsons
Time Time
oPG =12-14 PG =12-14
hh
oMG = 6-8 hMG = 6-8 h
oPG = 1-2 hPG = 1-2 h
oMG = ½- 1 MG = ½- 1
hh
PG &MG PG &MG
= 10-30 = 10-30
minmin

5. Management of stages of labor
How to deal
Diagnosis
Preparations
Monitoring
Procedures

6. Management of the First Management of the First
Stage of LabourStage of Labour

7. Diagnosis Diagnosis {{made within one hour of admission}made within one hour of admission}
A.A.symptoms:symptoms:
1.1.True labour painsTrue labour pains – colicky pain in the abdomen and back – colicky pain in the abdomen and back
are characterized byare characterized by::
charactercharacter True labour painTrue labour pain False labour painFalse labour pain
contractionscontractions regularregular IrregularIrregular
Interval between Interval between
contractions and contractions and
intensityintensity
Progressive (increase Progressive (increase
in frequency and in frequency and
intensity)intensity)
Short duration, not Short duration, not
progressiveprogressive
Changes in the cervixChanges in the cervix Associated with Associated with
effacement and effacement and
dilation of the dilation of the
cervixcervix
Not associated with Not associated with
effacement and dilation effacement and dilation
of the cervixof the cervix
Membranes Membranes Associated with Associated with
bulging of bulging of
membranesmembranes
Not associated with Not associated with
bulging of membranesbulging of membranes
Response to analgesiaResponse to analgesia Not relieved by Not relieved by
sedation sedation
Relieved by sedationRelieved by sedation
Labour Labour Followed by labourFollowed by labour Not followed by labourNot followed by labour

8. Patient preparations:Patient preparations:
Full Full historyhistory and clinical and clinical examinationexamination
PositionPosition: Encourage any non-supine : Encourage any non-supine
position and movement throughout position and movement throughout
labor and childbirth.labor and childbirth.
DietDiet:: nothing by mouth, IV fluid, or nothing by mouth, IV fluid, or
light diet but fat ,proteins are not light diet but fat ,proteins are not
allowed at all.allowed at all.
IV lineIV line : recommended. : recommended.

9. Patient preparations:Patient preparations:
Rectum:Rectum: no evidence that routine enema is no evidence that routine enema is
beneficial .beneficial .
BladderBladder: :
–Encouraged patient to empty her bladder Encouraged patient to empty her bladder
regularly. regularly.
–Urinary catheter only when woman is unable to Urinary catheter only when woman is unable to
void. void.
Pain Control: Pain Control: antenatal women education antenatal women education
about pain relief techniques- epidural anesthesia about pain relief techniques- epidural anesthesia
―› satisfaction.―› satisfaction.

10. 2.2.Show – blood stained mucous.Show – blood stained mucous.
3.3.SROMSROM
B.B.Signs:Signs:
opalpable or recorded uterine contractionpalpable or recorded uterine contraction
oeffacement and dilation of the cervixeffacement and dilation of the cervix
oformation of forewater formation of forewater

11. What is a partogram
(partograph) ?

12. PARTOGRAMPARTOGRAM
Def:Def: diagrammatic record of the events of diagrammatic record of the events of
labour.labour.
Advantages:Advantages:
–MonitoringMonitoring
 the progress of labour, the progress of labour,
maternal and fetal wellbeing maternal and fetal wellbeing
–Early detectionEarly detection and management of and management of
labour abnormalities.labour abnormalities.

13. Fetal Fetal
cervicalcervical
Descent Descent
Uterine Uterine
Maternal Maternal

14. Timing observations of different parameters of
partogram in the the1st stage of labor
Parameter
Ideal
in both
phases
)hrs(
Minimum acceptable
Latent
phase
Active
phase
Vaginal examination 4 8 4
Descent of head 4 8 4
Contractions ½ 4 2
Fetal heart beats ½ 4 1
Temperature, PR, BP, urine4 4 4

15. Phases of cervical dilatationPhases of cervical dilatation

16. ·The alert line: The alert line:
·DrawnDrawn from 3 cm dilatationfrom 3 cm dilatation ( at rate of dilatation of 1 cm ( at rate of dilatation of 1 cm
/ hour)./ hour).
· Represents the rate of dilatation of the slowest 10 % of Represents the rate of dilatation of the slowest 10 % of
labours in primigravidae. labours in primigravidae.
·Crossing the alert lineCrossing the alert line suggests that the patient should be suggests that the patient should be
transferred to a hospital for extra care. transferred to a hospital for extra care.
·The action lineThe action line : :
· parallel and 2 (4) hours to the right of the alert line; parallel and 2 (4) hours to the right of the alert line;
·crossing the action linecrossing the action line suggests the need for intervention suggests the need for intervention
(eg, artificial rupture of the membranes, administration of (eg, artificial rupture of the membranes, administration of
oxytocics.oxytocics.

17. Vaginal examination:Vaginal examination:
single individual to minimize interobserver single individual to minimize interobserver
variationsvariations
Indications:Indications:
·On admission On admission
·At one to four hour intervals in the At one to four hour intervals in the first stage first stage
·At At rupture of membranesrupture of membranes to evaluate for cord prolapse to evaluate for cord prolapse
·Feeling the Feeling the urge to pushurge to push to determine whether the to determine whether the
cervix is fully dilated cervix is fully dilated
·If the If the FHRFHR falls, to evaluate for conditions such as cord falls, to evaluate for conditions such as cord
prolapse or uterine rupture. prolapse or uterine rupture.

18. Vaginal examination:Vaginal examination:
Disadvantages:Disadvantages:
–Increases woman’s anxiety.Increases woman’s anxiety.
–Increasing numbers vaginal examinations in Increasing numbers vaginal examinations in
(PROM) increases neonatal sepsis (PROM) increases neonatal sepsis

19. Effacement and dilation of the cervixEffacement and dilation of the cervix

20. Assessing descent of the fetal head by Assessing descent of the fetal head by
vaginal examination;vaginal examination;
0 station is at the level of the ischial 0 station is at the level of the ischial
spine (Sp). spine (Sp).

21. 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:

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

23. Active management of Active management of
laborlabor
AmniotomyAmniotomy
Oxytocin Oxytocin
administrationadministration
for dilation rates for dilation rates
of <1 cm/hourof <1 cm/hour

24. Management of second stage
of labour

25. Onset of second stageOnset of second stage
Full cervical dilatation (sure) Full cervical dilatation (sure)
Involuntary Bearing downInvoluntary Bearing down
The urge to defecate and urinate.The urge to defecate and urinate.
Contractions becomes more prolonged.Contractions becomes more prolonged.
Expiratory grunting with expulsive efforts.Expiratory grunting with expulsive efforts.
Rupture of membranes (suggestive)Rupture of membranes (suggestive)

26. 
Position: Position: Patient is put in dorsal Lithotomy position and Patient is put in dorsal Lithotomy position and
the legs are half-flexed the legs are half-flexed
Patient is properly Patient is properly draped draped
AsepsisAsepsis: :
DietDiet
Bladder and rectumBladder and rectum
Pain reliefPain relief
Patient is asked to take Patient is asked to take deep breathdeep breath & breath held then & breath held then
exerts downward pressure at the time of uterine exerts downward pressure at the time of uterine
contraction and relax in betweencontraction and relax in between
Preparation for deliveryPreparation for delivery

27. Fetal heart rate monitoringFetal heart rate monitoring
 Low risk:Low risk: every 15 min every 15 min
 High risk:High risk: every 5 min every 5 min

Slowing of the FHR may occur due to Slowing of the FHR may occur due to
fetal head compressionfetal head compression

28. Obstetrical roleObstetrical role
Bearing down only during contraction.Bearing down only during contraction.
Delivery of the headDelivery of the head
–Crowning Crowning
–The main role of obstetrician is the The main role of obstetrician is the
prevention of perineal tearsprevention of perineal tears
Before crowningBefore crowning
After crowningAfter crowning) ) Ritgen maneuver )Ritgen maneuver )
EpisiotomyEpisiotomy
–Once head delivered clear upper air way. Once head delivered clear upper air way.

29. Ritgen maneuverRitgen maneuver

30. Posterior shoulderPosterior shoulderAnterior shoulderAnterior shoulder
Delivery of shoulderDelivery of shoulder
The rest of the body almost always follows the shoulder The rest of the body almost always follows the shoulder
without difficultywithout difficulty

31. Management of third stage of
labour

32. 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
Management of third stage of labour

33. 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.
Delivery of the placenta and membranes: uterus should
be examined for the presence of second baby

34. 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.

35. 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.

36. Controlled Controlled
cord tractioncord traction
Delivery of Delivery of
the placentathe placenta

37. 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 coomb’s test for Rh
negative mother.

38. 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.

39. Seven Cardinal MovementsSeven Cardinal Movements

EngagementEngagement
–descent of BPD to a level below the plane of the descent of BPD to a level below the plane of the
pelvic inletpelvic inlet

DescentDescent
FlexionFlexion
Internal rotationInternal rotation

ExtensionExtension

RestitutionRestitution
External rotationExternal rotation
ExpulsionExpulsion

41. InductionInduction
Assess adequacy of pelvis and cervical Assess adequacy of pelvis and cervical
examexam
Bishop scoreBishop score

42. Bishop score Bishop score

43. E.mail:::[email protected]