NORMAL LABOR, parturition|progress and stages of labor

It is about the progress of parturition.

1. By Dr. Eyob Dagnew (MD,Ob/Gyn R1)
Moderator : Dr. Sisay Teklu (MD, Associate Dr. Sisay Teklu (MD, Associate
professor of OBGYN)professor of OBGYN)
June 23,2022 G.C
NORMAL LABORNORMAL LABOR

2. Introduction
Physiology of Labor
Fetal orientation in utero
Maternal bony pelvis
Mechanism of initiation of Labor
Diagnosis of Labor
Events in labor
Management of Normal Labor
Summary
References
CONTENTS
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3. At the end of this seminar, we will able to;
Define, classify, diagnose and manage normal labor
Know the mechanics of labor
Understand cardinal movements
Understand Physiology of labor initiation
Know stages and management of normal labor
Basics of new born care
OBJECTIVE
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4. Labor:- is a physiologic process that begins with
regular uterine contractions which result in
effacement & dilatation of the cervix; ends with
delivery of the newborn and expulsion of the placenta
through the birth canal.
Labor is the 3
rd
phase of parturition.
Labor is a clinical diagnosis
Delivery:- The mode of actual expulsion of the fetus
& placenta.
INTRODUCTION:
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5. It is divided into 4 overlapping phases that correspond
to the major physiological transitions of the
myometrium and cervix during pregnancy
o Quiescence – non contractile state
o Activation – preparation for labor
o Stimulation – process of labor
o Involution – recovery
PARTURITION
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6. 02/26/25
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7. Comprises 95% of pregnancy period (the most dominant phase of parturition)
Characterized by uterine smooth muscle tranquility with maintenance of
cervical structural integrity
The myometrial cells are in a non contractile state
Represents that time in utero before labor begins,
Uterine activity is suppressed by the action of
Progesterone, How? ↓PG secretion,↓PG-R,↓OX-R, ↓# of Gap junction
Prostacyclin,
Relaxin
Nitric oxide
Parathyroid hormone–related peptide, and possibly other hormone
PHASE 1: UTERINE QUIESCENCE & CERVICAL
SOFTENING
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8. It is a phase for preparation For Labor
‒is a period during the last few weeks of pregnancy
‒Importantly, shifting events associated with phase 2 can cause either
preterm or delayed labor
Myometrium Changes expression
‒
contraction-associated
proteins (CAPs) include the oxytocin receptor, prostaglandin F
receptor and connexin 43 ion channel activation & increased gap
junctions

‒
Together, these lead to increased uterine irritability
and responsiveness to uterotonins
 Formation of the lower uterine segment from the isthmus
Cervical Ripening
PHASE 2: UTERINE AWAKENING
( ACTIVATION)
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9. Labor has 3 stages
stage of E & D of the CERVIX (1
st
)
stage of delivery of the FETUS(2
nd
)
stage of expulsion of the PLACENTA(3
rd
)
PHASE 3: LABOR
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Stages of LaborDuration of labor in NP Duration of
labor in MP
Latent 1
ST
Stage
(onset of TL-5cm CD)
20hr 14hr
<8hr after the Dx of true labor for both NP & MP
Active 1
st
stage (Full CD)5hr(1.2cm/hr) 4hr(1.5cm/hr)
2
nd
stage (last fetus)
3-4hr(wout/w) 2-3hr(wout/w)
3
rd
stage (placenta)
30 min 30min

10. STAGES OF LABOR
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11. Prolonged latent phase was defined if
stays
> 20 hours in the nullipara &
>14 hours in the multipara
by Friedman and Sachtleben (1963).
This time corresponded to the 95
th

centiles.
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12. Uterine involution and cervical repair are prompt
remodeling processes that restore these organs to the non
pregnant state
Reinstitution of ovulation signals preparation for the next
pregnancy
Ovulation generally occurs within 4 to 6 weeks after birth
PHASE 4: THE PUERPERIUM
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13. 1. True labor VS False labor
2. Normal labor (Eutocia)VS Abnormal labor(Dystocia)
3. Stages of labor
First stage – onset to full cervical dilatation
Second stage- full cervical dilatation to fetal delivery
Third stage- fetal delivery to delivery of the placenta
Fourth stage- the first hour following delivery
4. Based on gestational age when labor starts
Preterm labor- labor onset before 37 completed weeks
Term labor - labor onset after 37 weeks
post term labor- labor onset after 42 weeks
CLASSIFICATION OF LABOR
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14. Regular, rhythmic uterine contractions (≥ 2 contractions in 10 minutes)
& 1 or more of the following:
• ROM.
• CD of ≥ 4 cm.
• CE of ≥ 80 %.
• Show
NB: If ROM before presentation or if PV was done within the past 48
hours, show shouldn‘t be used as diagnostic criteria.
DIAGNOSTIC CRITERIA OF
TRUE LABOR
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15. TRUE LABOR VS. FALSE LABOR?
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Character True labor False labor (Braxton Hicks)
Pain 1.Pushing down type, also back and
lower abdominal pain that is
2.regular and
rhythmic(Predictable)
3.not relieved by regular analgesics
1.Predominantly mild lower
abdominal and back pain that is
2.Irregular, non rhythmic (un
predictable) & it can be
3.relieved by regular analgesics
Contractions Regular, rhythmic, recurrent coming at
least once every 10 minutes and
increasing in frequency and duration
Irregular, not rhythmic and
infrequent and is not progressive in
frequency and duration
Cervical
change
Documented progressive cervical
change
No cervical change
Membrane Ruptured Intact
Show(Blood
stained or
mucoid)
Present(Sure sign, detachment of cx
mucus plugs during CE&CD)
Absent

16. Criterias to diagnose normal labor:-
7 conditions MUST be fulfilled
1.Spontaneous onset,
2.Onset at term,
3.Vertex presentation,
4.All stages of labor lasting normal duration
5. Delivery should be by spontaneous vaginal delivery
6.Parturient without any riskfactor( pre-eclampsia ,
previous scar , APH ..)
7.No maternal or fetal complication
NB; The diagnosis of normal labor is retrospective, it is established
after the evolution of all the stages & 1-2 hours after delivery.
NORMAL LABOR (EUTOCIA)
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17. Why labor starts?
What is the exact trigger for the initiation of labor?
The placenta?
The fetus?
The fetal membranes?
The mother?
WHAT STARTS LABOR?WHAT STARTS LABOR?
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18. UNKNOWN
?
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19. Labor is species specific
Theories of labor initiation:
Factors that are responsible for the initiation of
labor are
1.Hormonal factors &
2.Mechanical factors
PHYSIOLOGY OF LABOR
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20. 1)Fetal cortisol theory- mature fetal adrenal glands secretes cortisol which
initiates labor
2)Prostaglandin theory- release of prostaglandins from fetal membranes
initiates labor
3)Estrogen theory: During pregnancy, most estrogens are in binding state.
more free estrogen appears increasing the excitability of the myometrium
and prostaglandins synthesis.
4)Oxytocin theory: The secretion of oxytocinase enzyme from the placenta is
decreased near term due to placental ischemia leading to predominance of
oxytocin’s action
5)Progesterone withdrawal theory(17ᾁ hydroxylase deficiency in humans
makes labor initiation unique in humans unique) & other theories
HORMONAL FACTORS
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21. 1.Optimal uterine distension theory - secretion of
oxytocin from posterior pituitary initiates labor.
Mechanical stretching  ↑PGE2, …supportive
evidences are occurrence of preterm labor incase of
polyhydramnios, multiple pregnancy
2.Stretching of LUS formed by the presenting part at
term, from isthmus (7.5 - 10cm)
MECHANICAL THEORIES
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22. (Liao’s & his friends theory)
Currently widely accepted theory.
Fetus:- Maturation of H-P-A axis(mature
fetus)↑cortisol(DHEA-S) 
placenta…
Placenta:- Estriol & Estradiol upregulates
transcription of PG,PG-R, oxytocin,O-R,
Gap junction proteins
↑ myometrial excitability…
onset of regular uterine contractions
INITIATION OF LABOR
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23. The ability of the fetus to successfully negotiate
the pelvis during labor.
It depends on the complex interactions of 4
variables:
This complex relationship has been simplified in
the mnemonic called the ‘’4P’’s.
Passenger /fetus/
Passage /birth canal/
Powers /uterine activity/
Pushing effort
MECHANICS OF LABOR
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24. Uterus is the strongest muscle in the human body.
During labor,
The uterus does 80% of the pushing, whereas the laboring
mother adds that extra "umph."
Even if the mother is unconscious, & in labor, their
uterus would still be able to push that baby out without
any additional pushing effort from the pregnant person.
UTERINE ACTIVITY (POWERS)
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25. There are 4 methods of assessing uterine activity
1.Simple observation
2.Manual palpation,
3.Indirect method /External tocodynamometry,
Electrohysterography/
4.Direct measurement /intrauterine pressure catheter
(IUPC)
ASSESSING UTERINE ACTIVITY
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26. (in our case, ? manual palpation is the most widely used
technique)
Method
Wash hands
Put palmar surface of fingers on the fundus lightly and check for
uterine indentablity
Advantages
Inexpensive
Harmless
Disadvantages
It requires constant presence of skilled attendant at bedside
MANUAL PALPATION
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27. Is the most widely used technique in westerns
It measures the change in shape of the abdominal wall as a result of uterine
contractions
it permits graphic display of uterine activity and
does not measure contraction intensity or basal intrauterine tone.
EH – put on maternal abdominal wall (fundus)& it records myometrial
electrical activity
EH=CTG accuracy
Advantages
Easy to apply
allows for accurate correlation of FHRPs with uterine activity,
Accurate info abt frequency & duration
Drawbacks : Obese patients
Tracing can be interrupted by maternal movement
Less accurate info abt amplitude
INDIRECT METHODS (EXTERNAL
TOCODYNAMOMETRY/CTG/ VS
ELECTROHYSTEROGRAPHY/EH/)
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28. The most precise method
The gold standard
Routine use doesnot improve perinatal outcome
Performed with indication
The most feared complication is
Infection, 50% risk of contamination (HIV, GBS, Fetal
scalp abscess …..) Vx => Dirty : Cx=>clean : Ux=>sterile
Placental disruption
Uterine perforation
4. DIRECT MEASUREMENT /INTRAUTERINE
PRESSURE CATHETER (IUPC)
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29. - Arrest of cervical dilatation(to quantify UCintensity
when frequency is adequate)
- When CTG is not informative, morbid obesity
- For oxytocin dose titration to quantify UC intensity
- To allow for indicated amnioinfusion
INDICATIONS TO PERFORM IUPC
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30. Montevideo unit: is the most common objective
measurement unit
Measures average frequency & amplitude above
basal tone
Intensity of contractions (in mmHg) multiplied by
number of contractions per 10 minutes
Adequate labor in latent phase : no data
Adequate labor in the active labor: 150 to 350
MVU……200-250MV most accepted
UTERINE ACTIVITY MEASUREMENT
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31. : Defn: 3-5/10’ Lasting 40 to 60 sec
Coming every 2 to 5 min in LFSOL to 2 to 3 min in
AFSOL & during the 2
nd
stage respectively
Causing IUP intensity of 60-90mmhg Or MVU of 200-
250 in active labor.
ADEQUATE UTERINE CONTRACTION
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32. Consists of:
1, Bony pelvis (sacrum, ilium, ischium, & pubis)
2, Soft tissue resistance
Bony pelvis divided by the pelvic brim* into:
1, False (greater) - above
2, True (lesser) pelvis - below
•Pelvic brim is demarcated
•posterior, laterally, anteriorly
sacral promontory
anterior ala of sacrum
arcuate line of ilium
pectineal line of pubis
pubic crest
THE BIRTH CANAL(PASSAGE)
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33. 1)pelvic inlet
2)Mid pelvis
3)pelvic outlet
CLASSIFICATION OF BONY PELVIS
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34. There are 4 broad categories
1.Gynecoid (Gyne = women): favorable for VD
2.Android(Aner=man)
3.Antropoid(Antropos=human)
4.Platypelloid(platys=broad pella= bowl)
TYPES OF BONY PELVIS
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35. 02/26/25
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36. 02/26/25
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37. Its by measuring length of sacrospinous
ligament.
Place 1 finger in the ischial spine
1 finger in sacrum in the midline
Measure the space b/n them
It should admit atleast 2 & half finger
HOW TO ASSES SACRO SCIATIC NOTCH?
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38. Method: Put your index finger in the ischial spine &
Put your thumb in the ipsilateral ischial tuberosity
Interpretition
If the tuberosity is lateral to the ischial spineDivergent sidewall
If the tuberosity is medial to the ischial spineConvergent sidewall
If the tuberosity is in the same line to the ischial spineStraight sidewall
HOW TO ASSESS PELVIC SIDEWALLS?
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39. 50%(most common in women)
Classic female shape
Near circular-shaped inlet,
midpelvic sidewalls are straight,
Far-spaced and flat ischial spines
Subpubic arch is wide
GYNECOID PELVIS:
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40. 41% of black woman
Long AP oval inlet
Convergent sidewalls
Narrow ischial spines
Narrow subpubic arch
Largest diameter being anteroposterior
Limited anterior capacity to the pelvis
More often associated with occiput posterior
delivery
Despite their fat they will have flat abdomen,
ANTHROPOID PELVIS
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41. 20% of black woman
Male in pattern
Heart-shaped inlet
Prominent sacral promontory
Prominent ischial spines
Shallow sacrum
Converging sidewalls
Narrow subpubic arch
Increased risk of CPD.(mostly outlet dystocia)
ANDROID PELVIS:
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42. Rarest(<3%)
Broad, and flat kidney shaped pelvic inlet
Exaggerated transverse oval-shaped inlet
Theoretically predisposing to transverse arrest
(OT arrest)
B/C its very flat and shallow, its difficult to
accommodate the abdominal contents so this
women have difficulty to have flat abdomen even if
small amount of abdominal fat)
Common in women with short stature
PLATYPELLOID PELVIS:
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43. Clinical pelvimetry: the only method of assessing shape &
dimension bony pelvic during labor
A. Internal pelvimetry for:- inlet, cavity, and outlet.
B.External pelvimetry for:- inlet and outlet.
Imaging pelvimetry:
X-ray, CT , MRI
N.B. CT and MRI are accurate but expensive and not always
available so they are not in common use.
Trial of labor: is the final and the only determinant of true
adequacy of the bony pelvis.
3 WAYS OF ASSESSING BONY PELVIS
ADEQUACY
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44. STANDARDIZED PROTOCOL STANDARDIZED PROTOCOL
FOR CLINICAL PELVIMETRYFOR CLINICAL PELVIMETRY
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45. 1. Sacral promontory reachability
 if reachable, DC measurement (Normal if, 12.5 cm)
2. Estimate TC(OC) (can be estimated by subtracting 1.5 to
2.0 cm from DC)
The narrowest diameter(rate limiting) of the pelvic inlet
Contracted if less than 10 cm
3.Transverse diameter - 13.5 cm
PELVIC INLET
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46. 1. Measure prominence of ischial spines (blunt vs
prominent).
2. The interspinous diameter –should be >10cm & is the
plane of the least pelvic dimensions
Internal rotation take place at this level.
Land mark for station and pudendal block.
3. Assess sacral curvature-should be concave(concave vs
straight)
MIDPELVIS
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47. rarely of clinical significance
1. Estimate subpubic angle – should be greater than 90º

- AP diameter is approximately 13 cm(atleast should
be ≥11)
2. Estimate inter tuberous diameter –should admit
clenched fist or knuckles or 8 cm
3. Estimate prominence of the coccyx mobility-should
be mobile
PELVIC OUTLET
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48. •Pelvic brim should be round
•Pelvic sidewalls should be straight (divergent,convergent)
•Sacrosciatic notch should admit 2.5 to 3 fingers
OTHER INDICATORS OF ADEQUATE OTHER INDICATORS OF ADEQUATE
PELVISPELVIS
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49. 6 things
1)Lie
2)Presentation
3)Position
4)Station
5)Attitude
6)Synclitism
THE FETUS (PASSENGER)
FETAL ORIENTATION IN UTERO
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50. Longitudinal axis of the fetus to the longitudinal axis of the mother.
3 fetal lie
1.Longitudinal(99% at term)= lied vertically
2.Transverse= horizontally 90º,perpendicular
3.Oblique= 45º
1. FETAL LIE
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51. The part of the fetus that occupies the lower uterine pole
5 types
1)Cephalic(96.8%) : based on the presenting bony
prominence(occiput>vertex,sinsiput, chin>mentum,forehead)
2)Breech (Complete,Footling,Frank)
3)Compound:>1 anatomic part
4)Shoulder
5)Funic (Cord) : rare at term
2. FETAL PRESENTATION
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52. The relationship of an arbitrarily chosen portion of the fetal
presenting part to the right or left side, anterior or
posterior to the birth canal.
The fetal occiput, chin(mentum), sacrum and acromion are
the determining points in vertex, face, breech and shoulder
presentations, respectively
Most fetuses deliver in the OA, left occiput anterior (LOA),
or ROA position
3. FETAL POSITION
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53. Degree of flexion & extension of fetal head in relation to fetal
spine.
Flexion attitudes
1)Vertex- Complete
2)Military-partial
Extension attitudes
I.Brow - partial
II.Face - complete, maximal
4. FETAL ATTITUDE
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54. A measure of descent of presenting part of the fetus
the relation of the presenting part of the fetus to ischial spines
Ischial spines -approximately 8 o’clock and 4 o’clock
5. FETAL STATION
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55. Descent
–Measured abdominally
–2/5 = engaged
DESCENT
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56. Centrality of sagittal suture relative to maternal pelvis.
Asynclitism occurs when the sagittal suture is not central relative to the
maternal pelvis
Posterior asynclitism - more parietal bone is present posteriorly and the
sagittal suture is more anterior
 Anterior asynclitism - more parietal bone presents anteriorly and the
sagittal suture is more posterior
Moderate degrees of asynclitism are the rule in normal labor, aids descent
With extreme asynclitism, ear may be palpable , causes CPD
6. SYNCLITISM
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57. It is large in relation to the fetal body, therefore, some adaptation must take
place during labour. The head is the most difficult part to be born whether
it comes first or last.
Moulding (change in the shape of the fetal head that takes place during its
passage through the birth canal) w/ch is a protective mechanism and
prevents the fetal brain from being compressed. How?
Because the bones of the vault allow a slight degree of bending and the
skull bone is able to override the sutures. The overriding allows a
considerable reduction in the size of the presenting diameter.
The skull of a preterm infant, is softer & have wider sutures, may mould
excessively,
The skull of a post-term infant does not mould well and have greater
hardness.
FETAL SKULLFETAL SKULL
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58. 1 OCCIPITAL
Lies at the back of the head & forms the region of occiput.
At the center is an occipital protuberance.
2 PARIETAL BONE
Lies on either side of the skull, ossification center of each called the parietal
eminence.
2 FRONTAL BONE
These form the forehead or sinciput. At the center of each is the frontal
eminence. It fuses into a single by 8 yrs of age.
In addition to these 5, the upper part of the temporal bone is flat and forms a
small part of the vault.
BONES OF THE VAULTBONES OF THE VAULT
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59. Sutures are bands of fibrous tissues that
connect bones of the skull.
Lambdoidal suture- This separates the 2
parietal bones from the occiput bone.
Sagittal suture- Lies between 2 parietal
bones.
Coronal suture- This separates the frontal
bone from the parietal bone passing from
one temple to another.
Frontal suture- This runs between the 2
halves of the frontal bone.
Squamous suture- Lies between the
temporal and parietal bone.
SUTURES SUTURES
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60. Where 2 or more sutures meet, a fontanelle is formed.
Anterior Fontanelle & Bregma
This is found at the junction of 3 sutures(sagittal, coronal,
and frontal sutures.)
It is broad kite-shaped, diamond and
It measures 3-4 cm long and 1.5-2  cm wide and
Normally closes by 18 months.
Posterior Fontanelle
This is situated at the junction of the 2 sutures(lambdoidal
and sagittal sutures.)
It is a small triangular shape.
It measures < 1cm
It closes by 6 weeks of age.
And the other 2 with less obstetrical significance is
anterolateral (Sphenoid) and posterolateral fontanelles
(Mastoid).
FONTANELLES
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61. The skull is divided into 3 regions with obstetrical importance.
Vertex- is the area bounded by posterior fontanelle, 2 parietal eminences &
by the anterior fontanelle.
Is the presenting part when the head is fully flexed, suboccipitobregmatic &
the biparietal diameter present. As both are of the same length 9.5 cm. The
presenting area is circular.
Brow/Sinciput- This extends from the anterior fontanelle & the coronal
suture to the superior orbital ridges.
It is the presenting part when the head is partially extended, the
mentovertical diameter(13.5cm.) & if this presentation persists, vaginal
delivery unlikely.
Face- The face is small & is poor dilator. It extends from the superior orbital
ridges up to the chin termed as mentum, including the jun b/n neck &
mentum.
REGIONS/ AREAS-
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62. 02/26/25
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63. DIAMETERS OF FETAL SKULLDIAMETERS OF FETAL SKULL
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64. The anteroposterior diameter which may engage
are-
Suboccipitobregmatic (9.5 cm)- from below the
occiput protuberance to the bregma (Center of AF).
Suboccipitofrontal (10 cm)- from below the occiput
protuberance to the center of a frontal suture.
Occipitofrontal (11.5 cm)- The diameter from the
occipital protuberance to glabella.
Mentovertical (13.5 cm)- The diameter from
mentum to highest point of a vertex.
Submentovertical (11.5 cm)- The diameter from the
point where the chin joins the neck to the highest
point of a vertex.
Submentobregmatic (9.5 cm)- The diameter from
the point where the chin joins the neck to the
bregma.
THE ANTEROPOSTERIOR
DIAMETER
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65. A.VERTEX/S.O.B/ B.MILITARY/O.F/ C.BROW/V.M/ D. FACE/S.M.B/
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66. The transverse diameter which may engage
are-
Biparietal diameter (9.5 cm)- The diameter
between the 2 parietal eminences.
Bitemporal diameter (8.2 cm)- The diameter
between the furthest point of coronal suture
at the temples.
Subparietal diameter (8.5cm)- It extends
from a point placed below one parietal
eminence to a point placed above the other
parietal eminence of the opposite side.
Bimastoid diameter (7.5 cm)- It is the
distance between the tips of the mastoid
processes.
THE TRANSVERSE THE TRANSVERSE
DIAMETERDIAMETER
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67. The cardinal movements refer to changes in the position of the
fetal head during its passage through the birth canal.
Because Shape of birth canal= sloppy gutter pipe, flextion extension &
rotations are required for the fetus to successfully negotiate the birth canal.
Although labor and birth comprise a continuous process, seven discrete
cardinal movements are described: (1) engagement, (2) descent,
(3)flexion, (4) internal rotation, (5) extension, (6) external rotation or
restitution, and (7) expulsion
7 CARDINAL MOVEMENTS IN
LABOR
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68. 02/26/25
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Mechanism Reasons
Engagement &
Descent
(1) Uterine contraction(80%)
(2) bearing-down efforts of the mother
(3) extension and straightening of the fetal body
(4)pressure of the amniotic fluid
Flexion
As soon as the head meets resistance from the cervix, pelvic walls & pelvic
floor, it normally flexes
Internal rotation
After each contraction, as the uterus relaxes, the rebound effect of forward
sloppy pelvic floor resistance leads to rotation of the head 90° from OT to OA
to lie under the subpubic arch. Completed when the head reachs pelvic floor.
Extension & delivery
of the head
When the head presses on the pelvic floor due to force exerted by the uterine
contractions(which acts downward & posteriorly) along with the forces
exerted by the muscles of the pelvic floor resistance(acts upward &
anteriorly) results in the direction of the vulvar opening → causing head
extension & delivery of the head
Restitution
(External rotation)
Once the head is delivered & free of resistance, it will return back to its original
anatomic position(untwists 45º to the rt or left)
This movement brings the anterior shoulder towards the symphysis pubis
brought by the same pelvic factors that produced internal rotation
Expulsion
delivery of the shoulder & the rest of the fetal part and the placenta.

69. 1)ENGAGEMENT
Refers to passage of the widest diameter of the presenting part
(BPD,Btrocha.D) below the plane of the pelvic inlet
 clinically engagement can be confirmed by, when the presenting
part is at zero station on PV exam.
Engagement is a good prognostic sign of labor, that, at least at the
level of the pelvic inlet, the maternal bony pelvis is adequate to allow
descent of the fetal head.
Timing of engagement
In nulliparas - usually occurs by 36 weeks’ gestation
In multiparas - occur later in gestation or even during the course of
labor b/c uterus is lax.

70. 2. DESCENT
Descent refers to the downward passage of the presenting part
through the pelvis
Timing of descent
In nulliparas, second-stage of labor.
In multiparas, descent usually begins with engagement.
Descent of the fetus is not continuous; the greatest rates of descent
occur in the late active phase and during the second stage of
labor

71. 3. FLEXION
As soon as the descending head meets resistance,
whether from the cervix,pelvic walls, or pelvic floor, it
normally flexes. With this movement, the chin draws
closer to the fetal thorax, and the appreciably shorter
suboccipitobregmatic diameter replaces the longer
occipitofrontal diameter. This is an essential requisite
for descent because it allows the smallest head
diameter to progress

72. 4. INTERNAL ROTATION
This movement turns the occiput gradually away from the transverse
axis.
Usually the occiput rotates anteriorly toward the symphysis pubis. LOT
positions transition to left occiput anterior (LOA) positions. ROT
positions rotate to right occiput anterior (ROA) positions. Less
commonly,
the head may rotate posteriorly toward the hollow of the sacrum to
generate occiput posterior positions. Internal rotation is essential for
completion of labor, except when the fetus is unusually small.

73. THE PELVIC FLOOR MUSCULATURE
, including the coccygeus and ileococcygeus muscles, forms a V-
shaped “hammock” that diverges anteriorly. As the head descends,
the occiput of the fetus rotates
toward the symphysis pubis—or, less commonly, toward the
hollow of the sacrum—thereby allowing the widest portion of
the fetus to negotiate the pelvis at its widest dimension. Owing to
the angle of inclination between the maternal lumbar spine and
pelvic inlet, the fetal head engages in an asynclitic fashion.
. With uterine contractions, the leading parietal eminence descends
and is first to engage the pelvic floor. As the uterus relaxes, the
pelvic floor musculature causes the fetal head to rotate until it is no
longer asynclitic

74. 5. EXTENSION
Extension occurs once the fetus has descended to the
level of the introits
This descent brings the base of the occiput into
contact with the inferior margin at the symphysis pubis.
At this
point, the birth canal curves upward.
The forces responsible for this motion are the
downward force exerted on the fetus by the uterine
contractions(which acts posteriorly) along with the
upward forces exerted by the muscles of the pelvic floor
resistance(acts anteriorly)

75. 6. EXTERNAL ROTATION
When the fetal head is free of resistance, it will
return back to its original anatomic
position(untwists 45° rt or left)
External rotation, also known as restitution, refers to
the return of the fetal head to the correct
anatomic position in relation to the fetal torso.
This movement brings the anterior shoulder
towards the symphysis pubis

76. 7. EXPULSION7. EXPULSION
Expulsion refers to delivery of the shoulder
& the rest of the fetal part and the placenta.

77. Every woman & her supporters (Doula, if not family) should feel welcomed &
comfortable, Warm and friendly acceptance.
In Our case? The reverse is true
Benefits
RCTs showed significant reduction in
Analgesia requirement
Oxytocin use
Operative vaginal delivery
C/S delivery
Higher Patient satisfaction
Encourage partner to accompany the spouse who is in labor. Partner support &
education should start during antenatal care and continue throughout child birth
MANAGEMENT OF NORMAL
LABOR
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78. 
For a woman without known risk & intact membrane,
if cervical dilation is ≥ 4 cm.
Those women with ruptured membranes & known risk

factor, at any cervical dilatation.
ADMISSION CRITERIA
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79. 
Immediately check for signs of imminent delivery.


Review ANC record and revise her birth preparedness plan.
Appropriate

Hx,P/E(including PV exam).
Perform

lab. Ixs which are not determined during ANC (e.g., Blood group and Rh,
urine analysis, VDRL, HBsAg and HIV test).
If CBC & U/A are not determined within the

past two weeks, repeat the test.
If serology for HIV is positive refer to section on PMTCT guide (HIV).



Regularly update client & attendants about her condition and the status of labor.
Provide loose fitting gown (if possible).

Revise her postpartum FP plan,

counsel and prepare accordingly. (If the
client is in active labor, postpone the counselling to the immediate postpartum period).
NOTE. Team approach is important, and all abnormal clinical/ laboratory findings
should be informed to the most senior personnel in charge of the labor ward activity.
ADMISSION PROCEDURE ADMISSION PROCEDURE : : STEPSSTEPS
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80. 
Notify the labor ward staff that delivery is imminent.
Take the woman to the delivery room (if it is a separate room).

Make sure all the equipment for delivery and newborn care are available at

the delivery room.
There should be a pre-warmed neonatal corner for neonatal care.

The birth attendant should wash hands and wear complete personal

protection equipment (gloves, gown, apron, mask, cap & eye protection).


Sterile draping in such a way that only the immediate area around the
vulva is exposed.


Perineal care: clean the vulva and perineum with antiseptics /tap water
(downward and away from the introits). Wipe feces downwards. Avoid
routine vaginal cleansing with antiseptic solution.
PREPARATION FOR DELIVERYPREPARATION FOR DELIVERY
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81. Every 4 hour, 3 exceptions


After spontaneous ROM
When there is abnormal

FHR (NRFHR), and
If symptoms are suggesting for

2
nd
stage of labor
(to confirm the diagnosis).
PV EXAM
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82. ACOG(2017) recommends that,
In the absence of any abnormalities, FHR
Q 30’ in 1
st
Stage & then
Q 15’ during 2
nd
stage labor.
For women with pregnancies at risk, FHR
Q 15’ during first-stage labor &
Q 5’ during the 2
nd
stage.
FETAL MONITORING
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83. T°, PR, & BP° at least Q 4 hr.
If prolonged ROM or if there is a borderline T° elevation,
the T° is checked hourly & Pulse rate - half hourly.
(National protocol)
MATERNAL MONITORING
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84. Note that the mother should not be confined to bed
unless contraindicated (e.g. sedated patient, for
frequent monitoring, high head & ruptured
membranes).
In bed, the laboring woman may assume the position
she finds most comfortable, and often this will be
lateral recumbency.
MATERNAL POSITION
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85. Researchs showed that walking
shortens labor,
lowers rates of oxytocin augmentation,
diminishes the need for analgesia, &
decreases the frequency of operative vaginal delivery
In their Cochrane review, Lawrence and associates (2013) reported that
labor in ambulant or upright positions shortened first-stage labor by
approximately 1hour and lowered cesarean delivery and epidural
analgesia rates.
ROLE OF AMBULATION
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86. Bloom and colleagues (1998) conducted a randomized trial to study the effects
of walking during first-stage labor. In 1067 women with
uncomplicated term pregnancies delivered at Parkland Hospital, these
investigators reported that ambulation did not affect labor duration.
Ambulation did not reduce the need for analgesia nor was it harmful to the
newborn. Because of these observations,
we give women without complications the option to select either
recumbency or supervised ambulation during labor.
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87. HOSPITALS SHOULD BE PAIN FREE.
Non pharmacologic
Provide continuous emotional support.
Inform laboring mothers about the procedures to which they will be
subjected during labor and delivery.
Relaxation (breathing, music, mindfulness) & Massaging (back rubbing)
Warm compress (back)
In first-stage labor in a large water tub, if available, for pain relief.
With this practice, one Cochrane review found lower rates of regional
analgesia use and no greater adverse neonatal or maternal effects
compared with traditional labor (Cluett, 2018).
Right now, ACOG recommends delivery shouldn’t take place in water.
PAIN MANAGEMENT
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88. A small dose given more frequently is preferable to a large dose
administered less frequently.
Whenever opioids are used during labor (>4 cm), all preparations should
be made to treat neonatal respiratory depression & use of the opioid
antagonist Naloxone.
Pethidine(Meperidine) or diamorphine or fentanyl are options
PHARMACOLOGIC
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89. Best method
Additional benefits
It increases placental circulation
It decrease post partal depression
Adverse outcomes: delivery in OP position, prolongs labor,hypotension , H/A
When to use?
For all laboring mothers who are at low risk for PPH. & no contraindication like ICP, skin
infection, back trauma
IN OUR SETUP, due to resource limitation reserved for cardiac patients…….
When to remove
Within or after 1 hr of delivery
EPIDURAL ANALGESIA
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90. Solid foods during labor and delivery. Gastric emptying time is remarkably prolonged
once labor is established and analgesics are administered.
As a consequence, ingested food and most medications remain in the stomach and
are poorly absorbed. They may be vomited and aspirated. However, oral intake of
moderate amounts of clear liquids is reasonable for women with uncomplicated
labor (American Academy of Pediatrics,2017;
American Society of Anesthesiologists, 2016). Water, clear tea, black coffee,
carbonated beverages, Popsicles, and pulp-free juices are options.
In those with appreciable risks for aspiration or those with significant risks for
cesarean delivery, further restriction may be instituted. For example, for those with
planned cesarean delivery, liquids are halted 2 hours before and solids are
stopped 6 to 8 hours prior to surgery (American College of Obstetricians and
Gynecologists, 2019b)
ORAL INTAKE
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91. Moreover, with longer labors, the administration of glucose,
sodium, and water to the otherwise fasting woman at the rate
of 60 to 120 mL/hr prevents dehydration and acidosis.
Although not mandatory, IV hydration may shorten labor
length, and most studies of fluid selection use first-stage
labor length as a primary outcome.
From these investigations, data support use of fluids
containing dextrose compared with fluid without it.
For administration, rates of 125 or 250 mL/hr are suitable. In
our practice, saline with 5-percent dextrose is infused at a
rate of 150 mL/hr.
IV FLUIDS
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92. In one meta analysis of 15 studies, normal spontaneous labor was not shortened by amniotomy, so
routine amniotomy is not recommended
Benefits
Do
– To know status of liquor,
_ to apply an electrode to the fetus or insert a pressure catheter
Risks infection , cord prolapse.
To help prevent prolapse, the fetal head must be well applied to the cervix and not dislodged from
the pelvis during amniotomy
Controlled amniotomy
– In polyhydramnios or unengaged fetal presenting part
– use a small gauge needle, rather than a hook or iv set
• To minimize risk of gushing amniotic fluid
– perform the procedure in the operating room
• permits emergency CS in the event of an umbilical cord prolapse

AMNIOTOMY
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93. Bladder Distention can hinder descent of the fetal presenting part &
lead to subsequent bladder hypotonia and infection.
Periodically,
suprapubic region is palpated to detect distention. If the bladder is readily
seen or palpated above the symphysis, the woman should be encouraged to
void. Those unable to do so on a bedpan may be able to ambulate with
assistance to a toilet. Catheterization is indicated if the bladder is distended
and voiding is not possible.
In these
cases, continuous or intermittent catheterization is suitable, and both have
comparable rates of puerperal urinary tract infection and urinary retention
URINARY BLADDER FUNCTION
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94. To determine head position.
The fingers are directed posteriorly and then swept
forward over the fetal head toward the maternal symphysis. During this movement, the
fingers necessarily cross the sagittal suture, and its
lie is delineated. Next, the positions of the two fontanels are ascertained. For
this, fingers are passed to the most anterior extension of the sagittal suture,
and the fontanel encountered there is examined and identified. The fingers
then pass along the sagittal suture to the other end of the head until the other
fontanel is felt and differentiated
Last, the station, or extent to which the presenting part has descended into the pelvis,
also can be established. Using these maneuvers, the various sutures and fontanels are
determined. In unclear cases, sonography can be used
HOW TO DETERMINE FETAL HOW TO DETERMINE FETAL
ORIENTATION?ORIENTATION?
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95. woman typically begins to bear down.
During pushing, coaching is desirable. When the next uterine contraction
begins, she is instructed to exert downward pressure as though she were
straining at stool. A woman is not encouraged to push after the completion
of contraction. Instead, she and her fetus are allowed to rest and
recover.
Fetal and obstetrical outcomes appear to be unaffected whether pushing is
coached or uncoached during second-stage labor (Bloom, 2006; Tuuli, 2012).
MANAGEMENT OF 2MANAGEMENT OF 2
NDND
STAGE STAGE
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96. Active 3
rd
stage management is recommended
- Oxytocin 10IU im
- Early cord- clamping
- Controlled cord traction and counter traction on uterus
- Uterine massage
MANAGEMENT OF 3MANAGEMENT OF 3
RDRD
STAGE STAGE
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97. Definition
– the 1st one/two hour following completion of the 3rd stage
• Vital signs: BP, PR Q 15min.
• Examine uterine fundus: palpate it to ensure that
– (1) no blood gets accumulated in the cavity
– (2) it is well contracted. If found relaxed, massage and give oxytocin if no response.
• Look for vaginal bleeding
• Inspect the perineum for hematoma
• Bladder care:
– Encourage urination, and
– If there is retention, catheterize
– Pain management for episiotomy pain
– Ice bag, cold water or sitz bath.
– NSAIDs (e.g. Ibuprofen) for after pain
FOURTH SOLFOURTH SOL
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98. If the client is in LFSOL and fulfills admission criteria, admit the
mother and follow her using the latent phase follow-up chart.
LABOR MANAGEMENT PROTOCOLSLABOR MANAGEMENT PROTOCOLS
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99. Initially a partogram was designed by the WHO for use in developing countries
• Currently WHO has shifted it to LCG
7 components
– Adapted from the previous partograph design
1. Identifying information & labor characteristics at admission
2. Supportive care
3. Care of the baby
4. Care of the woman
5. Labor progress
6. Medication
7. Shared decision-making
WHO LCG, 2020WHO LCG, 2020
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100. 100

101. 02/26/25
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102. 02/26/25
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103. 
Delay cord clamping for 1-3 minutes after delivery or until cord pulsation
is absent (which ever comes first).


Clamp the cord immediately in the f.f conditions: preterm baby, low birth
weight, neonatal asphyxia, Rh isoimmunized pregnancy or HIV.
Clamp the cord 4-5 cm away from the umbilicus.

Take cord blood if indicated

CORD CLAMPINGCORD CLAMPING
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104. Essential Newborn care
Neonatal Resuscitation
NEWBORN NEWBORN
CARECARE
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105. 1.Airway assessment, suction, if indicated, if not (Dry & Stimulate)
2.Breathing evaluation(APGAR) 30-60 breath/min.
3.Cord care(1 to 3 min)
4.Decrease hypothermia(warm room , remove the wet towel, hat, socks,
blanket, skin-skin contact)
5.Encourage breast Feeding(early)
6.Gonococci prevention(TTC 1%)
7.Hemorrhage prevention (IM Vitamin K 0.5-1mg)
8.Identification band at(wrist, ankle)
9.Weight
10.Record all the findings & all the treatments given and not given then
11.Inform the mother
ESSENTIAL NEWBORN CAREESSENTIAL NEWBORN CARE
11 COMPONENTS 11 COMPONENTS  MEMORY TIPS MEMORY TIPS
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106. 02/26/25
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107. Melbourne Chart
Our intervention is based on HR
Airway suctioning & stimulate (HR>100)
Breathing support(HR b/n 60-100)
CPR(HR<60)
Drug administration(if still <60 for >3min)
NEONATAL RESUSCITATION NEONATAL RESUSCITATION
SUMMARY SUMMARY
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108. Labor is defined as the process by which the fetus is expelled
from the uterus
There are four phases of parturition
There are three stages of labor
The use 1 cm/hr cervical dilatation lead to unnecessary
interventions
Labor coaching doesn’t improve perinatal & obstetric outcome
Oral intake of clear liquid drinks is recommended
Routine Amniotomy is not recommended
AMTSL is a standard management of 3
rd
stage of labor
After an uncomplicated vaginal birth mothers and newborns
should receive care in the facility for at least 24 hours after
birth
SUMMARYSUMMARY
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109. THANKS FOR LISTENING
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109

110. 1. Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS,Hoffman BL,
Casey BM, Sheffield JS (eds).William’s Obstetrics 26th edition; 2022
2. Poon et al, 2019. The International Federation of Gynecology and
Obstetrics (FIGO) initiative on pre-eclampsia: A pragmatic guide for
first-trimester screening and prevention
3. Gabbe, et al., Obstetrics: Normal and Problem Pregnancies 7thed, 2017:
Elsevier, Inc
4. ACOG practice bulletin #202, VOL. 133, NO. 1, JANUARY 2019 2019;
Gestational hypertension & preeclampsia
5. National obstetric management protocol of Ethiopia for hospitals may
2021.
6. Uptodate 2022.
7. Internet /googleedu.com/
REFERENCESREFERENCES
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