Normal Labor with all stages and complete management

Normal Labor with all stages and complete management

1. Normal Labor Sidra Khan Tayyaba Ghafoor Ayesha Tariq

2. Definition The onset of labour can be defined as the presence of strong regular/Rhythmic painful uterine contractions resulting in progressive cervical changes(Dilation and Effacement) The World Health Organization (WHO) defines normal labor as a process that begins spontaneously in a low-risk pregnancy, with the fetus in a vertex (head-first) position, and results in a spontaneous delivery where both the mother and infant are in good condition.

3. Ir regular No cervical changes No Show No radiation Another name ? . Pains; I ncrease in intensity, decrease in duration Cervical changes Bloody show Radiation to back Start from Fundus of uterus . True False

4. Physiology of labor The cervix, which is initially long, firm, and closed, with a protective mucus plug, softens, shorten, thin out (effacement) and dilate for labour to progress. The uterus must change from a state of relaxation to an active state of regular, strong, frequent contractions to facilitate transit of the fetus through the birth canal. Each contraction must be followed by a resting phase in order to maintain placental blood flow and adequate perfusion of the fetus . The pressure of the presenting part on the pelvic floor muscles as the fetus descends from the midpelvis to the pelvic outlet produces a maternal urge to push, enhanced further by stretching of the perineum. Uterine contractions are involuntary in nature. The frequency of contractions may vary during different labor phases .These are described in frequency within a 10-minute period, record on CTG.

5. Normal Lie and presentation and position of baby? Normal fetal lie is longitudinal , normal presentation is vertex , and occiput anterior is the most common position. Presenting diameter _ sub occipito bregmatic , 9.5cm, Attitude , well flexed

6. Definitions Presentation? Part at pelvic brim Lie? t he relationship between the long axis of the baby's body and the long axis of the maternal body . Position? Rotation of the denominator (Leading point )to the fixed maternal pelvis Effacement ? Effacement is a process by which the cervix shortens in length as it becomes incorporated into the lower segment of the uterus. Dilation ? Dilation of cervix (0-10cm )

7. How do we assess cervical changes ? .

8. Stages of Labor Labour can be divided into three stages;

9. First stage of Labor Time from the diagnosis of labour to full dilatation of the cervix (10 cm) 1.Latent phase 2.Active Phase .

10. . Latent Phase Time between the onset of regular painful contractions and 3–4 cm cervical dilatation. During this time, the cervix becomes ‘fully effaced’. The process of effacement may begin during the weeks preceding the onset of labour, but will be complete by the end of the latent phase.it usually lasts between 3 and 8 hours, being shorter in multiparous women. Contractions are infrequent ,could be mild to moderate

11. Active stage It is time between the end of the latent phase (3–4 cm dilatation) and full cervical dilatation (10 cm). It is also variable usually lasting between 2 and 6 hours, shorter in multiparous women. Cervical dilatation during the active phase occurs typically at 1 cm/hour in Nulliparous and 2cm/h in multiparous . Abnormal if it occurs at less than 1 cm in 2 hours. Contractions occur at rate of 3-5 contractions every 10 min and of moderate intensity(strong) , each contraction lasting for 45-50 sec.

12. Management of Normal labor Counselling 1. When to Consult Doctor/Midwife Painful, regular uterine contractions every 5–10 min. Rupture of membranes (“waters break”). Bloody show or vaginal bleeding. Decreased fetal movements. Any concern for mother/fetus. --- 2. Initial Assessment (On Admission) Confirm true labour (regular contractions + cervical changes). Assess vital signs and fetal heart rate (FHR). Abdominal exam: lie, presentation, engagement. Vaginal exam: cervical dilatation, effacement, membranes, station.

13. . 2. Initial Assessment (On Admission) Informed Consent Complete History and examination Confirm true labour (regular contractions + cervical changes). Assess vital signs and fetal heart rate (FHR) (CTG) Abdominal exam: lie, presentation, engagement ,contractions. Vaginal exam: cervix_ for length and effacement, consistency, dilatation, position and station of presenting part,attitude. Membranes intact or rupture , amount ,color ,smell of fluid if any . Investigations: Baselines Baseline charting: partograph started.

14. Management of latent phase Monitoring B.P, Temperature , Per-vaginal _ 4h Pulse _1h Contractions(frequency , duration , intensity) ,FHR , urine output_ half hourly Encourage Mobilization and reassure ,privacy ,oral fluids and light diet intake Pain relief _ breathing exercises , mild analgesia

15. Management of active phase Partogram Temp _4h ,B.P , PV_ 2-4h Pulse _1h contractions _30 min , FHR _15-20 min Hydration ,reassurance , Pain relief _ epidural analgesia If progress is slow -Asses 3 P’ s and ARM Still slow _ augementaion by oxytoxcin ( less than 1cm in 2h ) Preparation for delivery Episiotomy if needed

16. Criteria for good progress Dilation greater than or equal to 1cm/h Decent of presenting part Regular strong contractions Normal FHR -110-160 bpm ARM indications ; Induction or augumentation of labour , Liquor assessment Partogram benefits :Monitoring of progress of labour, detection of prolonged or obstructed labor, Reduces maternal morbidity and mrtality E pisiotomy indication : Fetal Bradycardia ,Rigid perineum Anticipating perineal tear, Operative delivery (forceps)

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18. 2nd stage of Labor Definition T he second stage of labour begins with full cervical dilatation (10 cm) and ends with the complete expulsion of the fetus from the birth canal. It s the “expulsive” stage, during which powerful uterine contractions and maternal bearing-down efforts bring about delivery of the baby . Duration 2hrs- primigravida and 1hr -multigravida

19. Signs of 2nd stage 1. Contractions become: Stronger, longer, and more frequent, Interval between contractions shortens,Each contraction lasts up to 90 seconds. 2. Bearing-down efforts:Due to the presenting part pressing on the pelvic floor and rectum → reflex desire to push. 3. Rupture of membranes may occur (if not already ruptured). 4. Vulva and perineum bulge; anus gapes. 5 Presenting part visible at vulva during contractions and remains visible even between contractions (crowning). 8. Increased show (blood-stained mucus) 9.Maternal behavior:Becomes irritable, restless, and may cry out or strain involuntarily.

20. Mechanism of labor

21. Vertex Presentation — Left Occipitoanterior most common The fetal head negotiates the pelvis through seven sequential cardinal movements: 1️⃣ Engagement The biparietal diameter (9.5 cm) passes through the pelvic inlet. Occurs often before labour in primigrav ida, during labour in multigravida. The sagittal suture lies in the transverse diameter of the inlet. 2️⃣ Descent Continuous movement of the head downwards through the pelvis. Caused by: Uterine contractions Bearing-down efforts Straightening of the fetal body occurs throughout labour, but maximum descent happens in the second stage. 3️⃣ Flexion As the head meets resistance from the pelvic floor and cervix, the chin is pressed to the chest, converting: The occipitofrontal (11.5 cm) → suboccipitobregmatic (9.5 cm) diameter. this smaller diameter allows easier passage. 4️⃣ Internal Rotation As the head descends to the pelvic floor, the occiput rotates anteriorly (toward the symphysis pubis). Purpose: To align the longest diameter of the head with the anteroposterior (AP) diameter of the outlet. Occurs due to: the shape of the pelvic floor,Oblique pressure of levator ani muscles 5️⃣ Extension When the occiput escapes under the symphysis pubis, the head extends. The perineum stretches and the head is delivered by controlled extension. 6️⃣ Restitution (External Rotation of Head) After the head is born, it turns 1/8 of a circle to one side. this is to realign with the shoulders, which are now entering the pelvic outlet in the oblique diameter.

22. 7️⃣ Delivery of Shoulders and Trunk (Expulsion) Anterior shoulder slips under the pubic symphysis by gentle downward traction. Posterior shoulder follows by upward movement. The rest of the body is expelled quickly and easily.

23. Stages 1.Propulsive (or Passive) Phase → From full cervical dilatation to the time when the presenting part reaches the pelvic floor. Duration Primigravida: longer (≈30–45 min) Multigravida: shorter (≈15–20 min) 2. Expulsive (or Active) Phase → From the time the presenting part reaches the pelvic floor until the baby is completely Delivered Duration Primigravida: ~30–60 minutes Multigravida: ~15–30 minutes

24. Conduct of 2nd stage of Labor 1. Preparation A.Confirm full cervical dilatation and vertex presentation, B. Empty the bladder (use a catheter if necessary)., C.Explain and encourage the mother. D.Check fetal heart rate every 5 minutes (normal: 110–160 bpm). E. Ensure all instruments, warm towels, and resuscitation equipment are ready. 2.Maternal Position: [Semi-recumbent (dorsal) or lithotomy for controlled delivery Lateral or squatting may be used if delivery is expected soon. 3.. During Contractions . Encourage the mother to bear down (push) with contractions. Between contractions, let her rest and breathe deeply. 4.. Perineal Support To prevent perineal tears: Use the modified Ritgen’s manoeuvre: One hand on the perineum to control the head and support it. Other hand on the occiput to allow gradual extension. Keep head flexed until occiput escapes under the pubic arch.

25. . . 5. Delivery of Head Allow head to extend slowly and spontaneously. 6. Once delivered: Clear mouth and nose with suction if needed. 7. Check for nuchal cord: If loose → slip over the baby’s head. If tight → clamp and cut between clamps. 8. Delivery of Shoulders Hold the baby’s head with both hands. Gently pull downward to deliver anterior shoulder, then upward for posterior shoulder. The body follows easily. 9. After Delivery of Baby, Place the baby on the mother’s abdomen or below uterine level. Delay cord clamping for 1–3 minutes (to improve neonatal iron stores). B Clamp and cut the cord using sterile instruments. .Hand over the baby for drying, warming, and assessment (Apgar score). 🧷 Care of the Mother After Baby’s Birth Observe perineum for tears or episiotomy extension. Check the uterus for contraction.

26. 3rd Stage of Labor The third stage of labour is defined as the time from the delivery of the baby until the complete expulsion of the placenta and fetal membranes.” • Physiological: Up to 30 minutes • Active management: Usually within 5–10 minutes Importance: Most dangerous stage — risk of postpartum hemorrhage (PPH

27. Phases of 3rd stage of Labor 1 . Separation of Placenta 2. Descent of Placenta into Lower Segment/Vagina 3. Expulsion of Placenta and Membranes

28. Mechanism of Placental Separation • After baby’s birth, uterus contracts and retracts, reducing placental site size. Placenta can’t contract, so it peels off from the uterine wall. Blood collects behind it, forming a retroplacental hematoma that aids separation. Mechanisms: 1. Schultze Mechanism (Central separation) – placenta delivered fetal side first (Shiny Schultze). 2. Matthews Duncan Mechanism (Marginal separation) – placenta delivered maternal side first (Dirty Duncan)

29. Signs of Placental Separation 1.Gush of blood from vagina 2. Lengthening of umbilical cord 3. Fundus becomes hard firm and globular 4. Fundus rises in abdomen

30. Mechanism of Placental Expulsion After separation, uterine contractions and maternal effort expel placenta. Methods: • Schultze Method – fetal surface first • Duncan Method – maternal surface first .

31. Expectant / Physiological Management No uterotonic drugs used. • Wait for spontaneous separation. • Placenta delivered by maternal effort or gravity. • Gentle cord traction when signs of separation appear. Disadvantages: • Higher risk of PPH • Longer duration • May require manual removal

32. Procedure 1. Place one hand over the fundus to feel for signs of placental separation. 2. When the uterus becomes firm and hard, ask the mother to bear down with contractions. 3. Wait up to 10 minutes for placenta to be expelled naturally. 4. Once the placenta appears at the vulva, grasp it gently with both hands and rotate or lift slightly to help deliver membranes completely. G eneral precautions Do not massage the uterus before placental separation (may cause partial separation and bleeding). Do not pull on the umbilical cord until the uterus is well contracted and placenta has separated. Do not attempt manual delivery of the placenta unless there is severe hemorrhage. Allow natural separation — wait patiently and observe.

33. Active management of 3rd stage of labor Definition: Use of prophylactic uterotonics and controlled cord traction to prevent PPH Steps: 1. Administer 10 IU Oxytocin IM within 1 minute after birth of the baby. 2. Early Cord Clamping and Cutting — usually within 1 minute after delivery. 3. Controlled Cord Traction (CCT): support uterus suprapubically, apply gentle traction. 4. Uterine massage after placenta delivery

34. Brandt–Andrews Maneuver It is a method used during Controlled Cord Traction to help deliver the placenta safely. Steps: 1. Place one hand above the pubic bone to support and stabilize the uterus. 2. With the other hand, hold the clamped umbilical cord and apply gentle downward traction. 3. As the placenta descends, lift the uterus slightly upward to prevent inversion. Purpose: • To aid placental delivery after separation. • To prevent uterine inversion and hemorrhage

35. Examination of placenta After placenta delivery, always check: • Cord – length, number of vessels, insertion site. • Membranes – are they complete and not torn? • Maternal surface – make sure all cotyledons are present and complete. .if any part is missing suspect that a small piece may still be inside the uterus

36. Care of newborn and mother .care for at least an hour after delivery. The mother should receive cleansing body wash, mouthwash and perineal care. She should be encouraged to empty bladder and bedpan offered. Blood pressure, pulse, uterine contraction and bleeding should be checked every 15 mts

37. Complications of 3rd stage 1. Postpartum Hemorrhage (PPH) 2. Retained Placenta 3. Uterine Inversion 4. Shock/Collapse 5. Infection (Puerperal Sepsis Prevention of complications • Use AMTSL for all deliveries. • Examine placenta and membranes. • Monitor vital signs and uterine tone. • Keep uterotonic drugs ready

38. Thank You .