Normal labour
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Nov 21, 2010
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Normal labourNormal labour
Definition of labour:-Definition of labour:-
series of events that take place in the series of events that take place in the
genital organs in an effort to expel the genital organs in an effort to expel the
viable fetus out of the uterus through the viable fetus out of the uterus through the
vagina in to the outer world.vagina in to the outer world.
Definition of delivery:-Definition of delivery:-
Is the expulsion or extraction of a viable Is the expulsion or extraction of a viable
fetus out of the uterusfetus out of the uterus..
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Definition of labour:-Definition of labour:-
series of events that take place in the series of events that take place in the
genital organs in an effort to expel the genital organs in an effort to expel the
viable fetus out of the uterus through the viable fetus out of the uterus through the
vagina in to the outer world.vagina in to the outer world.
Definition of delivery:-Definition of delivery:-
Is the expulsion or extraction of a viable Is the expulsion or extraction of a viable
fetus out of the uterusfetus out of the uterus..
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NormallabourNormallabour
Labour is normal when it isLabour is normal when it is
1.1.Spontaneous in onset Spontaneous in onset
2.2.At termAt term
3.3.single fetussingle fetus
4.4.vertex presentation vertex presentation
5.5.Without undue prolongation Without undue prolongation
6.6.With no maternal complications or With no maternal complications or
7.7.Fetal complicationsFetal complications
- Any deviation from this definition is abnormal - Any deviation from this definition is abnormal
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Labour is normal when it isLabour is normal when it is
1.1.Spontaneous in onset Spontaneous in onset
2.2.At termAt term
3.3.single fetussingle fetus
4.4.vertex presentation vertex presentation
5.5.Without undue prolongation Without undue prolongation
6.6.With no maternal complications or With no maternal complications or
7.7.Fetal complicationsFetal complications
- Any deviation from this definition is abnormal - Any deviation from this definition is abnormal
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OnOnset of labourset of labour
Based on naegel’s formula labour starts Based on naegel’s formula labour starts
approximately as follow.approximately as follow.
In the expected date of delivery in 4% of In the expected date of delivery in 4% of
cases cases
One week on either side in 50% of cases One week on either side in 50% of cases
Two weeks earlier and one week later on Two weeks earlier and one week later on
80% of cases 80% of cases
At 42 weeks in 10% of cases At 42 weeks in 10% of cases
At 43 weeks plus in 4% of cases At 43 weeks plus in 4% of cases
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Based on naegel’s formula labour starts Based on naegel’s formula labour starts
approximately as follow.approximately as follow.
In the expected date of delivery in 4% of In the expected date of delivery in 4% of
cases cases
One week on either side in 50% of cases One week on either side in 50% of cases
Two weeks earlier and one week later on Two weeks earlier and one week later on
80% of cases 80% of cases
At 42 weeks in 10% of cases At 42 weeks in 10% of cases
At 43 weeks plus in 4% of cases At 43 weeks plus in 4% of cases
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Causes of the onset of labourCauses of the onset of labour
Unknown the following theories were Unknown the following theories were
postulated postulated
1.1.Optimal distension theoryOptimal distension theory
-When the uterus is distended to a certain When the uterus is distended to a certain
limit, it starts to contract to evacuate its limit, it starts to contract to evacuate its
contents (multiple preg. Polyhydramnios)contents (multiple preg. Polyhydramnios)
2. 2. feto- placental theoryfeto- placental theory
- Due to unknown factors fetal pituitary is - Due to unknown factors fetal pituitary is
stimulated with increase release of stimulated with increase release of
ACTH that stimulate theACTH that stimulate the
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Unknown the following theories were Unknown the following theories were
postulated postulated
1.1.Optimal distension theoryOptimal distension theory
-When the uterus is distended to a certain When the uterus is distended to a certain
limit, it starts to contract to evacuate its limit, it starts to contract to evacuate its
contents (multiple preg. Polyhydramnios)contents (multiple preg. Polyhydramnios)
2. 2. feto- placental theoryfeto- placental theory
- Due to unknown factors fetal pituitary is - Due to unknown factors fetal pituitary is
stimulated with increase release of stimulated with increase release of
ACTH that stimulate theACTH that stimulate the
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fetal adrenal to produce cortisol which act in fetal adrenal to produce cortisol which act in
the placenta to produce estrogen and the placenta to produce estrogen and
prostaglandins.prostaglandins.
3- 3- estrogen theory:-estrogen theory:-
during the last trimester more free estrogen during the last trimester more free estrogen
appears increasing the excitability of the appears increasing the excitability of the
myometrium and prostaglandin synthesis myometrium and prostaglandin synthesis
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the placenta to produce estrogen and the placenta to produce estrogen and
prostaglandins.prostaglandins.
3- 3- estrogen theory:-estrogen theory:-
during the last trimester more free estrogen during the last trimester more free estrogen
appears increasing the excitability of the appears increasing the excitability of the
myometrium and prostaglandin synthesis myometrium and prostaglandin synthesis
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4- progesterone:4- progesterone:
Increase fetal production of Increase fetal production of
dehydroepiandro-sterone sulphate with dehydroepiandro-sterone sulphate with
cortisol may inhibit the conversion of fetal cortisol may inhibit the conversion of fetal
pregnenolone to progesterone there by pregnenolone to progesterone there by
altering the estrogen progesterone ratio.altering the estrogen progesterone ratio.
5- prostaglandins5- prostaglandins:-:-
- Attracted much attention in recent years - Attracted much attention in recent years
produced by-placenta –membrane –produced by-placenta –membrane –
decidual cells and myometrium decidual cells and myometrium
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Increase fetal production of Increase fetal production of
dehydroepiandro-sterone sulphate with dehydroepiandro-sterone sulphate with
cortisol may inhibit the conversion of fetal cortisol may inhibit the conversion of fetal
pregnenolone to progesterone there by pregnenolone to progesterone there by
altering the estrogen progesterone ratio.altering the estrogen progesterone ratio.
5- prostaglandins5- prostaglandins:-:-
- Attracted much attention in recent years - Attracted much attention in recent years
produced by-placenta –membrane –produced by-placenta –membrane –
decidual cells and myometrium decidual cells and myometrium
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Synthesis is triggered bySynthesis is triggered by
Rise in estrogen level Rise in estrogen level
Altered estrogen. Progesterone ratio Altered estrogen. Progesterone ratio
Mechanical stretching in later pregnancy Mechanical stretching in later pregnancy
Infection or separation of membranes Infection or separation of membranes
↑↑ oxytocin receptors oxytocin receptors
6. Oxytocin theory:-6. Oxytocin theory:-
although oxytocin is a powerful stimulator of uterine although oxytocin is a powerful stimulator of uterine
contraction its natural role in onset of labour is contraction its natural role in onset of labour is
doubtful .doubtful .
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Rise in estrogen level Rise in estrogen level
Altered estrogen. Progesterone ratio Altered estrogen. Progesterone ratio
Mechanical stretching in later pregnancy Mechanical stretching in later pregnancy
Infection or separation of membranes Infection or separation of membranes
↑↑ oxytocin receptors oxytocin receptors
6. Oxytocin theory:-6. Oxytocin theory:-
although oxytocin is a powerful stimulator of uterine although oxytocin is a powerful stimulator of uterine
contraction its natural role in onset of labour is contraction its natural role in onset of labour is
doubtful .doubtful .
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Diagnosis of labour :-Diagnosis of labour :-
Pre labour (premonitory stage :-Pre labour (premonitory stage :-
- May begins two to three weeks before the - May begins two to three weeks before the
onset of true labour in PG. and few days onset of true labour in PG. and few days
before in multi gravida and may consist of before in multi gravida and may consist of
the following .the following .
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Pre labour (premonitory stage :-Pre labour (premonitory stage :-
- May begins two to three weeks before the - May begins two to three weeks before the
onset of true labour in PG. and few days onset of true labour in PG. and few days
before in multi gravida and may consist of before in multi gravida and may consist of
the following .the following .
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1)Lightening :- 1)Lightening :- A sense of relief from the A sense of relief from the
upper abdominal pressure symptoms such upper abdominal pressure symptoms such
as dyspnoea or dyspepsia due to sink of as dyspnoea or dyspepsia due to sink of
the presenting part into the true pelvis .the presenting part into the true pelvis .
2.Pelvic pressure symptoms such as 2.Pelvic pressure symptoms such as
frequency of micturition due to frequency of micturition due to
engagement of the presenting part .engagement of the presenting part .
3.Cervical changes (ripening of the cervix) 3.Cervical changes (ripening of the cervix)
become soft , less than 1.3cm in length become soft , less than 1.3cm in length
,Admit tip of the finger and is dilatable .,Admit tip of the finger and is dilatable .
4.Appearance of false pain . 4.Appearance of false pain .
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upper abdominal pressure symptoms such upper abdominal pressure symptoms such
as dyspnoea or dyspepsia due to sink of as dyspnoea or dyspepsia due to sink of
the presenting part into the true pelvis .the presenting part into the true pelvis .
2.Pelvic pressure symptoms such as 2.Pelvic pressure symptoms such as
frequency of micturition due to frequency of micturition due to
engagement of the presenting part .engagement of the presenting part .
3.Cervical changes (ripening of the cervix) 3.Cervical changes (ripening of the cervix)
become soft , less than 1.3cm in length become soft , less than 1.3cm in length
,Admit tip of the finger and is dilatable .,Admit tip of the finger and is dilatable .
4.Appearance of false pain . 4.Appearance of false pain .
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True LabourTrue Labour
Features of true labour areFeatures of true labour are :-:-
1)1)Labour pain:-Labour pain:-
-Intermittened painful and regular .Intermittened painful and regular .
-Increase progressively in frequency, Increase progressively in frequency,
duration and intensity .duration and intensity .
-Felt in the abdomen and radiate to the Felt in the abdomen and radiate to the
back and thighback and thigh . .
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Features of true labour areFeatures of true labour are :-:-
1)1)Labour pain:-Labour pain:-
-Intermittened painful and regular .Intermittened painful and regular .
-Increase progressively in frequency, Increase progressively in frequency,
duration and intensity .duration and intensity .
-Felt in the abdomen and radiate to the Felt in the abdomen and radiate to the
back and thighback and thigh . .
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2)The show2)The show Expulsion of the cervical mucus Expulsion of the cervical mucus
plug mixed with blood –may occur few plug mixed with blood –may occur few
days before the onset of labour .days before the onset of labour .
3) Progressive effacement and dilatation of 3) Progressive effacement and dilatation of
the cervix .the cervix .
4) Formation of the bag of forewater ,the 4) Formation of the bag of forewater ,the
lower pole of the fetal membranes lower pole of the fetal membranes
become unsupported and tend to bulge become unsupported and tend to bulge
through the cervical canal . through the cervical canal .
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plug mixed with blood –may occur few plug mixed with blood –may occur few
days before the onset of labour .days before the onset of labour .
3) Progressive effacement and dilatation of 3) Progressive effacement and dilatation of
the cervix .the cervix .
4) Formation of the bag of forewater ,the 4) Formation of the bag of forewater ,the
lower pole of the fetal membranes lower pole of the fetal membranes
become unsupported and tend to bulge become unsupported and tend to bulge
through the cervical canal . through the cervical canal .
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Stages of labourStages of labour
Labour is divided into four Labour is divided into four
stages:-stages:-
1- 1- First stage of labour:-First stage of labour:-
-It is the stage of cervical It is the stage of cervical
dilatation .dilatation .
-Starts with the onset of labour Starts with the onset of labour
pain and ends with full pain and ends with full
dilatation of the cervix .dilatation of the cervix .
-It takes about 12 hours in a It takes about 12 hours in a
Primipara, and 8hrs in a Primipara, and 8hrs in a
multipara .multipara .
-It’s composed of two phases .It’s composed of two phases .
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Labour is divided into four Labour is divided into four
stages:-stages:-
1- 1- First stage of labour:-First stage of labour:-
-It is the stage of cervical It is the stage of cervical
dilatation .dilatation .
-Starts with the onset of labour Starts with the onset of labour
pain and ends with full pain and ends with full
dilatation of the cervix .dilatation of the cervix .
-It takes about 12 hours in a It takes about 12 hours in a
Primipara, and 8hrs in a Primipara, and 8hrs in a
multipara .multipara .
-It’s composed of two phases .It’s composed of two phases .
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A) Latent phase:A) Latent phase:
Starts from the onset of labour and ends Starts from the onset of labour and ends
when the cervix is (2 to3 cm) dilated . It when the cervix is (2 to3 cm) dilated . It
occurs because the thinning of the lower occurs because the thinning of the lower
segment and cervix take a lot of uterine segment and cervix take a lot of uterine
work before rapid dilatation can begin . It work before rapid dilatation can begin . It
takes about (6 to 8 hrs) . takes about (6 to 8 hrs) .
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Starts from the onset of labour and ends Starts from the onset of labour and ends
when the cervix is (2 to3 cm) dilated . It when the cervix is (2 to3 cm) dilated . It
occurs because the thinning of the lower occurs because the thinning of the lower
segment and cervix take a lot of uterine segment and cervix take a lot of uterine
work before rapid dilatation can begin . It work before rapid dilatation can begin . It
takes about (6 to 8 hrs) . takes about (6 to 8 hrs) .
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B) Active phase :-B) Active phase :-
It is the phase of rapid dilatation of the cervix It is the phase of rapid dilatation of the cervix
from 3cm dilatation up to full dilatation it also from 3cm dilatation up to full dilatation it also
take (6hrs) with a rate of cervical dilatation of take (6hrs) with a rate of cervical dilatation of
(1.2cm/hour)in PG and (1.5cm/hour)in (1.2cm/hour)in PG and (1.5cm/hour)in
multigravidamultigravida . .
It has three components:-It has three components:-
i) Accelerated phase of dilatation from i) Accelerated phase of dilatation from
(2.5cmto4cm).(2.5cmto4cm).
ii) Phase of maximum slope of (4to9cm) dilatation .ii) Phase of maximum slope of (4to9cm) dilatation .
iii) Phase of deceleration of (9-10cm) dilatationiii) Phase of deceleration of (9-10cm) dilatation . .
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It is the phase of rapid dilatation of the cervix It is the phase of rapid dilatation of the cervix
from 3cm dilatation up to full dilatation it also from 3cm dilatation up to full dilatation it also
take (6hrs) with a rate of cervical dilatation of take (6hrs) with a rate of cervical dilatation of
(1.2cm/hour)in PG and (1.5cm/hour)in (1.2cm/hour)in PG and (1.5cm/hour)in
multigravidamultigravida . .
It has three components:-It has three components:-
i) Accelerated phase of dilatation from i) Accelerated phase of dilatation from
(2.5cmto4cm).(2.5cmto4cm).
ii) Phase of maximum slope of (4to9cm) dilatation .ii) Phase of maximum slope of (4to9cm) dilatation .
iii) Phase of deceleration of (9-10cm) dilatationiii) Phase of deceleration of (9-10cm) dilatation . .
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Causes of cervical dilation:-Causes of cervical dilation:-
1.1.Contraction and retraction of uterine Contraction and retraction of uterine
musculature (primary force)musculature (primary force)
- Normal uterine contraction occur with - Normal uterine contraction occur with
frequency of one every 2-3 minutes with frequency of one every 2-3 minutes with
at least 1min between contraction. With at least 1min between contraction. With
a duration of 40-70 seconds and an a duration of 40-70 seconds and an
intensity of around 50 mmHg & a resting intensity of around 50 mmHg & a resting
tone less than 15 mmHgtone less than 15 mmHg
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1.1.Contraction and retraction of uterine Contraction and retraction of uterine
musculature (primary force)musculature (primary force)
- Normal uterine contraction occur with - Normal uterine contraction occur with
frequency of one every 2-3 minutes with frequency of one every 2-3 minutes with
at least 1min between contraction. With at least 1min between contraction. With
a duration of 40-70 seconds and an a duration of 40-70 seconds and an
intensity of around 50 mmHg & a resting intensity of around 50 mmHg & a resting
tone less than 15 mmHgtone less than 15 mmHg
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The contraction begins in two pace The contraction begins in two pace
makers near the utrotubal junction –only makers near the utrotubal junction –only
one pace maker is operative in each one pace maker is operative in each
contraction. It spread like a wave over the contraction. It spread like a wave over the
whole uterus- strong in the funds (fundal whole uterus- strong in the funds (fundal
dominance) less strong in the mid zone dominance) less strong in the mid zone
and relatively in the lower segment. and relatively in the lower segment.
Relaxation begins simultaneously in all Relaxation begins simultaneously in all
areas of the uterus.areas of the uterus.
The force generated by each contraction The force generated by each contraction
is applied to the amniotic fluid and directly is applied to the amniotic fluid and directly
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makers near the utrotubal junction –only makers near the utrotubal junction –only
one pace maker is operative in each one pace maker is operative in each
contraction. It spread like a wave over the contraction. It spread like a wave over the
whole uterus- strong in the funds (fundal whole uterus- strong in the funds (fundal
dominance) less strong in the mid zone dominance) less strong in the mid zone
and relatively in the lower segment. and relatively in the lower segment.
Relaxation begins simultaneously in all Relaxation begins simultaneously in all
areas of the uterus.areas of the uterus.
The force generated by each contraction The force generated by each contraction
is applied to the amniotic fluid and directly is applied to the amniotic fluid and directly
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Against the pole of the infant that occupies Against the pole of the infant that occupies
the upper segment therefore each time the the upper segment therefore each time the
muscle contracts the uterine cavity muscle contracts the uterine cavity
becomes smaller and the presenting part or becomes smaller and the presenting part or
the fore bag of water lying a head of it is the fore bag of water lying a head of it is
pushed down ward in to the cervix this pushed down ward in to the cervix this
tends to force it to open or dilatetends to force it to open or dilate..
A more potent factor in cervical dilatation A more potent factor in cervical dilatation
however is the retraction of the upper however is the retraction of the upper
segment. As this area of the uterus segment. As this area of the uterus
becomes shorter and thicker it pulls the becomes shorter and thicker it pulls the
lower segment and the dilating cervix lower segment and the dilating cervix
upward around the presenting part at the upward around the presenting part at the
same time thesame time the
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the upper segment therefore each time the the upper segment therefore each time the
muscle contracts the uterine cavity muscle contracts the uterine cavity
becomes smaller and the presenting part or becomes smaller and the presenting part or
the fore bag of water lying a head of it is the fore bag of water lying a head of it is
pushed down ward in to the cervix this pushed down ward in to the cervix this
tends to force it to open or dilatetends to force it to open or dilate..
A more potent factor in cervical dilatation A more potent factor in cervical dilatation
however is the retraction of the upper however is the retraction of the upper
segment. As this area of the uterus segment. As this area of the uterus
becomes shorter and thicker it pulls the becomes shorter and thicker it pulls the
lower segment and the dilating cervix lower segment and the dilating cervix
upward around the presenting part at the upward around the presenting part at the
same time thesame time the
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uterus contracting directly against the uterus contracting directly against the
infant tends to push it through the infant tends to push it through the
cervicalcervical opening .opening .
Cervical dilatation in primigravida Cervical dilatation in primigravida
occurs from above down ward occurs from above down ward
causing progressive shortening of causing progressive shortening of
the cervix.( effacement).the cervix.( effacement).
In multigravida effacement and In multigravida effacement and
dilatation occurs simultaneously. dilatation occurs simultaneously.
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infant tends to push it through the infant tends to push it through the
cervicalcervical opening .opening .
Cervical dilatation in primigravida Cervical dilatation in primigravida
occurs from above down ward occurs from above down ward
causing progressive shortening of causing progressive shortening of
the cervix.( effacement).the cervix.( effacement).
In multigravida effacement and In multigravida effacement and
dilatation occurs simultaneously. dilatation occurs simultaneously.
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2. Second stage of labour2. Second stage of labour
It is the stage of expulsion of the fetusIt is the stage of expulsion of the fetus
Begins with full cervical dilatation and Begins with full cervical dilatation and
ends with delivery of the fetusends with delivery of the fetus
Its duration is about one hour in Its duration is about one hour in
primigravida and ½ an hour in primigravida and ½ an hour in
multigravida.multigravida.
Delivery of the fetus is affected in addition Delivery of the fetus is affected in addition
to the uterine contraction( primary force) to the uterine contraction( primary force)
by voluntary contraction of the abdominal by voluntary contraction of the abdominal
muscles with the diaphragm fixed after muscles with the diaphragm fixed after
forced inspirationforced inspiration . .
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It is the stage of expulsion of the fetusIt is the stage of expulsion of the fetus
Begins with full cervical dilatation and Begins with full cervical dilatation and
ends with delivery of the fetusends with delivery of the fetus
Its duration is about one hour in Its duration is about one hour in
primigravida and ½ an hour in primigravida and ½ an hour in
multigravida.multigravida.
Delivery of the fetus is affected in addition Delivery of the fetus is affected in addition
to the uterine contraction( primary force) to the uterine contraction( primary force)
by voluntary contraction of the abdominal by voluntary contraction of the abdominal
muscles with the diaphragm fixed after muscles with the diaphragm fixed after
forced inspirationforced inspiration . .
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This will increase intra abdominal This will increase intra abdominal
pressure (secondary force).pressure (secondary force).
This secondary forces have no effect This secondary forces have no effect
on cervical dilatation but they are of on cervical dilatation but they are of
considerable importance in aiding the considerable importance in aiding the
expulsion of the infant from the uterus expulsion of the infant from the uterus
and vagina after the cervix is and vagina after the cervix is
completely dilated.completely dilated.
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pressure (secondary force).pressure (secondary force).
This secondary forces have no effect This secondary forces have no effect
on cervical dilatation but they are of on cervical dilatation but they are of
considerable importance in aiding the considerable importance in aiding the
expulsion of the infant from the uterus expulsion of the infant from the uterus
and vagina after the cervix is and vagina after the cervix is
completely dilated.completely dilated.
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3- third stage of labour:-3- third stage of labour:-
comprises the phase of placental separation comprises the phase of placental separation
its descent to the lower segment and finally its descent to the lower segment and finally
its expulsion with the membrane.its expulsion with the membrane.
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comprises the phase of placental separation comprises the phase of placental separation
its descent to the lower segment and finally its descent to the lower segment and finally
its expulsion with the membrane.its expulsion with the membrane.
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It begins after delivery of the fetus and end It begins after delivery of the fetus and end
with expulsion of the placenta and with expulsion of the placenta and
membrane.membrane.
Duration is about 10__20 minutes in both Duration is about 10__20 minutes in both
primigravide and multigravida.primigravide and multigravida.
Placental separation is due to marked Placental separation is due to marked
uterine muscle retraction which reduces uterine muscle retraction which reduces
the surface area at the placental site to the surface area at the placental site to
about its half but as the placenta is about its half but as the placenta is
inelastic a shearing force in instituted inelastic a shearing force in instituted
bringing about its separation. the plane of bringing about its separation. the plane of
separation runs through the deep spongy separation runs through the deep spongy
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with expulsion of the placenta and with expulsion of the placenta and
membrane.membrane.
Duration is about 10__20 minutes in both Duration is about 10__20 minutes in both
primigravide and multigravida.primigravide and multigravida.
Placental separation is due to marked Placental separation is due to marked
uterine muscle retraction which reduces uterine muscle retraction which reduces
the surface area at the placental site to the surface area at the placental site to
about its half but as the placenta is about its half but as the placenta is
inelastic a shearing force in instituted inelastic a shearing force in instituted
bringing about its separation. the plane of bringing about its separation. the plane of
separation runs through the deep spongy separation runs through the deep spongy
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Layer of the decidua basalis Layer of the decidua basalis
There are two mechanism of placental There are two mechanism of placental
separation.separation.
1- central separation (Schultz) occur in 80% 1- central separation (Schultz) occur in 80%
of cases- detachment of placenta from its of cases- detachment of placenta from its
uterine attachment starts at the centre.uterine attachment starts at the centre.
2- marginal separation( Mathews –Duncan) 2- marginal separation( Mathews –Duncan)
occurs in 20% of cases. Separation starts occurs in 20% of cases. Separation starts
at the margin as it is mostly un supported at the margin as it is mostly un supported
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There are two mechanism of placental There are two mechanism of placental
separation.separation.
1- central separation (Schultz) occur in 80% 1- central separation (Schultz) occur in 80%
of cases- detachment of placenta from its of cases- detachment of placenta from its
uterine attachment starts at the centre.uterine attachment starts at the centre.
2- marginal separation( Mathews –Duncan) 2- marginal separation( Mathews –Duncan)
occurs in 20% of cases. Separation starts occurs in 20% of cases. Separation starts
at the margin as it is mostly un supported at the margin as it is mostly un supported
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After complete separation of the placenta it After complete separation of the placenta it
is delivered by effective uterine contraction is delivered by effective uterine contraction
and retraction and expelled out by either and retraction and expelled out by either
voluntary contraction of abdominal muscle voluntary contraction of abdominal muscle
(bearing down effort) or by manipulative (bearing down effort) or by manipulative
procedures.procedures.
After placental delivery the uterine sinuses After placental delivery the uterine sinuses
and arterioles are occluded by effective and arterioles are occluded by effective
uterine contraction and retraction which is uterine contraction and retraction which is
the principle mechanism of haemostasis, the principle mechanism of haemostasis,
however thrombosis also occurs and is however thrombosis also occurs and is
facilitated by the hypercoagulable status of facilitated by the hypercoagulable status of
pregnancy.pregnancy.
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is delivered by effective uterine contraction is delivered by effective uterine contraction
and retraction and expelled out by either and retraction and expelled out by either
voluntary contraction of abdominal muscle voluntary contraction of abdominal muscle
(bearing down effort) or by manipulative (bearing down effort) or by manipulative
procedures.procedures.
After placental delivery the uterine sinuses After placental delivery the uterine sinuses
and arterioles are occluded by effective and arterioles are occluded by effective
uterine contraction and retraction which is uterine contraction and retraction which is
the principle mechanism of haemostasis, the principle mechanism of haemostasis,
however thrombosis also occurs and is however thrombosis also occurs and is
facilitated by the hypercoagulable status of facilitated by the hypercoagulable status of
pregnancy.pregnancy.
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4-fourth stage of labour4-fourth stage of labour
Begins immediately after expulsion of the Begins immediately after expulsion of the
placenta and membranes and last for one placenta and membranes and last for one
hour.hour.
Careful observation of the patient for signs Careful observation of the patient for signs
of postpartum hemorrhage is essential.of postpartum hemorrhage is essential.
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Begins immediately after expulsion of the Begins immediately after expulsion of the
placenta and membranes and last for one placenta and membranes and last for one
hour.hour.
Careful observation of the patient for signs Careful observation of the patient for signs
of postpartum hemorrhage is essential.of postpartum hemorrhage is essential.
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Mechanism of normal labour:-Mechanism of normal labour:-
It refers to the series of changes in position It refers to the series of changes in position
and attitude which the fetus under goes during and attitude which the fetus under goes during
its passage through the birth canalits passage through the birth canal
And it consist of the following.And it consist of the following.
1)1)Descent of the fetus is a continuous movement Descent of the fetus is a continuous movement
it is slow or insignificant in the first stage of it is slow or insignificant in the first stage of
labour but pronounced in the second stage. it labour but pronounced in the second stage. it
is completed with the expulsion of the fetus. It is completed with the expulsion of the fetus. It
is due to contraction and retraction of uterine is due to contraction and retraction of uterine
muscle (primary force). Added in the second muscle (primary force). Added in the second
stage by bearing down efforts (secondary stage by bearing down efforts (secondary
force).force).
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It refers to the series of changes in position It refers to the series of changes in position
and attitude which the fetus under goes during and attitude which the fetus under goes during
its passage through the birth canalits passage through the birth canal
And it consist of the following.And it consist of the following.
1)1)Descent of the fetus is a continuous movement Descent of the fetus is a continuous movement
it is slow or insignificant in the first stage of it is slow or insignificant in the first stage of
labour but pronounced in the second stage. it labour but pronounced in the second stage. it
is completed with the expulsion of the fetus. It is completed with the expulsion of the fetus. It
is due to contraction and retraction of uterine is due to contraction and retraction of uterine
muscle (primary force). Added in the second muscle (primary force). Added in the second
stage by bearing down efforts (secondary stage by bearing down efforts (secondary
force).force).
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2- flexion:-2- flexion:-
As the head meet the resistance of the As the head meet the resistance of the
birth canal during descent full flexion is birth canal during descent full flexion is
achieved to bring the shortest sub-occipito achieved to bring the shortest sub-occipito
bregmatic diameter. Of the head(9.5cm).bregmatic diameter. Of the head(9.5cm).
Flexion is essential for descent since it Flexion is essential for descent since it
reduces the shape and size of the plane of reduces the shape and size of the plane of
the advancing diameter of the head. the advancing diameter of the head.
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As the head meet the resistance of the As the head meet the resistance of the
birth canal during descent full flexion is birth canal during descent full flexion is
achieved to bring the shortest sub-occipito achieved to bring the shortest sub-occipito
bregmatic diameter. Of the head(9.5cm).bregmatic diameter. Of the head(9.5cm).
Flexion is essential for descent since it Flexion is essential for descent since it
reduces the shape and size of the plane of reduces the shape and size of the plane of
the advancing diameter of the head. the advancing diameter of the head.
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3- internal rotation3- internal rotation
In the second stage of labour the forces In the second stage of labour the forces
propel the fetus progressively down the propel the fetus progressively down the
birth canal, when the head meets the birth canal, when the head meets the
resistance of the pelvic floor the occiput resistance of the pelvic floor the occiput
rotates forward to lie under the sub pubic rotates forward to lie under the sub pubic
arch with the sagittal suture in the antero-arch with the sagittal suture in the antero-
posterior diameter of the pelvic out let . This posterior diameter of the pelvic out let . This
internal rotation of the head occurs internal rotation of the head occurs
because with a well flexed head the occiput because with a well flexed head the occiput
is leading and meets the slopping gutter of is leading and meets the slopping gutter of
thethe
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In the second stage of labour the forces In the second stage of labour the forces
propel the fetus progressively down the propel the fetus progressively down the
birth canal, when the head meets the birth canal, when the head meets the
resistance of the pelvic floor the occiput resistance of the pelvic floor the occiput
rotates forward to lie under the sub pubic rotates forward to lie under the sub pubic
arch with the sagittal suture in the antero-arch with the sagittal suture in the antero-
posterior diameter of the pelvic out let . This posterior diameter of the pelvic out let . This
internal rotation of the head occurs internal rotation of the head occurs
because with a well flexed head the occiput because with a well flexed head the occiput
is leading and meets the slopping gutter of is leading and meets the slopping gutter of
thethe
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Lavatores ani muscles which by their shape Lavatores ani muscles which by their shape
direct it anteriorly.direct it anteriorly.
4. extension:-4. extension:-
further advances of the head lead to its further advances of the head lead to its
passage through the vulva by a process of passage through the vulva by a process of
extension. Once the occiput has escaped extension. Once the occiput has escaped
from under the symphysis pubis the head from under the symphysis pubis the head
extends with the nape of neck pressed extends with the nape of neck pressed
firmly against the public arch. The firmly against the public arch. The
successive parts of the fetal head to born successive parts of the fetal head to born
through the stretched vulval .out let are through the stretched vulval .out let are
vertexvertex , brow and face. , brow and face.
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direct it anteriorly.direct it anteriorly.
4. extension:-4. extension:-
further advances of the head lead to its further advances of the head lead to its
passage through the vulva by a process of passage through the vulva by a process of
extension. Once the occiput has escaped extension. Once the occiput has escaped
from under the symphysis pubis the head from under the symphysis pubis the head
extends with the nape of neck pressed extends with the nape of neck pressed
firmly against the public arch. The firmly against the public arch. The
successive parts of the fetal head to born successive parts of the fetal head to born
through the stretched vulval .out let are through the stretched vulval .out let are
vertexvertex , brow and face. , brow and face.
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5- restitution:-5- restitution:-
As soon as the head is completely born it As soon as the head is completely born it
resumes its natural position with regard to resumes its natural position with regard to
the shoulders by rotating 1/8the shoulders by rotating 1/8
thth
of a circle in of a circle in
the direction opposite to that of internal the direction opposite to that of internal
rotation. The neck becomes untwisted and rotation. The neck becomes untwisted and
the head is restored to its natural relation the head is restored to its natural relation
to the shoulder. to the shoulder.
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As soon as the head is completely born it As soon as the head is completely born it
resumes its natural position with regard to resumes its natural position with regard to
the shoulders by rotating 1/8the shoulders by rotating 1/8
thth
of a circle in of a circle in
the direction opposite to that of internal the direction opposite to that of internal
rotation. The neck becomes untwisted and rotation. The neck becomes untwisted and
the head is restored to its natural relation the head is restored to its natural relation
to the shoulder. to the shoulder.
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6.6. External rotationExternal rotation
It is the movement of rotation of the head It is the movement of rotation of the head
visible externally due to internal rotation of visible externally due to internal rotation of
the shoulders it carries the head in a the shoulders it carries the head in a
movement through 1/8movement through 1/8
thth
of a circle in the of a circle in the
same direction as restitution.same direction as restitution.
7- Birth of shoulders and trunk:-7- Birth of shoulders and trunk:-
- Further descent takes place the anterior - Further descent takes place the anterior
shoulder escapes below the symphysis shoulder escapes below the symphysis
pubis and by lateral flexion of the spine the pubis and by lateral flexion of the spine the
posterior shoulder sweeps over the posterior shoulder sweeps over the
perineum. Rest of the trunk is there perineum. Rest of the trunk is there
expelled out expelled out
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It is the movement of rotation of the head It is the movement of rotation of the head
visible externally due to internal rotation of visible externally due to internal rotation of
the shoulders it carries the head in a the shoulders it carries the head in a
movement through 1/8movement through 1/8
thth
of a circle in the of a circle in the
same direction as restitution.same direction as restitution.
7- Birth of shoulders and trunk:-7- Birth of shoulders and trunk:-
- Further descent takes place the anterior - Further descent takes place the anterior
shoulder escapes below the symphysis shoulder escapes below the symphysis
pubis and by lateral flexion of the spine the pubis and by lateral flexion of the spine the
posterior shoulder sweeps over the posterior shoulder sweeps over the
perineum. Rest of the trunk is there perineum. Rest of the trunk is there
expelled out expelled out
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Management of normal labourManagement of normal labour
First stage:-First stage:-
On admission a complete history must be On admission a complete history must be
taken taken
Antenatal record is reviewed to discover Antenatal record is reviewed to discover
whether there have been any abnormalities whether there have been any abnormalities
during pregnancy during pregnancy
The women general condition is assessed The women general condition is assessed
her pulse-blood pressure and temperature her pulse-blood pressure and temperature
are recorded are recorded
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First stage:-First stage:-
On admission a complete history must be On admission a complete history must be
taken taken
Antenatal record is reviewed to discover Antenatal record is reviewed to discover
whether there have been any abnormalities whether there have been any abnormalities
during pregnancy during pregnancy
The women general condition is assessed The women general condition is assessed
her pulse-blood pressure and temperature her pulse-blood pressure and temperature
are recorded are recorded
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on abdominal examination the on abdominal examination the
presentation and position of the fetus and presentation and position of the fetus and
the relation of the presenting part to the the relation of the presenting part to the
brim of the pelvis are determined brim of the pelvis are determined
Abdominal examination will also show the Abdominal examination will also show the
frequency and strength of uterine frequency and strength of uterine
contraction .contraction .
The location, rate and regularity of the The location, rate and regularity of the
fetal heart tones are also determined.fetal heart tones are also determined.
A vaginal examination will show the A vaginal examination will show the
degree of cervical dilation, whether the degree of cervical dilation, whether the
membranes are intact or rupture and themembranes are intact or rupture and the
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presentation and position of the fetus and presentation and position of the fetus and
the relation of the presenting part to the the relation of the presenting part to the
brim of the pelvis are determined brim of the pelvis are determined
Abdominal examination will also show the Abdominal examination will also show the
frequency and strength of uterine frequency and strength of uterine
contraction .contraction .
The location, rate and regularity of the The location, rate and regularity of the
fetal heart tones are also determined.fetal heart tones are also determined.
A vaginal examination will show the A vaginal examination will show the
degree of cervical dilation, whether the degree of cervical dilation, whether the
membranes are intact or rupture and themembranes are intact or rupture and the
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Position with station of the presenting part.Position with station of the presenting part.
A urine specimen is examined for protein A urine specimen is examined for protein
and glucose and a hemoglobin or and glucose and a hemoglobin or
haematocrit determination is made.haematocrit determination is made.
Enema:-Enema:-
It’s routine use is unnecessary and has It’s routine use is unnecessary and has
no particular benefit.no particular benefit.
Usually given early in the first stage of Usually given early in the first stage of
labour to empty the rectum to prevents labour to empty the rectum to prevents
soiling of the perineum during the second soiling of the perineum during the second
stage. stage.
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A urine specimen is examined for protein A urine specimen is examined for protein
and glucose and a hemoglobin or and glucose and a hemoglobin or
haematocrit determination is made.haematocrit determination is made.
Enema:-Enema:-
It’s routine use is unnecessary and has It’s routine use is unnecessary and has
no particular benefit.no particular benefit.
Usually given early in the first stage of Usually given early in the first stage of
labour to empty the rectum to prevents labour to empty the rectum to prevents
soiling of the perineum during the second soiling of the perineum during the second
stage. stage.
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Shaving or clipping of the Shaving or clipping of the
vulval hairvulval hair
Is not necessary Is not necessary
Awarm bath or shower is both hygienic Awarm bath or shower is both hygienic
and pleasant.and pleasant.
Rest:-Rest:-
there is no need for the women to remain there is no need for the women to remain
in bed during early labour. She is allowed in bed during early labour. She is allowed
to walk about and to sit. This attitude to walk about and to sit. This attitude
prevents venacaval compression and prevents venacaval compression and
encourage descent of the presenting part. encourage descent of the presenting part.
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vulval hairvulval hair
Is not necessary Is not necessary
Awarm bath or shower is both hygienic Awarm bath or shower is both hygienic
and pleasant.and pleasant.
Rest:-Rest:-
there is no need for the women to remain there is no need for the women to remain
in bed during early labour. She is allowed in bed during early labour. She is allowed
to walk about and to sit. This attitude to walk about and to sit. This attitude
prevents venacaval compression and prevents venacaval compression and
encourage descent of the presenting part. encourage descent of the presenting part.
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Oral intakeOral intake
The major risk to be avoided is aspiration The major risk to be avoided is aspiration
of gastric contents, this only occurs in the of gastric contents, this only occurs in the
context of general anesthesia.context of general anesthesia.
Intake of solid food must be avoided, low Intake of solid food must be avoided, low
fat, low residuce food and drink can be fat, low residuce food and drink can be
given.given.
If dehydration needs to be corrected If dehydration needs to be corrected
normal saline should be infused. normal saline should be infused.
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The major risk to be avoided is aspiration The major risk to be avoided is aspiration
of gastric contents, this only occurs in the of gastric contents, this only occurs in the
context of general anesthesia.context of general anesthesia.
Intake of solid food must be avoided, low Intake of solid food must be avoided, low
fat, low residuce food and drink can be fat, low residuce food and drink can be
given.given.
If dehydration needs to be corrected If dehydration needs to be corrected
normal saline should be infused. normal saline should be infused.
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Bladder care:-Bladder care:-
The patient should be encouraged to empty The patient should be encouraged to empty
her bladder frequently as full bladder often her bladder frequently as full bladder often
inhibits uterine contraction.inhibits uterine contraction.
If the patient fails to pass urine specially in If the patient fails to pass urine specially in
late first stage catheterization is to be done late first stage catheterization is to be done
with strict aseptic precautionwith strict aseptic precaution..
Relief of pain:-Relief of pain:-
Pethidine (100) mg intramuscularly can be Pethidine (100) mg intramuscularly can be
given when the pains are well estabished. It. given when the pains are well estabished. It.
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The patient should be encouraged to empty The patient should be encouraged to empty
her bladder frequently as full bladder often her bladder frequently as full bladder often
inhibits uterine contraction.inhibits uterine contraction.
If the patient fails to pass urine specially in If the patient fails to pass urine specially in
late first stage catheterization is to be done late first stage catheterization is to be done
with strict aseptic precautionwith strict aseptic precaution..
Relief of pain:-Relief of pain:-
Pethidine (100) mg intramuscularly can be Pethidine (100) mg intramuscularly can be
given when the pains are well estabished. It. given when the pains are well estabished. It.
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should not be given if delivery is anticipated should not be given if delivery is anticipated
within two hourswithin two hours
Epidural analgesia is very effective & do Epidural analgesia is very effective & do
not cause depression of fetal respiration not cause depression of fetal respiration
If epidural is not used towards the end of If epidural is not used towards the end of
first stage a mixture of nitrous oxide & first stage a mixture of nitrous oxide &
Oxygen (Entonox) may be started with the Oxygen (Entonox) may be started with the
onset of each contraction.onset of each contraction.
Partogram:-Partogram:-
One labour has become established all One labour has become established all
events during labour should be recorded events during labour should be recorded
on the partogram.on the partogram.
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within two hourswithin two hours
Epidural analgesia is very effective & do Epidural analgesia is very effective & do
not cause depression of fetal respiration not cause depression of fetal respiration
If epidural is not used towards the end of If epidural is not used towards the end of
first stage a mixture of nitrous oxide & first stage a mixture of nitrous oxide &
Oxygen (Entonox) may be started with the Oxygen (Entonox) may be started with the
onset of each contraction.onset of each contraction.
Partogram:-Partogram:-
One labour has become established all One labour has become established all
events during labour should be recorded events during labour should be recorded
on the partogram.on the partogram.
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Cervical dilatation marked in centimeters at Cervical dilatation marked in centimeters at
the time of admission to ward and at every the time of admission to ward and at every
subsequent examination(2 hourly)subsequent examination(2 hourly)
Descent of head (in cm above or below the Descent of head (in cm above or below the
lschael spine).lschael spine).
Frequency, duration and strength of uterine Frequency, duration and strength of uterine
contration in (10)min. each half an hour.contration in (10)min. each half an hour.
Fetal heart rate every ½ an hour.Fetal heart rate every ½ an hour.
Condition of liquor and time and manner of Condition of liquor and time and manner of
membranes rupture.membranes rupture.
moulding of the fetal skullmoulding of the fetal skull
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the time of admission to ward and at every the time of admission to ward and at every
subsequent examination(2 hourly)subsequent examination(2 hourly)
Descent of head (in cm above or below the Descent of head (in cm above or below the
lschael spine).lschael spine).
Frequency, duration and strength of uterine Frequency, duration and strength of uterine
contration in (10)min. each half an hour.contration in (10)min. each half an hour.
Fetal heart rate every ½ an hour.Fetal heart rate every ½ an hour.
Condition of liquor and time and manner of Condition of liquor and time and manner of
membranes rupture.membranes rupture.
moulding of the fetal skullmoulding of the fetal skull
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Dosage of Oxytocin if used Dosage of Oxytocin if used
Maternal status (BP- pulse- temp-Maternal status (BP- pulse- temp-
urinalysis).urinalysis).
Medication (including epidural block if Medication (including epidural block if
usedused
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Maternal status (BP- pulse- temp-Maternal status (BP- pulse- temp-
urinalysis).urinalysis).
Medication (including epidural block if Medication (including epidural block if
usedused
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Management of the second Management of the second
stage:-stage:-
The transition from the first stage to the The transition from the first stage to the
second stage is evidenced by the second stage is evidenced by the
following features.following features.
-Appearance of bearing down effortsAppearance of bearing down efforts
-Complete dilatation of the cervix on Complete dilatation of the cervix on
vaginal examination.vaginal examination.
Principles of management are:-Principles of management are:-
1. To assist in the natural expulsion of the 1. To assist in the natural expulsion of the
fetus slowly fetus slowly
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stage:-stage:-
The transition from the first stage to the The transition from the first stage to the
second stage is evidenced by the second stage is evidenced by the
following features.following features.
-Appearance of bearing down effortsAppearance of bearing down efforts
-Complete dilatation of the cervix on Complete dilatation of the cervix on
vaginal examination.vaginal examination.
Principles of management are:-Principles of management are:-
1. To assist in the natural expulsion of the 1. To assist in the natural expulsion of the
fetus slowly fetus slowly
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2- to prevent perineal injuries 2- to prevent perineal injuries
General measuresGeneral measures::
oFHR every 5 minutes FHR every 5 minutes
oMaternal pulse and blood pressure every Maternal pulse and blood pressure every
15mins15mins
oIf epidural block is not used to administer If epidural block is not used to administer
inhalation analgesia (entonox) to relieve pain inhalation analgesia (entonox) to relieve pain
during contractionduring contraction
oVaginal examination to confirm the on set of the Vaginal examination to confirm the on set of the
second stage – to detect cord prolapse and to second stage – to detect cord prolapse and to
know the position and station of the headknow the position and station of the head
oNothing is given by mouthNothing is given by mouth
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General measuresGeneral measures::
oFHR every 5 minutes FHR every 5 minutes
oMaternal pulse and blood pressure every Maternal pulse and blood pressure every
15mins15mins
oIf epidural block is not used to administer If epidural block is not used to administer
inhalation analgesia (entonox) to relieve pain inhalation analgesia (entonox) to relieve pain
during contractionduring contraction
oVaginal examination to confirm the on set of the Vaginal examination to confirm the on set of the
second stage – to detect cord prolapse and to second stage – to detect cord prolapse and to
know the position and station of the headknow the position and station of the head
oNothing is given by mouthNothing is given by mouth
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Preparation for delivery:-Preparation for delivery:-
Bearing down efforts, bulging of the Bearing down efforts, bulging of the
perineum and gaping of the anal opening perineum and gaping of the anal opening
during contraction signify that delivery is during contraction signify that delivery is
imminent so the patient should be shifted imminent so the patient should be shifted
to the labour table to the labour table
Position of the patientPosition of the patient
Dorsal position is more widely preferred with Dorsal position is more widely preferred with
the thighs flexed and separated . Some the thighs flexed and separated . Some
however prefer delivery in lateral or however prefer delivery in lateral or
lithotomy position lithotomy position
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Bearing down efforts, bulging of the Bearing down efforts, bulging of the
perineum and gaping of the anal opening perineum and gaping of the anal opening
during contraction signify that delivery is during contraction signify that delivery is
imminent so the patient should be shifted imminent so the patient should be shifted
to the labour table to the labour table
Position of the patientPosition of the patient
Dorsal position is more widely preferred with Dorsal position is more widely preferred with
the thighs flexed and separated . Some the thighs flexed and separated . Some
however prefer delivery in lateral or however prefer delivery in lateral or
lithotomy position lithotomy position
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Toileting the external genitalia and inner Toileting the external genitalia and inner
Side of the thighs with cotton swabs Side of the thighs with cotton swabs
soaked in savlon . And the area is covered soaked in savlon . And the area is covered
with sterile sheet. Keeping only the with sterile sheet. Keeping only the
external genitalia uncovered external genitalia uncovered
The delivery attendant should scrub put on The delivery attendant should scrub put on
sterile gown ,mask and glovessterile gown ,mask and gloves
To catheterize the bladder if it is full.To catheterize the bladder if it is full.
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Side of the thighs with cotton swabs Side of the thighs with cotton swabs
soaked in savlon . And the area is covered soaked in savlon . And the area is covered
with sterile sheet. Keeping only the with sterile sheet. Keeping only the
external genitalia uncovered external genitalia uncovered
The delivery attendant should scrub put on The delivery attendant should scrub put on
sterile gown ,mask and glovessterile gown ,mask and gloves
To catheterize the bladder if it is full.To catheterize the bladder if it is full.
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Conduction of the deliveryConduction of the delivery
The patient is encourage to intensify the The patient is encourage to intensify the
bearing down efforts during contractions.bearing down efforts during contractions.
When the scalp is visible for about 5cm When the scalp is visible for about 5cm
diameter flexion of the head is maintained diameter flexion of the head is maintained
during contraction by pushing the occiput during contraction by pushing the occiput
down wards and back wards by using down wards and back wards by using
thumb and index fingers of the left hand thumb and index fingers of the left hand
while pressing the perineum by the right while pressing the perineum by the right
palm with a sterile vulval pad. This palm with a sterile vulval pad. This
process is repeated during subsequentprocess is repeated during subsequent
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The patient is encourage to intensify the The patient is encourage to intensify the
bearing down efforts during contractions.bearing down efforts during contractions.
When the scalp is visible for about 5cm When the scalp is visible for about 5cm
diameter flexion of the head is maintained diameter flexion of the head is maintained
during contraction by pushing the occiput during contraction by pushing the occiput
down wards and back wards by using down wards and back wards by using
thumb and index fingers of the left hand thumb and index fingers of the left hand
while pressing the perineum by the right while pressing the perineum by the right
palm with a sterile vulval pad. This palm with a sterile vulval pad. This
process is repeated during subsequentprocess is repeated during subsequent
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contraction until crowing of the head occurs contraction until crowing of the head occurs
(biparietal diameter stretches the vulval (biparietal diameter stretches the vulval
out let without any recession of the head out let without any recession of the head
even after the contractions is over).even after the contractions is over).
When the perineum is fully stretched and When the perineum is fully stretched and
threatens to tear specially in PG threatens to tear specially in PG
episiotomy is done at this stage after prior episiotomy is done at this stage after prior
infiltration with 10/ml of 1% lignocaine.infiltration with 10/ml of 1% lignocaine.
Slow delivery of the head is accomplished Slow delivery of the head is accomplished
by pushing the chin with sterile gauze .by by pushing the chin with sterile gauze .by
covered fingers of the right hand placed covered fingers of the right hand placed
over the anococcygeal region over the anococcygeal region
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(biparietal diameter stretches the vulval (biparietal diameter stretches the vulval
out let without any recession of the head out let without any recession of the head
even after the contractions is over).even after the contractions is over).
When the perineum is fully stretched and When the perineum is fully stretched and
threatens to tear specially in PG threatens to tear specially in PG
episiotomy is done at this stage after prior episiotomy is done at this stage after prior
infiltration with 10/ml of 1% lignocaine.infiltration with 10/ml of 1% lignocaine.
Slow delivery of the head is accomplished Slow delivery of the head is accomplished
by pushing the chin with sterile gauze .by by pushing the chin with sterile gauze .by
covered fingers of the right hand placed covered fingers of the right hand placed
over the anococcygeal region over the anococcygeal region
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While the left hand exerts pressure on the While the left hand exerts pressure on the
occiput. the forehead, nose, mouth and occiput. the forehead, nose, mouth and
the chin are thus born successively over the chin are thus born successively over
the stretched perineum by extension.the stretched perineum by extension.
The mucus and blood in the mouth and The mucus and blood in the mouth and
pharynx should be wiped with sterile pharynx should be wiped with sterile
gauze or alternatively mechanical sucker gauze or alternatively mechanical sucker
may be used.may be used.
The neck is then palpated to exclude the The neck is then palpated to exclude the
presence of any loop of cord if it is found it presence of any loop of cord if it is found it
should be slipped over the head or if it is should be slipped over the head or if it is
sufficiently tight it is cut in between two sufficiently tight it is cut in between two
pairs of kocher’s forceps.pairs of kocher’s forceps.
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occiput. the forehead, nose, mouth and occiput. the forehead, nose, mouth and
the chin are thus born successively over the chin are thus born successively over
the stretched perineum by extension.the stretched perineum by extension.
The mucus and blood in the mouth and The mucus and blood in the mouth and
pharynx should be wiped with sterile pharynx should be wiped with sterile
gauze or alternatively mechanical sucker gauze or alternatively mechanical sucker
may be used.may be used.
The neck is then palpated to exclude the The neck is then palpated to exclude the
presence of any loop of cord if it is found it presence of any loop of cord if it is found it
should be slipped over the head or if it is should be slipped over the head or if it is
sufficiently tight it is cut in between two sufficiently tight it is cut in between two
pairs of kocher’s forceps.pairs of kocher’s forceps.
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Wait for uterine contractions to come and for the Wait for uterine contractions to come and for the
movements of restitution and external rotation of movements of restitution and external rotation of
the head to occur, the anterior shoulder is born the head to occur, the anterior shoulder is born
behind the symphysis. If there is delay the head behind the symphysis. If there is delay the head
is grasped by both hands and is gently drawn is grasped by both hands and is gently drawn
posteriorly until the anterior shoulder is released posteriorly until the anterior shoulder is released
from under the pubis. by drawing the head in from under the pubis. by drawing the head in
upward direction the posterior shoulder is upward direction the posterior shoulder is
delivered out of the perineum.delivered out of the perineum.
After delivery of the shoulders the fore fingers of After delivery of the shoulders the fore fingers of
each hand are inserted under the axillae and the each hand are inserted under the axillae and the
trunk is delivered gently by lateral flexion.trunk is delivered gently by lateral flexion.
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movements of restitution and external rotation of movements of restitution and external rotation of
the head to occur, the anterior shoulder is born the head to occur, the anterior shoulder is born
behind the symphysis. If there is delay the head behind the symphysis. If there is delay the head
is grasped by both hands and is gently drawn is grasped by both hands and is gently drawn
posteriorly until the anterior shoulder is released posteriorly until the anterior shoulder is released
from under the pubis. by drawing the head in from under the pubis. by drawing the head in
upward direction the posterior shoulder is upward direction the posterior shoulder is
delivered out of the perineum.delivered out of the perineum.
After delivery of the shoulders the fore fingers of After delivery of the shoulders the fore fingers of
each hand are inserted under the axillae and the each hand are inserted under the axillae and the
trunk is delivered gently by lateral flexion.trunk is delivered gently by lateral flexion.
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Some delay in clamping and cutting the Some delay in clamping and cutting the
umbilical cord probably is beneficial to the umbilical cord probably is beneficial to the
infant. As much as a 75 to 100ml increase infant. As much as a 75 to 100ml increase
in fetal blood volume can be anticipated.in fetal blood volume can be anticipated.
The infant is placed in a heated crib with The infant is placed in a heated crib with
its head slightly lower than its body. Its air its head slightly lower than its body. Its air
passage should be cleared of Mucus by passage should be cleared of Mucus by
sucker before vigorous respiratory efforts sucker before vigorous respiratory efforts
are established.are established.
Apgar rating at 1 minute an at 5 minute is Apgar rating at 1 minute an at 5 minute is
to be recorded to be recorded
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umbilical cord probably is beneficial to the umbilical cord probably is beneficial to the
infant. As much as a 75 to 100ml increase infant. As much as a 75 to 100ml increase
in fetal blood volume can be anticipated.in fetal blood volume can be anticipated.
The infant is placed in a heated crib with The infant is placed in a heated crib with
its head slightly lower than its body. Its air its head slightly lower than its body. Its air
passage should be cleared of Mucus by passage should be cleared of Mucus by
sucker before vigorous respiratory efforts sucker before vigorous respiratory efforts
are established.are established.
Apgar rating at 1 minute an at 5 minute is Apgar rating at 1 minute an at 5 minute is
to be recorded to be recorded
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A sterile cotton thread is applied to the A sterile cotton thread is applied to the
cord 2.5cm away from the navel & the cord 2.5cm away from the navel & the
cord is divided with scissors about 1 cm cord is divided with scissors about 1 cm
beyond the ligature.beyond the ligature.
Episiotomy:-Episiotomy:-
Defined as a planned surgical incision of Defined as a planned surgical incision of
the perineum made to increase the the perineum made to increase the
diameter of the vulval outlet during diameter of the vulval outlet during
childbirth (perineotomy)childbirth (perineotomy)
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cord 2.5cm away from the navel & the cord 2.5cm away from the navel & the
cord is divided with scissors about 1 cm cord is divided with scissors about 1 cm
beyond the ligature.beyond the ligature.
Episiotomy:-Episiotomy:-
Defined as a planned surgical incision of Defined as a planned surgical incision of
the perineum made to increase the the perineum made to increase the
diameter of the vulval outlet during diameter of the vulval outlet during
childbirth (perineotomy)childbirth (perineotomy)
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Types of episiotomyTypes of episiotomy
1-midline:- 1-midline:-
the cut is made vertically from the fourchette the cut is made vertically from the fourchette
down towards the anus.down towards the anus.
Advantages of this incision are less blood loss, Advantages of this incision are less blood loss,
is easier to repair, the wound heals quicker, and is easier to repair, the wound heals quicker, and
less postpartum pain and dyspareunia. The less postpartum pain and dyspareunia. The
major disadvantage it carries a higher risk to major disadvantage it carries a higher risk to
extend to involve the anal sphincter.extend to involve the anal sphincter.
2-mediolateral:-2-mediolateral:-
This incision starts in the midline of the This incision starts in the midline of the
fourchette and then directed outwards to avoid fourchette and then directed outwards to avoid
the anal sphincterthe anal sphincter
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1-midline:- 1-midline:-
the cut is made vertically from the fourchette the cut is made vertically from the fourchette
down towards the anus.down towards the anus.
Advantages of this incision are less blood loss, Advantages of this incision are less blood loss,
is easier to repair, the wound heals quicker, and is easier to repair, the wound heals quicker, and
less postpartum pain and dyspareunia. The less postpartum pain and dyspareunia. The
major disadvantage it carries a higher risk to major disadvantage it carries a higher risk to
extend to involve the anal sphincter.extend to involve the anal sphincter.
2-mediolateral:-2-mediolateral:-
This incision starts in the midline of the This incision starts in the midline of the
fourchette and then directed outwards to avoid fourchette and then directed outwards to avoid
the anal sphincterthe anal sphincter
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management of the management of the
third stage:third stage:
Two methods of management are currently Two methods of management are currently
in practice in practice
1.1.Watchful expectancy:-Watchful expectancy:-
- In this management the placental - In this management the placental
separation and its descent into the separation and its descent into the
vagina are allowed to occur vagina are allowed to occur
spontaneously. When the features of spontaneously. When the features of
placental separation at its descent into placental separation at its descent into
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third stage:third stage:
Two methods of management are currently Two methods of management are currently
in practice in practice
1.1.Watchful expectancy:-Watchful expectancy:-
- In this management the placental - In this management the placental
separation and its descent into the separation and its descent into the
vagina are allowed to occur vagina are allowed to occur
spontaneously. When the features of spontaneously. When the features of
placental separation at its descent into placental separation at its descent into
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the lower segment are confirmed the patient the lower segment are confirmed the patient
is asked to bear down simultaneously is asked to bear down simultaneously
with uterine contraction. The raised intra- with uterine contraction. The raised intra-
abdominal pressure is often adequate to abdominal pressure is often adequate to
expel the placenta. If the patient fail to expel the placenta. If the patient fail to
expel the placenta. controlled cord traction expel the placenta. controlled cord traction
(Brandt- Andrews method) can be tried. (Brandt- Andrews method) can be tried.
The palmer surface of the fingers of the The palmer surface of the fingers of the
left hand is placed approximately at the left hand is placed approximately at the
junction of upper and lower uterine junction of upper and lower uterine
segment the body of the uterus is segment the body of the uterus is
displaced upwards and backwards displaced upwards and backwards
towards the umbilicus while by the right towards the umbilicus while by the right
hand steady tension is given in hand steady tension is given in
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is asked to bear down simultaneously is asked to bear down simultaneously
with uterine contraction. The raised intra- with uterine contraction. The raised intra-
abdominal pressure is often adequate to abdominal pressure is often adequate to
expel the placenta. If the patient fail to expel the placenta. If the patient fail to
expel the placenta. controlled cord traction expel the placenta. controlled cord traction
(Brandt- Andrews method) can be tried. (Brandt- Andrews method) can be tried.
The palmer surface of the fingers of the The palmer surface of the fingers of the
left hand is placed approximately at the left hand is placed approximately at the
junction of upper and lower uterine junction of upper and lower uterine
segment the body of the uterus is segment the body of the uterus is
displaced upwards and backwards displaced upwards and backwards
towards the umbilicus while by the right towards the umbilicus while by the right
hand steady tension is given in hand steady tension is given in
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Downwards and backward direction until the Downwards and backward direction until the
placenta comes outside .placenta comes outside .
Signs of placental separation:-Signs of placental separation:-
1. A show of blood appears as the uterus 1. A show of blood appears as the uterus
contracts.contracts.
2. Lengthening of the cord 2. Lengthening of the cord
3. The fundus become globular in shape, 3. The fundus become globular in shape,
rises above the umbilicus, become rises above the umbilicus, become
palatable. palatable.
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placenta comes outside .placenta comes outside .
Signs of placental separation:-Signs of placental separation:-
1. A show of blood appears as the uterus 1. A show of blood appears as the uterus
contracts.contracts.
2. Lengthening of the cord 2. Lengthening of the cord
3. The fundus become globular in shape, 3. The fundus become globular in shape,
rises above the umbilicus, become rises above the umbilicus, become
palatable. palatable.
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2. Active management:-2. Active management:-
Is associated with reduced blood loss.Is associated with reduced blood loss.
I.V ergometrine or syntometrine I.V ergometrine or syntometrine
(syntocinon 5 units +ergometrine 0.5mg) (syntocinon 5 units +ergometrine 0.5mg)
is given with delivery of the anterior is given with delivery of the anterior
shoulder.shoulder.
The placenta is immediately delivered The placenta is immediately delivered
after delivery of the baby by controlled after delivery of the baby by controlled
cord traction after insuring uterine cord traction after insuring uterine
contraction contraction
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Is associated with reduced blood loss.Is associated with reduced blood loss.
I.V ergometrine or syntometrine I.V ergometrine or syntometrine
(syntocinon 5 units +ergometrine 0.5mg) (syntocinon 5 units +ergometrine 0.5mg)
is given with delivery of the anterior is given with delivery of the anterior
shoulder.shoulder.
The placenta is immediately delivered The placenta is immediately delivered
after delivery of the baby by controlled after delivery of the baby by controlled
cord traction after insuring uterine cord traction after insuring uterine
contraction contraction
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As soon as the placenta passes through the As soon as the placenta passes through the
introitus it is grasped between the hands and introitus it is grasped between the hands and
twisted around and round with gentle traction so twisted around and round with gentle traction so
that the membranes are stripped intact.that the membranes are stripped intact.
The placenta and the membranes should be The placenta and the membranes should be
examined following their expulsionexamined following their expulsion
Vulva-vagina and perineum are inspected Vulva-vagina and perineum are inspected
carefully for injuries and to be repaired if any. carefully for injuries and to be repaired if any.
the episiotomy is sutured. The vagina is the episiotomy is sutured. The vagina is
evacuated from blood clots . The area is evacuated from blood clots . The area is
cleaned and a dry sterile vulval pad is placed.cleaned and a dry sterile vulval pad is placed.
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introitus it is grasped between the hands and introitus it is grasped between the hands and
twisted around and round with gentle traction so twisted around and round with gentle traction so
that the membranes are stripped intact.that the membranes are stripped intact.
The placenta and the membranes should be The placenta and the membranes should be
examined following their expulsionexamined following their expulsion
Vulva-vagina and perineum are inspected Vulva-vagina and perineum are inspected
carefully for injuries and to be repaired if any. carefully for injuries and to be repaired if any.
the episiotomy is sutured. The vagina is the episiotomy is sutured. The vagina is
evacuated from blood clots . The area is evacuated from blood clots . The area is
cleaned and a dry sterile vulval pad is placed.cleaned and a dry sterile vulval pad is placed.
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The maternal condition –pulse –blood The maternal condition –pulse –blood
pressure. Behavior of the uterus and any pressure. Behavior of the uterus and any
abnormal vaginal bleeding is to be abnormal vaginal bleeding is to be
watched at least for one hour after delivery watched at least for one hour after delivery
(fourth stage of labour).(fourth stage of labour).
When fully satisfied that the general When fully satisfied that the general
condition is good pulse and blood condition is good pulse and blood
pressure are steady the uterus is well pressure are steady the uterus is well
contracted and there is no abnormal contracted and there is no abnormal
vaginal bleeding the patient is sent to the vaginal bleeding the patient is sent to the
ward. ward.
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pressure. Behavior of the uterus and any pressure. Behavior of the uterus and any
abnormal vaginal bleeding is to be abnormal vaginal bleeding is to be
watched at least for one hour after delivery watched at least for one hour after delivery
(fourth stage of labour).(fourth stage of labour).
When fully satisfied that the general When fully satisfied that the general
condition is good pulse and blood condition is good pulse and blood
pressure are steady the uterus is well pressure are steady the uterus is well
contracted and there is no abnormal contracted and there is no abnormal
vaginal bleeding the patient is sent to the vaginal bleeding the patient is sent to the
ward. ward.
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