PRACTICAL 5 MONITORING LABOUR AND

PARTOGRAPH
Structure
5.0 Objectives
5J Introduction
5.2 Identifying High Risk Pregnancy
5.3 Points to Remember Before and After Conducting Delivery
5.4 Assessment, Supportive Care and Vaginal Examination During Labour
5.4.1 Assessment
5.4.2 Supportive Care
5.4.3 VaginalExamination
5.5 First Stage Of Labour
55.1 First Stage: From onset of Labour till Full Dilatation of Cervix
55.2 Monitoring of First Stage of Labour: Latent Phase
55.3 Monitoring of First Stage of Labour: Active Phase
5.6 Partograph
5.7 Second Stage of Labour
5.7.1 Delivery of the Head
5.7.2 Delivery of the Shoulders and the Rest of the Baby
5.8 Third Stage of Labour
5.8.1 i Active Management of the Third Stage of Labour (AMTSL)
5.8.2 Examination of the Placenta, Membranes and the Umbilical Cord
5.9 Fourth Stage of Labour
5.9.1 Care of the Mother
5.9.2 Care of the Newborn
5.10 Let Us Sum Up
5.11 Activity

5.0 OBJECTIVES
After completing this practical, you should be able to:
• identify and refer the woman at risk;
• review factors of high-risk pregnancy;
• monitor labour;
• conduct normal delivery;
• record clinical observations accurately on the partograph; and
• recognize the difference between latent and active phase of labour.

5.1 INTRODUCTION
In the previous practical you have learnt about antenatal examination & care. As you
know that even a normal pregnancy sometimes can become complicated during the
process of labor and delivery. In order to prevent and detect timely any complication
77
Practical Manual-I during intranatal period prompt action is required on your part. Therefore, it is very
essential for you to develop skills for proper management of first, second and third
stage of labor. In this practical you will learn and identify high risk women who may
have complicated delivery so that you can refer them immediately. You will also learn
about monitoring of labour and plotting a partograph.
•
5.2 IDENTIFYINGIDGHRISKPREGNANCY
Before going through this practical you should go through Block 2, Unit 4 of this
course (Theory). We shall review some of the important points briefly here. When
you are monitoring a mother at the time of labor, you have to see and identify the
high risk cases so that you can refer the high risk cases to appropriate centers
immediately without delay.

Examine the woman for:

• Short stature (less than 145 cm or 4' 10' )
• Age less than 18 years or more than 35 years.
Take history from woman regarding:
• Previous operative delivery
• Still births
• Complicated delivery, such as prolonged labour, retained placenta, post pactum
haemorrhage, and sepsis.
• More than four pregnancies.
• Any other disease associated with pregnancies - heart disease, diabetes and
hypertension.

Identify any of the following conditions that can lead to high risk or complicated
delivery:

• Abnormal presentation
• Bleeding in antenatal period

• Pre-eclampsia

• Severe anaemia
• Twins, over distended uterus
• Floating head in primigravidas at 38th week or later

• Big or very small fetus

•
.
Premature labour .
~
Once you identify these conditions during pregnancy, refer woman to first referral
unit (FRU) for delivery, so that complication that may arise can be dealt properly
to prevent fetal and maternal mortality and morbidity.

Most obstetrical complications are life threatening and ·can be treated in

hospital setting only such as obstructed and prolonged labour and
haemorrhage, So any delay in starting treatment can be fatal for both
mother and fetus.
78
 Some woman can deliver a child only by an operation. It is always better if the Monitoring Labour and
, Partograpb
operation is done before complications have started, operations done under such
conclitions will have a better prognosis as, both the woman and the fetus will be in
a better state of health to withstand the operation.

Woman who have had no antenatal examination are at risk as they may have an
underlying complication. It is very essential that all women receive antenatal care and
the families and the woman make a choice to where the delivery should take place.

All pregnant women and their families should be aware of the nearest hospital
(FRU) so that in advance, transportation is kept ready for any emergency. Family
members, friends, relatives who can donate blood should always accompany the
woman to hospital.

5.3 POINTS TO RE~1EMBER BEFORE AND AFTER

COND1JCTL~GDELIVERY
.. Before Conducting Delivery:
• Prepare room in which delivery is to be conducted. The room should be white
washed and kept dean, visitors should be restricted.
• Hands must be washed thoroughly with soap and water before any procedure
and before delivery. Do not dry your hands with towels but hold them up for
drying and keep your fingers spread and pointing upwards.

Step 1: Wash Palms Step 2: Wash back 01'hands Step 3: Wash fingers and knuckles

Step 4: Wash thumbs Step 5~ Wash finger tips Step 6: Wash wrists

Fig. 5.1: Hand washing

• Use sterile gloves. The gloves should be boiled for about 20 minutes before use.
• Use clean sheet, which is washed, dried in sun, and hot-ironed.
• Always use sterile scissors or blade for cutting the cord. Cord ties should be
sterile. Do not apply anything on the cord because it leads to infection.
79
Practical Manual-1 After Conducting Delivery:
• Use the Perineal Pad or if Pad is not available cloth which should be clean, sun
dried and hot ironed.
• If there is practice of burrying the placenta, spread bleaching powder in the pit
and on the Placenta then bury it.
.•.
• Clothes should be soaked in bleaching powder solution before washing.
• Before leaving examine both mother and baby.

5.4 ASSESSMENT,/SUPPORTIVE CARE AND

. VAGINALEXAMINATION DURING LABOUR
5.4.1 ~ssessnnent
Assessment consists of the following components:
• Inquire about the woman's history oflabour, asking the following questions:
When did the contractions begin?
How frequent are the contractions? How strong are they?
Has there been any watery discharge? If so, what colour was it?
Has there been any bleeding? If so, how much?
Is the baby moving?
Are there any other complaints?
• Check the woman's record for history of the present pregnancy, e.g. the
haemoglobin
• Status, IT immunisation, Rh status, any complications and any other significant
history.
• If there is no record, then ask the following:
When was the LMP Iwhat wa the period of amenorrhea? On this basis,
determine the EDD.
• Ask for the history of any past pregnancy.
• Any other significant history.
Conduct general physical examinations, record the temperature, pulse,
blood pressure and weight, and check for pallor, oedema, and so on.
Conduct an abdominal examination to assess the foeta1lie and presentation,
FHR and frequency, and duration of contractions.
Conduct a PN examination to decide the stage of labour (as mentioned
later in this section).

5.4.2 S.,pportive Care

• Encourage and re-assure the woman that things are going well.
• Maintain and respect the privacy of the woman during examination and discussion.
• Explain all examinations and procedures tobe carried out on the woman, seek
her permission before conducting them and discuss the findings with her.

80
• Encourage the woman to bath or wash herself and her genitals at the onset of Monitoring Labour and
Parfograph
labour.
• Make sure that the birthing area is clean, so as to prevent infection.

• See to it that the room where the delivery is to take place is warm and draught-
free, and the temperature is between 25°C and 28°C. ••

• Encourage the woman to empty her bladder frequently. Remind her to pass
urine every two hours or so.
• The presence of a second person or a birth companion of the woman's choice,
in addition to an SBA, is beneficial. However, the number of birth companions
should be limited to one.

• Birth companions provide comfort, emotional support, re-assurance,

encouragement and praise. At a practical level too, the presence of a second
person is valuable.

• Additional assistance may be required at any time during the labour or in the
event of an emergency.

• The companion can be useful even if it is only to go and seek help.

• The woman should be allowed to remain mobile during the first stage of labour
as this helps to make the labour shorter and less painful.

• The woman should be free to choose any position she wishes to and feels
comfortable during labour and the delivery. She may choose the left lateral,
squatting, kneeling, or even standing (supported by the birth companion) position.
Remember, given a choice, the woman will often change positions as no position
is comfortable for a long period of time

Encourage the birth companion to help relieve the woman's pain by:

• Massaging her back

• Holding her hand

• Sponging her face between contractions.

• There are certain other non-pharmacological methods of relieving pain during

labour, like speaking to woman in calm, soothing and gentle voice.

• Praise the woman and offer her encouragement and re-assurance.

• Practising relaxation techniques, such as deep breathing exercises, is beneficial.

• Placing a cool cloth on the woman's forehead is soothing.

• Assisting the woman in voiding urine and changing her position will make her
more comfortable.

• Women who are not likely to require general anaesthesia, can (if they wish)
have light, easily digestible, low-fat food during labour. This is because labour
requires large amounts of energy. In the case of women who have not eaten
for some time or who are undernourished, the effects of labour can quickly lead
to physiological exhaustion, dehydration and ketosis (maternal acidosis), which
can result in foetal distress.
81
 Practical Manual-I • Therefore, encourage the woman to eat and drink as she wishes throughout
labour. An enema should not be routinely given during labour. It should be
given only if there is an indication, e.g. if the woman complains of constipation
on admission or at the onset of labour.

Please remember that a soap and water enema should,never be given.

5.4.3 Vaginal Examination

During a vaginal examination, determine the following:
a) Pelvic adequacy
b) Progress of labour
c) Stage of labour

Remember
• Vaginal examinations are rarely required during pregnancy.

f· • During labour, vaginal examination should not be attempted more than once
every four hours (to avoid unnecessary infection).
• Do not carry out a vaginal examination if the woman is bleeding at the
time of labour or at any time during pregnancy. Manage this as a case
of 'vagina bleeding in pregnancy'.
Do not start a vaginal examination during a contraction.
Steps for doing a PN examination:
• Do not shave the perineal area.
• Explain to the woman what is being done and always ask for her consent
before doing a vaginal examination.
• Ask the woman to pass urine.
• Wash your hands with soap and water before and after each examination.
Carry out the vaginal examination under strict aseptic conditions.
• Place the woman in the supine position with her legs flexed and apart.
• Perform the vaginal examination very gently, wearing clean/sterile gloves.
• Clean the vulva and perineal area with a mild antiseptic solution. Wipe the vulva
first, then labia majora and lastly labia minora with cotton swabs from the
anterior to the posterior direction. Use a swab only once. Use separate swabs
for each side.
• Separate the labia with the thumb and foreftnger of the left hand and clean the
area once again.
• Use two ftngers of the right hand (index and middle fingers) and insert them
gently into the vaginal orifice without hurting the woman.

a) Pelvic adequacy
• Pelvic assessment is important in the case of both primigravidas and multigravidas
who have a past history of prolonged or difficultlabour, which could be associated
with Cephalopelvic Disproportion (CPD).

82
 In a normal pelvis: Monitoring Labour and
Partograph
• The sacral promontory is not reached.
• The sacrum is well curved.
• The ischial spines are not prominent and both ischial spines cannot be felt
by the finger inserted, at the same time.

b) Determining progress of labour-cervical effacement and cervical

dilatation in Centimeters
Assessing cervical effacement and dilatation during a vaginal examination is important
to monitor the progress of labour.
Cervical effacement:
This is progressive shortening and thinning of the cervix. during labour.

Cervical dilatation:
This is an increase in the diameter of the cervical opening in centimeters (distance
in centimeters between the outer aspects of both examining fingers). A fully dilated
cervix has an opening of 10 cm at this stage, the cervix is no longer felt on vaginal
examination.

Normal effacement and dilatation will facilitate expulsion of the foetus in the second
stage of labour

Presenting part
3()% effaced
80% effaced

No dilatation! Fully dilated

effact'rucllt FuUy effaced

3 ems dilated 8 ems dtlated

Fig. 5.2: Cervical Dilatation

5..5 FIRST STAGE OF LABOUR

5.5.1 First stage: From Onset of Labor Till Full Dilatation of
Cervix
• Latent Phase
Cervix < 4 ems
Contractions are weak
Less than 2 contractions per ten minutes
83
Practical Manual-I • Active phase
Cervix> or = 4 ems
Contractions >3 per 10 min lasting 45-50 sec
Rate of dilatation lcmlhour or more
Descent present

5.5.2 Monitoring of First Stage of Labour: Latent Phase

• Monitor every 1 hour:
Contractions
Frequency: How many contractions in 10 min
Duration: Each lasting for how many seconds
Fetal Heart Rate (FHR)
• Monitor the following every 4 hours:
Temperature, pulse, blood pressure
• Record time of rupture of membranes and color of amniotic fluid.
• Look for presence of any emergency signs: Difficulty in breathing, shock, vaginal
bleeding, convulsions or unconsciousness

Monitoring of first stage of labour: Latent phase

In Latent Phase
After 8 Hours

~
* ~
Contractions stronger, more No increase in intensity!frequency!
frequent, no change in dilation duration of contractions,
or effacement ROM+!- membranes not ruptured and no
progress in cervical dilation
~
Prolonged latent phase
+
Ask woman to relax
~
RefertoFRU

5.5.3 Monitoring of First Stage of Labour: Active Phase

• Monitor the following every 30 minutes:
Maternal pulse, uterine contractions, FHR
Look for presence of - Meconium or blood stained liquor or cord prolapse
• Monitor the following every 4 hours:
Cervical dilatation (in cm) by PN
Temperature
Blood pressure
84
In Active Phase Monitoring Labour and
Partograph
• Never leave the woman alone
• Start maintaining a partograph when the woman reaches active labour
• Ensure adequate hydration, avoid solid foods
.•.
• Encourage upright position and walking
• Monitor intensively using Partograph
• Refer immediately if no progress
True labour pain False labour pain
Begins irregularly but becomes regular and Begins irregularly and remains
predictable irregular
Felt first in lower back and sweeps around to Felt first abdominally and remains
the abdomen in ~ wave pattern. confined to the abdomen and groin
Continues no matter what the woman's level Often disappears with ambulation or
of activity sleep
Increases in duration, frequency and intensity Does not increase in duration, frequency
with the passage of time or intensity with the passage of time
Accompanied by 'show' (blood stained mucus Show absent
discharge)
Achieves cervical effacement and cervical Does not achieve cervical effacement
dilation and cervical dilatation

5.6 PARTOGRAPH
The partograph is a graphic recording of the progress of labour and the condition
of the mother and fetus. It is a tool which helps assess the need for action and
recognises the need for referral at the appropriate time. This facilitates timely referral
to save the life of the mother and fetus.

Follow the instructions below carefully while filling the partograph:

THE SIMPLIFIED PARTOGRAPH

Identification Data
Name: W/o: Parity: Reg. No.
Date & Tune of Admission Date & Tune of ROM:
Note down the woman's name and age, parity, date and time of admission, registration
number and time of rupture of the membranes.
Foetal condition
C...sI_

85
Practical Manual-l • Count the FHR every half an hour.

• Count the FHR for one full minute.

• The rate should be preferably counted immediately after a uterine contraction.

• If the FHR is below 120 beats per minute or above 160 beats per minute. it
indicates foetal distress. Manage as indicated later under 'Foetal Distress'.

• Remember that each of the small boxes in the vertical column of thepartograph
represents a half-hour interval.
• Note the condition of the membranes and observe the colour of the amniotic
fluid as visible at the vulva every half an hour.

Membranes:
~--------- --- - T
- -'-

• Membranes intact (mark '1')

• Membranes ruptured:
Clear liquor (mark 'C')
Meconium-stained liquor (mark 'M')

Labour

10
9
Cenb<_) 1
IfIoCXI 6
S
4 I~
1 1 J
J .
'1ftI 1 '.

s
,..,.....
eo••••.•••••.•
~
I

• Begin plotting on the partograph only when active labour starts. Active labour
starts when the cervical dilatation is 4 cm or more and the woman is having at
least two good contractions every 10 minutes.

• Record the cervical dilatation in centimetre every four hours.

• In this phase, cervical dilatation progresses by approximately 1 cm per hour
and is often quicker in multigravidae.
• Plot the first recording of cervical dilatation on the Alert line. Write the time
accordingly in the corresponding row for time. After four hours, conduct a
vaginal examination and plot the cervical dilatation in centimeters on the graph.

• If the Alert line is crossed (the plotting moves to the right of the Alert line), it
indicates prolonged/obstructed labour and you should be alert that something
is abnormal with the labour.

• Note the time when the Alert line is crossed. The woman needs to be referred
urgently to the FRU. Please remember to send the partograph along.

86
 • Cro.-.;stng of the Action line (the plotllllg moves to the right or the Action line) Mouitortng Labour und

indicates the need Ior intervention. There is a difference or four hours between Partoaruph

the Alert line and the Action line. By the time the Action line is crossed, the
woman should ideally have reached the FRU for the appropriate intervention.

Refer as soon as Alert line is crossed and do not wait for referral tiIJ the
ction line is crossed.
• Chart the contractions every half an hour: count the number of contractions
over 10 minutes and note their duration in seconds. Record the number of
g()od uterine contractions (I;hting more than 20 seconds) in 10 minutes every
half an hour and accordingly. blacken the boxes on the partograph.

( 'hart the contractions every half an hour

• Nuntber of contractions in 10 mins
• Duration in seconds:

Less than 20 seconds

..
Between 20 and 40 seconds

More than 40 seconds

l1aternal condition
Cl Maternal condition

ui\,
r·
I i
~I

..

• Record the maternal pulse on the graph every half an hour and mark with a dot
(.l.

• Record the woman's blood pressure on the graph every four hours. using a
vertical arrow (i ) with the upper end of the <UTOW sig!1ifying the systolic blood
pressure and the lower end indicating tbe diastolic blood pressure e.g. for
recording B.P. Reading of 130/80 mml-lg. Record T 130180.
'iJ Record the temperature every four hours and note it on the temperature graph.
Interventions
D) Interventions
\h..•..
t.~I. !jJHt

1;'\ Ifh4H: . h ~ fll

Mention any drug that has been administered during labour, including the dosage,
route and time of administration. Also include the food items and liquids consumed
by the woman during labour.
Practical Manual-l

THE SIMPLIFIED PARTOGRAPH

IDENTIFICATION DATA

Name: W/o: Age: Parity: •. Reg. No.

Date & Time of Admi~sion: Date & Time of ROM:

A) Foetal Condition
200~~~~~~-r-'--~-r~--.-~~-'--~-r~--.-.-~--~~-r~-'
190~4--+~~+--r-;--+-~-+--r-4--+-;--+-~-+--r-;--+--~4-~-+-;
1~O
170~4--+~~+--r-;--+-~-+--r-4--+-;--+-~-+--r-;--+--~4-~-+-;
Foetal 160
'heart 150~4--+~~+--r-;--+-~-+--r-4--+-;--+-~-+--r-;--+--~4-~-+-;
rate 140
130~4--+~~+--r-;--+-~-+--r-4--+-;--+-~-+--r-;--+--~4-~-+-;
120
110~4--+~r-+--r-;--+-~-+--r-4--+-;--+-~-+--r-;--+--~4-~-+-;
100~4--+~r-+--r-;--+-~-+--r-4--+-;--+-~-+--r-;--+--~4-~-+-;
90~4--+~~+-~-4--+-~-+ __r-4-~-4--+-~-+--r-4--+--~4-~~~
80~4-~~~~~~ __ L-~~ __ ~~~~ __ L-~~ __ ~~~ __ ~~~~~

Amniotic fluid I
B) Labour

T 1: ..- --
.--- •.....
.--- .- - ~

Cervic (cm) 7

- - .-
..,~~
.s- ..-
•.....

- ......
• el'
~

(Plot X)

1 Hour:
Time
6

-- 1
.-
•.....
I---
2 3 4 5
~

6 7 8 9 10 11 12

5~4-~-4--+-~-+--r-4--+~~+-~-+--r-;--+~r-4-~-4--+-~-~~
Contraction ~~4--+~~+-~-4--+-~-+--r-4-~-4--+-~-+--r-;--+~~-+-~~~
per 10 min. 2~4--+~~+-~-4--+-~-+--r-4-~-4--+-~-+-r-;--+~r-+-~~~
1~4--+~~+--r~--+-~-+--~;--r~--r-~-+--~1--+~~;-~-r-;

C) Interventions
Drugs and
IV fluids given '-- __ --L.. --L.. ~ -L-----lD
D) Maternal Condition

180~;--+~r-+-~-4--+-~-+--r-;--+-;--+-~-+--r-4--+~~+-~-+-;
170~4--+~~+--r~ __+-~-+__~;--r~ __r-~-+__~;--+~~;-~~-;
160~4-~-4__+-~-+__r-;--+~~+-~-+ __r-;--+~r-+--+-4
__+-;--+~
150~;--+~r-+--r-;--+-~-+---r-4--+-;--+-~-+--r-4--+~~~~-+-;
140
Pulse 130~;--r~--+-~-+--r-1--+~~+--r-+--~;--+~r-+--r~--+-;--+~
and 120~4-~~--+-~-+--r-1--+--~+--r-+--~4--+~r-+--r~--+-4--+~
BP 110~+-~-+--~+-~-+--r-+-~-+~r-+-~-+~r-+--r-+--r-+-1--+~
100~4-~-4__+-~-+__r-;--+
__~+--r-+__r-;--+~~~-+-4 __+-;--+~
90~4-~~--+-~-+--r-1--+--~+--r-+--r-;--+~r-+--r~--+-;--+~
80~+-~-4__+-~-+__+-4--+
__~+-~-+ __r-;--+~r-~~-4 __+-;--+~
70~4-~-4~+-~-+--r--+--+--r-+--r-+--r-4--+~r-+--+-4--+-;--+~
60~~~~ __~~~ __~~~ __~~-L~ __ ~~~~~~~~ __ ~~~~

Temp ("C)

Fig. 5.3: The Simplified Partograph

88
• By the time the action line is crossed the woman should ideally have reached Monitoring Labour and
Partograph
the FRU for the appropriate intervention to take place
What are the indications for referral to FRU on the basis of partograph?
• FHR is <120 beats/min or >160 beats/min
• Meconium and/or blood stained amniotic fluid
• When cervical dilatation plotting crosses the alert line (moves towards the right
side of the alert line)
• Contractions not increasing in duration, intensity and frequency (e.g. < 2
contractions lasting for < 20 sec in 10 min).

5.7 SECOND STAGE OF LABOUR

The second stage of labour begins when the cervix is fully dilated and ends with the
expulsion of the [Link] the woman reaches this stage, she should be transferred
to the labour room if she is in another room. She should not be allowed to walk
during this stage.

The following are the signs of imminent delivery:

• Vulval gaping
• Thinned-out and bulging perineum

• Anal pouting

• Visibility of the baby's head at the vulva.

• Usually, the above signs of imminent delivery appear within two hours of full
dilatation of the cervix in primigravidas and one hour in multigravidas.

• Monitor the frequency and duration of the contractions every half an hour.
Count the number of contractions occurring every 10 minutes and their duration
in seconds, and also monitor the FHR every five minutes. Be vigilant regarding
the presence of any emergency signs, such as shock, difficulty in breathing,
vaginal bleeding, convulsions and unconsciousness.

• During delivery, positions such as standing, squatting and being on all fours
make pushing easier. Therefore, if the woman finds it difficult to push, or there
is slow descent of the presenting part, you should help her to change her
position.

-v • When the cervix is fully dilated, during a contraction, encourage the woman
to take deep breaths and push down.

• Bearing down efforts are not required until the head has descended into
the perineum. Therefore, the woman should be advised not to push actively
until the foetal head is distending-the perineum.

X • Occasionally, the woman may feel the urge to push before the cervix is
fully dilated. This must be discouraged as it can result in oedema of the
cervix, which may delay the progress of labour.

• Do not apply fundal pressure on the abdomen to facilitate expulsion of the

baby.
89
Practical Manual-I 5.7.1 Delivery of the Head
Take the following precautions to ensure that the delivery of the head i'. a l'onlrollni
one:
• Keep one hand gently on the head as it advance'. with the contraction"
• Support the perineum with the other hand and cover the anus with a pad held
in position hy the side of the hand
• Ask the mother to take deep breaths and to hear down only durinr :1
contraction.
• Once the head is out. use gauze 10 .t!cntl) wipe the mucus offthe hah~'" t:h l'

• Feel gently around the baby. neck tor the pIT'-\e11cc of the umhi iicnl c on l
check:
If the cord i<.;present and h loo:-e around the neck. dclivc: th.: h;lh
through the loop of the cord. or slip the cord 1)\'Cr the huh~ 'v ill',ld
11the coni IS tight around the neck. place two clamp- on the coni dllll ,Ill
between the clamps. and then unwind It 11<)111 .uoun.l Ihl I'll', I.

5.7.2 Deliver)' of the Shoulders and the Rest of the Bahv

tI Wait for spontaneous rorauon and JelIVC/) 01 the shoulder', Tlus u-uall. happl'lh

within 1-2 minutes.

• Apply f.![Link] pressure downw ani. to deliver the lOp (untenor l sh()uldL'1

IP" ero .[1' r, "

,.'PI'~;I( I

b t.<lhn,ll H [~'""I ;[ h"'.-I! -ILl]

tnU'rni:.i H,!:"" I, (,\ q !Ill·

Fig 5.]: ••etal Head 1\Im cnu-nt during I .abour

• Then lift the huh up. 1<lv.~lId" the IlI\ltl1L~1...ahdomcn. tll 1k'11\'CI tlu: l<l\\l'l

(posterior) shO!ildcr

• The rest of the hah) " hod) follo\\ s smoothr,

• Note the time of birth and put identification tag on the baby.
• Place the baby on the mother's abdomen. (If the baby i~ not delivered onto tl1l
mother's abdomen, make sure there is a warm towel or cloth to reCCI\C III
baby.)
Look Ior meconium 11 Illl'I\: IS nuuc. Plt)Ll'l'd III Lil Y th,: [Link]» \ 1111;1 ~\ .um
• towel Ill' piccr III Lk~l11 ckuh. (D() IIllt wrpc (lit tl1l' white gICiI:-!' :-lIhSl~lIk'l
covering the baby's [Link] substance, called vernix, helps to protect the
90 baby's skin.l
• Alter drying. the wet towels or clothes should be replaced and the baby i- \\,,,.lIonnl! huur- anti
i ,••
l'artograpn
loosely wrapped in a clean. dry and warm towel. It the baby remains wet, Jl
k"d-; I() heat loss

• Wipe both the eves (separately) with sterile gauze,

• I I' meconium IS present and the baby i" not crying, apply suction to the mouth
.nd IIlLI1 the nose.

I ,", I,d/) , 1,\ /1/('111111111.; 111-i! and III( I I/( \' \ II fll~ le' '11' " I '1"\1 (',', 3/1 1/

"/I, " 111/1IUII' {)/"(I\ ill, /.lIiliil(' cure

Ihl! , ,., iu )! /;rl'tlIJlllIg 0," i\ t:f[\/11I1P, rall].» //1 '/ ill, 'it jl\ en J vt t vc t l u l t c»!

" ,'; I ",' ill th. "1/(/ (1

1 f'lI ,flUjJ!( I 11' I,' i "1 .n ic.. ou! [Link]:«

If'!' I 'Ill n(I'd fill (('\1/\( i'ut uvn i';,/I('('iu/il 'I i)/( ,\ onuui 11(/\ (/ 1/l1/"/"\ f /

I',. ,·'/,1':' {)((I/OII!!I drol». I!'!" It I 'ui» Ill)' tU 11f( fI //1 ht rth

"" 11. \i,i \\llllll..(lnll'It!·"lrl'1I1 ..;[tIP' 1111,II,L,tI'\ 1""-':' ,:!)uUl .: muuur, 11'
11 , in t h \ 'lllp pul"llllllg PUI \.l\,~li 1 thread Ill'''' I i:! htl~ .rrnum I th,' I.\\1J ;If
"ppn IX IlIIilll:h
II 1."111 th.: i' 111\ "elhdO'IIL'11 and cUI herv,L't'l lhl' 'I wuh u sI -rrlr. clc.u

I, 11" rl' I dOling,. place ~I second tIC hctw ccn the babv ' ,"~1I1 and [he I ir,1 t Il
,illil~ tlh ,old ;d~el .1Il interval 01 1-3 minutes. helps to avoid neonatul anaemia
I 1111 ,,1I1i JI1 rranstuxmn of all increased amount (11blood into the ioctal [Link]

I, ( l IlIl IILlh~ between Ihl' mother ., breast- 11\ 'lall "~1Il I "~1!1 earl ((l er th.
L ,I, ~ ht',11I \\ ith ,\ cloth Cover the mother .m.l th.: bab\ \t\ rth II warm cloth
---_ _-------------- ... ._------------
S.X THIRD STAGE ()F LAB(lUR
._--_._--------------------------
S.X.) Active Management of the Third Stage of Labour
(AMTSL)
\ f\ I rSI 1:-. recommended for all dcliv cries and cun"l:--.h or the loll(\WIll~ three uctiviuc.,

Uterutunic drug: lnj. Oxytocin IS till' drug 01 ·hUICl to! all [Link] Iacrlitie ...
I includiug se) whcrcu: Tab Mh()pro"loJ I" hI tk L1SL'(j \\ Ilel, .idcquu«:
1clrigcl;11 H)II 1)1 lnjccuon Ox \. tocm It., not pos'>lhlc dUring high icmpcnuurc Tab
Mrsoprostol can also be used tor home deliver- 01 an) OR dchvcr.

\11 uterotonic drug enhances COil traction ot the uterine muscles. therchv tal !lllal1n~
,'XPUbhllllllli1c pial' .rna and duunu-hme hlccduig. 1111:--' help, to prevent PPH
\11 uterotonic drug should be given altc: the JdIVCI"), Rule UUl me presence
(1/ (/IIOTher babv before giving the uterotonic drug,

• Ox ytocin is the drug of choice for AMTSL at the SCIPHCIFRU/health

Iuciluy, h should be kept at a temperature 4-8°C but should not be frozen,
I1 should ideal]" be stored in a rclriucrrnor

It .vdnurusicr 10 unus ul U,VIOCIIl lntccuou untramuscular r to thc mother JI

the delivery has taken place at the Sc/PHC/FRU/health facility O( give her
l)1
Practical Manual-l a Tablet Misoprostol tablet (600 mcg) orally if the mother has delivered
at home and Injection Oxytocin is not available due to the problems of
high ambient temperatures and unavailability of a refrigerator.

• You can also use it at the SCIPHC in case an Oxytocin injection is not
available or if there are problems related to refrigeration. Inform the woman
that shivering and gastrointestinal disturbances are c mmon side-effects of
Misoprostol, and should not be a cause for worry.

2) Controlled cord traction: CCT is a technique that assists in the expulsion of

the placenta, and helps to reduce the chances of a retained placenta and
subsequent bleeding, i.e. PPH.

• Clamp the maternal end of the umbilical cord close to the perineum with
a pair of artery forceps.

• Hold the clamped end of the cord with one hand.

• Place the other hand on the mother's abdomen to feel the uterine
contraction.

• Maintain slight tension on the cord.

• When the uterus contracts, as will be evidenced by the uterus becoming

hard and globular, gently pull downwards on the cord to deliver the
placenta. Simultaneously, place one hand just above the pubic symphysis
to apply counter-traction (pressure in the opposite/upward direction towards
the umbilicus) on the uterine fundus.

• If the placenta does not descend within 30-40 seconds of CCT, do not
continue to pull on the cord.

• Wait for the uterus to contract strongly again and repeat CCT with counter-
traction.

• Do not exert excessive traction on the cord while performing CCT. Do

not repeat the manoeuvre more than once.

• As the placenta delivers, hold it with both hands to prevent tearing of the
membranes.

• Normally, the placenta delivers within five minutes of the birth of the baby
if the third stage of labour is managed actively.

• If the membranes do not slip out spontaneously, gently turn the placenta
so that the membranes are twisted into a rope and move them up and
down to assist separation. If pulled at, the thin membranes can tear off and
get retained in the uterus.

• If the membranes tear, use your fingers or a pair of sponge forceps to

remove any pieces.

Remember, you should never apply cord traction (pull) without a

contraction and without applying counter traction (push) above the pubic
symphysis with the other hand.
92
 Monitoring Labour and
Partograph

Fig. 5.4: Controlled Cord Traction (CCT)

3) Uterine massage: Immediately after delivery of the placenta, massage the

fundus of the uterus through the woman's abdomen until it is well con .icted.

• Helps in contraction of the uterus and thus prevents PPH.

• Ensure that the uterus does not become relaxed (soft) after the massage.
• Watch for vaginal bleeding.

• Ensure that the placenta is delivered completely with all the membranes.
Retained placental fragments or pieces of membrane will cause PPH.
• This can ~ suspected if a portion of the maternal surface of the placenta
is missing or the membranes with their vessels are tom.
• If the placenta is not delivered after 30 minutes of Injection Oxytocin or
Tablet Misoprostol, refer the woman to an FRU.
• Information on the drugs given, the dosage and time of administration on
the referral slip, should also be sent along with the woman.

5.8.2 Examination of the Placenta, Membranes and the

Umbilical Cord
Examine the placenta and the membranes for completeness as follows:

Maternal surface of the placenta:

• Hold the placenta in the palms of the hands, keeping the palms flat and the
maternal surface facing you.

Maternal Surface Fetal Surface

Fig. 5.5: Surfaces of the Placenta

93
f H tf"'~ f 0' q t I)O~ tor the lollo« mg:
• All the lobule- (I 5-20l must he present
• The lohules should rittogether.
• There should be no ilTcgularitie"> in the margins.
• If any of the lobes arc missing or the lobules do not fit together. ,>U'·,PCl' [Link]

some placental fragments may have heen left behind 111 the utciu

Fig. 5.7: Examination of the Placenta

Foetal surface
h
• Hold the umhilical cord in one hand and let the placenta and I11CI11 l .nc- I'."j"

down like an inverted umbrella.

• The umbilical vessels will be seen passing from the cord and gradually f.ldil1g
into the edge of the placenta.

• Look' for free-ending vessels and holes which may indicate that a lobule n.r-
been left behind in the uterus.

• Look for the insertion of the cord. particularly the velamentous mxcrtion t i he
point where the cord is inserted into the membranes and from where it tr~t\' ,..,
to the placenta).

vlembranes
• Both the layers (chorion and amnion) can be seen at the edge of the hull' \\-i'

the membranes rupture and the fetus comes out.

• If the membranes are ragged. place them together ami make sure that the- :1\'

complete.

Umbilical cord

• Normally, the umbilical cord has two arteries and one vein. If onlv one art: rv
is found, look for congenital mal formations in the baby.

3) Uterine massage

This technique helps in contraction of the uterus and thus prevents PPH.
• Immediately after delivery of the placenta, massage the fundus of the uterus Monitoring Labour and
PaI10graph
through the woman's abdomen until it is well contracted. Repeat the uterine
massage every 15 minutes for the first two hours.

• Ensure that the uterus does not become relaxed (soft) after you stop the uterine
massage.

• If the uterus remains soft and flabby, the woman may be suffering from Atonic
PPH.

5.9 FOURTH STAGE OF LABOUR

The first two hours after the delivery of the placenta are referred to as the fourth
stage of labour. This stage comprises both observation and care of the mother and
new-born.

The mother and her new-born should not be separated, unless required.

5.9.1 Care of the Mother

• After the delivery 'of the placenta, check to see if the uterus is well contracted
(i.e. it is hard and round) and ascertain that there is no heavy bleeding. Repeat
the check every 15 minutes.

• If the uterus is not well contracted and there is bleeding, massage the uterus and
expel the clots. If the bleeding continues, manage as indicated under

Management of postpartum haemorrhage

• Examine the perineum, lower vagina and vulva for tears. If present, manage as
indicated under 'Management of vaginal and perineal tears'

• Clean the woman and the area beneath her. Put a sanitary pad or a folded cloth
underher buttocks to collect the blood. Counting the number of pads/cloths
soaked will help in estimating the amount of blood lost

• Estimate the amount of blood loss throughout the third stage of labour and
immediately afterwards. If the bleeding has stopped, observe the woman for
the next 24 hours. If bleeding has not stopped, then manage as post-partum
haemorrhage

Check the following every 15 minutes for the first two hours:
• General condition, blood pressure and pulse.

• Vaginal bleeding.

• Uterus, to make sure that it is well contracted.

• Dispose of the placenta in the correct, safe and culturally appropriate manner.
Use gloves while handling the placenta. Put the placenta into a leak-proof bag
containing bleach.

• Incinerate the placenta or bury it at least 10 metres away from a source of

water in a pit that is 2 metres deep.
95
Practical Manual-! • Counsel the mother to breastfeed, including colostrum feeding, within an hour
of the birth. Ask her to take warm fluids, eat well, take adequate rest, sleep
and maintain hygiene. The latter would include maintaining perineal hygiene, .
taking a bath every day and washing her hands before handling the baby.

• Encourage the woman to pass urine. If the woman [Link] in passing urine,
or the bladder is full (as evidenced by a swelling over the lower abdomen just
above the symphysis pubis) and she is uncomfortable, help her pass urine by
gently pouring warm water over her vulva.

• Ask the birth companion to stay with the mother and not leave her and the new
born alone.

Ask the companion to call for help if any of the following conditions occur:

• Excessive bleeding per vaginum

• Dizziness, severe headache, visual disturbance or epigastric pain

• Convulsions

• Increased pain in the perineum

• Urinary incontinence or inability to pass urine.

5.9.2 Care of the Newborn

• Place an identity label with the mother's name and any other identification
information as may be required on the baby's wrist or ankle, if not done earlier.

• Give the baby a vitamin K injection 1.0 mg, intra muscular to all new borns
weighing 1500 gms and above and in a dose of 0.5 mg to new borns weighing
less than 1500 gm.

• As per the current provision SNslLHVs are permitted to administer Injectable

drugs like Vitamin K to new born.

• The site for the injection is the quadriceps muscle group of the upper, outer
thigh by sterile l-inch needle of the smallest size, available.

• Vitamin K is needed for prevention of haemorrhagic disease of new born.

Babies have very little vitamin K in their bodies at birth. Vitamin K does not
cross the placenta into the developing baby, and the gut does not have any
bacteria to make vitamin K before [Link] is very little vitamin K in breast
milk and it takes several weeks before the normal gut bacteria start making it.

• Examine the baby quickly for malformations or any birth injury. If there is major
malformation or severe birth injury, refer the baby to the new born unit in the
FRU.

• Ensure that the baby is warm during the examination and when being transported.

96
 Monitoring Labour and
5.10 LET US S~I UP Partograph

In this practical you have learnt how to monitor the nonnallabour in the first, second
and third stage and do conduct normal delivery. This practical has emphasized how
to plot Partograph to assess the progress of labour. It has also helped to detect at
an earlier stage whether the labour progress is satisfactory or not, so as to shift the
woman at an earliest to the nearby hospital for delivery.

97
Practical Manual-l
5.11 ACTIVITY
Self Activity
i) Select two women in labour and plot partograph for them.
ii) Conduct two normal deliveries in hospita1/PHF/Home and maintain the following
records:
• Labour Progress Chart - first to third stage
• PN findings.

98