Normal Delivery
Dr. Kwadwo Sarbeng
MD, MPH
Objectives
• Define labour.
• Understand the components of labour
(passage, passenger, power).
• Be able to take a focused history, examination
and analyze the symptoms and signs to
diagnose labour.
• Describe the stages and phases of labour.
• Discuss the management of labour.
2
Labour (parturition)
• It Is the process whereby with timely regular
uterine contractions, brings about progressive
effacement and dilatation of the cervix, resulting
in delivery of the fetus from the uterus and
expulsion of the placenta at or beyond 28
completed weeks of pregnancy.
It is a social, psychological and economical event
for the couple, family and community.
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• Cervical dilatation: The cervix begins
dilating and stretching beyond the normal
dimensions and is measured in centimeters.
(0-10cm).
• Cervical effacement: softening, thinning
and shortening of the cervix. It is expressed in
percentage (0 – 100%)
4
Normal labour:
Spontaneous expulsion, through the natural
passages (birth canal) of a single, matured (37-
42 completed weeks of pregnancy) fetus,
presenting by vertex, within a reasonable time,
without fetal or maternal complications.
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passengers
The following will pass during labour (fetus,
cord, placenta and membranes). The most
important to pass is the head and shoulder
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Moulding of the skull:
means obliteration of the suture line between
the bones and overlapping of the un-united
bones of the fetal skull, and is measured by
degree.
Degree Clinical finding
+ Suture line closed, no overlap
++ Overlap of suture line reducible
+++ Overlap of suture line irreducible
As the degree of Moulding increase- means there is CPD
7
Fetal attitude: is the relation of the fetal parts to
each other
• 1- flexion attitude (common)
• 2- extension attitude (rare).
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Clinical course of labour
Onset of labour: not definitely known – however there
are several theories, but none of them is completely
proven.
Mechanical theories: - uterine distension
Hormonal theories:
1. Maternal :
o progesterone withdrawal
o oxytocin stimulation
o prostaglandins
o serotonin
2. fetal:
o fetal cortisol
o fetal membranes
3. Neuronal factors:
o sympathetic- alpha receptor stimulation
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Diagnosis
A. symptoms:
1. True labour pains – colicky pain in the abdomen and back are
characterized by:
character True labour pain False labour pain
contractions regular Irregular
Interval between Progressive (increase Short duration, not
contractions and in frequency and progressive
intensity intensity)
Changes in the cervix Associated with Not associated with
effacement and effacement and
dilation of the cervix dilation of the cervix
Membranes Associated with bulging Not associated with
of membranes bulging of
membranes
Response to analgesia Not relieved by Relieved by sedation
sedation
Labour Followed by labour Not followed by labour
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2. Show – blood stained mucous.
3. SROM
B. Signs:
o palpable or recorded uterine contraction
o effacement and dilation of the cervix
o formation of forewater
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THE ACTIVE STAGE OF LABOUR – WHEN THE CERVIX
IS MORE THAN 4 CM DILATED AND FULLY EFFACED
STAGES OF LABOUR:
I-The First stage: stage of cervical effacement
and dilatation
Definition: the first stage of labour refers to the
period from the onset of true uterine
contractions to the fully dilation of the cervix,
when the diameter of the cervical os measures
10cm.
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Duration:
o primigravida = 8-12 h
o multigravida = 6-8 h
Phases of the first stage:
Latent phase: started when the cervix dilated slowly
and reached to about 4cm.
A. in primigravida = 8hrs
B. in multigravida = 4hrs
- Active phase: rapid dilatation of the cervix to reach
10cm
A. in primigravida = 4-8hrs
B. in multigravida =2-6hrs
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The active phase is divided into:
1. Accelerative phase
2. Slopping phase
3. Decelerative phase:
A. prolonged active phase
B. primary dysfunction: dilation in active
phase of<1cm/hr
C. secondary arrest: active phase dilation
stops or slow significantly.
N.B – in primigravida, the cervix dilates
from above downwards, in multigravida
dilatation of the internal os, taking up of
the cervix and dilatation of the external
os occurs simultaneously.
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Factors affecting cervical dilatation:
1. Contraction and retraction of the
uterus.
2. The bag of fore-water.
3. Absence of membranes.
4. Fitting of the presenting part to the
lower segment and the cervix.
5. Pre-labour changes in the cervix (eg,
softening)
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II-The Second stage of labour: stage of
delivery of the fetus.
Definition: the second stage of labour
refers to the period from complete cervical
dilatation to the birth of the fetus.
Duration:
[Link] primigravida =1 h
[Link] multigravida = ½ h
however the timing of the second stage is
very difficult to determine and
controversial and can be extended as much
as there is progress in descent and no harm
to the mother or fetus
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The second stage of labour had two
phases:
1. Passive phase – stage of descent of the
presenting part and dilatation of the
vagina – due to contraction and
retraction of the uterine muscle.
2. Expulsive phase – stage of bearing down
– due to contraction and retraction of
the uterine muscle and voluntary efforts
by diaphragm and abdominal muscles.
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III-The Third stage of labour: the stage of
expulsion of the placenta and
membranes.
Duration: up to 30 minutes,
however the average length of
the third stage of labour is 10
minutes.
Mechanism: the third stage is
made of two phases:
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[Link] first phase: phase of placental
separation occurs at the time of
expulsion of the baby or very soon
afterwards. The shearing force
responsible for the separation is the
contraction and retraction of the
uterus, reducing the uterine volume
and the area of the placental site, as
the fetus is expelled.
19
[Link] second phase: phase of placental
expulsion – The separated placenta
descends from the upper (active)
segment into lower (passive) uterine
segment, cervix, and vagina by two
mechanisms:
A.-Schultze mechanism:(80%)
The placenta delivered as an inverted
umbrella with it’s fetal surface
presenting first followed by the
membranes with retro-placental
haematoma.
[Link] – Duncan mechanism: (20%)
The placenta delivered side way and it
presents with it’s inferior surface first.
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Management of labour
The management of labour should be
commenced during the antenatal
period, and the women should be
classified as high or low risk pregnancy.
The medical or surgical problems
should be corrected as in case of
(anaemia, hypertension, urinary tract
infection), vaccination should be given
if necessary, and all investigations
should be performed and prepared
such as (blood grouping…….etc).
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Also the patient should be advised to
attend the antenatal care and visit the
hospital including the labour ward to be
familiar to the place and staff.
Once labour is commenced and the
patient arrived to the admission room
the following to be done:
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A. -Taking history or reviewing the
antenatal book
1-Last menstrual period
2-Time of onset of labour.
3-Frequency and duration of
contraction.
4-Presence or absence of amniotic fluid
leakage.
5-Presence or absence of show or
vaginal bleeding.
6-Past obstetric history especially mode
of previous delivery, presentation,
mode of delivery, and weight of
previous children.
7-Past medical or surgical history that
may affect labour or delivery,
especially diabetes, heart disease,
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respiratory disease allergies, and any
B-Examination:
1. General:
a-pallor, edema, varicosities, height, and
built.
b-Vital signs (BP, P, T)
c-Examination of heart, lungs, breast and
other organs if necessary
2. .Abdominal Examination:
a-To determine fundal height in cm using
tape measure (to determine gestational
age clinically), fetal lie, presentation,
engagement in fifths, size of the fetus,
amount of liquor, fetal heart rate.
b-The frequency and duration of the
contraction.
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3. Vaginal Examination: to assess the
following.
a-Cervical dilatation in cm and effacement in
%.
b-Length of the cervix.
c-Consistency of the cervix
d-Position of the cervix
e-State of the membranes, amount and colour
of liquor.
f-fetal presentation, position and station.
g-pelvic architecture.
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DO NOT DO VAGINAL EXAMINATION IN
CASES OF VAGINAL BLEEDING BEFORE
PLACENTA PREVIA IS EXCLUDED.
DO STERILE SPECULUM EXAMINATION IF
SUSPECTED PROM, IF THE WOMAN IS
NOT IN LABOUR.
If the woman diagnosed as having active
labour – to be admitted to labour ward.
N.B- active labour means –regular strong and
frequent uterine contraction 3-4/10min
lasting 45-50 sec, and the cervix is fully
effaced and 4cm dilated.
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Arrival to the labour ward:
I-first stage of labour:
1-Ensure patient’s privacy by covering her
with sheaths or blankets.
2-Reassure and show great sympathy and
interest.
3-Record maternal vital signs every hour (BP,
P, T).
4-Take blood for grouping and cross matching
for high risk patients.
5-Monitor fetal heart every 30mins
a-high risk patients may require continuous
electronic fetal heart monitoring.
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b-low risk patients should have brief electronic
fetal heart monitoring if NORMAL, to be
followed by intermittent auscultation:
-first stage every FHR 30 min
-Second stage every 5 min if need be
6-Limit oral intake to small amount of clear
fluid or light diet.
7-Nurse the patient in:
a-left lateral position, sitting or semi-reclining
positions.
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9-Encourage spontaneous voiding,
catheterization may be necessary.
10-Test all urine specimen for proteins,
sugar, and acetone.
11-Give IV fluids during labour to avoid
dehydration if need be.
a-Supplementation with 5% dextrose to
prevent ketosis and hypoglycemia.
12-Give analgesia/anesthesia as required.
a-Pethidine (50-150mg)IM.
b-Diamorphin (5-10mg)IM. Every 3-4 hours.
*avoid giving it too early in labour < 3-4cm
cervical dilation or too late when the
delivery is expected within 1-2hours.
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*if given too late:
-inform the pediatrician
-give Naloxon (Narcon) 0.02mg IM to the
neonate.
c-Use Entonox (NO2 50%+O2 50%) by mask if
available.
d-Use epidural analgesia in selected cases if
available such as Breech, Twins, preterm
delivery.
e-Give anti-emetics such as Metoclopromide
(5-10mg)IM if necessary, but should not be
routine.
13-Do vaginal examination to:
a-assess progress of labour every 2-4hr
b-or immediately after rupture of membranes
c-FHR abnormalities.
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14-Recall all the observations in labour in
Partograph.
15-Consider augmentation with syntocinon if
progress of labour is slow (Partograph).
-500mls of normal saline and 5 units
syntocinon
Begin with 15 drops / min and increase the
rate by 5 drops every 30 minutes until
adequate contractions.
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II-second stage of labour:
Once the patient reach the second stage of labour and
have the desire to push down then:
1-Put the patient in lithotomy position or other
positions clean the vulva, and perineum with
antiseptic solution.
2-Encourage organized pushing down when she is
feeling to do so
3. -Monitor the uterine contraction and fetal heart
more frequent.
4. -Use syntocinon if progress is slow and no
contractions.
5. -When the head appears at the vulva, the perineum
is supported during uterine contraction by sterile
pad to promote flexion and prevent premature
extension of the head by pressing up on the sinciput
until crowning occur.
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6. -After crowning, the head is allowed to
be delivered by extension slowly in
between the contractions by sliding the
perineum over the face.
7. -DO episiotomy if necessary under local
anesthetic ( 10-20 ml) of 1% lignocaine,
but should not be routine.
8. -Wait for the next contraction to deliver
the shoulder and trunks.
9. -Clamp and deliver the cord and baby to
be handled to pediatrician / midwife.
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III-Third stage of labour:
The management of third stage is
aimed at:
1-Complete delivery of the after birth
(placenta and membranes).
2-Prevention of acute inversion of the
uterus.
3-prevention of postpartum
haemorrhage
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A-Delivery of the placenta and
membranes:
a-Conservative method: the left hand is
placed over the abdomen to detect any
change in the level of the fundus or
sign of placental separation and decent
are detected, the patient is asked to
bear down to deliver the placenta
spontaneously.
10units of syntocinon to be given IM or
Ergometrine 0.5mg or Syntometrine(5
units syntocinon + 0.5mg Ergometrine)
to be given intravenously.
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Procedure for Active Management
• Oxytocin
– Within 1 minute of birth, palpate abdomen to rule out
presence of another baby
– Give oxytocin
• CCT
– Await strong uterine contraction (2–3 minutes)
– Apply controlled cord traction while applying
countertraction above pubic bone
– If placenta does not descend, stop traction and await
next contraction
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Signs of separation and decent of the
placenta:
1. -The body of the uterus becomes smaller,
harder, and globular.
2. -The fundal level rises in the abdomen
because the lower segment becomes
distended by the placenta.
3. -Suprapubic bulge may appear due to
presence of the placenta in the lower
segment.
4. -Elongation of the cord out side the vulva.
5. -Sudden gush of blood from the vagina.
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Active Management: Advantages and
Disadvantages
• Advantages
– Decreases length of third stage
– Decreases risk of PPH
• Disadvantages
– Requires oxytocics and items needed for injection
– Requires a birth attendant with skills in:
• Observation
• Giving an injection
• CCT
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IV-Post Delivery:
1-examine the placenta for their
completeness, anomalies, length, and
number of vessels in the cord and record
the placental weight.
2-Suture the episiotomy or any laceration.
3-Estimate blood loss, count swabs, and take
cord blood for Hb, blood group, Rh,
bilirubin, and Coomb’s test for Rh negative
mother.
4-Check BP, P, T, Lochia and firmness of the
uterus before transferring the patient.
5-Continue an infusion of syntocinon through
the first hour if necessary.
6-Allow no food during the first hour, sips of
water may be taken, encourage nursing.
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V-Care of the new born infant:
1. -Clearance of the new passages.
2. -Determine the Apgar score one and five
minutes
- heart rate
- respiratory rate
- muscle tone
- colour
- reflex irritability
3-Care of the umbilical cord stump
4-General assessment of the infant to exclude
any congenital anomalies.
5-Identification of weight, estimate the
gestational age, dress it and put a mask to
identify it.
6-Protect the baby against cold.
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