LABOUR
DR. SAGHEERA ANJUM
ASSOCIATE PROFESSOR OBGYN – FRPMC
LEARNING OBJECTIVES
• By the end of the lecture final year students should be
able to
Define different stages of labour
Discuss the factors involved in onset of labour
Outline the physiological changes in labour and delivery
Outline the management of stages of labour
Describe the components of WHO labor guide and its
interpretation
DEFINITION
• Normal labour is defined as spontaneous
regular painful uterine contractions that cause
progressive dilation and effacement of cervix
and a viable fetus , placenta and membranes is
expelled from the uterus .
DIAGNOSIS OF LABOUR
• suspected when a woman presents painful uterine
contractions
• confirmed on vaginal examination that reveals effacement
and dilatation of the cervix.
• SHOW - a blood-stained plug of mucus passed from the
cervix
• SROM - spontaneous rupture of the membranes
These events may occur around the same time although
they do not define the onset of labour .
STAGES OF LABOUR
Labour can be divided into three
stages .
FIRST STAGE OF LABOUR
• From diagnosis of labour to full dilatation of the cervix
(10 cm).
• TWO PHASES
• The ‘LATENT PHASE’ is the time between the onset of
regular painful contractions and 3–4 cm. ( 3- 8 hours)
• The ‘ACTIVE PHASE’ and describes the time between
the end of the latent phase (3–4 cm dilatation) and full
cervical dilatation .
SECOND STAGE OF LABOUR
• From full dilatation of the cervix to delivery of
the fetus or
fetuses.
Passive phase
Active phase
DURATION : 1 hour in multiparous and 2 hour in
primigravida
THIRD STAGE OF LABOUR
• From delivery of the fetus or fetuses until
complete delivery of the placenta and
membranes .
DURATION OF LABOUR
• PROLONGED LABOUR
• > 12 hours in primigravida
• > 8 hours in multigravida
• PRECIPITOUS LABOUR
• < 3 hours
FACTORS INVOLVED IN
ONSET OF LABOUR
The onset of labor is a complex and multifactorial
process that can be influenced by various factors.
While the exact triggers for the onset of labor are not
fully understood, several key factors are believed to
play a role.
These factors can be broadly categorized into
Maternal
Fetal
placental
MATERNAL FACTORS
HORMONAL CHANGES: Hormones such as oxytocin,
prostaglandins, and cortisol play a role in initiating and regulating
contractions.
CERVICAL CHANGES: As the cervix undergoes changes in response
to hormonal signals, it may begin to efface and dilate .
FETAL POSITIONING: The position of the baby in the uterus can
influence the onset of labor. Engaged presenting part can put
pressure on the cervix promoting labor.
MATERNAL STRESS: Psychological and emotional factors can
influence the timing of labor. High levels of stress, anxiety, or other
emotional states may affect the release of hormones that trigger
labor.
FETAL FACTORS
FETAL HORMONE PRODUCTION:
Cortisol produced by the fetal adrenal glands and
can contribute to the initiation of labor.
FETAL LUNG MATURITY:
The fetal lungs play a role in signaling the
readiness for labor. The production of surfactant
is an indicator of fetal lung maturity and may
influence the timing of labor.
PLACENTAL FACTORS
AGING OF THE PLACENTA:
Placental function may decline as it ages, leading to
a reduced supply of oxygen and nutrients to the
fetus. This can trigger the factors that promote
labor.
PLACENTAL HORMONES:
The placenta produces hormones such as
prostaglandins, which can stimulate contractions
and initiate labor.
DEFINITIONS /
TERMINOLOGIES USED
• Lie
• Effacement
• Presenting part
• Presentation
• Position
• Station
• Attitude
• Engagement
LIE
The relationship
between the
longitudinal axis of the
fetus with respect to
longitudinal axis of
mother .
EFFACEMENT
It means the cervix
gets thinner and
shorter .
PRESENTATION
the leading part of the
fetus or the anatomical
structure closest to the
maternal pelvic inlet
during labor.
POSITION
Position of the fetus
is described by the
relationship of the
presenting part to
the maternal pelvis
The denominator for
Cephalic – occiput
Breech – sacrum
NORMAL POSITION AND
PRESENTATION
STATION
It is the relationship
of the presenting
part to ischial spine
ATTITUDE
A posture or position of
the body , the relation
of the various parts of
the fetal body to one
another.
ENGAGEMENT
Passage of the
widest diameter of
the presenting part
through the pelvic
inlet .
MANAGEMENT OF
NORMAL LABOUR
INITIAL ASSESSMENT
• History
• General Physical Examination
• Abdominal examination
• Per vaginal examination
FIRST STAGE OF LABOUR
First stage of labour is the interval from diagnosis of
labour to full dilatation of the cervix.
One-to-one midwifery care should be provided.
Additional emotional support should be encouraged.
Obstetric and anaesthetic care should be available as
required.
Maternal and fetal wellbeing should be monitored.
Vaginal examinations are performed 4 hourly or as
clinically indicated.
Progress of labour is monitored using a partogram
with timely intervention if abnormal
Appropriate pain relief should be provided consistent
MATERNAL MONITORING
• Vitals checked every 4 hours
• Monitoring of uterine contractions
FETAL MONITORING
• Fetal heart sounds be listened to for at least 1
minute immediately after a contraction. This
should be repeated every 15 minutes during
the first stage of labour
FETAL ASSESSMENT OPTIONS
IN LABOUR
• Inspection of amniotic fluid – fresh meconium staining,
absence of fluid, and heavy blood-stained fluid or
bleeding are markers of potential fetal compromise.
• Intermittent auscultation of the fetal heart using a
Pinard stethoscope or a handheld Doppler ultrasound.
• Continuous external electronic fetal monitoring (EFM)
using CTG. Continuous internal electronic fetal
monitoring using a fetal scalp electrode (FSE) and CTG.
• Fetal scalp blood sampling (FBS).
INDICATIONS FOR
CONTINUOUS EFM
• Significant meconium staining of the amniotic
fluid.
• Abnormal FHR detected by intermittent
auscultation.
• Maternal pyrexia (temperature ≥38.0°C or
≥37.5°C on two occasions).
• Fresh vaginal bleeding.
• Augmentation of contractions with an oxytocin
infusion.
• Maternal request
SECOND STAGE OF LABOUR
• The first sign of the second stage is likely to be an urge
to push experienced by the mother
• midwife has an important role to play, with advice,
support and reassurance , during contractions advice to
take a deep breath ,hold it, and strain down
• DURATION
• nulliparous women (without epidural) – 2 hours, (with
epidural) – 3 hours
• multiparous women (without epidural) – 1 hour, (with
epidural) – 2 hours
MATERNAL MONITORING
• BP – 1 hourly
• PR – 30 minutely
• T – 2 hourly
• Urine output – empty bladder regularly. Monitor for signs
of urinary retention.
• Amniotic fluid – frequent monitoring of colour
• Contractions
• progress of labour VE – 1 hourly in the active phase or at
the woman’s request.
FETAL MONITORING
• Auscultate the fetal heart rate (FHR) after every
5 minutes during the second stage of labour.
• Auscultation should be performed for at least
30 seconds after each contraction during active
pushing .
• Continuous fetal monitoring should be used if
the active second stage is > 1 hour and birth is
not imminent Continuous CTG in 2nd stage of
labour can be used if infrastructure is feasible
CARE OF NEONATE AFTER
DELIVERY
• After the baby is born, it lies between the mother’s legs or is
delivered directly on to the maternal abdomen
• There is no need for immediate clamping of the cord ,80 ml of
blood will be transferred from the placenta to the baby before
cord
pulsations cease
• oropharyngeal suction should only be applied if really
necessary.
• APGAR score should be calculated at 1 and 5 minutes .
• Initiation of breastfeeding should be encouraged within the
first hour of life
THIRD STAGE OF LABOUR
• Normally takes between 5 and 10 minutes and
is considered prolonged after 30 minutes
• Intramuscular injection of 10 IU oxytocin, given
as the anterior shoulder of the baby is
delivered, or immediately after delivery of the
baby.
• Early clamping and cutting of the umbilical
cord.
Controlled cord traction
Click icon to add pictur
SIGNS OF
PLACENTAL
SEPARATION
Apparent lengthening of the cord.
A small gush of blood from the
placental bed.
Rising of the uterine fundus to
above the umbilicus .
Uterine contraction resulting in
firm globular feel on palpation
CONTROLLED CORD TACTION
LABOUR GUIDE
• The principal aims are to:
• guide the monitoring and documentation of the well-being of
women and babies and the progress of labour
• guide skilled health personnel to offer supportive care
throughout labour to ensure a positive childbirth experience for
women
• assist skilled health personnel to promptly identify and address
emerging labour complications, by providing reference
thresholds for labour observations
• prevent unnecessary use of interventions in labour
• support audit and quality improvement of labour managemen
STRUCTURE OF THE WHO LABOUR
CARE GUIDE
The Labour Care Guide has 7
sections, which were adapted from
the previous partograph design:
Section 1: Identifying information
and labour characteristics at
admission
Section 2: Supportive care
Section 3: Care of the baby
Section 4: Care of the woman
Section 5: Labour progress
Section 6: Medication
Section 7: Shared decision-making
These sections contain a list of
labour observations.
THANK YOU