Management of

Labour and
Delivery.
• Content Outline
• Definition of and diagnosis of labour
• [Link] of normal labour at different stages
• [Link] partograph
• [Link] of abnormal labour including referral
• Definition of Labour
• Labour is a physiological process, characterised byrhythmic
regular uterine contractions increasing in frequencyand
intensity, accompanied by progressive cervical effacement
and dilatation, and descent of the presenting [Link]
may be spontaneous or induced.
• Definition of Normal Labour
• Normal labour is a physiological process, which
commences spontaneously at term (37 completed
weeks) with rhythmic regular uterine contractions
of increasing intensity and frequency, accompanied
by progressive cervical effacement and dilatation,
and descent of the presenting part (preferably
cephalic),resulting in expulsion of a healthy foetus,
a complete placenta and membranes and a healthy
mother
Essentials of Diagnosis
of Normal Labour
• Diagnosis of labour includes: diagnosis and confirmation of labour,
diagnosis of the stage and phase of labour, assessment of the
engagement and descent of the foetus, and identification of
presentation and position of the foetus.
• Symptoms of normal labour may include history of:Intermittent
low abdominal pains radiating to the back, blood-stained /mucoid
vaginal discharge (show), watery vaginal discharge or a sudden
gush of amniotic fluid (drainage of liquor)
• Labour is confirmed by the presence of: cervical effacement and
cervical dilatation.
• Labour may be classified as true or false labour. The differences are
outlined below.
Stages of Labour

• Labour is divided into four main stages:

• 1st Stage: from onset of labour to full dilatation of
the cervix.
• 2nd Stage: from full dilatation to expulsion of the
foetus.
• 3rd Stage: from delivery of the baby, to delivery of
placenta.
• 4th Stage: Up to one hour after expulsion of placenta
MANAGEMENT OF NORMAL
LABOUR
• Management of First Stage of Labour
• Note: Provide woman-centred individualized care.
• During the first stage of labour, encourage the woman to:
• Empty her bladder regularly
• Freely move about
• Maintain oral intake of fluids and food as required
• Exercise breathing techniques
• Observe personal hygiene
• Have a chosen companion with her.
• The health provider should:
• Practice universal infection prevention and control protocols
• Use partograph as appropriate for monitoring labour
• Listen to, encourage, support and reassure the woman
continually
• Prepare for management for the other stages of labour
• Ensure privacy and confidentiality
• Make arrangements to accommodate the birth companion or
male partner
• Anticipate the need for neonatal resuscitation and prepare for
it.
Control of pain may be
achieved by:
• Change of position/ moving around,
• Touch and back massage from a companion,
• Breathing techniques
• Verbal coaching and relaxation to help draw her attention
away from labour pain,
• Warm bath or shower
• Use of pharmacological agents e.g. tramadol 100mg 1M or
slow IV 6-8 hourly, pethidine 50-100 mg 1M or IV slowly 6-8
hourly, inhalational nitrous oxide combined with 50%
oxygen (Entonox) or epidural analgesia where available
Progress of First stage of
labour:
• Satisfactory progress in first stage of labour is indicated
by:
• Regular contractions progressively increasing in frequency
and intensity, cervical dilatation of at least 1cm per hour
with the cervix well applied to the presenting part.
• Unsatisfactory progress of first stage of labour is when the
contractions are infrequent and irregular after the latent
phase, cervical dilatation is less than 1 cm per hour during
the active phase and the cervix is poorly applied to the
presenting part.
Management of Second
Stage of Labour
• Diagnosis
• The second stage (full dilatation) is recognized by:
• Uterine contractions becoming strong and more frequent (4-5
per 10 minutes)
• The woman grunts or gets the urge to bear down
• The woman may retch or vomit
• The foetal head further descending into the pelvis
• The perineum bulging and the skin becoming tense and
glistening
• The anus may gape and may pass faecal matter.
Management of Second
Stage of Labour
• Note: Deliver in the position the woman finds most
comfortable. Allow and encourage her birth companion/
male partner to be present during childbirth
• Once confirmation of full cervical dilatation is performed by
digital vaginal examination (VE) and the woman is in the
expulsive phase of second stage, she should be encouraged
to bear down only during contractions and relax in between.
• At crowning, the perineum should be supported with a pad
firmly held to prevent perineal tears (avoid obstructing the
presenting part and allow foetal head to extend the
perineum).
• Note: Avoid routine episiotomy!
• Perform episiotomy only when it is clearly indicated.
Episiotomy should only be considered in case of:
• complicated vaginal delivery (breech, shoulder dystocia,
forceps or vacuum delivery);
• scarring from previous female genital cutting or poorly
healed perineal tears; and foetal distress.
• Routine episiotomy is associated with increased third
and fourth degree tears, and subsequent anal sphincter
muscle dysfunction. Whenever episiotomy is given,
administer local anaesthesia.
Delivery of the head:

• To control birth of the foetal head, place the fingers of one

hand against the baby’s head to keep it flexed.
• Continue to support the perineum gently as the baby’s head
is born. After the head is delivered, check for the cord
around the neck. If present but loose, slip it over the baby’s
head.
• If the cord is tight around the neck doubly clamp and cut it
before unwinding it from the head.
• Allow the baby’s head to turn spontaneously. Once the head
is delivered ask the patient not to push. Clear the airway of
the newborn gently with sterile swab
Delivery of the body

• Reduce the likelihood of tears by delivering one

shoulder at a time. With a hand on each side of the
baby’s head, move the head posteriorly to deliver
the anterior shoulder and vice versa.
• If there is difficulty in delivering the shoulders
suspect shoulder dystocia. DO NOT USE FORCE.
Support the baby’s body as it slides out and place
the baby on the mother’s abdomen
Immediate care of the
newborn
• Thoroughly but gently dry the baby. Drying helps to keep the baby warm and
stimulates breathing.
• A newly born baby wet with amniotic fluid can become cold even in a warm
room! Dry the body, arms legs and especially the head by gently rubbing with a
cloth.
• Remove the wet cloth and wrap in a dry cloth.
• Thereafter evaluate if the baby is crying. A baby who is drying needs routine care.
• The elements of routine care include the following:
• Keep the baby warm
• Check breathing (Baby should be crying or breathing quietly and easily)
• Clamp and cut the cord (DO NOT MILK THE CORD)
• Encourage breastfeeding and routine newborn care.
• Anticipate the need for neonatal resuscitation and prepare in advance for it
How to clamp or tie the
umbilical cord:
• Place 2 clamps or ties around the cord. The first clamp is placed
about 2 finger breadths from the baby’s abdomen while the
second clamp is put 5 fingerbreadths from the abdomen
• Cut between the clamps/ ties with a clean scissors or blade. If
bleeding occurs, place a second clamp between the first one
and the baby’s skin
• Leave the cut end of the umbilical cord open to the air to dry it
is recommended that as part of routine care, the provider waits
at least 1 minute and up to 3 minutes to clamp/tie and cut the
cord. There is now consconsiderable evidence that early cord
clamping does not benefit mothers or babies and may even be
harmful.
• The precise timing of clamping and cutting the umbilical cord
is important as there is some evidence of potential benefits
for the baby when the cord is not clamped and cut
immediately after birth.
• Physiological studies have shown that there is a transfer from
the placenta of about 80 ml of blood at 1 minute after birth,
reaching about 100 ml at 3 minutes after birth (1, 2). These
additional volumes of blood can supply extra iron amounting
to 40–50 mg/kg of body weight. When this extra iron is added
to the approximately 75 mg/kg of body iron that a full-term
newborn is born with, the total amount of iron can reach
115–125 mg/kg of body weight, which may help prevent iron
deficiency during the first year of life (3)
• Perform APGAR scoring and show the baby to the mother.
Let her confirm the sex of the baby.
• Apply an identification tag and wrap baby in warm soft,
dry towels and give to the mother to initiate breastfeeding
• within the first one hour of life. Once stable, perform a full
physical examination of the baby.
• To prevent ophthalmia neonatorum, apply 1% tetracycline
eye ointment.
• Palpate the abdomen to rule out the presence of an
additional baby before proceeding with active
management of third stage of labour.
Active Management of the
Third Stage of Labour
(AMTSL)
• To prevent postpartum haemorrhage (PPH), it is
recommended that active management of third
stage of labour (AMTSL), be practiced at all times.
• AMTSL includes:
a. Prophylactic use of oxytocin
b. Controlled cord traction for delivery of the
placenta
c. Uterine massage
[Link] Oxytocin to Prevent
Postpartum Haemorrhage

• Within one minute of delivery of the baby, palpate the abdomen to

rule out the presence of additional baby/babies.
• Give oxytocin 10 IU intramuscular (IM)
• Oxytocin is preferred because it is effective 2-3minutes after
injection, has minimal adverse effects and can be used in all women.
• If oxytocin is not available, ergometrine can be used as 0.25mg given
IM.
• However, ergometrine is contraindicated in women with pre-
eclampsia/eclampsia, high blood pressure and cardiac disease
because it increases blood pressure by peripheral vasoconstriction,
and may increase risk of convulsions and cerebrovascular accidents.
[Link] Cord Traction
•
• Within one minute of delivery, clamp the cord close to the
perineum using sponge forceps.
• Hold the clamped cord and the end of the forceps with one hand.
• Place other hand just above woman’s pubic bone and stabilize
the uterus by applying counter traction during controlled cord
traction. This helps prevent uterine inversion.
• Keep slight tension on the cord and await a strong uterine
contraction (2-3 minutes). When the uterus becomes rounded or
cord lengthens very gently pull downwards on the cord to deliver
placenta.
• Do not wait for a gush of blood.
• If placenta does not descend during 30-40 seconds of controlled cord traction
(i.e. there are no signs of placental separation). DO NOT continue to pull on the
cord.
• Gently hold the cord and wait until uterus is well contracted again.
• If necessary, roll the cord on the forceps or clamp the cord closer to perineum
as it lengthens.
• With next contraction, repeat controlled cord traction with counter traction.
• Never apply cord traction without applying counter traction above pubic bone
with the other hand.
• To reduce risk of the thin membranes tearing off as the placenta delivers, hold
the placenta in two hands and gently turn it until membranes are twisted.
Slowly complete delivery of the placenta.
• Inspect the maternal surface of the placental lobes for completeness and
remove any retained fragments
• Maintain infection prevention protocols at all times
[Link] Massage

• Immediately after delivery of the placenta, massage

the fundus of the uterus through the woman’s
abdomen until the uterus is contracted.
• Repeat uterine massage every 15 minutes for the
first 1-hour.
• Ensure that the uterus does not become relaxed
after you stop uterine massage.
• Ensure the urinary bladder is empty
Examination of the
placenta

• Carefully examine the placenta to ensure

completeness and that no lobe is missing.
• If a portion of the maternal surface is missing or
there are torn membranes, suspect retained
placental fragments.
• In such cases examine the upper vagina and cervix
and use a sponge forceps to remove any pieces of
membranes that are present.
• Also examine for infarcts, presence of a retro
placental clot and any other abnormalities e.g.
extra lobes.
• Examine the blood vessels in the cord. Normally it
has two arteries and one vein.
• The absence of one artery may be associated with
congenital abnormality, particularly renal agenesis.
• Weigh the placenta.
• Record all findings
Examination for tears

• Carefully examine the cervix, vagina and perineum

and repair any tears present as appropriate.
• Repair the episiotomy.
• Explain all procedures to the mother
Management of 4th Stage
of Labour

• The fourth stage of labour is the first hour after delivery

of the placenta.
• The mother should remain in labour ward where her
condition should be assessed, perineum, vagina, and
cervix should be examined for tears.
• During this time, observe the mother every 15 minutes
for vital signs and vaginal bleeding.
• Monitor newborn’s condition for bleeding from the
cord, maintenance of body temperature and where
appropriate, encourage initiation of breastfeeding