NORMAL LABOR — 10/31/2017

Term/preterm/postterm relatives to gestational age

• Early preterm labor. GA cutoff depends on threshold of
viability, GA22-26. Srinagarind Hospital, GA24.

• U/S estimated fetal weight: ≥550 or ≥500g.

• Late preterm, GA34.

• Early term, GA37.

• Term, GA39.

• Late-term, GA41-41+6.

• Postterm, GA>42.

Gravidity and parity

• Primagravida = pregnant for first time.

• Multigravida = pregnant more than once.

• Nulliparous = never carried a pregnancy to viability.

• Multiparous = has ≥2 delivery that were carried to

viability.

Phase of labor pain

• Phase 1: uterine relaxation, cervical soft.

• Phase 2: response to stimulation, lower segment

formation (GA28-40wk), irregular contraction.

• Phase 3: regular contraction, delivery.

• Phase 4: postpartum, uterine contraction.

Diagnosis of true labor pain

• History: painful contraction every 10m + back pain ± bloody show or ruptured membrane.
• Physical examination: abdominal increase intensity, cervical effacement >80%, cervical dilatation ≥2cm.

Findings True labor pain False labor pain

• Contractions Regular Irregular

• Contraction interval/intensity Progressive increase Short duration, not progressive

• Cervix effacement and dilatation Associated Not associated

• Membranes (bulging) Associated Not associated 

• Response to analgesia Not relieved Relieved

• Labour Followed by labor Not followed by labour

Component of labor: passage, passenger, power

Stage and phases of labor
• 1st stage: from true labor pain to cervical dilatation 10cm; further divided into latent phase (cervical dilatation <3cm) and
active phases (cervical dilatation ≥3cm); active phase further divided into (1) acceleration phase (2) phase of maximum
slope (3) deceleration phase.

Confirm GA: Naegele’s rule (EDC = LMP + 7d - 3mo), fundal hight, quickening, lightening, ultrasound .

Physical examination: general examination, Leopold’s maneuver (passenger), uterine contraction (power), pelvic examination
(passenger), auscultation of fetal heart sound.

• 2nd stage: from cervical dilatation 10cm to baby delivery.

• 3rd stage: from baby delivery to placenta delivery.

Leopold’s maneuver: (1) fundal grip, (2) umbilical grip, (3) pawlick’s grip, (4) inguinal grip

Presentation: cephalic* (occiput), breech (mentum), face (sacrum), foot (acromion)

Lie: longitudinal*, transverse, oblique

Attitude: flexion, extension; vertex (full flexion), sinciput (moderate flexion, military attitude); cephalic subtype:
suboccipitobregmatic (9.5cm), occipitofrontal (12.5cm), occipitomental (13.5cm), submentalbragmatic (9.5+cm)

Estimation of fetal weight: 2800-3500g

Clinical pelvimetry: inlet (estimate diagonal conjugate distance from public symphysis to prominence of sacral promontory;
normal ≥11.5cm), mid-pelvis (interischial distance; normal ≥10cm), outlet (biischial diameter (transverse outlet diameter),
pelvic angle; normal: ?)

gynecoid, anthropoid, android, platypelloid

Cervical dilatation (report as cm), cervical effacement (report as % compared to 2cm)

nulliparous vs multiparous

Position (palpate anterior and posterior fontanelles): transverse, ROP, LOP, ROA, LOA, occipito-anterior

Station: evaluate head engagement, report in cm (eg, station -1) relative to interischial spines

Membrane: intact, rupture: fluid (clear, meconium), amount (normal, abnormal)

Uterine contraction: can be measured by direct palpation or by external toco ;normal: interval 2-3m, duration 45-60s.

Low risk pregnancy: no complication, spontaneous onset of labor at GA37-42wk, singleton with cephalic presentation,
fetal weight 2500-4000g, normal volume and clear amniotic fluid, no intrapartum bleeding, normal fetal heart rate (normal:
110-160bpm), cervical dilatation progress >1cm/hr
Auscultation of fetal heart: in low risk patient: latent phase q30m active phase q15m; in high risk patient: q15m in both phase

First stage management

maternal vital sign, observe uterine contraction and fetal heart sound, IV fluid, maternal position, record labor progression
(partograph), analgesic drug

Second stage management

Mechanism of labor (7 cardinal movement): (1) engagement, (2) decent, (3) flexion, (4) internal rotation, (5) extension, (6)
external rotation, (7) expulsion
Restrictive episiotomy: techniques: median/midline (easier, wound heal faster and less visible, less blood loss but has
higher risk of rectal tear) vs mediolateral

Modified Ritgen’s maneuver:

APGAR score (at 1m and 5m): Appearance (0=central cyanosis, 1=peripheral cyanosis, 2=all pink), Pulse (0=none,
1=<100bpm, 2=≥100bpm), Grimace (0=none, 1=grimace, 2=cry), Activity (0=none, 1=some flexion, 2=all movement),
Respiration (0=absent, 1=irregular, 2=cry)

Third stage management (placental delivery)

Signs of placental separation: uterine sign, cord sign, vulva sign

Placental delivery methods: (1) modified Crede’s maneuver (2) Brandt-Andrew maneuver I and II (3) control cord traction

Prevention of postpartum hemorrhage: uterine massage, oxytocin

Episiotomy wound assessment and repair: Severity: first degree (vaginal wall tear), second degree (+perineal muscle tear),
third degree (+anal sphincter), fourth degree (+rectum tear). Repair: ?

Postpartum care
Order: One-day: routine postpartum care, observe vaginal bleeding, off IV, intermittent catheter if unable to void within 6h
after delivery. Continuous: regular diet, perineal care, record vital signs q4h, medication: paracetamol, obimin AZ.

10B: Blood pressure, Body temperature, Breathing, Brain, Breast, Bowel, Basket, Bladder, Body discharge, Baby, Blue
Complications
• Antepartum: hemorrhage (placenta previa), premature rupture of membrane.

• Intrapartum: fetal distress, nuchal cord (Mx: Summersault technique), prolapse cord, uterine rupture.

• Postpartum: vulva hemorrhage (Mx: Hot sitz bath + analgesic + amoxycillin/metronidazole ± evacuation), infection (Mx:
Hot sitz bath + analgesic + incision/drainage + amoxycillin/metronidazole or clindamycin±gentamicin or ampicillin/
gentamicin/metronidazole), hematoma.