Anda di halaman 1dari 90

NORMAL LABOUR

AND
DELIVERY
Prof Dr MOHD AZHAR MN
ROYAL COLLEGE OF MEDICINE PERAK
APRIL 2005
DEPARTMENT OF
OBST & GYNAE
RCMP
NORMAL LABOUR
AND
DELIVERY
APRIL 2005
DEPARTMENT OF
OBST & GYNAE
RCMP

1. Definition of normal labour
2. Factors influencing progress of labour
3. Diagnosis of labour
4. Stages of labour
5. Mechanisms of labour
6. Management of labour
CONTENTS
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

WHAT IS
NORMAL LABOUR ?

NORMAL
LABOUR

APRIL 2005
DEPARTMENT OF
OBST & GYNAE
RCMP
Labour is defined as the onset of regular painful contractions
with progressive cervical effacement and dilatation of the
cervix accompanied by descent of the presenting part.
DEFINITIONS
NORMAL LABOUR
Spontaneous expulsion,
of a single,
mature fetus (37 completed weeks 42 weeks),
presented by vertex,
through the birth canal (i.e. vaginal delivery),
within a reasonable time (not less than 3 hours or more than 18
hours),
without complications to the mother,
or the fetus
The following criteria should be present to call it normal labour
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
NORMAL LABOUR

APRIL 2005
DEPARTMENT OF
OBST & GYNAE
RCMP
Understanding the process of
labour is importance

problems can be identified
correctly managed
IMPORTANCE
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

WHAT FACTORS INFLUENCE
PROGRESS OF LABOUR ?

LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
FACTORS THAT INFLUENCE
PROGRESS OF LABOUR
Passenger Passage
Power
THE NORMAL FEMALE PELVIS
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
1. The female pelvis provides the basic framework of the
birth canal.

2. The obstetric pelvis is divided into false and true
pelvis by the pelvic brim or inlet
3. The true pelvis is important, for it is through this
confined space that the fetus must pass on its journey
through the birth canal.

4. The true pelvis is composed of inlet, cavity and outlet.

5. Types of female pelvis gynaecoid, anthropoid,
android and platypelloid
Outlet
Cavity
Inlet
THE NORMAL FEMALE PELVIS
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
1. The brim is slightly oval transversely.
2. The sacral promontory is not prominent.
3. The transverse diameter is slightly longer
than the anteroposterior.
4. The sidewalls are parallel and straight.
5. The ischial spines are not prominent.
6. The sacrosciatic notches are wide.
7. The sacrum has a good curve.
8. The pubic arch angle are wide, i.e. more than
90
9. Inter tuberous diameter is wide
The ideal normal female gynaecoid pelvis:
THE NORMAL FEMALE PELVIS
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
The important diameters of the female pelvis:
Anteroposterior Oblique Transverse

BRIM 11 11.5 12 12.5


CAVITY 12 12 12


OUTLET 12.5 12 11- 11.5
Diameters
(cm)
THE FETAL SKULL
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY



1. Sutures

2. Diameters
THE FETAL SKULL
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY




1. Sagittal suture: - The sagittal suture lies between the
parietal bones. It runs in an anteroposterior direction
between the anterior and posterior fontanelles.

2. Coronal sutures: - The suture uniting the parietal bones
to the frontal bones is called the coronal suture. Its
extend transversely from the anterior fontanels and lies
between the parietal and frontal bone.

3. Frontal suture: - The frontal suture is between the two
frontal bones. It is an anterior continuation of the sagittal
suture.

4. Lambdoidal suture: - Is between the parietal and
occiptal bones.
SUTURES
THE FETAL SKULL
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY



MOULDING OF THE FETAL SKULL
MOULDING is the ability of the fetal head
to change its shape and so to adapt itself
to the unyielding maternal pelvis during
the progress of labour.

This property is of the greatest value in the
progress of labour.
THE FETAL SKULL
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY



Diameters of the fetal skull anterior posterior diameters
A
B
C
D
E
F
G
AB ~ Suboccipto bregmatic 9.5

AC ~ Submento bregmatic 9.5

DE ~ Occipito frontal ~ 11.0

FG ~ Mento vertical 13.5
POWER Contractions + Maternal
pushing
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY



Uterine contractions:

1. Initiate by pacemakers ~ uterotubal junction
2. Contraction waves meet at the fundus
3. Contraction waves progress downward
Shortening of muscle fibres
Retractions
intra uterine pressure

EXPULSION OF THE FETUS

Additional force


maternal pushing


Intra abdominal pressure
UTERINE CONTRACTION
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY



NORMAL CONTRACTION

1. Frequency ~ one in every 2 3 min with at least 1 minute interval
2. Intensity ~ strong (> 50 mmHg)
3. Duration ~ 45 60 sec
Uterine contractions
LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

WHAT INITIATE LABOUR
ONSET OF LABOUR

NORMAL LABOUR
Hormonal factors
1) Estrogen theory
2) Progesterone withdrawal theory
3) Prostaglandins theory
4) Oxytocin theory
5) Fetal cortisol theory

Mechanical factors
1) Uterine distension theory
2) Stretch of the lower uterine segment by the presenting near
term
Causes of Onset of Labour:
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
- It is unknown but the following theories were postulated:
LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

DIAGNOSIS OF LABOUR

NORMAL LABOUR AND DELIVERY
Painful regular uterine contractions as
evidence by contraction at least one in ten
minutes
Show as evidence by mucus mixed with
blood
Rupture of membranes as evidence by
leaking liquor
Progressive shortening and dilatation of the
cervix
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
SYMPTOMS AND SIGNS OF LABOUR
Before labour begins, women usually notice one or more premonitory, or
warnings, signs that labour is about to begin.

They are:
LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

DESCRIBE THE STAGES OF
LABOUR

NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
STAGES OF LABOUR
FIRST STAGE SECOND STAGE THIRD STAGE
It begins with the onset of true
labour contractions and ends
when the cervix is fully dilated
(10 cm).

Cervical effacement and
dilatation occur in the first stage


First stage of labour consists of
two phases:- latent and active.

The first stage of labour is the
longest for both nulliparous and
parous women.
The second stage of labour
begins with complete dilatation
of the cervix and ends with the
birth of the baby.

The duration is about 1 to 1
hours in nulliparas and about 30
to 45 minutes in parous women.
The third stage is that of
separation and expulsion of
placenta and membranes and also
involves the control of bleeding.

It begins after the birth of the
baby and ends with the expulsion
of the placenta and membranes.

This is the shortest stage, lasting
up to 30 minutes, with an average
length of 5 to 10 minutes. There
is no difference in duration for
nulliparous and parous.

Labour can be divided into three stages, which are unequal in length.
APRIL 2005
DEPARTMENT OF
OBST & GYNAE
RCMP
FIRST STAGE OF
LABOUR
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
PHASES OF THE FIRST STAGE OF LABOUR
Divided into:

Latent phase begins with onset of contracts and ends when cervix is 3 cm dilated and effaced
Active phase begins after the cervix is 3 cm dilated
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
PHASES OF THE FIRST STAGE OF LABOUR
LATENT Phase ACTIVE Phase
1. Begins with onset of contractions
2. Slow progress
3. Little cervical dilatation
4. Progressive cervical effacement
5. Ends once the cervix reaches 3
cm dilatation
6. Durations
~ 8 hours for nulliparae
~ 6 hours for multiparae
1. Active process
2. Begins after 3 cm of cervical
dilatation
3. Period of active cervical dilatation
(average rate 1 cm/hr)
4. S-shaped curve which is used to
define progress of labour
5. It has 3 component
a) acceleration - slow
b) maximum - fast
c) deceleration - slow

NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
WHAT HAPPEN DURING
THE FIRST STAGE OF LABOUR
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
WHAT HAPPEN DURING THE FIRST STAGE OF LABOUR
1. Contractions:

CONTRACTIONS

1: Regular
2: Increasing in frequency
3: Stronger

NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
WHAT HAPPEN DURING THE FIRST STAGE OF LABOUR
2. Cervical dilatation and effacement:

Causes of cervical dilatation:
Contraction and retraction of uterine musculature
Mechanical pressure by the bulging membrane (fore
water)
The descend of the presenting part

Phases of cervical dilatation
Latent phase the first 3 cm of dilatation; a slow
process (8 hours in nulliparous and 3 hours
in multiparous

Active phase this is active process of cervical
dilatation; the normal rate is 1 cm/hour
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
WHAT HAPPEN DURING THE FIRST STAGE OF LABOUR
3. Engagement of the presenting part:

NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
Do Uterine Contractions Affect Fetal Heart Rate?

Uterine contractions can affect fetal heart rate by increasing or
decreasing that rate in association with any given contraction.

The three primary mechanisms by which uterine contractions can
cause a decrease in fetal heart rate are compression of:
Fetal head
Umbilical cord
Uterine myometrial vessels
FETAL HEART CHANGES
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
PROGRESS OF FIRST STAGE OF LABOUR

Findings suggestive of satisfactory progress in first stage of labour are:

- regular contractions of progressively increasing frequency and duration;
- rate of cervical dilatation at least 1 cm per hour during the active phase of
labour (cervical dilatation on or to the left of alert line);


Findings suggestive of unsatisfactory progress in first stage of labour
are:

- irregular and infrequent contractions after the latent phase;
- OR rate of cervical dilatation slower than 1 cm per hour during the active
phase of labour (cervical dilatation to the right of alert line);

APRIL 2005
DEPARTMENT OF
OBST & GYNAE
RCMP
SECOND STAGE OF
LABOUR
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
SECOND STAGE OF LABOUR


1. Begins with FULL DILATATION and ends with DELIVERY OF THE BABY.

2. It have TWO Phases
a) Propulsive phase from full dilatation until presenting part has descended
to the pelvic floor
b) Expulsive phase which ends with the delivery of the baby

Features of expulsive phase 1) mothers irresistible desire to bear down
2) distension of perineum
3) dilatation of the anus

3. Average length
a) Primigravidae 40 minutes
b) Multigravidae 20 minutes
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
PROGRESS OF SECOND STAGE OF LABOUR



Findings suggestive of satisfactory progress in second stage of labour
are:

- steady descent of fetus through birth canal;
- onset of expulsive (pushing) phase.

Findings suggestive of unsatisfactory progress in second stage of labour
are:

- lack of descent of fetus through birth canal;
- failure of expulsion during the late (expulsive) phase.
APRIL 2005
DEPARTMENT OF
OBST & GYNAE
RCMP
THIRD STAGE OF
LABOUR
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
THIRD STAGE OF LABOUR


1. Begins after DELIVERY of the baby and ends with DELIVERY OF THE
PLACENTA / MEMBRANES.

2. It have TWO Phases
a) Separation phase
b) Expulsion phase

3. Duration usually 15 minutes or less (if actively managed).

4. Average blood loss 150 to 250 ml.

NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
PHYSIOLOGICAL EFFECTS OF LABOUR
FIRST STAGE SECOND STAGE THIRD STAGE

ON THE MOTHER
1. Minimal effects 1. Pulse increases
2. Systolic BP
slightly increased
due to pain and
anxiety
3. Minor injuries to
the birth canal
1. Blood loss from
the placental site
(200 ml)
2. Blood loss from
laceration and
perineum (100 ml)

ON THE FETUS 1. Moulding overlapping of the vault bones
2. Caput succedaneum it is a soft swelling of the most dependent part of the
fetal head
MANAGEMENT
OF
LABOUR
NORMAL LABOUR AND DELIVERY
To achieve delivery of a normal healthy child

To anticipate, recognize and treat potential abnormal
conditions before significant hazard develops for the
mother or the fetus.
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
AIMS IN THE MANAGEMENT OF LABOUR
The AIMS include:
NORMAL LABOUR AND DELIVERY
Diagnosis of labour

Monitoring the progress of labour

Ensuring maternal well-being

Ensuring fetal well-being.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
PRINCIPLES IN THE MANAGEMENT OF LABOUR
The principles include:
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT
FIRST STAGE OF
LABOUR
NORMAL LABOUR AND DELIVERY
On admission:
When the women presents at hospital, the womans antenatal record is reviewed to
discover whether there have been any abnormalities during her pregnancy. When there are
no records of antenatal care a complete history must be taken.

General examination of the mother
a) General conditions evaluate the mother general health condition. Look for pallor,
edema, abdominal scar (LSCS) and maternal height.

b) Vital signs Blood pressure, pulse, respiration and temperature are taken and recorded

c) Heart and lungs

d) Urine analysis for protein, sugar and ketones
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE FIRST STAGE OF LABOUR
1

NORMAL LABOUR AND DELIVERY
Abdominal examination:
a) A detailed abdominal examination should be carried out and recorded.
b) Determine the presentation and position of the fetus and also the engagement
c) Auscultate the fetal heart
d) Evaluate the uterine contraction

Vaginal examination the purpose is to
a) To make a positive diagnosis of labour
b) To make a positive identification of presentation
c) To determine whether the fetal head is engaged in case of doubt
d) To ascertain whether the fore waters have ruptured or to rupture them artificially
e) To exclude cord prolapse after rupture of the fore waters
f) To confirm the degree of cervical dilatation and position of the presenting part
g) To assess progress of labour.
h) To assess the adequacy of the pelvis.
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE FIRST STAGE OF LABOUR
2

NORMAL LABOUR AND DELIVERY
Bowel preparation:
If there has been no bowel action for 24 hours or the rectum feels loaded on vaginal
examination an enema is given.

Bladder care
A full bladder may initially prevent the fetal head from entering the pelvic brim and later
impede descent of the fetal head. It will also inhibit effective uterine action.

The woman should be encouraged to empty her bladder every 1 - 2 hours during labour.

The quantity of urine passed should be measured and recorded and a specimen obtained for
testing.

Nutrition in early labour
No food is permitted after labour is established to prevent regurgitation and aspiration

It is important to maintain adequate hydration - via intravenous routes
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE FIRST STAGE OF LABOUR
3

NORMAL LABOUR AND DELIVERY
Position of labouring mother:
As long as the patient is healthy, the presentation normal, the presenting part engaged, and
the fetus in good condition, the patient may walk about or may be in bed, as she wishes

Monitoring the progress of labour
Once labour has become established, all events during labour should be recorded on a
partogram.
a) The well-being of the fetus
b) The well-being of the mother
c) The progress of the labour

Pain relief
When the pains are severe an analgesic preparation may be given.
a) Opiate drugs e.g. Pethidine given intramuscularly every 4 hour
b) Inhalational analgesia e.g. Entonox
c) Epidural analagesia
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE FIRST STAGE OF LABOUR
4

NORMAL LABOUR AND DELIVERY

Pain in labour

The pain experienced by the woman in labour is caused by the:

1): Uterine contractions and uterine ischaemia.

2): Cervical dilatation. Dilatation and stretching of the cervix and lower uterine
segment stimulate nerve ganglia and are a major source of pain.

3): Distention of the vagina and perineum. Marked distention of the vagina and
perineum occurs with fetal descent, especially during the second stage.
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
LABOUR PAIN

causes
1

NORMAL LABOUR AND DELIVERY

Pain in labour


Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
LABOUR PAIN causes
2

Table 1: PAIN DURING THE STAGES OF LABOUR
STAGES OF LABOUR SORCES OF PAIN

FIRST STAGE
Pain is caused mainly by uterine contractions, thinning of
the lower segment of the uterus, and dilatation of the
cervix.

SECOND STAGE
Pain result from two sources:
1.The stretching of the vagina, vulva and perineum.
2.The contraction of the myometrium.

THIRD STAGE
Pain is caused by the passage of the placenta through the
cervix, plus that produced by the uterine contractions.
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
PAIN RELIEF IN LABOUR types
Three methods are in common use during labour:

1. Analgesic drugs (narcotics, e.g. pethidine) which are
given by intramuscularly injection.

2. Inhalation analgesia (e.g. Entonox).

3. Regional anaesthesia (e.g. epidural, spinal) that
blocks the sensory pain pathways.


NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MONITORING FETAL HEART
How Do Uterine Contractions Affect Fetal Heart Rate?

Uterine contractions can affect fetal heart rate by increasing or
decreasing that rate in association with any given contraction.

The three primary mechanisms by which uterine contractions can
cause a decrease in fetal heart rate are compression of:
Fetal head
Umbilical cord
Uterine myometrial vessels
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MONITORING FETAL HEART
How To Monitor The Fetal Heart Rate?

Auscultation methods
Electronic monitoring ~ CTG
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MONITORING FETAL HEART
To detect fetal hypoxia

NORMAL
ABNORMAL
APRIL 2005
DEPARTMENT OF
OBST & GYNAE
RCMP
RECORDING THE
PROGRESS OF LABOUR
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
RECORDING THE PROGRESS OF LABOUR
PATIENT INFORMATION


FETAL INFORMATION
~ fetal well being




LABOUR INFORMATION
~ Dilatation
~ Descent
~ Contraction




MEDICATIONS



MATERNAL INFORMATION
~ Well being
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
RECORDING THE PROGRESS OF LABOUR - Partogram
Patient information: Fill out name,
gravida, para, hospital number, date and
time of admission and time of ruptured
membranes.

Fetal heart rate: Record every half hour.

Amniotic fluid: Record the colour of
amniotic fluid at every vaginal
examination:
I: membranes intact;
C: membranes ruptured, clear fluid;
M: meconium-stained fluid;
B: blood-stained fluid.

Moulding:
1: sutures apposed;
2: sutures overlapped but reducible;
3: sutures overlapped and not reducible.

NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
RECORDING THE PROGRESS OF LABOUR - Partogram
Cervical dilatation: Assessed at every
vaginal examination and marked with a
cross (X). Begin plotting on the partograph
at 3 cm.

Station : recorded as a circle (O) at every
vaginal examination.

Contractions: Chart every half hour;
palpate the number of contractions in 10
minutes and their duration in seconds.

Less than 20 seconds:
Between 20 and 40 seconds:
More than 40 seconds:

Assess the progress of labour:
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
RECORDING THE PROGRESS OF LABOUR - Partogram
Oxytocin: Record the amount of oxytocin
every 30 minutes when used.

Drugs given: Record any additional
drugs given e.g. Pethidine

Pulse: Record every 30 minutes and
mark with a dot ().

Blood pressure: Record every 4 hours
and mark with arrows ( )

Temperature: Record every 2 hours.

Protein, acetone and volume: Record
every time urine is passed.
Progress of maternal well being:
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT
SECOND STAGE OF
LABOUR
NORMAL LABOUR AND DELIVERY
Maternal position:
With the exception of avoiding supine position, the mother may assume any comfortable
position for effective bearing down.

The semi-recumbent or supported sitting position, with the thighs abducted, is the posture
most commonly adopted

Bearing down
With each contraction, the mother should be encouraged to bear down with expulsive
efforts

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE SECOND STAGE OF LABOUR
1

Once the onset of the second stage has been confirmed a woman should
not be left without attendance. Accurate observation of progress is vital,
for the unexpected can always happen.
NORMAL LABOUR AND DELIVERY
Observation during the second stage:
Four factors determine whether the second stage may be safely continued and these must
be carefully monitored throughout the second stage of labour.

1. Maternal conditions
Observation includes an appraisal of the mothers ability to cope emotionally as well as an
assessment of her physical wellbeing. A maternal pulse rate is usually recorded quarter-
hourly and bloods pressure hourly

2. Fetal conditions - During the second stage, the fetal heart should be monitored either
continuously or after each contraction. stage may be associated with fetal distress.
The liquor amnii is observed for signs of meconium staining.

3. Uterine contractions - The strength, length and frequency of contractions should be
assessed continuously.

4. The progress of descent - The progress should be recorded approximately every 30
minutes during the second stage.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE SECOND STAGE OF LABOUR
2

NORMAL LABOUR AND DELIVERY
CONDUCTING THE DELIVERY
1
:

When delivery is imminent, the patient is usually placed in the dorsal position, and the skin
over the lower abdomen, vulva, anus and upper thigh is cleansed with antiseptic solution
and draped.



DELIVERY OF THE HEAD

1) Control the delivery of the head to prevent laceration
2) Performed episiotomy if requires
3) Performed Ritgens method
4) Cleared the airway after delivery of the had

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE SECOND STAGE OF LABOUR
3

NORMAL LABOUR AND DELIVERY
PERFORMING AN EPISIOTOMY:


Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE SECOND STAGE OF LABOUR
3

"..is a surgical incision into the perineum to enlarge the space at the
outlet


EPISIOTOMY
IS EPSIOTOMY REALLY NEEDED?
Episiotomies are said to provide the following benefits:

1. Speed up the birth
2. Prevent Tearing
3. Protects against incontinence
4. Protects against pelvic floor relaxation
5. Heals easier than tears

medical research has not proven
any of these benefits
NORMAL LABOUR AND DELIVERY
PERFORMING AN EPISIOTOMY:


Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE SECOND STAGE OF LABOUR
3

Episiotomies are not always necessary
Episiotomy should be considered only in the case of:


Complicated vaginal delivery (breech, shoulder dystocia, forceps,
vacuum);

Scarring of the perineum;

Fetal distress.
NORMAL LABOUR AND DELIVERY
PERFORMING AN EPISIOTOMY:


Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE SECOND STAGE OF LABOUR
3

Episiotomy Types
Midline episiotomy Mediolateral episiotomy J-shaped episiotomy
Incision of episiotomy

The three major types of
episiotomy

NORMAL LABOUR AND DELIVERY
PERFORMING AN EPISIOTOMY:


Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE SECOND STAGE OF LABOUR
3

Infiltrate perineum with
local anaesthetic agent
Making an incision

Wait until:

1) the perineum is thinned
out;

and

2) 34 cm of the babys head
is visible during a
contraction.
Performing an episiotomy will
cause bleeding. It should not,
therefore, be done too early.
NORMAL LABOUR AND DELIVERY
CONDUCTING THE DELIVERY
2
:

DELIVERY OF THE SHOULDERS

Delivery of the anterior shoulder is aided by
gentle downward traction on the head.




The posterior shoulder is delivered by
elevating the head.
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE SECOND STAGE OF LABOUR
3

NORMAL LABOUR AND DELIVERY
CONDUCTING THE DELIVERY
3
:

DELIVERY OF THE TRUNK

After the delivery of the shoulders the baby is grasped around the chest to aid the birth of
the trunk.

Finally, the body is slowly extracted by traction on the shoulders and lifts the baby towards
the mothers abdomen.

The time of delivery is noted.

CUTTING THE UMBILICAL CORD

After delivery, it is therefore usual to wait 15 to 20 seconds before clamping and cutting
the umbilical cord.

After cutting the cord a plastic crushing clamp is placed on the cord 1 to 2 cm from the
umbilicus and the cord is cut again 1 cm beyond the clamp.

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE SECOND STAGE OF LABOUR
3

NORMAL LABOUR AND DELIVERY
CONDUCTING THE DELIVERY
4
:

IMMEDIATE CARE OF THE NEW BORN

Once the baby is breathing normally he should be dried and warmly wrapped to prevent
cooling and handle to the mother to hold, cuddle and enjoy.

If spontaneous respiration is not established soon after birth, resuscitation is the immediate
priority.

The Apgars score of the baby should be noted and
recorded.
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE SECOND STAGE OF LABOUR
3

LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

THE MECHANISMS OF
NORMAL LABOUR
- Occiput anterior -

NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
Occiput anterior (OA)
Anterior

Pubis









Sacrum

Posterior

Right Left
Occipital bone
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
Occiput anterior positions


NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MECHANISM OF LABOUR for occiput anterior
The mechanism of labour refers to the sequencing of
events related to posturing and positioning that allows the
baby to find the easiest way out.

For a normal mechanism of labour to occur, both the fetal
and maternal factors must be harmonious.

DEFINITION:
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MECHANISM OF LABOUR for occiput anterior

Events of mechanism of labour:

F: Flexion and descent
I: Internal rotation of the fetal head
C: Crowning
E: Extension
R: Restitution
I : Internal rotation of the shoulders
E: External rotation of the fetal head
L: Lateral flexion of the body
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MECHANISM OF LABOUR for occiput anterior (OA)
Descend
Flexion
Internal rotation

Crowning

Extension
Restitution
Internal rotation of shoulder
External rotation of head
Lateral flexion of body
LOA





LOA






OA
LOA






OA






OA
LOT
Delivery
F
I
C
E
R
I
E
L
NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT
THIRD STAGE OF
LABOUR
NORMAL LABOUR AND DELIVERY
BIRTH OF THE PLACENTA
1
:

Delivery of the placenta occurs in two stages:

(1) separation of the placenta from the wall of the uterus and into the lower uterine segment
and/or the vagina, and

(2) actual expulsion of the placenta out of the birth canal.
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE THIRD STAGE OF LABOUR
NORMAL LABOUR AND DELIVERY
MECHANISM OF PLACENTA SEPARATION
1
:


Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
THE THIRD STAGE OF LABOUR
Two mechanisms of placental separation occurs:
1- Mathews-Duncan mechanism

The leading edge of the placenta
separates first and the placenta is
delivered with its raw surface
exposed.
2- Schultz mechanism

If the placenta is inserted at the
fundus and central area separates
first, the placenta inverts and draws
the membranes after it, covering the
raw surface (inverted umbrella)
LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

WHAT ARE THE SIGNS OF
PLACENTA SEPARATION

NORMAL LABOUR AND DELIVERY
BIRTH OF THE PLACENTA
2
:

CLINICAL SIGNS OF PLACENTAL SEPARATION

Placental separation takes place within 5 minutes after the delivery of the infant. Signs
suggesting that detachment or separation has taken place include:

1. The uterus becomes globular and hard. This sign is the earliest to appear.

2. There is often a sudden gush of blood

3. The uterus rises in the abdomen because the placenta,
having separated, passes down into the lower segment
and vagina, where its bulk pushes the uterus upward.

4. Cord lengthening. This is the most reliable clinical sign
of placental separation.
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE THIRD STAGE OF LABOUR
NORMAL LABOUR AND DELIVERY
BIRTH OF THE PLACENTA
2
:


After the placental separation takes place the placenta can be
delivered by the:

1. Passive management wait for spontaneous expulsion of placenta

2. Active management

Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE THIRD STAGE OF LABOUR
LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY

ACTIVE MANAGEMENT OF
THE THIRD STAGE OF LABOUR

NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE THIRD STAGE OF LABOUR
ACTIVE MANAGEMENT OF THE THIRD STAGE

Active management of the third stage (active delivery of the placenta)
helps prevent postpartum haemorrhage.

Active management of the third stage of labour includes:

~ use of oxytocin
~ controlled cord traction, and
~ uterine massage.

NORMAL LABOUR AND DELIVERY
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE THIRD STAGE OF LABOUR
ACTIVE MANAGEMENT OF THE THIRD STAGE

~ Use of oxytocin

Oxytocic drugs should be given with the birth of the anterior shoulder.

Syntocinon is the most used oxytocic known to be effective; the addition of
ergometrine may reduce blood loss.

SYNTOMETRINE (oxytocin 5 IU + ergometrine 0.5 mg) widely used
NORMAL LABOUR AND DELIVERY
BIRTH OF THE PLACENTA
3
:

EXPULSION OF THE PLACENTA BY ACTIVE MANAGEMENT

When these signs have appeared the placenta is ready for expression. If the patient is
awake, she is asked to bear down while gentle traction is made on the umbilical cord.

The popular and effective method of delivering the placenta is by Brandt-Andrews method.
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE THIRD STAGE OF LABOUR
NORMAL LABOUR AND DELIVERY
BIRTH OF THE PLACENTA
4
:

BRANDTS ANDREW METHOD

Once the signs of placental separation have occurred the obstetrician assists delivery of the
placenta by controlled cord traction as described by Brandt-Andrews method.
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE THIRD STAGE OF LABOUR
A) Placenta separation B) Controlled cord traction C) Delivery of the membranes
NORMAL LABOUR AND DELIVERY
BIRTH OF THE PLACENTA
5
:

EXAMINATION OF THE PLACENTA

The placenta, membranes, and umbilical cord should be examined for completeness and for
anomalies.


EXAMINATION OF THE PERINEUM

At the same time, the perineal region, vulva outlet, vaginal canal, and the cervix should be
carefully examined for lacerations.

If the perineum has been torn or an episiotomy made, tear or incision should be repaired
immediately.
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE THIRD STAGE OF LABOUR
NORMAL LABOUR AND DELIVERY
REPAIR OF EPISIOTOMY:


Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
MANAGEMENT OF THE THIRD STAGE OF LABOUR
Note: It is important that absorbable sutures be used for closure.
Continuous sutures Interrupted sutures Interrupted suture or
subcuticular
Vaginal mucosa

1. Identify apex

2. Begin suturing
1.0 cm above apex

3. Continuous sutures

4. Ends at the level of
vaginal opening
APRIL 2005
DEPARTMENT OF
OBST & GYNAE
RCMP
MANAGEMENT AFTER
DELIVERY
NORMAL LABOUR AND DELIVERY
EARLY POSTPARTUM MANAGEMENT:

The hours immediately following delivery and the birth of the placenta are a critical
period as postpartum haemorrhage can occurs due the relaxation of the uterus.

The patient is kept in the delivery suite for 1 hour postpartum under close observation. She
is check for bleeding, the blood pressure is measured, and the pulse is counted.

Before discharging the patient from the delivery suit it is mandatory:

To check the uterus frequently to make sure it is firm and not relaxing.
To remove any presence of intrauterine blood clots. The presence of these clots will
interfere with retraction and the normal haemostatic mechanism of the uterus.
To look at the introitus to see that there is no haemorrhage.
To keep the bladder empties because full bladder can also interfere with uterine retraction.
To examine the baby to be certain that it is breathing well and that the colour and tone are
normal.
Prof DR MOHD AZHAR NOMAL LABOUR & DELIVERY
IMMEDIATE MANAGEMENT AFTER THE DELIVERY