Normal labor

and delivery

Sardjana Atmadja
Professor of
OB & GYN Department
Faculty of Medicine
Syarif Hidayatullah State University

Objectives

At the end of session, the student is able to

Diagnose true labor

Describe factors influence vaginal birth
Assess maternal and fetal condition
Assess progress of labor
Manage first stage of labor
Describe mechanism of normal vaginal
delivery
Describe steps for conduction vaginal
delivery
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?
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Estimation of fetal age

1. Naegeles rule:
*EDC = LMP +

days -

months

2.Fundal height
3. Quickening
4. Lightening
5. Ultrasonography
6. Fetal weight
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32,40
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Fundal height measurement

Bipariatal diameter - BPD

Femur length -FL

Abdominal circumference -AC

Diagnosis of true labor pain

History
A history of regular painful uterine
contraction in every 5- 8 min,
accompanied by the history of a bloody
show or spontaneous rupture of membrane
Physical examination
Reduction of interval between uterine
contractions
Abdominal pain of increasing intensity
Cervical effacement ( 50%)
Cervical dilation ( 2 cm)
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Different between true labor and false labor

Uterine contraction regular

irregular

Interval

decrease

irregular

Duration

increase

irregular

Intensity

increase

irregular

Cervical change

progress

no change
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Vaginal birth
3 P
Power

Good contraction?

Passage

Contracted pelvis ?

Passenger

Large baby ?
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Stage of labor

First stage ( true labor pain until

cervix fully dilate or 10 cm

Latent phase

Active phase

Second stage(cervix fully dilate

until deliver the baby)

Third stage (deliver the baby until

deliver placenta)
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Management in first stage

admission assessment
1.

Take history: LMP, EDC , labor pain , bleeding,

ruptured membrane, fetal movement, maternal
diseases, review ANC records , lab test

2.

Perform physical examination :

2.1 General examination
2.2

Leopold maneuver,

2.3 Auscultation fetal heart sound

2.3 Uterine contraction
2.4 Pelvic examination
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First Leopold

Third Leopold

Second Leopold

Fourth Leopold

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Uterine contraction (Power)

Interval
Intensit
Duration
D
Interval
Intensity
Good contraction ( I= 2-3 min,
D 45-60 sec)? If not :
correct by using oxytocic drug
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Pelvic examination
1. Birth canal
2. Cervical condition and
related part

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Birth canal ( passage)

Inlet

diagonal

conjugate diameter > 12 cm

Mid pelvis
interspinous

diameter > 10 cm

Outlet
subpubic

angle

intertuberosity

> 90

diameter > 10 cm

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Cervical condition and related

part
1.

Cervical condition
* dilatation 0-10 cm
* effacement 0-100%

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Nulliparous

Multiparous

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Cervical dilatation
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2. Presenting part : cephalic

Vertex

Sinciput

Brow

Face

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3. Position

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Presenting part : Breech

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Presentation

Vertex
Face
Breech
Shoulder

Denominating point
Occiput
Mentum
Sacrum
Acromium

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4. Station

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5 Membrane :
Status : intact or rupture
Color : clear or meconium stain
Amount : normal or abnormal

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Assess fetal condition

Auscultation of fetal heart (normal range 120-160 bpm)

High risk : 1st stage every 15 min , 2nd stage every 5

min

Low risk : 1st stage every 30 min , 2nd stage every 15

min

Electronic fetal heart rate monitoring (not essential in low risk

pregnancy)

Ultrasound

(not essential in low risk pregnancy)

Biophysical profile (not essential in low risk pregnancy)

: 5 component: fetal tone , fetal breathing , fetal
movement, NST, Amniotic fluid pocket
(Modified BPP = NST + AFI)

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Characteristics of normal low-risk labor

1.

2.

3.
4.
5.
6.
7.

8.

No pregnancy complications that may affect

labor( with adequate ANC)
Spontaneous onset of labor between 37-42
week of gestation
Singleton fetus with cephalic presentation
Estimate fetal weight > 2,500 g, < 4,000 g
Adequate volume of clear amniotic fluid
No abnormal intrapartum bleeding
Acceptable rate of cervical dilatation
(1 cm/hr in active phase)
Normal fetal heart rate
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Progress of labor

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Partograph

Progress of labor

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Management in first stage (cont)

1.
2.

3.
4.
5.
6.

Maternal vital signs

Regular record uterine contraction and
record fetal heart rate
Food / IV fluid consideration
Maternal position
Analgesic drug consideration
Record and assess progress of labor
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Second stage

Mechanism of labor : 7
cardinal movements in occiput
anterior presentation
engagement
descent
flexion
internal rotation
extension
external rotation
expulsion

Conduct vaginal delivery

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Episiotomy

type 1. median or midline

2. mediolateral

Routine episiotomy

Restrictive
episiotomy
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Video viewing

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Third stage

Delivery of placenta
sign

of placental separation (uterine sign,

vulva sign, cord sign)

Modified
Brandt

Crede,

Andrew

Controlled

cord traction

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Delivery of the placenta : Modified Cr

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Delivery of the placenta :Brandt-Andr

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Controlled cord traction

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Prevent postpartum
hemorrhage
oxytocic

drugs

Syntocinon

: IV push, IV drip, IM

Methergin

: IM, IV

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Repairing episiotomy wound

Perineal tear during vaginal birth

First-degree tear

Second-degree tear

Third-degree tear

Fourth-degree tear
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Repairing fourth-degree perineal tear

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Postpartum care : 10 Bs

Blood pressure
Bladder
Bloody discharge
Basket
Bowel
Breast engorgement
Breast feeding
Baby
Blue
Brain

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What is (are) the

evidence(s) in norm
and delivery?
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How do we know that we are giving

the best care possible to a pregnant
Woman or a Woman in labour?
How do we know we
are doing most good
and least harm?

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Are these procedures essential in low

risk vaginal birth?
1.
2.
3.
4.
5.
6.
7.
8.
9.

Shaving perineum
Enema
NPO
IV fluid
Keep in bed
Continuous fetal monitoring
Episiotomy
Dorsolithotomy position
Rush the mother to push
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Evidence-based practice

Best available
evidence
EBP

Clinical expertise,
experience, skills
and judgment

Woman needs, values,

preferences and
context
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What is Evidence-Based
Practice?
EBP is the integration
of best research evidence
with clinical expertise

and patient/parent values

in context

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Levels of Evidence

(therapeutic and preventive)

Level 1

Level 2

Level 3

1a)

systematic review of
randomised trials

1b)

individual randomised trial

2a)

systematic review of cohort studies

2b)

individual cohort (and low quality RCT)

2c)

outcomes research

3a)

systematic review of case-control studies

3b)

individual case-control study

Level 4

case series (and poor quality cohort and case control studies)

Level 5

expert opinion

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Bias +

The 6 steps of EBP

1. Ask an answerable question
2. Access the appropriate evidence
3. Appraise the evidence
4. Discuss with the patient
5. Assess the context of care and apply the
results to clinical practice
6. Evaluate your practice
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Shaving for Labour

Traditional belief:

To reduce infection

Best Evidence:
Painful, embarrassing
Re-growth

To facilitate

suturing/makes it
easier to stitch

uncomfortable
Microabrasions cause
infection
Risk of HIV
transmission
No benefits shown for
shaving
Small cost benefit

Enemas in Labour

Traditional belief:

Best Evidence:

Encourages bowel movement Painful, embarrassing

(peristalsis) and therefore
Does not stimulate
more prostaglandin is
released, which in turn
stimulates contractions

Shortens labour
Helps the babys head
descend

Necessary to avoid soiling at

the birth (keep it clean) and
therefore reduce the risk
of maternal and neonatal
infection

contractions
Does not shorten labour
No difference with
neonatal infections
Does not decrease
soiling at birth,
more messier bowel
movements
Marginally increases
cost of health care

Fluids and food during labour

Traditional belief

Risk of inhalation if
general anaesthetic
needed

Best evidence
No difference in

Keep everyone nil per

mouth

anaesthetic risk
Dehydration leads to
acidosis, leads to fetal
distress
Dehydration can lead to
incordinate contraction
Nil per mouth only for
specific reason

Continuous fetal monitoring

No significant difference in overall perinatal

death rate
But was associated with a halving of neonatal
seizures
No significant difference was detected in
cerebral palsy
There was a significant increase in caesarean
sections

Carroli G, Belizan J. Episiotomy for vaginal birth. Cochrane Databa

69
Issue 3. Art. No.: CD000081. DOI: 10.1002/14651858.CD000081

Routine Episiotomy

Traditional Belief:
Clean incision
Heals better
Fewer 3 and 4 degree
tears
Less pain
Use routinely
Adapted from the WHO Better Birth Initiative http: /www.liv.ac.uk/lstm/bbimainpage.html

Restrictive episiotomy 27.6% (673/2441)

vs
Routine episiotomy 72.7% (1752/2409)
Outcome

RR

CI 95%

Posterior Perineal Trauma

0.88

0.84 to 0.92

Suturing

0.74

0.71 to 0.77

Healing Complications

0.69

0.56 to 0.85

Anterior Perineal Trauma

1.79

1.55 to 2.07

Six studies included

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Cochrane Systematic Review

Authors' conclusions

Restrictive episiotomy policies appear to have a

number of benefits compared to routine episiotomy
policies.
There is less posterior perineal trauma, less
suturing and fewer complications, no difference for
most pain measures and severe vaginal or perineal
trauma.
But there was an increased risk of anterior
perineal trauma with restrictive episiotomy.
.

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THAILAND MALAYSIA
PHILIPPINES INDONESIA

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How to prevent perineal

tears?
Best Evidence:
During Pregnancy
Pelvic floor (Kegel) exercises during pregnancy
Stretching exercises during pregnancy (Yoga)
Perineal massage during pregnancy
During Labour
Mobility in labour for good fetal positioning
Birth positions off the perineum, no more

lithotomies
Slow pushing efforts
Hot packs on the perineum during second stage
Undisturbed hormones

Best Evidence: During Labour

Mobility during labour

Traditional belief
Bedrest is best for

the mother and baby

Best evidence
Improved progress

Less busy in the

labour ward if
labouring women are
confined to bed

of labour if mobile
(contractions are
stronger)
Augmentation less likely
Labour may be less painful
Assists with fetal descent
No harms have been
associated

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All illustrations from: Flint, C. (1987) Sensitive Midwifery. London: Heinemann Medical Books

Continuous Support in Labour

Traditional belief:

Best Evidence:

Companions discouraged because Better progress of labour

of concerns about cross
infections

Fewer caesariean sections

Extra people who are not health Less pain

professionals always get in the
way

There is no privacy for other

women in labour

Staff are already overworked

and can not care for labour
support people as well

More self-esteem
Better relationship with the
baby

More breastfeeding
Less depression

Best Evidence: During Labour

Birth Positions

Traditional belief
Supine position and

Best evidence
Supine -progressive

Supine safest position

lithotomy best access

for attendant

acidosis of baby, slower

progress (supine
hypotension)
Other positions (lateral
tilt, upright, squatting,
forward, on all fours)
less pain
less vaginal trauma
improved fetal outcome
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How to prevent perineal

tears?
Best Evidence: During Labour
Slow pushing efforts
- stretches the perineum slowly
- non-directive pushing
- not forcing/guiding the head
- not rushing shoulders
- no holding breaths, woman
breathes at her own pace
- panting/breathing the baby
out

Outcome

Hot packs on the

perineum
during second stage

Comfort

Experimental

Control

group

group

80%

Pain relief

70%

Intact perineum and

70%

54%

superficial tear, no sut. req.

Second degree tear

17%

23%

Episiotomy

3%

6%

Perineal Preservation and Heat Application During Second Stage of Labour - Randomised Controlled Trial,
Musgrove, Heather small RCT, we need a systematic review on this

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Questions
&
Answers

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