Prepared by:

Dr. Reshed Z. Obeid,

Department of Obstetrics and Gynecology,
College of Medicine,
Anbar University.

Management of normal labour

Women are advised to ask for medical help if they think their waters may
have broken (SROM) or when their contractions are occurring every 5
minutes or more.
It is important to recognize that women have very different thresholds for
seeking advice and reassurance.
Thereafter, assessment of the situation based on the history and on clinical
examination.

.
1-History
A detailed history should be taken including past obstetric history, history of the
current pregnancy, relevant medical history and events leading up to hospital
attendance.

• Admission history
Previous births and size of previous babies.
Previous caesarean section.
Onset, frequency, duration and perception of strength of the contractions.
Whether membranes have ruptured and, if so, colour and amount of amniotic
fluid lost.
 Presence of abnormal vaginal discharge or bleeding.
 Recent activity of the fetus (fetal movement).
 Medical or obstetric issues of note (e.g., diabetes, hypertension, fetal growth
restriction [FGR]).
 Any special requirements (e.g., an interpreter or particular emotional
/psychological needs).

General examination:

It is important to identify women who have a raised body mass index (BMI), as
this may complicate the management of labour. The temperature, pulse and
blood pressure must be recorded and a sample of urine tested for protein, blood,
ketones, glucose and nitrates.
 Abdominal examination
After the initial inspection for scars indicating previous surgery, it is important
to determine the lie of the fetus (longitudinal, transverse or oblique) and the
nature of the presenting part (cephalic or breech).

If it is a cephalic presentation, the degree of engagement must be determined

in terms of fifths palpable abdominally.
A head that remains high (five-fifths palpable) and unengaged (more than two-
fifths palpable) is a poor prognostic sign for successful vaginal delivery.
If there is any doubt as to the presentation or if the head is high, an ultrasound
scan should be performed to confirm the presenting part or the reason for the
high head (e.g. OP position, deflexed head, placenta praevia, fibroid, etc).

Components of obstetrical examination:

Fundal height:
(a) Height of the uterus in temrs of weeks (b) Symphysiofundal height in cm
The distance between the umbilicus and the xiphisternum is divided into
three equal parts. The fundal height corresponds to the junction of the upper
and middle third at 32 weeks, up to the level of xiat 36th week and it comes
down to 32 week level at 40th week because of engagement of the presenting
part.

To determine whether the height of the uterus corresponds to 32 weeks or 40

weeks, engagement of the head should be tested.
If the head is “floating, it is of 32 weeks pregnancy and if the head is engaged, it is
of 40 weeks pregnancy.
Symphysis fundal height (SFH). The upper
border of the fundus is located by the ulnar
border of the left hand and this point is
marked. The distance between the upper
border of the symphysis pubis up to the
marked point is measured by a tape in
centimeter.
After 24 weeks, the SFH measured in cm corresponds to the number of weeks
up to 36 weeks. A variation of ± 2 cm is accepted as normal. Variation beyond
the normal range needs further evaluation.

Obstetric grips (Leopold’s maneuvers):

a. First Leopold (fundal grip)

b. Second Leopold (lateral or umbilical grip)
c. Third Leopold (Pawlik’s grip)
d. Fourth Leopold (pelvic grip).
Palpation should be conducted with utmost gentleness.
Clumsy and purposeless palpation is not only uniformative but may cause undue uterine
irritability. During Braxton-Hicks contraction or uterine contraction in labour, palpation should
be suspended.
(i) Fundal grip: The palpation is done facing the patient’s face. The whole of the
fundal area is palpated using both hands laid flat on it to find out which pole of
the fetus is lying in the fundus: (a) broad, soft and irregular mass suggestive of
breech, or (b) smooth, hard and globular mass suggestive of head. In transverse
lie, neither of the fetal poles are palpated in the fundal area.

(ii) Lateral or umbilical grip: The palpation is done facing the patient’s face.
The hands are to be placed flat on either side of the umbilicus to
palpate one after the other, the sides and front of the uterus
to find out the position of the back, limbs and the anterior shoulder.
The back is suggested by smooth curved and resistant feel. The ‘limb
side’ is comparatively empty and there are small knob like irregular
parts.
 • (iii) Pawlik’s grip (Third Leopold): The examination is done facing toward the patient’s face.
• The overstretched thumb and four fingers of the right hand are placed over the lower pole of
the uterus keeping the ulnar border of the palm on the upper border of the symphysis pubis.
When the fingers and the thumb are approximated, the presenting part is grasped distinctly
(if not engaged) and also the mobility from side to side is tested. In transverse lie, Pawlik’s grip
is empty.

(iv) Pelvic grip (Fourth Leopold): The examination is done facing the patient’s feet.
Four fingers of both the hands are placed on either side of the midline in the
lower pole of the uterus and parallel to the inguinal ligament. The fingers are
pressed downward and backward in a manner of approximation of finger tips to
palpate the part occupying the lower pole of the uterus (presentation). If it is
head, the characteristics to note are: (1) precise presenting area (2) attitude and
(3) engagement.
Abdominal examination also includes an assessment of the contractions; this takes time
(at least 10 minutes) and is done by palpating the uterus directly, not by looking at the
tocograph.
The tocograph provides reliable information on the frequency, regularity and duration of
contractions, but not the strength while the most accurate way of assessment of uterine
contractions is the intrauterine pressure catheter.
Vaginal examination
The index and middle fingers are passed to the top of the vagina and the cervix.
The cervix is examined for position, length and effacement, consistency,
dilatation and application to the presenting part.

The length of the cervix at 36 weeks’ gestation is about 3 cm. It gradually shortens
by the process of effacement and may still be uneffaced in early labour. The
dilatation is estimated digitally in centimetres.
At about 4 cm of dilatation, the cervix should be fully effaced. the cervix should
at least be 4 cm dilated in order to determine both the position and the station
of the presenting part. When no cervix can be felt, this means the cervix is fully
dilated (10 cm).

• A vaginal examination also allows assessment of the fetal head position, station, attitude and
the presence of caput or moulding.

• In normal labour, the vertex will be presenting, and the position can be determined by
locating the occiput.
• The occiput is identified by feeling for the triangular posterior fontanelle and the three
suture lines.
Failure to feel the posterior fontanelle may be because the head is deflexed (abnormal
attitude), the occiput is posterior (malposition) or there is so much caput and moulding that
the sutures cannot be felt.
All of these indicate the possibility of a prolonged labour or a degree of mechanical
obstruction.

Normally, the occiput will be transverse (OT position) or anterior (OA position).
Relating the leading part of the head to the ischial spines will give an estimation
of the station. This vaginal assessment of station should always be taken
together with assessment of the degree of engagement by abdominal palpation.
If the head is fully engaged (zero-fifth palpable) at or below the ischial spines (0
to +1 cm or more) and the occiput is anterior (OA), the outlook is favourable for
vaginal delivery.

The condition of the membranes should also be noted. If they have ruptured, the
colour and amount of amniotic fluid draining should be noted.
A generous amount of clear fluid is a good prognostic feature; scanty, heavily
blood-stained or meconium-stained fluid is a warning sign of possible fetal
compromise.
Women who are found not to be in established labour should be offered
appropriate analgesia and support.
Most can safely go home, to return when the contractions increase in strength
and frequency.
The admission history and examination provide an initial screen for abnormal
labour and increased maternal/fetal risk.

If all features are normal and reassuring, the woman will remain under
midwifery care.
If there are risk factors identified, medical involvement in the form of the on-call
obstetric team may be appropriate.
Women in labour should have their pulse measured hourly and their
temperature and blood pressure every 4 hours.
The frequency of contractions should be recorded every 30 minutes and a
vaginal examination performed every 4 hours (unless other factors suggest it
needs to be repeated on a different time-frame).

It should be noted when the woman voids urine, and this should be tested for
ketones and protein.
Women who chose epidural analgesia may need to be catheterized. Once the
second stage is reached, the blood pressure and pulse should be performed
hourly, and vaginal examinations offered every hour also.

FETAL ASSESSMENT DURING LABOUR:(lecture)

The partogram:
Is a graghic record which allows instant visual assessment of the fetal and maternal wellbeing
in addition to the progress of labour. It contains three components:
- Fetal portion: in which each of fetal heart rate, colour of amniotic fluid(C, M, B, A) and the
state of moulding (-, +1, +2,+3) is being recorded.

• - progress of labour:
• Including cervical dilatation (×) , descent of the presenting part (O) and
frequency and strength of uterine contractions
A line can be drawn on the partogram at the end of the latent phase
demonstrating progress of 1 cm dilatation per hour. Another line (‘the action
line’) can be drawn parallel and 4 hours to the right of it. If the plot of actual
cervical dilatation reaches the action line, indicating slow progress, then
consideration should be given to a number of different measures that aim to
improve progress.
Progress can also be considered slow if the cervix dilates at less
than 1 cm every 2 hours.
- Maternal component:
 Management during the first stage of labour:

Women who are in the latent phase of labour should be encouraged to mobilize
and should be managed away from the labour suite where possible.
Indeed, they may well go home, to return later when the contractions are stronger or more
frequent.

Encouragement and reassurance are extremely important. Intervention during this

phase is best avoided unless there are identified risk factors.
Simple analgesics are preferred over nitrous oxide gas and epidurals.
There is no reason to restrict eating and drinking, although lighter foods and clear
fluids may be better tolerated. Vaginal examinations are usually performed every 4
hours to determine when the active phase has been reached (approximately 4 cm
dilatation and full effacement).

Thereafter, the timing of examinations should be decided by the midwife in

consultation with the woman. Four-hourly is standard practice; however, this
frequency may be increased if the midwife thinks that progress is unusually slow
or fast or if there are fetal concerns. The lower limit of normal progress is 1 cm
dilatation every 2 hours once the active phase has been reached.
Descent of the presenting part through the pelvis is another crucial component of
progress and should be recorded at each vaginal examination.
Full dilatation may be reached, but if descent is inadequate, vaginal delivery will not occur.
During the first stage, the membranes may be intact, may have ruptured
spontaneously or may be ruptured artificially.

If the membranes are intact, it is not necessary to rupture them if the progress of
labour is satisfactory.
Maternal and fetal observations are carried out as described previously and
recorded on the partogram.
Women should receive one-to-one care (i.e. from a dedicated midwife) and
should not be left alone for any significant period of time once labour has
established.
Mobility during labour is encouraged and it is likely that standing upright encourages progress.

Unfortunately, many women adopt a supine position (lying down), especially if there is a need
for continuous EFM (i.e. the CTG).
Women may drink during established labour and those who are becoming dehydrated may
benefit from intravenous fluids to prevent ketosis, which can impair uterine contractility.
Light diet is acceptable if there is no obvious risk factor for needing a general anaesthetic and
if the woman has not had pethidine or diamorphine for pain relief, which can cause vomiting.
Antacids need only be given to women with risk factors for complications, or to those who
have had opioid analgesia.

‘Active management of labour’ was a collection of interventions that was

routinely recommended to nulliparous women to maximize the chances of a
normal birth.
It included:
1. one-to-one midwifery care.
2. 2-hourly vaginal examinations.
3. early artificial rupture of membranes.
4. use of oxytocin augmentation if progress fell more than 2 hours behind the
schedule of 1 cm dilatation per hour.
A variety of studies failed to show any obvious benefit of active management,
except that derived from one-to-one care, the only component
now recommended for all women in normal labour.
Management during second stage
If the labour has been normal, the first sign of the second stage is likely to be an
urge to push experienced by the mother. Full dilatation of the cervix should be
confirmed by a vaginal examination if the head is not visible.
The woman will get an expulsive reflex with each contraction, and will generally
take a deep breath, hold it, and strain down (the Valsalva manoeuvre). Women
will be guided by their own urge to push; however, the midwife has an important
role to play, with advice, support and reassurance if progress is poor.

Women should be discouraged from lying supine, or semi-supine, and should adopt any other
position that they find comfortable. Lying in the left lateral position, squatting and
‘all fours’ are particularly effective options.
Maternal and fetal surveillance intensifies in the second stage, as described
previously. The development of fetal acidaemia may accelerate, and maternal
exhaustion and ketosis increase in line with the duration of active pushing. Use
of regional analgesia (epidural or spinal) may interfere with the normal urge to
push, and the second stage is more often diagnosed on a routine scheduled
vaginal examination.

Pushing is usually delayed for at least 1 hour and up to 2 hours if an epidural is in

situ (the ‘passive second stage’).
However, in all cases the baby should be delivered within 4 hours of reaching full
dilatation.
Descent and delivery of the head
The progress of descent of the head can be judged by watching the perineum.
At first, there is a slight general bulge as the woman bears down. When the head stretches the
perineum, the anus will begin to open and soon after this the baby’s head will be seen at the
vulva at the height of each contraction.
Between contractions, the elastic tone of the perineal muscles will push the head back into
the pelvic cavity.

The perineal body and vulva will become more and more stretched, until
eventually the head is low enough to pass forwards under the subpubic arch.
When the head no longer recedes between contractions it is described as
crowning. This indicates that it has passed through the pelvic floor, and
delivery is imminent.
Vaginal and perineal tears are common consequences of vaginal birth,
particularly during first deliveries.
• The ‘hands-on’ approach has been very popular. As crowning occurs, the hands of the birth
attendant are used to flex the fetal head and guard the perineum.

The belief is that controlling the speed of delivery of the fetal head will limit maternal soft-tissue
damage; however, there is little evidence to support this practice over the alternative ‘hands-
off’ approach. Once the head has crowned, the woman should be discouraged from bearing
down by telling her to take rapid, shallow breaths (‘panting’).

An episiotomy is a surgical cut, performed with scissors, which extends from the vaginal outlet
in a mediolateral direction, usually to the right, through the perineum and incorporating the
lower vaginal wall is done at this stage.
Delivery of the shoulders and rest of the body:
Once the fetal head is born, a check is made to see whether the cord is wound
tightly around the neck, thereby making delivery of the body difficult.
If this is the case, the cord may need to be clamped and divided before delivery
of the rest of the body. With the next contraction, there is restitution and
external rotation of the head and the shoulders can be delivered.

To aid delivery of the shoulders, there should be gentle traction on the head downwards and
forwards until the anterior shoulder appears beneath the pubis. The head is then lifted
gradually until the posterior shoulder appears over the perineum and the baby is then swept
upwards to deliver the body and legs. If the infant is large and traction is necessary to deliver
the body, it should be applied to the shoulders only, and not to the head.( shoulder dystocia)
Immediate care of the neonate After the baby is born, it lies between the
mother’s legs or is delivered directly on to the maternal abdomen. The baby will
usually take its first breath within seconds.

There is no need for immediate clamping of the cord, and indeed about 80 ml of
blood will be transferred from the placenta to the baby before cord pulsations
cease, reducing the chances of later neonatal anaemia and iron deficiency.

• The baby’s head should be kept dependent to allow mucus in the respiratory
tract to drain, and oropharyngeal suction should only be applied if really
necessary.
• After clamping and cutting the cord, the baby should have an Apgar score
calculated at 1 minute of age ,which is then repeated at 5 minutes.
• Immediate skin-to-skin contact between mother and baby will help bonding, and promote
the further release of oxytocin, which will encourage uterine contractions.

• The baby should be dried and covered with a warm blanket or towel, maintaining this
contact. Initiation of breastfeeding should be encouraged within the first hour of life, and
routine newborn measurements of head circumference, birthweight and temperature are
usually performed soon after this hour has elapsed.
Before being taken from the delivery room, the first dose of vitamin K should be
given (if parental consent has been given) and the infant should have a general
examination for abnormalities and a wrist label attached for identification.

Management of third stage:

The third stage is the interval between delivery of the baby and the complete expulsion
of the placenta and membranes.
This normally takes between 5 and 10 minutes and is considered prolonged after 30 minutes,
unless a physiological approach is preferred.
Separation of the placenta occurs because of the reduction of volume of the
uterus due to uterine contraction and the retraction (shortening) of the lattice-
like arrangement of the myometrial muscle fibres.
A cleavage plane develops within the decidua basalis and the separated placenta
lies free in the lower segment of the uterine cavity. Management of the third
stage can be described as ‘active’ or ‘physiological’.

• 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.
Active management of the third stage
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---- Brandet Andrew maneuver.

Active management of the third stage should be recommended to all women because it was
shown to reduce the incidence of postpartum haemorrhage (PPH) from 5% to 15%.

When the signs of placental separation are recognized, controlled cord traction is used to
expedite delivery of the placenta.
When a contraction is felt, the left hand should be moved suprapubically and the
fundus elevated with the palm facing towards the mother.
At the same time, the right hand should grasp the cord and exert steady traction
so that the placenta separates and is delivered gently, care being taken to peel
off all the membranes, usually with a twisting motion.

Uterine inversion is a rare complication, which may occur if the uterus is not
adequately controlled with the left hand and excessive traction is exerted on
the cord in the absence of complete separation and a uterine contraction.
In approximately 2% of cases, the placenta will not be expelled by this method.
If no bleeding occurs, a further attempt at controlled cord traction should be made
after 10 minutes. If this fails, the placenta is ‘retained’ and will require manual
removal under general or regional anaesthesia in the operating theatre.

It is now recognized that a modified approach to active management of the

third stage may be preferable with delayed cord clamping for between 1 and 3
minutes. This approach allows autotransfusion of placental blood to the
neonate while maintaining the benefit of a reduced risk of PPH. It is of
particular importance in preterm birth.
Physiological management
Physiological management of the third stage is where the placenta is delivered by
maternal effort and no uterotonic drugs are given to assist this process.
It is associated with heavier bleeding, but women who are not at undue risk of PPH
should be supported if they choose this option.
In the event of haemorrhage (estimated blood loss >500 ml) or if the placenta remains
undelivered after 60 minutes of physiological management, active management should be
recommended.

After completion of the third stage, the placenta should be inspected for
missing cotyledons or a succenturiate lobe.
If these are suspected, examination under anaesthesia and manual removal of
placental tissue (MROP) should be arranged, because in this situation the risk
of PPH is high. Finally, the vulva of the mother should be inspected for any
tears or lacerations. Minor tears do not require suturing, but tears extending
into the perineal muscles (or, indeed, an episiotomy) will require careful repair.

• Features of normal labour:

Spontaneous onset at 37–42 weeks’ gestation.

Singleton pregnancy.
Cephalic vertex presentation. No artificial interventions.
Cervical dilatation of at least 1 cm every 2 hours in the active phase of first stage.
Active second stage no more than 2 hours in primiparous and 60 minutes in multiparous
woman.
Spontaneous vaginal delivery.
Third stage lasting no more than 30 minutes with active management.