Lecture 6: Management & Monitoring of normal labour

Mr. BSI Sonti

Lecturer/Midwifery Specialist
Department of Obstetrics & Gynaecology
August 30, 2023

www.ufs.ac.za
 Overview of the lecture
• Definition and diagnosis of labour
• Criterion for normal labour
• Factors influencing the onset of labour
• Understand the mechanics of delivery
• Cardinal movements of normal labour
• Understand stages & phases of labour
• Understand and describe the principles in
management of the labour process
 Diagnosis of labour
Onset of painful regular involuntary coordinated uterine
contractions, plus one or more of the following:
a) show (separation of the operculum)
b) spontaneous rupture of membrane (SROM)
c) and/or cervical changes(complete effacement)
 Criterion for normal labour
Labor is considered normal when:
• Parturient w/out any risk (e.g., Pre-eclampsia, Previous scar).
• Labor should start spontaneously and at term.
• Fetal presentation must be by vertex.
• Delivery should be by spontaneous vertex delivery.
• All stages of labor are lasting normal duration
• neonate is alive, normal
• woman has uncomplicated pueperium
 TRUE vs False labour
True False

Regular contractions • Irregular

Increase in frequency and intensity • Remains the same
Cervix dilate • Cx unchanged
No relieve with sedation • Relieve
• Lower abd
Abd and back pain
 Onset of Labour
• It is postulated that it is a result of changes in the hypothalamic–
pituitary–adrenal axis, increasing fetal cortisol, and placental
enzymatic functions.
• Complex interactions of hormones between uterus, placenta and
fetus.
Factors influencing the onset of labour
2. Oxytocin and Prostaglandins
Positive feedback in the birth process
 Other factors
• Effect of catecholamines and other steroids still unclear.
• Distension of the uterus
– PTL in twins, polyhydramnios
• Rupture of membranes
– Owing to the release of endogenous prostaglandins
• Fetal oxytocin probably plays a role by sensitizing the uterus to
prostaglandins
• The fetal adrenal glands may be important in that, by means of
cortisol excretion, they may initiate the release of prostaglandins
in the maternal decidua
 Mechanics of labour
 Ability of the fetus to successfully negotiate the pelvis
during labor and delivery depends.
 Uterine activity
 Fetus &
 Maternal pelvic
 Simplified in the mnemonic patient, powers,
passenger, passage
 Rule of the 4P’s
1. Patient ( the woman)
– Hydration
– Pain relief
– Emptying the
bladder
– Positioning
– Psyche
 Rule of the 4P’s cntd..
2. Passenger (Fetus)
 Fetal lie
 Presentation
 Attitude
 Position
 Fetal size…
 Fetal lie
 Longitudinal : when
parallel
 Transverse: When
perpendicular
 Oblique (unstable):
when cross at a 45-
degree angle.
 Fetal presentation
 Depend on presenting part :
 Attitude
 Position of the head with regard to the fetal spine.
 Degree of flexion or extension of the fetal head.
 Fetal position
 Occiput for Vertex
 Chin (mentum) for Face &

 Sacrum for Breech

presentation.
 Each presentation has right
or left position.
 Fetal size
– Size
– Number
 Rule of the 4P’s cntd..
3. Powers( Contractions)
• External tocodynamometry is a qualitative
measurement of uterine activity, records uterine
activity and correlates fetal heart rate (FHR)
pattern with uterine contraction.
• Quantitative assessment of intrauterine pressure
to measure the strength of uterine contraction is
done by placement of an intrauterine catheter.
This is measured in Montevideo units (MVU).
Uterine activity varies in different stages of labor:
latent phase approximately 100 MVUs, active
phase of labor 175 MVUs and 250 MVUs during
the second stage
 Rule of the 4P’s cntd..
4. Passage ( Pelvis)
• Obesity
• Pelvic adequacy
• Other maternal features include:
• short stature, longer cervical length at mid pregnancy, and
post-term pregnancy.
• Uterine features:
• Bandl’s ring
• Uterine abnormalities
 Passage ( Pelvis) Cntd
 Involves:
 Bony pelvis— sacrum,
ilium, ischium, and
pubis—and
 resistance provided by
the soft tissues.
 Measurement
 Clinical pelvimetry
Clinical pelvimetry
NB

Cardinal movements in labour

 CARDINAL MOVEMENTS
Engagement
 Passage of the widest diameter of the presenting part
below level of the pelvic inlet.
 Largest transverse diameter is:
 Bi-parietal diameter (9.4 cm) for fetal head.
 Bi-trochanteric diameter for breech.
 Confirmed by palpation of the presenting part both
abdominally and vaginally.
 CARDINAL MOVEMENTS cntd
Descent
 Downward passage of the presenting part through
the pelvis.
 Greatest in active phase and 2nd stage of labor.

Flexion
 Occurs passively as the head descends due to
 The shape of the bony pelvis &
 Resistance by soft tissues of the pelvic floor.
 CARDINAL MOVEMENTS cntd

Internal rotation
 Rotation of the presenting part from its original position
as it enters the pelvic inlet
 Usually OT to the AP position

Extension
 Occurs once the fetus has descended to the level of the
introitus.
CARDINAL MOVEMENTS cntd
External Rotation(restitution)
 Return of the fetal head to the correct anatomic position
in relation to the fetal torso.

Expulsion
 Refers to delivery of the rest of the fetus.
Video : MECHANISM OF LABOUR
 Stages & Phases of labour
Stages of labour Duration

1st Stage ( onset of labour to full

dilatation)
 Latent Phase Nullipara: lasts 3-8 hours
Onset of labour to 5cm Multipara: Often shorter
dilatation Nullipara: 1cm/hour
• Active phase Multipara: 1.5cm/hr
From 5cm to full dilatation
Stages of labour Duration

2nd Stage ( time of full dilatation to Nullipara= 1 hour

time of delivery of the baby) Multipara: 45 minutes
 Phase i
Presenting part is high
• Phase ii
Presenting part is on the
perineum
Stages of labour Duration

3rd stage Depends on the method used but

• time of birth to delivery of usually 5-60mins
placenta and membranes
4th Stage • First hour
• period after delivery of the • Rest of puerperium
placenta up to 6 weeks post
partum
“Involution period”
 Initial management of labour
Diagnostic criteria
 Pain full contractions at least 2 contractions in 10 minute.
 Rupture of the membranes or
 Cervical dilatation after 100% effacement.
Admission of woman in labour
 All women with diagnosis of labor with known risk or ruptured membranes.
 For a woman without known risk and intact membrane - cervix dilation is
≥ 4 cms with complete effacement.
 Initial management of labour
Admission procedure
• Assess whether delivery is imminent or not.
• Careful review ANTENATAL RECORD - gestational age & risk
• Laboratory investigations.
• Appropriate history, physical examination.
• General examination
• Abdominal examination
– Fetal lie, presentation and attitude
– Level of presenting part (5ths above brim)
– Uterine contractions – duration and frequency
– Fetal heart before/after contraction
• Plan a scheme of management during labor.
 Management of the first stage of labour

www.ufs.ac.za
Critical intervals: Vital Signs
Vaginal examination to see:
 Rate of cervical dilation at least 1 cm./hr.
 Station, position, degree of moulding
 every 4 hrs unless the following condition occur:
o After spontaneous rupture of membranes.
o When there is abnormal FHR pattern.
o Before giving analgesia.
o Symptoms suggesting 2nd stage.
o All observations and findings should be recorded on Partograph.
 Chatting the progress of labour

www.ufs.ac.za
Friedman’s curve
Prof’s Philport & Castle
• Introduced the concept of
"ALERT" and "ACTION" lines for
African primigrivadae in 1972
 Zhang’s curve
• Zhang and his group published
a series of papers on the
natural progression of labour
and re-assessment of the
labour curve.
• One of the conclusions was
that labour may not naturally
accelerate before dilatation of
6cm, meaning that intervention
before 6cm to accelerate
labour may not be necessary
Friedman & Zhang’s curves
The BOLD Project
• Better Outcomes in labour
Difficulties (BOLD ) project led
by WHO…a multi centre study
conducted in Nigeria and
Uganda aimed to develop a
new labour monitoring to
action tool.
• The validity of the partogram
with the alert and action lines
should be re-evaluated
 Components of the partograph
Part 1 : Fetal condition ( at top )

Part 2 : Progress of labour ( at middle )

Part 3 : Maternal condition ( at bottom )

 Initial
assessment

In Labour Unsure Not in labour

Latent phase of
Active phase of labour
labour

Labour process Poor progress

progress

Obstructed Dysfunctional
labour contractions
Management second stage of labour
• Allow head to descend to pelvic floor ( 2 hrs)
• Empty bladder
• Encourage bearing down when head start to distend perinium
• Woman has urge to push
• Communicate & support
• Appropriate position
• Listen to fetal heart
• Protect perineum
• Deliver baby – assess APGAR score
• Clamp cord -1-2 minutes
video
Management 3rd stage labour
• Prevent excessive bleeding – active
management
• After delivery –palpate uterus
• Give oxytocin 10E IMI
• Feel for contraction – signs of
placenta release
• Steady tension on cord with upward
pressure on uterus
• Examine placenta for completeness
 First hour after delivery
• At risk for haemorrhage
• Check Heart rate, BP, Respiration rate
• Uterus well contracted
• Show mother how to rub uterus
• Assist with baby – skin-to-skin, breast feeding
• Repeat BP pulse
• Give mother light meal/ something to drink
• Transfer to postnatal ward
 FEW RULES
• SUN = Never let the sun rise or fall twice during labour
• Rule of the P’s
– Patient
• Pain relief
• Physiological status –hydration
• Psychological status and support
• Partner
– Passenger
– Passage
– Powers
 Aspects not covered
• Perform and suture episiotomy
• Referral communication
• Delivery safety checklists
• Cleanliness and sterility
 Thank you

www.ufs.ac.za