CONDUCT OF

NORMAL LABOUR
INTRODUCTION
• Labour is a normal physiological process and the majority of mothers
will need only minimal assistance and go through it without any
complications.

• At the same time intrapartum complications can arise quickly and

unexpectedly.

• Hence providers make the mother comfortable, ensure safety for

mother and baby if complications develop.
ON ADMISSION
• Diagnosis of labour:
-This is one of the most critical diagnoses in obstetrics, because if
labour is falsely diagnosed it can lead to unnecessary intervention.

-On the other hand if not diagnosed, complications can occur in

sites where medical facilities are not available.
• Assessment
- A proper history is recorded with special attention given to the
antenatal notes to see if there were any pregnancy complications.
-Risk assessment and risk scoring is done. Maternal vitals are
recorded.
• Preparation of local parts:
-The vulva and perineum are cleansed with antiseptic solution.
Early in active labour cleansing enema can be given.
• Vaginal examination in labour:
-The effacement, dilatation, consistency, and position of cervix
should be ascertained. If there is rupture of membranes it should be
mentioned.

-The presenting part and its position and station should be

assessed. Incase of PPROM ,only speculum examination is performed.
• Assessing descent of head
-Descent of head is best monitored by abdominal examination, to
assess the number of fifths palpable per abdomen(Crichton method).

-Vaginal examination can also be useful to assess the station of the

leading part of the fetal head in relation to ischial spines.
• Fetal heart rate and admission test
-The fetal heart rate is checked with pinard’s fetoscope or fetal
doppler or Electronic Fetal Monitoring (EFM).

- Electronic Fetal Monitoring for 20 min for women with low risk
pregnancies at admission is called admission test.
FIRST STAGE OF LABOUR
• This stage has 2 phases:
-The first is a slow latent phase during which the cervical canal
shortens to less than 0.5 cm (effacement) and dilates to 5 cm .

-The second is a faster active phase when the cervix dilates upto
10 cm.

The primary management goals in this stage are to monitor fetal

wellbeing and support the woman
• Maternal position
The woman need not be confined to bed and can be allowed to
walk about at the beginning of labour.
• Fluid management
During labour, gastric emptying is delayed. If general anaesthesia
is required, aspiration of gastric contents can lead to aspiration
pneumonia. Hence solid foods are avoided but oral fluids can be given.
• Bladder function
The woman should be encouraged to pass urine regularly to avoid
bladder distension. If there is bladder distension, it can hinder descent
of the presenting part.

• Monitoring
maternal pulse, blood pressure, temperature should be recorded.
Signs of maternal distress like tachycardia, dehydration, dry tongue,
sunken eyes and appearance of ketone bodies in urine.
• Fetal
All high risk women should have continuous Electronic Fetal
Monitoring. All women with intrapartum risk factors like meconium,
oxytocin on flow or epidural in situ should also have continuous EFM.

• Partogram
Once the patient enters the active phase, a partogram should be
put. Subsequent vaginal examinations are usually done every 3-4 hours,
but sometimes at shorter intervals depending on the individual
situation.
• Analgesia
There are various methods of obstetric analgesia. The most commonly
used methods are epidural analgesia, nitrous oxide(Entonox), intramuscular
narcotics, TENS.

• Artificial rupture of membranes (ARM) or amniotomy:

Many prefer to do in the active phase. It is done using Kocher forceps,
when the presenting part is well applied to the cervix. Vaginal bleeding after
amniotomy accompanied by fetal heart changes should alert to the possibility
of abruption or vasa previa.
Meconium stained liquor occurs in about one fifth of deliveries.
Advantages:
- Promotes labour by stimulating release of endogenous
prostaglandins.
- Encourages application of fetal head to cervix
- Colour of liquor can be observed and meconium staining can be
ruled out.
- permits the use of fetal scalp electrode for intrapartum fetal
surveillance.
• Disadvantages:
Cord prolapse, Infection, Abruption in case of polyhydramnios.

• Prophylactic antibiotics:
It can be given after rupture of membranes.
SECOND STAGE OF LABOUR
• It is recognized by the bearing down efforts of the patient. Vaginal
examination is done to confirm complete dilatation of cervix and to
note the position and station of the head.

1. Preparation for delivery:

The most widely used position for delivery is the dorsal position.
Cleansing the perineum with antiseptic solution like betadine is done
and sterile drapes are used.
2. Women on epidural:
The widespread use of epidural anaesthesia has influenced the
course of the second stage. They may not have a sense of pelvic
pressure and urge to bear down.
3. Episiotomy:
It is indicated if there is undue stretching of the perineum. It is
usually a right mediolateral episiotomy using scissors angled at 45
degree from the lower vulvar rim.
4. Delivery of head
-As the head becomes increasingly visible, the vaginal outlet and
vulva are stretched further until they encircle the biparietal diameter.
-This encirclement of the largest transverse diameter of the fetal
head by the vulva such that the it does not recede between
contractions is termed crowning.
• Then by the process of extension, the forehead, nose, mouth and chin
are delivered. After the delivery of the head, it undergoes restitution and
external rotation towards the maternal thighs such that the head
assumes a transverse position.

5. Delivery of the shoulders and rest of the body:

External rotation of the head indicate that the shoulders are in
the AP diameter of the pelvis. Usually the anterior shoulder appears
spontaneously at the symphysis pubis and is delivered with gentle and
downward traction. Then the head is raised so that the posterior shoulder
can be born over the perineum.
6. Cord clamping:
The umbilical cord is cut in between two clamps. Delayed cord
clamping until the cessation of pulsation. If the baby is held at a lower
level than the mother, about 80 ml of blood shifts from the mother to
the baby.
7. Care of the newborn
Baby is kept with the head slightly downwards to facilitate
drainage of mucus, liquor and debris from the airway. Apgar scores at 1
and 5 min are recorded and quick check for anomalies is carried out.
THIRD STAGE OF LABOUR
1. Signs of placental separation
-uterus becomes firm and globular
-sudden gush of blood from the vagina
-suprapubic bulge
-extra vulval portion of the umbilical cord lengthens.
2. Prophylactic oxytocics:
10 units of intramuscular oxytocin is given immediately after the
delivery of baby.

3. Delivery of placenta:
Placenta is delivered by controlled cord traction or modified
Brandt Andrews method
4. Uterine massage
Uterine massage is recommended immediately after delivery of
the placenta to promote contraction and retraction of the uterus. The
placenta and its membranes are checked for completeness.

5. Examination of birth canal:

Vulva, vagina and perineum are inspected for any injuries and if
present they are repaired. In case of instrumental delivery and if there
is excessive bleeding, the cervix should be inspected for tears using
three sponge holding forceps.
FOURTH STAGE OF LABOUR
• The hour immediately following the delivery of placenta is critical and
hence has been termed as the fourth stage.

• Maternal BP and pulse are monitored during this time frequently.

• The mother should be kept in the labour ward for atleast an hour to
check for bleeding.
WHO LABOUR CARE GUIDE