Labor

Labor
• Labor is the physiologic process by which a
fetus is expelled form the uterus to the
outside world.
• It involves the sequential integrated changes
in the uterine decidua, and myometrium.
• Changes in the uterine cervix tend to precede
uterine contractions
 Stages of labor
• First stage: onset of labor until complete dilation and
effacement
– Latent: gradual cervical change
– Active: rapid cervical change (contemporary data = 6 cm)

• Second stage: complete cervical dilation to delivery

– May have passive and active components

• Third stage: from delivery of infant to delivery of the

placenta
 Labor - Mechanics
Uterine contractions have two major goals:

• To dilate cervix
• To push the fetus through the birth canal
• Success will depend on the three P’s:
• Powers
• Passenger
• Passage
 Power
Uterine contractions
• Power refers to the force generated by the
contraction of the uterine myometrium
• Activity can be assessed by the simple observation by
the mother, palpation of the fundus, or external
tocodynamometry.
• Contraction force can also be measured by direct
measurement of intrauterine pressure using internal
manometry or pressure transducers.
 Power
• There is no specific criteria for adequate
uterine activity
• Generally 3-5 contractions in a 10 minute
period is considered adequate labor
 Passenger
Passenger =fetus
• Fetal variables that can affect labor:
• Fetal size
• Fetal Lie – longitudinal, transverse or oblique
• Fetal presentation – vertex, breech, shoulder, compound
(vertex and hand), and funic (umbilical cord).
• Attitude – degree of flexion or extension of the fetal head
• Position
• Station – degree of descent of the presenting part of the
fetus, measured in centimeters from the ischial spines
• Number of fetuses
• Presence of fetal anomalies – hydrocephalus,
sacrococcygeal teratoma
 Passage
Passage = Pelvis
• Consists of the bony pelvis and soft tissues of the
birth canal (cervix, pelvic floor musculature)
• Small pelvic outlet can result in cephalopelvic
disproportion
• Bony pelvis can be measured by pelvimetry but it not
accurate and thus has been replaced by a clinical trial
of labor
 Passage

• www.uptodate.com
 The Stages of Labor
First Stage
• Interval between the onset of labor and full
cervical dilation
• Two phases:
• Latent phase – onset o f labor with slow
cervical dilation to ~6 cm and variable
duration, 2 cm/hour
• Active phase – faster rate of cervical change,
1-1.2 cm /hour, regular uterine contractions
 The Labor Curve

• First stage - A: latent phase; B + C + D: active phase; B: acceleration; C:

maximum slope of dilation; D: deceleration; E: second stage.
Adapted from: Friedman. Labor: Clinical evaluation and management,
2nd ed, Appleton, New York 1978.
 Labor
Labor NulliG MultiG
• Freidman’s curve
1st Stage Active phase
is a good
guideline for Duration 6-18 h 2-10 h
expected
Dilation ~1 cm/h ~1.5 cm/h
progression in
labor and Arrested >2 h >2h
therefore helpful
2nd Stage 0.5-3 h 5-30 min
to note abnormal
labor patterns. 3rd Stage 0-30 min 0-30 min
 Labor
• Variables associated with longer labors:

– Electronic fetal monitoring

– Narcotic use
– Maternal age >30
– Ambulation
 First stage:
• It starts from the onset of true labor pain and to full
dilatation of the cervix.
• It lasts 6 to 18 hours in primigravida and 2 to 8
hours in multipara.
• Contraction. Contraction is a temporary reduction
in length of the fibers, which attain their full length
during relaxation.
• Retraction. Retraction is a phenomenon of the
uterus in labor in which the muscle fibres are
permanently shortened and the fibers shortened
once and for all.
 Duration.
• In the first stage the contractions lasts about
30 sec initially but gradually increases to 50-60
sec in duration with the progress of labor.
• Frequency. In the early stage of labor, the
contraction comes at intervals of 10 to 15
minutes.
• The intervals gradually shorten with
advancement of labor, until in the second
stage, when it comes every 1 or 2 minutes.
 First stage:
• The dilatation of the cervix, whereas in
multiparae, both occur simultaneously.
• Lower uterine segment. During labor, the
lower segment demarcation of an active
upper segment and relatively passive lower
segment is more pronounced. A distinct ridge
is produced at the junction of the two, called
physiological retraction ring (contraction ring).
 Labor – Second Stage
• Interval between full cervical dilation to delivery of
the infant.
• Characterized by descent of the presenting part
through the maternal pelvis and expulsion of the
fetus.
• Indications of second stage:
• Increased maternal show
• Pelvic/rectal pressure
• Mother has active role of pushing to aid in fetal
descent.
 Labor – Second Stage
• Examining the fetal head during the second stage
may become difficult due to molding
• Molding is the alteration of the fetal cranial bones to
each other as a result of compressive forces of the
maternal bony pelvis.
• Caput is the localized edematous area on the fetal
scalp caused by pressure on the scalp by the cervix.
• PrimiG – 0.5-3 h; mulitG 0-30min
 Labor – Third Stage
• The time from fetal delivery to delivery of the
placenta
• Three signs of placental separation:

– Lengthening of umbilical cord

– Gush of blood
– Fundus becomes globular and more anteverted
against abdominal hand
 Labor – Third Stage
• Placenta is delivered using one hand on
umbilical cord with gentle downward
traction. Other hand on abdomen supporting
the uterine fundus.
• Risk factor for aggressive traction is uterine
inversion.
• Obstetrical emergency!!
• Normal duration between 0-30 min for both
PrimiG and MultiG
 Labor – Fourth Stage

• Refers to the time from delivery of the placenta to 1

hour immediately postpartum
• Blood pressure, uterine blood loss and pulse rate
must be monitor closely ~ 15 minutes
• High risk for postpartum hemorrhage from:
• Uterine atony, retained placental fragments,
unrepaired lacerations of vagina, cervix or
perineum.
• Occult bleeding may occur – vaginal hematoma
• Be suspicious with increased heart rat, pelvic pain
or decreased BP
 Cardinal Movements of Labor
• Refers to changes in the fetal head position during its
passage through the canal.
• Seven distinct movements:

– Engagement
– Descent
– Flexion
– Internal rotation
– Extension
– External rotation/restitution
– Expulsion
 Occiput presentation

11 22 33

1
engagement
Definition
descent flexion

2 Four factors for labor

44 55 66
3 Mechanism
internal rotation
of
extension
labor
external rotation

7. expulsion
 Cardinal Movements of Labor
Engagement
• Passage of the widest diameter fetal
presenting part below the plane of the pelvic
inlet
• The head is said to be engaged if the leading
edge is at the level of the ishial spines.
 Cardinal Movements of Labor
Descent
• Refers to the downward passage of the
presenting part through the bony pelvis
• Not steady process
• Greatest at deceleration phase of first stage
and during 2nd stage of labor
 Cardinal Movements of Labor

Flexion
• Occurs passively as the head descends due to
the shape of the bony pelvis.
• Partial flexion occurs naturally but complete
flexion usually occurs only in the labor
process
• Complete flexion places the fetal head in
optimal smallest diameter to fit through the
pelvis
 Cardinal Movements of Labor
Internal Rotation
• Rotation of the fetal head from occiput
transverse to occiput either in anterior or
posterior position
• Occurs passively due to the shape of the bony
pelvis
 Cardinal Movements of Labor
Extension
• Occurs when the fetus has descended to the
level of the vaginal introitus
• When occiput is just past the level of the
symphysis, the angle of the birth canal
changes to upward position
 Cardinal Movements of Labor
External Rotation/Restitution
• As the head is delivered, it rotates back to its
original position prior to internal rotation
• It aligns anatomically with the fetal torso
• The release of the passive forces on the fetal
head allows it to return to appropriate
position
 Cardinal Movements of Labor
Expulsion
• Delivery of the fetus
• After delivery of the fetal head, descent and
intraabdominal pressure by mother brings
shoulder to the level of the symphysis
• Downward traction allows release of the
shoulder and the fetus is delivered.
Cardinal Movements of Labor
 Terminology
• Gravida - number of pregnancies
• Para - number of pregnancies carried to
viability and delivered
• Primigravida - pregnant for first time
• Multigravida - pregnant more than once
• Viability - able to survive outside the womb
(24+ weeks gestation)
• Nulliparous - never carried a pregnancy to
viability
• Multiparous - has had two or more
deliveries that were carried to viability
 Duration of Pregnancy
• Average 280 days or 40 weeks (9 lunar
months)
• Estimated Date of Confinement (EDC)
– Nagele’s rule
– Date of first day of LMP
– Subtract 3 months
– Add 7 days
• Accurate to plus or minus 2.5 weeks
 First Stage of Labor
• Begins with onset of coordinated contractions
leading to dilation of cervical os and ends with
complete dilation (10 cm) of the cervical os.
• False Labor (Braxton Hicks contractions)
– Cervix fails to dilate greater than 2 cm
• Duration of first stage -
– Primigravida: 12 hours
– Multiparous: 7 hours or less
 First Stage of Labor
• Interval Contractions
– 10 to 20 minutes between contractions: early labor
– 3 to 5 minutes between contractions: late labor
• Duration
– 20 second long contraction: early labor
– 40 to 80 second long contraction: late labor
• Quality
– Uterus can be dented (poor quality): early labor
– Uterus is hard (good quality): late labor
 First Stage of Labor
• Management
• Take VS between contractions
• Fetal Heart Rate should be between 120 - 160
BPM
• Mother should be coached to relax and
conserve energy between contractions
 Assessing Progress of Labor
• Vaginal Exam
• Cervix
– Soft or Hard
– Effaced or Thick
– Dilatation
• Presentation
– Part (cephalic, breech, shoulder)
– Flexion, Extension
– Station
 Second Stage of Labor
• Begins with complete dilation of the cervix
and ends with delivery of fetus
• Duration of Second Stage -
– Primigravida: 50 minutes
– Multiparous: 20 minutes or less
• Contractions
– Interval: 2 to 3 minutes
– Duration: 50 to 100 seconds
 Second Stage of Labor
• Management
– Mother may feel urge to push, coach to push only
during a contraction once the cervix has been
determined to be fully dilated
• Episiotomy
– Perform to avoid unecessary tearing when head is
crowning
– Controlled delivery avoids need for episiotomy in
most cases
 Second Stage of Labor
• Episiotomy
– Anesthetize with pudendal block
– Put two fingers into the vagina along the posterior
wall
– Place one blade of scissors between fingers inside
vagina, other blade outside vagina toward anus
– Cut to approximately 1 inch away from anus
during a contraction
 Second Stage of Labor
• Delivery of head - CONTROL head to prevent
explosive delivery and subsequent tearing
• Check for presence of cord around neck
• Aspirate oral and nasal cavities with bulb
syringe
• Deliver anterior shoulder with downward
pressure
• Complete delivery and HANG ON TO BABY!
 Second Stage of Labor
• Clear airway, Assess respirations, Resuscitate if
necessary
• Clamp cord when pulsations cease
• Leave 3 - 6 inches of cord on baby
• Obtain blood for fetal labs from the placental
stub of cord
 Third Stage of Labor
• Begins after delivery of baby and ends with
delivery of the placenta
• Average duration: 8 minutes
• Signs of separation
– Uterus rises to become globular
– Increase (gush) of blood from vagina
– Lengthening of cord
• Do not PULL cord. Apply gentle traction
• Check Placenta for completeness
 Third Stage of Labor
• Recover missing pieces of placenta as
necessary
• Massage uterus to aid in hemostasis
• IV Oxytocin can be given if available to aid
uterine contractions and aid in hemostasis
 Management first stage of labor
• 1. To asses the degree of risk.
• 2. To change adequate method of delivery.
• 3. Assessment in progress of labor by abdominal,
vaginal examination and partogramm recording.
• The following information are to be noted: Degree
of cervical effacement and dilatation in cm.
• 4. The patient condition and progress check
periodically. The pulse, temperature, and blood
pressure are measured every 2 hours.
 Management first stage of labor
• 5. The fetal heart is auscultated every 30 minutes
if normal and more frequently if irregulary or slow.
• 6. Over distension of the bladder is obviated by
urging the patient to pass urine every few hours. If
she not able to do so, catheterization may be
necessary, since a full bladder impedes progress.
• 7. Vaginal examination should be done at the
onset of labor – to confirm the onset of labor and
to detect presenting part and position.
 Management first stage of labor
• Partogramm is a graphical and record of cervical
dilatation and decent of head against duration
of labor in hours.
• It is also gives information about fetus and
maternal condition, which are all recorded on a
single sheet of paper.
 Management first stage of labor
• The first stage of labor has got 2 phases – a latent
phase and active phase.
• Latent phase begins from the onset of
contractions to the dilatation of the cervix of 6 cm.
• Active phase begins from dilatation of 6 cm to full
dilatation.
• Dilatation of the cervix at the rate of 1 cm per
hour in primigravida and 1.5 cm in multigravidae
beyond 6 cm dilatation is considered satisfactory.
 What is a Partograph?
Definition: A tool to assess & interpret the
progress of labour.

• The partograph is a means of graphic

presentation of labour:
– Progress of labour
• Cervical dilatation
• Foetal head descent
• Uterine contractions
– Foetal status
– Maternal status
 Key Principles for Using the Partograph (1)

• The partograph is used to record mainly the first

stage of labour
– However, after full cervical dilatation is reached, you
should continue to record vital information related to the
mother and the fetus (foetal heart rate, uterine
contractions, maternal pulse, and blood pressure)
• The partograph is started if there are
– Two or more uterine contractions in 10 min lasting 20 sec
or more in the latent phase
– One or more uterine contractions in 10 min lasting 20 sec
or more in the active phase
– No complications requiring urgent interventions or
delivery
 Key Principles for Using the
Partograph (2)
• The partograph is filled out during the labour not
after birth
• During labour, the partograph must be kept in the
labour room
• The partograph is filled in and interpreted by
trained personnel (midwife or obstetrician)
• Filling in the partograph should be stopped when
– Complications requiring urgent delivery arise
Component of Partogram
Mother information

Fetal well-being
• Fetal heart rate
• Character of liquor
• Moulding

Labour progress
• Dilatation
• Descent
• Uterine contraction

Medications
• Oxytocin
• Pain relief (e.g. pethidine)

Maternal well-being
• BP, Pulse, Temperature
• Urine – albumin, glucose, acetone
• Urine output
PARTOGRAM
WHAT NEED TO BE
RECORDED
 PARTOGRAM RECORDING
3
Notes should be
legible, dated and
timed.

4
1 Enter the outcome
of delivery
Begin plotting at the
“zero” hour on the
partogram

2
All entries made in
relation to time when
the observations are
made
PARTOGRAM RECORDING
Mother information

 Name
 Age
 Parity
 Gestational period
 Date/time of admission
 Time of rupture membrane
 Short antenatal history
 General Information

Boiko I. 3 2 425
12.04.06 16:35 5
PARTOGRAM RECORDING

Fetal information

 Fetal heart rate

 Membrane and amniotic

fluid

 Moulding

 Caput
Part 1 : Fetal condition
 Fetal Heart (Charting)

Basal fetal heart rate

• brady >110-160< tachy

Decelerations? yes/no
Relation to contractions?
• Early
• Variable
• Late
PARTOGRAM RECORDING

Fetal information

Fetal heart rate monitoring

1. Safe and reliable way of

knowing fetus is well.

2. Listen after each

contraction for one
minutes.

3. Recorded ½ hourly (each

square is ½ hour)
PARTOGRAM RECORDING

Fetal information

Character of amniotic fluid

1. State of liquor can assess in

monitoring fetal condition.

2. Observation to be recorded

- Membrane intact record as “I”

- Membrane rupture:
a) liquor clear record as “C”
b) meconium stained liquor “M”
c) liquor absent record as “A”
d) bloody “B”
 Amniotic Fluid
• I – the membranes intact

• C – clear amniotic fluid

• В – blood-stained amniotic fluid

• M – meconium-stained amniotic fluid

• A – absent amniotic fluid

PARTOGRAM RECORDING

Fetal information

Moulding of fetal skull

1. Provide information about the

adequacy of pelvis to
accommodate fetal head

2. Record the degree of moulding

0  bones separated
+  bones touching but can
be separated.
++  bone over lapping
+++  bones over lapping
severely
Moulding the fetal skull bones
Caput and Moulding
Information about Foetal Status
in Labour

“I”,
“C” “O”,“+
“M”, ”
“B”, “++”,
“A” “+++”
PARTOGRAM RECORDING

Part II- Labour Progress

 Cervical dilatation

 Descent

 Uterine contraction
Cervical Dilatation
PARTOGRAM RECORDING

Labour progress
Dilatation and Descent

1. Latent (0-6 cm) and Active (6-10

cm) phase.

2. Dilatation of cervix plotted as “X”

axis and Descent plotted as “O”
axis.

3. First vaginal examination done on

admission is recorded.

4. Subsequent vaginal examination is

done every 2-4 hourly.

5. Transfer from latent to active

phase.
 X
09:00
10:00
11:00
12:00
13:00
X
14:00
15:00
16:00
X

17:00
Cervical Dilatation: Latent Phase
 Descent of the Head Determined by
Abdominal Examination

Head is Head
mobile accommodates
above the the full width of
pelvic brim five fingers above
the pelvic brim =
5/5

Head is Head is two

engaged fingers width
above the pelvic
brim = 2/5

WHO, 1994
WHO EURO, 2002
77
 PARTOGRAM RECORDING
Labour progress recording
in latent phase

Plot dilatation as “X”

Latent phase Plot descent as “O”

At admission:
+
+

- Dilatation  2 cm
- Descent  -2

2 hours after admission:

- Dilatation  2 cm
- Descent  -1

As the dilatation is only 2 cm therefore

the labour progress is in the latent
phase
08:00

X
O
09:00
10:00
11:00
12:00
X
O
Foetal Head Descent
 PARTOGRAM RECORDING

Labour progress recording

in active phase
Plot dilatation as “X”
Latent phase
Plot descent as “O”
Active phase
+

Latent phase
+

+
+

0 hours 2 hours 4 hours

(admission)

Dilatation
“X” 2 cm 4 cm 7 cm

Descent
“O” -2 -1 +1
13:00

X
O
14:00
15:00
16:00
17:00

X
O

17:00
O
X

18:00
19:00
20:00
X

O
Foetal Head Descent
 09:0
X
O

0
10:00
11:0
0
12:00
13:00
O
X
Foetal Head Descent
 PARTOGRAM RECORDING

Cervical dilatation

Latent phase
If labour progress well plotting of
+

cervical dilatation should always

+

remain to the left of alert line.

+

If it cross to right of action line

this warns that labour may be
prolonged.
09:00

X
10:00
11:00
12:00
13:00
14:00
X
15:00
16:00
17:00
X

18:00
19:00
20:00
21:00
X
Alert Line
Active Phase: on the Left of the
14:00

X
15:00
16:00
17:00
18:00 X

18:00
X

19:00
20:00
21:00
22:00
X
Active Phase: at the Alert Line
Active Phase: on the Right of
the Alert Line (1)

X X

20:00
19:00
14:00
15:00
16:00
17:00
18:00

18:00

21:00
22:00
14:00

X
15:00
16:00
17:00
18:00 X

18:00
X

19:00
20:00
21:00
22:00
X

23:00
00:00
01:00
the Action line (2)

02:00
X
Active Phase: on the Right of
Active Phase: The Lines of Alert
and Action

4 hours
 Effect of Different Partograph
Action Lines on Birth Outcomes:
2-hour versus 4-hour Action Line
• Use of 2-hour partograph:
– More frequent crossing of Action line
– More interventions without improving maternal or
neonatal outcomes
– More women transferred to higher level of care

• No differences in cesarean delivery rate or women

dissatisfied with labor experience

2-hour Action line partograph has no advantages

compared with 4-hour partograph Lavender T et al, 2006
90
PARTOGRAM RECORDING

Labour progress
Uterine Contractions

1. Observation is made ½ hourly

2. Assess the frequency, duration.
3. Each square represent 1
contraction felt in 10 minutes.
4. Frequency – highlight the
numbers of square.
5. Duration – shade the contraction
in the square.

< 20 sec - Mild

20-40 sec - Moderate

> 45 sec - Strong

PARTOGRAM RECORDING

Labour progress

Recording the uterine on the

partogram

Nos. of
Contraction
in 10 mins

2 weak contractions
in 10 minutes
5 strong contractions
in 10 minutes

3 moderate contractions
in 10 minutes
Recording the Contractions and
Oxytocin
Contraction
s per 10
minutes

Oxytocin U/L
drops/min

Less than 20 seconds

From 20 to 40 seconds

Over 40 seconds
14:00
O
X

15:00
16:00
17:00
18:00
O
X

19:00
20:00
21:00
O
X
Recording the Contractions
PARTOGRAM RECORDING

Mother condition

 Vital signs – BP, Pulse, TºC

 Urine analysis – acetone,

albumin, glucose
 Urine volume
 Medications or drug given
PARTOGRAM RECORDING

Mother condition

 Vital signs recording

BP – 4 hourly or more
frequent if indicated
Pulse - ½ hourly

TºC – 4 hourly

 Urine analysis – dipstick

acetone  Nil or +
albumin  Nil or +
glucose  Nil or +

 Urine volume
Information about Maternal
Status in Labour
 PARTOGRAM RECORDING

Analyzing the progress of

labour from the partogram
Active phase
If progress is satisfactory the
Latent phase
+
plotting will remain on or to the left
+
of the alert line.
+

+
+

If labour is not progressing

normally the plotting will be to the
right of the alert line.
 PARTOGRAM RECORDING

LABOUR PATTERNS

Active phase
Latent phase
Normal labour

Prolonged latent phase

Primary dysfunctional
labour

Secondary arrest
MANAGEMENT OF THE SECOND STAGE

Principles: To assist in the natural expulsion of

the fetus slowly and steadily. To prevent perineal
injuries.
• 1. Constant supervision is mandatory and the
FHR is recorded at every 2-5 minutes
• 2. Vaginal examination is done at the
beginning of the 2nd stage not only to confirm
its onset but to detect any accidental cord
prolapse.
 MANAGEMENT OF THE SECOND STAGE
• 3. The position of the women during delivery may
be lateral, dorsal or partial sitting.
• 4. As the multiparous patient approaches
complete dilatation or as the nulliparous patient
begins to crown the fetal scalp, preparations made
for delivery.
• 5. Delivery of the head. The fetal head is delivered
by extension as the flexed head passes through the
vaginal introitus. Once the fetal head has been
delivered, external rotation to the occiput
transverse position occurs.
 THIRD STAGE OF LABOR
• Separation of placenta.
• Because the fetus in no longer in the uterus, the
extent of the retraction of the upper segment is larger
than during the first and second stage.
• This retraction decreases greatly the area where the
placenta is attached.
• During the process of separation blood (retroplacental
hematoma) accumulates between the placenta and
uterus. When the detachment is complete the blood
is realize and gushes from the vagina.
 THIRD STAGE OF LABOR
There are two ways of separation of placenta:
1. Central separation (Schultz): detachment of
placenta from its uterine attachment starts at the
center resulting in opening up of the few uterine
sinuses and accumulation of blood behind the
placenta (retroplacental hematoma).
2. Separation starts at the margin of the placenta.
Within progressive uterine contraction, more and
more areas of the placenta get separated.
 Active management of 3rd stage
1. To excite powerful uterine contractions
following birth of the anterior shoulder by
parental oxytocin that produce effective
uterine contraction following its
separation.
2. Then the deliver the placenta by
controlled tractions soon after the delivery
of the baby availing 1st uterine
contraction.
 Management of 3rd stage
Examination of the placenta.
The maternal surface is first inspected for its
completeness and anomalies.
The membranes and placenta are to be examined
carefully for completeness and presents of abnormal
vessels indicative of succenturiate lobe.

• Vulva, vagina and perineum are inspected carefully for

injuries and to be repaired, if any. The vulva is cleaned
with cotton swabs soaked in antiseptic solutions.
 Neonatal Care
• Reassess Airway and Respirations
• Keep warm and dry
• Eye drops (1% silver nitrate or Neosporin)
• Allow for maternal bonding
• Stimulation of nipples during attempts at
breastfeeding will aid in release of oxytocin by
posterior pituitary gland resulting in uterine
contraction and hemorrhage control
 APGAR
• Taken at 1 minute and 5 minutes after delivery
• Score of zero to two is given for each category
• The higher the score, the more vigorous and
“healthy” the child is considered to be
 APGAR
• APPEARANCE:
– 2: Completely Pink
– 1: Hands and Feet are blue
– 0: Paleness and blue color over entire body
• PULSE: (most important sign)
– 2: Greater than 100 BPM
– 1: Detectable rate below 100 BPM
– 0: No heart rate detected
 APGAR
• GRIMACE: (flexing and muscle tone of limbs and
resistance to straightening)
– 2: Normal muscle tone
– 1: Limp to normal muscle tone
– 0: No resistance to straightening
• ACTIVITY: (response to flicking of foot)
– 2: Infant cries in response to flick
– 1: Weak cry or head movement in response
– 0: No response
 APGAR
• RESPIRATORY: (Second most important)
– 2: Regular respirations and vigorous cry
– 1: Weak cry
– 0: No respiratory response
• Scoring:
– 7 to 10 provide supportive care
– 4 to 6 indicates moderate depression
– < 4 requires aggressive resuscitation