S. Time Specific Content A.V.

Teacher’s Learner’s Evalua

No. Objectives Aids Activity Activity tion

ASSESSMENT AND MANAGEMENT OF INTRANATAL PERIOD

TERMINOLOGIES
 LABOUR: Series of event that takes place in the genital organs in an effort to expel the viable products of
conception out of the world through the vagina into the outer world
 MINI LABOUR: Expulsion of previable live fetus occurs through the same process but in a mini mature form
 DELIVERY: It is the expulsion or extraction of a viable fetus out of the womb. Delivery can take place without
labour as in CS. It may be vaginal,spontaneous, aided or abdominal.
 PRETERM LABOUR: Labour occurs in prior to 37 completed weeks of gestation
 PARTURIENT: It is a patient in labour
 PARTURITION: It is a process of giving birth.
 NORMAL LABOUR(EUTOCIA): Labour is called normal if it fulfills the following criteria
 Spontaneous in onset and at term.
 With vertex presentation
 Without undue prolongation
 Natural termination with minimal aids
 Without causing any complications affecting the health of the mother or baby.
 ABNORMAL LABOUR (DYSTOCIA):Any deviation from the definition of normal labor, that is labour in a
case with presentation other than vertex or having some complication even with vertex presentation affecting the
course of labour or modifying the nature of termination of pregnancy or adversely affecting the maternal or fetal
prognosis.
 LIGHTENING: Few weeks prior to the onset of labour specially in primigravida, the
Presenting part sinks into the true pelvis. This is due to active pulling up of the lower pole of the uterus around the
presenting part. This diminishes the fundal height and hence minimizes the pressure on the diaphragm.
 SHOW: Expulsion of cervical mucus plug mixed with blood with onset of labour.
 RETRACTION: It is a phenomenon of the uterus in labour in which the muscle fibers are permanently
shortened.
 FALSE PAIN/LABOUR PAIN: The pain that are commonly occur in primigravida women’s due to stretching
of the cervix and lower uterine segment with consequent irritation of the neighboring ganglia .
 CERVICAL RIPENING: Softening of the cervix. Its position become central and 1-2cm dilation along with
shortened length of cervix.
CAUSES OF ONSET OF LABOUR

?????/X FACTOR

ACTIVATION OF FETAL
HYPOTHALAMO PITUITORY PLACENTA
CORTISOL
AXIS

MATERNAL POSTERIOR PITUITORY ALTERED BALANCE

OXYTOCIN PLACENTA, AMNION, CHORION, DECIDUA

OESTROGEN PROGESTRONE

OXYTOCIN PGE2 PGF2 ALPA

ACTIVATION OF MYOMETRIAL CONTRACTILE SYSTEM

 UTERINE CONTRACTION: Stretching effect on the myocardium by the growing fetus and liquor amni.
 FETOPLACENTAL CONTRIBUTION: Activation of fetal hypothalamic pituitary adrenal axis.
 OESTROGEN:
 Increases the releases of Oxytocin from maternal pituitary
 Promotes the synthesis of myocardial receptors for Oxytocin.
 Stimulates the synthesis of myocardial contractile protein.
 Increases the excitability of the myometrial cell membranes.
 PROSTOGLANDINS: It initiate and maintain labour
 PROGESTRONES: Increases fetal production of dehydroepiandrosterone sulphate (DHEA-S) and cortisol. It
inhibit the conversion of fetal prednisolone to progesterone. Progesterone level therefore falls before labour.
CHARECTERISTICES OF TRUE AND FALSE LABOUR PAIN
TRUE LABOUR PAIN
 Uterine contraction at regular interval
 Frequency of contraction increases gradually
 Intensity and duration of contraction increases gradually
 Associated with show
 Progressive effacement and dilatation of cervix
 decent of presenting part
 formation of bag of water
 not relieved by enema or sedative
FALSE LABOUR PAIN
 Dull in nature
 Confined to lower uterine segment and groin
 Not associated with hardening of the uterus
 Usually relieved by enema or sedative
STAGES OF LABOUR
 FIRST STAGE (CERVICAL STAGE): It starts from onset of true labour pain and ends with full dilatation of the
cervix. Its average duration is 12 hrs in primigravida and 6 hrs in multigravida.
 SECOND STAGE: It starts with full dilatation of cervix (not from the rupture of membranes) and ends with
expulsion of the fetus from the birth canal. Its average duration is 2 hrs in primigravida and 30 minutes in
multigravida. It has 2 phases:
 Propulsive phase-starts from full dilatation upto the descent of the presenting part to the pelvic floor.
 Expulsive phase-distinguished by maternal bearing down efforts and end with delivery of the baby
 THIRD STAGE: It starts with birth of the baby and ends with the complete expulsion of the placenta and
membranes. The average duration is 10-15 minutes.
 FOURTH STAGE: It is the golden hour and it is the observation stage lasts four 1 hr after expulsion of placenta.

PHYSIOLOGY OF NORMAL LABOUR

UTERINE CONTRACTIONS IN LABOUR

In the presence of oestrogen a impulse generated

Alters the electrical potential of cell membranes

Entry of ca ions into the muscle cells

Increased concentration of intracellular free calcium

Calcium binds with cytoplasmic protein calmodulin

Activation of myosin filaments actin and myosin

(convertion of ATP To ADP)
SHORTENING OF MUSCLE FIBER AND CONTRACTION
During contraction uterus become hard and pushed anteriorly to make the long axis of the uterus with that of
pelvic axis. Simultaneously the patient experiences pain. Probable causes for pain are
 myometrial hypoxia
 stretching of the peritoneum over the fundus
 stretching of the uterus during dilatation
 compression of the nerve ganglion
 contraction is distributed along the cutaneous nerve distribution of T10 to L1
TONUS: It is the intrauterine pressure in between contractions .During pregnancy it is 2-3mmHg, and first stage 8-10mm
of Hg
DURATION: In the first stage the contractions lasts for 30 sec initially and increases in duration with progress of labour.
FREQUENCY: In early stages of labour the contractions comes at interval of 10 to 15 mts and shortened in second stage
at every 2-3 mts.
RETRACTION: The net effect of retraction includes
 To reduces the surface area of the uterus favoring separation f placenta.
 Effective haemostatics after the separation of placenta.

EVENTS IN FIRST STAGE OF LABOUR

The main events in the first stage of labour include:
 Dilatation
 Effacement of cervix
 Full formation of lower uterine segment

 DILATATION
Predisposing factors that favour smooth dilatation are:
o Softening of the cervix
o Fibromusculo-glandular atrophy
o Increased vascularity
o Accumulation of fluid in between collagen fibers
Actual factors responsible for dilatation are:
o UTERINE CONTRACTION AND RETRACTION
The longitudinal muscle fibers of the upper segment are attached with circular muscle fibers of the lower
segment and upper part of the cervix in a bucket holding fashion. There is some co-ordination between
fundal contraction and cervical dilatation called polarity of the uterus. While the upper segment contracts,
retracts and pushes the fetus, the lower segment and the cervix dilate in response to the force of contraction
of the upper segment.
o BAG OF MEMBRANES
The membranes (amnion and chorion) are attached loosely to the decidua lining the uterine cavity except
over the internal os. In vertex presentation, the gridle of contact of the head (which first comes in contact
with pelvic brim) being spherical may well fit with the wall of the lower uterine segment. The amniotic
cavity is divided into two compartments. The part above the gridle of contact contain the fetus with bulk of
liquor called hindwaters and below contain small amount of liquor called forewater. With rise of intra
uterine pressure during contractions there is herniation of membranes through the cervical canal.
o FETAL AXIS PRESSURE
In labour with longitudinal lie, there is tendency of straightening out of the fetal vertebral column due to
contraction of circular muscles of the body of the uterus. This allows the mechanical stretching of the lower
uterine segment and opening up of the cervical canal.

 EFFACEMENT OF CERVIX
It is a process by which the muscular fibers of the cervix are pulled upward and merges with the fibers of the
lower uterine segment. The cervix becomes thin during first stage of labour or even before that in primigravida.
 FULL FORMATION OF LOWER UTERINE SEGMENT
During labour ,the demarcation of an upper segment and a relatively passive lower segment is more pronounced.
The wall of the upper segment become progressively thickened and progressive thinning of the lower segment. This
is pronounced at the late first stage, specially after rupture of the membranes and attains its maximum in 2nd stage. A
distinct ridge is produced at the junction of the two, called physiological retraction ring.
 CLINICAL COURSE OF FIRST STAGE OF LABOUR
The first symptom to appear is intermittent painful contractions followed by expulsion of blood stained mucus
(show) per vaginum.
PAIN: The pain is felt more anteriorly with simultaneous hardening of the uterus. Initially, the pain are not enough to cause
discomforts and comes at varying interval of 15-30 mts with duration of 30 sec. In normal labour, pains are usually felt
shortly after the uterine contractions begin and pass off before complete relaxation of the uterus. Clinically the pains are
said to be good .if they comes at an interval of 3-5 minutes and at the height of contraction the uterine wall cannot be
intended by the fingers.
DILATATION AND EFFACEMENT OF CERVIX: Cervical dilatation relates with dilatation of the external os and
effacement is determined by the length of the cervical canal in vagina. The anterior lip of the cervix is the last to be effaced.
The first stage is said to be completed only when the cervix is completely retracted over the presenting part during
contractions. Cervical dilatation is expressed in terms of centimeters (10cm if fully dilated in vertex presentation) and 1
finger equals 1.6cm.Dilatationof cervix at the rate of 1cm per hr in primigravida and 1.5cm per hr multigravida beyond 3cm
(active phase of labour is satisfactory).
STATUS OF MEMBRANES: It remains intact until full dilatation of cervix or sometimes beyond in second stage.
Rupture after onset of labour and before full dilatation of cervix called early rupture and before onset of labour called
premature rupture.
MATERNAL SYSTEM: Pulse rate increased by 10-15 beats per minute during contraction which settles down to previous
rate in between contractions. Systolic blood pressure is raised by 10mmHg during contractions. Temperature remains
unchanged.
FETAL EFFECT: During contraction there may be slowing of fetal heart rate of about 10-20 beats/ mt which soon returns
to normal rate at about 140 per mts as the intensity of contraction diminishes.
PARTOGRAPHY
This concept was introduced by Friedman in New York in 1954. It is a composite graphical record of key
data (maternal and fetal) during labour, entered against time on a single sheet of paper.
GRAPHICAL ANALYSIS OF LABOUR
The first stage of labour (onset of labour to full dilatation of cervix) is divided into 2 periods.
Latent phase: It begins with onset of labour and lasts until the beginning of the active phase of cervical
dilatation. At the end of latent phase the cervix is around 3 cm dilated, well effaced and soft.
Active phase: This phase lasts from the end of latent phase to the full dilatation of cervix. It consist of
two parts
 Alert line: Starts at 3cm dilatation and ends at 10cm dilatation (1cm/hr).
 Action line: It is drawn 3-4 hrs to the right and parallel to the alert line.
In normal labour, cervicograph should be either on the alert line or to the left of it.
COMPONENTS OF PARTOGRAPH
 Patient identification
 Fetal heart rate recorded in every 30 mts
 Liquor amni and membranes: I for intact C for clear and for Meconium stained.
 Uterine contractions
 Drugs and fluids
 Blood pressure
 Oxytocin
 Urine analysis
 Temperature
ADVANTAGES
 A single sheet of paper can provide detail of necessary information at a glance.
 No need to record labour events repeatedly
 It can predict deviation from normal progress of labour early.
 Introduction of partograph in management of labour has reduced the incidence of prolonged labour
and caesarian rates.
MANAGEMENT OF LABOUR

PRINCIPLES
Delivery of a normal healthy child with minimal physical discomforts to the mother
To recognize potentially abnormal condition and treat them before any significant danger develops for the mother or
the baby during the course of labour
ADMISSION
The admission procedure is discussed with the patient during the course of antenatal care. She should be well –
conversant with the hospital formalities and the location of the delivery unit.
EXAMINATION OF PATIENT IN LABOUR
 The lie, presentation and position of the fetus
 The attitude and the level of the presenting part and its relationship to the pelvis
 The presence and the character of the fetal heart sounds
VAGINAL EXAMINATION IN LABOUR
It should be performed as soon as it ia convenient after admission. Periodic vaginal examinations are indicated in labour.
 To assess progress of labour 2-4 hr intervals.
 Whenever the membranes rupture, to exclude cord prolapse
 As soon as patient starts bearing down efforts confirm full dilatation
Procedure
It is near to follow the same antiseptic ritual for a vaginal examination in labour as in any other operative procedure. After
scrubing,sterile gloves are worn and the vulva is cleaned with a swab soaked in a mild antiseptic lotion (dettol 5% or
cetavlon).The index and the middle finger of the glover right hand is negotiated carefully in the vagina after being
moistened with an anteseptic cream (dettol cream /lubricant jelly).
The following features are recorded during vaginal examination:
 Cervix: The effacement, dilatation consistency and how it is applied to the presenting part.
 Membranes: intact or ruptured and the formation of bag of waters when intact
 Liquor : colour of liquor if amnions have ruptured
 Fetus: The presenting part and its position ,station in relation to the ischial spines, molding and caput formation.
 Pelvis: assessment of the pelvis, mainly in the primigravida
 Abnormalities: cord prolapse and cord presentation ,any abnormalities in the vagina
 MANAGEMENT OF FIRST STAGE OF LABOR
PRINCIPLES
 Non interference with watchful expectancy
 Monitor carefully the progress of labour
PRELIMINARIES
This consists of evaluation of current clinical condition. General, physical and obstetrical examinations and evaluation of
antenatal visits, investigation reports.

As soon as possible after admittance, the remainder of the general examination is completed. A clinician can
best reach a conclusion about the normalcy of the pregnancy when all examinations, including record and laboratory
review, are completed. A rational plan for monitoring labor then can be established based on the needs of the fetus and the
mother. Because there are marked individual variations in lengths of labor, precise statements as to its anticipated duration
are unwise.
Monitoring Fetal Well-Being during Labor
During the first stage of labor, in the absence of any abnormalities, the fetal heart rate should be checked immediately after
a contraction at least every 30 minutes and then every 15 minutes during the second stage. If continuous electronic
monitoring is used, the tracing is evaluated at least every 30 minutes during the first stage and at least every 15 minutes
during second-stage labor. For women with pregnancies at risk, fetal heart auscultation is performed at least every 15
minutes during the first stage of labor and every 5 minutes during the second stage. Continuous electronic monitoring may
be used with evaluation of the tracing every 15 minutes during the first stage of labor, and every 5 minutes during the
second stage.
Uterine Contractions
Although usually assessed by electronic monitoring as also discussed in Chapter 18, contractions can be both quantitatively
and qualitatively evaluated manually. With the palm of the hand resting lightly on the uterus, the time of contraction onset
is determined. Its intensity is gauged from the degree of firmness the uterus achieves. At the acme of effective contractions,
the finger or thumb cannot readily indent the uterus during a “firm” contraction. The time at which the contraction
disappears is noted next. This sequence is repeated to evaluate the frequency, duration, and intensity of uterine contractions.
Maternal Vital Signs
Temperature, pulse, and blood pressure are evaluated at least every 4 hours. If membranes have been ruptured for many
hours before labor onset or if there is a borderline temperature elevation, the temperature is checked hourly. Moreover, with
prolonged membrane rupture, defined as greater than 18 hours, antimicrobial administration for prevention of group B
streptococcal infections is recommended.
Subsequent Vaginal Examinations
During the first stage of labor, the need for subsequent vaginal examinations to monitor cervical change and presenting part
position will vary considerably. When the membranes rupture, an examination should be performed expeditiously if the
fetal head was not definitely engaged at the previous vaginal examination.This excludes umbilical cord prolapse. The fetal
heart rate should also be checked immediately and during the next uterine contraction to help detect occult umbilical cord
compression.
Oral Intake
Food should be withheld during active labor and delivery. Gastric emptying time is remarkably prolonged once labor is
established and analgesics are administered. As a consequence, ingested food and most medications remain in the stomach
and are not absorbed. Instead, they may be vomited and aspirated sips of clear liquids, occasional ice chips, and lip
moisturizers are permitted.
Intravenous Fluids
Although it has become customary in many hospitals to establish an intravenous infusion system routinely early in labor,
there is seldom any real need for such in the normal pregnant woman at least until analgesia is administered. An
intravenous infusion system is advantageous during the immediate puerperium to administer oxytocin prophylactically and
at times therapeutically when uterine atony persists. Moreover, with longer labors, the administration of glucose, sodium,
and water to the otherwise fasting woman at the rate of 60 to 120 mL/hr prevents dehydration and acidosis. Labor lasted
morethan 12 hours in significantly more (26 versus 13 percent) of the women given a 125 mL/hr infusion compared with
those given 250 mL/hr—26 versus 13 percent, respectively.
Maternal Position
The normal laboring woman need not be confined to bed early in labor. A comfortable chair may be beneficial
psychologically and perhaps physiologically. In bed, the laboring woman should be allowed to assume the position she
finds most comfortable— this will be lateral recumbency most of the time. She must not be restricted to lying supine
because of resultant aortocarval compression and its potential to lower uterine perfusion
Analgesia
In general, pain relief should depend on the needs and desires of the woman.
Amniotomy
If the membranes are intact, there is a great temptation, even during normal labor, to perform amniotomy. The presumed
benefits are more rapid labor, earlier detection of meconium-stained amnionic fluid, and the opportunity to apply an
electrode to the fetus or insert a pressure catheter into the uterine cavity for monitoring.
Urinary Bladder Function
Bladder distension should be avoided because it can hinder descent of the fetal presenting part and lead to subsequent
bladder hypotonia and infection. During each abdominal examination, the suprapubic region should be inspected and
palpated to detect distension. If the bladder is readily seen or palpated above the symphysis, the woman should be
encouraged to void. At times, she can ambulate with assistance to a toilet and successfully void, even though she cannot
void on a bedpan. If the bladder is distended and she cannot void, catheterization is indicated.