8 Normal Labour and Puerperium

THE UNITED REPUBLIC OF TANZANIA
MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND

CHILDREN
DIRECTORATE OF HUMAN RESOURCE DEVELOPMENT
FACILITATOR’S GUIDE FOR TECHNICIAN CERTIFICATE

IN NURSING AND MIDWIFERY
NTA LEVEL 5
NMT 05208: Care of a Woman in Normal

Labour and Puerperium
© Ministry of Health, Community Development, Gender, Elderly and Children, Department of Human Resources
Development Nursing Training Section 2018, Dodoma, Tanzania
NMT 05208: Care of a Woman in Normal Labour and Puerperium ii

Table of Contents
Acronyms................................................................................................................................................. iv
Preamble.................................................................................................................................................. v
Acknowledgement....................................................................................................................................vi
1.0. Background...................................................................................................................................vii
2.0. Rationale.......................................................................................................................................vii
3.0. Goals and Objectives of the Training Manual..............................................................................viii
3.1. Overall Goal for Training Manual.................................................................................................viii
3.2. Objectives for Training Manual.................................................................................................... viii
4.0. Introduction.................................................................................................................................. viii
4.1. Module Overview......................................................................................................................... viii
4.2. Who is the Module For?...............................................................................................................viii
4.3. How is the Module Organized?....................................................................................................viii
4.4. How Should the Module be Used?................................................................................................ix
SESSION 1: CARE OF A PREGNANT WOMAN IN FIRST STAGE OF LABOUR................................10
SESSION 2: CARE OF A PREGNANT WOMAN IN LABOUR USING PARTOGRAPH.........................21
SESSION 3: CARE OF A PREGNANT WOMAN IN SECOND STAGE OF LABOUR............................30
SESSION 4: CARE OF A WOMAN WITH PERINEAL TEAR AND EPISIOTOMY.................................38
SESSION 5: CARE OF A WOMAN IN THE THIRD AND FOURTH STAGE OF LABOUR....................45
SESSION 6: CARE OF A WOMAN IN NORMAL PUERPERIUM..........................................................55
NMT 05208: Care of a Woman in Normal Labour and Puerperium iii

Acronyms
AGYW Adolescents Girl and Young Women
AIDS Acquired Immune Deficiency Syndrome
AIHA American International Health Alliance
ARV Antiretroviral
CDC Center for Disease Control
EVD Ebora Virus Disease
HQAU Health Quality Assurance Unit
HRH Human Resources for Health
KCMC Kilimanjaro Christian Medical College
MBM-RTz More and Better Midwives for Rural Tanzania
MOHCDGEC Ministry of Health, Community Development, Gender
MUHAS Muhimbili University of Health and Allied Sciences
NACTE National Council for Technical Education
NTA National Technical Award
PHCDP Primary Health Care Development Program
VMMC Voluntary Medical Male Circumcision
WHO World Health Organization
NMT 05208: Care of a Woman in Normal Labour and Puerperium iv

Preamble
The Ministry of Health Community Development Gender Elderly and Children among other roles
ensures that Tanzanians receive quality health care and service. This can be achieved through
production of competent nurses and midwives amongst other health cadres. The training of competent
nurses and midwives can be achieved through various teaching and learning materials; one of them
being facilitator’s guides and student’s manuals.
The directorate of human resources development in collaboration with partners conducted several
writers’ workshops to develop facilitator’s guides and student’s manuals. The availability of
standardized teaching and learning materials that is to say facilitator’s guides and student’s manual
enables proper acquisition of competence with minimal variation across health training institutions. The
achievement of clinical competence is acquired in step wise starting from classroom teaching using
facilitator’s guides and student’s manuals. This knowledge is then transferred to skills laboratory
teachings. In skills laboratory students learn clinical skills using models and maniquins and then shift to
clinical sites where more clinical skills on real patients are acquired. Clinical skills acquisition is an
important aspect and a bridge between gaining knowledge and clinical skills.
The increased demand for human resources for health to improve reproductive, maternal, newborn
child and adolescent health requires a thoughtful investment of human resources for health (HRH) on
the production side. The current approach of health service provision in support of task sharing, the
nurses and midwives are becoming the key ingredient for improving specific and general morbidity and
mortality indexes this includes maternal and newborn mortality rates and reducing the HIV and AIDs
burden through prevention, care & treatment. So it is necessary for them to be equipped with strong
knowledge, skills and attitudes upon their graduation. This will then improve the access to health
services to the community in which most of them are with limited purchasing power, residence in
underserved areas, and inadequate health literacy.
Considering the importance of facilitator’s guides and student’s manuals, it’s the hope of the Ministry
that tutors in nursing and midwifery health training institutions will use these guides as in fostering
acquisition of competence to learners of National Technical Award of education system of education.
Dr. Loishook Saitore Laizer

Director for Human Resource Development
Ministry of Health, Community Development, Gender, Elderly and Children
NMT 05208: Care of a Woman in Normal Labour and Puerperium v

Acknowledgement
Ministry of Health, Community Development, Gender, Elderly and Children through the Directorate of
Human Resource Development, Nursing training section has reviewed Facilitator’s guide for Nursing
and Midwifery training program. The review was informed by revised curriculum of the same. The
successfully completion of this facilitator’s guide has been made possible by the commitment of the
technical team through a series of writers’ workshops. Understanding the crucial role of the team, the
Ministry would like to express sincere appreciation to all those who involved in the completion of this
task.
Special gratitude goes to coordinators of Nursing and Midwifery training, technical expert from NACTE
and other facilitators who tirelessly supported the development of this guide whose names are listed
with appreciation:-
SN FULL NAME INSTITUTION/ORGANIZATION

1. Ndementria Vermand ADNT-MOHCDGEC-Dodoma
2. Nassania Shango CDNT -MOHCDGEC-Dodoma
3. Dr. Talhiya Yahya HQAU- MOHCDGEC-Dodoma
4. Dr. Omary Nassoro HQAU- MOHCDGEC-Dodoma
5. Professor Eliezer Tumbwene Lecturer -Aga Khan University
6. Ramadhani Samainda NACTE-Dodoma
7. Dr. Patrick Mwidunda Program Manager-Amref Health Africa
8. Lupyana Kahemela Program Officer-Amref Health Africa
9. Joseph Pilot ICT Officer- Amref health Africa
10. Dr. Julius Masanika Program Director-Jhpiego-MBM-RTz
11. Dr. Wilson Kitinya Deputy Program Director-Jhpiego-MBM-RTz
12. Mary Rwegasira Senior- Gender Advisor-Jhpiego-MBM-RTz
13. Ukende Shalla Senior Midwifery Advisor-Jhpiego-MBM-RTz
14. Benison Muchunguzi Technical Officer-Jhpiego-MBM-RTz
15. Harriet Hamis Jhpiego-MCSP
16. Happiness Shetui Jhpiego-MBM-RTz
17. Theresia Venance Technical Officer-Gender-Jhpiego-MBM-RTz
18. Sarah George Program Assistant-Jhpiego-MBM-rtz
19. Miraji A. Mawaka Tutor-Military College of Medical Science Lugalo
20. David Abincha Tutor –Sumve School of Nursing
21. Bupe Mwandali Ass. Lecturer –Hubert Kairuki Memorial University
22. Mary Kipaya Principal- Kahama School of Nursing
23. Mwanaaisha Fakhi Tutor-State University of Zanzibar
24. Paul Magesa Ag. Principal –Newala School of Nursing
25. Dominic Daudi Tutor –Newala School of Nursing
26. Dr. Beatrice Mwilike Lecturer-MUHAS
27. Lilian Wilfred Tutor KCMC School of Nursing
28. Upendo Mamchony Tutor KCMC School of Nursing
29. Tito William Nurse Officer Muhimbili National Hospital
30. Sixtus Ruyumbu Nurse Officer- Mbeya Refferal
31. Dr Lenatus Kalolo Medical Specialist-Mbeya Refferal
32. Emmanuel Mwakapasa Principal Mbeya –OTM
33. Ruth Mkopi Senior Research Officer TFNC
NMT 05208: Care of a Woman in Normal Labour and Puerperium vi
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34. Salma Karim Tutor- Dodoma Institute of Health and Allied Sciences
35. Athanas Paul Principal- Dodoma Institute of Health and Allied Sciences
36. Dr. Jiyenze Mwangu Kini Tutor –CEDHA
37. Joseph Mayunga Tutor- Kisare
38. Elizabeth Kijugu Principal-Kairuki School of Nursing
39. Charles Magwaza Principal Njombe School of Nursing
40. Alphonce Kalula ECSA
41. Meshack Makojijo Tutor Bugando School of Nursing
42. Stellah Kiwale Tutor- PHN Morogoro
43. Evance Anderson Tutor Geita School of Nursing
44. Juliana Malingumu Tutor Mchukwi School of Nursing
45. Rehema Mtonga Tutor –Dar- es- Salaam
46. Masunga Isassero Assistant Lecturer –MUHAS
47. Paulo Masika Lyimo Tutor –Huruma Health training institute
48. George Muro Tutor -Arusha Lutheran Medical Centre
49. Fredina Rweyemamu Principal -Same School of Nursing
50. James Marwa Tutor-Tarime School of Nursing
51. Nturu Simwanza Tutor-Kondoa School of Nursing
52. Everlasting Lema Tutor-Machame Health Training Institute
53. Rackel Masibo Ag. Dean-St. Johns University
54. Shamila Mwanga Nursing Officer-Muhimbili National Hospital
55. Dr. Stephen Mwaisobwa Clinician-Chamwino DC
56. Evarist Urassa Tutor -KCMC School of Ophthalmic
57. Madia Petro Tutor-Edgar Maranta School of Nursing
58. Sr. Vincenzo Malale Principal-Edgar Maranta School of Nursing
59. Edwin Mkwama Tutor-Centre for Distance Education
60. Elizabeth Mwakalinga Tutor-Muhimbili School of Nursing
61. Mariam Barabara Tutor-KCMC School of Nursing
62. Lucas Edward ICT Officer-National Institute of Transport
63. Mbaruku Luga Driver-Mirembe School of Nursing
Lastly would like to thank the collaboration and financial support from Amref Health Africa and Jhpiego
through More and Better Midwives for rural Tanzania and Maternal and Child Survival programs who
made this task successfully completed.
Ndementria Arthur Vermand

Assistant Director Nursing Training Section,
NMT 05208: Care of a Woman in Normal Labour and Puerperium vii
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1.0. Background
In 2015 the Ministry of Health, Community Development, Gender, Elderly and Children through the
Directorate of Human Resource Development, Nursing training section started the process of reviewing
the nursing and midwifery curricula NTA level 4-6. The process completed in the year 2017, its
implementation started in the same year. The rationale for review was to comply with the National
Council for Technical award (NACTE) Qualification framework which offers a climbing ladder for higher
skills opportunities. Amongst other rationale was to meet the demand of the current health care service
delivery. The demand is also aligned with human resource for health strategic plan and human
resource for health production plan which aims at increasing number of qualified human resource for
health.
The process of producing qualified human resources for health especially nurses and midwives require
the plentiful investment of resources in teaching at the classroom and practical setting and the
achievement of clinical competence is acquired in stepwise starting from classroom teaching to skills
laboratory teaching. In addition, WHO advocates for skilled and motivated health workers in producing
good health services and increase the performance of health systems (WHO World Health Report,
2006). Moreover, Primary Health Care Development Program (PHCDP) (2007-15) needs the nation to
strengthen and expand health services at all levels. This can only be achieved when the Nation has an
adequate, appropriately trained and competent workforce who can be deployed in the health facilities to
facilitate the provision of quality health care services.
In line with the revised curricula, the MOHCDGEC in collaboration with developing partners and team of
technical staff developed quality standardized training materials to support the implementation of
curricula. These training materials address the foreseen discrepancies in the implementation of the
curricula by training institutions.
This facilitator’s guide has been developed through a series of writers’ workshops (WW) approach. The
goal of Writer’s Workshops was to develop high-quality, standardized teaching materials and to build
the capacity of tutors to develop these materials. The new training package for NTA Level 5 includes
twelve (12) a Facilitator’s Guides and Student’s Manuals. This guide consists of 6 sessions aimed at
equipping learners with required competences in providing Care of a Woman in Normal Labour and
Puerperium
2.0. Rationale
The vision and mission of the National Health Policy in Tanzania focuses on establishing a health
system that is responsive to the needs of the people and leads to improved health status for all. Skilled
and motivated health workers are crucially important for producing good health by increasing the
performance of health systems (WHO, 2006). With limited resources, the MoHCDGEC supported tutors
by developing standardized training materials to accompany the implementation of the developed
CBET curricula. These training manuals address the foreseen discrepancies in the implementation of
the new curricula.
Therefore, this guide for Technician Certificate in Nursing and Midwifery (NTA Levels 5) aims at
providing a room for student Nurses and Midwives to achieve skills that will enable them to perform
competently. It will establish a conducive and sustainable training environment that will allow students
and graduates to perform efficiently at their relevant levels. Moreover, this will enable them to aspire for
the attainment of higher knowledge, skills and attitude in promoting excellence in nursing practice.
NMT 05208: Care of a Woman in Normal Labour and Puerperium viii
viii
3.0. Goal and Objectives of the Facilitators Guide
3.1. Overall Goal for Facilitator’s Guides
The overall goal of this guide is to provide high quality; standardized competence based training
materials for Technician Certificate in Nursing and Midwifery (NTA level 5) program.
3.2. Objectives for the Facilitator’s Guide

• To provide high quality, standardized and competence-based training materials.
• To provide a guide for tutors to deliver high quality training materials.
• To enable students to learn more effectively.
4.0. Introduction
4.1. Module Overview
This module content has been prepared as a guide for tutors of NTA Level 5 for training students. The
session contents are based on the sub-enabling outcomes of the curriculum for NTA Level 5
Technician Certificate in Nursing and Midwifery The module sub-enabling outcomes are as follows:
1.2.1 Provide care to woman in first stage of labour according to set standards and guidelines.
1.2.2 Manage a woman in second stage of labour according to guidelines and Standards
1.2.3 Manage a woman in third and fourth stages of labour according to guidelines and protocols
1.2.4 Provide care to a woman in puerperium according to guidelines
4.2. Who is the user of the Guide?

This guide is intended for use primarily by tutors of NTA Level 5, Technician Certificate in Nursing and
Midwifery schools.
The module’ sessions give guidance on the time and activities of the session and provide information
on how to facilitate the session to students. The sessions include different activities that focus on
increasing students’ knowledge, skills and attitudes.
4.3. How is the Module Organized?

The module is divided into sessions; each session is divided into sections. The following are the
sections of each session:
 Session Title: The name of the session.
 Learning Tasks – Statements which indicate what the student is expected to learn by the end of the
session.
 Session Content – All the session contents are divided into steps. This section includes instructions
for the tutor and activities with their instructions to be done during teaching of the contents.
 Key Points – Each session has a step which concludes the session contents near the end of a
session. This step summarizes the main points and ideas from the session.
 Evaluation – The last section of the session consists of short questions based on the learning
objectives to check the understanding of students.
 References: At the end of each session references have been provided for further reading.
 Handouts:- Some session have additional information which can be used in the classroom while
teaching or later for students’ further learning. Handouts are used to provide extra information
related to the session topic that cannot fit into the session time. Handouts can be used by the
Students to study material on their own and to reference after the session. Sometimes, a handout
will have questions or an exercise for the Students. The answers to the questions are in the
Facilitator Guide Handout, and not in the Student Manual Handout.
NMT 05208: Care of a Woman in Normal Labour and Puerperium ix
ix
4.4 How should the Guide be used?
Facilitators are expected to use this guide while facilitating students learning both in the classroom and
clinical settings. The contents of this guide are the basis for teaching students Care of a Woman in
Normal Labour and Puerperium Facilitators are therefore advised to use each session and the relevant
handouts and worksheets during class hours, clinical hours and self-study times. Facilitators will
provide guidance and respond to all difficulties encountered by students
NMT 05208: Care of a Woman in Normal Labour and Puerperium x
x
Acronyms
AIDS Acquired Immune Deficiency Syndrome
AIHA American International Health Alliance
ARV Antiretroviral
VMMC Voluntary Medical Male Circumcision
WHO World Health Organization
NMT 05208: Care of a Woman in Normal Labour and Puerperium xi
xi
Preamble
The Ministry of Health Community Development Gender Elderly and Children among other roles
ensures that Tanzanians receive quality health care and service. This can be achieved through
production of competent nurses and midwives amongst other health cadres. The training of competent
nurses and midwives can be achieved through various teaching and learning materials; one of them being
facilitator’s guides and student’s manual.
The challenges of today in nursing profession include among others, the preparation of the competent
nurses and midwives to meet the current and future complex clients’ needs. Therefore, the provision of
quality training to learners in nursing and midwifery is crucial in achieving the intended exit outcomes.
Therefore monitoring of the learners acquisition of practical competences is the cornerstone for judging
effectiveness of the programme. A logbook serves as a key instrument for monitoring the ability of the
learner towards deliberation of the expected quality of care to all clients in all areas of health care
services. The current logbook has taken into consideration the competencies stipulated in the revised
curriculum in order to meet the current societal, institutional and professional needs.
This Practical Experience Logbook is deemed to be an important tool to verify learners’ acquisition of
the necessary competences needed for the provision of quality health care services. Furthermore, it is
anticipated to also be used by other stakeholders of health care delivery industry in verifying the ability
of the graduate to deliver respected health care.
Dr. Loishook Saitrori

Director for Human Resource Development
NMT 05208: Care of a Woman in Normal Labour and Puerperium xii
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Acknowledgement
Ministry of Health, Community Development, Gender, Elderly and Children through the Directorate of
Human Resource Development, Nursing training section Developed Student’s manual for Nursing and
Midwifery training program. The development was informed by revised curriculum of the same. The
successfully completion of student’s manual have been made possible by the commitment of the
technical team through a series of writers’ workshops. Understanding the crucial role of the team, the
Ministry would like to express sincere appreciation to all those who involved in the completion of this
task.
Special gratitude goes to coordinators for Nursing and Midwifery training, technical expert from NACTE
and other facilitators who tirelessly supported the development of this guide whose names are listed
with appreciation:-
SN FULL NAME INSTITUON/ ORGANIZATION
64. Ndementria Vermand ADNT-MOHCDGEC-Dodoma
65. Nassania Shango CDNT -MOHCDGEC-Dodoma
66. Professor Eliezer Tumbwene Lecturer -Aga Khan University
67. Ramadhani Samainda NACTE-Dodoma
68. Dr. Patrick Mwidunda Program Manager-Amref Health Africa
69. Lupyana Kahemela Program Officer-Amref Health Africa
70. Joseph Pilot ICT Officer- Amref health Africa
71. Dr. Julius Masanika Program Director-Jhpiego-MBM-Rtz
72. Dr. Wilson Kitinya Deputy Program Director-Jhpiego-MBM-Rtz
73. Mary Rwegasira Senior- Gender Advisor-Jhpiego-MBM-Rtz
74. Ukende Shalla Technical Advisor-Jhpiego-MBM-Rtz
75. Benison Muchunguzi Technical Officer-Jhpiego-MBM-Rtz
76. Harriet Hamis Senior Program Officer-Jhpiego-MCSP
77. Theresia Venance Technical Officer-Gender-Jhpiego-MBM-Rtz
78. Sarah George Program Assistant-Jhpiego-MBM-rtz
79. Miraji A. Mawaka Tutor-Military College of Medical Science Lugalo
80. David Abincha Tutor –Sumve School of Nursing
81. Bupe Mwandali Ass. Lecturer –Hubert Kairuki Memorial University
82. Mary Kipaya Principal- Kahama School of Nursing
83. Mwanaaisha Fakhi Tutor-State University of Zanzibar
84. Paul Magesa Ag. Principal –Newala School of Nursing
85. Dominic Daudi Tutor –Newala School of Nursing
86. Dr. Beatrice Mwilike Lecturer-MUHAS
87. Lilian Wilfred Tutor KCMC School of Nursing
88. Upendo Mamchony Tutor KCMC School of Nursing
89. Tito William Nurse Officer Muhimbili National Hospital
90. Sixtus Ruyumbu Nurse Officer- Mbeya Refferal
91. Dr Lenatus Kalolo Medical Specialist-Mbeya Refferal
92. Emmanuel Mwakapasa Principal Mbeya -OTM
93. Ruth Mkopi Senior Research Officer TFNC
94. Salma Karim Tutor- Mirembe School of Nursing
95. Athanas Paul Principal- Mirembe School of Nursing
96. Dr. Jiyenze Mwangu Kini Tutor -CEDHA
NMT 05208: Care of a Woman in Normal Labour and Puerperium xiii
xiii
97. Joseph Mayunga Tutor- Kisare
98. Elizabeth Kijugu Principal-Kairuki School of Nursing
99. Charles Magwaza Principal Njombe School of Nursing
100. Alphonce Kalula ECSA
101. Meshack Makojijo Tutor Bugando School of Nursing
102. Stellah Kiwale Tutor- PHN Morogoro
103. Evance Anderson Tutor Geita School of Nursing
104. Juliana Malingumu Tutor Mchukwi School of Nursing
105. Rehema Mtonga Tutor –Dar- es- Salaam
106. Masunga Isassero Assistant Lecturer -MUHAS
107. Paulo Masika Lyimo Tutor –Huruma Health training institute
108. George Muro Tutor -Arusha Lutheran Medical Centre
109. Fredina Rweyemamu Principal -Same School of Nursing
110. James Marwa Tutor-Tarime School of Nursing
111. Nturu Simwanza Tutor-Kondoa School of Nursing
112. Everlasting Lema Tutor-Machame Health Training Institute
113. Dr. Talhya Yahya DHQA
114. Dr. Omary DHQA
115. Rackel Masibo Ag. Dean-St. Johns University
116. Shamila Mwanga Nursing Officer-Muhimbili National Hospital
117. Dr. Stephen Mwaisobwa Clinician-Chamwino DC
118. Evarist Urassa Tutor -KCMC School of Ophthalmic
119. Madia Petro Tutor-Edgar Maranta School of Nursing
120. Sr. Vincenzo Malale Principal-Edgar Maranta School of Nursing
121. Edwin Mkwama Tutor-Centre for Distance Education
122. Lucas Edward ICT Officer-National Institute of Transport
123. Mbaruku Luga Driver-Mirembe School of Nursing
Lastly would like to thank the collaboration and financial support from Amref Health Africa who made
this task successfully completed.
Ndementria Arthur Vermand

Assistant Director Nursing Training Section, Ministry of Health, Community Development, Gender,
Elderly and Children
NMT 05208: Care of a Woman in Normal Labour and Puerperium xiv
xiv
5.0. Background
In 2015 the Ministry of Health, Community Development, Gender, Elderly and Children through the
Directorate of Human Resource Development, Nursing training section started the process of reviewing
the nursing curricula NTA level 4-6. The process completed in the year 2017 and its implementation
started in the same year. The rationale for review was to comply with the National Council for Technical
award (NACTE) Qualification framework which offers a climbing ladder for higher skills opportunity.
Amongst other rationale was to meet the demand of the current health care service delivery. The
demand is also aligned with human resource for health strategic plan and human resource for health
production plan which aims at increasing number of qualified human resource for health.
The process of producing qualified human resource for health especially nurses and midwives requires
the plentiful investment of resources in teaching at the classroom and practical setting and the
achievement of clinical competence is acquired in step wise starting from classroom teaching to skills
laboratory teaching. In addition, WHO advocates for skilled and motivated health workers in producing
good health services and increase performance of health systems (WHO World Health Report, 2006).
Moreover, Primary Health Care Development Program (PHCDP) (2007-15) needs the nation to
strengthen and expand health services at all levels. This can only be achieved when the Nation has
adequate, appropriately trained and competent work force who can be deployed in the health facilities
to facilitate the provisions of quality health care services.
In line with the revised curricula, the MOHCDGEC in collaboration with developing partners and team of
technical staff developed quality standardized training materials to support the implementation of
curricula. These training materials address the foreseen discrepancies in the implementation of the
curricula by training institutions.
This facilitator’s guide has been developed through a series of writers’ workshop (WW) approach. The
goals of Writer’s Workshop were to develop high-quality, standardized teaching materials and to build
the capacity of tutors to develop these materials. The new training package for NTA Level 4-6 includes
a Facilitator Guide and Student Manual. There are 33 modules with approximately
520 content sessions
6.0. Rationale
The vision and mission of the National Health Policy in Tanzania focuses on establishing a health
system that is responsive to the needs of the people, and leads to improved health status for all.
Skilled and motivated health workers are crucially important for producing good health through
increasing the performance of health systems (WHO, 2006). With limited resources (human and non-
human resources), the MOHSW supported tutors by developing standardized training materials to
accompany the implementation of the developed CBET curricula. These training manuals address the
foreseen discrepancies in the implementation of the new curricula.
Therefore, this training manual for Certificate and Diploma program in Nursing (NTA Levels 4-6) aims at
providing a room for Nurses to continue achieving skills which will enable them to perform competently.
These manuals will establish conducive and sustainable training environment that will allow students
and graduates to perform efficiently at their relevant levels. Moreover, this will enable them to aspire for
attainment of higher knowledge, skills and attitudes in promoting excellence in nursing practice.
NMT 05208: Care of a Woman in Normal Labour and Puerperium xv
xv
7.0. Goals and Objectives of the Training Manual
7.1. Overall Goal for Training Manual
The overall goal of these training manuals is to provide high quality, standardized and
Competence-based training materials for Diploma in nursing (NTA level 4 to 6) program.
7.2. Objectives for Training Manual

• To provide high quality, standardized and competence-based training materials.
• To provide a guide for tutors to deliver high quality training materials.
• To enable students to learn more effectively.
8.0. Introduction
8.1. Module Overview
This module content has been prepared as a guide for tutors of NTA Level 5 for training students. The
session contents are based on the sub-enabling outcomes of the curriculum of NTA Level 5 Ordinary
diploma in Nursing and Midwifery.
The module sub-enabling outcome as follows:

1.2.1 Provide care to woman in first stage of labour according to set standards and guidelines.
1.2.2 Manage a woman in second stage of labour according to guidelines and Standards
1.2.3 Manage a woman in third and fourth stages of labour according to guidelines and protocols
1.2.4 Provide care to a woman in puerperium according to guidelines
8.2. Who is the Module For?

This module is intended for use primarily by tutors of NTA Level 5 certificate and diploma in nursing
schools.
The module’ sessions give guidance on the time and activities of the session and provide information
on how to teach the session to students. The sessions include different activities which focus on
increasing students’ knowledge, skills and attitudes.
8.3. How is the Module Organized?

The module is divided into 6 sessions; each session is divided into sections. The following are the
sections of each session:
 Session Title: The name of the session.
 Learning Tasks – Statements which indicate what the student is expected to learn at the end of the
session.
 Session Content – All the session contents are divided into steps. Each step has a heading and an
estimated time to teach that step. Also, this section includes instructions for the tutor and activities
with their instructions to be done during teaching of the contents.
 Key Points – Each session has a step which concludes the session contents near the end of a
session. This step summarizes the main points and ideas from the session.
 Evaluation – The last section of the session consists of short questions based on the learning
objectives to check the understanding of students.
 Handouts are additional information which can be used in the classroom while teaching or later for
students’ further learning. Handouts are used to provide extra information related to the session
topic that cannot fit into the session time. Handouts can be used by the participants to study
NMT 05208: Care of a Woman in Normal Labour and Puerperium xvi
xvi
material on their own and to reference after the session. Sometimes, a handout will have questions
or an exercise for the participants. The answers to the questions are in the Facilitator Guide
Handout, and not in the Student Manual Handout.
8.4. How Should the Module be Used?

Students are expected to use the module in the classroom and clinical settings and during self-study.
The contents of the modules are the basis for learning Care of a Woman in Normal Labour and
Puerperium. Students are therefore advised to learn each session and the relevant handouts and
worksheets during class hours, clinical hours and self-study time. Tutors are there to provide guidance
and to respond to all difficulty encountered by students.
NMT 05208: Care of a Woman in Normal Labour and Puerperium xvii
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Session 1: Care of a Pregnant Woman in First Stage of Labour
Total Session Time: 120 minutes
Prerequisite:
Human anatomy and Physiology
At the end of this session a student is expected to be able:

Define labour, normal labour and first stage of labour
Describe physiology of the first stage of labour
Explain signs of true labour
Assessment of a woman in labour( history taking, general examination of woman in
labour, abdominal examination, vaginal examination in labour
Provide care to a woman in first stage of labour
Resources Needed:
 Flip charts, marker pens, and masking tape
 Black/white board and chalk/whiteboard markers
 LCD Projector and computer
 Note Book and Pen
Session Overview
Step Time (min) Activity/ Content
Method
1 5 Presentation Session title and learning tasks
2 20 Brainstorming, Lecture Definitions of labour, normal labour and first stage of
discussion labour
3 30 Presentation Description on physiology of the first stage of labour
4 15 Presentation Signs of true labour
5 20 Presentation Assessment of a woman in labour
6 20 Group work, Lecture Care of a woman in first stage of labour
discussion
7 5 Presentation Key Points
8 5 Presentation Session Evaluation
Session Contents
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)

READ or ASK participants to read the learning objectives
ASK participants if they have any questions before continuing
NMT 06101: Care of a Woman with Abnormal Pregnancy, Labour and Puerperium 18
18
STEP 2: Definitions of labour, normal labour and first stage of labour (20 Minutes)
Activity: Brainstorming (5 minutes)
ASK students to brainstorm on the definitions of labour, normal labour and first stage of labour
ALLOW time for them to respond
WRITE their answers on a flip chart/board.
PROVIDE possible answers as indicated in the notes below.

Labour
 Is a painful, regular uterine contractions with increasing frequency and duration accompanied with
blood mucous discharge (show) leading to cervical change (dilatation and effacement) and descent
of the presenting part.
o It is described as the process by which the fetus placenta and membranes are expelled through
the birth canal.
Normal labour
 It is when labour occurs at term and is spontaneous in onset with the fetus presenting by the
vertex, the process is completed within 18 hours with no complications arise.
First stage of labour;
 It starts from the onset of true labour pain and ends with full dilatation of the cervix, it is, in other
words it is called “cervical stage” of labour.
Show
 It is the term used to describe the blood stained mucoid discharge at the onset of labour, which
comes from the cervical canal plug, the operculum.
Effacement of the Cervix
 It is also called 'taking up' is the progressive merging of the cervix with the lower part of the uterus.
Dilation of the Cervix
 Dilation, like effacement, mainly occurs due to pulling of the cervix by the contracting and retracting
uterine muscles.
Engagement
 The fetal head is said to be engaged when the largest diameter of the head has passed the
smallest diameter of the maternal pelvis.
Caput Succedaneum
 It is an area of localized edema or collection of fluid on the fetal scalp that develops during labor.
Molding of the Fetal Head
 Molding is physiological and harmless reduction in the size and shape of the fetal head during
delivery.
STEP 3: Physiology of the First Stage of Labour (30 Minutes)

Duration
 The length of labour varies widely and is influenced by parity, birth interval, psychological state,
presentation and position of the fetus.
 Maternal pelvis shape and size and character of the uterine contractions also affect the time scale.
 The active phase of labour is completed within 12 hours. On average, the primigravida will take
most of the time while the multigravida might expect to reach second stage within 6 hours.
19
Uterine Contractions
 Fundal dominance
o Each uterine contraction starts in the fundus and spreads across and downwards.
o The contraction last longer on the fundus where it is also most intense, however the pick is
reached simultaneously all over the uterus and the contractions fades from all parts together
o This pattern permits the cervix to dilate and the strongly contracting fundus to expel the fetus.
 Polarity
o The term used to describe neuromuscular harmony that prevails between the two poles or
segments of the uterus throughout the labour
o The upper pole contracts strongly and retracts to expel the fetus. The lower pole contracts
slightly and dilates to allow expulsion to take place
o If polarity is disorganized, then the progress of labour is inhibited.
 Contraction and retraction
o Uterine muscles have a unique property, during labour the contraction does not pass off
entirely, but muscle fibers retain some of the shortening of contraction instead of becoming
completely relaxed
o This is termed retraction, it assists in progressive expulsion of the fetus; the upper segment of
the uterus becomes gradually shorter and thicker and its cavity diminishes.
 Formation of upper and lower uterine segment
o By the end of pregnancy, the body of uterus has divided into two segments
o The upper uterine segment having been formed from the body of the fundus is mainly
concerned with contraction and retraction, It is thick and muscular
o The lower uterine segment is formed from the isthmus and cervix, and it’s about 8 to 10 cm in
length
o The lower segment is prepared for distention and dilatation.
 The retraction ring
o A ridge forms between the upper and lower uterine segments, this is known as retraction or
bundl’s ring
o Normally, the term retraction ring is used to describe the physiological retraction ring and the
term bundl’s ring is used for the exaggerated degree which becomes visible above the
symphysis in obstructed labour.
 Cervical effacement
o This is the taking up of the cervix
o If this has not been taken place during the last days of pregnancy, this process will take place
in labour
o The muscle fibers surrounding the internal os are drawn upwards by the retracted upper
segment and the cervix merges into lower uterine segment
o The cervical canal widens at the level of internal os.
 Cervical dilatation
o This is the process of enlargement of the external os from a tightly closed aperture to an
opening large enough to allow passage of the fetus
o This dilatation is measured in centimeters and full dilatation at term equals to 10 cm.
o Uterine contraction and the counter-pressure applied by the bag of membranes and the
presenting part results into cervical dilatation.
o A well flexed head closely applied to the cervix favors this cervical dilatation.
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 Show
o As a result of the dilatation of the cervix, the operculum which formed the cervical plug during
pregnancy is lost
o The woman will see a blood-stained mucoid discharge a few hours before or within a few hours
after labour starts.
Mechanical Factors
 Formation of fore water
o As the lower uterine segment stretches, the chorion becomes detached from it and the increase
intrauterine pressure causes this loosened part of the sack of fluid to bulge downwards into the
internal os.
o The well flexed head fits snugly into the cervix and cuts off the fluid in front of the head from that
which surrounds the body. The former is known as fore water and the later is known as hind
water.
 General fluid pressure
o While the membranes remain intact, the pressure of the uterine contractions is exerted on the
fluid and as the fluid is not compressible, the pressure is equalized throughout the uterus and all
over the fetal body.
o When the membranes rupture and a quantity of fluid emerges the fetal head and the placenta
and umbilical cord are compressed between the uterine wall and the fetus during contraction
and oxygen supplied to the fetus is diminished.
 Rupture of the membranes
o The optimum physiological time for the membranes to rupture spontaneously is at the end of the
first stage of labour after the full cervical dilatation and no longer supports the bag of fore
waters.
o The membranes may sometimes rupture days before labour begins or during the first stage.
Badly fitted presenting part which may lead to not cutting off the fore water, the membranes may
rupture early.
 Fetal axis pressure
o During each contraction the uterus rears forward and the force of the fundal contraction is
transmitted to the upper pole of the uterus down the long axis of the fetus, and applied to the
presenting part to the cervix
o This is known as fetal axis pressure.
 With respiratory alkalosis, hypoxia and hypocapnia.
STEP 4: Signs of true labour (15 Minutes)

A correct diagnosis of true labour has to be made before starting the partograp.
 At least 2 uterine contractions in 10 minutes
 Show
o As a result of the dilatation of the cervix, the operculum which formed the cervical plug during
pregnancy is lost
o The woman will see a blood-stained mucoid discharge a few hours before or within a few hours
after labour starts.
 Progressive shortening and thinning of the cervix during labour,
 Cervical dilatation 3 cm or more indicates active labour
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STEP 5: Assessment of a Woman in Labour (20 Minutes)
 History taking of woman in labour
o Recognition by the Mother, the woman herself who usually give complain of lower abdominal
pain which may be the onset of labour. The pain may be progressive increase in intensity.
o The history of blood mucoid discharge and leakage of fluids vaginally.
 General examination of woman in labour,
o General assessment head to toe, vital signs ,lower limbs for edema.
 Abdominal examination
o Starting by inspecting the abdomen for the nature if distension whether globular or pendulous
then palpation for any tenderness and then the fundal height, lying and presentation
o Then examine the abdomen to evaluate the character of the contractions and during a vaginal
examination she can assess the state of the cervix and cervical os.
o Fetal heart rate assessment
 Vagina Examinations
o A vaginal examination should be preceded by an abdominal examination, an explanation and
the obtaining of verbal consent from the woman
o This is done in 4 hourly intervals and must be recorded on the partograph
o The woman’s bladder should be empty as the head may be displaced by a full bladder as well
as being very uncomfortable for the woman.
o Indications of vaginal examination
 Make a positive identification of presentation
 Determine whether the head is engaged in case of doubt
 Ascertain whether the fore water have ruptured, or to rupture them artificially
 Exclude cord prolapse after rupture of fore waters, especially if there is an ill-fitting
presenting part or fetal heart rate changes
 Assess progress or delay in labour
 Confirm full dilatation of the cervix
 Confirm the axis of the fetus and presentation of the second twin in multiple pregnancies and
if necessary in order to rupture the second amniotic sac.
o Vaginal examination is an aseptic procedure
 The midwife should explain the procedure to the woman and give her an opportunity to ask
questions.
 Vaginal examination is an aseptic procedure.
 In order for the midwife to avoid exogenous infections she should adhere to aseptic
techniques.
 She should wash her hands with soap and water before preparing the equipment.
o Prepare a tray with:
 Sterile bowel with antiseptic solutions.
 Sterile swabs
 Sterile gloves.
 Perineal pad
 Lubricant cream
 Sterile hand towel.
 A receiver for soiled swabs
 A cocher forceps if the indication is to rupture the membranes
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Activity: Group Discussion (10 minutes)
DIVIDE: students in small manageable groups
ASK students to discuss in groups the care of a woman in the first stage of labour
AFTER small group discussion
Refer students to Handout no.1.1 cares during labour

CLARIFY and summarize by using the contents below
STEP 6: Care of a Woman in First Stage of Labour (20 Minutes)

Admission of a Woman in Labour; when a woman comes to the labour ward:
 Welcome her together with her companion
 Create a good therapeutic interpersonal relationship with her and the companion
 Once you have welcomed the woman and her companion;-
o Review the woman’s antenatal records (if available), if not, take her history
o Perform quick assessment
o Perform physical examination and per vaginal examination (if signs of true labour are present)
o Record all findings of the latent 1st stage on a woman’s card. If the woman comes after the
latent phase of the 1st stage (cervix dilated 3 cm and above), during active phase record all
findings in the partograph.
o Allow a companion to remain with the woman (if possible), and continue monitoring the progress
of labour, fetus and the woman (using partograph)
Note:
 Skills in inspiring confidence and establishing a trusting relationship with a woman is an integral
part of good midwifery care, as is an understanding that each individual couple will respond
differently to the onset of labour.
 A welcoming attitude and a comfortable environment will encourage the couple to relax and
respond positively to the forces of labour, and the labour is likely to progress normally until the end.
 The midwife must make an immediate assessment of whether delivery is imminent and, if so,
admission procedures are curtailed and preparation is made for the birth.
 Continue with the care through delivery.
STEP 7: Key Points (5 minutes)

 During admission, the midwife must make an immediate assessment of whether delivery is
imminent and, if so, admission procedures are curtailed and preparation is made for the birth
 The midwife should avoid unnecessary vaginal examinations.
 Under no circumstances should a midwife make a vaginal examination if there is any frank
bleeding unless the placenta is positively known to be in the upper uterine segment
 Recording and reporting findings to the appropriate person is mandatory
 After the examination the results should be explained to the woman.
23
STEP 8: Session Evaluation (05 minutes)
 What are the indications of vaginal examination?
 How can a midwife recognize 1st stage of labour?
 Where do you record the observation of the latent 1st stage of labour?
24
References
Fraser, D, M., Cooper, M. A., & Nolte, A. G. (2006). Myles textbook for midwives (African ed.). London:
Churchill Livingstone.
MOHSW. (2008). Focused antenatal care, malaria and syphilis in pregnancy: Learner’s guide for ANC
service providers and supervisors. JHPIEGO: Dar es Salaam.
Tiran, D. (2003). Bailliere’s midwives dictionary (10th ed.). Bailliere Tindall.
25
Handout 1.1 Table showing cares during labour
Element 1st stage – Latent phase 1st stage – Active phase
(Cervical dilatation 1 – 3 cm) (Cervical dilatation 3 – 10 cm)
Communication/  Attend the woman as needed at  Never leave the woman alone for
Attendance least every 4 hours. more than 30 minutes
 Periodically engage her in  Closer attendance may be necessary
conversation even if briefly if woman is having difficulty copying or
 Encourage the birth companion to fetal or maternal condition requires
stay with her (if possible) close monitoring.
 Periodically engage her in
conversation even if briefly
 Provide continuing information and
reassurance about her progress
 Never make false promises
 Encourage the birth companion to
stay with her (if possible)
Rest & Activity/  Allow the woman to remain as  Allow the woman freedom to choose
Positions active as she desires from a variety of positions while
 Encourage rest or sleep as she guiding her to find a position that
desires so that she is well rested easies her discomfort and promotes
when active labour begins labour
 Assist her in relaxing between
contractions in order to conserve her
energy
 Encourage position changes (e.g.
sitting, sporting, side lying, hands and
knees) as well as walking, pacing,
standing, rocking and leaning of a
chair.
Comfort  Give the woman a back rub or  Lightly massage, rub her back or apply
massage. pressure to the lower back as she
 Teach hear to breath out more desires
slowly than usual during  Provide a cool cloth for the face and
contractions and relax with each chest as she desires
breath  Continue to coach her to breathe
through her mouth during contraction
in deliberate slow breath
Nutrition  Encourage food as tolerated,  Encourage light meals/food as
there are no restriction on intake tolerated. There are no restrictions on
as long as the woman has no intake as long as the woman has no
nausea and/or vomiting nausea and/or vomiting
 Provide the woman with nutritious  Provide the woman with nutritious
drink to maintain hydration. Two drink to maintain hydration. Two litres
litres of oral fluids per 24-hour of oral fluids per 24-hour period is a
period is a minimum amount minimum amount
26
Elimination  Encourage the woman to empty  Encourage the woman to empty her
her bladder every two hours and bladder every two hours and empty
empty her bowels as needed. her bowels as needed.
 Do not give the woman an enema  Record urine output on partograph
 Do not give the woman an enema
Hygiene/ Maintain cleanness of the woman Maintain cleanness of the woman and her
Infection and her environment environment
Prevention  Encourage her to bath before  Encourage her to bath before active
active labour begins labour begins
 Cleans the genital area if  Cleans the genital area if necessary
necessary before each before each examination
examination  Do not shave the vulva
 Do not shave the vulva  Before and after each examination
 Before and after each wash hands
examination wash hands  Clean up spills immediately
 Clean up spills immediately  Replace soiled linen
 Replace soiled linen
Observations Maternal condition Maternal condition
 Blood pressure  Blood pressure - 4 hourly
 Pulse rate  Pulse rate - ½ hourly
 Temperature  Temperature - 4 hourly
Fetal condition Fetal condition
 Fetal heart rate  Fetal heart rate - ½ hourly
 Molding  Molding - 4 hourly
 Liquor amnii  Liquor amnii - 4 hourly
Progress of labour Progress of labour
 Descent of the fetal head  Descent of the fetal head – 4 hourly
 Contractions  Contractions – ½ hourl
 Cervical dilatation  Cervical dilatation – 4 hourly
Note: The above observations are Note: The above observations are
performed 4 hourly and can be recorded on the partograph
recorded on the woman’s ANC
card.
27
Session 2: Care of a Pregnant Woman in Labour using Partograph
Prerequisite: Human anatomy and Physiology
Learning Tasks
Give the definition of partograph
Explain the importance of partograph
Identify parts of the partograph
Explain the symbols used during partograph recording
ResourcesMonitor
Needed:progress of labour using partograph
Session Overview
Method
2 5 Brainstorming, Definition of partograph
presentation
3 15 Lecture discussion The importance of partograph
4 15 Lecture discussion Identification parts of the partograph
5 20 Demonstration Symbols used during partograph recording
6 50 Lecture discussion Monitoring progress of labour using partograph

SESSION CONTENTS

READ or ASK participants to read the learning Tasks
28
Step 2: Definition Of Partograph (5 Minutes)
ASK students to brainstorm on the definitions of partograph
 Partograph is a chart on which the salient features of labour are entered in a graphic form and
therefore provides the opportunity for early identification of deviations from normal.
o Is a graphic recording of progress of labour, and conditions of the mother and fetus
o A tool that graphically represents key events during labour
STEP 3: The Importance of Partograph (15 Minutes)

The Importance of Using Partograph
 Gives a complete picture of the progress of labour, and the condition of mother and child
 Helps to recognize the abnormal labour
 Helps to give continuity of care
 Increases the quality of all observations on the mother and fetus in labour
 Serves as an early warning system
 Assists in early decision on transfer, augmentation and termination of labour
 It reduces prolonged labour, need for augmentation, emergency caesarian section and reduces
intrapartum still birth rates.
NB: When to start a Partograph
 The partograph is started when the mother is in true labour (true labour has two phases; latent and
active phase)
STEP 4: Parts of the Partograph (15 Minutes)

 The partograph as document it should have general information of the patient before plotting a
graph.
 A graph itself is started when a woman is in true labour and it has three parts
o Fetal monitoring section
o Labour progress monitoring section
o Maternal monitoring section
Foetal Monitoring Section

 Foetal heart rate is recorded to monitor the condition of the fetus
 Liquor or amniotic fluid is observed and write “C” if it is clear or “M” if meconium stained
 If the membranes are not ruptured record “I” for intact
Labour Progress Monitoring Section

 Cervical dilatation is the most important observation in monitoring progress of labour. The dilatation
is plotted with an “X”.
29
 Descent of the fetal head is very important in monitoring of labour progress. The descent is plotted
with an “O”
 Time is recorded using the time of admission as zero time. The actual time of the day is recorded
below the hours line.
 Progress of labour and contractions- the contractions are recorded below the time line, along with
cervical dilatation and descent of presenting part, they all tell the progress of labour.
Maternal Monitoring Section

 Blood Pressure, Pulse and Temperature are recorded in the space provided.
 Urine amount is recorded every time urine is passed
 Albumin (protein) and acetone (ketones) every time the woman passes urine or are tested at least
once
 Medications- intravenous fluids (infusion) are recorded in the space provided.
NB: General Information of the Mother

 This part is sometimes taken as one of the partograph though it carries very important information
like the name, gravid, parity, registration/hospital number, date of admission, time of admission and
initial vagina assessment it is not considered as part for monitoring the patient, it is not a part of the
graph.
STEP 5: Symbols Used During Partograph Recording (20 Minutes)

Activity: Demonstration (10 minutes)
DIVIDE students in a group of 3-6 students
DEMONSTATE to the students how the symbols are plotted on the partograph form
ALLOW students to practice
CLARIFY and summarize using the information given below
30
Figure 2.1 Example of a partograph Source: http://www.tpub.com/content/army/medical
31
Figure 2.2: Symbols used in Partograph Source: http://www.tpub.com/content/army/medical
32
When often to check using standard partograph guidelines
IF NORMAL AND IN STAGE I IF NOT NORMAL OR IN STAGE II

WHAT
LABOR LABOR
Dilatation 4 Hours Variable
Fetal Heart Rate:
 1 Hourly
 Latent phase 15 Minutes (or more often if needed)
 30 Minutes
 Active phase
Contractions:
 1 hour  Abnormal: 30 minutes
 Latent Phase
 30 Minutes  Abnormal: Continuously
 Active Phase
Pulse 30 Minutes 30 Minutes
Blood pressure 1 Hour 30 Minutes
Temperature 2 Hours 1 Hour
Fluid 1 Hour 1 Hour (More often if needed)
Urination 2 Hours 2 Hours (More often if needed)
Figure 2.3: Standard Partograph Guidelines Source: http://www.tpub.com/content/army/medical
STEP 6: Monitoring Progress of Labour using Partograph (50 Minutes)

When monitoring the woman in labour using partograph should be considered that she need moral
support and a verbal informed consent every time she is assessed.
 Fetal monitoring
o Fetal Heart Rate
 Fetal heart rate should be checked and recorded every hour or half hourly when possible
 When there are problems to be checked after every contraction
 Listen to the fetal heart rate for a full one minute after contraction ends
 Normally the fetal heart rate is between 120 and 160 beats in a minute, and should be
regular.
o Recording Membranes and Liquor
 The state of the liquor can assist in assessing the fetal condition.
 The observations are recorded on the partograph just below the fetal heart recordings
 The observations are made at each vaginal examination.
o Moulding of the Fetal Skull Bones
 The amount of molding helps in assessing how well the pelvis is making room for the fetal
head.
 Molding is evaluated at each vaginal examination
 Molding when the head is too high is a sign of disproportion.
33
 Progress of labour monitoring
o Cervical Dilatation
 The first stage of labour is divided into the latent and active phase.
 The latent phase is a period of slow cervical dilatation, is from 0 to 3 cm with gradual
shortening of cervix.
 The active phase is a period of faster cervical dilatation, is from 3 to 10 cm.
 The dilatation of the cervix is measured in cm and is plotted with an X, vaginal examination are
made every 4 hours unless contraindicated. However in advanced labour women may be
assessed frequently especially multipara.
o Descent of the Fetal Head
 Descent of the head is measured by palpating the head through the abdomen and recording
the findings every 4 hours.
 The decent is measured in ‘fifths’ of the head palpable above the brim
 Descent of the head can also be assessed by doing vaginal examination and recorded as fetal
stations.
o Uterine Contractions
 In order for labour to progress well there must be good uterine contractions
 In normal labour contractions usually become more frequent and last longer, as labour
progresses
 Contractions are observed hourly in latent phase and half hourly in active phase.
 Contractions are observed for frequency and duration
 The frequency of contractions is assessed by the number of contractions in a ten-minute
period. The duration is from the time the contraction is first felt abdominally to the time when
the contraction passes off
o Three ways of recording the duration are:
 Below 20 seconds – mild contractions.
 20 – 40 seconds – moderate contractions,
 More than 40 seconds but should not exceed 60 – strong contractions.
 Recording Maternal Condition
o All observations on the mother’s condition are recorded at the bottom of the partograph
o Pulse rate half hourly
o Blood pressure, temperature and pulse hourly or more frequently when indicated.
o Urine; ask the woman to pass urine every 2 to 4 hours look for amount and concentration.
Concentrated urine is sign of dehydration
o The protein and acetone should be assessed on admission.
o All entries are made on the line at which the observations are made.
Step 7: Key Points (5 minutes)

 Progress of labour includes cervical dilatation, uterine contractions and descent of the presenting
part.
 Fetal condition includes fetal heart rate, liquor and Moulding of the fetal skull
 Maternal condition includes vital signs, urine, drugs and oxytocin regime.
Step 8: Session Evaluation (15minutes)

 What is a partograph?
 Why is partograph important?
34
 What are symbols used to plot strengths of uterine contractions on the partograph?
35
References
MOHSW. (2008). Focused antenatal care, malaria and syphilis in pregnancy: Learner’s guide for ANC
service providers and supervisors. JHPIEGO: Dar es Salaam.
Tiran, D. (2003). Bailliere’s midwives dictionary (10th ed.). Bailliere Tindall.
36
Session 3: Care of a Pregnant Woman in Second Stage of Labour
Prerequisites: NMT 05107 Care of a woman during antenatal period
Learning Tasks
At the end of this session participants are expected to be able:
Define second stage of labour
Describe physiology of the second stage of labour
Identify signs of second stage of labour
Describe mechanism of normal labour
Give care to a woman in second stage of labour
Resources Needed:
Session Overview
Method
2 5 Brainstorming, Definition of second stage of labour
presentation
3 15 Lecture discussion Physiology of second stage of labour
4 10 Buzzing, Lecture Signs of second stage of labour

discussion
5 20 Lecture discussion Mechanism of normal labour
6 55 Demonstration, Lecture Care of a woman in second stage of labour

discussion
37
Session Contents

READ or ASK participants to read the learning tasks
STEP 2: Definition of Second Stage of Labour (05Minutes)

ASK students to brainstorm on the definition of second stage of labour
CLARIFY and provide summary using the content below
It is defined as follows
 The phase between full dilatation of the cervical os and the birth of the baby
 It begins with the complete dilatation of the cervix and end with the expulsion of the fetus
STEP 3: Physiology of Second Stage of Labour (15Minutes)

The physiological changes are the continuation of the same forces in the early hours of labour but the
activities are accelerated though the acceleration does not occur abruptly. The changes include:
 Uterine action
o The contractions becomes stronger and longer but may be less frequent allowing the mother
and fetus regular recovery period
o The membrane usually rupture during the first stage or during the transition to the second stage
o The consequent draining of the liquor allows the hard ,round fetal head to be directly applied to
the vagina tissues
o This pressure aids distension
o Fetal axis pressure increases flexion of the head resulting in smaller presenting diameters
o The contraction becomes expulsive as the fetus descends further into the vagina
o And the pressure from the presenting part stimulates the nerve receptor in the pelvic floor a
phenomenon called Ferguson reflex which in turn the woman experience the need to push.
o This reflex initially can be controlled in a limited extent but then it becomes increasingly
compulsive , overwhelming and involuntary
o The mother responds by pushing the fetus out through contracting her abdominal muscles and
diaphragm
 Soft tissues replacement
o As the head descends ,the soft tissues of the pelvis becomes displaced
o Anteriorly the bladder is pushed upwards into the abdomen to prevent any risk of injury by the
descent of the head
o Posterior the rectum becomes flattened into the sacrum and the pressure of the descending
head expels any residue of the faecal matters
o As descend continues the fetal head becomes visible at the vulva
38
o Then the head is born followed by the shoulder and body follows as contraction continues,
accompanied by the gush of amniotic fluid and sometimes blood.
STEP 4: Signs of Second Stage of Labour (10 Minutes)

Activity: Buzzing (3 minutes)
ASK students to buzz on the signs of second stage of labour
The signs of the second stage of labour include

 The progress from the first to second stage is not always clinically apparent but there presumptive
sign which include
o Expulsive uterine contraction
 The mother feels the urge to push, though others feel the urge even before fully dilatation
o Rupture of the forewaters
 But sometimes it can happen any time during labour
o Dilatation and gaping of the anus
o Anal cleft line
 Some midwives have reported observing this line (purple line) as a pigmented mark in the
cleft of the buttocks which creeps up the anal cleft.
 Show
o This is a loss of the blood stained mucus
 Appearance of the presenting part at the vulva
STEP 5: Mechanism of Normal Labour (20Minutes)

As the fetus descends, soft tissues and bony structures exert pressure which leads to descent through
the birth canal by a series of movements
 The principle common to all mechanism are
o Descent takes place
o Whichever part leads and first meets the resistance of the pelvic floor will rotate forwards until it
comes under symphysis pubis
o Whatever emerges from the pelvis will pivot around the pubic bone.
 During the mechanism of normal labour the fetus turns slightly to take advantage of the widest
available space in each plane of the pelvis
 The widest diameters of the pelvic brim are the transverse diameter at the pelvic the greatest space
lies in the anterior-posterior diameter.
 At the onset of labour the most common presentation is the vertex with the position either left or
right occipito anterior, therefore it is this mechanism which will be described
39
 For instance:
o The lie longitudinal
o The presentation is cephalic
o The position is right or left occipito anterior
o The attitude is one of good flexion
o The denominator is the occiput
o The presenting part is the posterior part of the anterior parietal bone
Main movements
 Descent
o Descent of the fetal head into the pelvis often begins before onset of labour
o For a primigravida, this usually occurs during the later weeks of pregnancy
o In multigravida, descent and engagement of the fetal head may not occur until labour begins
 Flexion
o This increases throughout labour.
o At the onset of labour, the suboccipitofrontal diameter 10 cm is presenting
o With greater flexion, the suboccipitobregmatic diameter 9.5 cm presents
o The occiput becomes the leading part
 Internal rotation of the head
o During a contraction, the leading part is pushed downwards onto the pelvic floor.
o The resistance of the pelvic diaphragm brings about rotation
o In a well flexed vertex, the occiput leads and meets the pelvic floor first, and rotates anteriorly
through 1/8 of a circle until it comes under the symphysis pubis.
 Crowning
o The occiput slips beneath the subpubic arch and crowning occurs when the head no longer
recedes between contraction and the widest diameter (biparietal) is born.
o The subocipitobregmatic diameter 9.5 cm distends the vaginal orifice.
 Extension of the head
o Once crowning has occurred, the fetal head can extend, pivoting on the subocipital region
around the pubic bone
o Sinciput, face and chin sweep the perineum and they are born by movement of extension.
 Restitution
o The twist in the neck of the fetus which resulted from internal rotation is now corrected
o The occiput rotates 1/8 of the circle towards the side from which it started
 Internal rotation of the shoulders
o The shoulders undergo the similar rotation to that of the head
o The anterior shoulder is the first to reach the pelvic floor, and rotates anteriorly to lie under the
symphysis pubis.
 External rotation of the head
o It accompanies the internal rotation of the shoulders
o It occurs in the same direction as restitution and the occiput now lies laterally.
 Lateral flexion
o The anterior shoulder slips beneath the sub-pubic arch and the posterior shoulder passes over
the perineum
o The body is born by lateral flexion as the spine bends sideway through the birth canal
40
STEP 6: Care of a Woman During Second Stage (55 Minutes)
 Never leave the woman alone during the second stage
 Monitor the progress of labour and record it in the partograph
 Monitor the contractions
 Monitor the fetal heart rate and record it in the partograph
 Provide continue information and reassurance about her progress and the wellbeing of the baby
 Allow the woman freedom to choose from a variety of positions while guiding her find a position that
eases her discomfort and promotes labour
 Offer sips of cool sweetened fluids between contractions
 Lightly massage or rub her back as she desire or apply lower back pressure to relieve back pain
 Prepare the equipment for delivery of the baby

o Surgical gloves
o Clean gloves
o Two kidney dishes
o Pair of scissors
o Cord clamps
o Drapes
o Forceps
o Gauze
o Syringe of 5ml
o Oxytocin 10 iu
o Cannula gauge 18
o Iv fluids ie normal saline or ringer lactate
Assisting Normal delivery
DIVIDE students in a group of 3-6 students
Demonstrate: Normal delivery
ALLOW One student from each group to do return demonstration and let others comment on it
CLARIFY and summarize by using the information below
 Once the cervix is fully dilated and the woman is in second stage, encourage the woman to assume
the position she prefers and encourage her to push when the urge is felt.
 Continually assess the speed at which the baby is descending through the birth canal
 Have the woman continue spontaneous bearing down efforts until the baby’s head crowns
 Coach the woman to push and/or breathe so that the birth of the head will be slow, steady and
controlled.
 If the baby is coming fast, help the woman stop pushing by asking her to blow repeatedly or
breathe steadily which make it easier to refrain from pushing.
 Birth of the head
o Clean the woman’s perineum with antiseptic solution
o Ask the woman to pant or give only small pushes with contractions as the baby’s head is born
41
o As the pressure of the head thins out the perineum, one way to control the birth of the head is
with fingers of one hand applying a firm gentle downward (but not restrictive) pressure to
maintain flexion, allow natural stretching of perineal tissues and prevent tears.
o Use the other hand to support the perineum using a compressor or cloth and allow the head to
crown slowly and be born spontaneously
o Do not manipulate the labia or perineum over the baby’s head because this increases the risk of
tears.
o Wipe the mucus from the baby’s mouth and nose with clean swab
o Feel around the baby’s neck to ensure that the umbilical cord is not around it
 If the cord is around the neck but loose, slip it over the baby’s head
 If the cord is loose but cannot reach over the head, slip it backward over the shoulders
 If the cord is tight around the neck,tie or clamp a cord in two places 2 cm apart and cut the
cord between the ties/clamps
 Unwind the cord from around the baby’s neck and proceed
 Delivery of the shoulders
o Restitution and external rotation of the head must occur in order to deliver the shoulders safely
and avoid the perineal lacerations
 Allow the baby’s head to turn spontaneously
 After the head turns, place a hand on each side of the baby’s head over the ears, avoiding
pressure around the neck
 Advice the woman to push gently with the next contraction
 Then, apply slow gentle pressure downward and outwards until the anterior shoulder slips
under the pubic bone
 When the axilla is seen, guide the head upwards towards the woman’s abdomen as the
posterior shoulder is born over the perineum
 Support the baby’s head with one hand and the rest of the baby’s body with the other hand
as it is slides out and place the baby on the woman’s abdomen

 Second stage of labour is a phase between full dilatation of the cervical os and the birth of the baby
 The signs of the second stage of labour
o It begins with the complete dilatation of the cervix and end with the expulsion of the fetus
o Expulsive uterine contraction
o Rupture of the forewaters
o Dilatation and gaping of the anus
o Anal cleft line
o Show
o Appearance of the presenting part at the vulva

 What is the mechanism of normal labour
 What are the physiological changes during normal labour?
42
References
Bennett, V. R., & Brown, L. K. (2009). Myles’ textbook for midwives (15th ed.). London: Churchill
Livingston.
Dutta, D. C. (2004). Text Book of Obstetrics: Including Perinatology and Contraception . New central
book agency.
Fraser, D. M., Cooper, M. A., & Fletcher, G. (2003). Myles’ textbook for midwives 14thed.).London:
Churchill Livingston.
Fraser, D. M., & Cooper, M. A. (2009). Myles’ textbook for midwives (15th ed.). London: Churchill
Livingston.
John,N.K,& Bacchus ,M.Y.(2010). Gyanaecology and family planning(2nd ed).Dae es salaam.
Varney H., (2004). Varney’s Midwifery text book 4th edition massarchusets, Tones & Bartelt Pg 666-66
43
Session 4: Care of a Woman with Perineal Tear and Episiotomy
Prerequisites:
Module 7: NMT 05107 Care of a woman during antenatal period
Learning Tasks
Define perineal tear
Classification of perineal tear
Risk factors for perineal tear
Care of a woman with perineal tear
Care of the woman with episiotomy
Complications of perineal tear and episiotomy
Resources Needed:
Session Overview
Method
2 5 Brainstorming, presentation Definition of Perineal tear
3 15 Lecture discussion Classification of perineal tear
4 10 Buzzing Lecture discussion Risk factors for perineal tear
5 30 Lecture discussion Care of a woman with perineal tear
6 40 Lecture discussion Care of a woman with episiotomy
7 5 Lecture discussion Complication of perineal tear and episiotomy
SESSION CONTENTS
44
STEP 2: Definition of Perineal Tear (05 Minutes)
ASK students to brainstorm on the definition of perineal tear
Perineal tear /laceration

 Is the trauma of the perineum that occurs during delivery
o The perineum is the region between the vaginal opening and the anus.
o The perineum may be injured when there is overstretching or over-distension during delivery
STEP 3: Classification of Perineal Tear (15 Minutes)

 First degree tear
o laceration is limited to the fourchette and superficial perineal skin or vaginal mucosa
 Second degree tear
o Injury to perineum involving perineal body (muscles) but not involving the anal sphincter.
 Third degree tear
o Injury to perineum, involving the anal sphincter complex (both external and internal)
 Fourth degree tear
o Injury to perineum involving the anal sphincter complex (External and internal anal sphincter)
and anal epithelium.
STEP 4: Risk Factors for Perineal Tear (10 Minutes)

Activity: Buzzing (3 minutes)
ASK students to buzz on the risk factors for perineal tear
The risk factors for perineal tear includes

 Big babies
 Malpresentation/malposition
 Narrow vaginal outlet
 Shoulder dystocia
 Instrumental vaginal delivery
 Precipitate labour
 Scar in perineum
 Midline episiotomy
45
STEP 5: Care of a Woman with Perineal Tear (30 Minutes)
Repairing perineal tear
 Trauma is best repaired as soon as possible after birth in order to secure haemostasis and before
oedema forms
 Ensure the mother is warm and comfortable as possible
 Prepare the appropriate instruments including
o Surgical gloves
o Needle holder
o Suture material
o Antiseptic solution
o Local anaesthetic
o Dissecting forceps
o Stitching scissors
o Sterile gauze
o Kidney dish
o Two galipots
 Place the mother in lithotomy position
 Then assess the extent of the tear
First-degree tear
 Most first degree tears close spontaneously without sutures
Second degree tear
 Apply antiseptic solution to the area around the tear.
 Infiltrate local anaesthesia beneath the vaginal mucosa, beneath the skin of the perineum and
deeply into the perineal muscle
 Repair the vaginal mucosa using a continuous 2-0 suture
 Start the repair about 1 cm above the apex (top) of the vaginal tear.
 Continue the suture to the level of the vaginal opening
For third and fourth degree tear
 These tears should be repaired in the theatre
Care after repair
 Instruct the patient to clean the wound using antiseptic after urination and defecation
 Give the woman analgesics to relieve pain
 Give the woman broad spectrum antibiotics
 Instruct the woman not to use hot water on the wound
STEP 6: Care of a Woman with Episiotomy (40 Minutes)

 Episiotomy
o Is a surgically planned incision on the perineum and the posterior vaginal wall during the second
stage of labor
Indications of episiotomy
 In elastic (rigid) perineum:
o Causing arrest or delay in descent of the presenting part as in elderly primigravidae
 Anticipating perineal tear due to the following
o Big baby
46
o Face to pubis delivery
o Breech delivery
o Shoulder dystocia.
 Operative delivery:
o Forceps delivery, ventouse (vacuum) delivery.
 Previous perineal surgery
Types of episiotomy
 Medio-lateral
o The incision is made downward and outward from midpoint of fourchette either to right or left.
o It is directed diagonally in straight line which runs about 2.5 cm away from the anus (midpoint
between anus and ischial tuberosity).
 Median
o The incision commences from center of the fourchette and extends on posterios side along
midline for 2.5 cm.
 Lateral
o The incision starts from about 1 cm away from the center of fourchette and extends laterally.
 'J' shaped
o The incision begins in the center of the fourchette and is directed posteriorly along midline for
about 1.5 cm and then directed downwards and outwards along 5 or 7 o'clock position to avoid
the anal sphincter. This is also not done widely.
Figure 4:1 Episiotomy Source: healthjade.com (2018)
Making an incision
 A straight bladed, blunt ended pair of Mayo scissors is usually used.
 The blade should be sharp.
 Two fingers are inserted into the vagina and open the blades are positioned.
 The incision is best made during contractions when the tissues are stretched so that there is a clear
view of the area and bleeding is less likely to be severe.
 A single deliberate cut 4-5 cm long is made at the correct angle.
47
 Birth of the head should follow immediately and its advance must be controlled in order to avoid
extension of the episiotomy.
 If there is any delay before the head is emerging, pressure should be applied to the episiotomy
between the contractions in order to minimize bleeding.
 Post-partum bleeding can occur from an episiotomy site unless bleeding points are compressed
Care of a woman with episiotomy

 The care is the same as in perineal tear
STEP 7; Complication of Episiotomy and Perineal Tear (05 minutes)

 Increased long-term discomfort eg dyspareunia, chronic perineal pain,
 Infection.
 Hematoma formation
 Fecal or gas incontinency

 Perineal tear is the trauma of the perineum that occurs during delivery
o The perineum is the region between the vaginal opening and the anus.
o The perineum may be injured when there is overstretching or over-distension during delivery
 Episiotomy
o Is a surgically planned incision on the perineum and the posterior vaginal wall during the second
stage of labor

 What are the indications of episiotomy?
 What are the complications of episiotomy and perineal tear?
48
References
Livingston.
Dutta, D. C. (2004). Text Book of Obstetrics: Including Perinatology and Contraception . New central
book agency.
Livingston.
John,N.K,& Bacchus ,M.Y.(2010).Gyanaecology and family planning(2nd ed).Dae es salaam.
Varney H., (2004). Varney’s Midwifery text book 4 th edition massarchusets, Tones & Bartelt Pg 666-
667
49
Session 5: Care of a Woman in the Third and Fourth Stage of Labour.
Pre-requisite: None
Learning Tasks
Define third and fourth stages of labour
Describe physiology of third stage of labour
Assess signs of placenta separation
Explain management of third stage of labour
Explain how to perform active third stage of labour
ResourcesAssessment
Needed: of the placenta
 Flip charts, marker
Provide carepens, and masking
to a mother tape
in fourth stage of labour
Session Overview
Method
2 10 Brainstorming Definition of third and fourth stages of labour
presentation
3 20 Lecture discussion Physiology of third stage of labour
4 5 Lecture discussion Signs of placenta separation
5 20 Presentation Management of third stage of labour
6 30 Lecture discussion, Active management of third stage of labour
Demonstration
7 10 Lecture discussion Assessment of the placenta
8 10 Lecture discussion Provide care to a mother in fourth stage of
labour
Session Contents
50
STEP 2: Definition of Third and Fourth Stages of Labour (10 Minutes)

ASK students to brainstorm on the definitions of third stage and fourth stage of labour.
 The third stage of labour: is defined as the period from the birth of the baby to complete expulsion
of the placenta and membranes
o Involving the separation of and descent and expulsion of the placenta and membranes and
control of haemorrhage from the placenta site.
 Fourth stage of labour: The hour or two after delivery when the tone of the uterus is re-established as
the uterus contracts again, expelling any remaining contents.
o These contractions are hastened by breastfeeding, which stimulates production of the hormone
oxytocin.
STEP 3: Physiology of Third and Fourth Stages of Labour (20 Minutes)

Physiology of the third stage
 During this stage, separation and expulsion of placenta and membranes occur as the results of
mechanical and haemostatic factors.
Mechanical Factors
 The unique characteristic of uterine muscles still lies on the retraction, thus by the beginning of the
third stage, the placenta has already began to diminish in size.
 The placenta itself becomes squeezed and the blood in the intervillous spaces is forced back into
the spongy layer of the deciduas.
 Retraction of the oblique uterine muscle fibers exerts pressure on the blood vessels so that blood
does not drain back into the maternal system.
 The vessels during this process become tense and congested, with the next contraction, the
distended vessels burst and a small amount of blood sips in between the spongy layer and the
placental surface stripping it from its attachment
 As the surface area of the placental attachment reduces, the non-elastic placenta begins to detach
from the uterine wall.
 Separation usually begins centrally so that a retro placental clot is formed, the weight of this clot
may further aid the separation. The increased weight also helps to peel the membranes off the
uterine wall
51
 This process of separation was first described by Schultze (see figure below) and is associated with
more complete shearing of both placenta and membranes and less fluid blood loss.
 Alternatively, the placenta may begin to detach unevenly at one of its lateral borders.
 The blood escapes so that the separation is unaided by the formation of the retroplacental clot.
 The placenta descends slipping sideways maternal surface first
 This process (first described by Mathews Duncan) takes longer and is associated with rugged
incomplete expulsion of the membranes and higher fluid blood loss.
Homeostasis
 The normal volume of blood flow through the placental site is 500 – 800 ml per minute
 At placental separation this has to be arrested within seconds or serious hemorrhage will occur.
The three factors within the normal physiological processes that control bleeding are:
o Retraction of oblique uterine muscle fibers in the upper uterine segment through which the
tortuous blood vessels intertwine, the resultant thickening of the muscles exert pressure on the
torn muscles acting as clamps so securing a ligature action.
o The presence of vigorous uterine contractions following separation brings the uterine walls into
opposition so that further pressure is exerted on the placental site.
o There is a transitory activation of the coagulation and fibrinolytic systems during and
immediately following placenta separation. This protective response is especially active at the
placental site so that clot formation in the torn vessels is intensified.
Figure 5.1: Placental separation Source: http://www.tpub.com/content/army/medical
STEP 4: Signs of Placenta Separation (05 Minutes)

 The most reliable sign is the lengthening of the umbilical cord as the placenta separates and is
pushed into the lower uterine segment by progressive uterine retraction.
 The body of the uterus becomes smaller, harder and globular
 The fundal level rises as the upper segment overrides the lower uterine segment which is now
distended with the placenta.
 Suprapubic bulge due to presence of the placenta in the lower uterine segment.
 Gush of blood from the vagina.
52
STEP 5: Management of Third Stage of Labour (20 Minutes)
 Third stage is the most crucial stage of labour. The progress of the first and second stages are
likely to impact on the management on the third stage so may not be excluded.
 The principles underlying the management of third stage are to ensure strict vigilance and to follow
the management guidelines strictly in practice so as to prevent the complications, the important one
being postpartum hemorrhage.
 Two methods of management are currently in practice.
o Expectant management
o Active management (preferred)
Expectant management (traditional):

 In this management, the placental separation and its descent into the vagina are allowed to occur
spontaneously.
 Minimal assistance may be given for the placental expulsion if it needed.
o Constant watch is mandatory and the patient should not be left alone.
o If the mother is delivered in the lateral position, she should be changed to dorsal position to note
features of placental separation and to assess the amount of blood loss.
o A hand is placed over the fundus
 To recognize the signs of separation of placenta,
 To note the state of uterine activity (contraction and relaxation)
 To detect, though rare, cupping of the fundus which is an early evidence of inversion of the
uterus.
 With this approach the therapeutic administration of uterotonics drugs would either to stop bleeding
once it has occurred or to maintain the uterus in a contracted state when there are indications for
bleeding.
 Steps for expectant (conservative) management) are as follow:
o Put the ulnar border of the left hand just above the fundus at the level of the umbilicus to detect
any bleeding inside the uterus known by rising level of the atonic uterus
o Wait for signs of placental separation and descent but do not massage the uterus
o As soon as they are detected massage the uterus to induce its contraction, ask the patient to
bear down and push the uterus downwards to deliver the placenta.
o Hold the placenta between the two hands and roll it to make the membranes like a rope in
order not to miss a part of it
o Give ergometrine 0.5 mg or oxytocin 10 units IM after delivery of the placenta to help uterine
contraction and minimize blood loss. These may be given before delivery of the placenta.
Active management of third of labour

 The underlying principle in active management of third stage of is to excite powerful uterine
contractions within one minute of delivery of the baby (WHO) by giving parenteral oxytocic.
 The advantages;
o Will minimize blood loss in third stage approximately to 1/5th and
o Will shorten the duration of third stage to half.
o Will prevent up to 60% of uterine atony
o Decreases the number of cases of PPH
53
 The only disadvantage is slight increased incidence of retained placenta (1–2%) and consequent
increased incidence of manual removal. Of course, accidental administration during delivery of the
first baby in undiagnosed twins may endanger the unborn second baby caused by asphyxia due to
tetanic contraction of the uterus.
Figure 5:2 Scheme of Management of third Stage of Labour Source: DC Duttas Text Book of Obstetrics
and perinatology
STEP 6: Performing Active Management of Third Stage of Labour (30 Minutes)

DIVIDE student’s in-group of 3-6
DEMONSTRATE to students on how to conduct active management of third stage using the
childbirth model
ALLOW one student to do a return demonstration and let others comment on it and arrange for
more practice to other students during lab. Skills practicum.
CLARIFY and summarize by using the information below
ENCOURAGE students to practice more until they become competent
Steps of Active Management of Third Stage of Labour
 Give 10 International units (IU) of oxytocin intramuscular (IM) within one minute of birth of the baby
after excluding an additional fetus. If not available, give Ergometrine or Misoprosol
 Assist delivery of the placenta by controlled cord traction while supporting the contracted uterus
 Massage the uterus immediately after delivery of the placenta
Performing Active Management of Third Stage of Labour
54
 Within 1 minute of birth, palpate the abdomen to rule out the presence of another baby/babies) and
give oxytocin 10 IU, IM.
 Perform controlled cord traction
o Clamp the cord close to the perineum. Hold the clamped cord at the end of the clamp in one
hand
o Place the other hand just above the pubic bone and apply counter traction to stabilize the
uterus and prevent uterine inversion
o Keep light tension on the cord and await a strong contraction (2 – 3 minutes)
o When the uterus becomes rounded or the cord lengthens, very gently pull downward on the
cord to deliver the placenta.
o Do not jerk on the cord or pull on it between contractions. Do not wait for a gush of blood before
applying traction on the cord.
o Continue to apply counter traction (push upward on the uterus) with the other hand
 If the placenta does not descend during 30-40 seconds of controlled traction, relax the tension and
repeat with the next contraction
 If the placenta does not deliver in 30 minutes, immediately report to the incharge for further
management.
 As the placenta delivers, hold it with both hands and twist it slowly so that the membranes are
expelled intact
 If membranes do not slip spontaneously, gently twist them into a rope and move them up and down
to assist separation without tearing them
 If the cord is pulled off, immediately report to the in-charge for further management
 Rapidly inspect the placenta, cord and membranes for general completeness
 Inspect the vagina and perineum for tears
STEP 7: Assessment of The Placenta (10 Minutes)

The examination of the placenta and membranes is performed as soon as possible after delivery to
check for their completeness.
 The midwife should make every attempt to piece the membranes together to get the overall picture
of completeness.
 Assess membranes, hold the placenta by the cord and allow the membranes to hang. Identify the
hole through which the baby was delivered and spread hand out inside the membranes to aid
inspection.
 After that, lay the placenta on a flat surface and under good lighting minutely examine both
placental surfaces.
 Peal the amnion from the chorion right up to the umbilical cord to fully view the chorion.
 During the examination of the placenta, any clots on the maternal surface should be removed and
kept for measurement.
 Broken cotyledon must be carefully replaced before an accurate examination is possible.
 Recent infarction looks bright red, old infarction forms grey patches whereas localized calcification
can be seen as flattened white plaques feeling gritty to touch.
 Normally, lobes are neatly fitted and edges forms uniform circle. Blood vessels should not radiate
beyond the edges of the placenta, otherwise denote succenturiate lobe. If this lobe has retained,
you will see the tissue abruptly ending at a hole in the membrane.
 On the fetal surface, note the position of the insertion of the cord.
55
 Normally, two umbilical arteries and one vein are present, therefore absence of one or more of
these mean congenital fetal abnormality, particularly renal agenesis.
 Placenta is also weighed; its weight may vary depending on the time of clamping. In early clamping,
there is an increase of one fifth of the baby’s weight whereas in a delayed clamping, placenta
weigh approximately one sixth of the baby’s birth weight.
 Disposal of the placenta is done in respect of the mother’s choice; however that choice must not be
against healthy way of handling the placenta.
STEP 8: Care of a Woman in Fourth Stage of Labour (10 Minutes)

 The fourth stage of labour is the period from the delivery of the placenta until the uterus remains
firm on its own
 This is usually a 1 to 2 hours period. In this stabilization phase, the uterus makes its initial
readjustment to the non-pregnant state
 The primary goal is to prevent hemorrhage from the uterine atony and the cervical or vaginal
lacerations.
Management
 The midwife should attend the woman, check vital signs: Blood Pressure, Pulse and Respiration
every 15 minutes for an hour, then every 30 minutes for the next hour.
 Care of the perineum and apply clean perineal pad between the legs and change accordingly.
 Ensure that the woman and baby has enough blankets to maintain warmth
 Maintain calm environment conducive to rest for the woman to facilitate bonding with her baby and
initiation of breastfeeding.
 Encourage early and exclusive breast feeding
 Encourage the woman to eat and drink as she desires
 Encourage the woman to pass urine when the urge is felt, or if bladder is palpable, as a full bladder
may actually cause postpartum hemorrhage because it prevents the uterus from contracting
appropriately.
 Evaluate fundal height from the umbilicus to the symphysis pubis using tape measure. The fundus
should remain in the midline. If it deviates from the middle, identify this and evaluate for distended
bladder.
 Massage the fundus every 15 minutes during the first hour, every 30 minutes during the next hour.
 Ensure emergency equipment are available in the recovery room or post natal ward for possible
complications.
 Observe the mother for chills. The cause of the mother being chilled following birth is unknown.
However, it refers primarily to the result of circulatory changes after delivery. The best means of
relief is to cover the mother with a warm blanket.
 Transfer the patient to the recovery room or postnatal ward, this is done after cleaning the woman
and dressing a clean gown on the patient, obtaining a complete set of vital signs, evaluating the
fundal height and firmness, and the lochia.
 Record all findings and report any abnormality detected
56
 The separation and expulsion of placenta and membranes occur as the results of mechanical and
haemostatic factors.
 Never apply cord traction without applying counter-traction above the pubic bone with the other
hand
 Hold the placenta with both hands and twist it slowly so that the membranes are expelled intact

 What is the purpose of the active management of the third stage of labour?
 What are the steps of the active management of the third stage of labour
 Explain two methods of placenta separation
57
References
Fraser, D, M., & Cooper, M. A. (2003). Myles textbook for midwives (1fourth ed.). London: Churchill
Livingstone.
Fraser, D, M., & Cooper, M. A. (2009). Myles textbook for midwives (15th ed.). London: Churchill
Livingstone.
Konar, H. (2014). DC Dutta's Textbook of Obstetrics and Perinatology (17th ed). JP Medical Ltd.
58
Session 6: Care of a Woman in Normal Puerperium
Prerequisites: Human anatomy and physiology
Learning Tasks
At the end of this session participants are expected to be able:
Define terms related to puerperium
Describe physiology of puerperium
Explain mood changes in puerperium
Give care to a woman in normal puerperium
Resources Needed:
Session Overview
Method
2 10 Brainstorming, Definition terms related to puerperium
presentation
3 60 Lecture discussion Physiology of normal puerperium
4 15 Lecture discussion Mood changes in puerperium
5 20 Presentation Care of a woman in normal puerperium
SESSION CONTENTS
59
STEP 2: Definition of Terms Related to Puerperium (10Minutes)
ASK students to brainstorm on the definitions of:
 Puerperium
 Normal puerperium,
 Involution
 Puerperium
o Is defined as the time from the delivery of the placenta through the first few weeks after the
delivery. Or
o is the period following childbirth during which the body tissues, specially the pelvic organs revert
back approximately to the pre pregnant state both anatomically and physiologically
o This period is usually considered to be 6 weeks in duration
 Normal puerperium
o Is that period when a woman reverts/heals without developing complications So it is the
puerperium without complications
 Involution
o Is the process whereby the genital organs revert back approximately to the state as they were
before pregnancy
STEP 3: Physiology of Normal Puerperium (60Minutes)

During puerperium there several physiological changes occurring in order for the body to return to its
pre non pregnant state, the reproductive organs undergo involution as follows:
The involution of the uterus
 Uterus
o Immediately following deliveries, the uterus becomes firm and retracts with alternate hardening
and softening.
o The uterus measures about 20cm lenghth,12 cm breadth and 7.5 cm thickness and thickness)
and weighs about 1000 gm
o At the end of 6 weeks, its measurement is almost similar to that of the non-pregnant state and
weighs about 60 gm.
o This physiological phenomenon is brought about by the process known as autolysis during
which proteolytic enzymes digest the muscle fibres which have increased during pregnancy to
10 times their normal length and 5 times their normal thickness.
o The end products of autolysis are removed by the phagositic action of polymorphs and
macrophages in the blood lymphatic system.
o This process is further assisted by the contraction and retraction of the uterine muscles under
the influence of oxytocin.
o Endometrium
60
 It becomes 2 –5 mm
 Regeneration occurs from the epithelium of the uterine glands
o Lower uterine segment:
 Immediately following delivery, the lower segment becomes a thin, flabby and collapsed
structure.
 It takes a few weeks to revert back to the normal shape and size of the isthmus, i.e. the part
between the body of the uterus and internal os of the cervix.
o Cervix:
 The cervix contracts slowly
 The external os admits two fingers for a few days but by the end of first week, narrows down
to admit the tip of a finger only.
 The contour of the cervix takes a longer time to regain (6 weeks) and the external os never
reverts back to the nulliparous state
o Muscles
 There is marked hypertrophy and hyperplasia of muscle fibers during pregnancy and the
individual muscle fiber enlarges to the extent of 10 times in length and 5 times in breadth.
 During puerperium the number of muscle fibers is not decreased but there is substantial
reduction of the of the muscle size which is due to withdraw of the steroids hormones which
in turn lead to autolysis by activating the proteolytic enzymes
o Blood vessels
 Arteries are constricted by contraction of its wall and thickening of intima by thrombosis
 New blood vessels grow inside the thrombi
 Hyaline degeneration of tissue wall
o Vagina:
 The distensible vagina, noticed soon after birth takes a long time (4-8 weeks) to involute. It
regains its tone but never to the virginal state.
 The mucosa remains delicate for the first few weeks and submucous venous congestion
persists even longer.
 Rugae partially reappear at third week but never to the same degree as in pre-pregnant state.
 The introitus remains permanently larger than the virginal state.
 Hymen is lacerated and is represented by nodular tags (the carunculae myrtiformes)
 Lochia
o It is the vaginal discharge for the first fortnight during puerperium
o The discharge originates from the uterine body, cervix and vagina.
o Depending on the variation of colour of the discharge lochia is divided in three categories
 Lochia Rubra (Red) 1 –4 days consists of blood, shreads of foetal membrane and deciduas,
vernixcaseosa, lanugo and meconium
 Lochia Serosa (Yellowish Or Pink Or Pale Brownish): 5 to 9 days consists of less RBC, but
more leukocytes, wound exudates, mucous from the cervix and micro organism
 Lochia Alba (Pale White): 10 –15 days contains plenty of decidual cells leucocytes, mucous
cholestrincrystals, fatty and granular epithelial cells and micro organisms
o Amount -250ml (first 5-6days) LOCHI
o Odour - if offensive indicates infection
o Amount - if excessive –indicates infection
o Colour - red colour signifies sub involution or retained products
o Duration -beyond three weeks suggest local genital lesion
61
 Perineum
o The perineum has been stretched and traumatized, and sometimes torn or cut, during the
process of labor and delivery.
o The swollen and engorged vulva rapidly resolves within 1-2 weeks.
o Most of the muscle tone is regained by 6 weeks, with more improvement over the following few
months.
o The muscle tone may or may not return to normal, depending on the extent of injury to muscle,
nerve, and connecting tissues.
 Abdominal wall
o The abdominal wall remains soft and poorly toned for many weeks. The return to a pre-pregnant
state depends greatly on maternal exercise.
 Ovaries
o The resumption of normal function by the ovaries is highly variable and is greatly influenced by
breastfeeding the infant.
o The woman who breastfeeds her infant has a longer period of amenorrhea and an ovulation
than the mother who chooses to bottle-feed.
o The mother who does not breastfeed may ovulate as early as 27 days after delivery.
o Most women have a menstrual period by 12 weeks; the mean time to first menses is 7-9 weeks
 Breast
o With loss of the placenta, circulating levels of estrogen and progesterone decrease and levels of
prolactin increase, thus initiating lactation in the postpartum woman.
o Colostrum, a yellowish fluid that contains more minerals and protein but less sugar and fat than
mature breast milk, and has a laxative effect on the infant, is secreted for the first 2 days
postpartum.
o Mature milk secretion is usually present by the third postpartum day, but may be present earlier
if a woman breast-feeds immediately after delivery.
o Breast engorgement with milk, venous and lymphatic stasis, and swollen, tense, and tender
breast tissue may occur between day 3 and day 5 postpartum.
 Kidney and Bladder
o Mild proteinuria is common for 1 to 2 days after delivery in 50% of postpartum women.
o Bladder tone returns between 5 and 7 days postpartum.
o Stress incontinence is common during the first 6 weeks postpartum
 Neurological function
o Discomfort and fatigue are common.
o After pains and discomfort from the delivery, lacerations, episiotomy, and muscle aches are
common.
o Frontal and bilateral headaches are common and are caused by fluid shifts in the first week
postpartum.
 Cardiovascular function
o Most dramatic changes occur in this system.
o Cardiac output decreases rapidly and returns to normal by 2 to 3 weeks postpartum.
o Hematocrit increases and increased red blood cell (RBC) production stops.
o Leukocytosis with increased white blood cells (WBCs) common during the first postpartum week
 Respiratory function
o Returns to normal by approximately 6 to 8 weeks postpartum.
62
o Basal metabolic rate increases for 7 to 14 days postpartum, secondary to mild anemia, lactation,
and psychological changes
 Gastrointestinal tract
o GI tone and motility decreases in the early postpartum period, commonly causing constipation.
o Normal bowel function returns approximately 2 to 3 days postpartum.
o Liver function returns to normal approximately 10 to 14 days postpartum.
o Gall bladder contractility increases to normal, allowing for expulsion of small gallstones
 Musculoskeletal function
o Generalized fatigue and weakness is common.
o Decreased abdominal tone is common.
 Integumentary function
o Striae lighten and melasma is usually gone by 6 weeks postpartum.
o Hair loss can increase for the first 4 to 20 weeks postpartum and then regrowth will occur,
although the hair may not be as thick as it was before pregnancy.
STEP 4: Mood Changes in Puerperium (15 Minutes)

With rapid changes occurring during the puerperium many women experience some degree of mood
changes during the first few days of puerperium which can be maternal blues or even worse maternal
depression which requires help.
 Maternal blues/postpartum /Baby blues
o It is a transient condition that 75-80% of mothers could experience shortly after childbirth with a
wide variety of symptoms including
 Weepiness and bursting into tears.
 Sudden mood swings.
 Anxiousness and hypersensitivity to criticism.
 Low spirits and irritability.
 Poor concentration and indecisiveness.
 Feeling 'unbounded' with the baby.
 Restless insomnia
o Baby blues is not postpartum depression, unless it is abnormally severe.
 Maternal depression /Postpartum depression
o Postpartum depression occurs in women soon after giving birth. Symptoms include sadness and
hopelessness.
o Counselling and antidepressants are treatment options
STEP 5: Care of a Woman in Normal Puerperium (20 Minutes)

The key principles in caring for women in puerperium are
 To restore the health of the mother
 To prevent infection
 To take care of the breasts including promotion of breastfeeding
 To motivate the mother for contraception
The general care includes

 Monitoring of vital signs including
o Blood pressure , temperature , respiration and pulse rate
63
 General examination including
o Breasts
 A complete breast examination should be performed
o The uterus
 The abdomen should be palpated daily; the uterus should be well contracted and not painful
 Sub involution is identified if the uterus remains the same size for several days, tenderness of
the uterus suggests infection
 Bladder should be empted prior to examination.
o Perineum, vulva and anus
 The perineum, vulva and anus should be inspected to ensure that any trauma is healing
satisfactory the midwife should ensure that vulva pads are changed frequently.
o The lochia
 The character and amount of lochia are noted and the midwife should expect to see gradual
Change in the colour and amount of the lochia as the puerperium progresses.
o The legs
 The mother’s legs should be examined for any tenderness which may suggest thrombosis of
the superficial veins.
 Thrombophlebitis of superficial veins is characterized by swelling, hardness and redness of the
affected veins.
 Deep vein thrombosis which may predispose to pulmonary thrombosis should be suspected if
there is any tenderness on working or when the deep veins of the calf of the leg are pressed.
 Ambulation and exercises
o Ambulation increases muscle tone and venous return from the legs and lower abdomen, it also
increases drainage of lochia and voiding of urine
o Ambulation should be encouraged as soon as possible after delivery
o Mothers are encouraged to walk around not just sit by the bed side.
o Post natal exercises help increase muscle tone and are usually commenced during the first
three days of delivery.
 Care of the breasts, instruct the mother on the following
o The nipple should be washed with sterile water before each feeding.
o It should be cleaned and kept dry after the feeding is over.
 Nutrition
o The diet of a puerperal woman should be nourishing, balanced and varied
o It should include adequate protein to aid tissue renewal and milk production, iron and vitamins to
counteract anaemia, fiber to aid excretion and plenty of fluids
 Follow up visits
o The postnatal mother should be followed up in the post natal clinic on the 7day, 28th day and at
6 weeks.
 Immunization
o Administration of anti–D–gamma globulin to unimmunized Rh–negative mother bearing Rh–
positive baby
o Women who are susceptible to rubella can be vaccinated safely with live attenuated rubella
virus.
o Mandatory postponement of pregnancy for at least two months following vaccination can easily
be achieved.
64
o The booster dose of tetanus toxoid should be given at the time of discharge, if it is not given
during pregnancy
65
 Puerperium Is defined as the time from the delivery of the placenta through the first few weeks after
the delivery
 Normal puerperium
o Is that period when a woman reverts/heals without developing complications So it is the
puerperium without complications
 Involution
o Is the process whereby the genital organs revert back approximately to the state as they were
before pregnancy

 What are the physiological changes during pregnancy?
 What are the maternal mood changes during pregnancy?
66
References
Livingston.
Livingston.
John, N.K,& Bacchus ,M.Y.(2010).Gynecology and family planning(2nd ed). Dar es Salaam.
Varney H., (2004). Varney’s Midwifery text book 4th edition Massachusetts, Tones & Bartelt Pg 666-667
67

8 Normal Labour and Puerperium

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8 Normal Labour and Puerperium

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THE UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND

DIRECTORATE OF HUMAN RESOURCE DEVELOPMENT

FACILITATOR’S GUIDE FOR TECHNICIAN CERTIFICATE

NMT 05208: Care of a Woman in Normal

NMT 05208: Care of a Woman in Normal Labour and Puerperium ii

NMT 05208: Care of a Woman in Normal Labour and Puerperium iii

NMT 05208: Care of a Woman in Normal Labour and Puerperium iv

Dr. Loishook Saitore Laizer

NMT 05208: Care of a Woman in Normal Labour and Puerperium v

SN FULL NAME INSTITUTION/ORGANIZATION

NMT 05208: Care of a Woman in Normal Labour and Puerperium vi

Ndementria Arthur Vermand

NMT 05208: Care of a Woman in Normal Labour and Puerperium vii

NMT 05208: Care of a Woman in Normal Labour and Puerperium viii

3.2. Objectives for the Facilitator’s Guide

4.2. Who is the user of the Guide?

4.3. How is the Module Organized?

NMT 05208: Care of a Woman in Normal Labour and Puerperium ix

NMT 05208: Care of a Woman in Normal Labour and Puerperium x

NMT 05208: Care of a Woman in Normal Labour and Puerperium xi

Dr. Loishook Saitrori

NMT 05208: Care of a Woman in Normal Labour and Puerperium xii

NMT 05208: Care of a Woman in Normal Labour and Puerperium xiii

Ndementria Arthur Vermand

NMT 05208: Care of a Woman in Normal Labour and Puerperium xiv

NMT 05208: Care of a Woman in Normal Labour and Puerperium xv

7.2. Objectives for Training Manual

The module sub-enabling outcome as follows:

8.2. Who is the Module For?

8.3. How is the Module Organized?

NMT 05208: Care of a Woman in Normal Labour and Puerperium xvi

8.4. How Should the Module be Used?

NMT 05208: Care of a Woman in Normal Labour and Puerperium xvii

At the end of this session a student is expected to be able:

STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)

STEP 3: Physiology of the First Stage of Labour (30 Minutes)

STEP 4: Signs of true labour (15 Minutes)

Refer students to Handout no.1.1 cares during labour

STEP 6: Care of a Woman in First Stage of Labour (20 Minutes)

STEP 7: Key Points (5 minutes)

Total Session Time: 120 minutes

Prerequisite: Human anatomy and Physiology

6 50 Lecture discussion Monitoring progress of labour using partograph

STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)

ASK students to brainstorm on the definitions of partograph

ALLOW time for them to respond

WRITE their answers on a flip chart/board.

PROVIDE possible answers as indicated in the notes below.

STEP 3: The Importance of Partograph (15 Minutes)

STEP 4: Parts of the Partograph (15 Minutes)

Foetal Monitoring Section

Labour Progress Monitoring Section

Maternal Monitoring Section

NB: General Information of the Mother

STEP 5: Symbols Used During Partograph Recording (20 Minutes)

IF NORMAL AND IN STAGE I IF NOT NORMAL OR IN STAGE II

Figure 2.3: Standard Partograph Guidelines Source: http://www.tpub.com/content/army/medical

STEP 6: Monitoring Progress of Labour using Partograph (50 Minutes)

Step 7: Key Points (5 minutes)

Step 8: Session Evaluation (15minutes)

Prerequisites: NMT 05107 Care of a woman during antenatal period

4 10 Buzzing, Lecture Signs of second stage of labour

6 55 Demonstration, Lecture Care of a woman in second stage of labour