PRACTICE TEACHING CLASS ON :-

STAGES OF LABOUR AND ITS

MANAGEMENT
 INTRODUCTION
• Series of events that takes
place in the genital organs
in an effort to expel the
viable products of
conception out of the
womb through the vagina
into the outer world is
called labour.
DEFINITION OF NORMAL LABOR(EUTOCIA) :-
Normal labour occurs at term and is
spontaneous in onset with the fetus
presenting by the vertex. The process is
completed within 18 hrs and no complication
arise .
 STAGES OF LABOUR
NORMAL LABOR —  divided into Four stages
• First stage: time from the onset of labor pain
until complete cervical dilatation
• Second stage: time from complete cervical
dilatation to expulsion of the fetus
• Third stage: time from expulsion of the fetus
to expulsion of the placenta
• Fourth stage: the 1st post partum hour..
Stages of labour
 Causes of onset of labour :-

• Oxytocin stimulation
• Progestrone withdrawal
• Estrogen stimulation
• Prostaglandin stimulation
DEFINITION
&DURATION
The first stage of labour it
start from the onset of
labour pains to the full
dilatation of the cervix. It
also called as cervical stage.
Average duration for
primigravida is 10-12 hour
and multgravida is 5-6hours
 Physiological changes in first stage of
labour
• Uterine contraction and retraction- The
longitudinal muscle fibres of the upper
segment are attached with circular muscle
fibres of the lower segment and upper part of
the cervix in a bucket holding fashion. Thus
with each uterine contraction, not only the
canal is opened up from above down but it
also becomes shortened and retracted
• Formation of upper and lower segment :
By the end of pregnancy the body of uterus has
divided into 2 segment – upper and lower
segment .
-Upper segment is thick and muscular .
-Lower segment is prepared for distension and
dilatation and is thinner.
IN FIRST STAGE Of LABOUR EVENTS
. The main events that occur in the first
stage are – a] Dilatation and effacement
of the cervix
b] Full formation of lower uterine
segment
 
ACTUAL FACTOR RESPOSABLE ARE
-Uterine contraction and
retraction
-bag of membranes
-Fetal axis pressure
BAG OF MEMBRANES
EFFACEMENT OR TAKING UP OF CERVIX
Effacement is the process by which the
muscular fibers of the cervix are pulled
upward and merges
with the fiber of the lower uterine
segment. The cervix becomes thin
during first stage of labour or even
before that in primigravida. In
primigravida , effacement precedes
dilatation of cervix, whereas in
multipara, both occur simultaneously.
Expulsionof mucus plug is caused by
effacement .
 LOWER UTERINE SEGMENT
. During the labour the body of the uterus
has devided into two anatomically
distinct segment. The wall of the upper
segment becomes progressively
thickened with progressive thinning of
the lower uterine segment.A ridge form
between the upper and lower uterine
segment which is known as retraction
ring.
 partograph
Partograph is a record of all the observations
made on a woman in labour ,the central
feature of which is the graphic recording of
the dilatation of the cervix as assessed by
vaginal examination   
 Purpose :-

• To record the clinical observation

accurately.
• To identify the difference between
latent phase and active phase of labour
• To interpret the recorded partograph
and to identify any deviation from
normal .
 
 Uses of partograph
The partograph should have all data related to
the client in labour and the physiological
changes during the process .It is
recommended to be used in the following
manner.
• Patient information :-
• Name
• Obstetric score
• Hospital number
• Date and time of admission
• Status of membrane on admission to labour
room
 Foetal condition

• Fetal heart rate (FHR) is recorded hourly

during 1st stage and half hourly in 2nd stage of
labour.
• Liquor amini :- aminiotic fluid is observed
and recorded as:
• “I”if the membrane are intact
• “C”if the liquor is clear
• “B” for blood stained liquor
• “R” if membrane are ruptured
• “M”for meconium stained liquor
 Progress of labour :-

• The latent phase

– From onset of labour until the cervix reaches 3 cm
dilatation
– If > 8 hrs  REFER
• The active phase
– After 3 cm dilatation, labour enters the active
phase
– In about 90% of primigravida the cervix dilates at
the rate of 1 cm / hr or faster
 Cont..
• The station is stated in minus figure if it is
above the spine.-1, -2, -3, -4,-5cm
• The station is in plus figure if it is below the
spines. +1,+2,+3,+4,+5cm.
Management on admission
MANAGEMENT OF FIRST STAGE
OF LABOUR
PRINCIPLES:
•Non interference with watchful
expectancy so as to prepare the
patient for natural birth.
•To monitor carefully the
progress of labour, maternal
conditions and fetal behavior so
as to detect any intrapartum
complication early
ACTUAL
MANAGEMENT
-General

-Antiseptic dressing
-Encouragement and
assurance are given to keep
up the morale
•Constant supervision is
ensured
Bowel – An enema with soap and
water or glycerine suppository is
traditionally given in early stage..
This may be given if the rectum
feels loaded on vaginal
examination. But enema neither
shortens the duration of labour
nor reduces the infection rate
 Rest and ambulation – If the
membranes are intact, the patient is
allowed to walk about. This attitude
prevents venacaval compression and
encourages descent of the head
Bladder care: patient is encourage
to pass urine by herself as full
bladder often inhibit uterine
contraction and lead to infection. If
the women can not go to the toilet
she is given a bed pan
Diet – There is delayed
emptying of the stomach in
labour. Food is withheld
during active labour. Fluids
in the form of plain water,
ice chips or fruit juice may
be given in early labour.
Intravenous fluid with
ringer solution is started
where any intervention is
anticipated or the patient is
under regional anesthesia
 Pain control
• The pain of childbirth is likely to be the most
severe pain that a woman experiences during
her lifetime.
 Position change
• Position Changes are recommended for
comfort throughout labor as well as to help
labor progress. Some positions helpful for
pain relief are hands-knees, walking,
standing and leaning on labor partners, side-
lying and straddling while seated on a birth
ball. Mother should continue to change
positions during pushing as well
KNEE PRESS WOMAN SIDE-LYING
WALKING DURING LABOUR
KNEELING ON THE BIRTH BALL
Standing on birth ball
 Relaxation Techniques
• Relaxation Techniques can be helpful
between contractions or during if mother
desires. Use relaxation techniques in rhythm
to the mother's breathing pattern
 Nursing process
Nursing diagnosis
• Anxiety related to concern for self and foetus.
• Acute pain related to uterine contractions and
nausea and vomiting.
• Impaired urinary elimination related to epidural
anaesthesia or from the pressure of the foetus.
• Risk for infection related to rupture of the
membranes.
• Impaired physical mobility related to medical
interventions and discomfort.
• Ineffective breathing pattern related to pain and
fatigue.
 Nursing interventions

-RELIEVING ANXIETY
-RELIEVING PAIN
-IMPROVE URINARY FUNCTION
-PREVENTION FROM INFECTION
-IMPROVE PHYSICAL MOBILITY
-IMPROVE BREATHING PATTERN
•SECOND STAGE OF LABOUR
•The second stage of labour begins with
complete cervical dilatation and ends with the
expulsion of the fetus.

•This stage of labour is concerned with the

descent and delivery of the fetus through the
birth canal.
 Signs of second stage of LABOUR

• EXPULSIVE CONTRACTION
• RUPTURE OF MEMBRANE
• PROGRESSIVE VISIBILITY OF THE FETAL HEAD
AT THE INTROITUS
• DESCENT OF THE FETAL HEAD
 Indications of labour
• The lie is longitudinal
• The presentation is cephalic
• The position is right or left occipitoanterior
• The attitude is one of good flexion
• The denominator is the occiput
• The presenting part is the posterior part of the
anterior parietal bone
 Fetal lie

Longitudinall Transverse
Oblique
T
 MECHANISM OF LABOUR WITH OCCIPUT PRESENTATIONS

ENGAGEMENT

The greatest transverse diameter 9.5cm, BPD passes

through the pelvic inlet
In primigravida, engagement occurs in a significant
number of case before onset of labour and in
multipara ,the same occur in late first stage with
rupture of membrane
Engagement

Occurs when the

fetal presenting part
has passed through
the maternal inlet of
the pelvis
2-DESCENT
• It is the downward movement of the
biparietal diameter of the fetal head to
with in the pelvic inlet. This movement is
the first prerequisite for birth of the
newborn. Descent is brought about by one
or more of four forces.
Descent

• 1. pressure by the amniotic

fluid
• 2. direct pressure by the
contracting fundus on the
fetus
• 3. force of the contraction of
the maternal diaphragm and
abdominal muscles in second
stage labor
• 4. extension and straightening
of the fetal body
 FLEXION

•Flexion increases throughout the labour. As

descent occurs, pressure from the pelvic floor
causes the foetal head to bend forward onto
the chest. The flexion increases the
suboccipito-frontal diameter 10 cm is changed
into suboccipito-bregmatic diameter 9.5 cm.
 Fetus makes his head smaller

flexion

Suboccipito frontal > Suboccipito bregmatic

 Lever action producing flexion of the head; conversion
from occipitofrontal to suboccipitobregmatic diameter
typically reduces the anteroposterior diameter from
nearly 12- to 9.5 cm.
 INTERNAL ROTATION
• During a contraction the leading part is
pushed downward on to the pelvic floor. The
resistance of this muscular diaphragm brings
about rotation. As the contraction fades, the
pelvic floor rebounds causing the occiput to
glide forwards rotates at 45 degree or one eighth
circle . During descent, the head enters the
pelvis with the foetal antereo-posterior head
diameter in a diagonal or transverse position.
Internal rotation
Allows fetal head to
pass beneath the
pubic arch

rotation from transverse

position to an anteroposterior
position
 CROWNING
The head has crowned when it escapes under
the pubic arch and no longer recedes between
contractions because the widest transverse
diameter of the head is born
It stretches the vulval outlet without any
recession of that head even after the
contraction is over called crowning of the
head.
 EXTENSION
• After delivery of the head it returns to the position it
occupied at engagement , the natural position
relative to the shoulders (oblique
position)Restitution
• When the force pushes the head in downward
direction while the pelvic floor offers a resistance in
the upward and forward direction. The sucessive
parts of the fetal head to born through the stretched
to bringing the chin in maternal anal opening
Extension

• Fetal head
extends to allow
the birth of the
occiput, face, and
chin
• Occurs in
response to the
pressure from
uterine
contractions and
shape of pelvic
floor
 RESTITUTION
• It is the visible passive movement of the head
due to untwisting the neck sustained during
internal rotation
• Movement of restitution occurs rotating the
head through 1/8th of a circle in the direction
opposite to that of internal rotation,the
occiput thus points to the maternal thigh of
the corresponding side to which it originally
lay.
Restitution and external
rotation
 EXTERNAL ROTATION
• It is the movement of the rotation of the head visible
externally due to internal rotation of the shoulders.as
the anterior shoulder rotates towards the symphsis
pubis from the oblique diameter,it carries the head in
a movement of external rotation through 1/8th of a
circle in the same direction as restitution.
• The shoulders now lie in the antero- posterior
diameter.the occiput points directly towards the
maternal thigh to side to which directs time of
engagement.
 BIRTH OF SHOULDERS AND TRUNK

After the shoulders are positioned in

antero-posterior diameter of the
outlet,further descent takes place until
the anterior shoulder escapes below the
symphysis pubis first
 Expulsion

Once
shoulders are
delivered, rest
of the body
just slides out
MANAGEMENT OF SECOND STAGE OF LABOR
MANAGEMENT OF SECOND STAGE OF LABOUR

• PREPARATION FOR DELIVERY

• 1) Birthing room -:
• Convert the room to a birth room by opening
the sterile packs of supplies on waiting tables.
The drapes and materials used for birth are
sterile so no microorganisms are accidentally
introduced into the uterus.
• EQUPIMENTS
• Sponges
• Drapes
• Scissors
• Basins
• Clamps
• Bulb syringe
• Vaginal packing
• Gloves
• Towels
 2) POSITIONING FOR BIRTH

A variety of positions can be used for

birth. Alternative birth positions include
the lateral or Sim’s position, dorsal
recumbent semisitting and squatting.
The woman is usually positioned for
birth on a bed with use of leg supports,
in a squatting position, or perhaps on
her hand and knees.
• 3) PERINEAL CLEANING -:
• Clean the perineum with a warmed
antiseptic and then rinse it with a
designated solution before birth. Clean
from the vagina outward, using a clean
compress for each stroke. Include a wide
area (Vulva, upper inner thighs, pubis and
anus) shows a typical pattern for cleaning.
• 4) SUPPORTING THE COUPLE -:
• Both the woman’s partner and the nurse
who has been with the woman during the
labour continue to provide support during
contractions. The woman is encouraged to
push with each contractions and as the
foetal head emerges, is asked to take
shallow breaths and pushing.
•  
• NURSING MANAGEMENT OF SECOND
STAGE OF LABOUR
NURSING DIAGNOSIS
Fear or anxiety related to impending
delivery.
Acute pain related to descent of the
fetus.
Risk for infection related to episiotomy
and trauma.
• IMMEDIATE CARE OF NEWBORN
• AIR PASSAGE -: It should be cleared by
gentle suction.
• APGAR RATING -: It should be done at 1
minute and 5 minute.
• CLAMPING THE CORD -:
• The cord is cut between two clamps
placed 4-5 cm from foetal abdomen and
later umbilical cord is applied 2 -3 cm
from the foetal abdomen. After delivery
the newborn is placed at or below the
level of vagina.
 THIRD STAGE OF LABOR AND
MANAGEMENT

• DURATION:- The third stage of labour

starts after the birth of the baby and ends
with the expulsion of the placenta, umbilical
cord and membranes. Average duration is 5-
15 min.
 MECHANISM OF SEPERATION

• Central separation:
• Marginal separation:
• METHOD OF PLACENTA EXPULSION:-

• 1.SCHULTZE METHOD:-In this there is central

separation of the placenta , with the fetal side
presenting. As the fetal side is shiny and glistening, so it
is called as ‘shiny Schultz’ method. There is the formation
of retro placental clot which puts weight on the placenta,
causing the central portion of the placenta to descend
first. The placenta and amniotic sac gets inverted and it
shows- inverted umbrella type of separation.
• MATHEWS DUNCAN METHOD:-In this there is
marginal separation of the placenta, with the
maternal side presenting. As the maternal side is
rough and red looking, so it is called as ‘dirty Duncan’.
Placental separation starts at margin and placenta
slides on the uterine wall. Blood is visible externally
as it escapes the membranes
 • MANAGEMENT AND TECHNIQUES:-

• ASSISTED EXPULSION:-
• In this assistance is required for the expulsion of
the placenta. It mainly consists of two methods-
• FUNDAL PRESSURE-
• CONTROLLED CORD TRACTION
(MODIFIED BRANDT- ANDREWS
METHOD)
• ACTIVE MANAGEMENT:-
• For the active management of the third
stage, parental oxytocins are given after
delivery of the head or anterior shoulder
of the baby. This excites the powerful
uterine contractions which facilitates early
separation of the placenta and produces
effective haemostasis after the placental
separation.
• ASSESSMENT OF THE PLACENTA:-
• Any clots from the maternal surface must be
removed and kept for measuring. Broken fragments
of cotyledons must be carefully replaced before an
accurate assessment is made.
• *Lobes-The lobes of a complete placenta fit neatly
together without any gaps, the edges forming a
uniform circle.
• Insertion of the cord (on the fetal surface)-normal
insertion is central. Lateral insertion is abnormal.
• *Umbilical vessels-Two umbilical arteries and one
vein should be present. The absence of one artery
may be associated with congenital abnormality,
particularly renal agenesis.
• *Cord length-Average length is 50 cm.
• *Weight of placenta-Approximately one sixth
of the baby’s weight.
• EXAMINATION OF PERINEUM:-
• After the delivery of the baby and placenta,
the perineum is also examined carefully. One
should look for any injuries and to be
repaired, if present. If episiotomy is given, it
is now sutured. The perineal area is cleaned
with cotton swabs soaked in antiseptic
solution. After cleaning, a sterile pad is
placed over the vulva.
• MANAGEMENT OF FOURTH STAGE OF LABOR

• The fourth stage of labor begins with the birth of the

placenta and ends one hour later. The mother may have
expressions of relief and accomplishment, intermingled
with excitement.

EVALUATION AND INSPECTION

• 1. Evaluation of the uterus.
• 2. Inspection and evaluation of the perineum,
vagina and cervix.
• 3. Inspection and evaluation of the placenta,
membranes and umbilical cord.
• 4. Repair of episiotomy and laceration,
USE OF OXYTOCIC DRUGS

Oxytocic drugs stimulate uterine

contractions. A number of factors
should be considered in using
oxytocics during the immediate
postpartum period. They include –
determination of the need, action,
effect, dosage and route.
• QUESTIONS
THANK YOU