NORMAL LABOR

05/30/2024 1
 Definition of Labor
• Broadly defined as:
– A coordinated effective sequence of involuntary
uterine contractions that result in effacement and
dilatation of the cervix; and
– voluntary bearing down efforts leading to the
expulsion per vagina of products of conception.
• A physiologic process and is clinical diagnosis
• Parturient: patient in labor
• Parturition: process of giving birth

05/30/2024 2
 Physiologic preparations of labor
• Lightening - the settling of the fetal head into
the brim of the pelvis.
• Braxton Hicks contractions
– irregular, generally painless uterine contractions
during the last 4–8 weeks of pregnancy occur with
slowly increasing frequency.
– may occur with greater intensity during the last
weeks of pregnancy
• Bloody show - passage of a small amount of
blood-tinged mucus from vagina, as the cervix
begins to soften, efface, and dilate.
05/30/2024 3
 Dx of labor
• At least 2 Painful contractions in 10minute
with one of the following:
- Show
- Rupture of the membranes or
- Cervical change Effacement and dilatation
NB
– Rapture of membranes in the absence of painful
contractions is PROM
– Cervical change in the absence of painful contraction is
either cervical incompetence or normal finding in most
multipara women
05/30/2024 4
 Factors for Successful Labor
• The passage
– maternal bony pelvis & soft tissues (uterus,
cervix, pelvic floor, perineum)
• The Passenger
– The Fetus
• The Powers
– uterine contraction, maternal bearing effort,

NB.Needs the complex interaction among these three factors!

05/30/2024 5
 The Passage

• The passage includes the bony pelvis and the

resistance provided by the soft tissues
• The bony pelvis is comprised of;
– The two hip bones/inominate bones
• i.e. ilium, ischium, and pubis, which fuse at the acetabulum,
– the sacrum; and
– the coccyx .
• Fused by four joints:
- Two sacroiliac joints:
- Symphysis pubis
- Sacrococcygeal joint
05/30/2024 6
 Female pelvis – Superior/Anterior view

05/30/2024 7
 False & True pelvis
• Pelvis is anatomically divided in to two:
- False pelvis and true pelvis
• Demarcation between the two is by:
– the sacral promontory,
– anterior ala of sacrum,
– arcuate line of ilium,
– the pectineal line of pubis &
– the pubic crest culminating in Symphysis
– pubis from posterior to anterior on both sides.

05/30/2024 8
 The False pelvis
• Formed by the iliac portions of the innominate
bone and limited by the iliac crests
• Little obstetric significance
• Only supports the uterus during pregnancy

05/30/2024 9
 The True Pelvis
• Forms the canal through which the fetus has
to pass
• Shallow in front (4cm), and deep posteriorly
(11.5 cm) formed by the sacrum and coccyx
• For descriptive purposes, it is divided into 3
planes
I. Inlet,
II. Mid cavity and
III. Outlet.
05/30/2024 10
 Pelvic Inlet
• Also called the superior strait,
• The pelvic inlet is also the superior plane of
the true pelvis.
• Boundaries:-
– Posteriorly; the promontory and alae of the
sacrum,
– Laterally ;the linea terminalis, and
– Anteriorly; the horizontal pubic rami and the
symphysis pubis.

05/30/2024 11
 Pelvic Inlet …….
• During labor, fetal head engagement is defined
by the fetal head’s biparietal diameter passing
through this plane.
• To aid this passage, compared with the male
pelvis the inlet of the female pelvis is more
nearly round than ovoid.
• In erect position, pelvis is tilted forward
making an angle of 60° from horizontal.
• engagement is defined by the fetal head’s
biparietal diameter passing through pelvic inlet.
05/30/2024 12
 Inlet Axis

05/30/2024 13
 The Pelvic Inlet
• Four diameters of the pelvic inlet are usually
described:
Anteroposterior (AP), transverse, and two oblique
diameters.
– Measurements are;
• clinical, x-ray or CT and MRI
1.Anteroposterior Diameters
– There are 3 distinct AP diameters (conjugates)
– True
– Obstetric and
– Diagonal conjugates
05/30/2024 14
 Anteroposterior Diameters
I.The true conjugate (11-11.5 cm )
– Most cephaled, extends from the uppermost
margin of the symphysis pubis to the sacral
promontory.
– Measured indirectly Diagonal Conjugate – 1cm
II. Obstetrical conjugate (10-10.5cm)
– clinically important and the shortest distance
between the sacral promontory and the
Symphysis Pubis
– estimated indirectly by subtracting 1.5 to 2 cm
from the DC Diagonal conjugate—1.5 cm
05/30/2024 15
05/30/2024 16
 III. Diagonal Conjugate
• the distance from the lowest margin of the
symphysis to the sacral promontory (~12cm)
• Determined clinically (PV)

05/30/2024 17
 PELVIC INLET……
2.The Transverse Diameter(`13cm)
– the greatest distance between the linea
terminalis on either side
– constructed at right angles to the O/C. Diameter.
– It usually intersects the obstetrical conjugate at a
point approximately 5 cm in front of the
promontory
3.Oblique Diameters (~12 Cm)
– Each of the two ODs extends from one sacroiliac
synchondrosis to the contralateral iliopubic
eminence.
05/30/2024 18
 Inlet Diameters

05/30/2024 19
 The Midpelvis
• Also called the midplane or plane of least pelvic
dimensions
• The midpelvis is measured at the level of the ischial
spines,
• During labor the midpelvis and ischial spines serve
to mark zero station.
• The Transverse (inter-spinous) diameter ~10cm;
– is the smallest pelvic diameter and, in cases of
obstructed labor, is particularly important.
• The AP diameter through the level of the ischial
spines normally measures at least 11.5 cm.
05/30/2024 20
• the interspinous diameter of the midpelvis.
• The anteroposterior and transverse diameters of the pelvic inlet

05/30/2024 21
 Pelvic Outlet
• The pelvic outlet consists of two
approximately triangular areas whose
boundaries mirror those of the perineal
triangle
• They have a common base, which is a line
drawn between the two ischial tuberosities.
• The apex of the posterior triangle is the tip of
the sacrum, and the lateral boundaries are the
sacrotuberous ligaments and the ischial
tuberosities.
05/30/2024 22
 Pelvic Outlet …
• The anterior triangle is formed by the
descending inferior rami of the pubic bones.
• These rami unite at an angle of 90 to 100 to
form a rounded arch under which the fetal
head must pass.
• Clinically, three diameters of the pelvic outlet
usually are described
– the anteroposterior, transverse, and posterior
sagittal.
05/30/2024 23
05/30/2024 24
 The out let …
• Anteroposterior diameter:
- 9.5-11.5 cm and extends from the lower margin of
the symphysis pubis to the coccyx.
• Transverse diameter:
- 11 cm and is the distance between the inner edges of
the ischial tuberosities.
• Posterior sagittal diameter:
- 8 cm and extends from the tip of the sacrum to a
right-angle intersection with the line between the
ischial tuberosities.
NB :-Unless there is significant pelvic bony disease, the
pelvic outlet seldom obstructs vaginal delivery.
05/30/2024 25
 Out let pelvis

05/30/2024 26
 The Pelvic Axis (Birth axis)
• Anatomical( curve of carus):
– formed by joining the axis of inlet, cavity & outlet.
- Uniformly curved with convexity fitting the
concavity of sacrum
- Fetus doesn’t traverse the uniform curve.
• Obstetrical:
– Fetus negotiates the pelvis, not uniformly curved
- 1st downwards & backwards to the level of ischial
spines and then abruptly forwards

05/30/2024 27
 Pelvic Shapes
• 04 types of pelvis based on shape , anterior
and posterior sagital diameters of the pelvic
inlet
– ie gynecoid, anthropoid, android and platypelloid
• Many pelvis are not pure but are mixed types.
– For example, a gynecoid pelvis with an android
tendency means that the posterior pelvis is
gynecoid and the anterior pelvis is android
shaped.

05/30/2024 28
 Pelvic types
1.Gynecoid:
• The Posteriorsagital diameter of the inlet is only
slightly shorter than the Anteriorsagital diameter
+
• Transverse diameter slightly greater than APD
– most common type (50%);
– overall shape is round
– straight sidewalls and ischial spines are not prominent
– a wide pubic arch
– Straight side walls
– Concave sacrum
05/30/2024 29
 Pelvis types
2.Anthropoid: Ape Type
• The AP diameter is greater than the transverse
• Seen in about 33% of women;
– Overall shape is long and oval;
– Long and narrow sacrum
– Divergent side walls
– Prominent ischial spines;
– Wide sacro-sciatic notch
– Narrow pubic arch
most often associated with persistent OP position.
05/30/2024 30
 Pelvis types
3. Android(male type)
the posterior sagittal diameter of the inlet is much shorter than
anterior sagittal
In ~20% of women
– overall shape is heart-like;
• limiting the posterior space for the fetal head;
– S. Promontory and Ischial spines are prominent;
– Shallow sacrum
– Convergent side walls
– Narrow sacro-sciatic notch
– A narrow pubic arch
associated with persistent occiput posterior position and deep
transverse arrest.
05/30/2024 31
 Pelvis Types
4.Platypelloid:
– least frequent, seen in less than 3% of women;
– flattened shape with short anteroposterior diameter
and wide transverse diameter
– Wide sub-pubic angle
Deep transverse arrest patterns of labor are commonly
associated with this pelvic type occipito frontal diametere
accommodates it self to the long transverse axis with no room for rotation
anteriorly or posteriorly

05/30/2024 32
05/30/2024 33
 Summary

05/30/2024 34
Physiological changes during pregnancy &
labor in the passage
• Increase in width & mobility of symphysis
• Relaxation & mobility of sacro-iliac joint
• Increase in antero-posterior diameter of inlet
during labor- rotatory movement of sacroiliac
joint
• In dorsolithotomy position, the antero-
posterior diameter of outlet by 1.5-2 cm

05/30/2024 35
 The Passenger (the fetus)
Several fetal variables influence the course of labor and
delivery including
1. Fetal size: Estimated clinically, by ultrasound or the
mother
- Fetal macrosomia: 4500 gm (ACOG)
2. Fetal lie: relation of longitudinal axis of the fetus with
the mother and It could be
– longitudinal – > 99% of cases at labor
– transverse
– oblique- 450 with maternal axes, unstable ( change to
longtudinal or transverse lie)
NB In a singleton pregnancy, only fetuses in a longitudinal lie can
be safely delivered vaginally
05/30/2024 36
 The Passenger
3-Presentation
• Refers to that portion of the fetal body that is
either foremost within the birth canal or in closest
proximity to it.
• can be felt through the cervix on vaginal
examination.
– cephalic (Head) or Breech presentations in
longitudinal lies
– Shoulder presentation in transverse lie
– Compound presentation
– Funic (cord) presentation
05/30/2024 37
 The passenger
Cephalic presentations
• Classified according to the relation b/n the head and body ( degree of
flexion)
• Vertex/ Occiput presentation
– Well flexed head chin in contact with the chest
– Occiputal fontanel is the presenting part
• Face presentation
– the fetal neck is sharply extended so that the occiput and back come in contact,
and the face is foremost in the birth canal
– Chin/ Mentum is the denominator
• The fetal head may assume a position between these extremes, I.e.
partially flexed in some cases, with the anterior (large) fontanel, or
bregma, presenting—sinciput presentation —or partially extended in
other cases, to have a Brow presentation
• Sinciput and Brow presentations are usually transient. As labor
progresses they almost always convert into vertex or face presentations
by neck flexion or extension respectively
05/30/2024 38
Longitudinal lie. Cephalic presentation. Differences in attitude of the fetal body
in (A) vertex, (B) sinciput, (C) brow, and (D) face presentations.
05/30/2024 39
 The Passenger
Breech Presentation
• The incidence of breech presentation
decreases with gestational age. It approximates
– 25% at 28 weeks,
– 17 % at 30 weeks,
– 11 % at 32 weeks, and then decreases to
approximately 3 % at term.
• Breech presentation has three general
configurations ie frank, complete, and footling
breech presentations
05/30/2024 40
05/30/2024 41
 Fetus- cont’d
4. Attitude/ Posture : position of head
with regard to fetal spine ie flexed,
extended or military attitude
5. Position refers to the relationship
of an arbitrarily chosen portion of
the fetal presenting part to the
right or left side of the birth canal.
• The fetal occiput, chin (mentum),
sacrum and acromion are the
determining points in vertex, face, Posssible positions in Vertex
presentation
breech and shoulder
presentations, respectively
05/30/2024
Longitudinal lie. Vertex presentation. A. Left occiput anterior (LOA). B. Left occiput
posterior (LOP).
05/30/2024 43
 Longtudinal Lie , Vertex presentationA. Right occiput posterior
05/30/2024 44
(ROP). B. Right occiput transverse (ROT).
 Positions of Face Presentation

05/30/2024 45
 Landmarks of fetal skull for determination of fetal
position-GABEE
05/30/2024 46
05/30/2024 47
 Landmarks of fetal skull for determination of fetal
position-GABEE

• Submentobregmatic (face)-----9.5 cm
• Verticomental (brow)…13.5cm
• Occipito frontal (vertex, military)----11cm
• Suboccipitobregmatic (vetex,flexed)---9.5

05/30/2024 48
05/30/2024 49
 The Passenger
6. Station:
– Measure of descent of bony presenting parts of
fetus through the birth canal
7. Number of fetuses
8. Congenital malformations of fetus
– Abnormalities of the above variables may affect
both the course and likelihood of vaginal
delivery.

05/30/2024 50
 The Power (Uterine activity)
• Is characterized by the frequency, amplitude
(intensity) & duration of contractions.
• Assessment:
- Simple observation
- Manual palpation
- indentablity of uterine fundus during contraction
- Duration of contraction
- External objective assessment-
- Tocodynamometer
- Direct measurement by intrauterine pressure catheter
(IUPC)

05/30/2024 51
 Power-cont’d
• Most precise method is the intrauterine pressure
catheter.
• Adequate uterine contraction remains unclear, but
classically 3-5 contraction in 10 minutes.
• Various units have been used, most common is the
“Montevideo Unit”,
- Adequate uterine contraction if 200-250 MV
• Hyper stimulation, tachysystole(Ux contraction >
5/10 minute), hypertonus.

05/30/2024 52
 Physiology of labor
• The physiology of labor initiation has not been
completely elucidated.
• Labor is species specific, mechanism in humans is
unique.
• Different theories have been postulated:
1. HORMONAL FACTORS:
a. Estrogen theory:
– During pregnancy, most estrogens are in binding
state.
– more free estrogen appears increasing the
excitability of the myometrium and prostaglandins
synthesis.

05/30/2024 53
 Physiology- cont’d
b. Progesterone withdrawal theory
c. Prostaglandins theory:
– PGF2a was found to be increased in maternal and
fetal blood as well as the amniotic fluid late in
pregnancy and during labor w/c increase
contraction.
d. Oxytocin theory:
– The secretion of oxytocinase enzyme from the
placenta is decreased near term due to placental
ischemia leading to predominance of oxytocin’s
action
e. Fetal cortisol theory:
– Increased cortisol production by adrenal increases
estrogen production.
05/30/2024 54
 Physiology- cont’d
2. MECHANICAL FACTORS:
a. Uterine distension theory:
– explains the preterm labor in case of multiple
pregnancy and polyhydramnios.
b. Stretch of the lower uterine segment by the
presenting part at term

05/30/2024 55
 Parturition: Process of Birth
• Phase 0 (Phase of quiescence):
- Refers the time in utero before onset of labor.
- Uterine activity is suppressed by progesterone,
prostacyclin, relaxin, nitric oxide, parathyroid-
related peptide, HPL, etc.
• Phase 1 (Activation phase):
- Estrogen facilitates expression of myometrial
receptors for PGs and oxytocin- Gap junctions
- Prepares the uterus for subsequent stimulation
phase

05/30/2024 56
 Phases-cont’d
• Phase 2 (Stimulation phase):
- Uterotonics, particularly PGs and oxytocin stimulate
regular uterine contractions
• Phase 3 (Uterine involution):
- After delivery, mainly mediated by oxytocin.

 The quiescence, activation and stimulation phases

require endocrine, paracrine and autocrine
interaction between the fetus, membranes, placenta
& mother.
05/30/2024 57
 Mechanisms of labor
• The mechanisms of labor, also known as the cardinal
movements, are described in relation to a vertex
presentation, as is the case in 95% of all pregnancies.
• Refers to the changes in position of fetal head
during its passage through the birth canal.
• Although labor and delivery occurs in a continuous
fashion, the cardinal movements are described as 7
discrete sequences Engagement, Descent ,Flexion,
Internal Rotation, Extension, External Rotation
(Restitution), Expulsion

05/30/2024 58
 Cardinal Movements of Labor
1. Engagement
• The mechanism by which the biparietal diameter /the
greatest transverse diameter/ in an occiput
presentation,passes through the pelvic inlet is designated
engagement.
• Engaged head is at least at station ‘0 ‘ ( level of ischial spines)
• Engagement usually takes place with the the sagittal suture
directed transversely or obliquely
• The fetal head may engage during the last few weeks of
pregnancy in most nulliparous women.
• In most multiparous women the head does not engage until
after labor commencement.
 i.e.the fetal head is freely movable above the pelvic inlet
at labor onset i.e. Floating
05/30/2024 59
 Cardinal movements - cont’d

2.Descent:
• downward passage of presenting part through
the birth canal
• This occurs intermittently with contractions.
• Greatest descent occurs in deceleration
phase (late active stage) & second stage
05/30/2024 60
 Cont’d
3. Flexion: Occurs passively
• Helps to present the smallest presenting
diameter (i.e. from occipitofrontal (11.0 cm) to
suboccipitobregmatic (9.5 cm) for optimal
passage through the pelvis.).
4. Internal rotation:
• Passive movement due to shape of pelvis and
pelvic musculature.
• Rotation of the presenting part from its
original position to AP position & in line with
the AP diameter of the pelvic outlet.
05/30/2024 61
 Cont’d
5.Extension:
• Occurs once fetus descended to a level of interoitus
• Is because of force of uterine contraction versus
muscles of the pelvic floor.
• the result is delivery of the head
6.External rotation: also called as restitution
• Return of fetal head to the correct position in
relation to fetal torso.
• Passive movement
• Results from maternal bony pelvis & its musculature
and basal tone of fetal musculature
7. Expulsion: Delivery of rest of fetus.

05/30/2024 62
05/30/2024 63
05/30/2024 64
Engagement

05/30/2024 65
05/30/2024 66
 Diagnosis of labor
• Made on the presence of :
– At least two contraction per 20 minutes
lasting 20 seconds, and
– Cervical dilatation of 3-4 cm or more
– Cervical effacement of 80% or more
– Show
– Rupture of membranes
• At least two criterias needed to make
the diagnosis /contraction is must/.
05/30/2024 67
 True labor vs. False labor
True labor pain False labor pain
Regular Irregular

Increase progressively not

Lower abdomen & back Lower abdomen

Dilatation & effacement of No effect on cervix
cervix
Not relieved by sedatives Relieved
& antispasmodics
05/30/2024 68
 Stages of Labor
Four arbitrary stages of labor:
 First stage of labor:
- onset of labor till full(10cm) cervical dilatation
 Second stage of labor:
- full cervical dilatation of cervix to delivery of
fetus
 Third stage of labor:
- from delivery of fetus till delivery of placenta
 Fourth stage of labor:
- one to two hours after delivery of placenta.
05/30/2024 69
 First stage of labor
• Two phases: latent and active
1. Latent phase: onset of labor to 3 cm cervical dilatation
2. Active phase: 4 cm – 10 cm cervical dilatation.
• Rate of cervical dilatation is 1.2cm/hr in primi & 1.5
cm/hr for multi.
• Active phase of first stage of labor has three phases:
acceleration, phase of maximal slope, and
deceleration phases for primigravidas.
• Average duration of first stage is 12 hrs in primi and 6 hrs in
multi.

05/30/2024 70
 Stages- cont’d
 SECOND STAGE OF LABOR
• Two phases:
1. Propulsive/anatomical/ passive phase &
2. Expulsive/ Physiological phase
Second stage lasts an hour in primi and
20 minutes in multi.
Rate of descent is 1cm/ hr in primi &
2cm/hr for multi.

05/30/2024 71
 Stages- Cont’d
• THIRD STAGE OF LABOR: Average duration is
15 minutes for both.
• FOURTH STAGE: first one to two hours where
PPH is high.
– This stage is a critical time for monitoring of vital
signs and observe for blood loss & uterine
contractility.

05/30/2024 72
Graphic illustration of the composite dilatation time and descent time
functions in normal labor.
05/30/2024 73
 Composite of the average dilatation curve for nulliparous labor.

05/30/2024 74
 Normal labor- cont’d
 Uterine contractions: pace makers of uterus are at
tubal Ostia on both sides.
• Basic elements in contractile system are:
actin, myosin, ATP, calcium & myosin light chain
kinase.
• Contraction and retraction of uterine muscle.
• Effect of retraction :------------------
 Effacement:
- Taking up the length of cervix expressed in
percentage OR remaining cx length in cm.
-Effacement in primi occur before cervical dilatation
05/30/2024 75
 Events in first stage of labor
• Main events are:
- Dilatation and effacement of cervix
- Full formation of lower uterine segment
 Factors responsible for dilatation:
Uterine contraction & retraction
Bag of waters
Fetal axis pressure in the proper direction
Pressure by the presenting part.

05/30/2024 76
 Events in second stage
• Descent and delivery of fetus
• Delivery effected by two factors:
- Downward thrust by uterine contraction
- Voluntary contraction of abdominal muscles
(maternal pushing)

05/30/2024 77
 Events in third stage of labor
 Phase of placental separation and expulsion
Mechanism of separation:
 Because of retraction there would be marked
decrement in surface area.
 Two types of placental separation
1. Central separation (Schultze):
– Retroplacental clot
2. Marginal separation (Mathews-Duncan):
– separation starts at the margin
– most frequent.
05/30/2024 78
 SUMMARY OF LABOR EVENTS

05/30/2024 79
 Management Of Labor
A. Initial Evaluation
• Maternal BP, PR,RR and Temp.are recorded.
• Review of ANC record
• Most often, unless there has been bleeding in excess
of bloody show, a vaginal examination is performed.
• The gloved index and second fingers are then
introduced into the vagina while avoiding the anal
region
• The number of vaginal examinations correlates with
infection-related morbidity, especially in cases of early
membrane rupture.
05/30/2024 80
 Initial Evaluation- contd.
B.Pelvic Examination
– Cervical assessment
• Dilatation
• Effacement
• Position of cervix ( in relation to the fetal head)
– station of the presenting part
• Pelvis divided into 5th s above and below ischial spines
( -5-4-3-2-1 0 +1+2+3+4+5 cms)
– Position of the presenting part
– Pelvic adequacy assessment
– Status of the membranes- raptured or intact
05/30/2024 81
 Cont’d
C. Investigations:
– urine analysis, Hgb, rapid HIV testing if not tested.
D. preparation:
– No routine enema & perineal shaving
– No routine catheterization
– Position: can assume any position except supine.
– Diet: fluid diet, intravenous hydration when
indicated.

05/30/2024 82
 Contd.
Oral Intake
• Food should be withdrawn during active labor
and delivery.
• Gastric emptying time is remarkably
prolonged once labor is established and
analgesics are administered.
– Risk of vomiting and aspiration,
• Only sips of clear liquids, occasional ice chips,
and lip moisturizers are permitted.
05/30/2024 83
 Contd.
IV Fluids
• Seldom required for normal laboring women.
• An IV infusion system is advantageous during
the immediate puerperium to administer
oxytocin (both prophylactically and
therapeutically).
• Moreover, with longer labors, the
administration of glucose, sodium, and water to
the otherwise fasting woman at the rate of 60
to 120 mL/hr prevents dehydration and acidosis.
05/30/2024 84
 Cont’d
• Pain Control:
- Pain is felt in 1st stage T10-L1; 2nd stage S2-S4
- psycho-prophylaxis, IV analgesics, epidural
analgesia, spinal; etc
 Amniotomy: Not performed routinely
- Indications are: - for Augmentation/induction
- Fetal distress
• Antibiotic prophylaxis: when indicated

05/30/2024 85
 MONITORING OF LABOR
First stage:
FHB
– Every 30 minutes in low risk & every 15 minutes in
high risk women
– FHB has to be counted for a full minute just after
contraction.
Uterine contraction
– every 30 minutes, monitor for 10 minutes
Pelvic evaluation every 4 hrs unless indicated.
Maternal vital signs: BP & Temp. Q 2 Hrly
05/30/2024 86
 Cont’d
Second stage:
FHB every 15 minutes & 5 minutes in low risk
& high risk mothers respectively
Monitor descent hourly.
DELIVERY
– Reduce risk of maternal perineal injury
– Prevent fetal injury
– Provide initial support to newborn

05/30/2024 87
 Management- cont’d
Delivery: Essential aseptic techniques
• No routine perineal massage , individualize
episiotomy
- Optimal position for pushing is not clear.
- Avoid closed glottis
 Delivery of the head: modified Ritgen’s maneuver
 Delivery of shoulders
 Delivery of the rest of body.

05/30/2024 88
 Management- cont’d
 Clear oro-pharynx immediately after delivery
of head /suctioning/.
 Nuchal cord has to be slipped over head if
loose or doubly clamped & cut.
 Cord clamping:
– immediate with in one minute

05/30/2024 89
 LABOR Management- cont’d
Third stage management: Two types
1. Physiological/ expectant:
– waiting for signs and symptoms of separation and
with little assistance.
2.Active:includes
– Cord clamping & cutting,
– Uterotonic administration,
– Controlled cord traction and uterine
massage.
05/30/2024 90
 Management- cont’d
• Care of Newborn:
– APGAR score at the 1st , 5th, 10th minutes, etc.
– Drying
– Avoid heat loss & covering with cotton
clothes
– Label, anthropometric measurements
– Initiate breast feeding or other options
– TTC eye ointment & Vit. K administration
– If needed, neonatal resuscitation
05/30/2024 91
 Management- cont’d
• Examination of genitalia
• Examination of placenta, membranes & cord
• Transfer of the parturient
• Discarding and disinfecting the equipments.

05/30/2024 92
 Partograph
INTRODUCTION
• Early detection of abnormal labor and
prevention of prolonged labour
►↓ maternal - perinatal morbidity & mortality
• The Partograph was developed to this endeavor

05/30/2024 93
 Introduction
• The Partograph is the graphic recording of
1. the progress of labour and
2. the salient condition of the mother & fetus .
• It serves as an “early warning system” and
assists in:
a. early decision to transfer,
b. augmentation and
c. termination of labor.

05/30/2024 94
 Normogram for cervical dilation

05/30/2024 95
 The WHO Partograph
Principles:
• The active phase commences at 3 cm cervical dilation
• The latent phase should not last longer than 8 hrs
• During active phase, the rate of cervical dilation
should not be slower than 1cm/hr
• Vaginal examination;
– infrequently as compatible with safe practice (Q 4 hrs is
recommended)
• Midwives and other personnel managing labor may
have difficulty in constructing alert and action line
►pre-drawn lines
05/30/2024 96
 Modified WHO Partograph
• The WHO Partograph has been modified to
make it simpler and easier to use(2001)
• The latent phase has been removed and
plotting begins in the active phase when the
cervix is 4 cm dilated. (it was 3 cm)

05/30/2024 97
05/30/2024 98
05/30/2024 99
 The WHO partograph-cont’d
Components: 4
- Patient information
- Fetal condition
- Progress of labor
- Maternal condition

05/30/2024 100
Sample
Partogr
aph
for
Normal
Labor

05/30/2024 101
05/30/2024 102
05/30/2024 103
 The WHO partograph-cont’d
• For whom to use it?
- Make sure that there are no complications of
pregnancy that require immediate action
- Make sure that the women is in labor
- In the peripheral health units

05/30/2024 104
 The WHO partograph-cont’d
• Who should use it?
Health workers who are able to:
- Observe and conduct normal labour and delivery
- Perform vaginal examination in labor and assess
cervical dilatation accurately
- Plot cervical dilation accurately on graph against time
• Where to use it?
- No place for home delivery

05/30/2024 105
 Advantages of partograph
• Prevention of prolonged labor
• Avoids unnecessary use of augmentation
• Hand over of patients
- More precise and fluent
- At a glance appreciation of preceding
hours of labor

05/30/2024 106
Advantages of Partograph (Ctd.)
• Pictorial (graphic or clear) display of events of labor:
- Clarifies recordings
- Avoids lengthy written notes
- Facilitates recognition of any omissions
- Saves time → Companionship
• Considerable educational value:
- All interrelated variables of labor can be
seen on a single paper
• Low cost, feasible
• Improved out come of labor →↑Credibility
(trustworthiness) of formal health sector.

05/30/2024 107
 Thank You

05/30/2024 108