NORMAL LABOUR BY Dr SHANZA AUROOJ

2. Dr shanza aurooj
FCPS part-II trainee
Under Prof Dr Naila Ehsan

3. Table of contents:
 Defination of labour
 Female pelvis and fetal head diameters
 Physiology of labour
 Stages of labour
 First stage of labour
 Second stage of labour
 Third stage of labour

4. LABOUR IS A CLINICAL DIAGNOSIS
CHARACTERIZED BY REGULAR PHASIC UTERINE
CONTRACTIONS INCREASING IN FREQUENCY AND
INTENSITY RESULTING IN DILATATION AND
EFFACEMENT OF UTERINE CERVIX,AND ENDS WITH
THE DELIVERY OF THE BABY AND EXPULSION OF
THE PLACENTA

5. THE BIRTH
CANAL:
 The bony pelvis
 Joints & ligaments
 Pelvic muscles

6. Represented by a prominent line starting from the upper border of
pubic symphysis, passing over iliopectineal the anterior aspect of ala of
sacrum, ending at the upper border of first sacral vertebrea called
promontory
 False pelvis:
Above the pelvis brim,having no obstetric importance
 True pelvis:
Below the pelvic brim,related to child birth
A typical female pelvis with optimal configuration for easy vaginal
delivery is called gynecoid pelvis,It is comprised of
1. Pelvic inlet
2. Pelvic cavity
3. Pelvic outlet

7. Pelvic inlet: Anteroposterior
diameter
(true conjugate)=12
cm,from upper border of
pubic symphysis to sacral
promontory
Obstetric conjugate
Shortest AP
diameter=11.5 cm,from
posterior surface of
pubic symphysis to
sacral promontory
Diagonal
conjugate
Measured from the
lower border of
pubic symphysis to
sacral
promontary=12.5 cm
Transverse
diameter:
Between the
farthest two
points on
iliopectineal
line,largest=13 cm

8. The true conjugate can be
measured only on radiographic
films The obstetric conjugate
is measured indirectly by
subtracting 1-2 cm from diagonal
conjugate.The diagonal
conjugate is the most easily and
commonly assessed.
By deeply inserting the wrist, the
promontory may be felt by the tip of
the second finger as a projecting
bony margin. the vaginal hand is
elevated until it contacts the pubic
arch. The immediately adjacent
point on the index finger is
marked.The distance between the
mark and the tip of the second
finger is the diagonal conjugate.

9.  Pelvic cavity:
Lies between outlet &
inlet,bounded in front
by pubic symphysis and
behind by sacrum
 AP diameter :
midlevel of pubic
symphysis & junction of
2nd & 3rd sacral
vertebrae=13 cm
 Transverse diameter:
Measured at the level of
ischial
spines(interspinous
diameter)=11.5 cm

10. Pelvic outlet
Transverse
diameter:
Between ischial
tuberosities=11 cm
Anteroposterior
diameter:
From lower border
of pubic symphysis
to coccyx = 13 cm

11. Caldwell moloy classification of
female pelvis:
 Gyneacoid pelvis (50%)
 Anthropoid pelvis( 25%)
 Android pelvis (20%)
 Platypelloid pelvis(5%)

12. Round inlet &
cavity with
oval
outlet,most
suitable for
vaginal
delivery
Oval inlet &
outlet with
round
cavity,delayed
engagement of
head ,OCP
Heart shaped
inlet,narrow cavity
(prominent spines)&
oval outlet with
narrow subpubic
angle,most
troublesome
pelvis,persistent OCP
& deep transverse
arrest
Kidney
shaped.Flat
inlet,reduced
true
conjugate,wide
subpubic
angle,delay in
head
engagement

13. Fetal diameters:
 Fetal skull diameters
 Transverse
 Anteroposterior
 Fetal body diameters
 Biacromial
(11.5-12cm)distance between the acromial
processes of scapula,if large may cause shoulder dystocia
 Bitrochanteric
(10 cm) distance between the greater
trochanters of femur

14. Bones of fetal skull:

15. Fetal diameters:
biparietal
diameter(9.5
cm),between two
parietal eminence
Bitemporal
diameter(8cm),between
the farthest points of
coronal suture

16. SOB,from base of occipit to
bregma.most favourable as it is
shortest,fully flexed head in vertex
presentation
OPF,from occipital
protruberence to
nasion,slightly
defled
head,favours OCP
SMB,from junction of chin
&neck to bregma,
hyperextended head with
face presentation
VM,from point of chin
to centre of saggital
suture,largest & most
unfavourable,BROW
presentation

17. PHYSIOLOGY OF LABOUR:
oestriol
oestradoil
dehydroepiandrosterone
pregnenolone
cholestrol
Placental oxytoxcin
Prostaglandins
Placental CRH
hypothalamus
Posterior
pituatry
oxytoxcin
Oxytoxcin
receptors
SROM
LABOUR
hypothalamus
anterior
pituatry
ACTH
ADRENAL
GLAND
CRH
DHEA
CORTISOL
Fetal lung
maturity

18. Stages of labour:
STAGES DEFINATION DIVISION DURATION
First stage Begins with the onset of
regular , phasic & co-
ordinate uterine
contractions & end s with
full cervical
dilatation(10cm)
Latent phase:
Begins at onset of
labour & lasts till
cervix is 3 cm dilated
Active phase:
Begins at 3 cm
dilatation till cervix is
fully dilated
8 hrs in Nulliparous,5
hrs in multiparous
5 hrs in nulliparous,2
hrs in multiparous
Total duration is 14
hrs in nulliparous,7
hrs in multiparous
Second
stage
Interval between full
cervical dilatation &
delivery of infant
2 hrs in
nulliparous,1 hr in
multiparous
Third stage Delivery of the placenta &
fetal membranes
30 minutes in
either

19. First stage of labour:
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13 14
hours of labour
hours of labour
Active phase
Dilatationincms
Latent phase
Freidman’s graph of labour

20. Management of first stage of labour:
 DIAGNOSIS
 INITIAL EVALUATION
 GENERAL MEASURES
 DETERMINATION OF PROGRESS OF LABOUR
 MATERNAL MONITORING
 FETAL MONITORING
 MAINTAINING PARTOGRAM
 DOSE OF OXYTOXCIN
 PAIN RELIEF DURING FIRST STAGE

21. DIAGNOSIS OF LABOUR:
HISTORY
• labour pains
• Show
• Sudden loss of
fluid from
vagina
ABDOMINAL
EXAMINATION
• Uterine contractions
• Frequency(3/10)
• Duration(40-60 s)
• Severity(pressure>80
mmhg)
PELVIC EXAMINTAION
• Cervical dilatation
• Effacement
• Consistency
• position
• Level of presenting
part
Diagnosis of labour is confirmed when in the presence of
regular & painful uterine contractions,the cervix is more than 2
cm dilated or more than 80% effaced

22. INITIAL EVALUATION:
BOOKED
PATIENT
Antenatal record
review
Admission test CTG
Vitals/urine
analysis
Usual
management&
Monitoring of
labour
UNBOOKED
PATIENT
Detailed
history/examinat
ion
Routine
investigations(an
tenatal visit)
Usual
management &
monitoring

23. General measures:
ENEMA/
GLYCERINE
SUPPOSITORIES
IV line position
Oral
intake
Bladder
care
Prophylactic
antibiotics

24. Determination of progress of labour
Descent of the presenting part
On P/A examination
(Chricton’s
technique)(number of
fifths head is
palpable)
5/5=free floating
4/5,3/5=entering brim
2/5=fixed,1/5=engaged
On p/v examination(level
of head in relation to
ischial spine)
-1,-2,-3 no of centimters
above ischial
spines,0=ischial spines &
+1,+2,+3 below the ischial
spine
1/5 0
Cervical dilatation
Roughly
assessed by
fingers,1
finger=1.5 cm
P/V examination
Latent phase=3 hourly
Active phase=hourly

25. • VITALS (4 hourly)
• Intake/output chart
• Level of hydration
MATERNAL
• Detection of passage of
meconium
• Fetal cardiac behaviour
• Fetal blood sampling
FETAL

26. DETECTION OF PASSAGE OF MECONIUM
GRADE THREE
Meconium dominates over liquor passed as
semisolid material or black paste
Immediate delivery is indicated
GRADE TWO
both liquor & meconium are drained in equal amounts giving
it a dark green appearance
Fetal distress,labour allowed in
selected cases only
GRADE ONE
small amount of meconium staining liquor light green
or Yellow
LABOUR can be allowed to progress

27. Fetal blood sampling
Normal
PH=7.25-7.30
Suspicious=7.2
-7.25
abnormal=<7.2
in first stage
<7.15
in second
stage

28. Fetal cardiac behaviour
Intermittent fetal heart rate
monitoring
Continous fetal heart rate
monitoring
Pinnard stethoscope
Doppler heart rate
detector(sonicaid)
Performed after a uterine
contraction every 15-30 min during
first stage of labour
CTG

29. Cardiotocograph is the graphical
record of fetal cardiac behaviour &
uterine contractions,measured by
cardiotocogram

32. Admission test
HIGH RISK
CONTINOUS
FETAL HEART
RATE
MONITORING
INTERMITTENT
FETAL HEART
RATE
MONITORING

33. ADMISSION TEST CTG:
 Carried out for 20 minutes at the time of admission,good
predictor of fetal condition for the next 4-6 hrs
 The parameters assesed are
 Baseline fetal heart rate
 Variability
 Acceleration
 Deceleration
 Contractions
 The CTG is then classified according to FIGO classification as
 Normal
 Suspicious &
 Pathological
 Further monitoring is carried out on the basis of this
classification

34. Baseline fetal heart
rate=110-160/min
Fetal
tacycardia>160/min
Fetal hypoxia
Chorioamnionitis
Hyperthyroidism
Anemia
Fetal tachyarrthmiasFetal bradycardia<120/min
Mild100-120/min),OCP,post-
date,transverse
Severe (<80/min for >3 min),cord
compression/prolapse,epidural,mater
nal seizures

35. Normal
variability is
between 10-25
bpm³
Variability can be categorised as: 4
Reassuring – ≥ 5 bpm
Non-reassuring – < 5bpm for between 40-90
minutes
Abnormal – < 5bpm for >90 minutes
Reduced variability:
Fetal
hypoxia,sleep,prematurity,co
ngenital heart diseases

36. 180-
200/min
I60-
180/min
130/min

37. Early decelerations

38. Reduced utero-placental blood flow can be caused by: ¹
Maternal hypotension
Pre-eclampsia
Uterine hyper-stimulation

39. Variable decelerations are usually caused by umbilical cord compression¹
The umbilical vein is often occluded first causing an acceleration in response
Then the umbilical artery is occluded causing a subsequent rapid
deceleration
When pressure on the cord is reduced another acceleration occurs & then the
baseline rate returns

40. Prolonged deceleration
 A deceleration that last
more than 2 minutes
 If it lasts between 2-3
minutes it is classed as
Non-Reasurring
 If it lasts longer than 3
minutes it is
immediately classed as
Abnormal
 Action must be taken
quickly – e.g. Foetal
blood sampling /
emergency C-section

41. •A smooth, regular, wave-like pattern
•Frequency of around 2-5 cycles a
minute
•Stable baseline rate around 120-160
bpm
•No beat to beat variability
•Severe foetal hypoxia
•Severe foetal anaemia
•Foetal/Maternal Haemorrhage

42. FIGO CTG pattern
A. Normal -
(1) Baseline 110-150 bpm
(2) Baseline variability
5-25 bpm
(3) No decelerations /
sporadic mild
deceleration of short
duration
(4) ≥ 2 accelerations
during a 10 minutes
period
B. Suspicious -
(1) Baseline 150-170 or 110-
100 bpm
(2) Variability 5-10 bpm for
> 40 min
(3) Variability > 25 bpm
(4) No accelerations > 40
min
(5) Sporadic mild
decelerations of any type
(6) Variable
deceleratopms
Antepartum - (1) - (5) any
one / combination
Intrapartum - (1) - (4) &
(6) any one / combination
C. Pathological :
Antepartum
(1) Baseline < 100 or
> 170 bpm
(2) Variability < 5
bpm for > 40 min
(3) repeated
decelerations of
any type
(4) Sporadic
noncurrent severe
variable,
prolonged or late
decelerations
(5) Sinusoidal
pattern
Any one or in
combination

43. Interpretations of result:
 Reactive/normal CTG:
low risk,Intermittent fetal heart rate monitoring
required
 Suspicious CTG:
High risk,require continous fetal heart rate monitoring
 Abnormal CTG:
High risk,require EmLSCS

44. PARTOGRAM
 Partogram is a composite graphical record of key data
(maternal and fetal) during labour entered against
time on a single sheet of paper
 Advantages
 Provides information on single sheet of paper at a
glance
 Prediction of deviation from normal progress of labour

45. Patient’s data
Fetal heart rate
Liqour/membranes I C
cervical dilatation
Descent of
presenting part
Uterine contractions Frequency=no of contractions in 10 min
Dots<20 sec,cross hatchin<40 sec,shaded>40 sec
Oxytoxcin=5 u/1 l
BP= 2hrly,PR=30
min.temp 2 hrly
Drugs/IV fluids
Urine(amount,an
y + findings)

47. Systemic anelgesia
Narcotic
Pethidine,Pentazocine
Fentanyl,Butorphenol
Nalbuphine,mepiridine
Non-narcotic:
Benzodiazepam,barbiturates
Penothiazine,ketamine
Inhalation
Entonox
Enflurane
isoflurane
conduction
Lumbar epidural
analgesia
Paracervical block
Spinal anesthesia

48. Lumbar epidural analgesia:
 Pain in first stage is transmitted through T11-
L1,local anesthetic administration in the
epidural space at this level reduces pain by
95%
Procedure:
1. A preload of 500-1000 R/L or hartman’s
solution is given to avoid maternal
hypotension
2. Patient is put in left lateral position or
made to sit at the edge of the bed
3. Local anesthetic is given in the lumbar
region
4. Tuohy needle is advanced in the epidural
space
5. Catheter is inserted through the needle,
needle is withdrawn,punctured site is
sprayed with an antibiotic & dressing
applied
6. Bupivacaine is the drug given,10 ml
initially then top up doses of 3-4 ml 2
hourly

49. PARACERVICAL BLOCK:
 Blocks the sensory
nerves from the uterus as
they traverse the broad
ligament close to each
lateral fornix of vagina
through blockade of
paracervical ganglia
 Given when cervix is 5-7
cm dilated,a 12.5 cm long
needle is introduced in
the lateral fornix,local
anesthesia is given &
lignocaine or
bupivacaine is given

50. OXYTOXCIN FOR LABOUR
AUGMENTATION
• If the
cervix is
unfavoura
ble
(Bishop
score <6)
induction
with
vaginal
prostaglan
dins
should be
considered
• Oxytocin
to induce
labour in
women
with
history of
previous
caesarean
should be
discussed
with the
lead
obstetricia
n prior to
use
• Oxytocin
should not
be used
within 6
hours of
prostaglan
din PGE2
• Oxytocin
should not
be used
with
dinoprosto
ne PGE2)
• Oxytocin
to
augment
labour in a
multigravi
da should
be
discussed
with the
lead
obstetricia
n prior to
use
•
Physiologi
cal
manageme
nt of third
stage is
contraindi
cated in
women
receiving
oxytocin
during
labour
PRECAUTIONS

51. CONTRAINDICAT
ION
Malpresentatio
n: transverse or
oblique lie,
footling breech,
brow
presentation
• Previous
classical
uterine
incision
• Cord
presentatio
n
• Any other
contraindicat
ion to labour
or vaginal
birth
•
Spontaneous
labour
• Abnormal
cardiotocogr
aph (CTG) or
known fetal
compromise
• Placenta
praevia or
vasa praevia
• Active
genital
herpes
• Persisting
maternal
fever

52. oxytocin to the woman and obtain verbal consent
• Explain the anticipated outcome, benefits and risks of
induction of labour with
• Vaginal examination and Bishop Score to reassess
indication and method of induction
A normal cardiotocograph (CTG) must be recorded prior to
the use of oxytocin
P/A should be performed to detect fetal lie/presentation
Document baseline maternal vitals/including uterine
activity

53. EQUIPMENT REQUIRED:
Volumetric pump
IV tubing, Y
extension set, IV
pole and tapes
• 10 units of
oxytocin
(Syntocinon®) for
both multigravid
and primigravid
• 1000 mL flask of
Compound
Sodium Lactate
(Hartmann’s
Solution) or
Normal Saline
• CTG

54. Preparation & administration
• Once the maximum has been reached and a further increase in the infusion
rate is required it must be discussed with the senior obstetrician
• Titrate the infusion rate as may be required to maintain 4 contractions in 10
minutes lasting 40-90 seconds each
• Once 4 contractions in 10 minutes are achieved maintain the infusion rate
• Increase the rate every 30 minutes aiming for 4 contractions in 10 minutes
lasting 40 – 90 seconds each
• Commence the oxytocin infusion at 2 milliunits/min (12 mL/hr) via
volumetric infusion pump
Add 10 units of oxytocin to a 1000 mL flask of Compound Sodium Lactate
(Hartmann’s solution) or Normal Saline. Label flask and sign entries on the
Intravenous Infusion Chart

55. mls per hour of oxytocin infused in measures of milliunits/minute in a solution
of 10 units of oxytocin in 1000ml
ml/hr mu/min Time(minutes)
12 2 0
24 4 30
36 6 60
48 8 90
72 12 120
96 12 120
120 20 180
144 24 210
168 28 240
192 32 270
10 units of oxytoxcin in 1000 ml R/L consist of 10
mU/ml

56. Calculating Flow Rates/drop rates for Infusion Pumps
Calculating Flow Rates for Infusion Pumps in mL/hr:
1oooml/4=250 ml/hr
Calculating Flow Rate in Drops per
Minute
Microdrip: 60 gtt/mL
Macrodrip: 20gtt/mL
15 gtt/mL
10 gtt/mL
36 ml/hr*15÷60=9 drops/min

57. Standard regime of oxytoxcin for
augmentation of labour
REGIMEN
STARTING
DOSE(Mu/m
in)
Incremental
increase(mU
/ml)
Dosae
interval(min
)
Maximum
dose(mU/ml
)
Low dose
0.5-1
1-2
1
2
30-40
15
20
40
High
dose
6 6,3,1 15-40 42

58. OBSERVATION/MONITORING
Continuous (CTG) is
indicated with
commencement of
oxytocin infusion
Uterine contractions
should be assessed
carefully for a 10 minute
period at 30 minute
intervals. Contraction
frequency and duration
should be reconciled with
uterine activity recorded
on the CTG
• Strength of contraction is
a subjective assessment
requiring manual palpation
(correlated with how the
woman perceives her
contractions
• Support and pain relief
options should be offered to
women accordingly
• Record the units of
oxytocin in the flask
(ie 10 units)
• Record the rate of infusion in
mLs/hr (ie 12) at the beginning
of each set of observations
• Enter the
rate of
infusion in
mLs/hr at
the end of
each set of
observations
For example:
12 /24

59. Complications
• Uterine hyperstimulation
• Ruptured uterus - especially in multigravida and
women with a previous caesarean
• Water intoxication with high dose regimen or
prolonged periods of use

60. Monitoring
Mechanism of
labour
Mangement
• Pain relief
• Delivery
procedure

61.  Done on same lines as in first stage
 FHR:
 Intermittent counted immediately following every second
contraction to detect dip in HR
 Continous
 Meconium
 Fetal scalp PH

62. FETAL LIE:  Relationship of the long axis of fetus to long
axis of uterus,normally it is longitudinal

63. ATTITUDERelationship of the fetal head & trunk to the limbs,normally it is flexion
flexed deflexed extended
hyperextend
ed

64. PRESENTATION
Presentation is the part of the fetus present in the
lower pole of the uterus or in the pelvic brim

65. POSITION
Position is determined by selecting a denominator on presenting
part & several points on maternal pelvis, the relationship
between denominator & these points is then determined
Symphysis
pubis
sacrum
Sacroiliac joints
Iliopectineal lines
occiput

69. ENGAGEMENT
When the presenting
part has passed plane of
the pelvic brim and is
less than 2/5th palpable
abdominally,head
engages usually in LOA
or ROA position with
saggital suture
occupying the
transverse diameter

70. FLEXION
Uterine contractions
push the fetus
downwards,while the
cervix resist to this
change resulting in
increased flexion of the
head

71. INTERNAL ROTATION
At the pelvic inlet,head
enters in OL position
to occupy the larger
transverse diameter
At the outlet,the head has to
rotate to occupy the larger AP
diameter & comes to occupy
occipitoanterior position by
rotating through 90 degree

72. EXTENSION
After internal rotation the occiput lies under the pubic arch and to be
born safely,it has to go extension so the sinciput sweeps forward as the
neck extends & intoitus is distended,this is the right time to give an
episiotomy

73. RESTITUTION
Alignment of the head to the
shoulders is called restitution
EXTERNAL
ROTATION
The internal rotation of
the shoulder to come to lie
in AP diameter of the
outlet is viewed outside as
external rotation
Anterior shoulder is delivered from under
the pubic arch followed by posterior
shoulder with lateral flexion of the trunk
and delivery of trunks & buttocks
DELIVERY OF
SHOULDERS
& BODY

75. CONDUCTION ANALGESIA
EPIDURAL
SPINAL
PUDENDAL
NERVE BLOCK
CAUDAL
BLOCK
(low epidural
block)
SADDLE
BLOCK (low
spinal
anesthesia)
LOCAL
ANESTHESIA

76. PUDENDAL NERVE BLOCK

77. PATIENT
PREPARATION
PERINEAL
SUPPORT
DELIVERY OF
HEAD
OXYTOXCIN
ADMINISTRATION
DELIVERY OF
SHOULDERS &
TRUNK
MUCUS
CLEARANCE
SUCTION & CORD
CLAMPING
DELIVERY OF
PLACENTA
INFANT CARE

78. Third stage of labour
 After the delivery of baby marked reduction occurs in
the size of uterus due to contraction & retraction
causing placental separation,the separated placenta is
delivered spontaneously by maternal efforts by
SCHULTZ METHOD MATTHEW DUNCAN
METHOD

79. Signs of placental separation
 Lengthening of cord
 Gush of blood
 Uterus
 Becomes hard
 Mobile from side to side
 Height rises to umbilicus

80. ACTIVE MANAGEMENT OF THIRD
STAGE :
CONTROLLED
DELIVERY OF
PLACENTA
OXYTOXIC
DRUGS

81. OXYTOXCIC DRUGS
 OXYTOXCIN:
 Promotes rhythmical contraction of uterus
 Effects are noticeable after 3 min of IM injection,40-60 sec of IV
injection
 5 units of oxytoxcin produces contraction for about 15 min
 Ergometrine:
 Promotes prolonged contraction with retraction
 effects noticeable after 7 min of i.m injection,40-60 sec of IV injection
 Syntometrine:
 Combined form of 5 units oxytoxcin & 0.5 mg ergometrine
 Oxytoxcin induces early contraction,while ergometrine prolongs it,but
ergometrine should be avoided in PIH,CVS disease,Chronic HPT
These are given after excluding the second twin

82. Time of administration
 IM is carried out crowning of head or after delivery of
head
 IV administration is carried out at the delivery of
anterior shoulder or after the delivery of infant
 Too early administration results in precipitate
labour,while too late results in Postpartum
hemmorhage

83. Controlled delivery of placenta
 Brand Andrews method:
 Umbilical cord is held taught at the vulva in one hand while
uterus is pushed upward with the other hand placed above
the symphysis pubis

84. • Crede’s method:
– Cord is fixed with the lower hand & upward
traction is applied using on the uterus using
abdominal hand
– After delivery of placenta,check for the
completion of placenta