Management of normal labour

What is labour?

​

• The series of events that take place in the genital organs in an effort to expel the viable products of conception out of womb through the vagina into the outer world is called labour.
• Expulsion of a pre-viable live foetus occurs through the same process but in a miniature form & is called mini labour.

Pre-labour (premonitory stage)

• The premonitory stage may begin 2-3weeks before the onset of true labor in primi & a few days before in multi.

Features are :

• Lightening
• Cervical changes
• Appearance of false pain

What is normal labour ?

• Labour is called normal if it fulfills the following criteria :

1.spontaneous in onset & at term

2.with vertex presentation

3.without undue prolongation

4. Natural termination with minimal aids

5.without having any complications affecting the health of the mother & the baby

Difference between true & false labour pains

True labour pains

• Painful uterine contractions at regular intervals
• Frequency of contractions increase gradually
• Intensity & duration of contractions increase progressively
• Show
• Progressive effacement & dilatation of the cervix
• Decent of the presenting part
• Formation of bag of fore waters
• Not relieved by enema or sedatives

False labour pains

• Dull in nature , Confined to lower abdomen & groin
• Not associated with hardening of the ut
• Without any effect on dilatation of the cervix
• Usually relieved by enema or sedative

Stages of labour

First stage :starts from the onset of true labour pain and ends with full dilatation of cervix.

Average duration : primi:12hrs, multi:6hrs.

Second stage : starts from full dilatation of the cervix and ends with expulsion of foetus from the birth canal. Average duration : primi:2hrs , multi:30min.

Third stage : begins after expulsion of foetus and ends with expulsion of the placenta & membranes.

Average duration : primi:15min , multi:15min.

Fourth stage : it is the stage of observation for atleast 1 hr after expulsion of the after- births.

​

MECHANISM OF LABOUR �

Descend

Flexion

Internal rotation

​

Crowning

​

Extension

Restitution

Internal rotation of shoulder

External rotation of head

Lateral flexion of body

LOA

​

​

​

​

​

LOA

​

​

​

​

​

​

OA

LOA

​

​

​

​

​

​

OA

​

​

​

​

​

​

OA

LOT

Delivery

F

I

C

E

R

I

E

L

Actual management of first stage of labour

​

​

• Consent to be taken
• General : part preparation, antiseptic dressing, Encouragement & emotional support, constant supervision
• Bowel :s/w enema should be given
• Rest & ambulation
• Diet
• Bladder care
• Relief of pain
• Assessment of progress of labour & partograph recording.
• Abdominal palpation: . A)uterine contractions : frequency/intensity/duration

B)Shifting of the maximal impulse of the FHR downwards & medially

​

​

Contd…

• Vaginal examination:

A)dilatation of the cx & to note the station of the head in relation to the ischial spines

B)Colour of the liquor

C)Degree of moulding of the head

D)caput formation

• w/f maternal condition

Management of the second stage

The transition from the first stage to the second stage is evidenced by the following features :

• Increasing intensity of uterine contractions
• Appearance of bearing down efforts
• Urge to defecate with descent of the presenting part
• Complete dilatation of the cervix as evidenced on vaginal examination

General measures

• The pt should be in bed
• Constant supervision is mandatory & the FHR is recorded in every 5 min
• The position & the station of the head are once more to be reviewed & the progressive descent of the head is ensured by p/v

Preparation of delivery

• Position
• Puts on sterile gown ,mask, & gloves & stands on the rt side of the table
• Toileting the ext.genitalia
• Sterile sheets is placed
• 3C”S: a)Clean hand b)Clean surface c) Clean cutting & ligature of the cord
• Catheterise the bladder

Conduction of delivery

• Delivery of the head
• Delivery of the shoulders
• Delivery of the trunk

Delivery of the head

• The pt is encouraged for the bearing down efforts during contractions
• Crowning of the head takes place
• Episiotomy
• Slow delivery of the head in between the contractions is to be regulated
• The forehead nose , mouth, & the chin are thus born successively over the stretched perineum by extension

​

Care following delivery of the head :

​

• Immediately following delivery of the head ,the mucus & blood in the

mouth & pharynx are to be wiped with sterile gauze piece on a little finger.

• The eyelids are then wiped with sterile dry cotton swabs
• The neck is then palpated to exclude the presence of any loop of cord.

​

​

​

Delivery of the shoulders

• Not to be hasty in delivery of the shoulders
• Movements of restitution & ext.rotation of the head to occur during uterine contractions
• Traction on the head should be gentle to avoid excessive stretching of the neck

Delivery of the trunk

• The fore finger of each hand are inserted under the axillae & the trunk is delivered gently by lateral flexion

​

Immediate care of the newborn

• Air passage should be cleared of mucus & liquor by gentle suction
• APGAR rating ---at 1min & 5min
• Clamping & ligature of the cord,
• Baby handed over to paediatrician.

Management of the third stage

​

​

Most crucial stage of labour.

Expectant management:

• Constant watch
• A hand is placed over the fundus to recognise the signs of separation of placenta
• Expulsion of placenta: When the features of placental separation & its descent in to lower segment are confirmed

If placenta is not separated (fails)

• Assisted expulsion by CCT
• Inj.oxytocin 5-10 units IV or methergin 0.2mg im
• To Examine of placenta & memb
• To inspect vulva ,vagina,perineum
• Maintaine vitals

​

​

​

​

Active management of 3^rd stage

• Inj.oxytocin 10 units im (preffered) or inj.methergin 0.2mg im to the mother with in 1min of the delivery of the baby.
• Followed by slow delivery of the baby taking atleast 2 to 3 min.
• If the placenta is not delivered instantaneously, it should be delivered by CCT
• If the first attempt fails ---another attempt is made after 2 to 3 min –this also fails ---another attempt is made at 10 min.
• If this still fails manual removal is to be done.