Active Management Of Normal Labour..

Aims

 To achieve delivery of a normal healthy child with minimal physical and

psychological maternal effects.
 Early anticipation, recognition and management of any abnormalities during
labour course.

Antenatal Preparation

 Maternal education: about the physiology of labour and symptoms of impending

labour.
 Breathing exercise: adapt the mother to breathing during labour to guard against
respiratory alkalosis caused by hyperventilation.

First Stage of Labour

•History:
Complete obstetric history.
History of present pregnancy:

 Duration of pregnancy.
 Medical disorders during this pregnancy.
 Complications during this pregnancy as antepartum haemorrhage.

History of present labour:

 Labour pains: onset, frequency and duration.

 Passage of "show", fluid or blood per vaginum.
 Sensation of foetal movement.

•Examination:
General examination:

 Height and build.

 Maternal vital signs: pulse, temperature and blood pressure.
 Chest and heart examination.
 Lower limbs for oedema.

Abdominal examination:

 Fundal level.
 Fundal grip.
 Umbilical grip.
  Pelvic grips.
 FHS.
 Scar of previous operations (e.g. C.S, myomectomy or hysterotomy).

Pelvic examination:
Cervix:

1. Dilatation: the diameter of the external os is measured by the finger (s) during P/V
examination and expressed in cm, one finger = 2 cm, 2 fingers = 4 cm and the
distance resulted from their separation is added to the 4 cm in more dilatation.
2. Effacement.
3. Position (posterior, midway, central).

Membranes: ruptured or intact. If ruptured exclude cord prolapse nd meconium stained liquor.
Presenting part and its position.
Station: of the presenting part.
Pelvic capacity.
Investigations: If not done before or if indicated:

 Blood group-Rh typing.

 Urine for albumin and sugar.
 Hb%.
 Ultrasonography.

•Active procedures:
Evacuation of the rectum by enema to;

 avoid uterine inertia,

 help the descent of the presenting part,
 avoid contamination by faeces during delivery.

Evacuation of the bladder:

 ask the patient to micturate every 2-3 hours, if she cannot use a catheter.
 It prevents uterine inertia and helps descent of the presenting part.

Preparation of the vulva:

 Shave the vulva, clean it with soap and warm water from above downwards, swab
it with antiseptic lotion and apply a sterile pad.
Nutrition:
 When labour is established no oral feeding is allowed, but sips of water.
 15 ml magnesium trisilicate is given every 2 hours as an oral antacid to guard
against bronchospasm occurs if the acid vomitus is inhaled during general
anaesthesia "Mendelson’s syndrome". Antacid injections may be used instead.
  If labour is delayed more than 8 hours, IV drip of glucose 5% or saline-glucose
solution is given

.
Posture:

 Patient is allowed to walk during the early first stage particularly with intact
membranes.
 If rest is needed the patient lies on her left lateral position to prevent inferior vena
cava compression and hence placental insufficiency and foetal distress.

Analgesia:

 Pethidine 100 mg IM,

 trilene inhalation, or
 epidural anaesthesia are the most common use.

N.B. Patient should not bear down during the first stage as this is useless, exhausts the
patient and predisposes to genital prolapse.

The partogram:
It is the graphic recording of the course of labour including the following observations:
The mother:

 Pulse every 30 minutes,

 blood pressure every 2 hours,
 temperature every 4 hours,
 uterine contractions: frequency, strength and duration every 30 minutes by
manual palpation or better by tocography if available,
 cervical dilatation,
 fluid input and output,
 drugs including oxytocins.

The foetus

 FHR every 15 minutes by Pinard’s stethoscope or by doptone,

 descent of the presenting part,
 degree of moulding.
 Cardiotocography if available is more valuable for continuous monitoring of both
uterine contractions and FHR particularly in high risk pregnancy.

Second Stage of Labour

Its beginning is identified by:

•The patient feels the desire to defecate.
•The contractions become more prolonged and painful.
•Reflex desire to bear down during the contractions.
•The expulsive effort is accompanied by a sustained expiratory grunt.
•Rupture of membranes, although this is not specific as it may occur earlier i.e.,even before start
of labour ("prelabour rupture of membranes") or later-even to the degree that the foetus is
delivered in an intact sac.
•Full dilatation of the cervix (10 cm) in between uterine contractions is the most sure sign.
Delivery
•The patient is asked to lie in the lithotomy position.
•The lower abdomen, upper parts of the thighs, vulva and perineum are swabbed with antiseptic
lotion.
•Sterile towels are applied.

Bearing down
Ask the patient to bear down during contractions and relax in between.

Delivery of the head

The main aim during delivery of the head is to prevent perineal lacerations through the following
instructions:
•Support of the perineum:
When the labia start to separate by the head, a sterile pad is placed over the perineum and
pressed on with the right hand during uterine contractions. This is continued until crowning
occurs to maintain flexion of the head.
•Crowning:

 is the permanent distension of the vulval ring by the foetal head like a crown on
the head. The head does not recede back in between uterine contractions.
 This means that the biparietal diameter has just passed the vulval ring and the
occipital prominence has escaped under the symphysis pubis.
 After crowning, allow slow extension of the head so the vulva is distended by the
suboccipito frontal diameter (10 cm).
 If the head is allowed to extend before crowning the vulva will be distended by
the occipito-frontal (11.5 cm), increasing the incidence of perineal lacerations.
 Ritgen manoeuvre: upward pressure on the perineum by the right hand and
downward pressure on the occiput by the left hand to control the extension of the
head.

•Episiotomy: It is done at crowning when the perineum is stretched to the degree that it is about
to tear.
•Swab and aspirate: the mouth and nose once the head is delivered and before respiration is
initiated to prevent the liquor, meconium or blood being inhaled.
•Coils of the umbilical cord: if present around the neck, are slipped over the head; but if tight or
multiple, they are cut between 2 clamps.

Delivery of the shoulders

Gentle downward traction is applied to the head till the anterior shoulder slips under the
symphysis pubis. The head is lifted upwards to deliver the posterior shoulder first;then
downwards to deliver the anterior shoulder.

Delivery of the remainder of the body

Usually slips without difficulty otherwise gentle traction is applied to complete delivery.

Clamping the cord

The baby is held by its ankles with the head downwards at a lower level than its mother for few
seconds. This is contraindicated in:
•Preterm babies.
•Erythroblastosis foetalis.
•Suspicion of intracranial haemorrhage.
This may be enhanced by milking the cord towards the baby, to add about 100 ml of blood to its
circulation.
The cord is divided between 2 clamps to avoid bleeding from a possible 2nd uniovular twin.

Third Stage of Labour

Delivery of the placenta

Conservative method:
•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.
•Wait for signs of placental separation and descent but do not massage the uterus.
•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.
•Hold the placenta between the two hands and roll it to make the membranes like a rope in order
not to miss any part of it.
•Give ergometrine 0.5 mg or oxytocin 5 units IM after delivery of the placenta to help uterine
contraction and minimise blood loss. These may be given before delivery of the placenta.

Signs of placental separation and descent:

•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.
•Elongation of the cord particularly on pressing on the uterine fundus and it does not recede back
into the vagina on relieving the pressure.
•Gush of blood from the vagina.

The active method (Brandt- Andrews method):

•With delivery of the anterior shoulder, 0.5 mg ergometrine or syntometrine (0.5 mg ergometrine
+ 5 units oxytocin) is given IM.
•When the uterus contracts, put the left hand suprapubic and push the uterus upwards while
gentle downward and backward traction is applied on the cord by the right hand when the
placenta is delivered it is rolled as in the conservative method.
•Advantage: reduction of the blood loss.
•Disadvantages:

1. Constriction ring may occur with retention of the placenta.

2. Avulsion of the cord if undue pressure is applied.
3. Inversion of the uterus if fundus is pressed while the uterus is lax.

Routine examinations
•Examination of the placenta and membranes:
by exploring it on a plain surface to be sure that it is complete. If it's not,exploration of the uterus
is done under general anaesthesia.
•Explore the genital tract:
For any lacerations that should be immediately repaired.

Repair of episiotomy

Fourth Stage of Labour

Observation of the patient (particularly for atony of the uterus and vaginal bleeding).

Care of The Newborn

Clearance of the air passages
•The newborn is placed in supine position with the head lower down. A metal, rubber or
disposable plastic catheter is used to aspirate the mucus from the pharynx and mouth directly by
the physician’s mouth or by attaching it to an electric suction pump.
•Crying of the baby usually occurs within seconds.If delayed,slapping its soles, flexion and
extension of the legs and rubbing the back usually stimulates breathing.
Apgar score
Is calculated at 1 and 5 minutes and further steps of resuscitation are arranged according to it.
The umbilical cord
•A disposable plastic umbilical clamp is applied about 5 cm from the umbilicus to avoid the
possibility of tying an umbilical hernia then cut about 1.5 cm distal to the clamp. Inspect for
bleeding and paint it with alcohol.
•If the plastic umbilical clamp is not available, 2 ligatures of silk are applied instead of it.
•The umbilical stump is painted daily with an antiseptic till its fall within 10 days.
Congenital anomalies
The newborn is examined for injuries or congenital anomalies as imperforate anus, hypospadias
(not to be circumcised as the cut skin will be used in the repair later on), cyanotic heart
diseases.... etc.
Weight:
Weigh the newborn and record it.
Dressing
Dressing (as well as all previous procedures) should be done in a warm place to prevent heat loss
which occurs rapidly after delivery increasing the metabolism and acidosis.
Care of the eyes
Antibiotic eye drops (eg.chloramphenicol) are instilled into the eyes as a prophylaxis against
ophthalmia neonatorum.
Identification:
of the baby by a plastic bracelet on which its mother’s name is written.

Definition of labour.
Labour or parturition is the process whereby the products of conception are expelled from the
uterine cavity after the 24th week of gestation.

The three stages of labour.

 The first stage commences with the onset of labour and terminates when the cervix has
reached full dilatation and is no longer palpable.
 The second stage or stage of expulsion begins at full cervical dilatation and ends with
expulsion of the fetus.
 The third stage or placental stage begins with the delivery of the child and ends with the
expulsion of the placenta.

Onset of labour.
The onset of The onset of labour is defined as the time of onset of regular, painful uterine
contractions, which produce progressive effacement and dilatation of the cervix. It is often
difficult to be certain of the exact time of onset of labour because of the occurrence of ?false
labour? where the onset of painful contractions is not associated with progressive dilatation of
the cervix.

The clinical signs of the onset of labour include:

 The onset of regular, usually painful contractions that produce progressive cervical
dilatation
 The exhibition of a vaginal show ? the passage of blood stained mucus.
 Rupture of the fetal membranes ? this is variable and may occur at the time of onset of
contractions or it may be delayed until the delivery of the fetus.

Making a decision about the time of onset of labour has important implications for the
subsequent management of labour. An assumption that labour is abnormally prolonged may
result from an erroneous decision as to the time of onset of labour - see active management of
labour.

The initiation of labour.

Despite extensive research, the mechanism of the onset of labour remains uncertain.
There are many factors that change at the time of the onset of labour. Furthermore, the inhibition
and promotion of certain factors can both delay or accelerate the process of parturition. It is
unlikely that any one factor is sufficient to provide an explanation for the onset of labour as
intervention at any one of several biochemical points can either stimulate or delay it.

It is likely that there is a cascade of events regulated and controlled by the fetoplacental unit.

During pregnancy, uterine activity is present but is minimal. At the end of gestation, there is a
gradual downregulation of those factors that keep the uterus and cervix quiescent and an
upregulation of procontractile influences.

 At term, the fetus increases its production of cortisol and this cortisol reduces the
production of placental progesterone and increases the production of oestrone and
oestradiol.
 Progesterone suppresses uterine activity and oestradiol increases it. 
 These changes also result in increased production of prostaglandins by the placenta and
thus a further increase in myometrial activity. These changes also stimulate oxytocin
release, which also enhances myometrial activity. Other hormones produced in the
placenta also act directly or indirectly on the myometrium, such as relaxin, activin A,
follistatin, hCG and corticotrophin-releasing hormone (CRH).

The cervix contains myocytes and fibroblasts and serves to contain the products of conception.
Towards term, the cervix becomes softened as there is a decrease in the amount of collagen and
an increase in proteolytic enzyme activity. Increased production of hyaluronic acid reduces the
affinity of fibronectin for collagen and, in conjunction with the affinity of hyaluronic acid for
water, there is a conse quent softening and ripening of the cervix.

Increasing cervical compliance allows progression of labour with reduced intrauterine pressure.
The cervix also contracts during labour up to 3?4 cm dilatation but, in the active phase of labour,
cervical dilatation occurs secondary to uterine contractions alone. In other words, the cervix is
passively stretched by the increasing strength of the uterine contractions.

The Powers - Uterine Activity In Labour

The uterus exhibits infrequent, low-intensity contractions throughout pregnancy. As full term
approaches, uterine activity increases in both the Frequency and strength of contractions. With
the onset of labour, intrauterine pressures rise to 20?30 mmHg during contractions that occur
every 10?15 minutes and last approximately 30?40 seconds. Normal resting tonus in labour starts
at around 10 mmHg and increases slightly during the course of labour. Contractions increase in
intensity to reach pressures of 50 mmHg ? around 5 kPa ? in terms of active pressure in the first
stage of labour (Figure 1).
 Figure 1.

Uterine contractions reach pressures of 50 mmHg (6.5 kPa) with first stage of labour.
Contractions become painful when amniotic pressure exceeds 25 mmHg (3.2 kPa).

(From Symonds E M: Essential Obstetrics and Gynaecology, 4th ed. Edinburgh, C hurchill
Livingstone, 2003, p 153)

In the second stage, with the additional effect of voluntary expulsive efforts, intrauterine pressure may rise to 100
mmHg. Throughout labour, contractions produce effacement (Figure 2) and dilatation of the cervix as the result of
shortening of myometrial fibres in the upper uterine segment and stretching and thinning of the lower uterine
segment. This process is known asretraction. The lower segment becomes elongated and thinned as
labour progresses and the junction between the upper and lower segment rises in the abdomen.
Where labour becomes obstructed, the junction of the upper and lower segments may become
visible at the level of the umbilicus; this is known as a retraction ring.

Contractions are initiated by a pacemaker in the left uterine cornua and spread downwards
through the myometrium. Contractions occur first in the fundus of the uterus, where they are
stronger and last longer than in the lower segment. This phenomenon is known as fundal
dominance and is essential to progressive effacement and dilatation of the cervix. As the uterus
and the round ligaments contract, the axis of the uterus appears to straighten, pulling the
longitudinal axis of the fetus towards the anterior abdominal wall in line with the inlet of the true
pelvis.

The realignment of the uterine axis promotes descent of the presenting part as the fetus is pushed
directly downwards into the pelvic cavity.
 Figure 2. Cervical Effacement.

The Passages
The female

The female pelvis has a wide birth canal and wide pubic arch (Figure 3). Because of softening of
the sacroiliac ligaments and the pubic symphysis, some expansion of the pelvic cavity can occur.
The soft tissues also become more distensible than in the non-pregnant state and substantial
distension of the pelvic floor and vaginal orifice occurs during the descent and birth of the head.
This commonly results in tearing of the perineum and of the vaginal walls and sometimes in
tearing and disruption of the external anal sphincter.
 Figure 3. The female pelvis

The Second Stage of Labour

 

The Mechanism Of Labour

 

The head normally engages in the pelvis in the transverse position and the passage of the head
and trunk through the pelvis follows a well-defined pattern (Figure 4).

Figure 4.
The process of normal labour involves the adaptation of the fetal head to the various segments
and diameters of the maternal pelvis and the following processes occur. Descent occurs
throughout labour and is both a feature and a pre-re quisite for the birth of the baby. Engagement
of the head normally occurs before the onset of labour in the primigravid woman but may not
occur until labour is well established in a multipara. Descent of the head provides a measure of
the progress of labour.

Flexion of the head occurs as it descends and meets the pelvic floor, bringing the chin into
contact with the fetal thorax. Flexion produces a smaller diameter of presentation, changing from
the occipito-posterior diameter, when the head is deflexed, to the suboccipito-bregmatic diameter
when the head is fully flexed. 

Figure 5. Head descending.

Internal rotation: The head rotates as it reaches the pelvic floor and the occiput normally rotates
anteriorly from the lateral position towards the pubic symphysis (Figure 6). Occasionally, it
rotates posteriorly towards the hollow of the sacrum and the head may then deliver as a face-to-
pubes delivery.
 Figure 6. Rotation of head to occipito-anterior position.

Extension: The acutely flexed head descends to distend the pelvic floor and the vulva, and the
base of the occiput comes into contact with the inferior rami of the pubis. The head now extends
until it is delivered. Maximal distension of the perineum and introitus accompanies the final
expulsion of the head, a process that is known as crowning (Figure 7).

Figure 7. Delivery of the head.

Restitution: Following delivery of the head, it rotates back to be in line with its normal
relationship to the fetal shoulders (Figure 8).
 Figure 8. External rotation of the head allowing delivery of the shoulders.

External rotation: When the shoulders reach the pelvic floor, they rotate into the antero-posterior
diameter of the pelvis. This is accompanied by rotation of the fetal head so that the face looks
laterally at the maternal thigh.

Delivery of the shoulders Figures 9 and 10.

Figure 9. Delivery of the Anterior Shoulder.

 Figure 10. Delivery of the Posterior Shoulder.

Final expulsion of the trunk occurs following delivery of the shoulders. The anterior shoulder is
delivered first by traction posteriorly on the fetal head so that the shoulder emerges under the
pubic arch. The posterior shoulder is delivered by lifting the head anteriorly over the perineum
and this is followed by rapid delivery of the remainder of the trunk and the lower limbs.

The Valsalva pushing technique (the glottis is closed so that the mother pushes without expelling
air) is used routinely in the second stage of labour in many countries, and it is accepted as
standard obstetric management in Turkey.

The purpose of a study in Turkey was to determine the effects of pushing techniques on mother
and fetus in birth in this setting. This randomized study was conducted between July 2003 and
June 2004 in Bakirkoy Maternity and Children's Teaching Hospital in Istanbul, Turkey. One
hundred low-risk primiparas between 38 and 42 weeks' gestation, who expected a spontaneous
vaginal delivery, were randomized to either a spontaneous pushing group or a Valsalva-type
pushing group. Perineal tears, postpartum haemorrhage, and haemoglobin levels were evaluated
in mothers; and umbilical artery pH, Po(2) (mmHg), and Pco(2) (mmHg) levels and Apgar
scores at 1 and 5 minutes were evaluated in newborns in both groups. No significant differences
were found between the two groups in their demographics, incidence of nonreassuring fetal
surveillance patterns, or use of oxytocin. The second stage of labour and duration of the
expulsion phase were significantly longer with Valsalva-type pushing. Differences in the
incidence of episiotomy, perineal tears, or postpartum hemorrhage were not significant between
the groups. The baby fared better with spontaneous pushing, with higher 1- and 5-minute Apgar
scores, and higher umbilical cord pH and Po(2) levels. After the birth, women expressed greater
satisfaction with spontaneous pushing. It was concluded that educating women about the
spontaneous pushing technique in the first stage of labour and providing support for spontaneous
pushing in the second stage result in a shorter second stage without interventions and in
improved newborn outcomes. Women also stated that they pushed more effectively with the
spontaneous pushing technique.0801
 

The Third Stage of Labour

The third stage of labour starts with the completed expulsion of the baby and ends with the
delivery of the placenta and membranes.

Immediately after delivery of the baby, the placenta is still attached inside the uterus. Some time
after delivery, the placenta will detach from the uterus and then be expelled. This process is
called the "3rd stage of labour" and may take just a few minutes or as long as an hour.

Signs that the placenta is beginning to separate include:

 A sudden gush of blood

 Lengthening of the visible portion of the umbilical cord.
 The uterus, which is usually soft and flat immediately after delivery, becomes round and
firm.
 The uterus, the top of which is usually about half-way between the pubic bone and the
umbilicus, seems to enlarge and approach the umbilicus.

Immediately after the delivery of the baby, uterine contractions stop and labour pains go away.
As the placenta separates, the woman will again feel painful uterine cramps. As the placenta
descends through the birth canal, she will again feel the urge to bear down and will push out the
placenta.

Figure 11. Separation of the placenta from the uterus