OVERVIEW OF NORMAL LABOUR

Objectives
By the end of this session, the participant should be able to:

 Define labour and differentiate between normal and abnormal labour

 Describe true labour versus false labour
 Describe the 4 stages of labour

Definition of labour
Labour is a physiological process, characterized by rhythmic regular uterine contractions increasing in
frequency and intensity, accompanied by progressive cervical effacement and dilatation, and descent of
the presenting part. Labour may be spontaneous or induced.

Definition of normal labour

The foetus is born at term (38-42 weeks gestation) with a single foetus, presenting by the vertex (head)
without complications and is completed within 18 hours with natural, un-aided efforts of the mother
and with no artificial injury to the mother or baby.

Definition of abnormal labour

Abnormal labour has one or more of the following characteristics:

 The pregnancy may not be at term (preterm or postdates)

 There may be one or more fetuses
 Presenting by other presentations than the vertex (head)
 Labour lasting for more than 24 hours
 Assistance needed to effect delivery

Essential diagnosis of normal labour

 Symptoms of normal labour may include:
o History of Intermittent low abdominal pains radiating to the back
o Blood-stained /mucoid vaginal discharge (show)
o Watery vaginal discharge or a sudden gush of amniotic fluid (drainage of liquor)
 Labour is confirmed by the presence of
o Cervical effacement and cervical dilatation.
o Descent of the presenting part

True versus False labour

Labour may be classified as true or false labour. Table below highlights the differences between true and
false labour
Table: Differences between true and false labour
Features True labour False labour

Contractions Regular Irregular

Interval between pains Intensity Gradually shortens Remains long

Intensity Increases Remains the same

Cervical dilatation/effacement Present and progressive Absent

Bulging membranes Present Absent

(Sedation)Analgesic Pain not stopped Pain relieved

Descent of presenting part Present and progressive Absent

Stages of labour
Labour is divided into four main stages:

 First Stage - from onset of labour to full dilatation of the cervix. It has 2 phases

o Latent labour is characterized by;

 Mild to moderate contractions at term.
 Cervix less that 4cm dilated and cervix not effaced.
 Membranes are usually intact but may have ruptured
 Duration <8 hours (the latent phase is prolonged if it has lasted more than 8 hours)

o Active phase of labour is characterized by

 More than 2 regular, painful and progressive uterine contractions in 10minutes
 Progressive shortening and thinning of the cervix
 Cervical dilatation of 4 cm or more

 Second Stage - from full dilatation to expulsion of the foetus.

 Third Stage - from delivery of the baby, to delivery of placenta, membranes and control of
haemorrhage.
  Fourth Stage - Up to one hour after expulsion of placenta.

DIAGNOSIS OF STAGE AND PHASE OF LABOUR

MONITORING LABOUR USING THE PARTOGRAPH

Objectives
By the end of this session, the learner should be able to:

 Describe the importance of the Partograph in identifying and prevention of complications during
labour
 Discuss the various components of the Partograph and how examination findings are plotted
and interpreted

Definition of the Partograph

 It is a simple reliable tool for recording the progress of labour and monitoring the mother and
the foetus.
 The Partograph is an "early warning system" and helps in early decision making for interventions
in labour.
 When used correctly, the Partograph results in reduced complications from prolonged labour for
the mother and baby including;
o Postpartum haemorrhage
o Sepsis
o Obstetric fistula
o Uterine rupture
o Birth asphyxia
o Perinatal mortality and morbidity
Components of the Partograph
There are 4 parts on the Partograph as follows;

1. Identification / Patient's information -Including name, age, parity, name of health facility, date
and time of admission, time of rupture membrane
2. Foetal condition - Foetal heart rate, amniotic fluid and moulding
3. Progress of labour - Cervical dilatation, uterine contractions and descent of the head.
4. Maternal Condition - Drugs and Intravenous (IV) fluids given, vital signs (blood pressure pulse
and temperature), urine test for protein, acetone and volume
 MANAGEMENT OF NORMAL LABOUR
Objectives
By the end of this session, the learner should be able to:

 Discuss the management of the mother during the 4 stages of labour

 Describe active management of the third stage of labour (AMTSL)

Management during the first stage of labour

 Provide supportive, encouraging atmosphere for birth respectful of the woman's wish
 Keep her informed about the progress of labour, explaining all procedures, seek permission and
discuss findings with the woman
 Ensure and respect privacy during examinations and discussions
 Ensure cleanliness of labour and birthing areas.
 Encourage the woman to walk around freely during the first stage of labour
 Remind her to empty her bladder every 2 hours
 Encourage the woman to eat light food and nutritious drinks as she wishes.
 Provide pain relief by suggesting change of position, mobility as comfortable to her, massage her
back if she finds it helpful, holding her hand and sponge her face between contraction, warm
shower if available.
 Support her choice of position (left lateral, squatting, kneeling, standing supported by
companion) for each stage of labour and delivery.
 Teach her breathing techniques during labour.
 If cervical dilatation is 4 cm or greater begin plotting on the Partograph. Monitor the woman and
foetus.

Satisfactory progress in first stage of labour is indicated by

 Regular contractions progressively increasing in frequency and intensity

 Cervical dilatation of at least 1cm per hour with the cervix well applied to the presenting part
 Decent of the presenting part

Management during the second stage of labour

Signs of second stage of labour
 Women have the urge to bear down
 Cervix is fully dilated (i.e. 10 cm dilated)
 Vulva gapes
 Contraction frequent and strong
 Bulging of the perineum
 Rectum looks like a rose bud
 Visible presenting part.

Steps involved in managing second stage of labour

 Once the cervix is fully dilated and the woman is in the expulsive phase of the second stage,
remain with the woman until delivered.
 DO NOT start pushing before the cervix is dilated as that can cause cervical tears! Minimize
cervical exams and manipulation!
 Encourage the woman to assume the position she prefers and encourage her to push.
 Tell the woman to pant or give small pushes with contraction as the baby's head delivers.
 Place the fingers of one hand on the baby's occiput to keep the baby's head flexed (bent) and
control the delivery of the head
 Continue to gently support the perineum as the baby's head delivers
 Once the baby's head delivers, ask the woman not to push
 Check for cord round the baby's neck; if loose, slip it over the baby's head, if tight doubly clamp
and cut before unwinding it from around the neck.
 Allow restitution to take place (spontaneous turning of the baby's head).
 After the baby's head has turned, place a hand on each side of the baby's head and tell the
woman to push gently with the next contraction
 Deliver one shoulder at a time to reduce tear. Move the baby's head posteriorly to deliver the
shoulder that is anterior and lift the head anteriorly to deliver the shoulder that is posterior,
 Grasp the baby under the axilla and support the body as it delivers
 Note and record time of delivery of the baby and sex
 Place the baby on the mother's abdomen or chest. Thoroughly dry the baby, wipe the eyes and
assess the baby's breathing
 Clamp and cut the cord
o Wait for about 1 to 3 minutes if the baby is breathing well before clamping the cord but dry the
baby and keep it warm during this period
o If the baby needs resuscitation, clamp and cut the cord immediately and, proceed with
resuscitation
 Ensure that the baby is kept warm and in skin to skin contact with the mother. Wrap the baby in
a soft dry cloth, ensure the head is covered to prevent heat loss and cover with a blanket
 Encourage the mother to breast feed immediately and within 1 hour of birth
 Palpate the abdomen to rule out the presence of another baby and proceed to actively manage
the third stage of labour.
Managing the Third Stage of Labour
Third stage of labour is the time between delivery of the baby and expulsion of the placenta and
membranes. During this stage, the muscles of the uterus contract downwards and the placenta begin to
separate from the uterine wall.

Active management of the 3rd stage of labour (AMTSL)

It is an effective measure to prevent postpartum haemorrhage. AMTSL includes:

 Prophylactic use of oxytocin

 Controlled cord traction for delivery of the placenta
 Uterine massage after the placenta is delivered

1. Prophylactic use of oxytocin

o Within one minute of delivery of the baby, palpate the abdomen to rule out the presence of
additional baby/babies.
o Give oxytocin 10 IU intramuscular (IM)
o Oxytocin is preferred because it is effective 2-3minutes after injection, has minimal adverse
effects and can be used in all women.

Figure: IM oxytocin 10IU IM

 2. Control Cord Traction
o Wait at least 1-3 minutes before clamping the cord. Before beginning the procedure, observe
signs of separation; cord-lengthening, small bleeding as placenta separates, the uterus usually
becomes rounded.
o Hold the clamped cord and the end of the forceps with one hand.
o Place the other hand just above the woman's pubic bone and stabilize the uterus by applying
counter traction during controlled cord traction. This helps prevent uterine inversion.
o Keep slight tension on the cord and await a strong uterine contraction (2-3 minutes).
o When the uterus becomes rounded or the cord lengthens very gently pull downwards the cord
to deliver the placenta.
o Do not wait for a gush of blood.

Figure: Controlled cord traction

Source: Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors. WHO
2007

o To reduce the risk of the thin membranes tearing off as the placenta delivers, hold the placenta
in two hands and gently turn it until the membranes are twisted. Slowly complete delivery of the
placenta.
o Inspect the maternal surface of the placental lobes for completeness and remove any retained
fragments
3. Uterine Massage
o Immediately after delivery of the placenta, massage the fundus of the uterus through the
woman's abdomen until the uterus is contracted.
o Repeat uterine massage every 15 minutes for the first 1-hour.
o Ensure that the uterus does not become relaxed after you stop uterine massage.
o Ensure the urinary bladder is empty, if not catheterize.

Figure: Uterine massage

Source: Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors. WHO
2007
 Management during the 4th stage of labour
The mother should remain in labour ward where her condition should be assessed

 The perineum, vagina, and cervix should be examined for tears.

 Check vital signs of the mother every 15 minutes
 Observe for vaginal bleeding
 Monitor the newborn's condition for bleeding from the cord, maintain body temperature
Encourage initiation of breastfeeding where appropriate and within 1 hour of birth