PHYSIOLOGY AND MANAGEMENT

OF
NORMAL LABOUR

FOR

MIDWIFERY STUDENTS
COMPILED BY:
RACHEAL ANNOR

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 TABLE OF CONTENT

CONTENT PAGES
TABLE OF CONTENT ....................................................................................................... 2
CHAPTER ONE ................................................................................................................... 4
PHYSIOLOGICAL PROCESS OF LABOUR .................................................................. 4

CHAPTER TWO ................................................................................................................ 14

CLINICAL DECISION MAKING ................................................................................... 14

CHAPTER THREE ............................................................................................................ 32

PHYSIOLOGY AND MANAGEMENT OF THE FIRST STAGE OF LABOUR ...... 32
FACTORS AFFECTING FIRST STAGE OF LABOUR .............................................. 32

CHAPTER FOUR .............................................................................................................. 47

MONITORING OF LABOUR USING THE PARTOGRAPH ..................................... 47

CHAPTER FIVE ................................................................................................................ 60

FETAL MONITORING IN LABOUR ............................................................................. 60

CHAPTER SIX ................................................................................................................... 67

PHYSICAL NEEDS OF CLIENTS IN LABOUR........................................................... 67
NUTRITIONAL NEEDS OF CLIENT IN LABOUR. .................................................... 67

CHAPTER SEVEN ............................................................................................................ 85

PHYSIOLOGY AND MANAGEMENT OF THE SECOND STAGE OF LABOUR . 85

CHAPTER EIGHT ........................................................................................................... 118

PHYSIOLOGY AND MANAGEMENT OF THE THIRD STAGE OF LABOUR ... 118

CHAPTER NINE .............................................................................................................. 147

MANAGEMENT OF THE FOURTH STAGE OF LABOUR ..................................... 147

CHAPTER TEN ............................................................................................................... 152

PERINEAL TRAUMA (TEARS AND EPISIOTOMY) ............................................... 152
CHAPTER ELEVEN ....................................................................................................... 162
POSITIONING AND HANDLING ................................................................................ 162

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INTRODUCTION ............................................................................................................ 172
OBJECTIVE OF THIS MANUAL ................................................................................. 173
TARGET AUDIENCE ..................................................................................................... 173
THE LABOUR CARE GUIDE ....................................................................................... 174
STRUCTURE OF THE LCG .......................................................................................... 176
NOMENCLATURE TO COMPLETE THE LCG ....................................................... 181
HOW TO COMPLETE SECTION 4: CARE OF THE WOMAN .............................. 195
REFERENCES ................................................................................................................. 210

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 CHAPTER ONE
PHYSIOLOGICAL PROCESS OF LABOUR
Definition of Labour
Labour is a process by which products of conception (foetus, placenta, cord and
membranes) are expelled from the uterus (Beckman C. R.B et al 1995).
Labour, according to Kwawukume Y (2002), is defined as the occurrence of uttering
contractions of sufficient frequency of one contraction every two to three minutes,
intensity and duration of 40 to 60 seconds resulting in effacement and dilatation of
the cervix.
Process by which the fetus, placenta and membranes are expelled from the birth
canal (Daine M.Fraser & Margaret A. Cooper 2003)
“Onset of labour can be defined as regular contractions bringing about progressive
cervical change. Therefore labour is usually made in retrospect. Loss of show or
spontaneous rupture of membranes does not define the onset of labour, although
they may occur at the same time. Labour can be well established before any of these
event occur, and both may precede labour by many days” (Baker N & Kenny C.
2011).
Labor is a sequence of uterine contractions that results in effacement and dilatation
of the cervix and voluntary bearing-down efforts leading to the expulsion per vagina
of the products of conception.
Delivery is the mode of expulsion of the fetus and placenta. Labor and delivery is a
normal physiologic process that most women experience without complications.
The goal of the management of this process is to foster a safe birth for mothers and
their newborns

Normal Labour-definition
The following criteria should be present to call it normal labour (WHO):
Occurs between 37 and 42 weeks gestation. That is around 280 days plus or
minus 10 days. Thus the pregnancy should be at term.
Spontaneous onset
of a single,
mature foetus,
Lie-longitudinal,
presented by vertex,
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 Spontaneous expulsion,
all through the birth canal,
within a reasonable time (not less than 3 hours or more than 18 hours),
without complications to the mother (low risk throughout) or the foetus.
THEORIES OF ONSET OF LABOUR
The exact mechanism that initiates labour is unknown. However, Combination of
factors can initiate labor. These factors can be grouped under hormonal and
mechanical
Hormonal Factors
1. Oestrogen Theory: during pregnancy, most of the oestrogens are present in a
binding form. Later part of pregnancy more free oestrogens appears increasing
the excitability of the myometrium (display of oxytocic receptors and gap
junctions) and prostaglandins synthesis (produced enzyme that digest collagen
fibers in the cervix to soften)
2. Progesterone Withdrawal Theory: this is the hormone designed to promote
pregnancy. Its presence inhibits uterine motility. There is a drop in progesterone
synthesis with aging placenta leading to predominance of excitatory action of
oestrogens
3. Oxytocin Theory: Secretion of oxytocinase enzyme from the placenta is
decreased near term due to placental ischaemia leading to predominance of
oxytocin action. One of the most important biochemical factors in stimulating
uterine contractions.
Oxytocin stimulates myometrial contractions. Oxytocin and prostaglandin work
together to inhibit calcium binding in muscle cells, raising intracellular calcium
levels and activating contractions. The oxytocin level surges from stretching of
the cervix.
4. Foetal Cortisol theory: increased cortisol production from the foetal adrenal gland
before labour inhibit progesterone production from the placenta
5. Prostaglandin Theory: is another most important biochemical factors in
stimulating uterine contractions. It’s secreted from the fore bag. PE2 and PF2a
are powerful stimulators of uterine muscle activity. A decrease in progesterone
production elevates prostaglandin synthesis. The factors which may bring about
increased production of prostaglandins include trauma, haemorrhage and (most

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 importantly) infection which now recognized as a major factor in initiating many
premature deliveries.

Mechanical Factors
1. Uterine Distension: there is a concept that any hollow body organ when
stretched to its capacity will inevitably contract to expel its contents. The uterus
which is a hollow muscular organ becomes stretched due to the growing foetal
structures. Labour therefore follows when forces of retention are overcome by the
force of release.
2. Stretch of The Lower Uterine Segment: Pressure on the cervix stimulates the
hypophysis (pituitary gland) to release oxytocin from the maternal posterior pituitary
gland

Other Factors
The onset of labour can also be associated with hyperpyrexia, cyanosis and
emotional upset

PRE-LABOUR SIGNS
During the last few weeks of pregnancy the following changes occur:
1. Lightening: the combined effect of Braxton Hicks painless contractions and
relaxation of pelvic joints which occurs in late pregnancy causes the head to
descend into the pelvic brim resulting in a decrease in the fundal height as a
result of expansion of the lower uterine segment. This is much more common in
nullipara because of the firmer abdominal musculature.

Characteristics of lightening:
Occurs 2-3 weeks before the onset of labour,
the lower uterine segment expands and allows the fetal head to sink lower,
and there may be engagement of the head particularly in nullipara
The fundus drops 2 — 3 fingerbreadths that is about 4 cm below the
xiphisternum.
This reliefs the woman of symptoms like dyspnoea, dyspepsia and palpitations

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2. Pelvic pressure symptoms: as the fetus descend into the pelvis, the woman
experiences symptoms as follows:
Frequency of micturition resulting from increased pressure of the foetal head on
the bladder.
Rectal tenesmus-the sensation of inability or difficulty to empty the bowel at
defecation, even if the bowel contents have already been excreted as a result of
increased pelvic pressure
Difficulty walking: this is due to the mobility of the symphysis pubis and relaxation
of the sacroiliac joint caused by the hormone relaxin which may give rise to
backache
Increase vaginal discharge resulting from venous congestion
The futoes’s head in pelvis pushes against cervix causing relaxation and
effacement.

3. Cervical Effacement/taking up of the cervix: effacement of the cervix is an

essential prerequisite to its dilatation. It depends on the softening and ripening
of its connective tissue. The cervix becomes shorter, softer (ripen) and moves
from its position in the posterior vaginal fornix towards the anterior vaginal fornix.
The cervix is drawn up and gradually merges into the lower uterine segment. The
cervix becomes shorter in such a way that the vaginal portion ceases to protrude
into the vaginal lumen. The internal os widens but the lower part of the cervical
canal does not open, leaving the cervical canal a funnel-shaped appearance.
Effacement is earlier in primigravida than in multiparas
Cervix thins out becoming closely applied to the presenting part. External os does
not dilate. If full cervical effacement has not been achieved before the onset of
regular uterine activity there may be a prolonged latent phase when uterine activity
completes the process of cervical effacement.
4. Spurous labour: Irregular intermittent contractions; “false labor”; DO NOT
initiate true labor. Stronger in multips and at night when patient is in bed and
weak during the day.
Features of spurious/False Labor
irregular uterine contractions
the discomfort is localized in abdomen
there is no progressive cervical dilation/effacement
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 intensity of contractions do not increase with ambulation
contractions are weak when client is up and about
contractions do not increase in duration & intensity
the pain can be relieved by antispasmodic or sedative
No bulging of the membranes

Management of spurious labour

Reassure client and partner to alley anxiety
Encourage client to change positions or activities with the pain
Encourage client to drink enough fluids.
Encourage her to rest and relax.
5. Shelfing: Falling forward of the uterine fundus making the upper abdomen look
like a shelf when standing
6. Mood swings and surge of energy: there is Nesting instinct; she cleans house,
sets up nursery. This results from increase release of epinephrine resulting from
decrease secretion of progesterone/estrogen as pregnancy advances.

SIGNS OF TRUE LABOUR

1. Onset of Painful Rhythmic Contractions
2. Show’
3. Rupture of the Membranes
4. Dilatation of the cervix
1. Onset of Painful Rhythmic Contractions
Clinical labour, is considered to begin with the onset of regular painful uterine
contractions. Characteristics of true labour contractions
They increase in intensity (strength) with time; stronger and more painful.
They increase in frequency with time and the interval between contractions
decrease with time.
In the late first stage of labour, there are 3-4 contractions every 10 minutes (a
contraction every 3 minutes)
They increase in duration with time; i.e. successive contractions last longer. In
the late first stage, each contraction lasts => 40 seconds
They do not disappear when the patient is sedated.

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Effects of True Labour Contractions
True labour contractions produce the following results:
Progressive effacement of the cervix
Progressive dilatation of the cervix
Progressive descent of the presenting part
Rupture of the membranes
Show

2. ‘Show’
During pregnancy the cervical canal contains a mucous plug (operculum). Apart
from acting as a mechanical barrier to ascending infection, the mucous plug has
antibacterial properties. It therefore protects the conception from ascending
infection.
This plug is adherent to the cervical canal mucosa. As the cervix dilates during
labour, the membranes overlying the cervix are sheared off, resulting in some
bleeding. At the same time, the mucous plug is torn from the endocervical rnucosa.
The membranes and the torn mucous plug freed together with some blood from the
torn mucosa. The show is therefore mucus mixed with blood, and is a sign that
cervical dilatation is occurring and it’s a positive sign of true labour.

Significance of show
In the presence of regular painful uterine contractions, the presence of the show at
the vulva conclusively shows that the contractions are true labour contractions.
Note:
A finger pushed through the cervix during vaginal examination will dislodge the
operculum and produce a similar result. Digital vaginal examination therefore vitiates
“show” as a sign of labour.
3. Rupture of the Membranes
During pregnancy, the only area of the amniotic sac that is not supported by the
uterus or cervix is the small area overlying the internal os. As the cervix dilates, the
unsupported area increases. Soon, the intrauterine pressure causes the
membranes in this area to bulge through the cervix into the vagina.
When the tension becomes too much for the strength of the membranes, it ruptures.
The of rupture membranes when labour is well established is referred to as
spontaneous rupture of membranes (SROM).
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Rupture of the membranes can occur before the onset of labour it is termed
premature rupture of the membranes (PROM). If it occurs before term, it is called
preterm, premature rupture of the membranes (PPROM).
Once the membranes have ruptured, the protective barrier to infection is lost and
ideally the woman should deliver within 24 hours to reduce the risk of infection to
her and her fetus.
Assessing the status of membranes
Nitrazine paper: Nitrazine paper is placed in a visible pool of fluid around the
cervix. The paper turns blue when in contact with amniotic fluid.
Ferning: A sterile speculum exam may be performed to confirm rupture of
membranes (ROM). A sample of fluid in the upper vaginal area is obtained.
The fluid is placed on a slide and assessed for “ferning pattern” under a
microscope. A ferning pattern confirms ROM.

Nursing Actions
Assess the amniotic fluid for color, amount, and odor.
o Normal amniotic fluid is clear or cloudy with a normal odor that is similar
to that of ocean water.
o Fluid can be meconium stained and this needs to be reported to the care
provider, as this may be an indication of fetal compromise in utero.
Assess the FHR.
o There is an increased risk of umbilical cord prolapse with ROM.
o There is a higher risk of umbilical cord prolapse when the presenting part
is not engaged.
Document the date and time of SROM, characteristic of fluid, and FHR

4. Dilatation of the cervix

The cervix dilates till the lips can no longer be felt during vagina examination. It is
said to‘ be fully dilated.

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Difference between True and False Labour
CHARACTERISTICS TRUE LABOR FALSE LABOR
CONTRACTIONS Regular contractions that Irregular or regular mild
increase in frequency, contractions with no
intensity, and duration increase in frequency,
intensity, and duration
DISCOMFORT Begins in the back and Felt in the middle of the
radiates to the lower abdomen or groin area.
abdomen and the front Can be mentally and
physically tiring.
CERVICAL Progressive cervical dilation Little or no cervical
CHANGES and effacement change
BLOODY SHOW Usually present and None present
increases with cervical
changes
ACTIVITY Activity such as walking Activity or position change
may increase intensity of often lessens
contraction contractions.

STAGES OF LABOUR
Labour is divided into four stages:
First stage
Second stage
Third stage
Fourth stage

First Stage of Labour

It is the stage of cervical dilatation. Starts with the onset of true labour pain and ends
with full dilatation of the cervix i.e. 10 cm in diameter. The spinal cord segment
through with pain fibers pass are T11 and T12 in the latent phase. It spread to T10-
L1 in active phase. Duration of first stage is an average of 12 (GHS, 2008)

The first stage is clinically characterizes by:

progressive uterine contraction,
Progressive taking up of the cervix
progressive dilatation of the cervical os
Rupture of membranes.

Phases of First stage of Labour

The first stage of labour is subdivided into: latent and active phases of labour. To be
completed within 12-18 hours.
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Latent Phase/Prodromal Phase/preparatory phase: The latent or preparatory
phase begins at the onset of regularly perceived uterine contractions and ends when
rapid cervical dilatation begins.
Contractions during this phase are mild and short, lasting 20 to 40 seconds.
Cervical effacement occurs, and the cervix dilates from 0 to 3 cm-4cm.
The duration of this phase is variable and time limits are arbitrary. However, it lasts
between 3-8 hours in a nullipara and 4.5 hours in a multipara.
Active Phase: is characterized by an increased rate of cervical dilation (4cm-10 cm)
and descent of the presenting fetal part. Contractions grow stronger, lasting
averagely 40 to 60 seconds, and occur approximately every 3 to 5 minutes. This
phase lasts 7.7 in nullipara and 5.6 hours in a multipara. Thus, the normal rate of
cervical dilatation in active phase is 1.2 cm/hour in primigravidae and 1.5 cm/hour in
multiparae.
If the rate is < 0.5cm / hour it is considered prolonged. However, should be
completed within 6-l2 hours.
Show and perhaps spontaneous rupture of the membranes may occur during this
time. This phase can be a difficult time for a woman because contractions grow so
strong, last longer, and begin to cause true discomfort.
It can be a frightening time as she realizes labor is truly progressing and her life is
about to change forever.
It ends with complete cervical dilation, and is further subdivided into:
Acceleration Phase: A gradual increase in the rate of dilation initiates the active
phase and marks a change to rapid dilation.
Phase of maximum slope/Transitional phase. The period of active labor with the
greater rate of cervical dilation. During the transition phase, contractions reach their
peak of intensity, occurring every 2 to 3 minutes with duration of 60 to 90 seconds
and causing maximum dilatation of 8 to 10 cm. If the membranes have not previously
ruptured or been ruptured by amniotomy, they will rupture as a rule at full dilatation
(10 cm).

Second Stage
It is the stage of expulsion of the foetus. Begins with full cervical dilatation and ends
with the delivery of the foetus. Its duration is about 1 hour in primipara and 1/2 hour
in multipara.

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Third Stage
It is the stage of expulsion of the placenta and membranes and control of bleeding.
Begins after delivery of the foetus and ends with expulsion of the placenta and
membranes. Its duration is about 10-20 minutes in both primi and multipara
Fourth Stage
It is the stage of early recovery. Begins immediately after expulsion of the placenta
and membranes and lasts for 6 hours. During which careful observation for the
patient, particularly for signs of postpartum haemorrhage is essential. Routine
uterine massage is usually done every l5 minutes during this period.

FACTORS THAT AFFECT LABOR

The “Passage” or Pelvic Architecture: During labor, the fetus assumes positions
and attitudes that are determined in part by the configuration of the mother’s pelvis.
The “Passenger,” or fetal size, presentation, and position; as well as the placenta
are important factors in the conduct of labor.
The “Powers,” or Uterine Action and Cervical Resistance; this talks about the force
needed to push the fetus out from the uterus and includes primary and secondary
powers.
The Primary powers consist of all involuntary muscular activity of the uterus. Thus,
the primary force moves the fetus through maternal pelvis during lst stage of labor.
Secondary powers is also made up of voluntary contraction of the thoracic
diaphragm, abdominal muscles and pushing effort of mother; thus woman adds
voluntary pushing force to force of contractions during 2nd stage of labor to propel
fetus through the pelvis.

The “Patient” / “Provider.”

It is assumed that the physician factor is significant in the effective management of
normal labour.
Physicians may be influenced by the patient’s attitude, the time of day, anesthesia
support, the medico legal climate, and their own training and experience.
The patient’s level of anxiety and pain tolerance also may influence the character
and duration of labor.

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 CHAPTER TWO
CLINICAL DECISION MAKING
Introduction
Making good decisions consistently involves choosing options that have the best
chances leading to favourable outcomes.
Decision making can range from fast, intuitive, or heuristic decisions through to well-
reasoned, analytical, evidence-based decisions that drive patient and client care.
There is a spectrum of decision making - at one end of the spectrum we use our
intuition and experience to make decisions, where there are typically a high volume
of simple decisions to be made.
-At the other end of the spectrum, there may be complex decisions to be made,
where the level of uncertainty is high and an analytical and evidence-based
approach is needed to support the rules-based heuristics or experience we have
gained over time in 'similar' situations.

What is decision making?

A decision is the point at which a course of action is determined
Decision-making: The internal processes by which a course of action or inaction is
chosen (McFall, 2015).
Decision making is the process of developing an answer to a particular problem.
Making sound decision based on individual and group decision making is principal
for midwifery due to the fact that professional choices directly influence people’s
wellbeing and life.
For example administering the wrong dosage of a drug could lead to deadly
outcomes affecting the client and the family.
The quality of the care that is provided by midwives is directly related to the quality
of the decision-making process (Jefford, 2012).
Poor decision-making is a theme evident in confidential enquiries and audit reports,
indicating that poor clinical decision-making contributes to poor maternal and
neonatal outcomes (Draper et al, 2015; Knight et al, 2015)

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Types of Decision-making theories considered
Descriptive theory: is concerned with each individuals’ moral beliefs regarding a
particular decision. This approach describes how individuals reach their
decisions and is process-focused
Normative theory: This approach assumes the individual is rational and logical,
and is concerned with how decisions should be made. What is important is how
‘good’ the outcome is. Thus connotes what decisions individuals should make
logically
Prescriptive theory: encompasses the policies that govern the remits of a
decision within the evidence base that informs practice. This approach attempts
to improve decisions. Examples are policies and protocols.

DECISION-MAKING MODELS
A decision-making model is a process used to guide teams to make decisions that
can benefit their companies.
Each model uses different methods to help you analyze and overcome a challenge.
Common types of decision-making model
1. Rational decision-making model:
Rational decision-making is making choices while thinking rationally. Rational
decision-making will often follow a method or process to reach desirable outcomes.
Rational decision-making employs the use of logic over emotions while making
decisions.
It has six steps:
1. Define the problem
2. Identify the criteria you will use to judge possible solutions
3. Decide how important each criterion is.
4. Generate a list of possible alternatives
5. Evaluate those alternatives
6. Determine the best solution
7. Implement the decision
The rational model lessens a lot of the factors – like faulty assumptions – that can
lead us to bad decisions. It can minimize risk and uncertainty. However, it's not the
best model to use when you're under time constraints or in a fast-changing situation.
It's also important to remember that you won't always have all the information you
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need to use this model. And, even if you do, going through the full process isn't
efficient or necessary for some decisions.
Bounded Rationality Decision-Making Model/ Making “Good Enough”
Decisions
According to this model, individuals knowingly limit their options to a manageable
set and choose the best alternative without conducting an exhaustive search for
alternatives.
An important part of the bounded rationality approach is the tendency to satisfice,
which refers to accepting the first alternative that meets your minimum criteria.
Satisficing is similar to rational decision making, but it differs in that rather than
choosing the best choice and maximizing the potential outcome, the decision maker
saves time and effort by accepting the first alternative that meets the minimum
threshold.

Intuitive Decision-Making Model

It refers to arriving at decisions without conscious reasoning. The intuitive decision-
making model argues that, in a given situation, experts making decisions scan the
environment for cues to recognize patterns (Breen, 2000; Klein, 2003; Salas & Klein,
2001).
Once a pattern is recognized, they can play a potential course of action through to
its outcome based on their prior experience.
Due to training, experience, and knowledge, these decision makers have an idea of
how well a given solution may work.
Novices are not able to make effective decisions this way because they do not have
enough prior experience to draw upon.

Recognition-Primed Decision-Making Model

The recognition-primed model has a lot in common with the intuitive model. Here's
how it works:
The decision-maker recognizes a pattern in available information.
They then pick a course of action and run through that "action script" in their
mind.

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 If the action script seems like it will work, the decision-maker moves forward.
If it doesn't seem like it will work, the decision-maker either tweaks the script
or ditches it and starts over with a new script.
Like the intuitive model, the recognition-primed model works best in situations
where you can draw on deep experience or expertise. In those cases, it's an
especially handy model to use when you're under time pressure.

CLINICAL DECISION-MAKING
Deciding what information to gather, which tests to order, how to interpret and
integrate this information to draw diagnostic conclusions, and which treatments to
suggest is known as clinical decision making.
Clinical decision-making is a process that is fundamental to good professional
practice (Thompson and Dowding, 2002).
When evaluating a patient, clinicians usually must answer the following questions:
o Do the history and physical examination suggest specific diagnoses?
o Are there "red flags" that suggest an urgent medical or social issue that needs
to be addressed prior to confirming a diagnosis?
o Should testing be done or consultations be obtained?

The Core Skills of Clinical Decision Making

Good, effective clinical decision making requires a combination of experience and
skills. These skills include:
❖ Pattern recognition: learning from experience.
❖ Critical Thinking: removing emotion from our reasoning, being 'skeptical', with
the ability to clarify goals, examine assumptions, be open-minded, recognise
personal attitudes and bias, able to evaluate evidence.
❖ Communication Skills: active listening - the ability to listen to the patient, what
they say - what they don't say, their story, their experiences and their wishes
thus enabling a patient-centred approach that embraces self-management;
information provision - the ability to provide information in a comprehensible
way to allow patients/clients, their carers and family to be involved in the
decision making process.
❖ Evidence-based approaches: using available evidence and best practice
guidelines as part of the decision making process.

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 ❖ Team work: using the gathered evidence to enlist help, support and advice
from colleagues and the wider multi-disciplinary team. It's important to liaise
with colleagues, listen and be respectful, whilst also being persistent when
you need support so that you can plan as a team when necessary.
❖ Sharing: Learning and getting feedback from colleagues on your decision
making.
❖ Reflection: using feedback from others, and the outcomes of the decisions to
reflect on the decisions that were taken in order to enhance practice delivery
in the future. It's also important to reflect on your whole decision making
strategies to ensure that you hone your decision making skills and learn from
experience.

Factors that Affect Decision Making

There are many factors involved in clinical decision making and each of the core
skills has the potential to impact effective decision making.
In an ideal world decisions would be made objectively, with a full set of evidence, no
time pressures, minimal interruptions, decision support tools to hand and plenty of
energy to handle any decision making situation at any time of the day. However, this
is not always the reality in clinical setting.
1. Knowing the Environment. Awareness and recognition of the approach to
decision making and the wider team dynamics within your organisation
2. Knowing yourself. Being aware of your behaviour, competencies, attitudes,
emotions and values and not just your own but also those of your
patients/clients and colleagues. It's also important to know your limitations -
being aware of when to seek help, advice and support. Remember - you are
part of a team.
3. Knowing the evidence
4. Knowing the Patient and Person. Knowing the patient's preferences, their
experiences of illness and their current situation or care needs and what is
normal for that patient in terms of observation, mobility and level of function.
It's important to consider feedback from decision making tools that you can
use to capture patient information and analyse results

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Some Models of Clinical Decision Making Applied In Midwifery
According to Kahneman (2011), there are two ‘thinking’ systems, namely system 1
and system 2.
❖ System 1 is quick to act and does so without great (or any) effort, thus uses
intuitive/humanistic approaches. It generates impressions or feelings about
stimuli/situations
❖ System 2 purposefully directs attention to cognitive activities. It uses these to
create explicit beliefs and deliberate choices. Thus uses rational logic
approach.
Kahneman implies that although separate systems, the two processes can work
cooperatively.
Most clinical decision-making models appear to focus on decision-making being
either rational and logical, or intuitive.
One branch of rational decision-making is the hypothetico-deductive theory, thought
to be the dominant decision-making approach within health sciences
One type of hypothetico-deductive theory is ELSTEIN ET AL (1978) FOUR- STAGE
MODEL
STAGE DESCRIPTION APPLICATION
Cue The collection of History-taking, observation
acquisition information
Hypothesis Retrieval of problem Potential diagnosis e.g. early
generation formulations from memory labour
Cue Interpretation of Physical examinations e.g. internal
interpretation information in light of vaginal examination
diagnosis under
consideration
Hypothesis Weighing and combining Confirm or deny hypothesis of
evaluation of information to confirm early labour in light of findings
or deny diagnostic
hypothesis

❖ The model is objective

❖ It is in in-agreement with the medicalisation of obstetric-led maternity care
(Goodman and Ley, 2012)
❖ The step-by-step process can be applied to everyday decisions.
❖ However, the four-stage model focuses purely on the objective and
observable cues available to clinicians and does not consider the role of

19
 emotion or beliefs and values, all of which play a part in holistic midwifery care
and woman-centred decision-making (Barber, 2012).
JESSICA SMITH’ S MODIFIED DECISION-MAKING TOOL combining Elstein et
al (1978) and Kahneman (2001) to aid decision-making in midwifery practice

APPLICATION OF THE MODEL TO MIDWIFERY PRACTICE

Scenario
Laura*, a woman at term, was visited at home for an early labour assessment. On
arrival she appeared to be experiencing one uterine contraction every 7 minutes.
Contractions were moderate to palpate, but did not seem to be causing her too much
discomfort. The rationale for a vaginal examination to assess her cervical
effacement and dilatation was discussed and the woman requested this procedure.
Upon examination, it was found that the cervix was mid-anterior, soft and stretchy,
0.5 cm long and 4 cm dilated, which could be stretched to 6 cm. Although 4 cm
dilated, the woman's uterine contractions were in-coordinate, and too lacking in
strength and frequency to diagnose active labour.
The woman appeared to be anxious and lacking in confidence, and expressed her
concern regarding going to hospital as she feared intervention. She had previously
experienced a Neville Barnes forceps delivery, a postpartum haemorrhage and a
retained placenta that required manual removal in theatre.

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Discussion

The first two stages occur intuitively and through system 1 thinking. Based on Klein's
(2015) distinction, the midwife in the case study used pattern recognition to arrive at
hypothesis generation. In Pattern recognition, the midwife uses previous experience
to evaluate the situation. Consequently, the midwife’s previous experience of
assessing a patient in acute labour.
Subsequently, the decision to assess Laura formed the hypothesis generation phase
of the decision and the recognition of the clinical signs as indicating Laura is in early
stage of labour. This hypothesis focused the assessment to identify and examine
pertinent factors that supported this guesswork (Pearson, 2013). Hence, begin the
next step as cue interpretation.

The midwife required more data to frame a strong hypothesis thereby initiating the
cue interpretation phase by conducting abdominal and vaginal examination. Lindsey
(2013) argued that during cue interpretation, the health professional uses
prescriptive guidelines to direct the assessment process and provide a rationale.

21
The clinical knowledge of the physiology of labour is fundamental to effective cue
interpretation

The additional feature in this modified decision-making tool that is fundamental to

midwifery is the consideration of individual circumstances—for example, the values,
preferences and wishes of the woman. This stage ensures that woman-centred care
is provided, and that the individual needs of the woman are considered (Ménage,
2016b)

Finally, the midwife evaluated the hypothesis and by using the merits from the cues
established that Laura was in early stage of Labour and could escalate her care
appropriately using the prescriptive theory tools.

Simplified Steps in clinical decision making in midwifery

1. Gather information
➢ Done through history taking (ask and listening). E.g. personal, present
and past obstetric history of the client
➢ By performing physical examination (look and feel). The midwife is able
to gather some information like palor and gestational age of client through
a head to toe examination.
➢ Also, through testing. Information about client is gathered through the
series of laboratory investigations such as haemoglobin, HIV status
carried out at the antenatal clinic.
2. Interpret information/ identify the problem
➢ Consider each sign /symptom in context of other findings. For instance, if
you identified palor of conjunctiva, link to the results of the haemoglobin.

22
 ➢ Compare signs and symptoms to accepted description / definitions of
health and disease. E.g. recording a fetal heart rate of 100b/m, meanwhile,
the accepted value is between 120 to 160 b/m.
➢ Consult reliable sources of up to date information. The midwife can consult
persons working at special units such as the HIV clinic and persons who
have had workshops currently on that issue.
3. Develop care plan
➢ This is based on the assessment made
➢ The care plan should be individualized to meet the client’s needs
(preferences, lifestyle, cultural beliefs, socio-economic status, needs,
problems).
➢ It should be collaborative, that is the responsibility is shared by the care
provider, the woman and the family.
4. Implement care plan.
➢ This should also be collaborative. It includes;
➢ Treatments
➢ General education/ counsel for specific needs or problems
➢ Laboratory test
➢ Referral if necessary
➢ Record information
➢ Return appointment
5. Evaluate care plan and modify as needed
➢ Monitor continuously to ensure if the set plans are effective.
➢ Compare present and past findings. Has there been improvement in her
condition currently compared to the previous complains?
➢ Do the interventions carried out need any change or modification?
➢ The care is described as effective ;
• If it improves or maintains woman’s health
• Restores abnormal findings to normal
• Addresses woman’s needs
• Is acknowledged as valuable by woman and her family.

23
Importance of clinical decision making to the midwife
1. It ensure safe and holistic care is delivered
2. It maintains midwife’s responsibility and accountability.
3. Accountability is defined as having to answer to a higher authority for one's
actions, whereas responsibility refers to an individual's authority over
someone else.
a. In the scenario, the midwife had a responsibility to consider Laura's values
and priorities when making a decision about her plan of care. However, the
midwife was also accountable for the diagnosis of early labour; accountable
to Laura, to society as a whole, to her own employer and to the profession
(the NMC).
b. The NMC outlines in its Midwives Rules and Standards that a practising
midwife is responsible for providing care to a woman and that through doing
this, the needs of the woman and her baby are the midwife's primary focus.
c. The NMC Code states that midwives must be accountable for their decisions
and, if this is not adhered to, a midwife's fitness to practise is called into
question.
d. Midwives have a duty of care (Griffith, 2012) to ensure no harm is caused
through their practice.
4. It improves client midwife communication thereby preserving client's
autonomy

SHARED DECISION MAKING

Shared decision making is a partnership in which the woman and provider share
information and values to make the best decisions regarding a plan of care.
Shared decision making is a foundational, integral part of patient-centered midwifery
care and is necessary for the provision of quality, evidence-based health care.
The woman and family collaborate with the midwife to make health care decisions
that promote quality and promote safe outcomes.
Shared decision-making is vital to consider in terms of patient autonomy and
professional duty of care as set out in the Nursing and Midwifery Council (NMC)
(2018) Code, which underpins nursing practice.

24
Sample clinical decision-making article
Scenario
Linda was a 71-year-old who had been admitted to the cardiac ward following an
episode of unstable angina. She was on continuous cardiac monitoring as
recommended by the National Institute for Health and Care Excellence (NICE)
(2016) guideline for chest pain of recent onset. During her stay on the ward, the
tracing on the cardiac monitor indicated possible ST-segment elevation (Thygesen
et al, 2018). It was initially hypothesized that she might be experiencing an ACS
(Box 1) and could be hemodynamically unstable.
Acute coronary syndrome
Acute coronary syndrome is an umbrella term that includes three cardiac conditions
that result from a reduction of oxygenated blood through the coronary arteries,
causing myocardial ischaemia. An ST-segment elevation myocardial infarction
(STEMI) connotes the complete occlusion of one or more of the coronary arteries,
which is demonstrated by patient symptoms and ST-segment elevation seen on an
electrocardiogram (ECG)
A non-ST-segment elevation myocardial infarction (NSTEMI) results from a partial
occlusion of a coronary artery. Patient symptoms often present alongside dynamic
ST-segment depression, T-wave inversion or a normal ECG
Unstable angina is a result of a transient occlusion of the coronary arteries causing
symptoms at rest or on minimal exertion, which may be eased/resolved with rest
with or without glyceryl trinitrate (GTN)
Signs and symptoms of ischaemia experienced by patient include: chest pain with
or without radiation to jaw, neck, back, shoulders or arms, which is described as
squeezing or crushing. Associated symptoms of lethargy, syncope, pre-syncopal
episodes, diaphoresis, dyspnoea, nausea or vomiting, anxiety or a feeling of
impending doom often also prevail
The possibility that Linda was experiencing ST-segment elevation myocardial
infarction (STEMI) meant that she needed rapid assessment of her condition.
Stephens (2019) recommended the use of the ABCDE assessment as a timely and
effective tool to identify physiological deterioration in patients with chest pain. The
student nurse's ABCDE assessment of Linda is shown in ABCDE assessment* of
‘Linda’

25
Airway: patent, no audible sounds of obstruction; however, unable to speak in full
sentences due to dyspnoea
Breathing: dyspnoeic, respiratory rate of 27, saturations of 85% on room air—with
guidance from the senior charge nurse, 80% oxygen via non-rebreathe mask was
administered (O'Driscoll et al, 2017)
Circulation: tachycardia of 112 beats per minute, hypotensive at 92/50 mmHg,
oliguric, diaphoretic, and with cool peripherals and a thready radial pulse
Disability: She was alert on the AVPU scale, but anxious and feeling lethargic. Blood
glucose was 5.7 mmol/litre
Exposure: no erythema or wounds noted. She stated she had central chest pain,
which was radiating to her jaw and back, described as ‘pressure’, and rated as a
seven out of ten* in line with Resuscitation Council (2015)
NICE (2016) recommends that the first investigation for patients with chest pain is
to conduct an ECG as a rapid and non-invasive assessment for a cardiac cause of
the pain. This was carried out and 2 mm ST-segment elevation in the precordial
leads V1-V3 was noted, indicating a possible anterior STEMI (Amsterdam et al,
2014). The student nurse had had basic ECG interpretation training as part of the
nursing degree undertaken, but had also received informal teaching from registered
nursing staff in cardiology. The ECG findings were confirmed by the senior charge
nurse after they were alerted to Linda's condition, symptoms, and National Early
Warning Score 2 (NEWS 2) (Royal College of Physicians, 2017). The senior charge
nurse escalated her care to the cardiology team. A diagnosis of STEMI was made
by the cardiology team using the ECG findings and her physiological signs of
deterioration from their assessment, within the context of her initial presentation to
hospital for unstable angina. This diagnosis, coupled with the deterioration in her
condition, meant that she required primary percutaneous coronary intervention
(PCI). The NICE (2014) quality standard for acute coronary syndromes and the
clinical guideline on STEMI (NICE, 2013a) recommend that primary PCI is initiated
within 120 minutes to reperfuse the myocardium and prevent further myocardial
cellular necrosis. This improves long-term patient outcomes (Thygesen et al, 2018).

Decision-making theories
The recognition of an evolving STEMI on the cardiac monitor corresponds with the
model of hypothetico-deductive reasoning (Pearson, 2013) within the descriptive
26
and normative theories (Box 3). Thompson and Dowding (2009) highlighted that this
model recognizes that decision-making comprises four stages, beginning with cue
acquisition. The specific pre-counter cues can be identified as the recognition of the
abnormal tracing on the cardiac monitor (Pearson, 2013), suggestive of ST-segment
elevation, that indicated Linda might be experiencing hemodynamic deterioration
with a cardiac cause. Subsequently, the decision to assess Linda formed the
hypothesis generation phase of the decision and the recognition of the clinical signs
as indicating STEMI (Nickerson, 1998; Johansen and O'Brien, 2016). This
hypothesis focused the assessment to identify and examine pertinent factors that
supported this conjecture (Pearson, 2013). However, the student nurse required
more data to formulate a robust hypothesis thereby initiating the cue interpretation
phase by conducting an ABCDE systematic assessment, including ECG. Lindsey
(2013) argued that during cue interpretation, the health professional uses
prescriptive guidelines to direct the assessment process and provide a rationale.

Decision-making theories considered

Descriptive theory: is concerned with each individuals’ moral beliefs regarding a
particular decision
Normative theory: connotes what decisions individuals should make logically
Prescriptive theory: encompasses the policies that govern the remits of a decision
within the evidence base that informs practice
Source: Pearson, 2013
Arguably, however, clinical knowledge of the pathophysiology of ACS is fundamental
to effective cue interpretation, not simply the individual's knowledge of the NICE
guidance (NICE, 2013a; 2013b; 2014; 2016). The student nurse's existing
knowledge of the symptoms of ACS supported the cue interpretation with assessing
Linda's condition and possible diagnosis of ACS. This knowledge enriched the
student nurse's understanding of the guidance, which could then effectively be
applied as the central aspect of cue interpretation (Deen, 2018).
Elstein and Schwartz (2002) conceded that the prescriptive theory knowledge
synthesized for the decision must be accurate and evidence-based for hypothetico-
deductive reasoning to be effective. Courtney and McCutcheon (2009) argued that
reliance solely on clinical guidelines can limit decision-making and result in
erroneous outcomes and should consequently be used in collaboration with the

27
evidence base. By combining normative theory with prescriptive guidance, clinical
decisions can be enriched and validated. Stevens (2013) highlighted that it is vital
that the guidance used in corroboration with decision-making models is valid and
reliable and therefore prescriptive theory must be critically evaluated against the
evidence-base. The guidance published by NICE (2013a) is supported by the
American College of Cardiology (O'Gara et al, 2013), European Resuscitation
Council (Nikolaou et al, 2015), European Society of Cardiology (Steg et al, 2012)
and Cardiac Society of Australia and New Zealand (Chew et al, 2016). Accordingly,
these guidelines highlight the clinical signs of STEMI and the diagnostic
investigations pertinent to this condition. Within the remits of practice as a student
nurse, this evidence supported the decision to escalate Linda's condition.
Antithetically, during cue interpretation and the hypothesis generation phases,
Pearson (2013) emphasized the importance of considering multiple hypotheses
extrapolated from the clinical data, resulting in the selection of the most appropriate
hypothesis when more data are obtained. Despite this, during the interpretation of
the cues for the hypothesis, the student nurse failed to consider differential
diagnoses, such as pneumothorax or pulmonary embolism, which have similar
presentations to STEMI (Deen, 2018). Consequently, this hypothesis generation
had an element of uncertainty (Bjørk and Hamilton, 2011), which could have
impeded Linda's care by erroneously considering only one potential diagnosis and
therefore focusing the assessment on that diagnosis. Student nurses can be
considered ‘novice’ health professionals, demonstrating limitations in knowledge
regarding differential diagnoses and therefore in potential hypotheses. Pearson
(2013) argued that this is because student nurses lack the requisite experience to
cluster information as effectively as an ‘expert’ health professional. Consequently,
the presentation of one hypothesis is permissible within the remits of practice as a
student nurse.
Assessment tools such as ABCDE (Resuscitation Council UK, 2015) ensure that all
factors indicative of deterioration are recognised. Consequently, by using a
systematic assessment, any potential erroneous hypothesis can be precluded.
Therefore, as Carayon and Wood (2010) state, the assessment tool was a barrier to
active failure to recognise alternative diagnoses thus circumventing any serious
consequences, highlighting the importance of comprehensive assessment to avoid
error and safeguard the ethical principle of non-maleficence (Beauchamp and
28
Childress, 2013) fundamental to nursing. Antithetically, Benner et al (2008) argued
that even the novice nurse should be able to consider multiple hypotheses within a
situation, although they may not be able to reflect on these decisions within the
moment. However, as Keller (2009) noted, the hypothetico-deductive model is
based on presuppositions recognised by the health professional, such as the
evolving cardiac tracing and history of pain, indicating that STEMI was the higher
probable cause (Deen, 2018). Consequently, a limitation of hypothetico-deductive
reasoning is sufficient experience to aid in generating hypotheses.
Thereafter, in the hypothesis generation phase, the decision-making process
evolved to include elements of pattern recognition theory (Croskerry, 2002). The
clinical decision that focuses on a single hypothesis can be compared to the use of
pattern recognition (Pearson, 2013) where existing knowledge is used to establish
the hypothesis. Pearson (2013) commented that hypothetico-deductive reasoning is
based on the synthesizing and analyzing of information whereas the formulation of
one hypothesis is suggestive of pattern recognition, where the nurse uses previous
experience to evaluate the situation. Consequently, the student nurse's previous
experience of assessing a patient in acute STEMI may have guided practice to
recognise ST-segment elevation on the telemetry, and then subsequently to conduct
an ECG, and to recognise the associated clinical signs of STEMI and to gather a
history of the pain using NICE (2013b) guidance on unstable angina, in line with
Linda's initial presentation. Croskerry (2002) identified that health professionals who
rely on pattern recognition initially recognise visual cues that are then supplemented
with more in-depth data, often using assessment tools such as NEWS (and now
NEWS 2) and ABCDE. Arguably, the recognition of similarities in clinical
presentation, past medical history, and cardiac monitoring tracing of Linda's case to
the previous case and use of ABCDE and NEWS 2 to further assess her condition
and extrapolate data, identifies that previous experience can facilitate decision-
making outcomes.
Finally, in the last phase of the decision-making in the hypothetico-deductive model,
the student nurse evaluated the hypothesis and by using the merits from the cues
(Banning, 2008) established that STEMI was the most probable cause of Linda's
deterioration and could escalate her care appropriately using the prescriptive theory
tools described above.

29
Arguably, by using previous experience to guide practice, an element of confirmation
bias may have affected the selection of data (Thompson and Dowding, 2009) and
consequently the student may have neglected other important data (Croskerry,
2003). For instance, student nurses are inexperienced with chest auscultation and
consequently could not have ruled out differential respiratory diagnoses. Stanovich
et al (2013) acknowledged that confirmation bias can be circumvented when
evidence is assimilated with hypothesis generation. The consideration that Linda
may have been at an increased risk of myocardial infarction due to her age, history
of smoking and admission to hospital for unstable angina (Piepoli et al, 2016),
indicated that the cause of her deterioration would most likely be cardiac. Thus, an
evidence-based approach could inform practice and consequently, any limitations
as a ‘novice’ would be minimized through rationalization and critical thinking. Indeed,
Stanovich et al (2013) argued that rationalizing and critical thinking are markedly
more important than existing knowledge. This is because even an ‘expert’ in a
specific field does not have completely comprehensive knowledge, and therefore
relies on a critical thought process to make rational decisions.
Conclusively, health professionals must be able to rationalise their decisions
(Johansen and O'Brien, 2016) and justify these decisions within the context of each
presentation as a central concept of nursing (NMC, 2018).
Communication is vital to establishing consent to treatment where the patient is
regarded as having capacity under the Mental Capacity Act 2005. This is particularly
significant when conducting investigations and escalating care to ensure that the
patient's wishes are respected, and that the patient is empowered with knowledge
regarding their condition and care (Coultier and Collins, 2011). Linda was informed
that her care required escalation to the appropriate clinical team, and then
subsequently recommended to have PCI intervention as the most effective
treatment for STEMI (NICE, 2013a; 2014). Presenting a default decision and using
choice architecture can be construed as methods of liberal paternalism used to avoid
impeded decision-making from choice overload (Rosenbaum, 2015) or irrational
decision bias (Marewski and Gigerenzer, 2012). To escalate Linda's care within the
recommended timeframe (NICE, 2013a; 2014), it was important to use elements of
liberal paternalism (Beauchamp and Childress, 2013) while preserving Linda's
autonomy of choice (Kemmerer et al, 2017). Linda had a right to make a decision
against medical advice as per Re B (Adult, refusal of medical treatment) [2002] and
30
these choices were presented to her by the cardiology team. As a health
professional, a duty of care was owed to the patient to escalate concerns regarding
her condition under the Code (NMC, 2018).

Conclusion
Conclusively, all three theories of decision-making pertained to this patient's
effective care. Nurses must be accountable for their decisions and act within the
remits of the NMC (2018)Code. Patient care must consequently be effective,
evidence-based and patient-centred. Accountability requires the health professional
to act within the remits of their role to ensure safe care is delivered to the patient.
This is a fundamental aspect of patient-centric care and principal to effective
decision making. Demonstrably, the use of descriptive and normative theories can
be interchangeable, however, the use of prescriptive theory is pivotal to validate
clinical decision-making. The decision-making process can be further facilitated by
use of structured assessment tools to reduce margin of error and improve outcome.
Collaborative decision making is pivotal to advancing patient autonomy and
empowerment but certain decisions require elements of paternalism to improve the
process and uphold the ethical principles of beneficence and non-maleficence.
Nevertheless, health professionals have a duty of care to adhere to decisions made
by patients established to have capacity to give informed consent, irrespective of the
personal beliefs of the professional.

31
 CHAPTER THREE
PHYSIOLOGY AND MANAGEMENT OF THE FIRST STAGE OF LABOUR
FACTORS AFFECTING FIRST STAGE OF LABOUR
l. Uterine factors
2. Duration of labour
3. Mechanical factors

1. Uterine Factors
Fundal dominance: That is, the wave of excitation passes downward, the resulting
contraction forcing the content out of the uterus. Uterine contraction start from the
fundus of the uterus (near one of the conua) and moves downward. Contractions of
the fundus are strong and intense and last for a longer time in the fundus.
Polarity: It is used to describe the neuromuscular harmony between upper uterine
segment and the lower uterine segment. The two uterine poles act in harmony. The
upper pole contracts strongly and retracts to expel the foetus whiles the lower pole
contracts slightly and dilate to allow expulsion of the foetus.
Contraction and retraction: contraction is the ability of the uterine muscle fibers to
shorten in length. If all fibers contract in unison, the contraction is said to be
coordinate or synchronous, if not, the contraction is incoordinate or asynchronous.

The contractions are involuntary.

During labour the contraction does not pass off entirely but muscle fibers retain some
of the shortening of contraction instead of becoming completely relaxed. This is
referred to as retraction. This retraction will favour in further contractions and
expulsion of the fetus.
The contractions occur with rhythmic regularity and intervals between them
gradually lessen. By the end of first stage, they become powerful at shorter interval;
about 2-3 minutes’ interval lasting for 60-90secs.
Formation of upper and lower uterine segment: The uterus forms a thick upper
layer and thin lower muscular layer by the end of the pregnancy.
The upper segment is composed of longitudinal muscles i.e. the fundus which pull
on the lower circular muscles situated in the lower uterine segment (isthmus and
cervix) aiding the descent of the presenting part.
Although there is no clear division of these two segments, the muscle content
reduces from the fundus to the cervix.

32
Retraction ring: This is a ridge formed between the upper and the lower uterine
segment. It’s also referred to as Bandl’s Ring in exaggerated situation that makes it
visible above the symphysis pubis in obstructed labour when the lower segment
thins out abnormally.
Cervical effacement: It is the thinning out of the cervix which is accomplished in the
first stage of labour. It is expressed in terms of percentage. 100% effaced means
that the cervix is fully effaced. In primipara effacement precedes the dilatation of the
cervix. In multiparous, both occur simultaneously.
Cervical dilatation: It is a process of enlargement of the external os which is a
tightly closed aperture to an opening large enough to permit the passage of the fetal
head.
This is expressed in centimeters and ranges from 0-10cm.
Presence of show: As the cervix dilates, operculum is discharged out with light
blood stains called as ‘Show’. This is due to the ruptured capillaries of the decidua’s,
where the chorion detaches due to dilatation of the cervix.

2. Mechanical Factors
Formation of forewaters: As the chorion detaches a loosened sac of amniotic fluid
bulges downwards into dilating internal os.
In case of complete flexion where the presenting part gets completely fixed, fluid
cuts into two compartments. -One compartment with fluid behind called ‘hind waters’
and another compartment with fluid in front of the presenting part called ‘forewaters’.
Forewaters when ruptured releases prostaglandins causing uterine contractions.
Rupture of membranes: It occurs at the end of the first stage of labour. It can
sometimes rupture before the dilation of the cervix. Foetal head may sometimes
appear at the vulva covered with the bulging sac, known as caul
General fluid pressure: When the bag of membranes is not ruptured, the pressure
of uterine contraction is on the fluid also and aid in equalizing it over the uterus and
fetal body. -early ARM may lead to foetal distress and chorioamnionitis although
studies suggest may help reduce the length of the labour by 60-120 minutes.
Fetal axis pressure: At each uterine contraction, the uterus rears forwards and the
force of fundal contraction is transmitted to the upper pole of the fetus, down the
long axis of the fetus and is applied by the presenting part to the cervix. -The

33
pressure on the foetus is intensified after the rupture of membranes and during the
second stage.

3. Duration of Labour
Length of labour can be influenced by:
parity
birth interval
psychological state
presentation and position of foetus
maternal pelvic shape and size
character of uterine contractions

MANAGEMENT OF THE FIRST STAGE OF LABOUR

The goal of care during labour is to ensure the most positive outcome of a healthy
mother and a healthy baby
The goal can be achieved by:
Proper management of the four stages of labour
Early identification and proper management of complications

Role of the midwife During Labor and Delivery

Recognize and manage complications that may arise during the process
Give intensive support to the laboring woman and her partner or coach
Facilitate the labor process and ensure safe passage of the laboring woman and
fetus through the event
When a woman comes to you (midwife) in labour, give the needed care and identify
risks or problems for the needed attention. Nursing assessment for signs that birth
is imminent begins from the moment the woman arrives in the labor and delivery
unit. If the woman is introverted and stops to breathe or pant with each contraction,
you can infer that she is in an advanced stage of labor. In addition, if the woman
makes statements such as, “I feel a lot of pressure,” or “The baby is coming,” or “I
want to have a bowel movement,” it is likely the woman is in the second stage of
labor, and the baby will be born soon.
The midwife does a complete evaluation when birth is not imminent including:
Cue acquisition/ASK and LISTEN (history taken) is the first part of finding out
Generation of hypothesis

34
 Interpret hypothesis
o LOOK and FEEL (physical examination/ labs etc
o IDENTIFY and RECORD THE PROBLEMS/NEEDS
Hypothesis evaluation
Use prescriptive theory tools /TAKE THE NEEDED ACTION based on protocol
or policies.

ASK AND LISTEN (HISTORY TAKEN)

Equipments
-ANC card
-Labour record e. g partograph
-Pen

Procedure
1. Welcome the woman and others with her.
2. Show her a comfortable place to sit or lie depending on her condition/choice.
3. the history may be taking slow or fast depending on the condition of the woman
4. explain to the woman that you are going to ask some questions about her labour
5. Go through her ANC card.
6. Start the labour record by writing the woman’s name and other admission
information.
7. write the time of arrival which you will use to follow the progress of labour
8. As you LISTEN to the answers from the woman, write the information on the
labour record.
9. ASK the following questions and LISTEN
When did your labour pains begin? How often do they come? Thus ask about
Onset, strength, and frequency of contractions.
Has your bag of waters (membranes) broken/ any leakage of fluid?
Have you had any bloody show?
When did you last eat?
Have you been attending antenatal clinic?
When did you last past stool?
Have you taken any medicine to increase or decrease your labour?
Do you have a TBA? What is her name?
Have you bled from your birth canal (vagina)?
35
Additional points to note: if the woman is a non-attendant ask the following questions
How old are you? Women younger than 16 years often have problems. Over
35years and/ or having first pregnancy may have prolonged labour; difficult
delivery; more likely to give birth to preterm baby.
Is this your first pregnancy? Women with history of any of these should be
referred to a hospital: grand multipara, stillbirth, previous cesarean section,
and pre W eclampsia/eclampsia, prolong labour etc. E.g. grand multiparous
woman will have the following issues:
❖ Have weak uterine muscle that prone her to uterine atony resulting in
postpartum heamorrhage
❖ Increasing tendency to develop hypertension
❖ Predisposed to anaemia
❖ Predisposed to Malpresentations because of spacious uterine cavity
❖ Uterine rupture may occur
❖ Weak uterine ligaments from numerous deliveries may lead to uterine
prolapse.

LOOK and FEEL (physical examination)

When you examine a woman in labour, you look for changes that happen at the start
of labour and during labour.

Equipment
-Fetal stethoscope - BP apparatus -thermometer-sterile gloves —bowl-cotton balls
-Pulsometer / watch-Labour record-soap and water-antiseptic solution -Urine testing
kit.

You examine the Woman in labour to find out:

1. the stage of her labour
2. the condition of the baby
3. any problems that might affect the woman or baby
The woman in labour needs a complete general physical examination, abdominal
examination and vaginal examination.

36
General Physical Examination
1. The woman should be clean and comfortable and if possible be allowed to
bathe.
2. Assist client to undress and wear a gown
3. Explain what you are going to do. During the examination, tell her why you
are doing what you are doing.
4. Ask the woman to empty her bladder
5. Provide privacy
6. Help her to lie down
7. Wash and dry your hands. Ensure you warm your hands
8. If the midwife is right handed, stand at the woman’s right side then vice versa.
9. Take the"Blood Pressure
10. Look/Identify the presence of the following—anaemia/pallor; jaundiced;
oedema; enlarged veins at the neck
11. LOOK and LISTEN to the respiratory system. Look at how fast and deep the
woman breaths between contractions (16-20) and during contractions
(normal 20-40). Listen to the breath sounds of the lungs (normal breathing
sounds). Listen to the heart for heart sounds (regular heart rate between
contractions and normal). Count the heart rate; look for enlarged veins in the
neck.
12. Look and feel the breast for problem that might interfere with breast feeding
such as inverted nipples.
13. Look and feel the arms and legs for swelling, enlarged veins. Look for
deformities of her legs, back and pelvis which may make delivery difficult or
impossible. Check reflexes if indicated.

14. Perform Abdominal Examination

Purpose
To provide information about fetal presentation, position, presenting part i.e.
lie, attitude, and descent
To aid in location of fetal heart rates
To aid in assessment of fetal size
determination of single versus multiple gestation

37
 To rule out any abnormal condition in abdomen. E.g. splenomegaly,
hepatomegaly

Procedure
1. Ask the woman to empty her bladder if not done already
2. Help the woman relax. This can be done by placing a pillow under her head
and upper shoulders. Her arms by her side and knees slightly flexed.
3. Uncover her abdomen.
4. LOOK/inspect the abdomen for shape; size; scars; any fetal movement
5. Estimate Fundal height
6. FEEL/ do a general abdominal palpation for tenderness to exclude enlarged
spleen or liver; uterus for tenderness; suprapubic tenderness
7. Feel/palpate the pregnant uterus via Leopold's maneuvers

38
Leopold step No. 1: Facing the Woman’s head. Palpate the fundus to ascertain a
fetal pole and obtain fundal height. The fundus feels round, hard and moveable with
the fetal head whiles the buttocks is irregular, bulky and soft. If lie is transverse, then
fundus and will be empty.
Leopold step No. 2: Still facing woman’ head. Palpate the lateral walls of the uterus
to determine fetal lie (vertical vs transverse) and the location of fetal spine and
extremities. A firm continuous smooth, part represents the back, Small, bumpy,
irregular parts which may hit your palm, represent the limbs
Leopold step No. 3: Still facing woman’ head. Determine what part is lying above
the inlet. Grasp and palpate the upper and lower poles to determine presentation,
assess mobility. Confirm presenting part (opposite of what’s in the fundus). If the
mass move up, the presenting part is not engaged. This is mostly the head. If it
cannot be moved from side to side, then head is engaged. Empty lower abdomen is
transverse lie.
Leopold step No. 4: To locate brow and assess descent of the presenting part. Turn
to face the woman’s feet. Move fingers of both hands gently down the sides of the
abdomen towards the pubis. Palpate for the cephalic prominence (vertex). Assess
descent of the head in fifth.
8. LISTEN to the Fetal Heart Sounds. Listen for one full minute during and
immediately after each contraction. Establish the rate after differentiating it from
maternal pulse by simultaneous palpation of maternal radial pulse. Check for volume
and rhythm as well
9. FEEL for /Time Uterine contraction: two observations are made: Frequency and
duration in 10 minutes. Timed hourly in latent phase and every 30 minutes in active
phase.

Need a second-hand clock

PROCEDURE
Sit on a chair beside the woman’s bed
Exposed abdomen only
Place palm on the fundus
Check time and start procedure

39
 Check number of contractions in 10 minutes and duration of each contraction in
seconds
Starts counting immediately the fundus harden, and end when the fundus softens
Maintain your hand on the fundus for the 10 minutes- note how many
contractions the woman had during the l0 minutes-(3:10 lasting 40-50 sec)
15. Perform vaginal examination: Do a vaginal examination every 4 hours when a
woman is in active labour but frequent when indicated (This is done to reduce
possibility of infection to the mother).

Reasons/indication for vaginal examination

Feel the condition of the cervix
Feel the presentation/position of the baby especially with an obese person or
when the abdominal wall is rigid
To monitor progress of labour
To confirm second stage
To rupture the membranes artificially
To ascertain rupture of membranes
To assess fetal station
To make sure the cord has not prolapsed after spontaneous rapture of
membranes

Requirement preparation
Set up a tray containing the following:
HLD/examination glove
A gallipot with cotton wool swabs
An antiseptic solution
Sanitary pad and receiver
Sterile linen

Procedure;
1. Explain procedure to the client
2. Ensure bladder is emptied
3. Assist mother into lithotomy position and drape
4. Wash hands with soap and water. Dry and wear sterile glove
5. Ask mother to bend her knees with the legs spread apart
40
6. Remove soiled pad with left hand
7. Look/inspect the vulva for the following:
Scars from previous births/ genital cutting
fie Inflammations, /irritation/discoloration/lesions/vesicles
Discharge /show
Presence or absence of liquor. Look at the colour.
8. Gently swab the vulva and dispose of swab according to infection prevention
guidelines
9. With the labia minora separated, gently insert the right middle finger into the
vagina gently but firmly pressing downwards then add the index finger
10. Move your fingers around the vaginal walls. Feel for the following once you
have your fingers in the vagina.
Condition of the vagina for warmth, dryness and moisture.
Condition of the cervix, whether soft, hard or oedematous
Check the cervix for effacement/thinning out
Assess how much the cervical os has opened-dilatation
Determine presenting part and position if membranes are ruptured
Assess how well the presenting part is well applied to the cervix
Feel for the membranes (like a full balloon). It may be intact until cervix is
10cm dilated. If ruptured membranes, look at condition of amniotic fluid (note
colour, odour, consistency, and quantity)
If presentation is vertex, feel suture lines for separation-moulding. Feel the
fontanels, posterior fontanel felt if head is well flexed vertex presentation in a
deflexed head, both fontanels are felt.
F eel how far the presenting part has progressed into the pelvis.
F eel for cord presentation or cord prolapsed
11. Do pelvic assessment
Attempt to reach the sacral promontory
Palpate the ischial spines and note if they are prominent
12. Remove your hand from the woman’s vagina.
13. Dry her and apply clean sanitary pad
14. Remove your glove according to IP guidelines
15. Wash your hands and dry
16. Assist client to be comfortable
41
 17. Explain your findings to her
18. Document all your information gathered. Either latent phase chart or
partograph in active phase.

Investigations
Hemoglobin count
ABO, RH typing
Routine Urine

IDENTIFY and RECORD THE PROBLEMS/NEEDS then TAKE THE NEEDED

ACTION
These are the third and fourth steps that happen when seeing a woman in labour.
Based on the information gathered in the first two steps (history and physical
examination) identify the mothers needs and take action. Example, the following
problems identified during your history taking should be referred to the obstetrician.
Grand multiparity
Previous caesarean section
Pre-eclampsia
Diabetes mellitus
Post-date
Cardiac conditions etc.
A woman in distress needs prompt attention. If action is not taken, serious
complications can occur to both mother and baby.
Nursing Interventions during the Latent Phase (Early Labor)

Assessment
Assess F HR and contractions at least once every hour
Contractions are usually 5-10 min. apart and last 30-45 sec.
Assess maternal status
Cervix is dilated 1-3 cm and effacement begins
Assess status of fetal membranes
Assess the woman’s psychosocial state

42
 Sample nursing diagnosis
Risk of injury (fetal and matemal) related to possible complications of labor
Anxiety related to uncertainty of labor onset and insecurity regarding ability to
cope
Acute pain related to contractions
Deficient Knowledge of labor process related to inadequate preparation for
delivery or unexpected circumstances of labor
Impaired verbal communication regarding the effects of a language barrier
Ineffective coping regarding fear, anxiety, and feelings of powerlessness
❖ Outcome identification and planning.
Primary goals are matemal and fetal safety
Other goals and interventions are planned according to the individual needs of the
laboring woman and her partner
❖ Implementation.
Preventing fetal and maternal injury
Relieving anxiety
Promoting comfort
Providing patient teaching
Goals and expected outcomes.
Goal: The woman and fetus remain free from injury
Goal: The woman’s anxiety is reduced
Goal: The woman’s pain is manageable
Goal: The woman and her partner have adequate knowledge of the labor
process

Nursing Interventions during Active Labor

Assessment
Evaluate contraction pattern every 30 min.-typically contractions occur every
2-5 min., last 45-60 sec., cervix dilates progressively 4-8 cm
Assess woman’s psychosocial state-more introverted, restless, or anxious;
helpless; distraction techniques are failing
Assess labor progress
Assess fetal status-FHR every 30 min
Assess maternal status-ability to relax between contractions

43
Selected nursing diagnoses
Risk for trauma to the woman or fetus related to intrapartum complications or
a full bladder.
Acute pain related to the process of labor.
Anxiety related to fear of losing control.
Ineffective coping related to situational crisis of labor.
Ineffective breathing pattern: hyperventilation related to anxiety and/or
inappropriate application of breathing techniques.
Impaired oral mucous membrane related to dehydration and/or mouth
breathing.
Risk for infection related to invasive procedures (e. g.,, vaginal examinations)
and/or rupture of amniotic membranes.

Outcome identification and planning

Primary goal remains maintaining maternal and fetal safety.

Implementation
Preventing trauma during labor.
Providing pain management.
Reducing anxiety.
Promoting effective coping strategies.
Promoting effective breathing patterns.
Maintaining integrity of the oral mucosa.
Preventing infection.

Nursing Interventions during the Transition Phase of Labor

Assessment.
Assess contraction pattern at least every 30 min., should occur every 2-3 min.,
last 60-90sec. and strong in intensity; dilation 8-10 cm.
Assess for signs that woman has reached transition phase-increase in bloody
show and strong urge to push if fetal station is low.
Assess woman’s ability to cope.
Assess maternal status-nausea and vomiting are common; hyperventilation.
Assess fetal status.

44
Selected nursing diagnoses
Acute pain related to frequent, intense uterine contractions and pressure of the
descending fetal head.
Ineffective breathing pattern: hyperventilation related to intense uterine
contraction pattern and loss of control of breathing techniques.
Powerlessness related to intensity of the labor process.
Fatigue related to energy expended coping with the intense labor

Outcome identification and planning

Specific objectives
The woman’s pain will be manageable
She will exhibit effective breathing patterns
She will maintain a sense of control
She will rest between uterine contractions.

Implementation
Managing pain
Promoting effective breathing patterns
Promoting a sense of control
Supporting the woman through fatigue
Preparing the room

REVIEW QUESTION
1. List four physiological changes that occur during first stage of labour
2. Enumerate three signs of true labour
3. Write nine questions you will ask a woman who come to you in labour when
taking history
4. What additional information will you ask a non-attendant?
5. You are a rotational midwife assigned to the labour ward of your hospital. Madam
Ami. A non-attendant is admitted in labour.
a. What obstetrical history will you collect from madam Ami.
b. Give four reasons for performing vaginal examination on madam Ami
c. Give four abnormal condition of the vulva.
d. Why will you examine Ami in labour.
6. Enumerate six category of pregnant women you will refer to deliver at the hospital.
45
7. List the steps involved in physical examination.
8. Describe the palpation steps to decide the position of the foetu.
9. Why is the foetal heart rate monitored?
10. List seven problems you can identify by history taking.
11. Mrs. Jones, a gravida 4 para 3, has just come in to the labor and delivery suite.
She tells the admission nurse that her water broke 2 hours ago and she feels like
pushing.
What is the first assessment the nurse should make?
a. Maternal vital signs.
b. Imminence of birth.
c. Take an obstetric history.
d. Find a good vein and start an IV.
12. When planning care for a client in the latent phase of labor what is one primary
goal?
a. Mother’s pain is adequately controlled.
b. Mother’s anxiety is controlled.
c. Mother has adequate knowledge of labor process.
d. Mother is safe.
12. Tell whether the following question is true or false. Your patient is in the
transition phase of labor. One of your nursing interventions will be supporting
the woman’s coach through the woman’s fatigue.

46
 CHAPTER FOUR
MONITORING OF LABOUR USING THE PARTOGRAPH
Definition
Partograph is a graphical presentation of a woman’s progress of labour (WHO
2000). The Partograph is for monitoring/ managing labour only. Graphic recording
of the progress of labour. Recording of salient conditions of the mother and fetus
Once the woman is in active phase, the midwife initiates the use of the partograph
to record her findings.
Monitoring help the midwives and the mother in achieving spontaneous vaginal
delivery with low risk to both morbidity and mortality.
Furthermore, accurate partograph recordkeeping enables an effective
communication between healthcare professionals who manage women in labour. .

History Of Partogram
Friedman's partogram devised in 1954 was based on observations of cervical
dilatation and fetal station against time elapsed in hours from onset of labour. The
time onset of labour was based on the patient's subjective perception of her
contractility.
Plotting cervical dilatation against time yielded the typical sigmoid or 'S' shaped
curve and station against time gave rise to the hyperbolic curve. Limits of normal
were defined

Philpott and Castle in 1972 introduced the concept of "ALERT" and "ACTION"
lines.
The aim of this study was to fulfill the needs of paramedical personnel practising
obstetrics in Rhodesian African primigravidae.

47
The alert line represented the mean rate of progress of the slowest 10% of patients
in the African population whom they served. Alert line was drawn at a slope of 1
centimetre/hr for nulliparous women starting at zero time i.e. time of admission .
Action line drawn four hours to the right of the alert line showing that if the patient
has crossed the alert line active management should be instituted within 4 hours,
enabling the transfer of the patient to a specialised tertiary care centre.
Studd's labour stencils It were introduced in 1972. These stencils predicted the
expected pattern of progression of labour based on the extent of dilataton achieved
by the time the patient is admitted (zero time).
Curves showing the average course of cervical dilatation were constructed for
various dilatation on admission. Five separate patterns representing normal labour
progression were constructed.
The curves were transcribed onto acrylic stencils On admission in labour, the
cervical dilatation was assessed and a stencil was used to draw the relevant pencil
line of expected progress on the patient's cervicograph which was then completed.
Those crossing the nomogram line were found to have a three fold increase in
instrumental delivery.

WHO PARTOGRAPH?
Objectives the WHO partograph
early detection of abnormal progress of a labour
prevention of prolonged labour
recognize cephalopelvic disproportion long before obstructed labour
assist in early decision on transfer , augmentation , or termination of labour
increase the quality and regularity of all observations of mother and fetus
early recognition of maternal or fetal problems
the partograph can be highly effective in reducing complications from
prolonged labor for the mother (postpartum hemorrhage, sepsis, uterine
rupture and its sequelae) and for the newborn (death, anoxia, infections, etc.).

Partograph function
The partograph is designed for use in all maternity settings , but has a different
level of function at different levels of health care:
 In health center, the partograph’s critical function is

48
To give early warning if labour is likely to be prolonged and to indicate that the
woman should be transferred to hospital (ALERT LINE FUNCTION )
 In hospital settings, moving to the right of alert line serves as a warning for
extra vigilance , but the action line is the critical point at which specific
management decisions must be made
 Other observations on the progress of labour are also recorded on the
partograph and are essential features on management of labour

WHO SHOULD NOT HAVE A PARTOGRAPH

Women with problems which are identified before labour starts or during labour
which need special attention

COMPONENTS OF THE PARTOGRAPH

Profile of the client includes Name, Gravida, Para, Registration/hospital number,
Date of admission, Time of admission. The time elapsed since membranes ruptured
before admission unto partograph is also written. All the above information written
at the top of the partograph

49
Fetal condition
Fetal heart rate
Membranes and liquor
Moulding of the fetal skull

Membranes and liquor

Intact membranes ……………………………………...I
Ruptured membranes + clear liquor ………………….C
Ruptured membranes + meconium- stained liquor …M
Ruptured membranes + blood – stained liquor ……..B
Ruptured membranes + absent liquor………………..A

Moulding the fetal skull bones

Moulding is an important indication of how adequately the pelvis can
accommodate the fetal head
increasing moulding with the head high in the pelvis is an ominous sign of
cephalopelvic disproportion
separated bones . sutures felt easily ……………….….O
bones just touching each other ………………………..+
overlapping bones ( reducible ) ……………………...++
severely overlapping bones ( non – reducible ) ..…..+++

50
The Progress of labour
This section of the partograph has as its central feature: a graph of cervical dilatation
against time
Cervical dilatation
Descent of fetal head
Uterine contractions:
❖ Duration,
❖ Frequency

Maternal condition
Pulse/ BP / Temp
Urine — volume, acetone, protein
Drugs & IV Fluids
Oxytocin regime

STARTING A PARTOGRAPH
A partograph should be started only when a woman is in active phase of labour
Contractions must be l or more in 10mins
Cervical dilatation must be 4cm or more

DESCRIPTION OF A PARTOGRAPH
In the center of Partograph is a Graph. Along the left side are numbers 0 -10 against
squares. Each square represents 1 cm dilatation. Along the bottom of the graph are
numbers O-12. Each square represents 1 hour

51
Alert line (health facility line)
 The alert line drawn from 4 cm dilatation represents the rate of dilatation of 1
cm / hour
 Moving to the right of the alert line means referral to hospital for extra vigilance
Action line ( hospital line )
 The action line is drawn 4 hour to the right of the alert line and parallel to it
 This is the critical line at which specific management decisions must be made
at the hospital
Cervical Dilatation
 It is the most important information and the surest way to assess progress of
labour , even though other findings discovered on vaginal examination are
also important
 when progress of labour is normal and satisfactory , plotting of cervical
dilatation remains on the alert line or to the left of it
 if a woman arrives in the active phase of labour , recording of cervical
dilatation starts on the alert line
 The dilatation of the cervix is plotted with an ‘X’. Vaginal examinations are
done at admission and once in 4 hours.
 Then after spontaneous rupture of membranes and as when it is indicated

Descent of the Foetal Head

On the left hand side of the graph is the word “descent’ with lines going from
5—0
Descent is plotted with an “O’ on the Partograph.
It should be assessed by abdominal examination immediately before doing a
vaginal examination, using the rule of fifth to assess engagement
52
The rule of fifth means the palpable fifth of the fetal head felt by abdominal
examination to be above the level of symphysis pubis
When 3/5 or less of fetal head is felt above the level of symphysis pubis , this
means that the head is engaged , and by vaginal examination , the lowest
part of vertex has passed or is at the level of ischial spines

53
Uterine Contractions
On the Partograph below the time line, there are 5 blank squares going across the
length of the graph. Each square represents l contraction.
 Observations of the contractions are made every half-hour in the active phase
 frequency how often are they felt ?
 Assessed by number of contractions in a 10 minutes period
 duration how long do they last ?
Measured in seconds from the time the contraction is first felt abdominally , to the
time the contraction phases off
 Each square represents one contraction

Methods of assessment of uterine contractions:

1. Manual assessment
2. Cardiotocography
The above methods measure the frequency and duration of contractions
3. Intrauterine catheters to measure intrauterine pressure in Montevido units
This method will measure the intensity in addition to frequency and duration
Palpate number of contraction in ten minutes and duration of each contraction
in seconds
 Less than 20 seconds:

 Between 20 and 40 seconds:

 More than 40 seconds:

54
Maternal Condition
• Recorded at the foot of the Partograph
• Oxytocin: i.e. any amount per volume in if per minute every 30min when used
for augmentation of labour
• Drugs: refers to any additional drugs given i
• Pulse: every half hour
• BP: every 4 hrs or more frequently
• Temperature: every 2hrs or more frequently
• Urine: Protein Acetone Volume checked every hour or any time urine is
passed
• Measured every 2 hours

MANAGEMENT OF LABOUR USING THE PARTOGRAPH

55
Between alert and action lines
 In health center , the women must be transferred to a hospital with facilities
for cesarean section , unless the cervix is almost fully dilated
 Observe labor progress for short period before transfer
 Continue routine observations
 ARM may be performed if membranes are still intact

At or beyond action line

 Conduct full medical assessment
 Consider intravenous infusion / bladder catheterization / analgesia
Options.
- Deliver by cesarean section if there is fetal distress or obstructed labour
- Augment with oxytocin by intravenous infusion if there are no contraindications

ABNORMAL PROGRESS OF LABOUR

One of the main functions of the partograph is to detect early deviation from normal
progress of labor

Moving to the right of alert line

 This means warning
 Transfer the woman from health center to hospital
 Reaching the action line
 This means possible danger
 Decision needed on future management (usually by obstetrician or resident )

56
Figure 1Prolonged Active phase

Secondary arrest of cervical diltation

Abnormal progress of labor may occur in cases with normal progress of cervical
diltation then followed by secondary arrest of diltation

57
Secondary arrest of head descant
Abnormal progress of labor may occur with normal progress of descent of the fetal
head then followed by secondary arrest of descent of fetal head

The partograph in the management of labor following cesarean section.

 In women undergoing a trial of labor following cesarean section, the
partographic zone 2-3 h after the alert line represents a time of high risk of
scar rupture.
 An action line in this time zone would probably help reduce the rupture rate
without an unacceptable increase in the rate of cesarean section

58
REVIEW QUESTION
Mrs. Jennifer Konogini, a 40-year-old Gravida 4 Para 3 “was admitted to your labour
ward on January 14, 2022 at 4: 00am with a history of labour pains. Her hospital
number is 14/0l/19
a. Plot the observations attached on the partograph sheet provided
b. State SIX (6) advantages of the partograph
c. Identify 6 women who cannot be monitored on partograph

59
 CHAPTER FIVE
FETAL MONITORING IN LABOUR
Fetal condition during labour can be assessed by obtaining information about the
fetal heart rate, the PH of the blood and the amniotic fluid.
What is fetal heart rate monitoring?
Fetal heart rate monitoring is the process of checking the condition of the fetus
during labor and delivery by monitoring his or her heart rate with special equipment.

IMPORTANCE OF FETAL HEART MONITORING IN LABOUR

1. l. Fetal heart rate monitoring help detect changes in the normal heart rate pattern
during labor.
2. If certain changes are detected, steps can be taken to help treat the underlying
problem.
3. Fetal heart rate monitoring also can help prevent treatments that are not needed.
4. A normal fetal heart rate can reassure the patient and the health care provider
that it is safe to continue labor if no other problems is present.

THE TYPES OF MONITORING

There are two methods of fetal heart rate monitoring in labor.
Intermittent monitoring is a method of periodically listening to the fetal heartbeat.
Electronic fetal monitoring is a procedure in which instruments are used to
continuously record the heartbeat of the fetus and the contractions of the mother’s
uterus during labor. The method that is used depends on the health care provider’s
or hospital’s policy, the risk of problems, and how labor is progressing. If you do not
have any complications or risk factors/problems during labor, either method is
acceptable.

INTERMITTENT AUSCULTATION
This term is used when the fetal heart is auscultated at intervals using a monaural
(Pinard’s) or a handheld Doppler transducer. When the transducer is pressed
against the abdomen, the Fetus’s heartbeat can be heard.
Using Pinard during contraction is uncomfortable for the woman and the fetal heart
sounds may not be inaudible. However, the fetal heart rate can be listened to as the
contraction is finishing to detect any slow recovery

60
CONTINUOUS ELECTRONIC FETAL MONITORING
This uses a fetal cardiograph and maternal tocograph in a CTG apparatus.
Cardiotocography (CTG) is a technical means of recording the fetal heartbeat and
the uterine contractions during pregnancy. The machine used to perform the
monitoring is called a cardiotocograph, more commonly known as an electronic fetal
monitor (EFM).
This presents a graphic record of the response of the fetal heart to uterine
contractions and also information about its rate and variability.
Early identification of fetal compromise is one benefit of using EFM. There are also
risks, including false-positive tests that may result in unnecessary surgical
intervention.
EF M can be done in two forms: 1. External 2. Internal

External cardiotocography
The continuous or intermittent monitoring of the fetal heart rate and the activity of
the uterine muscle are detected by two transducers placed on the mother's abdomen
(one above the fetal heart and the other at the fundus).
The abdominal belt used interferes with palpation, uncomfortable and can easily be
displaced. it is less invasive

Internal cardiotocography
This uses an electronic transducer connected directly to the fetal scalp. A wire
electrode is attached to the fetal scalp through the cervical opening with ruptured
membranes and it’s connected to the monitor. Cervix must be dilated to about 2cm-
3cm before this method can be used
Internal monitoring provides a more accurate and consistent transmission of the fetal
heart rate than external monitoring because factors such as movement do not affect
it.
Internal monitoring may be used when external monitoring of the fetal heart rate is
inadequate, or closer surveillance is needed.

Contraindications
1. Preterm gestation
2. Women with known clotting disorder
3. Women with blood borne diseases

61
Cardiotocography (CTG)

KEY COMPONENTS OF FETAL HEART RATE/CTG

The CTG provides information on
Baseline fetal heartrate
Baseline variability
Acceleration
Deceleration
Uterine activity

BASELINE FETAL HEART RATE

This is the heart rate between uterine contractions Baseline — between ll0-l60bpm
A rate more than l6Obpm is termed baseline tachycardia. Whiles a rate less than
110 bpm is baseline bradycardia
Foetal tachycardia can be caused by:
1. Foetal hypoxia
2. Chorioamnionitis - if maternal fever also present
3. Hyperthyroidism
4. Foetal or maternal anaemia
5. Foetal tachyarrhythmia

62
Foetal bradycardia
Mild bradycardia of between 100-120bpm is common in the following
situations:
1. l. Post-date gestation
2. Occiput posterior or transverse presentations
3. Second stage of labour

Severe prolonged bradycardia (less than 80 bpm for more than 3 minutes)
indicates severe hypoxia.
Causes of prolonged severe bradycardia are:
1. Prolonged cord compression
2. Cord prolapse
3. Epidural & spinal anaesthesia
4. Matemal seizures
5. Rapid foetal descent

If the cause cannot be identified and corrected, immediate delivery is

recommended.
Baseline Variability.
This is the beat to beat changes in the heart rate, occurs as a result of the interaction
between the nervous system, chemoreceptors, baroreceptors and cardiac
responsiveness.
Therefore, it is a good indicator of how healthy the foetus is at that particular moment
in time.
This causes the tracing appear as a jagged rather than a straight line.
This is because a healthy foetus will constantly be adapting its heart rate to respond
to changes in its environment.

Forms of Variability -
Absent - undetectable
Minimal - detectable but <5 beats
Moderate — 6 to 24 beats**(normal)
Marked >24 beats

63
Reduced variability can be caused by:
1. Foetal sleeping — this should last no longer than 40 minutes — most common
cause
2. Foetal acidosis (due to hypoxia) — more likely If late decelerations are also
present
3. Foetal tachycardia
4. Drugs — opiates / benzodiazepines / methyldopa / magnesium sulphate
5. Prematurity — variability is reduced at earlier gestation (<28 weeks)
6. Congenital heart abnormalities

ACCELERATIONS —an abrupt increase in the heart rate of at least 15 beats above
baseline and lasting for at least l5 seconds. **a healthy baby should have 2 in 20
minutes.

DECELERATIONS
Variables-abrupt decrease in heart rate of at least 15 beats below baseline (before,
during, or after contraction) and lasting at least 15 seconds.
Late- subtle decrease in heart rate beginning after onset of contraction and ending
after completion of contraction
Early- gradual decrease in the heart rate, appears symmetrical and the bottom of
the deceleration usually occurs with the peak of the contraction
Prolonged- decelerations lasting >2min but < 10min

64
INTERMITTENT AUSCULTATION
Auscultate immediately after contractions for one minute. T
Listen for the rate, accelerations and decelerations. You will not be able to hear
variability or subtle decelerations. Listen for repetitive and prolonged deceleration '

Overall impression
Once you have assessed all aspects of the CTG you need to give your overall
impression.
The overall impression can be described as either:
Reassuring/Normal
Suspicious /Nonreassuring
Pathological
Reassuring (Normal)
Tracings with all these findings present are strongly predictive of normal fetal acid-
base status at the time of observation and the fetus can be followed in a standard
manner:
Baseline rate 110-160 bpm,
Moderate variability,
Absence of late, or variable decelerations,
Early decelerations and accelerations may or may not be present.

65
Nonreassuring (suspicious)
Bradycardia with normal baseline variability
Tachycardia
Minimal or Marked baseline variability of PH
Periodic or Episodic decelerations: Longer than 2min but shorter than 10min;
Recurrent late decelerations with moderate baseline variability
Variable decelerations with other characteristics such as slow return to baseline

Pathological (Abnormal):
Tracing is predictive of abnormal fetal acid-base status at the time of observation;
this requires prompt evaluation and management:
Absence of baseline variability with recurrent late or variable decelerations or
bradycardia

Emergency Interventions for Nonreassuring Patterns

1. Call for assistance.
2. Administer oxygen through a tight-fitting face mask.
3. Change maternal position (lateral or knee-chest).
4. Administer fluid bolus (lactated Ringer's solution).
5. Perform a vaginal examination and fetal scalp stimulation.
6. When possible, determine and correct the cause of the pattern.
7. Consider tocolysis (for uterine tetany or hyperstimulation).
8. Discontinue oxytocin if used.
9. Consider amnioinfusion (for variable decelerations).
10. Determine whether operative intervention is warranted and, if so, how urgently it
is needed.

66
 CHAPTER SIX
PHYSICAL NEEDS OF CLIENTS IN LABOUR.
NUTRITIONAL NEEDS OF CLIENT IN LABOUR.
The nutritional and biochemical requirements of the woman and the grave risk of
anaesthetic death must be given due consideration. Nutrition in labour is purely for
energy.
Oral intake is avoided in some cases for the fear of aspiration in cases where client
might need general anaesthesia.
However, fasting can equally lead to increase acidic gastric juice which can also
lead to chemical pneumonitis when inhaled (mendelson’s syndrome)
To prevent this, most obstetricians prescribe antacid 2 hourly throughout labour.
Gastric emptying is prolonged following the administration of narcotic analgesic.
Carbohydrate and low fat meals that are easily digested can be taken by the client.
Glucose and fluids are constantly needed by the uterus to provide its vigorous
contracting activities to prevent ketoacidosis. Ketosis can lead to excessive
vomiting, extreme exhaustion and shock. The client’s urine is therefore examined
for ketones every 2 hours.
Fluids may be taken freely in no risk women
5% or 10% dextrose may be given but in moderate since large amount may
artificially increase
foetal blood glucose causing foetal hyperinsulinism and hypoglycaemia in the
neonate.
Dehydration must be avoided so the woman in labour must receive about 75mls of
fluid per hour. A fluid balance chart should be kept
Pain and nervous tension inhibit appetite and retard the absorption of food

BLADDER CARE
It’s the duty of the midwife to ensure the bladder is emptied every 2 hours throughout
labour.
During each abdominal examination, the suprapubic region should be inspected and
palpated to detect distension. If the bladder is readily seen or palpated above the
symphysis, the woman should be encouraged to void.

67
At times, she can ambulate with assistance to a toilet and successfully void, even
though she cannot void on a bedpan. If the bladder is distended and she cannot
void, catheterization is indicated. Catheterization should not be a routine.

Effects of full bladder on labour

A full bladder may prevent the head from entering the brim and lead to
subsequent bladder
hypotonia and infection.
It will cause unnecessary pain during labour
Poor uterine contractions are often associated with full bladder
Full bladder may also cause minor CPD
Retention of urine may occur because:
✓ -the bladder may lack tone
✓ -due to inability of the woman in labour to use the bedpan
✓ -pressure of the foetal head on the neck of the bladder during the latter part
of first stage of labour; posture and suggestions are of no value.

Risk factors of urine retention

Primiparity
oxytocin-induced or -augmented labor,
perineal lacerations,
instrumented delivery,
catheterization during labor,
prolong labour

ANALGESIA IN LABOUR
There is no other circumstance where it is considered acceptable for a person to
experience untreated severe pain, amenable to safe intervention, while under a
skilled birth attendant’s care...
Maternal request is a sufficient medical indication for pain relief during labor.
The pain-free comfort expected by parturient negates the Biblical quotation that in
pain thou shall labour
Fear, anxiety and uncertainty may lower the pain threshold during labour. Patients,
therefore, need to be counseled at the antenatal clinic. Labour needs to be managed

68
by sympathetic attendants. Health care providers always have a duty to alleviate the
pain and suffering of their patients.

The ideal analgesic technique in labour should:

Provide rapid, effective and safe pain relief for all stages.
Not compromise maternal vital physiology or normal activity.
Not compromise fetal vital physiology or well-being.
Not hamper the normal processes of labour.
Be flexible enough to convert to anaesthesia for urgent operative delivery or other
intervention, e.g. manual removal of placenta.

Indications for Analgesia

First stage of labour
Patient's request.
When there are painful uterine contractions,
Painful contractions with Oxytocin infusion.
Painful contractions with poor progress in the active phase e.g. due to occipito-
posterior position.

Second stage of labour

When giving episiotomy.
For instrumental delivery.

Third stage of labour

For removal of retained placenta

Fourth stage
For the suturing of genital tract injuries

PAIN RELIEF IN LABOUR

Non-pharmacological Management of Labor Discomfort
This includes preparation by the woman for childbirth, cutaneous stimulation,
thermal stimulation, mental stimulation, and the presence of a support person.
It is essential that midwives have a range of strategies to manage discomfort and
pain during labor. A willingness to try variety of strategies, adapt those that are
effective, and modify and abandon those that are not effective are important aspects

69
of care. Usually no one strategy works for very long in labor, making flexibility and
adaptability key qualities for midwives.

Childbirth Preparation Methods:

Education and explanation of birth process is offered during antenatal care to the
woman and her support person before the delivery time. During the care, the woman
and her partner learn about pregnancy, the labor process, the painful aspects of
labor, and methods to help relieve the discomforts of pregnancy and childbirth.
Some of the major methods of childbirth preparation include:
o Dick-Read method: Advocates birth without fear by education and
environmental control and relaxation.
o Lamaze: Promotes psych prophylaxis with conditioning and breathing.
o Bradley: This is husband-coached childbirth and support by working with and
managing the pain rather than being distracted away from it.
o Relaxation and breathing techniques: Varied breathing patterns that promote
relaxation and avoidance of pushing before complete cervical dilation. Most
women are taught to take a deep breath at the beginning of the contraction to
signal the onset of the contraction and then to breathe slowly during the
contraction. As labor pain increases, the woman may need to breathe in a
more rapid and shallow manner. On occasion, a woman will experience
hyperventilation from this type of breathing. Symptoms are related to
respiratory alkalosis and include tingling of the fingers or circumoral
numbness, light-headedness, or dizziness. This undesirable side effect can
be eliminated by having the woman breathe into a bag or cupped hands. This
causes her to rebreathe carbon dioxide and reverses the respiratory alkalosis.

Cutaneous Stimulation.
This is done by massage by self-such as effleurage. Effleurage is done by lightly
stroking the abdomen in rhythm with breathing during contractions.
Another form of cutaneous stimulation is back massage and/or counterpressure to
the sacral area by another.
Counterpressure is exerted to the sacral area with the heel of the hand or fist to
relieve the sensation of intense pain in the back caused by internal pressure of the
fetal head. This increased internal pressure by the fetal head is often associated

70
with the posterior position of the fetus during labor. As labor advances, women may
not want to be touched.

Thermal Stimulation:
Application of warmth or cold such as use of warm showers or ice packs. The use
of hydrotherapy via whirlpools, warm baths, or showers is very effective and
promotes relaxation and comfort. This may reduce the woman’s anxiety and
promote well-being, causing a reduction in catecholamine production, which
interferes with uterine contractility.
Application of cold may release musculoskeletal pain and the numbing effect of cold
may decrease the sensation of pain.

Mental Stimulation:
Focal points, imagery, and music help the woman to concentrate on something
outside her body. This helps her to focus away from the pain. With imagery, the
woman is encouraged to bring into her mind a picture of a relaxing scene.

Support Person:
A significant other and/or a doula provides emotional support and physical comfort
and aids in a beneficial form of care. Research has shown that support early in labor
significantly relieves pain, improves outcomes, decreases interventions and
complication rates, and thus enhances overall maternal satisfaction (Simkin &
O’Hara, 2002).

Pharmacological Management of Labor Discomfort

Pharmacological management of discomfort and pain in labor requires the midwife
to assess the woman’s preferences for pain management throughout labor. The
decision to use pain medication in labor should be made by the woman in
collaboration with her physician or midwife. Assessment of pain is an essential part
of nursing care. The standard 0 to 10 pain scale is insufficient for assessment of
labor pain. Assessment of labor pain should include:
o intensity,
o location,
o pattern,
o degree of distress for the woman.

71
The use of medication in the relief of pain during labor falls into two major categories:
o Analgesia
o Anesthesia.

Basic principles when using analgesia include:

Labor should be established.
Medication should provide relief to the woman with minimal risk to the baby.
o Neonatal depression may occur if medication is given within an hour
before delivery.
o Women with a history of drug abuse may have a lessened effect from
pain medication and require higher doses.
Opioids-
Examples: Pethidine, meperidine, morphine, Fentanyl, Nalbuphine, Butorphanol
Pethidine has been the most widely used systemically administered opioid for
obstetric analgesia (Ally et al 2000) When uterine contractions and cervical dilatation
cause discomfort, pain relief with a narcotic such as, pethedine plus one of the
tranquilizer drugs such as promethazine, is usually appropriate.

Advantages
Ease of administration
Sedation and euphoria for the agitated mother
Onset of action l5-30mins
Peak effect 30 mins- lhour
Duration of action up to 3hours

Disadvantages
Drowsiness
Severe nausea and vomiting
Blurred vision
Severe respiratory depression in both mother and baby
Should not be given 1-2hrs to the estimated time of delivery
May cause loss of beat-to-beat variability of fetal heart rate tracings
Naloxone should be prescribed as well as PREPARATION FOR RESUSCITATION
of the newborn once opioids are given. Naloxone is a narcotic antagonist capable of
reversing respiratory depression induced by opioid narcotics.

72
It acts by displacing the narcotic from specific receptors in the central nervous
system.
Withdrawal symptoms may be precipitated in recipients who are physically
dependent on narcotics. For this reason, naloxone is contraindicated in a newborn
of anarcotic-addicted mother.

Dosages
Pethidine 50 to 100 mg, with promethazine, 25 mg, may be administered
intramuscularly at intervals of 2 to 4 hours. A more rapid effect is achieved by
giving pethedine intravenously in doses of 25 to 50 mg every 1 to 2 hours.
Pethedine readily crosses the placenta, and its half-life in the newborn is
approximately 13 hours or longer
MEDICATION CLASS SIDE EFFECTS NURSE INTERVENTION
Morphine Opioid CNS depression Avoid use when close to
5 mg–10 mg IM Neonatal delivery time (about 1
2 mg–5 mg IV respiratory hour).
depression
Meperidine Opioid CNS depression Avoid use close to
(Demerol) 50 mg– Neonatal delivery time (about 1
100 mg IM respiratory hour).
25 mg–50 mg IV depression
Butorphanol Opioid No respiratory Check maternal history for
(Stadol) agonist– depression in drug abuse.
2 mg–4 mg IM antagonist woman or Do not give to drug
0.5 mg–2 mg IV neonate dependent woman due to
Nalbuphine possible precipitation of
(Nubain) sudden withdrawal
10 mg IM or IV response in woman and
baby.
Monitor effective
response.
Sublimaze Short acting FHR changes Monitor for side effects
(Fentanyl) May be opioid Hypotension such as sedation, nausea,
used in antagonist Maternal/fetal/ne vomiting, itching. Monitor
conjunction with Crosses the onatal CNS respiratory rate and effort.
regional placenta depression
anesthesia rapidly Respiratory
depression

73
Promethazine Ataractics Drowsiness Monitor effective
(Phenergan) Agonist effect of response. Potentiates
25 mg–75 mg IM narcotics narcotic effect.
25 mg–50 mg IV
Hydroxyzine
(Vistaril) 25–100
mg IM
or Z tract
Naloxone (Narcan) Antagonist- Review appropriate
used to dosing for adult vs.
reverse newborn.
narcotic
effect May
be used to
relieve
maternal
itching and
respiratory
depression

Basic Principles for ANESTHESIA include:

Local anesthesia is used at the time of delivery for episiotomy and repair.
Regional anesthesia is used during labor and at delivery.
o Regional anesthesia includes the pudendal block, epidural block, and
spinal block.
o Regional or general anesthesia is used for cesarean deliveries
Local Anesthesia
Anesthetic injected into perineum at episiotomy site
Time given and effects
It’s given during the second stage of labor, immediately before delivery to
Anesthetize local tissue for episiotomy and repair
Adverse Effects
Risk of a hematoma
Risk of infection
Monitor for:
Return of sensation to area
Increased swelling at site of injection

74
Regional Analgesia
Most effective means of providing analgesia for labour and delivery Melzack
R 1984.
Present the most flexible, effective, and least depressant options
Regional techniques provide unparalleled pain relief in labour with minimal
maternal and neonatal side effects.
Commonly performed techniques are epidural, spinal and combined spinal-
epidural other methods include paracervical, pudendal, and local perineal
infiltration techniques.
Epidural Anesthesia
Epidural anesthesia involves the placement of a very small catheter and injection of
local anesthesia and or analgesia between the fourth and fifth vertebrae into the
epidural space. A combined spinal epidural analgesia (CSE) involves the injection
of local anesthetic and/or analgesic into the subarachnoid space. Some patients
may be able to ambulate with this type of anesthesia, hence it is referred to as a
“walking epidural.”

The tip of a specialised needle (17 or 18 gauge) is positioned within the epidural
space. Plastic catheter is threaded through the needle and introduced in to the
epidural space. Catheter is left in and the analgesia is given continuously or
intermittently. Bupivacaine and fentanyl

75
Advantages
The most effective pain relief without appreciable motor block
The absence of pain allows enjoyment and control of labour
Reduces maternal fatigue and anxiety
Ideal in high risk pregnancies
Safe and versatile. Can be extended to provide analgesia for instrumental and
operative delivery

Disadvantages
Restriction of movement during labour
Requires CTG
Requires resident anesthetist, cardiorespiratory facilities and one to one care
increase rate of instrumental delivery
Urine retention

Complications
Failure
Hypotension
Epidural tap (headache)
back pain

Contraindications Epidural analgesia

Absolute
patient refusal
overt coagulopathy,
frank infection @ needle site,
maternal hemodynamic instability
Increased intracranial pressure.
Inadequate training

Relative
Systemic maternal infection
Pre-existing neurological disease
Mild or isolated coagulation abnormalities
Relative (correctable) hypovolaemia

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Before Epidural analgesia
Informed consent
Assess fetal well being
Resuscitation equipment and drugs are immediately available
Intravenous rehydration
Monitoring of BP l to 2 mins for 20 mins after injection of drugs
Continuous maternal heart rate monitoring
Continuous F HR monitoring
Continuous verbal communication

Post-procedure care.
Monitor maternal vital signs and FHR every 5 min initially and after every re-
bolus then every
15 minutes and manage hypotension or alterations in FHR.
Urinary retention is common and catheterization may be needed.
Assess pain and level of sensation and motor loss.
Position woman as needed (on side to prevent inferior vena cava syndrome)
Assess for itching, nausea and vomiting, and headache and administer meds
PRN.
When catheter discontinued, note intact tip when removed.
Pudendal Blocks
Anesthetic injected in the pudendal nerve (close to the ischial spines) via needle
guide known as “trumpet”. Provide sensory innervation to vagina, vulva and
perineum, innervation to perineal muscles. Transvaginal approach; local anesthetic
behind sacrospinous ligament.
77
Given during the second stage of labor, prior to time of delivery.

Monitor for:
Return of sensation to area
Increased swelling
Signs and symptoms of infection
Urinary retention

PARACERVICAL BLOCK
This block usually provides satisfactory pain relief during the first stage of labor. We
do not use it routinely in our institutions. Because the pudendal nen/es are not
blocked, however, additional analgesia is required for delivery. For paracervical
blockade, usually lidocaine or chloroprocaine, 5 to l0 mL of a 1-percent solution, is
injected into the cervix laterally at 3 and 9 o’clock. Bupivacaine is contraindicated
because of an increased risk of cardiotoxicity (American Academy of Pediatrics and
American College of Obstetricians and Gynecologists, 2007; Rosen, 2002b).
Because these anesthetics are relatively short acting, paracervical block may have
to be repeated during labor

LOCAL ANESTHETICS
Bupivacaine
Lidocaine/Xylocaine

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GENERAL ANESTHESIA
General anesthesia is indicated for cesarean section delivery when regional
techniques cannot be used because of:
Coagulopathy
Infection
Hypovolaemia,
Urgency
Preference
Other indications include:
manual removal of placenta,
repair 3rd and 4th degree perineal lacerations

PSYCHOLOGICAL NEEDS OF A CLIENT.

Childbirth can be an intense event and strong emotions, both positive and negative,
can be brought to the surface.
Abnormal and persistent fear of childbirth is known as tokophobia.
It has been proved that the emotions of a woman in labour profoundly influence her
reaction to discomfort and pain.
The whole process of childbirth should be handled with sensitivity and compassion.
Every woman needs a different kind of support. But all women need kindness,
respect and attention. Watch and listen to her to see how she is feeling. Encourage
her, so she can feel strong and confident in labour.
Help her relax and welcome her labour.
The influence of the midwife in psychology of labour
It has been known that the personality and attitude of the midwife play an
important part in influencing the behaviour of the woman in labour
Good human relationship are most essential
Qualities accepted by all women in labour are sympathetic understanding and
patient kindliness
The midwife must demonstrate a caring attitude

79
EMOTIONAL AND PSYCHOLOGICAL SUPPORT FOR THE WOMAN IN
LABOUR
Emotional and psychological support for the woman in labour consists of helping the
mother to feel in control of herself, to feel accepted whatever her reactions and
behaviour may be to complete her labour feeling that she is a success, even if the
outcome was not what she hoped for.
There are several ways you can help her to achieve the above

l. Companion in labour
You do not have to work alone to give support to the mother during labour.
There is evidence that the presence of constant support from the woman’s husband,
close relatives or friends in labour favours good progress.
There is no rule about who should support her if they care about her and are willing
to help her.
Most important, they should be people the mother wants to have at the birth.

2. Good communication
Keep the woman informed about the progress of labour. The woman has the right
to know about the progress of labour and the condition of herself and the baby.
Counsel the woman and her support person about ongoing care such as physical
care, comfort and emotional support.
Counsel the woman (and her support person) on what to expect early in labour,
before contractions become too painful, and later when contractions become
stronger (where feasible).
Explain about the contractions getting stronger and closer together as she gets
closer to the time to deliver baby.
Explain what to expect during the delivery. Reassure the woman that you will be
with her throughout the process of giving birth.

Communication Goals:
Patient actively participates in care
Patient understands and able to carry out tasks of self-care
Patient is comfortable asking questions
Patient’s needs are met
Patient understands their condition
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 Patient feels confident that they are receiving excellent care
Patient understands the processes involved in their care
Patient feels respected
We (clinical staff) understand the patient (i.e. problems, needs, challenges to
their health maintenance)
Members of the health care team work together with a common goal

Patient Communication and its Psychological Effects of Birth

Communication failures compromise care. “Achievement of the best outcome
demands excellent communication.”
A common indicator of communication failure is the phrase: “the patient is non-
compliant” this phrase usually means:
The patient does not understand our instruction
We do not understand the patient

3. A peaceful atmosphere
The atmosphere of the labour ward must be as quiet and tranquil (free from
emotional or mental disturbance or calm) as possible
Keep rude and unkind people away.
The mother should not have to worry about family problems. Sometimes even
supportive and loving friends can interfere with the labour. At some births, the
best way to help is to ask everyone to leave the room so that the mother can
labour without being distracted.
The woman “in labour should never be aware of any doubt or anxiety the staff
may experience such as inability to hear the foetal heart rate or that haemorrhage
is taking place.
No conversation should take place between members of staff in the presence of
the woman in labour other than its necessary for the conduct of labour
An attitude of reverence should always prevail while in attendance on women
during childbirth.

81
4. Helping the mother to manage her contractions
In early labour she may be able to sleep. Many women feel very tired when their
contractions are;
They may fear they will not have the strength to push the baby out. But feeling tired
is the body’s way of making the mother rest and relax. If everything is all right, she
will have the strength to give birth when the time comes.
To save her strength, the mother should rest between contractions, even when
labour first begins.
This means that when she is not having a contraction, she should let. her body relax,
take deep breaths, and sometimes sit or lie down.
Touch can help a woman in labour, but find out what kind of touch she wants.

Here are some examples of touch that women often like:

A firm, still hand pressing on the lower back during contractions
Massage between contractions, especially on the feet or back
Hot or cold cloths on the lower back or belly. If the mother is sweating, a cool wet
cloth on the forehead usually feels good. ..
Effleurage: massage technique for early labour.

Summary of Factors Influencing a Positive Birth Experience

Clear information on procedures
Support, not being alone
Sense of mastery, self-confidence
Trust in staff caring for her
Positive reaction to the pregnancy
Personal control over breathing
Preparation for the childbirth experience

Nursing responsibilities
1. Reassure client and explain all procedures carried out on her to her
2. Provide emotional support to client
3. Allow client to ask questions and explain in simple clear terms to the mother’s
understanding
4. Orient patient to the environment, equipment, procedures, routines and
anticipatory guidance of what she can expect.
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5. Use events to identify or estimate when things will occur (e.g., before sunset,
after lunch).
6. Encourage family members to visit client.
7. Encourage patient to express fears and concerns.
8. Assess childbirth and newborn cultural practices and rituals that are important to
patient.
Unless contraindicated or unsafe, allow patient to participate in those practices.
9. Helping the mother to manage her contractions
10. Support client to have personal control over breathing
11. Explain what to expect during the delivery. Reassure the woman that you will be
with her throughout the process of giving birth.
12. Counsel the woman (and her support person) on what to expect early in labour,
before contractions become too painful, and later when contractions become
stronger (where feasible).
13. The atmosphere of the labour ward must be as quiet and tranquil (free from
emotional or mental disturbance or calm) as possible.
14. Maintain a nonjudgmental attitude toward cultural practices that are safe to
implement
15. Provide physical support to the patient when possible

POSITION AND MOBILITY

Several considerations govern the choice of position during the first stage of labour.
Of these the most important is that of maternal preference. But some women need
your encouragement to try different positions.
Help the woman move during labour. She can squat, sit, kneel or take other
positions. All of these positions are good.
Changing positions helps the cervix open more evenly. Prolonged back-lying or
semi-sitting and even prolonged side-lying may impede rotation and progress of
labour.
An all-fours or side-lying position combined with pelvic rocking position may be used
to turn an occipito posterior fetus to a more favorable position.
Lunge can also help in the same manner. It widens the side of the cervix towards
where it is lunging.

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The woman should not be nursed in a dorsal position since it can lead to diminished
utero- placental blood flow resulting in fetal distress
Thus nursing a woman in labour in the dorsal position can lead to foetal distress and
supine hypotension syndrome: is compression of the abdominal aorta and inferior
vena cava by the gravid uterus when a pregnant woman lies on her back, i.e. in the
supine position.
Signs of supine hypotension include:
Bradycardia
dizziness
sweating
Hypotention
Pallor
nausea
The best way to prevent or immediately treat this is to place a rolled up towel or
wedge under the right hip, so that the central weight is tilted at least fifteen degrees.
Giving water and oxygen and placing cold towels on the forehead will help relieve
symptoms of faintness.
The legs should immediately be raised above the head to increase venous return of
blood to the heart, such as in a chair.

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 CHAPTER SEVEN
PHYSIOLOGY AND MANAGEMENT OF THE SECOND STAGE OF LABOUR
It is the stage of expulsion of the foetus. Begins with full cervical dilatation and
ends with the delivery of the foetus.
Physiological Changes of the Second Stage of Labour
The physiological changes result from the continuation of the same forces that has
been at work from the beginning of the labour, however, activity has accelerated
once the cervix is fully dilated.
The onset of the second stage of labour is traditionally confirmed with vaginal
examination to check for full cervical dilatation. This examination is often taking in
response to transitional maternal behaviours. The following changes occur:
l. Uterine action
Contractions become stronger and longer but may be less frequent (to allow both
mother and foetus regular recovery periods).
The membranes may rupture spontaneously towards the end of the second stage
(increasing the rate of descent, helps presenting part well apply to the cervix to aid
dilatation).
Fetal axis pressure increases flexion of the fetal head leading to smaller diameters
presenting, more rapid progress and less trauma to both mother and foetus.
The contractions become expulsive as foetus further descent into the vagina.
Pressure from presenting part stimulate nerve receptors in the pelvic floor (Ferguson
reflex) leading to the urge to push. Ferguson reflex initially can be controlled but will
later become compulsive, overwhelming and involuntary.
Mother responds by applying her secondary powers of expulsion.
2. Soft tissue displacement- The bladder is pushed upwards into the abdomen
where it is at less risk of injury during fetal descent. As a result the urethra stretches
and thins out occluding its lumen. The rectum flattens into the sacral curve and the
pressure from the advancing head expels it content.
The lavetorani muscles dilate, thin out and are displaced laterally. This makes the
perineal body to
flatten, stretch and thins out. Fetal head now becomes visible at the vulva.
The powers help the head to continuously advance in descent till the head is finally
delivered. The rest of the body also delivered with lateral flexion followed by gush of
amniotic fluid and sometimes blood.
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RECOGNITION OF THE COMMENCEMENT OF THE SECOND STAGE OF
LABOUR
A. Presumptive evidence
1. Expulsive uterine contractions
Some women feel a strong desire to push before full dilatation occurs. Traditionally,
it has been assumed that an early urge to push will lead to maternal exhaustion
and/or cervical oedema or trauma.
More recent research indicates that the early pushing urge may in fact be
experienced by a significant minority of women, and that, in certain circumstances,
spontaneous early pushing may be physiological.
It is not clear whether these findings are influenced by factors such as maternal or
fetal position, or parity, and there is not enough evidence to date to determine the
optimum response to the early pushing urge.

2. Rupture of the fore Waters

Rupture may occur at any time during labour.

3. Dilatation and gaping of the anus

Deep engagement of the presenting part may produce this sign during the later part
of the first stage.

4. Anal cleft line

Some midwives have reported observing this line (also called ‘the purple line’) as a
pigmented mark in the cleft of the buttocks which gradually ascends the anal as the
labour progresses.

5. Appearance of the rhomboid of Michaelis

It presents as a dome-shaped curve in the lower back, and is held to indicate the
posterior displacement of the sacrum and coccyx as the fetal occiput moves into the
maternal sacral.

6. Upper abdominal pressure & epidural analgesia

It has been observed that women who have an epidural in situ often have a sense
of discomfort under the ribs towards the end of the second stage of labour.
7. Show
This is the loss of bloodstained mucus which often accompanies rapid dilatation of
the cervical os towards the end of the first stage of labour. It must be distinguished
86
from frank fresh blood loss caused by partial separation of the placenta or a ruptured
vasa praevia.

8. Appearance of the presenting part

Excessive moulding of the fetal head may result in the formation of a large caput
succedaneum which can protrude through the cervix prior to full dilatation of the os.
Very occasionally, a baby presenting by the vertex may be visible at the perineum
at the same time as remaining cervix.
This is more common in women of high parity. Similarly, a breech presentation may
be visible when the cervical os is only 7-8 cm dilated.

B. Confirmatory evidence
In many midwifery settings, it is held that a vaginal examination must be undertaken
to confirm full dilatation of the cervical os. This is both to ensure that a woman is not
pushing too early, and to provide a baseline for timing the length of the second stage
of labour.

DURATION OF SECOND STAGE OF LABOUR

The duration of second stage is therefore based on when the woman’s cervix is
assessed as being fully dilated by the midwifery or medical staff. Its duration is about
1 hour in primigravida and 1/2 hour in multipara.
However, there is no good evidence about the absolute time limits of physiological
labour. The second stage of labour can last for up to three hours or so before the
risk of maternal and/or fetal compromise begins to increase.
In the presence of regular contractions, maternal and fetal wellbeing, and
progressive descent, considerable variation between women is to be expected.

PHASES OF THE SECOND STAGE

Two distinct phases in second stage progress have been recognized in some
women. These are the latent phase, during which descent and rotation occur, and
the active phase, with descent and the urge to push.

The latent phase /Passive / Descent Phase

During this passive “phase the presenting part descends toward the pelvic outlet,
and rotation and flexion occurs.

87
In some women, full dilatation of the cervical os is recorded, but the presenting part
may not yet have reached the pelvic outlet. Women in this situation may not
experience a strong expulsive urge until the head has descended sufficiently to exert
pressure on the Perineal tissues.
It is hypothesized that the prolongation of second stage progress when epidural
analgesia is used is due to the relaxation effect of epidural analgesia on the pelvic
floor muscles, meaning that the fetal presenting part does not encounter the
necessary resistant force from the pelvic floor to bring about the normal rotation
process.
This tends to be particularly evident in nulliparous women. Passive descent of the
fetus can continue with good midwifery support for the woman until the head is
visible at the vulva, or until the woman feels a spontaneous desire to push.

The active phase /Pelvic Floor Phase

Most women without epidural analgesia will experience a compulsive urge to push,
or bear down, once the fetal head has rotated and started to descend. The phase of
labour that involves active bearing down is termed the active second stage of labour.
The onset of the active phase of second stage labour is recognized when following
/ on confirmation of full dilation of the cervix:
the fetal presenting part is visible
we there are expulsive contractions and other signs indicating full dilatation.
there is active maternal effort in the absence of expulsive contractions

MATERNAL RESPONSE TO TRANSITION AND THE SECOND STAGE

Pushing
Traditionally, the maternal urge to push occurs before confirmation of full dilatation
of the cervical os, or the appearance of a visible vertex, the mother must be
encouraged to avoid active pushing. This has been done to conserve maternal effort
and allow the vaginal tissues to stretch passively. Techniques to avoid active
pushing efforts in this situation include:
position change, left lateral.
using controlled breathing.
inhalation analgesia.
or even narcotic or epidural pain relief.

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POSITIONS USE IN LABOUR — FIRST /SECOND STAGE OF LABOUR
Recumbent Position-This can lead to reduced placental perfusion and diminished
fetal oxygenation.
The semi-recumbent or supported siting position, with the thighs abducted, is the
posture most commonly used in Westem cultures.
It affords the midwife good access and a clear view of the perineum,
However, the woman's weight is on her sacrum, which directs the coccyx forwards
and reduces the pelvic outlet.
In addition, the midwife needs to bend forward and laterally to support the birth,
which may lead
to injury.

Left lateral position

Lies on her left side with her leg extended and her right knee drawn-up against her
abdomen or with both legs bent at the knee. This is less common in current practice.

Advantages
The perineum can be clearly viewed
Uterine action is effective
It provides an alternative for women who find it difficult to abduct their hips.
It may also aid fetal rotation, especially in the context of epidural analgesia.

Disadvantages
An assistant may be required to support the right thigh, which may not be ergonomic.

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Upright positions
Squatting
Advantages
Comfortable and relieve backaches
Uses gravity to help the baby descend and rotate;
partner can support your back and arms;
widens pelvic outlet to its maximum
allows freedom to shift mass for comfort
requires less bearing down
helpful if the mother does not have the urge to push
squatting position was less painful and more effective during the second stage
of labor

Disadvantage
Perineum inaccessible leading to poor control of birth
All-fours, Standing, Using a birthing ball
Many women find that being upright is more comfortable than lying down at this
point. Plus, it may put gravity to work for you. Some women find the all- fours position
to be the optimum approach for all or part of their labours, especially in the case of
an occipitoposterior position, due to relief of backache.
Other advantages include - reduced duration of second stage labour, fewer assisted
births, fewer episiotomies, reduced severe pain in second stage labour, and fewer
abnormal heart rate patterns.
However, increased rates of perineal damage and of estimated blood loss >500 ml
also occurred.

Lithotomy
It involves lying on your back with your legs flexed 90 degrees at your hips -Lying
back with legs in stirrups. Your knees will be bent at 70 to 90 degrees, and padded
foot rests attached to the table will support your legs.

Advantages
good for forceps or vacuum,
good for giving extensive episiotomy and repair
enhances asepsis
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 allow for the monitoring of the foetus

Disadvantages
an increased risk of injury to the perineum when compared with squatting lying
on your side
more likely to need a Caesarian section or forceps to remove their baby.
increased a woman’s risk of a sphincter injury due to increased pressure

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HOW COULD UPRIGHT POSITIONS BENEFIT NORMAL LABOR AND BIRTH?
Researchers believe that giving birth in an upright position can benefit the mother
and baby for several physiologic reasons. Physiologic refers to a healthy body’s
normal function. In an upright position, gravity can help bring the baby down and
out. Also, when someone is upright to give birth, there is less risk of compressing
the mother’s aorta, which means there is a better oxygen supply to the baby. Upright
positioning also helps the uterus contract more strongly and efficiently and helps the
baby get in a better position to pass through the pelvis. Magnetic resonance imaging
(MRI) studies have shown that compared to the back-lying position, the dimensions
of the pelvic outlet become wider in the squatting and kneeling or hands-and-knees
positions (Gupta et al. 2017). Finally, research has shown that upright birthing
positions may increase maternal satisfaction and lead to more positive birth
experiences (Thies-Lagergren 2013).

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However, despite these potential benefits of giving birth in an upright position, most
people who give birth vaginally in U.S. hospitals report that they push and give birth
lying on their backs (68%) or in a semi-sitting/lying position with the head of the bed
raised up (23%). A small minority push and give birth in other positions such as side-
lying (3%), squatting or sitting (4%), or hands-and-knees position (1%) (Declercq et
al. 2014). In contrast, a U.S. home birth midwife told us that the majority of her clients
spontaneously choose the hands-and-knees position (Personal communication, K.
Brown, Feb. 8, 2018). In Europe, a study of nearly 3,000 people who had planned
home births between 2008 and 2013 found that the majority (65%) gave birth in non-
back-lying positions (Edqvist et al. 2016).
It may be helpful to go over some of the terms that are used to describe non-upright
birthing positions.
General terms that refer to lying on your back or side are called recumbent and semi-
recumbent positions. The side-lying position is not often described as recumbent or
semi-recumbent in practice, but we include it in this group since most of the evidence
on upright vs. non-upright positions puts the side-lying position with the other non-
upright positions.

WHY DO MOST PEOPLE GIVE BIRTH ON THEIR BACKS?

Many caregivers around the world still prefer non-upright positions today, even
though current obstetric textbooks state that it is beneficial, especially for first-time
mothers, to push in upright positions (Kilpatrick & Garrison 2012).
It is thought that most people giving birth are encouraged to push in a back-lying or
semi-sitting position—one that puts weight on the tailbone—because it is more
convenient for the care provider during the birth of the baby.
Also, when the mother is lying or semi-sitting in bed, it is easier for caregivers to
access her abdomen to monitor the fetal heart rate electronically. The use of
continuous EFM often means that mothers cannot move freely or change positions
easily during labor.
Care providers may also be more comfortable with the lying or semi-sitting position
because this is how most are trained to attend births (Gupta et al. 2017). If a
physician has only been trained in birth with the mother in the lithotomy position,
they may not feel that they can safely handle complications if the mother were in an
upright position.
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FACTORS INFLUENCING THE CHOICE OF POSITION
It is important not to insist on any position as the ‘right’ one. Positive and dramatic
effects on labour progress can be achieved by encouraging the woman to change
and adapt her position in response to the way her body feels.
The mother’s preference
The environment
The midwife’s confidence
The maternal and fetal condition

THE MECHANISM OF NORMAL LABOUR (CEPHALIC PRESENTATION)

As the fetus descends, soft tissue and bony structures exert pressures that lead to
descent through the birth canal by a series of movements. Collectively, these
movements are called the mechanism of labour
Knowledge and recognition of the normal mechanism enables the midwife to
anticipate the next step in the process of descent. Understanding and constant
monitoring of these movements can help to ensure that normal progress is
recognized, that the woman gives birth safely and positively, or that early assistance
can be sought should any problems occur.
At the onset of labour the most common presentation is the vertex and the most
common position either left or right occipitoanterior. The situation in normal labour
can be described as:
the lie is longitudinal
the presentation is cephalic
the position is right or left occipitoanterior
the attitude is one of good flexion
the denominator is the occiput

FETAL LIE
This describes the relation of the long axis of the fetus to that of the mother.
Longitudinal lie is found in 99% of labours at term
Predisposing factors for transverse lie/oblique lie multiparity, placenta previa,
hydramnious, & uterine anomalies

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FETAL PRESENTATION
The presenting part is the portion of the body of the fetus that is foremost in the birth
canal
The presenting part can be felt through the cervix on vaginal examination.
Longitudinal lie:
• cephalic presentation
• breech presentation
Transverse lie -shoulder presentation

Cephalic presentation
Head is flexed sharply is vertex / occiput presentation
Head is extended sharply is face presentation
Partially flexed is bregma presenting (sinciput presentation)
Partially extended is brow presentation

Breech presentation
Frank breech
Complete breech
Footling breech

ATTITUDE
Describes the posture the fetus assumes in relationship between its head and chest
to accommodate the shape of the uterus. Example: in vertex presentation- Flexed
head, thighs, knees and feet then arms crossed over the chest.
Longitudinal lie, Cephalic presentation and Differences in attitude of fetal body

Figure 2Note changes in fetal attitude in relation to fetal vertex as the fetal head becomes less flexed

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POSITION
This is the relation of an arbitrary chosen point of the fetal presenting part to the
Right or Left side of the maternal birth canal
The chosen point of the foetus depending on the type of presentation:
✓ Vertex presentation is occiput
✓ Face presentation is mentum
✓ Breech presentation is Sacrum
Each chosen point will either face the Right or Left side of the mother's pelvis
towards either the anterior (pubic bone), posterior (sacrum) or lateral (ischial spine)

MECHANISM OF VERTEX PRESENTATION

The fetal skull when fully flexed is almost spherical in outline since equal
diameters are presenting in the two planes, each measuring 9.5cm.
An oval shape of the head present from the beginning of labour- biparietal in
one plane and longer occipitofrontal/suboccipitofrontal in the other.
Hence the head lies in the transverse position at the brim (more often to the
left), oblique at midpelvis and Anterioposteriorat the outlet.

Main movements of the fetus

i. Descent
ii. Flexion
iii. Engagement
iv. Internal rotation
v. Extension
vi. Restitution

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vii. internal rotation of the shoulders
viii. External rotation of the head
ix. Lateral flexion of the body

Descent
Descent of the fetal head into the pelvis often begins before the onset of
labour. For a primi-gravid woman this usually occurs during the later weeks
of pregnancy.
In multigravid women muscle tone is often laxer and therefore descent and
engagement of the fetal head may not occur until labour actually begins.
Thus continuous throughout labour unless an insuperable obstruction is
present.
It is affected by the uterine contractions & thinning of the lower segment.
Rupture of membranes enhances descent (increase fetal axis pressure)
Engagement is not strictly a mechanism (not a movement made by the
foetus)
It occurs at certain point in the descent of the head when the maximum
diameters of the head have passed through the brim.
It may occur before labour starts; although this is not a rule (20-25% of
nulliparas). It is possible that nonnal labour is eminent after engagement.
Flexion
This increases throughout labour. Pressure exerted down the fetal axis will
be more forcibly transmitted to the occiput than the sinciput.
The effect is to increase flexion which results in smaller presenting diameters
that will negotiate the pelvis more easily.
At the onset of labour the suboccipito-frontal diameter, which is approximately
10 cm, is presenting.
With greater flexion, the sub-occipitobregmatic diameter, that is,
approximately 9.5 cm, presents.
The descending head meets resistance of pelvic floor, Cervix and walls of the
pelvis resulting to flexion of the fetal head.
With full flexion the posterior fontanel is in the center of the area outlined with
the cervix and a much more favorable diameter present

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 Lever action producing ftexion of the head; conversion fromoccipitofrontal to
suboccipitobregmatic diameter typically reduces the anteroposterior diameter
from nearly 12- to 9.5 cm.

Four degrees of head flexion. Indicated by the solid line the occipitomental diameter;
the broken line connects the center of the anterior fontanel with posterior fontanel:
A. Flexion poor.
B. Flexion moderate.
C. Flexion advanced.
D. Flexion complete.
Note that with flexion complete the chin is on the chest, and the
suboccipitobregmatic diameter, the shortest anteroposterior diameter of the fetal
head, is passing through the pelvic inlet.

Internal rotation of the head

During a contraction, the leading part is pushed downwards onto the pelvic
floor.
The resistance of this muscular diaphragm brings about rotation.
As the contraction fades, the pelvic floor rebounds, causing the occiput to
glide forwards.
Resistance is an important determinant of rotation

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 This means rotation of the head inside the pelvis. This explains why rotation
is often delayed following epidural analgesia, which causes relaxation of
pelvic floor muscles.
Thus the main cause of internal rotation is associated with
o the shape of the birth canal (90 degrees forward curve)
o The easier fit of the suboccipital area of the fetal head behind the
symphysis pubis
o The outlet of the pelvis is oval with the long axis in the AP diameter
Usually the rotation is anterior, i.e. the denominator swings from left
occipitolateral to left occipitoanterior and finally to the direct occipitoanterior
position.

Extension of the head

The head remains flexed until the leading part reaches the perineum.
Once crowning (the largest diameter of the fetal head is encircled by the
vulvar ring) has occurred, the fetal head can extend, pivoting on the
suboccipital region around the pubic bone.
This releases the sinciput, face and chin, which sweep the perineum, and
then are born by a movement of extension,

Restitution
The twist in the neck of the fetus which resulted from internal rotation is now
corrected by a slight untwisting movement.
The occiput moves of a circle towards the side from which it started.

Internal rotation of the shoulders

The shoulders undergo a similar rotation to that of the head to lie in the widest
diameter of the pelvic outlet, namely anteroposterior.
The anterior shoulder is the first to reach the levatorani muscle and it therefore
rotates anteriorly to lie under the symphysis pubis.
This movement can be clearly seen as the head turns at the same time
(external rotation of the head).
It occurs in the same direction as restitution, and the occiput of the fetal head
now lies laterally.

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Lateral flexion
Then the fetal body will rotate to bring one shoulder anterior behind the
symphysis pubis
(biacromial diameter into the APD of the pelvic outlet)
Because of the curve of the birth canal, the anterior shoulder appears first.
It is delivered downward outward pressure on the head by the
aecoucheur/midwife
This means that the full bisacromial diameter (l2.5cm) does not traverse the
vulva ring but the shorter acromiohumeral diameter (l0em).
This will prevent/reduce posterior vulva tear.

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PREPARATION FOR THE SECOND STAGE OF LABOUR
1. Identify a helper and review the emergency plan.
a. Prepare the birth companion or another skilled helper to assist if the baby does
not breathe. - A birth companion can help the mother and call for another helper.
– A second skilled helper can assist in caring for the baby.
b. The emergency plan should include communication (call referral center) and
transportation to advanced care.
2. Prepare the area for delivery. The area where a baby is born should be:
a. Clean - Help mother wash her hands and chest to prepare for skin-to-skincare.
A clean area should be prepared to receive the baby, and waterproof covers
provided to protect the bed and floor.
b. Warm - Close windows and doors to stop drafts. Supply heat if needed.
c. Well-lighted - Use a portable lamp if needed to assess the baby. Spotlight should
be available so that the perineum can be easily observed if necessary. Thus
ensure the room is well lighted
3. Wash hands.
Good hand washing helps prevent the spread of infection. Wash hands thoroughly
with soap and clean water or use an alcohol-based cleaner before and after caring
for a mother or a baby Gloves protect you from infections-carried by blood and body
fluids.
4. Prepare an area for ventilation and check equipment.
Prepare a dry, flat, and safe space for the baby to receive ventilation if needed. In
addition to a safe delivery kit, have equipment to help a baby breathe. Equipment
should be disinfected after use and kept clean. Check that all equipment and
supplies are ready for use in the area for ventilation.
Test the function of the ventilation bag and mask and suction device and
stethoscope.
Set the tray for resuscitation
-sterile
Ventilation bag (newborn size)
Two infant masks (size 0, 1)
Penguin suction device
Warm cot sheet

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Non-sterile
Stethoscope
Clock
5. Set a trolley for delivery sterile
Sterile cord clamp,
2 sterile gloves
2 sterile cot sheets
Prepacked delivery kit-two artery forceps, one cord scissor, a receiver
A gallipot containing cotton wool swabs,
l sterile pack of gauze
Prepared oxytocic agent
6. A clean apron, boots and eye goggle are placed to hand.
7. Warm clothes should be prepared for the baby.

General nursing responsibilities during the second stage of Labour

1. Continuously provide information, support, and encouragement to the woman
and her
2. Encourage active pushing once the urge to bear down is present, with
encouragement to adopt any position for pushing preferred by the woman, except
lying supine which risks aortocaval compression and reduced utero placental
perfusion.
3. Listen frequently (every 5 minutes) to the fetal heart in between contractions to
detect bradycardia.
4. Check the maternal pulse and blood pressure, especially where there is a pre-
existing problem of hypertension, severe anemia, or cardiac disease. i
5. Observe progressive descent and rotation of the presenting part.
6. This includes observing progressive distension of the perineum and visibility of
the presenting part, and vaginal examination especially where progress appears
to be slow.
7. Conduct the delivery with support for the perineum to avoid tears, and use of
episiotomy only where a tear is very likely
8. Be ready to augment contractions with an intravenous oxytocin infusion during
the second stage where contractions have become infrequent and where the

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 fetal heart rate remains normal, to avoid the need for instrumental vaginal
delivery or transfer.
9. Be ready to undertake instrumental vaginal delivery (vacuum or forceps) where
indicated for fetal bradycardia or non-advancement of the presenting part

BIRTH OF THE BABY

1. Once the birth is imminent, explain the condition to the mother and transfer her
to the delivery bed.
2. Assist her to the position of her choice/ hospital’s protocol
3. Ensure that the woman’s bladder is emptied.
4. Push delivery trolley to bedside
5. Put on protective clothing
6. Wash your hands and dry
7. Put on two sterile gloves
8. Ensure the woman is in the position of her choice/ the hospital’s protocol
9. Clean the perineum-vulva, pubis, and upper thighs then the abdomen and chest-
observe infection prevention control
10. Place a clean sheet under the buttocks and a sterile cot sheet on the chest
11. Confirm full dilation
12. Apply a pad to the anus
13. Encourage mother to push only when she has the urge to do so
14. Help to safeguard the perineum from trauma, either observing the gradual
advancement of the fetal head or controlling it with light support from her hand
on the head
15. Once the head has crowned, the woman can achieve control by gently blowing
or ‘sighing’ out each breath in order to minimize active pushing.
16. The head is born by extension as the face appears at the perineum.
17. Once the baby’ head is born, ask mother to stop pushing.
18. Gently wipe the baby’s face
19. Check that the cord is not around the baby's neck. If found, it is usual to slacken
it to form a loop through which the shoulders may pass. If the cord is very tightly
wound around the neck, apply two artery forceps approximately 3 cm apart and
sever the cord between the two clamps

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20. Wait for the head to restitute and rotate
21. One shoulder is released at a time to avoid overstretching the perineum, A hand
is placed on each side of the baby's head, over the ears, and gentle downward
traction is applied. This allows the anterior shoulder to slip beneath the
symphysis pubis while the posterior shoulder remains in the vagina.
22. When the axillary crease is seen, the head and trunk are guided in an upward
curve to allow the posterior shoulder to escape over the perineum.
(A) Downward traction releases the anterior shoulder. (B) An upward curve allows
the posterior shoulder to escape.
23. The rest of the fetus should now be easily delivered with gentle traction away
from the mother, then unto the mother’s abdomen
24. Note time of delivery
25. Dry baby thoroughly, place baby skin-to-skin on mother’s abdomen. Change the
wet cot sheet and cover baby with the dry, sterile and warm cot sheet.
26. Now ask your first evaluation question “is my baby crying?”
27. Start to resuscitate or provide routine care based on your answer.
28. Immediately palpate the mother’s abdomen to rule out the presence of any twin
29. Ask your assistance to administer IM oxytocin 10 IU within one minute after birth
of the baby
30. Practice delayed cord clamping

IMMEDIATE CARE OF THE NEWBORN (Until around 1 hour after birth)

Newborn transition and initial care typically occur in the labor and delivery room.
Initial assessments can be safely done with the infant skin-to-skin on the mother’s
abdomen after delivery, if the infant is stable. The first hour after birth has a major
influence on the survival, future health, and wellbeing of a newly born infant. The

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care healthcarers provide during this period is critical in helping to prevent
complications and ensuring survival. All mothers need help, support, and advice in
the initial few days after delivery to ensure proper care of their newly born baby.

THE BASIC NEEDS OF A NORMAL BABY AT BIRTH

The four basic needs of ALL babies at the time of birth (and for the first few weeks
of life) are:
To be warm
To breathe normally
To be protected
To be fed
These basic needs indicate that a baby's survival is totally dependent upon her
mother and other caregivers. Therefore, it is important to provide proper care to all
the neonates immediately after birth. All newborns require essential newborn care
to minimize the risk of illness and maximize their growth and development.
This care will also prevent many newborn emergencies. For example, the umbilical
cord may be the most common source of neonatal sepsis and also of tetanus
infection, and good cord care can dramatically reduce the risks of these serious
conditions. Exclusive breastfeeding has a significant protective effect against
infections.
Early breastfeeding and keeping the baby close to the mother reduce the risk of
hypothermia and hypoglycemia.

Basic steps involved in the immediate care

NB
if the baby is not crying or breathing well, the next steps of resuscitation
have to be carried out after immediate clamping the cord and taking the baby
to warmer

1. Wipe both the eyes with sterile swab.

Once head is delivered, clean the eyes using sterile gauze/cotton. Use separate
gauze for each eye. Wipe from the medial side (inner canthus) to the lateral side
(outer canthus).

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2. Call out the time of birth
It is important to call loudly the time of birth - this helps in accurate recording of the
time and more importantly, alerts other personnel in case any help is needed.

3. Receive the baby on to a warm, clean and dry towel or cloth

The baby should be delivered on to a warm clean towel and kept on the mother's
abdomen or chest.
If this is not possible, the baby should be kept in a clean, warm, safe place close to
the mother

4. Immediately dry the baby thoroughly with a warm sterile towel or cot sheet
Immediately dry baby the baby by applying a firm but gentle stroke on the body.
Blood or meconium on the baby's skin and head should be wiped away; however,
the white greasy substance covering the baby's body (vernix) should not be wiped
off, because the vernix helps to protect the baby's skin and gets reabsorbed within
few hours. Immediately change the wet cot sheet and cover with another dry, warm,
sterile cot sheet.

5. Assess the baby's breathing while drying

At the time of drying itself, the baby's breathing should be assessed. A normal
newborn should be crying vigorously or breathing regularly at a rate of 40-60 breaths
per minute. If the baby is not breathing well, then the steps of resuscitation have to
be carried out. (refer to basic resuscitation)

6. Clamp and cut the umbilical cord-delayed cord clamping

Remove the top glove used for the delivery before clamping and cutting of the cord.
The umbilical cord should be clamped after 1-3 minutes or after cessation of pulse
in the umbilical cord using a sterile, disposable clamp or a sterile tie and cut using a
sterile blade about 2-3 cm away from the skin.

7. Leave the baby between the mother's breasts to start skin-to-skin care-Once
the cord is cut, the baby should be placed between the mother's breasts to initiate
skin-to-skin care. This will help in maintaining the normal temperature of the baby
as well as in promoting early breastfeeding.

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8. Cover the baby's head with a cap. Cover the mother and baby with a warm cloth
- Both the mother and the baby should be covered with a warm cloth, especially if
the delivery room is cold (temperature less than 25°C). Since head is the major
contributor to the surface area of the body, a newborn baby's head should be
covered with a cap to prevent loss of heat.

9. Place an identity label on the baby - This helps in easy identification of the
baby, avoiding any confusion. The label should be placed on the wrist or ankle.
10. Encourage mother to initiate exclusive breastfeeding. Breastfeeding should be
initiated within half an hour of birth in all babies

ENSURING WARMTH: ‘WARM CHAIN"

A baby's skin temperature falls within seconds of being bom.
If the temperature continues to fall, the baby will become ill and may even die.
This is why a baby MUST be dried immediately after birth and delivered onto
a warm towel or piece of cloth, and loosely wrapped before being placed
naked between the mother's breasts or over abdomen.
Keeping the baby between the mother's breasts ensures that the baby's
temperature is kept at the correct level for as long as the skin contact
continues.
This first skin-to-skin contact should last uninterrupted for at least one hour
after birth or until after the first breastfeed.
The mother and baby should be covered with a warm and dry cloth, especially
if the room temperature is lower than 25°C.
The steps of prevention of heat loss are explained in the module on ‘Thermal
protection’. For maintaining the temperature, it is important to understand the
concept of ‘Warm chain‘.
It means that the temperature maintenance should be a continuous process
starting from the time of delivery and continued till the baby is discharged from
the hospital.

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Keeping a new born baby warm after delivery
Newborn can lose heat in four ways

Method of heat loss Prevention

Evaporation: Wet baby Immediately after birth dry baby with a
clean, warm, dry cloth
Conduction: Cold surface e.g. weighing Put the baby on the mother’s abdomen or
scale etc. on a warm surface
Convection: Cold draught Provide a warm, draught free room for
delivery at 225°C
Radiation: Cold metallic surroundings Keep the room warm

HELPING TO ESTABLISH NORMAL BREATHING

The baby‘s breathing should be assessed at the time of drying.
If the baby is crying vigorously or breathing adequately (chest is rising
smoothly at a rate of 40 to 60 times per minute), then no intervention is
needed.
However, if the baby is not breathing or gasping, then skilled care in the form
of initial steps, positive pressure ventilation etc. might be required.

INITIATING BREASTFEEDING
During the initial skin-to-skin contact position after birth, the baby should be
kept between the mother's breasts; this would ensure early initiation of
breastfeeding. Initially, the baby might want to rest and would be asleep.

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 This rest period may vary from a few minutes to 30 or 40 minutes before the
baby shows signs of wanting to breastfeed.
After this period (remember each baby is different and this period might vary),
the baby will usually open his/her mouth and start to move the head from side
to side; he may also begin to dribble.
These signs indicate that the baby is ready to breastfeed. Baby may also try
reaching the breast by making directed movements -called ‘Breast Crawl‘
The mother should be helped in feeding the baby once the baby shows these
signs. Both the mother and the baby should be in a comfortable position.
The baby will be put next to the mother's breasts with his mouth opposite the
nipple and areola.
The baby should attach to the breast by itself when it is ready.
When the baby is breastfeeding, attachment and positioning should be
checked.
The mother should be helped to correct anything which is not quite right.
If in the initial first feeding session baby does not latch, don't give any liquid
other than breast milk (or colostrum) even if baby doesn’t feed.
Most of the babies are ready to take feed with in 30min to one hour.
The procedure of counseling and support for breastfeeding are explained in
the module on ‘Feeding of normal and low birth weight infants”.

PREVENTION OF INFECTIONS: ‘CLEAN CHAIN

Babies are secure placed in their mothers’ womb.
When they are born, they have to be protected from the adverse environment
of the surroundings.
Cleanliness at delivery reduces the risk of infection for the mother and baby,
especially neonatal sepsis and tetanus.
Cleanliness requires mothers, families, and health professionals to avoid
harmful traditional practices, and prepare necessary materials.
Hand washing is the single most important step to be emphasized to both
family members and health care workers.
Similar to warm chain, ‘Clean chain’ has to be followed both at the time of
delivery and then till the time of discharge to protect the infant from infections.
The components of clean chain are summarized below:

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Clean delivery (WHO’s six cleans)
Clean attendant's hands (washed with soap)
Clean delivery surface
Clean cord- cutting instrument (i.e. razor, blade)
Clean string to tie cord
Clean cloth to cover the baby
Clean cloth to cover the mother

After delivery
All caregivers should wash hands before handling the baby
Feed only breast milk
Keep the cord clean and dry; do not apply anything
Use a clean absorbent cloth as a diaper/napkin
Wash your hands after changing diaper/napkin.
Keep the baby clothed and wrapped with the head covered

APGAR SCORE
The Apgar score is a rapid assessment of five physiological signs that indicate the
physiological status of the newborn. The areas of assessment are:
Color based on observation
Pulse/ Heart rate based on auscultation
Grimace/Reflex irritability based on response to tactile stimulation
Muscle tone based on degree of flexion and movement of extremities
Respiratory rate based on observed movement of chest
Apgar scores should be obtained at 1 minute and 5 minutes after birth. Each
component is given a score of 0, 1, or 2.
Criteria 0 1 2
Appearance (colour) Blue or pale Acrocyanotic-pink Completely pink
body blue extremities
Pulse/heart rate Absent > slow (<100/min) >100/min)
Grimace-Reflex No Grimace, noticeable Cough, sneeze,
response response facial movement pulls away,
Activity/music tone Limp Some flexion Active motion
Respiration/breathing Absent Slow, irregular Good, crying

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Impression
At most, a child will receive an overall score of 10. However, a baby rarely
scores l0 in the first few moments of life. This is because most babies have
blue hands or feet immediately after birth. Low Apgar scores may indicate
the baby needs special care, such as extra help with their breathing.
A score of7 to 10 is considered normal.
A score of 4 to 6 –fairly low and may indicate that the baby needs some
resuscitation measures (oxygen) and careful monitoring.
A score of 3 or below-critically low. Indicates that the baby requires immediate
resuscitation and lifesaving techniques.
A low score on the one-minute test may show that the newborn requires
medical attention but is not necessarily an indication that there will be long-
term problems, particularly if there is an improvement by the stage of the five-
minute test.
If the 5-minute Apgar score is less than 7, additional scores should be
assigned every 5 minutes up to 20 minutes. Temperature, heart and
respiratory rates, skin color, adequacy of peripheral circulation, type of
respiration, level of consciousness, tone, and activity should be monitored
and recorded at least every 30 minutes until the newborn’s condition has
remained stable for at least 2 hours.
NOTE
The Apgar score is not used to determine the need for resuscitation, nor is it
predictive or long-term neurological outcome of the neonate (American
Academy of Pediatrics [AAP] & American College of Obstetrics and
Gynecology [ACOG], 2006).
Rather it is a rapid, objective, convenient shorthand for reporting the status of
the newborn and the response to resuscitation immediately after birth.

ESSENTIAL NEWBORN CARE (ENC)

Introduction
Majority of babies born healthy and at term
Care during first hours, days and weeks of life determine whether they remain
healthy
Basic care to support survival and wellbeing is called ENC
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 It includes immediate care at birth, care during the first day and up to 28 days
Neonatal deaths are a major contributing factor to U5 mortality in India

Postnatal environment/6 hours after delivery

Kept warm with no draughts from open doors or windows. Temperature of 25
C required.
Mother and her baby kept together in same bed (rooming-in)
Helps to form bonding, can respond quickly when her baby wants to feed,
reduces breastfeeding difficulties

Ask the mother

Do you or baby have any problems?
Has infant passed stools, urine?
Have you started breast feeding infant?
Is there any difficulty in feeding infant?
Do you have any pain while breast feeding?
Have you given any other foods or drinks to infant? If yes, what and how?

Essential Newborn Care Interventions

Clean childbirth and cord care
o Prevent newborn infection
Thermal protection
o Prevent & manage newborn hypo/hyperthermia
Early and exclusive breastfeeding
o Started within 1 hour after childbirth
Initiation of breathing and resuscitation
o Early asphyxia identification and management

Examine the baby

Count breaths in one minute
Look for severe chest indrawing
Look and listen for grunting
Look at umbilicus. Is it red or draining pus?
Look for skin pustules. Are there 10 or more pustules or a big boil?
Measure axillary temperature (if not possible, feel for fever or low body
temperature)
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 See if young infant is lethargic
Look for jaundice. Are the face, abdomen or soles yellow?
Look for malformations

Assess Breastfeeding
If infant has not fed in previous hour, ask mother to put her infant to breast.
Observe the breastfeed for 4 minutes.
• Is the infant able to attach?

To check attachment, look for:

Chin touching breast
Mouth wide open
Lower lip turned outward
More areola above than below the mouth
If not well attached, help mother to position so that baby attaches well.
Is the infant suckling effectively (that is, slow deep sucks, sometimes
pausing)?
If not sucking well, then look for:
ulcers or white patches in mouth (thrush)
If there is difficulty or pain while feeding, then look for
Engorged breasts or breast abcess
Flat or inverted, or sore nipples

Look for Normal Phenomena

milia, epstein pearls, mongolian spots, enlarged breasts, capillary nevi etc.
Transitional stools
Vaginal white discharge/bleeding in female babies
Red rashes on skin on 2-3 days of life.
Weight loss of 6-8% (10-12% in preterms) in first few days of life

Cord Care
Umbilical cord is important portal of entry for pathogenic organism.
Instruct mother not to apply anything on cord and keep it dry.
Umbilical stump must be inspected after 2-4 hours of clamping.
Bleeding may occur at this time due to shrinkage of cord and loosening of
ligature
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Skin and Eye Care
Babies are not bathed routinely in hospital to prevent complications like
hypothermia and infection,
May be sponged with lukewarm water.
No routine eye care is required

Counsel the mother

Keep baby warm
Breastfeed frequently and exclusively
Advise mother to wash hands with soap and water after using toilet and after
cleaning bottom of baby.
Advise mother regarding danger signs and care seeking.
Immunization
The baby should receive
o -BCG
o -OPV-0
o -Hepatitis B (HB-1) - if included in immunization schedule

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REEVIEW QUESTIONS
SITUATION: Salima is a primigavida who has just been admitted to the labour unit.
After
Salima’s orientation to the unit, the midwife applied the external fetal monitor and
conducts a vagina examination.
Question 1 to 8 refers to the situation. ,
l. The vaginal examination reveals that the fetus is in a vertex presentation and at a
-l station.
The nurse would interpret these findings to indicate that the fetal:
a. Buttocks are the ischial spines.
b. Buttocks re crowning
c. Head is above the ischial spines
d. Head is engaged

2. The nurse is teaching Ms. Salima’s partner Maj eed how to time the duration of
his wife’s contractions. Which of the following statements would the nurse used in
her teaching?
a. “Duration is timed from the beginning of the one contraction to the beginning of
the next contraction”
b. “Duration is timed from the beginning of a contraction to the end of the same
contraction”
c. “Duration can be determine only with an intemal pressure catheter, which will be
inserted after the membranes are ruptured”
d. “Duration is measured by timing the interval between the end of one contraction
and the beginning of the next contraction”

3. The midwife continues to monitor Mrs. Salima’s progress in labor. Which of the
following assessments would require the nurse to collect additional data?
a. Blood-tinged vaginal discharges at complete dilation
b. Left occipitoanterior (LOA) fetal presentation
c. Maternal pulse between 90 and 95 beats/minute
d. Meconium-stained amniotic fluid

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4. Mrs. Salima’s husband has gone to phone the family to report on the progress of
labour. As the nurse enters the room, she observes Ms. Salima focusing on
Majeed’s picture and breathing deeply with her contractions. The nurse would
interpret this behaviour as characteristics of which phase of labour?
a. Active first stage
b. Active second stage
c. Latent first stage
d. Latent second stage

5. When Ms. Salima has reach transition, which of the following behaviour would the
midwife expect Ms. Salima to display?
a. Explaining in details her birth plan
b. Panting rapidly at the peak at the end of each contraction
c. Pushing the nurse’s hand off her abdomen.
d. Slowly breathing with her contractions

6. While monitoring your full-term labor patient, you notice persistent variable
decelerations.
Your first intervention for maximizing fetal oxygenation is to:
a. Administer oxygen
b. Change maternal position
c. Discontinue oxytocin
d. Increase IV rate

7. In the same patient as above, you now recognize that the FHR tracing has been
showing a decrease in variability for the last 45 minutes. Your first intervention
should be to.
a. Administer oxygen
b. Discontinue iv fluids
c. Encourage ambulation
d. Increase oxytocin rate

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8. The above intervention improves the baby's variability, but the FHR is still not
reactive.
You attempt fetal scalp stimulation (FSE) because you know that a well-oxygenated
fetus will respond to FSE with
a. Acceleration
b. Deceleration
c. Foetal movement
d. Sleep patterns

9. The best placement of a tocodynamometer to pick the uterine contractions is the:

a. Fundus
b. lower abdomen
c. perineum
d. vagina

10. Which options describes the proper order of the cardinal movements of labour
(mechanism of labour
a. Engagement, internal rotation, descent, flexion
b. Engagement, external rotation, descent, extension
c. Engagement, extension, internal rotation, flexion
cl. Engagement, flexion, internal rotation, extension, extemal rotation

11. Engagement is best defined as which of the following

a. when the presenting part goes through the pelvic inlet
b. When the presenting part is level with the ischial spines
c. When the greatest biparietal diameter of the fetal head passes the pelvic inlet
d. When the presenting part is level with the symphysis pubis

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 CHAPTER EIGHT
PHYSIOLOGY AND MANAGEMENT OF THE THIRD STAGE OF LABOUR
Third stage of labor is that period during the course of labor which begins
immediately after delivery of the baby and involves separation and expulsion of
placenta and its attached membranes.
DURATION OF THIRD STAGE OF LABOUR
Within normal limits, the third stage usually lasts between 5 and 15 minutes, but any
period up to
30 minutes may be considered. With the active management of labor, the average
duration of third stage of labor is reduced to 5 minutes from 15 minutes. The duration
of third stage of labor lasts for more than 30 minutes in 3% of women with an
increasing incidence of complications.
The third stage of labor is diagnosed as prolonged, if not completed within 30
minutes of the birth of the baby with active management and 60 minutes with
physiological management.
Considerable research has examined how active management affects the third
stage of labor. Investigations found that 50 percent of placental deliveries occur
within 5 minutes, and 90 percent are delivered within 15 minutes. Other studies
confirm the rapid delivery of the placenta; a WHO study found a mean delivery time
of 8.3 minutes. A third stage of labor lasting longer that 18 minutes is associated
with a significant risk of PPH. When the third stage of labor lasts longer than 30
minutes, PPH occurs six times more often than it does among women whose third
stage lasted less than 30 minutes.

Significance Of The Third Stage Of Labour

Many significant complications like primary postpartum hemorrhage (PPH), which is
the most common cause of maternal mortality can occur in this period.

PHYSIOLOGY OF THE THIRD STAGE OF LABOR

Physiology of third stage of labor has three phases:
l. The phase of uterine contractions.
2. The phase of placental separation.
3. The phase of placental expulsion

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1.-Phase of Uterine Contractions
After completion of 2nd stage of labor, there occur strong uterine contractions which
lead to thickening of uterine muscle and creating a shearing force between the
elastic uterine wall and the placenta. At this phase, the uterine fundus lies just below
the level of umbilicus and is round and hard with painful rhythmic uterine
contractions.

2.-Placental Separation and Expulsion

By the end of the second stage of the labour the uterus suddenly becomes empty.
This reduces the surface area of the decidua placental site. The non-elastic nature
of the placenta causes it to begin separating from the decidua.
As this occurs the placenta becomes compressed and blood in the intervillous space
is forced back into the spongy layer of the deciduas. The blood vessels now become
tensed and congested.
Once the uterus contract, the congested vessels burst and the blood either trickles
down or may form a retro placental clot.
The second mechanism of separation is through hematoma formation due to venous
occlusion and vascular rupture in the placental bed caused by uterine contractions.
As the placenta detaches, the spiral arteries are exposed in the placental bed;
massive hemorrhage would occur if not for the structure of uterus.
Separation usually start centrally so that the retro placental clot formed aid
separation by exerting pressure at the midpoint of placenta attachment so that this
increased weight helps to strip the lateral borders as well as the membranes from
the uterine wall.
In this instance, the clot thus formed become enclosed in a membranous bag as the
placenta descends. The fetal surface is the first to appear at the vulva. This method
of placental separation and descent is referred to as Central (Schultze) separation
Alternatively, the placenta may begin to detach unevenly at one of the lateral
borders. Here the ruptured distended intervillous space blood vessels escape
without forming the retroplacental clot.
The placenta descends slipping sideways. Maternal surface appears first. This
process of separation and descent of the placenta is referred to as Marginal
(Mathews Duncan) separation.

119
Once the placenta has separated, the uterus contracts strongly, forcing the placenta
into the lower uterine segment and finally to the vagina and be expelled, with the
margin coming first (Matthew
Duncan method), or it will invert and deliver with the fetal side first (Schultze
method).

3.-Control of Hemorrhage
After complete expulsion of placenta, permanent contraction and retraction of the
uterus occurs.
This is due to three factors:
l. The contraction and retraction of the uterus constricts the vessels passing through
the uterine wall to the placental site. The vessels supplying the placental bed
traverse a lattice of crisscrossing muscle bundles that occlude and kink-off the
vessels as they contract and retract following expulsion of the placenta. This
arrangement of muscle bundles has been referred to as the "living ligatures" or
"physiologic sutures" of the uterus.

120
2. The occlusion of the torn vessels themselves.
3. Activation of coagulation and fibrinolytic systems, securing hemostasis by the
formation of a fibrin mesh over the placental site

Several agents cause uterine contraction:

The sensitivity of the myometrium to oxytocin, a nonapeptide produced in the
posterior pituitary, increases greatly in late pregnancy and even more so
during labor.
Locally produced and exogenous prostaglandins, especially those of the F
series, also cause myometrial contraction.
Synthetic ergot alkaloids cause strong tetanic contraction of the uterus.
Agents that cause uterine relaxation can lead to dangerous bleeding following
delivery:
Beta-sympathomimetics (eg, ritodrine, terbutaline, salbutamol) relax the
uterus via beta-2 stimulation.
Nonsteroidal anti-inflammatory agents have a dual action, with both
antiprostaglandin and antiplatelet activity. The former effect makes them
useful for treating dysmenorrhea and afterpains, both due to uterine

121
 cramping; however, in the postpartum period and especially following PPH,
strong uterine contraction is desired.
Calcium antagonists, such as nifedipine and, to a lesser extent, magnesium
sulfate, may also inhibit uterine contractions.
Nitroglycerin and some inhalational anesthetic agents also decrease uterine
contractility.

MANAGEMENT OF THIRD STAGE

Essential care during the third stage of labor
The time immediately following birth can be particularly active and involved because
the skilled birth attendant must attend to both the woman and newborn. Regardless
of how the third stage of labor is managed, basic care for the woman and baby
during labor and postpartum remains the same. The following actions represent the
elements of essential care for the provider and for the woman and newborn during
the third stage of labor.

Essential precautions for the provider

Health care providers should take the following precautions for themselves:
Wear protective gear (gloves, face mask/goggles, apron, and boots or closed
shoes).
Safeguard against splashes and sharps-related injuries.

Essential care for the woman

Health care providers should follow these guidelines in caring for the woman:
Ensure the woman is in a comfortable position.
Explain to woman and family what is happening around them.
Inform the woman about her baby and explain what is happening while you
attend to immediate newborn care.
Encourage breastfeeding, if this is the woman's choice for infant feeding.
Follow national guidelines for maternal interventions to prevent/ reduce the
risk of mother-to-child transmission (MTCT) of HIV/AIDS.

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Throughout all phases of care:
Give continuous empathetic and physical support.
Give the woman as much information and explanation as she desires.
Facilitate good communication among the woman and her caregivers and
companions.
Practice infection prevention.
Approaches to the Clinical Management of the Third Stage of Labor:
l. Expectant management
2. Active management,
3. Mixed management (Combination of components of both expectant and active
management)

EXPECTANT MANAGEMENT OF THE THIRD STAGE OF LABOR

Expectant management is also known as conservative or physiological
management and is practiced in some parts of the developing world.
The main principle of expectant management s a hands-off approach, to wait till
signs of placental separation and allow placenta to deliver spontaneously.

Components of expectant management are:

Look for 3 classic signs of placental separation
1. The most reliable sign is the lengthening of the umbilical cord as the placenta
separates and is pushed into the lower uterine segment by progressive uterine
retraction.
Placing a clamp on the cord near the perineum makes it easier to appreciate
this lengthening.
Never place traction on the cord without countertraction on the uterus above the
symphysis; otherwise, one may mistake cord lengthening due to impending
prolapse or inversion for that of uncomplicated placental separation.
2. Change in shape of uterine fundus from discoid to globular with elevation of
fundal height
The uterus takes on a more globular shape and becomes firmer.
This occurs as the placenta descends into the lower segment and the body of
the uterus continues to retract.
This change may be clinically difficult to appreciate.

123
 The uterus rises in the abdomen.
The descent of the placenta into the lower segment, and finally into the vagina,
displaces the uterus upward.
3. A gush of blood occurs.
The retroplacental clot is able to escape as the placenta descends to the lower
uterine segment.
The retroplacental clot usually forms centrally and escapes following complete
separation; however, if the blood can find a path to escape, it may do so before
complete separation and thus is not a reliable indicator of complete separation.
This occurrence is sometimes associated with increased bleeding and a
prolonged third stage, with the delivery of the leading edge of the placenta and
maternal surface first (Matthews Duncan method), rather than the cord insertion
and fetal surface, which is more common (Schultze method).
The management will include the following after observing the above signs
Spontaneous/Controlled cord traction (CCT)
Expulsion of placenta is within 20 minutes
Massage the uterus
Intramuscular Oxytocin: 10 lU
Examination of placenta, membranes, cord
Inspect vulva, vagina & perineum

UTEROTONIC AGENTS
An uterotonic, also known as ecbolic, are pharmacological agents used to induce
contraction or greater tonicity of the uterus.
Use of Uterotonics
Uterotonics act directly on the smooth muscle of the uterus and increase the tone,
rate, and strength of rhythmic contractions. The body produces a natural uterotonic-
the hormone oxytocin-that acts to stimulate uterine contractions at the start of labor
and throughout the birth process.
Drugs such as oxytocin, ergometrine, and misoprostol have strong uterotonic
properties and are' used to treat uterine atony and reduce the amount of blood lost
after childbirth.

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Oxytocin is widely used for induction and augmentation of labor. The use of a
uterotonic drug immediately after the delivery of the newborn is one of the most
important actions used to prevent PPH.

OXYTOCIN (PITOCIN®):
Oxytocin is a synthetic version of the natural nonapeptide produced in the
posterior pituitary.
The drug comes in solution at a concentration of 10 U/ml. For postpartum use,
including third stage of labor, oxytocin is dosed at 10-40 U per liter of IV fluid and
given as an IV infusion.
The rate of infusion should be sufficient to maintain uterine contractility.
The plasma half-life of oxytocin is 1-6 minutes and the clinical response is rapid
after IV infusion.
Alternatively, the agent may be given as an IM injection (10 units).
Intramuscular response to the drug occurs within 3-5 minutes, with a clinical
response lasting about 2-3 hours.
The drug may be stored at room temperature.
Oxytocin should not be given intravenously as a large bolus because an
intravenous bolus of 10 units of oxytocin can lead to:
o fall in blood pressure
o Mean pulse rate increased 28 bpm,
o mean arterial pressure decreased 33 mm Hg,
o electrocardiogram changes of myocardial ischemia
o chest pain
o subjective discomfort
In cases of postpartum hemorrhage, direct injection into the uterus, either
transvaginal or trans abdominally, following a vaginal birth or cesarean
delivery has proven effective.
The use of nipple stimulation in the third stage of labor also has been shown
to increase uterine pressures and to decrease third-stage duration and blood
loss

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Side effect
Side effects are rare in the absence of prolonged use.
Nausea and vomiting have been reported.
The most serious side effect from prolonged use of IV oxytocin is water
intoxication with subsequent dilutional hyponatremia.
Rapid IV infusion is associated with hypotension and tachycardia.

Contraindications:
The only postpartum contraindication to use of oxytocin would be hypersensitivity to
the drug.

METHERGINE® (METHYLERGONOVINE MALEATE):

Methergine is a semi-synthetic ergot alkaloid that is FDA-approved for routine
management of the third stage of labor and postpartum atony.
It is supplied in ampoules containing 0.2 mg of active drug in a volume of 1
mL or as a single tablet of
0.2 mg of active drug.
The drug is given either as an intramuscular injection (1 ampoule) or orally
(single tablet).
When given as an oral agent, the onset of action is within 5-10 minutes with
a bioavailability of 60%. When given as an intramuscular injection, the onset
of action is 2-5 minutes and the bioavailability is 78% (about 25% greater than
when given orally).
The plasma half-life is about 3.4 hours. The agent should not be given by
intravascular injection.
The frequency of administration is 2-4 hours for IM administration and 6-8
hours when given orally. The drug must be refrigerated when stored.

Side Effects:
Side effects are rare in the absence of prolonged use.
Most common side effects are nausea and vomiting.
Chest pain, arterial spasm, myocardial infarction, and hallucination have been
reported in cases of toxicity.

126
Contraindications:
Methergine should be used with extreme caution in the setting of hypertension
or preeclampsia.
Care should be exercised when there has been recent administration of other
vasoconstrictive agents (i.e. ephedrine). In these settings, there may be an
exaggerated blood pressure response to the use of this agent.
Care should also be taken when CYP 3A3 inhibiting agents, such as
macrolide antibiotics, protease inhibitors, or azole antifungals, have recently
been used

HEMABATE® (CARBOPROST OR 15 METHYL PGF2 ALPHA):

Hemabate is FDA-approved for the treatment of postpartum hemorrhage
secondary to uterine atony not responsive to conventional treatment
(massage and oxytocin).
The drug is supplied in 1 ml ampoules containing 250 mcg of the drug.
The dose is one ampoule given as an IM injection.
The peak plasma level of the drug is reached about 30 minutes after injection.
A successful clinical response is expected after a single injection in about
75% of cases. In refractory cases, additional dosing at 15-90 minute intervals
may be beneficial.
The total amount of drug given should not exceed 2 mg (8 doses).
The clinical response may be enhanced with concomitant use of oxytocin. It
may be less effective when used in the setting of chorioamnionitis.
It should be noted that other uterotonic agents are also less effective in the
setting of chorioamnionitis. The drug must be refrigerated when stored.

Side Effects:
Recognized side effects include nausea, vomiting, diarrhea, fever (up to 1 degree
Celsius), bronchospasm, and hypertension.

Contraindications:
It is recommended that the drug be given with caution to patients with active hepatic
or cardiovascular disease, asthma, or hypersensitivity to the drug.

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CYTOTEC® (MISOPROSTOL):
This agent is a synthetic prostaglandin E1 analog.
This agent is FDA approved for reducing the risk of NSAID-induced gastric
ulcers.
It comes in either 100 or 200 mcg tablets.
This agent is not FDA-approved for uterine atony or obstetrical hemorrhage,
although its effectiveness has been clearly demonstrated in the obstetrical
literature.
The drug is water-soluble and is quickly absorbed after sublingual, oral,
vaginal, and rectal use.
The most common method of administering misoprostol for postpartum
hemorrhage is rectally, although in a conscious patient sublingual use would
also be reasonable.
The dose usually ranges between 800-1000 mcg.
The time to peak plasma concentration is shortest for sublingual
administration and the plasma
concentration is higher than when given rectally.
However, after rectal administration, plasma concentrations are maintained
for a longer period.
The drug undergoes a series of chemical reactions after ingestion, converting
the agent to a prostaglandin F analog, making the drug very similar to
hemabate (15 methyl PGF2 alpha).
Therefore, it is unlikely that misoprostol would be effective if hemabate has
failed, or vice versa.
Unlike hemabate, misoprostol does not appear to exacerbate
bronchoconstriction in patients with asthma.
One of the major advantages of this agent is that the drug does not need to
be refrigerated and may be easily stored on labor and delivery hospital units.

Side Effects:
Diarrhea, shivering, pyrexia and headaches are the most common side effects.

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Contraindications:
Hypersensitivity to the drug.

UTEROTONIC DRUGS USED FOR AMTSL

The table below compares dosage, route of administration, drug action and
effectiveness, side effects, and cautions for the most common uterotonic drugs used
for AMTSL
Name of drug/ Dosage and Drug action and Side effects and cautions
preparation route effectiveness
Oxytocin -Acts within 2 to -First choice.
Posterior pituitary Give 10 units 3 minutes. -No known
extract. Commonly IM injection.* -Effect lasts contraindications for
used brand names about 15 to 30 -postpartum use.**
include Pitocin or minutes. -Minimal or no side
Svntocinon. effects.
Misoprostol Give 600 Orally: •No known
mcg -Acts within 6 contraindications for
Synthetic (three 200 minutes. postpartum use.**
prostaglandin mcg tablets) -Peak serum Common side effects:
E1 (PGE1) analogue. orally. concentration shivering and elevated
Commonly used between 18 and temperature.
brand 34
names include minutes.
Cytotec, -Effect lasts 75
Gymiso, Prostokos, minutes.
Vagiprost, U-Miso
Ergometrine Give 0.2 mg Acts within 6 to 7 Contraindicated in
( methylergometrine), IM injection. minutes IM. women with a history of
also known as • Effect lasts 2 hypertension, heart
ergonovine to disease, retained
( methylergonovine) 4 hours. placenta, pre-
Preparation of ergot eclampsia, or
(usually comes in eclampsia.***
dark brown • Causes tonic
ampoule). contractions (may
Commonly used increase risk of retained
brand names include placenta).
Methergine, Side effects:
Ergotrate, nausea, vomiting,
Ergotrate Maleate headaches, and
hypertension.

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 Note: Do not use if drug
is cloudy. This means it
has been exposed to
excess heat or light and
is no longer effective.
Syntometrine Give Combined rapid Same cautions and
Combination of 5 IU 1 ml IM action of oxytocin contraindications as
oxytocin plus 0.5 mg injection and sustained ergometrine.
ergometrine. action •Side effects:
Not currently of ergometrine. nausea, vomiting,
recommended headaches and
hvoertension.

'If a woman has an IV, an option may be to give her 5 IU of oxytocin by slow IV push.
"This is intended as a guide for using these uterotonic drugs during the third stage
of labor. Different guidelines apply when using these uterotonic drugs at other times
or for other reasons.
"'Lists of contraindications are not meant to be complete; evaluate each client for
sensitivities and appropriateness before use of any uterotonic drug. Only some of
the major postpartum contraindications are listed for the above drugs.
Oxytocin is fast-acting, inexpensive, and in most cases, has no side effects or
contraindications for use during the third stage of labor. Oxytocin is also more stable
than ergometrine in hot climates and light (when. cold/dark storage is not possible).
WHO recommends oxytocin as the drug of choice for AMTSL and advises that
ergometrine, syntometrine, or misoprbstol, be used only when oxytocin is not
available.
WHO recommends oxyfocin as the drug of choice for AMTSL.
Misoprostol is a synthetic prostaglandin E1 (PGE1) analogue and is an alternative
drug for AMTSL. Oxytocin is the uterotonic of choice for AMTSL; however,
administration of an injection requires skills and sterile equipment for safe
administration. Oxytocin may be inactivated if exposed to high ambient
temperatures.
Misoprostol is reportedly more stable than oxytocin and has been administered by
oral, sublingual and rectal routes in several studies. Oral misoprostol is being viewed
as an alternative drug for AMTSL for women delivering in low-resource settings
where oxytocin and a skilled birth attendant may not be available and as a PPH

130
treatment when used in combination with other uterotonics. It has also been
suggested that providers can provide misoprostol tablets where oxytocin is not
available to non-skilled providers21 and to women themselves for the prevention of
PPH.

Recommendations for Selection of an Uterotonic Drug for Prevention of PPH

In the context of active management of the third stage of labor, if all injectable
uterotonic drugs are available:
Skilled attendants should offer oxytocin to all women for prevention of PPH in
preference to ergometrine/methylergometrine.
This recommendation places a high value on avoiding adverse effects of
ergometrine and assumes similar benefit for oxytocin and ergometrine for preventing
PPH.
Skilled attendants should offer oxytocin for prevention of PPH in preference
to oral misoprostol (600 mcg).
This recommendation places a high value on the relative benefits of oxytocin
in preventing blood loss compared to misoprostol, as well as the increased
adverse effects of misoprostol compared to oxytocin.23
In the context of active management of the third stage of labor, if oxytocin is
not available but other injectable uterotonics are available:
Skilled attendants should offer ergometrine/methylergometrine or the fixed
drug combination of oxytocin and ergometrine to women without hypertension
or heart disease for prevention of PPH.
Skilled attendants should offer 600 micrograms (mcg) misoprostol orally for
prevention of PPH to women with hypertension or heart disease for
prevention of PPH.
In the context of prevention of PPH, if oxytocin is not available or birth attendants'
skills are limited, misoprostol should be administered soon after the birth of the baby•
The usual components of giving misoprostol include:
Administration of 600 micrograms (mcg) misoprostol orally after the birth of
the baby
Controlled cord traction ONLY when a skilled attendant is present at the birth
Uterine massage after the delivery of the placenta as appropriate.

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Keeping Uterotonic Drugs Effective
The stability of a drug is defined by how well it maintains active ingredient potency
(and other measures such as pH) when stored over time. Pharmaceutical
companies conduct stability studies to determine the appropriate shelf-life, storage
conditions, and expiration dating for safe storage of the oxytocin they produce. A
manufacturer will recommend storage conditions based on the conditions under
which he has performed stability studies, and will set the expiry date to be consistent
with this. It is therefore important to read storage recommendations made by the
manufacturer.
Since ergometrine and syntometrine are sensitive to heat and light, and oxytocin
is sensitive to heat, following storage guidelines is critical to ensure the optimal
effectiveness of injectable uterotonic drugs. When drugs are inadequately stored,
drug effectiveness can diminish, posing serious consequences for the postpartum
woman.
Storage practices in health care facilities vary widely and may not follow guidelines
for correct storage. For example, vials of uterotonic drugs might be kept on open
trays or containers in the labor ward, leaving them exposed to heat and light.
Pharmacists, pharmacy managers, and birth attendants using the oxytocin need to
carefully read and follow recommended guidelines for transporting and storing
uterotonic drugs.

Drug Transport Storage

Unrefrigerated Check manufacturer's recommendations -

transport is some manufacturers are producing oxytocin
possible if no more that is more heat stable than previously
than one month at available
Oxytocin 30°C. • Temporary storage outside the refrigerator
at a maximum of 30°C is acceptable for no
more than three months.
• If possible, keep refrigerated at 2 0C.
• Store at room temperature in closed
Misoprostol Protect from container and protected from humidity.
humidity.
Unrefrigerated • Store in the dark.
Syntometrine transport in the • Keep refrigerated at 2-8°C.
dark is possible if • Store in closed container.

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 no more than one • Protect from freezina.
month at 30°C.
Protect from
freezing.
Unrefrigerated • Store in the dark.
transport in the • Keep refrigerated at 2-8°C.
Ergometrine dark is possible if • Store in closed container.
no more than one • Protect from freezing.
month at 30°C.
Protect from
freezing.

Recommended guidelines for transport and storage of uterotonic drugs

Effect of Heat and Light on Uterotonic Drugs
Two factors can influence the effectiveness of uterotonic drugs: temperature and
light. This is especially important in hot temperatures and in conditions where
refrigeration is not always available or reliable. A WHO research program examined
the effectiveness of different injectable uterotonic drugs at various temperatures and
light conditions. Table below shows one comparison from this study.
Uterotonic Dark 4- Dark Light 21- Effects of heat and
drug s·c 3o•c 2s·c light/key findings
Oxytocin 0% loss 14% 7% loss Minimal effect from light,
loss more stable for longer time
at higher temperatures than
ergometrine
Ergometrine 5% loss 3·1% 90% loss Significantly more affected
loss by heat and light, not stable
at higher temperatures

ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOR (AMTSL)

Definition
AMTSL is a combination of actions to speed the delivery of the placenta by
increasing uterine contractions and minimizing uterine atony. Using AMTSL helps
prevent unnecessary blood loss and PPH.

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Scientific Evidence Supporting Use of AMTSL
Giving a uterotonic drug to prevent PPH promotes strong uterine contractions and
leads to faster retraction and placental separation- arid delivery. Several large,
randomized controlled trials have investigated whether physiologic management or
active management is more effective in preventing PPH. These trials have
consistently shown that active management provides several benefits for the mother
compared to physiologic management. Their results show that only 12 women need
to receive AMTSL to prevent one case of PPH. This means that AMTSL is a very
effective and cost-efficient public health intervention (Jangsten, Mattsson,
Lyckestam, Hellström, & Berg, M. (2011); Prendiville, Elbourne & McDonald,
(2000)). These studies also confirm that AMTSL decreases:
Incidence of PPH.
Length of third stage of labor.
Percentage of third stages of labor lasting longer than 30 minutes.
Need for blood transfusion.
Need for uterotonic drugs to manage PPH.

Preparing for active management

Before or during the second stage of labor:
Prepare the injectable uterotonic (10 IU of oxytocin is the preferred injectable
uterotonic) in a sterile syringe before second stage or have oxytocin in
Inject™ or 600 mcg of misoprostol available.
Prepare other essential equipment for birth and the third stage of labor
before onset of second stage of labor.
Ask the woman to empty her bladder when second stage is near.
Assist the woman into her preferred position for giving birth (e.g., squatting,
semi-sitting).

Steps for AMTSL

There are three main components or steps of AMTSL
administering a uterotonic drug,
CCT, and
massaging the uterus-

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1. Thoroughly dry the baby; assess the baby's breathing and perform
resuscitation if needed, and place the baby in skin-to-skin contact with the
mother.
After delivery, immediately dry the infant and assess the baby's breathing.
Then place the reactive infant, prone, on the mother's abdomen.* Remove
the cloth used to dry the baby and keep the infant covered with a dry cloth
or towel to prevent heat loss.
*If the infant is pale, limp, or not breathing, it is best to keep the infant at the
level of the perineum to allow optimal blood flow and oxygenation while
resuscitative measures are performed. Early cord clamping may be
necessary if immediate attention cannot be provided without clamping and
cutting the cord. These should be implemented along with the provision of
immediate newborn

2. Administer a uterotonic drug within one minute of the baby's birth

Administering a uterotonic drug within one minute of the baby's birth
stimulates uterine contractions that will facilitate separation of the placenta
from the uterine wall. Before giving the uterotonic drug it is important to rule
out the presence of another baby. If the uterotonic drug is administered when
there is a second baby, there is a small risk that the second baby could be
trapped in the uterus.

The steps for administering a uterotonic drug include:

Before performing AMTSL, gently palpate the woman's abdomen to rule
out the presence of another baby. At this point, do not massage the uterus.
If there is not another baby, begin the procedure by giving the woman 10
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IU of oxytocin IM in the upper thigh. This should be done within one minute
of childbirth. If available, a qualified assistant should give the injection
3. Cut the umbilical cord
Clamp and cut the cord following strict hygienic techniques after cord
pulsation have ceased or approximately 2-3 minutes after birth of the baby,
whichever comes first.
4. Keep the baby warm
Place the infant directly on the mother's chest, prone, with the newborn's
skin touching the mother's skin. While the mother's skin will help regulate the
infant's temperature, cover both the mother and infant with a dry, warm cloth
or towel to prevent heat loss. Cover the baby's head with a cap or cloth
5. Perform controlled cord traction
CCT helps the placenta descend into the vagina after it has separated from
the uterine wall and facilitates its delivery. It is important that the placenta be
removed quickly once it has separated from the uterine wall because the
uterus cannot contract efficiently if the placenta is still inside. CCT includes
supporting the uterus by applying pressure on the lower segment of the
uterus in an upward direction towards the woman's head, while at the same
time pulling with a firm, steady tension on the cord in a downward direction
during contractions. Supporting or guarding the uterus (sometimes called
"counter-pressure" or "counter-traction") helps prevent uterine inversion
during CCT. CCT should only be done during a contraction
Note: CCT is not designed to separate the placenta from the uterine wall but
to facilitate its expulsion only. If the birth attendant keeps pulling on an
unseparated placenta, inversion of the uterus may occur.

The steps for CCT include:

Wait for cord pulsations to cease or approximately 2-3 minutes after birth
of the baby, whichever comes first, and then place one clamp 4 cm from the
baby's abdomen.
Note: Delaying cord clamping allows for transfer of red blood cells from
tie placenta to the baby that can decrease the incidence of anemia during
infancy
Gently milk the cord towards the woman's perineum and place a second

136
clamp on the cord approximately 2 cm from the first clamp.
Cut the cord using sterile scissors under cover of a gauze swab to prevent
blood spatter. After mother and baby are safely cared for, tie the cord.
Place the clamp near the woman's perineum to make CCT easier

Hold the cord close to the perineum using a clamp

Place the palm of the other hand on the lower abdomen just above the
woman's pubic bone to assess for uterine contractions. If a clamp is
not available, controlled cord traction can be applied by encircling the
cord around the hand.

137
 Wait for a uterine contraction. Only do CCT when there is a contraction
With the hand just above the pubic bone, apply external pressure on the
uterus in an upward direction (toward the woman's head).
At the same time with your other hand, pull with firm, steady tension on the
cord in a downward direction (on (follow the direction of the birth canal). Avoid jerky
or forceful pulling.
Do not release support on the uterus until the placenta is visible at the vulva.
Deliver the placenta slowly and support it with both hands.

As the placenta is delivered, hold and gently turn it with both hands until the
membranes are twisted.
Slowly pull to complete the delivery. Gently move membranes up and down
until delivered.
If the membranes tear, gently examine the upper vagina and cervix wearing
high- level disinfected or sterile gloves and use a sponge forceps to remove
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 any pieces of remaining membrane.
6. Massage the uterus
Massage the uterus immediately after delivery of the
placenta and membranes until it is firm. Massaging the
uterus stimulates uterine contractions and helps to
prevent PPH. Sometimes blood and clots will be
expelled during this process. After stopping massage, it
is important that the uterus does not relax again. Instruct
the woman how to massage her own uterus, and ask
her to call if her uterus becomes soft.
7. Examine the placenta
Examine the fetal and maternal sides of the placenta
and membranes to ensure they are complete. A small
amount of placental tissue or membranes remaining in
the woman can prevent uterine contractions and cause
PPH.
Note: Follow infection prevention guidelines when
handling contaminated equipment, supplies, and sharps
To examine the placenta for completeness
Hold the placenta in the palms of the hands with the
maternal side facing upward and make sure that all
lobules are present and fit together
Hold the cord with one hand, allowing the placenta and
membranes to hang down. Place the other hand inside
the membranes, spreading your fingers to ensure that
membranes are complete.
Dispose of the placenta as appropriate
8. Examine the lower vagina and perineum
Gently separate the labia and inspect the lower vagina
and perineum for lacerations that may need to be
repaired to prevent further blood loss.
Repair lacerations or episiotomy
Gently cleanse the vulva, perineum, buttocks, and back
with warm savlon solution and a clean compress
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 Apply a clean pad or cloth to the vulva.
Evaluate blood loss.
Explain all examination findings to the woman and, if
she desires, her family
Comparison of physiologic and active management of the third stage of labor
(AMTSL)
Physiologic (expectant)Active management*
management
Uterotonic is given
Uterotonic is not given within one minute of the
Uterotonic
before the placenta baby's birth (after
de1ivered. ruling out the presence
of a second baby).
Wait for signs of Do not wait for signs
separation:
• Gush of blood. of placental
Signs of • Lengthening of cord. separation. Instead:
placental • Uterus becomes rounder Palpate the
separation and smaller as the uterus for a
placenta descends. contraction.
Wait for the uterus
to contract. Apply
CCT with
countertraction.
Delivery of Placenta delivered by Placenta delivered by
the gravity CCT while supporting
placenta assisted by maternal and stabilizing the
effort. uterus by applying
countertraction.
Massage the uterus Massage the uterus
Uterine
after the olacenta is after the olacenta is
massage
delivered. delivered.
• Does not interfere
with normal labor • Decreases length of
process. third stage.
• Does not require • Decrease likelihood
special of prolonged third
drugs/ supplies. stage.
Advantages • May be appropriate • Decreases average
when immediate blood loss.
• Decreases the
care is needed for number of PPH
the baby (such as cases.
resuscitation) and • Decreases need for
no trained assistant blood transfusion.
is available.
• May not require a birth
Attendant with
140
 injection skills.
• Requires
• Length of third stage is
uterotonic and
longer compared to
items needed for
AMTSL.
injection/injection
Disadvantages • Blood loss is greater
compared to AMTSL. safety.
• Increased risk of PPH. • Requires a birth
attendant with
experience and skills
giving injections and
using CCT.

NURSING CARE PLAN DURING LABOUR

Selected nursing diagnoses
- Risk of deficient fluid volume related to blood loss in the intrapartum period
- Risk of trauma: hemorrhage, amniotic fluid embolism, retained placenta, or
uterine inversion related to delivery of the placenta

Outcome identification and planning

- Major goals during the third stage of labor
• The new mother will maintain adequate fluid volume
• She will remain free of trauma.

Implementation
- Preventing fluid loss
- Maintaining safety and preventing trauma—oxytocin ‘given to prevent
hemorrhage, deliver an intact placenta, keep blood loss <5 00ml

FREQUENTLY ASKED QUESTIONS

How is a newborn affected if 10 IU of oxytocin IM is given before clamping the
cord?
There are no known harmful effects from .giving oxytocin before cord clamping.
Mothers naturally produce some oxytocin during labor which is transmitted to the
infants. Oxytocin given either IM or IV at delivery supplements this natural process.
Also, giving a uterotonic drug immediately after birth can speed the transfer of blood
into the baby from the placenta. This increases the infant's red cell mass

141
Are there more complications with AMTSL such as a ruptured cord (cord tears
off), inverted uterus, or retained placenta?
Some providers express concern that active management increases uterine
inversion rates and ruptured cords due to cord traction and increases the risk of
retained placenta due to entrapment caused by uterotonic drugs. However research
shows:
No uterine inversions were seen in any of the trials comparing active and
physiologic management. However, these trials were not designed to
evaluate very rare outcomes.
Trials using oxytocin alone showed reduced rates of manual removal of the
placenta, whereas those using ergot preparations (e.g., ergometrine) showed
increased rates.
The trial findings did not show increased risk of cord rupture.

If oxytocin is supplied in 5 IU ampoules, is one ampoule sufficient for performing

AMTSL?
Although the recommended dose of oxytocin has changed over the years, WHO
now recommends administering 10 IU of oxytocin IM for AMTSL. Trials comparing
active and physiologic management have also compared the different uterotonics in
active management protocols. Results suggest that increasing the intramuscular
dose of oxytocin from 5 IU to 10 IU increases the effectiveness of oxytocin.

Will routine manual exploration of the uterus after AMTSL help reduce the
incidence of PPH from retained placenta or placental fragments?
Routine manual exploration of the uterus is no longer recommended for normal
deliveries or those following previous cesarean delivery. Manual exploration is
painful and may likely increase the risk of complications, especially infections.
Exploration is justified for women with a well-contracted uterus experiencing
bleeding from high in the genital tract.

Will "milking" the cord help to increase the baby's hemoglobin?

Because there is no documented benefit from the practice, "milking" the cord toward
the baby to exaggerate the transfer of blood to the newborn is discouraged.
WHO supports the practice of delaying cord clamping. The practice of clamping for
2 to 3 minutes has proven beneficial to the baby as it results in higher hemoglobin
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and hematocrit values and possibly lower levels of early childhood anemia and
greater iron stores. This may be particularly important for low birthweight and
premature infants. If maternal bleeding in the first few minutes after childbirth is
significant, a decision to delay cord clamping for 2 to 3 minutes must be
determined by assessing the risk of PPH with the benefit of delayed cord clamping.

What are the risks of giving oxytocin for AMTSL when there is an undiagnosed
multiple pregnancy?
There is a theoretical risk of a trapped twin if providers administer oxytocin with an
undiagnosed twin. Original research trials on AMTSL that established the
effectiveness of AMTSL included giving a uterotonic drug with birth of the anterior
shoulder. However, updated AMTSL protocols take the theoretical risk of a trapped
twin into account and now recommend giving oxytocin after birtlY of the baby and
only after excluding the presence of an additional baby. Quality clinical assessment
in labor and following delivery of the first baby can establish the diagnosis before
giving a uterotonic drug.

If the woman has an IV infusion running at the time the baby is born, how
should oxytocin be delivered (dosage and route) for AMTSL?
Typically with vaginal delivery, a dose of 10 IU of oxytocin is administered IM. In
patients with an IV, the provider may give 5 IU of oxytocin as a slow intravenous
bolus and then continue with the oxytocin infusion.

What part does each of the steps of AMTSL play in preventing PPH?
Trials that administered uterotonics at the time of delivery with physiologic
management showed some reduction in PPH rates.8 However, a greater reduction
in PPH rates is evident with AMTSL. In cases where a uterotonic drug is given
without CCT, women experienced a greater incidence of retained placenta;
additionally, no reduction in the number of patients receiving blood transfusions was
detected.
A single trial examined the effect of CCT with and without the administration of
oxytocin after delivery of the baby. The results suggest that CCT alone does not
reduce the incidence of PPH or severe PPH. Another trial found that CCT used with
oxytocin immediately after placental delivery resulted in outcomes similar to those
with using all three components of AMTSL. A third trial showed that true active
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management resulted in lower PPH rates when compared with CCT followed by
oxytocin at the time of placental delivery.

Should CCT be performed by an SBA if there are no uterotonic drugs?

CCT is not recommended unless uterotonic drugs are used or a skilled birth
attendant is present. If CCT is applied in the absence of uterotonic drugs or a skilled
birth attendant, the practice can cause partial placental separation, and might
increase the risk of a ruptured cord, excessive bleeding, and uterine inversion.
Should uterine massage be performed by an SBA before the delivery of the
placenta?
There is no evidence to support the recommendation of providing uterine massage
before delivery of the placenta in the absence of a uterotonic drug, and evidence is
increasing that uterine massage before delivery of the placenta may lead to
increased rates of PPH.

How should the third stage of labor be managed in the absence of uterotonic
drugs?
In some settings there will be no uterotonics available due to interruptions of supplies
or the setting of birth. In the absence of current evidence, ICM and FIGO recommend
that when no uterotonic drugs are available to either the skilled or non-skilled birth
attendant, management of the third stage of labor includes the following
components:
Waiting for signs of separation of the placenta (cord lengthening, small blood
loss, uterus firm and globular on palpation at the umbilicus)
Encouraging maternal effort to bear down with contractions and, if necessary,
to encourage an upright position
Controlled cord traction is not recommended in the absence of uterotonic
drugs, or prior to signs of separation of the placenta, as this can cause partial
placental separation, a ruptured cord, excessive bleeding and uterine
inversion
Uterine-massage after the delivery- of the placenta as appropriate.

144
How should the third stage of labor be managed in situations where no
oxytocin is available or birth attendants' skills are limited?
In situations where no oxytocin is available or birth attendants' skills are limited, the
2006 FIGO/ICM joint statement recommends administering misoprostol soon after
the birth of the baby to reduce the occurrence of hemorrhage. The most common
side effects are transient shivering and pyrexia. Education of women and birth
attendants in the proper use of misoprostol is essential.
The usual components of giving misoprostol include:
Administration of 600 micrograms (mcg) misoprostol orally or sublingually after
the birth of the baby
Controlled cord traction ONLY when a skilled attendant is present at the birth
Uterine massage after the delivery of the placenta as appropriate.
In the absence of active management, should uterotonic drugs be used alone for
prevention of PPH?
The most recent WHO recommendations for the prevention of postpartum
hemorrhage promote the use of a uterotonic drug (oxytocin or misoprostol) by a
health worker trained in its use for prevention of PPH in the absence of active
management of the third stage of labor. This recommendation is based on results
from two randomized trials and places a high value on the potential benefits of
avoiding PPH. In the case of misoprostol, there is the additional benefit of ease of
administration of an oral drug in settings where other care is not available.

How does practicing AMTSL differ for women who are infected with HIV?
The practice of AMTSL is the same for all women regardless of their HIV status.
However, women who are HIV infected may choose not to breastfeed, so providers
need to respect and support the woman's choice for infant feeding. In addition,
providers need to ensure that national guidelines for PMTCT are implemented for
the woman and newborn in addition to routine care during labor, childbirth, and in
the immediate postpartum.
Does nipple stimulation prevent PPH?
Nipple stimulation results in the release of the oxytocin hormone in the woman. The
nipples are easily stimulated through early breastfeeding. Research has not shown
that nipple stimulation significantly helps to reduce the risk of PPH so this should not

145
replace AMTSL to prevent PPH. However, promoting breastfeeding after birth has
several benefits:
Stimulates natural production of oxytocin.
May help maintain tone of the contracted uterus.
Promotes bonding between the mother and newborn .
Breast milk is perfectly suited to nourish infants and protect them from illness

146
 CHAPTER NINE
MANAGEMENT OF THE FOURTH STAGE OF LABOUR
The 6 hours immediately following delivery is critical, and it has been designated by
some as the fourth stage of labor. Although oxytocics are administered, postpartum
hemorrhage as a result of uterine atony is more likely at this time. Consequently, the
uterus and perineum should be frequently evaluated.

NURSING CARE DURING THE FOURTH STAGE OF LABOR

a. Transfer the patient from the delivery table.
Remove the drapes and soiled linen. Remove both legs from the stirrups at the same
time and then lower both legs down at the same time to prevent cramping. Assist
the patient to move from the table to the bed.

b. Provide care of the perineum.

An ice pack may be applied to the perineum to reduce swelling from episiotomy
especially if a fourth degree tear has occurred and to reduce swelling from manual
manipulation of the perineum during labor from all the exams. Apply a clean perineal
pad between the legs.

c. Transfer the patient to the recovery room.

This will be done after you place a clean gown on the patient, obtained a complete
set of vital signs, evaluated the fundal height and firmness, and evaluated the lochia.

d. Ensure emergency equipment is available in the recovery room for possible

complications.
1) Suction and oxygen in case patient becomes eclamptic.
2) Pitocin® is available in the event of hemorrhage.
3) IV remains patent for possible use if complications develop.

e. Check the fundus.

(1) Ensure the fundus remains firm.
(2) Massage the fundus until it is firm if the uterus should relax.

147
f. Massaging the fundus.
(3) Massage the fundus every l5 minutes during the first hour, every 30 minutes
during the next hour, and then, every hour until the patient is ready for transfer.
(4) Chart fundal height. Evaluate from the umbilicus using fingerbreadths. This is
recorded as two fingers below the umbilicus (U/2), one finger above the umbilicus
(1/U), and so forth. The fundus should remain in the midline. If it deviates from the
middle, identify this and evaluate for distended bladder.
(5) Inform the Charge midwife or physician if the fundus remains boggy after being
massaged.
NOTE: A boggy uterus many indicate uterine atony or retained placental fragments.
Boggy refers to being inadequately contracted and having a spongy rather than firm
feeling. This is descriptive of the post delivery of the uterus.

g. Monitor lochia flow. Lochia is the maternal discharge of blood, mucus, and
tissue from the uterus.
This may last for several weeks after birth.
1) Keep a pad count. Record the number of pads soaked with lochia during
recovery.
2) Identify presence of bright red bleeding or blood clots.
3) Document thick, foul-smelling lochia.
4) Observe for constant trickle of bright red lochia. This may indicate lacerations.
5) Identify lochia amounts as small, moderate, or heavy (large)
6) Document lochia flow when the fundus is massaged.
(a) Every fifteen (15) minutes times one hour.
(b) Every thirty (30) minutes times one hour.
(c) Every hour until ready for transfer.

g. Observe the mother for chills.

The cause of the mother being chilled following birth is unknown. However, it refers
primarily to the result of circulatory changes after delivery. The best means of relief
is to cover the mother with a warm blanket.

148
h. Monitor the patient’s vital signs and general condition.
1) Take BP, P, and R every l5 minutes for an hour, then every 30 minutes for an
hour, and then every hour as long as the patient is stable. Take the patient’s
temperature every hour.
2) Observe for uterine atony or hemorrhage.
3) Observe for any untoward effects from anesthesia.
4) Orient the patient to the surroundings (bathroom, call bell, lights, etc.).
5) Allow the patient time to rest.
6) Encourage the patient to drink fluids.
i. Observe patient’s urinary bladder for distention.

Be able to recognize the difference between a full bladder and a fundus

(1) Characteristics of a full bladder.
(a) Bulging of the lower abdomen.

Bulging of the lower abdomen.

(b) Spongy feeling mass between the fundus and the pubis.
(0) Displaced uterus from the midline, usually to the right.
(d) Increased lochia flow.
(2) Full bladders may actually cause postpartum hemorrhage because it prevents
the uterus from contracting appropriately.
(3) Nerve blocks may alter the sensation of a full bladder to the patient and prevent
her from urinating.
(4) If possible, ambulate the patient to the bathroom.
(5) Urine output less than 300cc on initial void after delivery may suggest urinary
retention.
(a) Document the fundal height and bladder status before the patient urinates.
(b) Reevaluate and document the fundal height and bladder status after the patient
urinates to accurately document an empty bladder.

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j. Evaluate the perineal area for signs of developing edema and/or hematoma.
(1) Predisposing conditions includes prolonged second stage, delivery of a large
infant, rapid delivery, forceps delivery, and fourth degree lacerations.

(2) Nursing considerations for perineal edema.

(a) Apply an ice pack to the perineum as soon as possible to decrease the amount
of developing edema.
(b) Stress the importance of peri-care and use of “sitz-baths” on the postpartum
ward.
(c) Assess for urinary distention which is due to edema of the urethra.

(3) Assessment for perineal hematoma.

(a) Look for discoloration of the perineum.
(b) Listen for the patient’s complaints or expression of severe perineal pain.
(c) Observe for edema of the area.
(d) Observe/listen for patient’s feeling the need to defecate if forming hematoma is
creating rectal pressure.
(e) Observe for patient’s sensitivity of the area by touch (by sterile glove).

k. Observe for signs of hemorrhage.

(l) Uterine atony.
(2) Vaginal or cervical lacerations.
(3) Retained placental fragments.
(4) Bladder distention.
(5) Severe hematoma in vagina or surrounding perineum.

l. Assess for ambulatory stability

(1) The patient is at risk of fainting on initial ambulation after delivery due to
hypovolemia from blood loss at delivery and hypoglycemia from prolonged nothing
by mouth (NPO) status.
(2) The patient should be accompanied on the first ambulation and observed for
stability.
(3) Ammonia ampuls should be readily available.

150
(4) The patient should be closely monitored while in the bathroom to prevent injury
if fainting does occur.
(5) The patient who received regional anesthesia at deliver (that is, pudendal block)
should be assessed for possible loss of sensation in the lower extremities.

m. Observe C-section patients.

Most C-section patients are still initially recovered in the recovery room. If not,
monitor the patient as you would any patient in a recovery room immediately during
post-delivery. Include monitoring of the fundus and lochia flow. Times are consistent
with the normal vaginal delivery patient.

n. Instruct the patient in the proper perineal care.

The patient should proper perineal care after each void and bowel movement, wipe
from front to back to avoid contamination, and apply the perineal pad from front to
back.
o. Discontinue IV on a normal patient once she is stable and the physician has
ordered removal.

p. Complete notes and transfer the stable patient to the ward (on normal vaginal
delivery-others require physician clearance).

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 CHAPTER TEN
PERINEAL TRAUMA (TEARS AND EPISIOTOMY)
Introduction
Perineal trauma may occur spontaneously during vaginal birth or by a surgical
incision (episiotomy). It is possible to have an episiotomy and a spontaneous tear
(for example, an episiotomy may extend into a third-degree tear). Over 85% of
women who have a vaginal birth will sustain some degree of perineal trauma and of
these 60-70% experience suturing
EPISIOTOMY
Episiotomy is a surgical incision of the perineum and the posterior vaginal wall
generally done by a midwife or obstetrician during second stage of labor to quickly
enlarge the opening for the baby to pass through“
PURPOSE OF EPISIOTOMY
To prevent excessive trauma
To expedite delivery
To prevent cerebral damage
INDICATIONS FOR EPISIOTOMY
Situation under which labour should be expedite are:
Fetal or matemal distress if head is on the perineum
forceps or vacuum extractor deliveries
previous vaginal repair of third degree laceration
Pre-eclampsia
Eclampsia when in second stage
cord prolapsed (2“d stage and delivery imminent)
When a tear of the perineum appears inevitable with crowning of the head

Situation under which excessive trauma should be prevented

presence of FGM scaring
rigid perineum
face delivery
previous third degree tear
Narrow pubic arch
Persistent occipitoposterior delivery

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Situation under which cerebral damage should be prevented
Aftercoming head of breech delivery
Preterm baby/prematurity
Slow advance of fetal head

EPISIOTOMY RISKS
Episiotomy may result in a few different complications, including:
Infection
Large tears from the incision that may extend through the anus
Bleeding and perineal hematoma, a collection of blood in the perineal tissues
Painful intercourse
Perineal pain

TIMING OF EPISIOTOMY
If performed unnecessarily early, bleeding from the episiotomy may be considerable
during the interim between incision and delivery. If it is performed too late,
lacerations will not be prevented.
Typically, episiotomy is cut when the head is visible during a contraction to a
diameter of 3 to 4 cm-crowning of the head.

EPISIOTOMY METHODS
1. Median episiotomy:
Less bleeding and less pain.
Easy to repair.
High probability of 3rd and 4th degree perinea rupture occurrence.

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2. Mediolateral episiotomy

EPISIOTOMY STEPS
When perineum is thinned down and 3-4 cm section of the baby’s head is visible
episiotomy is conducted.
As bleeding shall occur, it should not be conducted unnecessarily early.
Local ansthesia is administered.
Two fingers of the same hand are positioned between the baby’s head and
perineum.
Perinial median or mediolateral 3-4 cm cut is made with scissors.
The emerging of the baby’s head is checked by supporting the perineum in order
to avoid
it coming out fast.
Evaluation is made whether perinial tear occurred or not.
After birthing, the place of episiotomy is appropriately sutured.

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LOCAL ANESTHESIA TECHNIQUES
Local anesthesia is definitely required.
10-20ml 0.05% of lidocain is prepared.
Vagina mucosa is infiltrated among perine subcutaneous and perine skin muscles.
After waiting minimum 3 minutes episiotomy is carried out.
The absorbed suture is utilized /Polyglycolic suture (Vicryl) if not available Catgut
Chrome is utilized

PRINCIPLES GUIDING THE REPAIR OF EPISIOTOMY

Obtain homeostasis
Align edges anatomically
Not to suture too tightly

TECHNIQUE----STEPS
Repair of the vaginal epithelium
Approximation of the perineal muscles
Loosely approximation of perineal skin

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COMPLICATIONS OF EPISIOTOMY
Blood loss in excess of 300mls occurs in 5-10%
Oedema and bruising (10-20%)
Perineal extension can cause 3rd degree tear
Infection (2-5%)
Temporal loss of libido
Unsatisfactory anatomical result
Bladder and anal sphincter dysfunction

DIAGNOSIS OF PERINEAL TEAR/RUPTURE

After birthing do not fail to examine the perineum.
In case rupture is detected determine the degree of the rupture
o lst degree tear
o 2nd degree tear
o 3rd degree tear
o 4th degree tear

FIRST DEGREE TEAR/RUPTURE

There is rupture only in vaginal mucosa and connective tissue.
If rupture is bleeding pressure is applied.
If bleeding continues it is sutured.

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 For suturing, a needle of 21 gauge and 4 cm inclination and absorbed suture
shall be utilized.
The edge of the rupture shall be definitely seen and suturing shall be made.
Care shall be taken to ensure that 2 sides come together.

SECOND DEGREE RUPTUREI TEARS

The vagina mucosa, connective tissue and muscles underneath are ruptured. If over
12 hours has passed since delivery, the place of rupture shall be covered with sterile
gauze and referred elsewhere.

THIRD DEGREE RUPTURE

Aside from the perineum the anal sphincter is also ruptured.
The ruptured section is covered with sterile pad and referred to hospital

FOURTH DEGREE RUPTURE

Perineal, anal sphincter and rectal mucosa is ruptured
Covered with sterile pad and referred to hospital.

STEPS FOR REPAIRING PERINEAL TEARS

The ruptured area is examined and cleansed.
First degree ruptures that do not bleed are left open.
Those 1. and 2. degree ruptures that bleed, pressure is applied. When bleeding
stops it is cleansed and left open.

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 Inspite of the pressure applied to the bleeding l. and 2. degree ruptures, the
bleeding does not stop, the wound area is cleansed.
Upper edge is determined.
Starting from upper edge until the vagina entrance it shall be sutured with 0
numbered catgut. The perineal muscles shall be sutured with 0 numbered catgut.
It shall be done in a continous way or one by one.
Examination of perineal rupture
Suture of the vagina
Suture of perineal muscles
Suture of the skin
Examination of perineal rupture
Suture of the vagina
Suture of perineal muscles
Suture of the skin

FACTORS ASSOCIATED WITH AN INCREASED RISK OF THIRD AND FOURTH-

DEGREE
midline episiotomy
nulliparity
second-stage arrest of labor
persistent occiput posterior position
mid or low forceps
use of local anesthetics
Asian race

MANAGEMENT OF PERINEAL WOUNDS

Care of the episiotomy/tear wound begins immediately after delivery and should
include a combination of local wound care and pain management.

Local wound care

During the first 12 hours after delivery, apply an ice pack to help in preventing
both pain and swelling of the site of the episiotomy/tear.
The incision should be kept clean and dry to avoid infection.
Frequent sitz baths (soaking the area of the wound in a small amount of warm
water for about 20 minutes several times a day), can help keep the area clean.
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 The episiotomy site should also be cleaned after a bowel movement or after
urination; this can be accomplished with use of a spray bottle and warm water. A
spray bottle may also be used during urination to decrease the pain that occurs
when urine comes in contact with the wound. After the site has been sprayed or
soaked, the area should be dried by gently blotting with tissue paper (or a hair
dryer can be used to dry the area without the irritation of abrasive paper).
Prevent constipation by eating roughages and adequate fluids. Stool softeners
may also be employed to prevent further injury or re-injury of the episiotomy/tear
site. To facilitate the healing of a larger wound, a patient may be kept on stool
softeners for more than a week.
Patients should avoid the use of tampons or douches in the postpartum period
to ensure proper healing and to avoid re-injury of the area.
Patients should be instructed to abstain from sexual intercourse until the
episiotomy has been reevaluated and is completely healed. This may take up to
four to six weeks after delivery.

Management of pain
Several studies have evaluated the use of different pain medications in the
management of pain associated with episiotomies.
The nonsteroidal, anti-inflammatory medications, such as ibuprofen, have
consistently been found to be the best type of pain reliever. However,
acetaminophen (Tylenol) has also been used with encouraging results.
Narcotic analgesics may be helpful 3rd – 4th perineal tear.

Infection of the Perineum

Maintaining intact vaginal and perineal tissues is a common goal in midwifery
practice. In a study evaluating the effect of second-stage midwifery practices on
perineal trauma, a group of 12 experienced midwives maintained an intact genital
tract in women they attended in more than 23% of vaginal births, and had only
minimal trauma (i.e., trauma that did not require suturing) in 73% of vaginal births.
Maintaining genital tract tissue integrity is particularly important for women who have
factors that predispose to infection, such as diabetes mellitus. Evidence-based
recommendations for the performance of episiotomy are restricted to maternal or
fetal indications rather than routine performance of this procedure.

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Most women who give birth vaginally and require perineal repair experience rapid
and uneventful perineal healing. However, a small subset of women experience
significant pain and a delay in healing secondary to infection. Postpartum perineal
infection is most often associated with midline episiotomy, third- or fourth-degree
laceration or episiotomy extension, and vaginal hematoma.
The differential diagnosis of perineal infection is based on the presence of either
purulent drainage from the episiotomy or laceration site, or the presence of a
perineal abscess. Evaluation includes assessment of the presence and level of
perineal pain, and examination for approximation of tissues and the presence of
edema, redness, ecchymosis, temperature elevation, and wound discharge. Women
with perineal infections require a rectovaginal examination to rule out occult rectal
injury with its devastating potential for rectovaginal fistula formation.
Occult rectal injury has been noted in the absence of episiotomy. The rectovaginal
examination also provides an opportunity to assess for the presence of inadvertent
rectal stitches, undetected rectal injury that may result in fistula formation, or the
presence of a hematoma.
Women with localized perineal infection, as evidenced by heat, redness and
erythema and an absence of systemic signs or symptoms, or those with superficial
breakdown of a first- or second-degree repair, are commonly treated with expectant
management and perineal wound care, such as frequent sitz baths and meticulous
attention to perianal hygiene. In the absence of co-morbidities, antibiotic therapy is
rarely indicated for these women.
For women with serious perineal wound infection, as evidenced by the presence of
perineal abscess, purulent drainage, systemic symptoms and/or extensive repair
breakdown, prompt referral for evaluation and treatment is indicated. Initiation of
antibiotic therapy and surgical debridement may be required to remove devitalized
tissue. Severe systemic symptoms may be an indication of sepsis from organisms
such as community-acquired methicillin-resistant S aureus, which is derived from an
infected episiotomy site.
The recommended surgical treatment of perineal wound infections consists of taking
down the repair; removal of all suture material; and thorough debridement of infected
or necrotic tissue under local, regional, or general anesthesia. Careful inspection is
performed to identify the development or presence of necrotizing fasiitis. Unlike

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infected abdominal incisions, which are left to close by secondary intention, the early
closure of perineal wounds may be attempted in order to maintain perineal integrity.

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 CHAPTER ELEVEN
POSITIONING AND HANDLING
Introduction
It has been identified that active muscle tone begins to develop at around 36 week’s
gestation, when babies achieve a postural state known as physiological flexion. At
this stage the baby is curled up in a confined space, in the womb, developing
stronger muscles by pushing up against the walls during movement.
Once a baby is born at this time, they would be able to keep their bodies in a midline
position, with flexed arms and legs. They would be able to use this position of
stability to observe the world and begin to learn to move and explore. Therefore
these final weeks in the womb, moving towards physiological flexion are essential
to each baby’s future development.
Premature babies have low muscle tone (have not achieved physiological flexion)
as they have missed out on some or all of the essential stages of muscle tone
development in the womb. A premature baby has to work against gravity in order to
move its’ limbs and research has shown that it is often difficult for them to maintain
the positions that best provide and support rest, sleep and self-comfort
Babies usually feel more secure and are more physiologically stable if they have
boundaries (nesting) placed around them, as they are used to an enclosed womb.
In addition they gain comfort from being able to grasp their hands together, suck
their fingers or hold onto bedding.
Without support, gravity tends to cause preterm babies shoulders and hips to flatten
onto the bed, often called ‘frog leg position’ and ‘W arm position’. This excessive
abduction and rotation of the hip and shoulder joints can result in poor or delayed
development and mobility problems in the future, including the ability to crawl, stand,
walk and fine motor skills such as hand-mouth co-ordination.
All infants requiring respiratory support should be nursed with the head of the cot
elevated to 30. All infants no longer requiring respiratory support including low flow
oxygen therapy are to be nursed with the mattress flat unless medically ordered and
documented.
Boundaries should support and contain rather than restrict spontaneous
movements.

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The infant face should be clear of rolls /nest to avoid occlusion and distortion of
nares.
Correct alignment of head, trunk and limbs in any position will assist in preventing
acquired postural deformity.
Peanut pillows are available to maintain head alignment during all cares only.
Remove before leaving the bedside.
Positioning is based on how much and how little assistance the infant needs. Avoid
over-protection and recognise each infant’s competency. Positioning and positioning
aids should be based on the infant’s cues and capabilities.
Explain to parents the use of positioning aids and why they should not be used in
the home environment (SIDS recommendations).

POSITIONING
Inappropriate positioning can cause:
Discomfort
Physiological instability
Disturbed sleep
Poor temperature control
Skin problems
Abnormal posture
Increased oesophageal reflux
Increased intracranial pressure
Difficulties with self-regulation, e.g. BP, temperature, heart rate, respiratory
rate
Developmental delays
Head moulding

Aims of Proper Positioning

Provide optimal ex-uterine development
Promote a flexed and tucked posture that aids hand-to-mouth movement, and
promotes
comfort, enabling baby to self-regulate and promote effective sleep wake
cycles
Facilitate skin integrity and assist with temperature regulation

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 Development of social interaction and provide parents with a positive image
of their baby
Nurse baby in a position most appropriate to their medical condition, whilst
taking into account their individual behavioural cues
Improve and maintain physiological status or autonomic system of the infant.
Facilitate flexion in limbs and trunk appropriate for gestational maturation.
Promote recommendations for infants preparing for discharge home in line
with current recommendations of Sudden Infant Death Syndrome (SIDS)
prevention.
Incorporate position changes where appropriate to facilitate mobility, prevent
developmental delays and hospital acquired deformities as well as support
self-regulatory behaviours.

Positioning Babies <34 weeks’ gestation

Use gel supports under head and shoulders and consider in other babies if
hypotonic/sick/neurologically compromised

Positioning Preterm, Sick or Neurologically Compromised Babies

Use nest, Bendy® bumper etc. to provide containment and bracing
To prevent head and neck hyper-extension, ensure Bendy® bumper does not
reach any further than the shoulders
Utilise containment/swaddling/side-lying when moving babies
Whenever possible, utilise prone or side-lying position and perform
procedures/care in flexed side-lying
Position prone or left lateral to reduce gastro-oesophageal reflux
Ensure head position is changed regularly to avoid right or left side preference
When baby 34 weeks’ gestation or nursed in cot, encourage tummy time
Positioning a Baby
Types
Prone: baby is placed face down or lie on its tummy.
Supine: baby lies on its back with face up.
Side lying/Lateral position: Avoid: • putting a roll behind the head as it can
overextend the neck and thick rolls between the legs pushing them apart

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Advantages and disadvantages of particular positions.
Prone position.
Advantages:
Particularly beneficial for babies with respiratory compromise as it improves
oxygenation, ventilation (higher tidal volumes) and lung compliance. Believed
to be due in part, from the mattress surface bracing the chest wall and
compensating for weak muscles. Also the prone position inhibits other body
movements that might disrupt breathing.
Gastro-oesophageal reflux is reduced and gastric emptying is optimised.
These may lead to an improved sleep state as the baby is more comfortable
and consequently there is a decrease in energy expenditure.
Heat loss is minimised and metabolic rate is reduced, babies tend to sleep
more often and have lower levels of apnoea of prematurity.
When placed on mother‟s abdomen with tummy touching that of the mother,
it promotes bonding and warmth for baby.
Hand to mouth behaviours is encouraged.

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 Has been found in one study to reduce the distress levels of babies
withdrawing from narcotics when compared to the supine position. Felt to be
a prone quieting response.

Disadvantages:
Gravity has the greatest effect as it pushes the limbs to the sides, shoulders
become elevated (W arm position.)
The head is always to one side so bilateral head flattening and facial moulding
are encouraged.
The hips are forced into abduction and rotation (frog leg position) as lower
limb flexion and elevation under the pelvis cannot be well maintained.
The baby’s chest cannot be seen, so there is increased risk of delay in
recognising upper airway obstruction.
Not safe if umbilical lines are in situ as the insertion site cannot be closely
monitored for oozing or bleeding or dislodgement of the lines.
The baby cannot be positioned midline (head, spine and neck in alignment),
which is necessary for developing physiological flexion.
Without appropriate support the baby’s head and neck will be over rotated,
causing marked discomfort and muscle imbalance.

Supine Position.
Advantages:
It is easy to observe the baby and provide nursing care.
If the baby is maintained in a supine, midline position then gravitational
pressure is more evenly distributed, leading to a more rounded head shape.
This position is recommended to reduce the risk if sudden infant death
syndrome. Thus it lowers the risk of crib death and choking.
This position favours sleeping with the head turned to one side.
Another advantage is

Disadvantages:
Increased energy expenditure and less effective ventilation often leading to
higher oxygen requirements.
Head flattening will occur if the head is always to one side.

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 If not supported correctly limbs will ‘flay’ out and this can result in poor muscle
tone.
Gastric emptying is delayed.
Lateral position.
Advantages:
Minimises hip and shoulder abduction and rotation and allows the baby to lie
in a flexed position, closest to the foetal position maintained in the womb.
Gravity tends to draw the arms and legs towards the midline.
Beneficial for self-comfort and fine motor skill development as the baby can
easily hold its own hands and explore its face, body and surroundings.
Babies often feel more secure and able to self-regulate, meaning they are
most likely to reach an awake-alert state and able to interact & bond with their
parent/carer.
Right lateral position increases gastric emptying, as the stomach empties to
the right and is aided by gravity.
Left lateral position reduces gastric reflux, because the oesophagus attaches
to the top of the stomach at an angle. Gravity will mean the stomach contents
have to flow upwards, making reflux more difficult.

Disadvantages:
Head flattening is exacerbated as weight is always placed on the side of the
face.
If the baby is muscle relaxed or unable to move independently their lower arm
and leg could feel ‘squashed’ and/or receive pressure injuries if left in the
same position for a prolonged period.

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HANDLING

Hold the baby like a football with their back on your forearms and their head
nestled in the crook of one of your arms – is among the safest and most
sustainable ways to hold a newborn. Angle the baby so their stomach is turned
toward yours. This position is comfortable for the baby and gives you a more
secure hold of the newborn, especially while sitting down.
Mind the baby’s fontanels. Don not apply substances to deliberately close them

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Keep the baby upright after feeding
Wash hands before touching a baby
Keep the umbilical stump clean and dry.
Don’t lift the newborn by or under their arms. Instead, place one hand behind
their head and neck and the other hand under their bottom.

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 BIBLIGRAPHY
1. Baillie L (2007) Developing Practical Nursing Skills, 2nd edition. London, UK, 338
Euston Road. Arnold Hodder, an imprint of Hodder Education.
2. Baker P.N &Kenny L. C (2011) Obstetrics by Ten Teachers, 19th edition, London,
UK, 338 Euston Road. Arnold Hodder, an imprint of Hodder Education.
3. BeckmannR. B, Barzansky M.B et al (1995) Obstetrics and Gynaecology, 2nd
edition,
Baltimore, Maryland USA, 428 East Preston street, Williams and Wilkins.
4. Campbell LA, Klocke RA (April 2001). Implications for the pregnant patient.
American Journal of Respiratory and Critical Care Medicine
5. Cunningham, ct al., (2010). Williams Textbook of Obstetrics, chapter 8.Baltimore,
Maryland USA,428 East Preston street, Williams and Wilkins.
6. Frazer D. M .& Cooper A. M (2004) Myles Text Book for Midwives, 14‘h edition,
London, UK, 90 Tottenham court roads, CHURCHILL LIVINGSTONE an imprint
of Elsevier limited.
7. Kwawukume E.Y & Emuveyan E..E (2002) Comprehensive Obstetrics in the
Tropics, 1“edition, Accra, Ghana. Dansoman, Asante &Hittscher Printing Press
Limited
8. Marshall A.M & Buffingston S.T (l99l) Life Saving Skills Manual for Midwives,
2““‘edition, Washington DC, USA, American College of Nurse-Midwives.
9. Stacey T, Thompson, Mitchell E.A, et al (2011). Association between maternal
sleep practices and risk of late stillbirth: a case-control study. BMJ (Clinical
research ed.)
10. Jefford, E., Fahy, K., & Sundin, D. (2011). Decision‐making theories and their
usefulness to the midwifery profession both in terms of midwifery practice and
the education of midwives. International Journal of Nursing Practice, 17(3), 246-
253.
11. Care Quality Commission 2018, 2017 Survey of Women’s Experiences of
Maternity Care Statistical Release [online] Newcastle upon Tyne: Care Quality
Commission, p.40, viewed 22 November 2019,
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df

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12. Desseauve, D, Pierre, F, Gachon, B, Decatoire, A, Lacouture, P and Fradet, L
2017, ‘New Approaches for Assessing Childbirth Positions’, Journal of
Gynecology Obstetrics and Human Reproduction, 46(2), pp.189-195
13. Huang, J, Zang, Y, Ren, L, Li, F and Lu, H 2019, ‘A Review and Comparison of
Common Maternal Positions During the Second-Stage of Labor’, International
Journal of Nursing Sciences, 6(4), pp.460-467
14. Prendiville, W. J., Elbourne, D., & McDonald, S. J. (2000). Active versus
expectant management in the third stage of labour. Cochrane database of
systematic reviews, (3). Prendiville, W. J., Elbourne, D., & McDonald, S. J.
(2000). Active versus expectant management in the third stage of
labour. Cochrane database of systematic reviews, (3).
15. Jangsten, E., Mattsson, L. Å., Lyckestam, I., Hellström, A. L., & Berg, M. (2011).
A comparison of active management and expectant management of the third
stage of labour: a Swedish randomised controlled trial. BJOG: An International
Journal of Obstetrics & Gynaecology, 118(3), 362-369.
16. Fahy, K., Hastie, C., Bisits, A., Marsh, C., Smith, L., & Saxton, A. (2010). Holistic
physiological care compared with active management of the third stage of labour
for women at low risk of postpartum haemorrhage: a cohort study. Women and
Birth, 23(4), 146-152.
17. Smith, J. (2016). Decision-making in midwifery: A tripartite clinical decision.
British Journal of Midwifery, 24(8), 574-580.

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 Introduction
More than one third of maternal deaths, half of stillbirths and a quarter of
neonatal deaths result from complications during labour and childbirth (1,2). The
majority of these deaths occur in low-resource settings and are largely
preventable through timely interventions (3). Monitoring of labour and childbirth,
and early identification and treatment of complications are critical for preventing
adverse birth outcomes. Improving the quality of care around the time of birth
has been identified as the most impactful strategy for reducing stillbirths and
maternal and newborn deaths, compared with antenatal or postnatal care
strategies (4).

In February 2018, the World Health Organization (WHO) published a

consolidated set of recommendations on intrapartum care for a positive
childbirth experience (5). The recommendations include new definitions of the
duration of the first and second stages of labour and provide guidance on the
timing and use of labour interventions to improve the health and well-being of
women and their babies (5–7). The recommendations are based on the principle
that, through the use of effective labour and childbirth practices and avoidance
of ineffective (and potentially harmful) practices, health personnel can support
women to achieve their desired physical, emotional and psychological outcomes
for themselves, their babies and their families (8).

WHO recommendations on intrapartum care specify evidence-based practices

that should be implemented throughout labour and the immediate postnatal
periods, and discourage ineffective practices that should be avoided. WHO
recommendations cover:

care throughout labour and birth: respectful maternity care, effective

communication, labour companionship, and continuity of care;

first stage of labour: definition of the latent and active first stages, duration and
progression of the first stage, labour ward admission policy, clinical pelvimetry
on admission, routine assessment of fetal well-being on labour admission, pubic
shaving, enema on admission, digital vaginal examination, vaginal cleansing,
continuous cardiotocography, intermittent fetal heart rate (FHR) auscultation,
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 pain relief, oral fluid and food, maternal mobility and position, active
management of labour, routine amniotomy, oxytocin for preventing delay,
antispasmodic agents, and intravenous fluids for preventing labour delay;

second stage of labour: definition and duration of the second stage of labour,
birth position (with and without epidural analgesia), methods of pushing,
techniques for preventing perineal trauma, episiotomy, and fundal pressure;

third stage of labour: prophylactic uterotonics, delayed umbilical cord clamping,

controlled cord traction, and uterine massage;

care of the newborn: routine nasal or oral suction during resuscitation, skin-to-
skin contact, breastfeeding, haemorrhagic disease prophylaxis using vitamin K,
and bathing and other immediate postnatal care of the newborn;

care of the woman after birth: uterine tonus assessment, use of antibiotics, routine
postpartum maternal assessment, and discharge following uncomplicated
vaginal birth.

To facilitate effective implementation of the above recommendations, WHO

reviewed and revised the design of the previous partograph. The LCG was
designed for health personnel to monitor the well-being of women and babies
during labour through regular assessments to identify any deviation from
normality. The tool aims to stimulate shared decision-making by health-care
providers and women, and to promote women-centred care. The LCG is
intended as a resource to ensure quality evidence-based care, with a special
emphasis on ensuring safety, avoiding unnecessary interventions, and
providing supportive care.

Objective of this manual

This manual has been developed to help health personnel who care for women
during labour and childbirth to successfully use the LCG.

Target audience
The primary target audience for this manual is skilled health personnel directly
providing labour and childbirth care in all settings. This includes midwives,
nurses, general medical practitioners and obstetricians. The manual will also be
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 of interest to staff involved in training health care personnel, health-care facility
managers, implementers and managers of maternal and child health
programmes, nongovernmental organizations (NGOs), and professional
societies involved in the planning and management of maternal and child health
services.

The labour Care Guide

The principal aims of the LCG are to:

guide the monitoring and documentation of the well-being of women and babies
and the progress of labour

guide skilled health personnel to offer supportive care throughout labour to

ensure a positive childbirth experience for women

assist skilled health personnel to promptly identify and address emerging labour
complications, by providing reference thresholds for labour observations that
are intended to trigger reflection and specific action(s) if an abnormal
observation is identified prevent unnecessary use of interventions in labour

support audit and quality improvement of labour management.

For whom should the LCG be used?

The LCG has been designed for the care of women and their babies during
labour and childbirth. It includes assessments and observations that are
essential for the care of all pregnant women, regardless of their risk status.
However, the LCG was primarily designed to be used for the care of apparently
healthy pregnant women and their babies (i.e. women with low-risk
pregnancies). Women at high risk of developing labour complications may
require additional specialized monitoring and care (9).

Upon arrival in the labour unit, women should have an initial assessment to
determine whether labour has started. Detailed guidance on how to perform an
initial evaluation to assess the well-being of the woman and her baby and
determine the stage of labour can be found in Pregnancy, childbirth, postpartum
and newborn care: a guide for essential practice (10). Women in labour will
require further monitoring of the progress of labour with the LCG.

174
When should the LCG be initiated?
Documentation on the LCG of the well-being of the woman and her baby as well
as progression of labour should be initiated when the woman enters active
phase of the first stage of labour (5 cm or more cervical dilatation), regardless
of her parity and membranes status.

Although the LCG should not be initiated in the latent phase of labour, it is
expected that women and their babies are monitored and receive labour care
and support during the latent stage. Detailed guidance on care for women in the
latent phase of labour can be found in Pregnancy, childbirth, postpartum and
newborn care: a guide for essential practice (10).

Where should the LCG be used?

The LCG is designed to be used for all births in health facilities, including
primary, secondary and tertiary care settings. Women giving birth in lower-level
facilities may require referral to a higher level of care if complications ensue.
Women in such settings should therefore have access to appropriate referral
and transportation options for safe and timely transfer. The use of the LCG can
facilitate early identification of potential complications; hence, it should
contribute to timely referrals when required.

Summary of key points on starting to use the LCG

For whom should the LCG be used?
All women in labour. High-risk women may require additional monitoring and
care.

When should the LCG be initiated?

When women have entered the active phase of the first stage of labour (i.e.
cervical dilatation of 5 cm or more).

Where should the LCG be used?

The LCG is designed for use at all levels of care in health facilities.

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 Structure of the LCG
The LCG has seven sections, which were adapted from the previous partograph
design. The sections are as follows (see Fig. 1):

1. Identifying information and labour characteristics at admission

2. Supportive care

3. Care of the baby

4. Care of the woman

5. Labour progress

6. Medication

7. Shared decision-making

Section 1 is for documenting the woman’s name and labour admission

characteristics that are important for labour management: parity, mode of labour
onset, date of active labour diagnosis, date and time of rupture of membranes,
and risk factors. This section should be completed with the information obtained
when active labour diagnosis is confirmed.

Sections 2–7 contain a list of labour observations. The health-care provider

should record observations for all sections soon after the woman is admitted to
the labour ward. The remainder of the LCG is then completed following
subsequent assessments throughout labour. For all observations, there is a
horizontal time axis for documentation of the corresponding time of observation
and a vertical reference values axis for determination of any deviation from
normal observations. The LCG also provides a second-stage section to continue
the observations made during the first stage of labour (except for cervical
dilatation assessment, which ends at the first stage of labour).

176
Fig. 1. sections of the lCG

177
Instructions: Circle Any Observation Meeting, The Criteria In the ‘Alert’
Column, Alert the Senior Midwife Or Doctor And Record The Assessment And
Action Taken. If Labour Extends Beyond 12h, Please Continue on A New
Labour Care Guide.
Abbreviations: Y – Yes, N – No, D – Declined, U – Unknown, SP – Supine,
MO – Mobile, E – Early, L – Late, V – Variable, I – Intact, C – Clear, M –
Meconium, B – Blood, A – Anterior, P – Posterior, T – Transverse, P+ – Protein,
A+ – Acetone

How to use the labour Care Guide

Labour monitoring to action
Regular assessments of labour events are required to ensure the well-being of
women and their babies during labour. The decision to intervene in the course
of labour is primarily based on observation of a deviation from expected
observations during these assessments.

To facilitate action-oriented labour monitoring, the LCG provides explicit

reference values for labour observations and includes a section to document
shared decisions to address any deviation from the expected norm. To ensure
the systematic and consistent application of the LCG, health providers are
encouraged to use the Assess Ò Record Ò Check Ò Plan approach, which
involves:

assess (assess the well-being of woman and her baby, and progress of labour)

record (document labour observations)

Check reference threshold (compare labour observations with reference

values in the “Alert” column)

Plan (decide whether and what interventions are required, in consultation with
the woman, and document accordingly).

178
It is important for health-care providers to prospectively monitor the wellbeing of
women and babies and the progression of labour, and to apply the Assess Ò
Record Ò Check Ò Plan process at each assessment throughout labour.

The sections below provide explanations on how to complete the LCG. A clinical
example follows each section to illustrate the use of the LCG.

The LCG is intended as a guide and is not a substitute for good clinical judgment
with respect to the individual women’s circumstances and preferences.

Further guidance on the clinical management of women during labour and

childbirth, including management of complications, can be found in Pregnancy,
Childbirth, Postpartum and Newborn Care: A guide for essential practice (10)
and Managing complications in pregnancy and childbirth: a guide for midwives
and doctors (9).

For practical reasons this manual describes women’s and babies’ observations
separately. However, decisions should not be based on findings from individual
observations, but rather on an overall assessment of the woman and her baby.

Using the LCG

Time axis: The first row of the time axis (“Time”) is to register the actual time
for each observation, while the second row (“Hours”) identifies the number of
hours that have elapsed during the course of labour (see Fig. 2). The “Time” row
is divided into columns for recording the actual time in hours and minutes. Each
column represents 1 clock hour.

As described in the example below, if the first assessment is conducted at 06:30

and the second and third assessments are conducted 1 and 2 hours later, at
07:30 and 08:30, these should all be recorded in the respective columns. If at
12:30 the woman reaches full cervical dilatation, recording of time in the cells
under the second stage should continue.

If labour extends beyond 12 hours, a second LCG form should be commenced.

Time should be recorded using the 12- or 24-hour format, depending on local
practice.

179
The reference (“alert”) column: The “Alert” column presents thresholds for
abnormal labour observations that require further assessment and action by the
health-care provider, as summarized in Tables 3–7. If labour observations do
not meet any of the criteria in the “Alert” column, labour progression and care
should be regarded as normal, and no medical intervention is warranted.

Health-care providers should circle any observations meeting the criteria in the
“Alert” column. This should help to highlight those observations that require
special attention.

While the reference thresholds are largely based on WHO guidance, a few were
derived from expert consensus. It is important to note that the reference
thresholds are meant to be used as early-warning signals. Therefore, reference
values should be adapted in accordance with local guidelines and should not
replace the expert clinical judgement of a care provider.

Frequency of assessment: The frequency of observations is similar to that in

the previous partograph design, as presented in Tables 4–7. While the
frequency of assessment in the LCG is largely based on WHO guidance, for
some variables the frequency of monitoring is based on expert consensus rather
than high quality evidence. It is important that health personnel adapt the
monitoring frequencies to each particular clinical case and in accordance with
local guidelines. It is expected that the required frequency of assessment will
depend on the results of labour observations and the status of the woman and
her baby.

180
Nomenclature to complete the LCG
Where a measurement is numerical, actual numbers should be recorded. When
documenting non-numerical observations – i.e. observations not based on
counting – a list of abbreviations is presented to standardize the nomenclature
used by health-care teams and to allow consistent interpretation of the “Alert”
column (see Table 1).

Table 1. abbreviations for recording non-numerical observations

section 1: Identifying information and labour
characteristics at admission
Ruptured membranes
U = Unknown
(Date; Time)
section 2: supportive care
Y = Yes
Companionship N = No
D = Woman declines
Y = Yes
N = No
Pain relief D = Woman declines to receive
pharmacological or
nonpharmacological pain relief
Y = Yes
Oral fluid N = No
D = Woman declines
SP = Supine
Posture
MO = Mobile
section 3: Baby
N = No
E = Early
FHR deceleration
L = Late
V = Variable
I = Intact membranes
C = Membranes ruptured, clear fluid
M = Meconium-stained fluid: record +,
Amniotic fluid ++ and +++ to represent non-significant,
medium and thick meconium,
respectively
B = Blood-stained fluid
181
 A = Any occiput anterior position
Fetal position P = Any occiput posterior position
T = Any occiput transverse position
0 (None)
+
Caput
++
+++ (Marked)
0 (None)
+ (Sutures apposed)
Moulding ++ (Sutures overlapped but reducible)
+++ (Sutures overlapped and not
reducible)
section 4: Woman
P – (No proteinuria)
P Trace (Trace of proteinuria)
Urine P 1+
P 2+
P 3+
A – (No acetonuria)
A 1+
Acetone A 2+
A 3+
A 4+
section 5: labour progress
Not applicable

section 6: Medication
Oxytocin N = No
If “Yes”, U/L and drops/min
Medication N = No
If “Yes”, describe medication name,
dose and route of administration
IV fluids Y = Yes
N = No
section 7: shared decision-making
Not applicable

182
How to complete Section 1: Identifying information and labour
characteristics at admission
This section captures the woman’s name and key information that is needed to
understand the baseline characteristics and risk status of the woman at the time
of labour admission. Other important demographic and labour characteristics,
such as the woman’s age, gestational age, serology results, haemoglobin, blood
type and Rh factor, referral status and cause, and symphysis–fundal height,
should be included in the woman’s medical record.

Table 2 shows how to assess the variables in this section and how the
information obtained should be recorded on the LCG.

Table 2. Guidance for completing section 1

Variable Step 1: Assess Step 2: Record
Ask the woman her full Record the woman’s full name and verify
name. that it matches the name on her medical
record.
Extract from medical Use the local coding system to record parity,
records the number of e.g. Parity (or P) = number of babies born
(after the local definition of viability).
times the woman has
given birth to a baby
after the age of viability
(as per local
guidelines).
Was onset of labour Record “Spontaneous” if the woman
spontaneous or induced achieved active first stage of labour without
any artificial stimulation of labour onset
(using any artificial
(either through pharmacological or
means)? nonpharmacological means).
Record “Induced” if the onset of labour was
artificially stimulated, by administering
oxytocin or prostaglandins to the pregnant
woman, artificially rupturing the amniotic
membranes, applying a balloon catheter into
the cervix, or any other means.

183
 On what date was Date of active labour diagnosis. Use local
active first stage of format to record dates (e.g. dd/mm/yy, or
mm/dd/yy, or dd/ mm/yyyy).
labour diagnosed?

On what date and at Date and time [hh: mm] that rupture of
what time were amniotic membranes occurred. These data could be
reported by the woman or her companion, or
membranes ruptured (if
they could be extracted from medical
membranes have records if membranes ruptured after
ruptured before admission but prior to initiating the LCG.

admission)? Use local format to record time.

Record “U” or “unknown” if rupture of
membranes is confirmed and the woman
cannot report the date and/ or time and there
is no documentation in the medical record.
Risk factors Known obstetric, medical and social risk
factors with implications for care provision
and potential outcome of labour
management. For example, preexisting
medical condition (e.g. chronic
hypertension), obstetric conditions (e.g. pre-
eclampsia), woman’s advanced age,
adolescent pregnancy, preterm labour, and
group B Streptococcus colonization.

example of how to complete section1

Date: June 07, 2020 Time 06:00

Mary Jane, a low-risk pregnant woman, presented with contractions
and reports that she has experienced leakage of fluid from the vagina
for the last hour. Her gestational age is 38 weeks.
This is her fourth pregnancy. She previously had two births, one of a
live baby and one of a stillbirth at term. She also had a miscarriage.
She is taking oral iron to treat anaemia.
The midwife in charge of the admission asked all necessary
questions and she offers Mary Jane clinical evaluation to assess the
baby’s well-being and labour stage. Among other parameters, the
midwife found that Mary Jane has regular contractions (3

184
 contractions every 10 minutes), 5 cm dilatation and ruptured
membranes.

Figure 3 shows how the LCG would be completed with the above information.

Fig. 3. How to complete section 1

WHO LABOUR CARE GUIDE
Name Mary Jane Williams Active labour
diagnosis
Parity 2 Labour onset spontaneous
[Date
Ruptured membranes [Date Time 06/07/20] 5:00
06/07/20 ]
Risk factors History of stillbirth; anaemia

How to complete Section 2: Supportive care

Respectful maternity care is a fundamental human right of pregnant women and
is a core component of the WHO intrapartum care recommendations (5). WHO
also recommends effective communication between maternity health providers
and women in labour, including the use of simple and culturally appropriate
language at every stage of labour care? Clear explanations of procedures and
their purpose should always be provided to each woman. The findings of
physical examinations should be explained to the woman and her companion,
and the subsequent course of action made clear to enable shared decision
making.

This section of the LCG aims to encourage the consistent practice of respectful
maternity care during labour and childbirth, through the continuous provision
and monitoring of supportive care. This includes labour companionship, access
to pharmacological and non-pharmacological pain relief, ensuring women are
185
offered oral fluid, and techniques to improve women’s comfort (such as
encouraging women to be mobile during labour) (see Table 3). Supportive care
measures should be offered and evaluated continuously during labour.
However, to streamline documentation, observations regarding the provision of
supportive care should be recorded every hour.

Table 3. Guidance for completing section 2 of the lCG

Step 1: Step 2: Step 3: Step 4: Plan
Assess Record Check
threshold
Does the Y = Yes Alert: N = No If you recorded “No”,
woman have N = No D = offer to find a
a companion Woman companion of the
of her choice declines woman’s choice.
present and If you recorded “Yes”
providing or “Declines”, continue
support at the to assess her
time of preference during the
assessment? progress of labour and
childbirth.
Has the Y = Yes Alert: N = No If you recorded “No”,
woman N = No offer pain relief
received any D = Woman according to the
form of pain declines to woman’s preferences,
relief? receive availability of pain
pain relief relief and provider’s
experience. You can
offer an epidural at the
lowest effective
concentration of local
anaesthetic to avoid
complications, or

186
 opioids such as
fentanyl, diamorphine
and pethidine.
Relaxation techniques
such as those using
muscle relaxation,
breathing, music,
mindfulness and
manual techniques
can also be used,
based on the woman’s
preferences.
Has the Y = Yes Alert: N = No If you recorded “No”,
woman N = No D = encourage the woman
taken oral Woman to take a light diet and
fluid on declines drink as she wishes
demand during labour.
since her last
assessment?
What posture SP = Supine Alert: SP = If you recorded “SP”,
is the woman MO = Mobile Supine encourage the woman
adopting (includes to walk around freely
during labour walking, during the first stage of
and swaying or labour.
childbirth? any non- Support the woman’s
supine choice of position (left
position, e.g. lateral, squatting,
left lateral, kneeling, standing
squatting, supported by
kneeling, companion) for each
standing) stage of labour.

187
example of how to complete section 2
Date: June 07, 2020 Time 06:00

Mary Jane received a general and clinical assessment,

and she has been admitted to the labour ward.

She is monitored by the midwife on duty but she is not

accompanied by a relative or someone from her social
network.

She reports feeling significant pain due to the uterine

contractions, and requests pain relief.

She drank a fruit juice and is walking.

The midwife caring for and monitoring Mary Jane during

labour offered her a companion of her choice. Mary
Jane wanted to be accompanied by her sister. The
midwife gave directions to Mary Jane’s sister as to when
and how to call for assistance.

Given that another woman was in labour in the same

room, the midwife used a divider between beds to
provide more privacy.

Mary Jane is with her sister and receiving instructions

on relaxation techniques for pain relief.

Time 07:00

Mary Jane is with her sister and using relaxation

techniques for pain relief.

She has been drinking water when thirsty, and Mary

Jane is now lying in bed in a supine position.

Figure 4 shows how the LCG would be completed with the above information.
Circled in red are those observations that meet the corresponding criterion in
the “Alert” column.

188
Fig. 4. How to complete section 2

How to complete Section 3: Care of the baby

This section is to facilitate decision-making while monitoring the well-being of
the baby. The well-being of the baby is monitored by regular observation of
baseline fetal heart rate (FHR) and decelerations in FHR, and of amniotic fluid,
fetal position, moulding of the fetal head, and development of caput
succedaneum (diffuse swelling of the scalp) (see Table 4).

Table 4. Guidance for completing section 3 of the lCG

Step 1: Assess Step 2: Record Step 3: Check Step 4: Plan
threshold
Listen to the Record the Alert: <110, If FHR is <110
FHR for a baseline FHR ≥160 or ≥160, ask the
minimum of 1 (as a single Intermittent woman to turn
minute. counted number auscultation of on her left side,
Auscultate of beats in 1 the FHR with then alert a
during a uterine minute). either a Doppler senior care
contraction and For the second ultrasound provider and
continue for at stage, record device or a follow clinical
least 30 the most Pinard guidelines.
seconds after clinically fetal If FHR ranges
the contraction. significant value stethoscope is between 110
Assess the within the 15 recommended and 159,
woman’s pulse minute for healthy continue to
to differentiate timeframe. pregnant assess FHR
between the women in labour every 30
heartbeat of the (5). minutes during
woman and that Very slow FHR the first stage
of the baby. in the absence and every 5

189
 of contractions minutes during
or persisting the second
after stage of labour
contractions is (10).
suggestive of
fetal distress. In
the absence of
a rapid maternal
heart rate, a
rapid FHR
should also be
considered a
sign of fetal
distress (9).
Listen to the Record the Alert: L = Late If Late
FHR for a presence of Record the decelerations or
minimum of 1 decelerations presence of a single
minute. using: decelerations prolonged
Auscultate N = No (5). Very slow deceleration are
during a uterine E = Early FHR in the present, ask the
contraction and L = Late absence of woman to turn
continue for at V = Variable contractions or on her left side,
least 30 persisting after then perform a
seconds after contractions is prolong
the contraction. suggestive of auscultation,
fetal distress alert a senior
(9). care provider
and follow
clinical
guidelines. If No
decelerations
are present,
continue
monitoring FHR
every 30
minutes during
the first stage
and every 5
minutes during
the second
stage (10).

190
What is the I = Intact Alert: M+++ If blood-stained
status of membranes C = (thick fluid or thick
membranes? Is Membranes meconium), B meconium is
there leakage of ruptured, clear = Blood Note present, alert a
amniotic fluid? If fluid M = the status of the senior care
“Yes”, what is Membranes membranes. If provider and
the colour of the ruptured, the membranes follow clinical
amniotic fluid? meconium- have ruptured, guidelines. If
stained fluid: note the colour membranes are
use +, ++ and of the draining Intact or
+++ to amniotic fluid. ruptured and
represent non- The presence of amniotic fluid is
significant, thick meconium Clear, assess
medium and indicates the amniotic fluid
thick meconium, need for close during the next
respectively B = monitoring and vaginal
Membranes possible examination in 4
ruptured, blood- intervention for hours, unless
stained fluid management of otherwise
fetal distress indicated.
(9). Bloody
amniotic fluid is
common in
placental
abruption,
placenta
praevia, vasa
praevia or
uterine rupture
(11).

Step 1: Assess Step 2: Record Step 3: Check Step 4: Plan

threshold

191
Perform gentle A = Occiput Alert: P = If Occiput
vaginal anterior position Occiput posterior or
examination P = Occiput posterior, T = Occiput
using aseptic posterior Occiput transverse
technique to position transverse position is
assess fetal T = Occiput With descent, detected, alert a
position, after transverse the fetal head senior care
obtaining the position rotates so that provider and
woman’s the fetal occiput follow clinical
consent and is anterior in the guidelines. If
ensuring maternal pelvis. Occiput anterior
privacy. Do not Failure of a fetal position is
start the occiput diagnosed,
examination transverse or reassess
during a posterior position during
contraction. position to next vaginal
Assess all rotate to an examination in 4
parameters that occiput anterior hours, unless
require a position should otherwise
vaginal be managed as indicated.
examination at abnormal fetal
the same time. position (9).
When Grade caput Alert: +++ If caput = +++,
performing from 0 (none) to Assess caput alert a senior
vaginal +, ++ or +++ succedaneum provider and
examination to (marked). along with other follow local
assess other maternal and protocols. If
clinical fetal caput = 0 to ++,
parameters, observations to repeat the
assess the monitor the well- assessment
presence of being of the during next
caput woman and her vaginal
succedaneum baby and examination in 4
(diffuse swelling identify risks for hours, unless
of the scalp). adverse birth otherwise
outcomes (5). If indicated.
the presenting
part has large
caput
succedaneum,
this (along with

192
 other abnormal
observations)
could be a sign
of obstruction
(9).
When Grade from 0 Alert: +++ If moulding =
performing (none) to +++ Assess +++, alert a
vaginal (marked). moulding along senior provider
examination to Assign: with other and follow local
assess other + (sutures maternal and protocols. If
clinical apposed), ++ fetal moulding = 0 to
parameters, (sutures observations to ++, usually
assess the overlapped but monitor the well- signs of
shape of the reducible), +++ being of the normality
fetal skull and (sutures woman and her (mainly if ++ is
the degree of overlapped and baby and developed in
overlapping not reducible). identify risks for the later stages
fetal head adverse birth of labour),
bones during outcomes (5). reassess during
labour. Third degree next vaginal
moulding (along examination in 4
with other hours, unless
abnormal otherwise
observations) indicated.
could indicate
obstructed
labour (9).

193
example of how to complete section 3

Date: June 07, 2020 Time 06:00

The baby moves during monitoring and shows a heart rate of 140
beats per minute (bpm) without deceleration.
Vaginal examination shows 5 cm cervical dilatation, cephalic
presentation. There is no caput or moulding and the fetal position
is occiput posterior. Amniotic fluid is clear.
Time 06:30
FHR 136 bpm without decelerations
Time 07:00
FHR 132 bpm with variable decelerations
Time 07:30
FHR 148 bpm without decelerations. The midwife checks Mary
Jane’s pad and observes that the amniotic fluid is clear. Given
that all other clinical parameters are normal and that Mary Jane
is coping well with labour, her midwife continues checking the
FHR every 30 minutes and will check the amniotic fluid during
the next vaginal examination.

Figure 5 shows how the LCG would be completed with the above information.
The observations that meet the criteria in the “Alert” column are circled in red.

194
Fig. 5. How to complete section 3
How to complete Section 4: Care of the woman
This section is to facilitate decision-making for consistent, intermittent
monitoring of the woman’s well-being. The woman’s health and well-being are
monitored on the LCG by regular observation of the pulse, blood pressure,
temperature and urine (see Table 5).

Table 5. Guidance for completing section 4 of the lCG

Step 1: Step 2: Step 3: Check Step 4: Plan
Assess Record threshold
Count Record Alert: <60, ≥120 If pulse <60 or
woman’s woman’s If the woman’s pulse is ≥120 bpm,
pulse rate pulse (bpm). increasing, she may be alert a senior
for at least 1 dehydrated or in pain, care provider
full minute. she may be developing and follow
a fever, or it could be a local
sign of bleeding or guidelines.
shock (9). Maternal If pulse ≥60 or
bradycardia should <120 bpm,
trigger a series of assess pulse
maternal (and fetal) rate every 4
assessments to identify hours.
the probable cause,
including use of specific
medications, supine
position, pain, bleeding
or cardiac disease (12).
Measure Record Alert: <80, ≥140 If SBP <80 or
blood woman’s Assess blood pressure ≥140 alert a
pressure in systolic to monitor the well- senior provider
sitting blood being of the woman and and follow
position. pressure identify risks for local
(SBP) in adverse birth outcomes guidelines.
mmHg. (5). Low blood pressure If SBP ≥80 or
could be a sign of <140, assess
haemorrhagic shock, SBP every 4
septic shock, occult or hours.
frank haemorrhage.
Systolic blood pressure
of 140 mmHg could be
195
 a sign of hypertension
(further assessments
are required to reach a
diagnosis) (10,12).
Measure Record Alert: ≥90 If DBP ≥90,
blood woman’s Diastolic blood pressure alert a senior
pressure in diastolic ≥90 could be a sign of care provider
sitting blood hypertension (further and follow
position. pressure assessments are local
(DBP) in required to reach a guidelines.
mmHg. diagnosis) (10). If DBP <90,
assess DPB
every 4 hours.
Measure Record Alert: <35.0, ≥ 37.5 If temperature
axillary woman’s Temperature should be <35.0 or
temperature. temperature monitored throughout ≥37.5, alert a
in degrees labour to assess the senior care
Celsius. wellbeing of the woman provider and
and identify risks for follow local
adverse birth outcomes guidelines.
(5). If temperature
is between
35.0 and 37.4
degrees,
assess
temperature
every 4 hours.
Check Record Alert: P++, A++ If P++, A++ or
protein and readings of A 2+ protein (P++) more, interpret
acetone in protein (P) could guide further measurements
urine with a and acetone management, although in
reagent (A) as confirmation may be the context of
strip. Negative, done with a second a full clinical
Trace, +, ++, dipstick of 2+ at the examination.
+++, ++++. next urine void. Alert a senior
Proteinuria could be a provider and
sign of pre-eclampsia, follow local
urinary tract infection, guidelines.
severe anaemia, or If P =
previously undiagnosed Negative,
renal or cardiac Trace or +,
196
 disease. Ketonuria assess every
could be a sign of 4 hours or
dehydration secondary each time the
to reduced fluid intake woman voids
or excessive losses during labour.
(vomiting or diarrhea),
prolonged labour or
previously undiagnosed
diabetes (13).

example of how to complete section 4

Date: June 07,2020 Time 06:00

Mary Jane’s pulse rate is 88 bpm, with blood pressure

of 120/80 mmHg. Her temperature is 36.5°C.

She passed urine at admission, without proteinuria or

acetone.

Given that all clinical woman parameters are normal,

the midwife plans to reassess woman’s observations in
4 hours unless otherwise indicated.

Time 10:00

Mary Jane’s pulse is 96 bpm, with blood pressure of

128/84 mmHg. Her temperature is 36.9°C.
She passed urine again, without proteinuria or acetone.
Figure 6 shows how the LCG would be completed with the gathered information.
Circled in red are those observations meeting the criteria in the “Alert” column.
For those observations that are evaluated and recorded every 4 hours, leave
the cells blank at times where assessment is not required.

197
Fig. 6. How to complete section 4

How to complete Section 5: Labour progress

This section aims to encourage the systematic practice of intermittent
monitoring of labour progression parameters. Labour progress is recorded on
the LCG by regular observation of the frequency and duration of contractions,
cervical dilatation and descent of the baby’s head (see Table 6).

198
Table 6. Guidance for completing section 5 of the lCG
Step 1: Step 2: Step 3: Check Step 4: Plan
Assess Record threshold
Count the Record the Alert: ≤2, >5 If contractions
number of absolute If contractions are are ≤2 or >5 per
uterine number of inefficient, suspect 10 minutes,
contractions contractions. inadequate uterine verify the
over a 10 activity (9). number of
minute Continuous contractions
period. contractions are a over another 10
sign of obstructed minutes. If
labour (10). frequency is
confirmed, alert
a senior care
provider and
follow clinical
guidelines.
If contractions
are 3–5 per 10
minutes, assess
uterine
contractions
every 30
minutes during
the first stage of
labour and at
least every 15
minutes during
the second
stage.

199
Assess the Record Alert: <20, >60 If contractions
duration of duration of Short contractions last <20 or >60
contractions. contraction in could indicate seconds, verify
seconds. inadequate uterine the number of
activity. More than contractions
five contractions in over another 10
10 minutes or minutes. If
continuous duration is
contractions are confirmed, alert
signs of obstructed senior provider
labour or and follow local
hyperstimulation clinical
(9). guidelines.
If contractions
last ≥20 or ≤60
seconds,
assess
contractions
every 30
minutes during
the first stage of
labour and at
least every 15
minutes during
the second
stage.

200
Step 1: Step 2: Step 3: Step 4: Plan
Assess Record Check
threshold
Perform In the active Alert values Alert
gentle vaginal first stage of for first triggered
examination, labour, plot “X” stage: when lag
after obtaining in the cell that 5 cm = ≥6 h time for
the woman’s matches the (cervical current
consent and time and the dilatation cervical
ensuring cervical remains at 5 dilatation or
privacy. Use dilatation each cm for 6 or in second
aseptic time you more hours) 6 stage is
technique to perform a cm = ≥5 h exceeded
examine the vaginal (cervical with no
cervix. Do not examination. dilatation progress.
start the In the second remains at 6 During the
examination stage, cm for 5 or first stage,
during a insert “P” to more hours) 7 if labour
uterine indicate when cm = ≥3 h progresses
contraction. pushing (cervical as
Assess all begins. dilatation expected,
parameters remains at 7 assess
that require a cm for 3 or cervical
vaginal more hours) 8 dilatation
examination cm = ≥2.5 h every 4
at the same (cervical hours
time. dilatation unless
remains at 8 otherwise
cm for 2.5 or indicated.
more hours) 9 When
cm = ≥2h performing
(cervical a vaginal
dilatation examinatio
remains at 9 n less than
cm for 2 or 4 hours
more hours) after the
Alert value previous
for second assessmen
stage: t, be sure
that the
examinatio

201
 ≥3h in n will add
nulliparous important
women; information
≥2h in to the
multiparous decision-
women (birth making
is not process.
completed by
3 hours from
the start of
the active
second stage
in nulliparous
and 2 hours in
multiparous
women)
Evidence
shows
important
variations in
the
distribution of
cervical
dilatation
patterns
among
women
without risk
factors for
complications,
with many
women
progressing
more slowly
than 1
cm/hour for
the most part
of their labour
and yet still
achieving
vaginal birth
with normal
202
 birth
outcomes
(5,14).

Assess Plot “O” in the There are no During first

descent by cell that reference stage,
abdominal matches the thresholds for assess
palpation; time and the this descent
refer to the level of observation, every 4
part of the descent. Plot which will hours
head (divided an “O” at every vary on each before
into five parts) vaginal individual performing
palpable examination. case. vaginal
above the 5/5, 4/5, 3/5, examinatio
symphysis 2/5, 1/5 and n, unless
pubis. 0/5 should be otherwise
used to indicated.
describe the During the
fetal station by second
stage, take
203
abdominal into
palpation (9). account the
woman’s
behaviour,
effectivene
ss of
pushing,
and baby’s
position
and
wellbeing
when
deciding
the timing
of descent
assessmen
t.

204
example of how to complete section 5
Date: June 07, 2020 Time 06:00
At the time of admission, Mary Jane presented with three uterine
contractions every 10 minutes, of moderate intensity, and lasting 40
seconds.
Vaginal examination shows 5 cm cervical dilatation, cephalic
presentation. Fetal descent is 4/5.
Given that all other clinical parameters are normal and that Mary Jane is
coping with the labour, the midwife assesses the number and duration of
uterine contractions half-hourly Unnecessary vaginal examinations are
avoided and vaginal examinations are only performed after 4 hours.
Time 10:00
Mary Jane complains of strong pains. Her sister left the labour ward and
Mary Jane is alone, lying in bed in a supine position. Her vitals are heart
rate 96 bpm, blood pressure 128/84 mmHg, and FHR is 151 bpm with
variable decelerations. Mary Jane has three strong uterine contractions
in 10 minutes, lasting 50 seconds each. Fetal descent is 3/5. Cervical
dilatation is 8 cm and the fetal position is occiput transverse. Amniotic
fluid shows meconium 1+/4.
The midwife offers her a companion of her choice. Mary Jane wants to
be accompanied by her sister who had left to speak with the family in the
waiting room. The midwife gives directions to Mary Jane’s sister on how
to support Mary Jane and comfort her by using a cool, damp cloth on her
face and body, and by massaging her back.
Time 13:00
Mary Jane maintains three uterine contractions in 10 minutes, lasting 50
seconds each. Fetal descent is 2/5. Cervical dilatation is 10 cm and the
fetal position is occiput anterior. Amniotic fluid shows meconium 1+/4.
FHR 132 bpm, without decelerations.
Time 13:30
Mary Jane maintains four uterine contractions in 10 minutes, lasting 50
seconds each. Fetal descent is 0/5. FHR 118 bpm, with early
decelerations.
Childbirth takes place vaginally at 13:45.

Figure 7 shows how the LCG would be completed with the information provided
above.

205
This section aims to facilitate consistent recording of all types of medication
used during labour, by describing whether the woman is receiving oxytocin, and
its dose, and whether other medications or IV fluids are being administered (see
Table 7).

206
Table 7. Guidance for completing section 6 of the lCG
Step 1: Assess Step 2: Record

Is oxytocin If oxytocin is not being administered, record N

currently being = No.
administered to the If oxytocin is being administered, record the
woman? amount of oxytocin in units per litre (U/L) and
drops per minute (drops/min).
When oxytocin is used, record the amount
being administered every 60 minutes.
Is the woman If no other medication is being administered,
receiving any other record N = No.
medication? Record the name, dose and route of
administration of any additional medication that
is being administered to the woman during
active first or second stage of labour (e.g. 50
mg pethidine, intramuscular (IM)).
Step 1: Assess Step 2: Record

Is the woman on IV Record:

fluids? Y = Yes
N = No
The routine administration of IV fluids for all
women in labour is not recommended, given that
it reduces women’s mobility and unnecessarily
increases costs. Low-risk women should be
encouraged to drink oral fluids, and they should
receive IV fluids (4) only if indicated (5).
How to complete Section 7: Shared decision-making
This section aims to facilitate continuous communication with the woman and
her companion, and the consistent recording of all assessments and plans
agreed (see Table 8).

207
Table 8. Guidance for completing section 7 of the lCG
Record

Record the overall assessment and any additional findings not

previously documented but important for labour monitoring.

Re cord the plan following assessment. For example: continuation of

"" routine monitoring prescription of diagnostic tests augmentation

"" of labour with oxytocin infusion procedures, such as artificial

rupture of membranes assisted birth with vacuum or forceps
""
""
""
"" caesarean section.

Take into consideration that women should be involved in

discussions and be allowed to make informed decisions.
Each time a clinical assessment of the woman’s and baby’s well-
being is completed, record the plan based on the shared decision.
example of how to complete sections 6 and 7
Many Jane had normal progress of labour and
childbirth.

During labour, Many Jane was encouraged to walk and

to have a companion of her choice present.

Clinical parameters remained within normal thresholds.

Consequently, additional interventions were not
required.

Below you will find an example of how to complete Sections 6 and 7 of the LCG
(see Fig. 8) based on the above information.

208
Fig. 8. How to complete sections 6 and 7

209
 references
1. Say L, Chou D, Gemmill A, Tuncalp O, Moller AB, Daniels J, et al. Global causes
of maternal death: a WHO systematic analysis. Lancet Glob Health.
2014;2(6):e323–33.

2. Lawn JE, Blencowe H, Waiswa P, Amouzou A, Mathers C, Hogan D, et al.

Stillbirths: rates, risk factors, and acceleration towards 2030. Lancet.
2016;387(10018):587–603.

3. Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA,

World Bank Group and the United Nations Population Division: executive
summary. Geneva: World Health Organization; 2019. Contract No.:
WHO/RHR/19.23.

4. Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, et al. Can available
interventions end preventable deaths in mothers, newborn babies, and stillbirths,
and at what cost? Lancet. 2014;384(9940):347–70.

5. WHO recommenations: intrapartum care for a positive childbirth experience.

Geneva: World Health Organization;2018.

6. Oladapo OT, Diaz V, Bonet M, Abalos E, Thwin SS, Souza H, et al. Cervical
dilatation patterns of ‘low-risk’ women with spontaneous labour and normal
perinatal outcomes: a systematic review. BJOG. 2018;125(8):944–54.

7. Abalos E, Oladapo OT, Chamillard M, Diaz V, Pasquale J, Bonet M, et al. Duration

of spontaneous labour in ‘low-risk’ women with ‘normal’ perinatal outcomes: a
systematic review. Eur J Obstet Gynecol Reprod Biol. 2018;223:123–32.

8. Oladapo OT, Tunçalp Ö, Bonet M, Lawrie TA, Portela A, Downe S, et al. WHO
model of intrapartum care for a positive childbirth experience: transforming care
of women and babies for improved health and wellbeing. BJOG. 2018
Jul;125(8):918–922

210
9. Managing complications in pregnancy and childbirth: a guide for midwives and
doctors. Geneva: World Health Organization; 2017.

10. WHO, UNFPA, UNICEF. Pregnancy, childbirth, postpartum and newborn care: a
guide for essential practice. Geneva: World Health Organization; 2015.

11. Liabsuetrakula T. Algorithm of intrapartum care for abnormal vaginal loss: liquor
abnormalities, blood and purulent discharge. BJOG 2020. (in press).

12. Haddad SM, Souza RT, Cecatti JG. Pulse and blood pressure: developing
algorithms for supporting digital-Health for management of maternal intrapartum
complications. BJOG 2020. (in press).

13. Cheung KW, Meher S. Clinical algorithm for the management of intrapartum
maternal urine abnormalities. BJOG 2020. (in press).

14. Zhang J, Landy HJ, Branch DW, Burkman R, Haberman S, Gregory KD, et al.
Contemporary patterns of spontaneous labor with normal neonatal outcomes.
Obstet Gynecol. 2010;116(6):1281–7.

15. Fischer F, Lange K, Klose K, Greiner W, Kraemer A. Barriers and strategies in

guideline implementation – a scoping review. Healthcare (Basel). 2016;4(3):36.

16. Vogel JP, Comrie-Thomson L, Pingray V, Gadama L, Galadanci H, Goudar S, et

al. Usability, acceptability, and feasibility of the World Health Organization Labour
Care Guide: A mixed-methods, multicountry evaluation. Birth. 2020 Nov 22.

17. Standards for improving quality of maternal and newborn care in health facilities.
Geneva: World Health Organization; 2016.

211
1 WHO labour Care Guide

WHO LABOUR CARE GUIDE

212
Name Parity Labour onset Active labour diagnosis [Date ]

213
INSTRUCTIONS: CIRCLE ANY OBSERVATION MEETING THE CRITERIA IN
THE ‘ALERT’ COLUMN, ALERT THE SENIOR MIDWIFE OR DOCTOR AND
RECORD THE ASSESSMENT AND ACTION TAKEN.IF LABOUR EXTENDS
BEYOND 12H, PLEASE CONTINUE ON A NEW LABOUR CARE GUIDE.
Abbreviations: Y – Yes, N – No, D – Declined, U – Unknown, SP – Supine, MO
– Mobile, E – Early, L – Late, V – Variable, I – Intact, C – Clear, M – Meconium,
B – Blood, A – Anterior, P – Posterior, T – Transverse, P+ – Protein, A+ – Acetone
2 adapting the WHO labour Care Guide

The WHO Labour Care Guide has been developed to align with WHO
recommendations on intrapartum care for a positive childbirth experience (5).
Some adaptations may be needed to reflect local conventions (e.g. the use of
Hodge planes for classifying fetal descent).

Removing recommended practices from the LCG is strongly discouraged. Even

in those settings where some interventions are less feasible or not consistently
available, monitoring the use of these interventions is important to help drive
improvements in overall quality of care.

Below we describe a process for reviewing the LCG and identifying elements to
be adapted (see Fig. 9).

214
 Any adaptations of the LCG should be
undertaken with caution to ensure that
effective interventions are not removed.

National or local experts should review the

LCG in light of relevant national standards and
guidelines. Healthcare providers working in
maternity-care settings should be involved in
adaptation activities.

Prior to any rollout of an adapted LCG, pilot it

in clinical settings and encourage end-users’
feedback. This can facilitate successful adoption.

Keep the LCG focused on labour monitoring and avoid incorporating too many
new variables. The LCG should not replace a medical record. The more items are
added, the more likely clinicians are to record variables twice. When incorporating
new variables or parameters, consider:

Is it relevant for labour monitoring?

Is it evidence based?
Is it feasible to collect it in any different setting?
Is it already in the medical record?
Would it be more appropriate in the medical record?

annex 3 Introducing the WHO labour Care Guide into labour wards
The LCG is a tool that aims to support implementation of the WHO
recommendations:
intrapartum care for a positive childbirth experience (5). The current level of
implementation of different care practices in the LCG may vary. For example, the

215
LCG includes practices that may already be well implemented in labour wards
(e.g. offering pharmacological pain relief). Other practices may not be well
implemented, and the LCG can help managers and healthcare providers to set
goals to improve the quality of labour and childbirth care.

It is well known that simply disseminating recommendations will not ensure their
successful adoption by health-care providers (15). There may also be additional
barriers to implementing the LCG into routine care. For example, providers in
facilities with high workloads or fewer resources may consider the LCG time
consuming or less feasible. In other facilities, providers may be unwilling to update
their long-standing practice or may be otherwise resistant to adopting the LCG in
routine care. In such situations, a robust implementation strategy should be
designed to introduce the LCG into labour wards.

To introduce the LCG in labour care wards, an active multi-component

implementation strategy will be required. A pilot study in six countries identified a
number of strategies for implementing the LCG (16) (see Table 9).

Table 9. strategies for implementing the lCG

Review and adaptation Leadership and training

216
✔ Critically review the LCG and decide✔ Build a team with expertise in LCG,
whether local adaptation is needed. from various disciplines (obstetrics,
✔ Ensure the abbreviations that midwifery, nursing), to provide
providers are required to use in the training.
LCG are locally meaningful. ✔ Ask thought leaders and local
✔ Involve local leaders and champions to familiarize themselves
administrators in adaptation with the LCG.
activities. ✔ Plan initial training, refresher
✔ Optimize providers’ time: minimize trainings and continuous support and
any duplication of recording between mentoring activities.
the LCG and medical record. ✔ Include a strong practical component

✔ Avoid adding variables, mainly if they in the training programme.

are not meaningful for labour and ✔ Give time for skills acquisition.
childbirth care. Providers may find the LCG initially
✔ Target best quality; do not remove off putting, and will need some time
LCG components just because they to familiarize with the LCG.
cannot be accomplished. ✔ Conduct training in the local
✔ Review policies and associated language.
procedures required to provide an ✔ Provide early and structured
enabling environment for use of the feedback on completed LCGs to help
LCG. users improve their skills.
✔ Translate the LCG, manual and other
educational materials if necessary.

Teamwork in completing the LCG Monitoring and evaluation

✔ The use of the LCG should be the ✔ Maintain or establish a monitoring
responsibility of the entire health- system based on the LCG to track
care team. quality-of-care indicators, for
✔ The LCG guides objective data- example the proportion of women
driven decision making. Take into with a labour companion of choice,
account that some staff completing and the caesarean section rate.
the LCG may require extra support ✔ Show and share quality-of-care
and supervision. indicators to help drive
improvements.

217
✔ Target universal implementation (in
all shifts). The LCG can work well to
support handover between shifts.

summary list of recommendations on intrapartum care for

for a positive childbirth experience

Category of
Care option recommendation
recommendation
Care throughout labour and birth

Respectful 1. Respectful maternity care – which Recommended

maternity care refers to care organized for and
provided to all women in a manner
that maintains their dignity, privacy
and confidentiality, ensures freedom
from harm and mistreatment, and
enables informed choice and
continuous support during labour and
childbirth – is recommended.
Effective 2. Effective communication between Recommended
communication maternity care providers and women
in labour, using simple and culturally
acceptable methods is recommended.
Companionship3. A companion of choice is Recommended
recommended for all women
throughout labour and childbirth.

218
Continuity of4. Midwife-led continuity-of-care models, Context-specific
care in which a known midwife or small recommendation
group of midwives supports a woman
throughout the antenatal, intrapartum
and postnatal continuum, are
recommended in settings with well-
functioning midwifery programmes.

First stage of labour

Definitions of5. The use of the following definitions of Recommended

the latent and the latent and active first stages of
active first labour is recommended for practice:
stages of"" The latent, first stage is a period of
labour time characterized by painful uterine
contractions and variable changes of
the cervix, including some degree of
effacement and slower progression of
dilatation up to 5 cm for first and
subsequent labours.
"" The active first stage is a period of
time characterized by regular painful
uterine contractions, a substantial
degree of cervical effacement and
more rapid cervical dilatation from 5

219
 cm until full dilatation for first and
subsequent labours.

Duration of the 6. Women should be informed that Recommended

first stage of a standard duration of the latent
labour first stage has not yet been
established and can vary widely
from one woman to another.
However, the duration of active
first stage (from 5 cm until full
cervical dilatation) usually does
not extend beyond 12 hours in
first labours, and usually does
not extend beyond 10 hours in
subsequent labours.

220
 Category of
Care option recommendation
recommendation
First stage of labour
Progress of the7. For pregnant women with Not
first stage of spontaneous labour onset, the recommended
cervical dilatation rate threshold of 1 Not
labour
cm/hour during active first stage (as recommended
depicted by the partograph alert line) Not
is inaccurate to identify women at recommended
risk of adverse birth outcomes and is
therefore not recommended for this
purpose.
8. A minimum cervical dilatation rate of
1 cm/hour throughout active first
stage is unrealistically fast for some
women and is therefore not
recommended for identification of
normal labour progression. A slower
than 1 cm/hour cervical dilatation
rate alone should not be a routine
indication for obstetric intervention.
9. Labour may not naturally accelerate
until a cervical dilatation threshold of
5 cm is reached. Therefore, the use
of medical interventions to
accelerate labour and birth (such as
oxytocin augmentation or caesarean
section) before this threshold is not
recommended, provided that fetal
and maternal conditions are
reassuring.
Labour ward 10. For healthy pregnant women Research-context
admission policy presenting in spontaneous labour, a recommendation
policy of delaying labour ward
admission until active first stage is

221
 recommended only in the context of
rigorous research.

Clinical 11. Routine clinical pelvimetry on Not

pelvimetry on admission in labour is not recommended
recommended for healthy pregnant
admission
women.
Routine 12. Routine cardiotocography is not Not
assessment of recommended for the assessment of recommended
fetal well-being on labour admission Recommended
fetal well-being
in healthy pregnant women
on labour presenting in spontaneous labour.
admission 13.Auscultation using a Doppler
ultrasound device or Pinard fetal
stethoscope is recommended for the
assessment of fetal well-being on
labour admission.
Perineal/pubic 14. Routine perineal/pubic shaving Not
shaving prior to giving vaginal birth is not recommended
recommended.
Enema on15. Administration of an enema for Not
admission reducing the use of labour recommended
augmentation is not recommended.
Digital vaginal16. Digital vaginal examination at Recommended
examination intervals of four hours is
recommended for routine
assessment of active first stage of
labour in low-risk women.
Continuous 17. Continuous cardiotocography is not Not
cardiotocography recommended for assessment of recommended
fetal well-being in healthy pregnant
during labour
women undergoing spontaneous
labour.

222
Intermittent fetal18. Intermittent auscultation of the fetal Recommended
heart rate heart rate with either a Doppler
ultrasound device or Pinard fetal
auscultation
stethoscope is recommended for
healthy pregnant women in labour.
Epidural 19. Epidural analgesia is recommended Recommended
analgesia for for healthy pregnant women
requesting pain relief during labour.
pain relief
This depends on a woman’s
preferences.
Opioid analgesia20. Parenteral opioids, such as Recommended
for pain relief fentanyl, diamorphine and pethidine,
are recommended options for
healthy pregnant women requesting
pain relief during labour. This
depends on a woman’s preferences.
Category of
Care option recommendation
recommendation
First stage of labour
Relaxation 21. Relaxation techniques such as Recommended
techniques for including progressive muscle
pain relaxation, breathing, music,
management mindfulness and other techniques are
recommended for healthy pregnant
women requesting pain relief during
labour. This depends on a woman’s
preferences.
Manual 22. Manual techniques, such as massage Recommended
techniques for or application of warm packs, are
pain recommended for healthy pregnant
management women requesting pain relief during

223
 labour. This depends on a woman’s
preferences.

Pain relief for23. Pain relief for preventing delay and Not
preventing reducing the use of augmentation in recommended
labour delay labour is not recommended.
Oral fluid and24. For women at low risk, oral fluid and Recommended
food food intake during labour are
recommended.
Maternal 25. Encouraging the adoption of mobility Recommended
mobility and and an upright position during labour in
position women at low risk is recommended.
Vaginal 26. Routine vaginal cleansing with Not
cleansing chlorhexidine during labour for the recommended
purpose of preventing infectious
morbidities is not recommended.
Active 27. A package of care for active Not
management management of labour for prevention of recommended
of labour delay in labour is not recommended.
Routine 28. The use of amniotomy alone for the Not
amniotomy prevention of delay in labour is not recommended
recommended.
Early 29. The use of early amniotomy with early Not
amniotomy oxytocin augmentation for prevention of recommended
and oxytocin delay in labour is not recommended.
Oxytocin for30. The use of oxytocin for prevention of Not
women with delay in labour in women receiving recommended

224
epidural epidural analgesia is not
analgesia recommended.
Antispasmodic31. The use of antispasmodic agents for Not
agents prevention of delay in labour is not recommended
recommended.
Intravenous 32. The use of intravenous fluids with the Not
fluids for aim of shortening the duration of labour recommended
preventing is not recommended.
labour delay

Second stage of labour

Definition and33. The use of the following definition and Recommended
duration of the duration of the second stage of labour
second stage is recommended for practice:
of labour "" The second stage is the period of time
between full cervical dilatation and birth
of the baby, during which the woman
has an involuntary urge to bear down,
as a result of expulsive uterine
contractions.
"" Women should be informed that the
duration of the second stage varies
from one woman to another. In first
labours, birth is usually completed
within 3 hours whereas in subsequent

225
 labours, birth is usually completed
within 2 hours.

Birth position34. For women without epidural analgesia, Recommended

(for women encouraging the adoption of a birth
without position of the individual woman’s
epidural) choice, including upright positions, is
recommended.
Birth position35. For women with epidural analgesia, Recommended
(for women encouraging the adoption of a birth
with epidural) position of the individual woman’s
choice, including upright positions, is
recommended.

226
 Category of
Care option recommendation
recommendation
Second stage of labour
Method of36. Women in the expulsive phase of the Recommended
pushing second stage of labour should be
encouraged and supported to follow
their own urge to push.
Method of37. For women with epidural analgesia, Context-specific
pushing (for delaying pushing for one to two hours recommendation
women with after full dilatation or until the woman
epidural regains the sensory urge to bear down
analgesia) is recommended in the context where
resources are available for longer stay
in second stage and perinatal hypoxia
can be adequately assessed and
managed.
Techniques for38. For women in the second stage of Recommended
preventing labour, techniques to reduce perineal
perineal trauma and facilitate spontaneous birth
trauma (including perineal massage, warm
compresses and a “hands on” guarding
of the perineum) are recommended,
based on a woman’s preferences and
options available to her.
Episiotomy 39. Routine or liberal use of episiotomy is Not
policy not recommended for women recommended
undergoing spontaneous vaginal birth.

227
Fundal 40. Application of manual fundal pressure Not
pressure to facilitate childbirth during the second recommended
stage of labour is not recommended.

Third stage of labour

Prophylactic 41. The use of uterotonics for the Recommended
uterotonics prevention of postpartum haemorrhage Recommended
(PPH) during the third stage of labour is Recommended
recommended for all births.
42. Oxytocin (10 IU, IM/IV) is the
recommended uterotonic drug for the
prevention of postpartum haemorrhage
(PPH).
43. In settings where oxytocin is
unavailable, the use of other injectable
uterotonics (if appropriate, ergometrine/
methylergometrine, or the fixed drug
combination of oxytocin and
ergometrine) or oral misoprostol (600
µg) is recommended.
Delayed 44. Delayed umbilical cord clamping (not Recommended
umbilical cord earlier than 1 minute after birth) is
clamping recommended for improved maternal
and infant health and nutrition
outcomes.
Controlled 45. In settings where skilled birth Recommended
cord traction attendants are available, CCT is
(CCT) recommended for vaginal births if the

228
 care provider and the parturient woman
regard a small reduction in blood loss
and a small reduction in the duration of
the third stage of labour as important.
Uterine 46. Sustained uterine massage is not Not
massage recommended as an intervention to recommended
prevent postpartum haemorrhage in
women who have received prophylactic
oxytocin.
Care of the newborn
Routine nasal47. Suctioning of the mouth and nose Not
or oral suction should not be performed in the case of recommended
neonates born through clear amniotic
fluid who start breathing on their own
after birth.
Skin-to-skin 48. Newborns without complications Recommended
contact should be kept in skin-to-skin contact
with their mothers during the first hour
after birth to prevent hypothermia and
promote breastfeeding.
Category of
Care option recommendation
recommendation
Care of the newborn
Breastfeeding 49. All newborns, including low birth- Recommended
weight babies who are able to
breastfeed, should be put to the breast
as soon as possible after birth when

229
 they are both clinically stable, and the
mother and baby are ready.

Haemorrhagic50. All newborns should be given 1 mg of Recommended

disease vitamin K intramuscularly after birth (i.e.
prophylaxis after the first hour by which the infant
using vitamin K should already be in skin-to-skin
contact with the mother and
breastfeeding should already be
initiated).
Bathing and51. Bathing should be delayed until 24 Recommended
other hours after birth. If this is not possible
immediate due to cultural reasons, bathing should
postnatal care be delayed for at least six hours.
of the newborn Appropriate clothing of the baby for
ambient temperature is recommended.
This means one to two layers of clothes
more than adults, and use of hats/caps.
The mother and baby should not be
separated and should stay in the same
room 24 hours a day.
Care of the woman after birth
Uterine tonus52. Postpartum abdominal uterine tonus Recommended
assessment assessment for early identification of
uterine atony is recommended for all
women.

230
Antibiotics for53. Routine antibiotic prophylaxis is not Not
uncomplicated recommended for women with recommended
vaginal birth uncomplicated vaginal birth.
Routine 54. Routine antibiotic prophylaxis is not Not
antibiotic recommended for women with recommended
prophylaxis for episiotomy.
episiotomy
Routine 55. All postpartum women should have Recommended
postpartum regular assessment of vaginal bleeding,
maternal uterine contraction, fundal height,
assessment temperature and heart rate (pulse)
routinely during the first 24 hours
starting from the first hour after birth.
Blood pressure should be measured
shortly after birth. If normal, the second
blood pressure measurement should be
taken within 6 hours. Urine void should
be documented within 6 hours.
Discharge 56. After an uncomplicated vaginal birth in Recommended
following a health-care facility, healthy mothers
uncomplicated and newborns should receive care in
vaginal birth the facility for at least 24 hours after
birth.

annex 5 Basic equipment and supplies for intrapartum care

Health facilities require basic essential equipment and supplies for routine care
and detection of complications in the areas of the maternity unit for labour and
childbirth, which should be available in sufficient quantities at all times (17).

231
 The information listed in this section is neither meant to be an exhaustive list nor
to imply that, by omission, other equipment and supplies may not be necessary
for the provision of quality intrapartum care, based on the availability of resources
and on women’s and provider’s preferences.

Warm and clean room equipment

Sufficient examination tables or beds Sphygmomanometer or other blood

with clean linens pressure machine
Light source Stethoscope
Heat source Body thermometer
Clean and accessible bathrooms for Fetal stethoscope or Doppler
the use of women in labour
Curtains if more than one bed
Hand washing Medication

Clean water supply Bag of IV fluids, Oxytocin

Soap Injectable magnesium sulfate
Nail brush or stick Antibiotics, Antiretroviral
Clean towels Antihypertensive
Alcohol-based hand rub Analgesics
Anaesthetic
Waste sterilization

Bucket for soiled pads and swabs Instrument sterilizer

Receptacle for soiled linens Jar for forceps
Container for sharps disposal Vacuum extractor

232
 Miscellaneous supplies

Printed LCG Gloves

Wall clock Urinary catheter
Torch with extra batteries and bulb Syringes and needles
Log book Sterilized blade/scissors
Medical records IV tubing
Informed consent forms Suture material for tear or
Refrigerator episiotomy repair
Basic accommodation facilities for Antiseptic solution (iodophors or
companions chlorhexidine)
(chair, space to change, clothes, Spirit (70% alcohol)
access to a toilet) Swabs
Private physical space for the woman Bleach (chlorine-based compound)
and her companion Impregnated bed net
Power supply Urine dipsticks
Food and drinking water Clamps
Oxygen cylinder/concentrator

233