PHYSIOLOGY OF

LABOUR

By Mr. Adan

01/22/2025 Adan. A. D, BscN, BML

 LABOUR

• LABOUR--It’s the process by which the fetus, placenta and

membranes (Conceptus) are expelled through the birth canal

• OR, is a physiological process, characterized by rhythmic regular

uterine contractions increasing in frequency and intensity,
accompanied by progressive cervical effacement and dilatation, and
descent of the presenting part. It may be spontaneous or induced.
• Normal labour is a physiological process, which commences
spontaneously at term (37 completed weeks) with rhythmic regular
uterine contractions of increasing intensity and frequency,
accompanied by progressive cervical effacement and dilatation, and
descent of the presenting part (preferably cephalic), resulting in
expulsion of a healthy fetus, a complete placenta and membranes and
a healthy mother.
 CAUSES OF NORMAL LABOUR
• The cause is unknown but there are important aspects attributed to
the occurrence. They include: Mechanical factors

• Overstretching and over-distension of the uterus

• Uterine contractibility increases towards term

• Cervical nerves are irritated by pressure from the presenting part,

stimulating cervical dilatation

• Stressful situations such as fever or emotional uproar

 Hormonal factors:
• (a) Oestrogen theory-- During pregnancy, most of the oestrogens are
present in a binding form.
• During the last trimester, more free oestrogen appears increasing the
excitability of the myometrium and prostaglandins synthesis.
• (b) Progesterone withdrawal theory– Before it, there is a drop in
progesterone synthesis leading to predominance of the excitatory action
of oestrogens.
• (c) Prostaglandins theory
• (d) Oxytocin theory—lack of secretion of oxytocinase enzyme
• (e) Foetal cortisol theory-- cortisol production from the fetal adrenal
gland before labor may influence its onset by increasing oestrogen
production from the placenta
Essentials of Diagnosis of Normal Labour
• Diagnosis of labour includes: c) watery vaginal discharge or a
• diagnosis & confirmation of sudden gush of amniotic fluid
labour, diagnosis of the stage & (drainage of liquor)
phase of labour, assessment of • Labour is confirmed by the
the engagement & descent of the presence of: cervical effacement
foetus & identification of and cervical dilatation.
presentation & position of the
foetus.
Symptoms
a) Intermittent low abdominal
pains radiating to the back,
b) blood-stained /mucoid vaginal
discharge (show),
 CLINICAL PRESENTATION OF
LABOUR
Premonitory signs of labour
There are changes that occur in last few weeks of pregnancy (pre-
labour period). They occur all or just a few and include:
• Mood swings
• Energy surge
• Difficult in walking (symphyisis pubis dysfunction)
• Cervix softens and has the ability to dilate
• Increased lekorrhoea
 cont…
• Lightening

• Braxton hicks contractions

• Frequency of micturation

• Cervical changes

• Late pregnancy feelings

• Labour may be classified as true or false labour.
• The differences are outlined below.
 STAGES OF LABOUR
• Labour is divided into four main stages:

• 1st stage – from onset of labor to full dilatation of the cervix.

• Its dividend into latent and active phases

• 2nd stage – stage of fetal expulsion, begins from full cervical dilatation and
ends when the baby is born.

• 3rd stage – stage of separation and expulsion of the placenta

• 4th stage – stage of observation following birth, lasts 1-2 hours after expulsion
of placenta
 PHYSIOLOGY OF LABOUR
• Physiological changes that occur during labor are divided into three
stages
• The duration of first stage of labor determines the duration of labor
because it takes the most time. The duration of labor is determined
by:
• Parity
• Birth interval
• Psychological state of the mother
• Presentation and position of the fetus
• Pelvic shape and size
• Character of uterine contractions
 Physiology of first stage

• Physiology of first stage is divided into two categories.

• Uterine action
• Mechanical factors
 a) THE UTERINE ACTION
• a) Fundal dominance

• During a contraction the uterus feels hard to touch.

• At the beginning of the process, contractions are painless and involuntary, and are
controlled by the nervous system under the influence of endocrine system.

• The contraction starts at the upper part of fundus near the cornua, spreading across,
and downwards.

• The contractions last longer and are very intense at the fundus.

• The peak of the contraction is reached simultaneously over the whole uterus and fades
from all parts together.

• This pattern allows the cervix to dilate & the contracting fundus to expel the fetus.
 Fundal dominance during uterine
contractions.
b) Polarity
 The term used to describe the neuromuscular harmony that exist
between the upper and lower uterine segments
 The upper uterine segment contracts strongly and retracts to expel
the fetus while lower segment contracts slightly and dilates to allow
expulsion of the fetus
c) Contraction and retraction

• The uterine muscles have a unique characteristic in labour.

• The contracted muscle does not return to its original length when
the contraction passes off.
• Each succeeding contraction leads to further shortening of the
muscle fibres so that the uterine cavity becomes smaller and
smaller.
• This is known as retraction and it is what makes the cervix dilate.
• When talking about contractions, the midwife is basically concerned
with 4 factors, namely;
 The intensity

 The duration

 The tone

 The frequency of the contraction.

 Characteristics of contractions
i. Intensity: the strength. It is greater on the fundus towards the
lower segment
ii. Tone: the basal intra-amniotic pressure between contractions and
averages between 5-12MMHG
iii. Duration: the time between the start and end of a contraction.
May last from 30-60 seconds
iv. Interval between contractions diminishes gradually from about 10
minutes at the onset of labour to 1 minute or less in second stage
v. Frequency: number of contractions per 10 minutes is 3-4 by end of
first stage
(d) Formation of the upper and lower uterine segment
This is a functional division that occurs to the uterus at term.
The uterus is divided into the upper and lower segment.
The upper segment is thick and muscular concerned with
contraction when the lower segment is thin prepared for
distention and dilatation
e) Retraction Ring

 An imaginary ridge that forms between the upper and the lower
uterine segment is functionally separated from the lower segment
by a ridge known as retraction ring.
 it rises with the increase in contractions until full cervical dilatation
is achieved
 It is not seen abdominally but if it does, it known as Bandl’s ring and
denotes obstructed labor.
Retraction Ring cont…
 f) The Shortening & Dilation of
the Cervix
• Before labor begins, the cervix of a primigravida is a thick hard cone,
which protrudes into the vagina.
• The canal is at least one-inch long.
• When labor begins, the strongly contracting upper segment of the
uterus starts retracting and getting shorter, while the thinner lower
segment of the uterus gets pulled away from the presenting part.
• This stretches the lower segment & the latter, in turn, pulls the
internal os.
• The dragging away of the internal Os from the presenting part starts
dilating the upper part of the cervical canal.
• This goes on until the canal is shorter and shorter and finally there is
no canal at all.
• The canal becomes part of the uterine cavity, with only the un-
dilated external Os and the thinly stretched cervix separating this
cavity from the vagina.
• When this happens, it is said that the cervix has been 'effaced' or
'taken up’
• Effacement refers to the inclusion (taking up) of the cervical canal
into the lower uterine segment.
• After this, further progress in labor leads to dilation of the cervix.
• Dilatation of the cervix is the process of enlargement of the os
uteri from a tightly closed aperture to an opening large enough to
permit passage of the fetus.
• It is assessed in cm & full dilatation at term equates to about 10 cm.
 h) The 'Show'
• Throughout pregnancy, the cervical canal is sealed by a plug of mucus known as an
operculum.

• Together with the intact membranes this prevents organisms ascending into the
uterine cavity.

• When labour starts, the internal Os is pulled away from the foetal membranes and
the canal is opened up.

• This releases the mucous plug, which oozes out of the vagina mixed with a little
blood. This is called the 'show’

• The blood is from the ruptured capillaries as the chorion detaches from the
decidua
 2) Mechanical factors during
first stage of labor
a) Fetal axis pressure.

• During a contraction the uterus rises forward and the force of the
fundal contraction is transmitted to the upper pole of the fetus
down to the long axis of the fetus and applied to the presenting part
to the cervix.

• This is more significant after the rupture of membranes and

especially during second stage of labor.
Fetal axis pressure.
 b) Formation of the fore-
waters
•As the lower uterine segment forms and stretches, the chorion becomes
detached from it and the increased intrauterine pressure causes this loosened
part of the sac of fluid to bulge downwards into the internal Os to a depth of
1-12mm.

• The well flexed head fits snugly into the cervix and cuts off the fluid in front
of the head from that which surrounds the body.

• This fluid in front is called the fore waters and the reminder is hind waters.

• This helps to keep the membranes intact and prevent ascending infection
during first stage of labor since the pressure is only applied to the hind waters
c) Rupture of membranes

 Membranes may rupture at any stage in labor.

 Towards the end of first stage the membranes ruptures due to

extensive cervical dilatation.
 In poorly fitting presenting part, the waters are not cut off
effectively and is subjected to intense pressure leading to early
rupture of membranes.
 Early rupture of membranes leads to increased decelerations which
leads to caesarean section.
d) General fluid pressure

 When the membranes are intact, the pressure from uterine

contractions is exerted on the fluid.
 Since the fluid is incompressive, the pressure is equalized
throughout the uterus and over the fetal body.
 This is known as general fluid pressure

 After membranes rupture, the pressure is felt between the uterus

and the fetus, with placenta compressed between them.
 This causes diminished oxygen supply to the fetus
General fluid pressure.
 PHYSIOLOGICAL CHANGES IN
the 2nd STAGE
a) Contractions
•The strength of contractions increases once the cervix is fully
dilated.
•They are more stronger and frequent due to irritation of the
uterus.
•As the vagina is being stretched by the fetus, the reflex
stimulates the uterus causing more labor pains
 2nd stage physiology
• Membranes often rupture spontaneously towards the end of 1st
stage, the drainage of liquor allows the hard, round fetal head to be
directly applied to the vaginal tissues. This pressure aids in
distension.
• Increased flexion of the head results in smaller presenting
diameters.
• The physiological stages are:-
a) Contractions become expulsive as the fetus descends further into
the vagina.
• Pressure from presenting part stimulates nerve receptors (Ferguson
reflex) and the woman experiences the urge to push.
 b) Abdominal and diaphragmatic muscles (secondary powers)
•These muscles becomes more active and expulsive in action.
•This is known as pushing or bearing down.
•The expulsion becomes involuntary when the presenting part
reaches the pelvic floor and distends it.
c) Displacement of the pelvic floor
• The pelvic floor organs are displaced to allow the fetus to pass
through:
The bladder is drawn up into the abdomen.
The vagina dilates
The posterior part of the pelvic floor is pushed downwards in front of
presenting part.
 If there is any fecal matter in the rectum it is expelled
 The anus gapes until the anal opening is about 2.5 cm in
diameter.
The triangular perineal body is flattened . It becomes thin,
almost transparent and lengthens the vaginal canal.
• At this point, the presenting part is seen at the vulva
advancing with each contraction and receding between
contractions until crowning takes place.
• The presenting part is born by extension as the shoulders
and body follow
 MECHANISM OF NORMAL
LABOR
• This describes a series of movements done by the fetus as it moves
through the birth canal during delivery.

• Knowledge and recognition of the normal mechanisms enables the

midwife anticipate the next step in the process of descent, which in turn
will dictate her response to the birth as it progresses.

• This ensures that normal progress is recognized, and abnormalities are

detected and dealt with appropriately early.
 Principles of mechanism
• The principles common to all mechanisms are:-
• Descent takes place
• Whichever part leads and meet the resistance of the pelvic floor will rotate
forwards until it comes under the symphysis pubis.
• Whatever emerges from the pelvis will pivot around the pubic bone.

• During the mechanism of normal labor, the fetus turns slightly to

take advantage of the widest available space in each plane of the
pelvis.
• The widest diameter of the pelvic brim is the transverse, and the
outlet greatest diameter is the antero- posterior.
• In normal vertex presentation, the fetus is situated as follows:
• The lie is longitudinal.
• The presentation is cephalic
• Position is right or left occipito-anterior.
• The attitude is one of good flexion.
• The denominator is the occiput
• The presenting part is the posterior part of the anterior parietal bone.
 Main movements
• Descent:- this takes place throughout labor.

• Flexion:- it increases throughout labor.

• It ensures that a small diameter, suboccito-brematic, is presenting.

• Internal rotation of the head:- the leading part(occiput) meets the

pelvic floor and rotates anteriorly through 1/8th of a circle.

• This causes a slight twist in the neck of the fetus and head is no
longer in direct alignment with the shoulders.
 cont…

• The anteroposterior diameter of the head now lies in the widest outlet
diameter, the anteroposterior diameter.

• Crowning then occurs when the occiput slips beneath the subpubic arch.

• Extension of the head:- after crowning the fetal head extends pivoting
on the subpubic arch.

• This releases the sinciput, face and chin which sweeps the perineum and
are born by a movement of extension
• Restitution:- the twist in the neck of the fetus resulting from the internal
rotation of the head is corrected by a slight untwisting movement.

• The occiput moves 1/8th of a circle towards the side from which it started.

• Internal rotation of the shoulders:- the anterior shoulder reaches the pelvic
floor and rotates anteriorly to lie under the symphysis pubis.

• It occurs in the same direction as restitution, and the occiput now lies
laterally.
 cont…
• Lateral flexion:- the anterior shoulder escapes beneath the subpubic
arch and the posterior shoulder sweeps the perineum.

• The reminder of the body is born by lateral flexion as the spine

bends sideways through the curved birth canal
 Mnemonic device : Every Decent Family In Europe Eats Eggs’.
i. Engagement
ii. Descent
iii. Flexion
iv. Internal rotation
v. Extension
vi. External restitution of the head
vii. Expulsion
• Mechanism of Normal labour in second stage of labour i.e.
i. Descent of the presenting part
ii. Flexion of head
iii. Internal rotation of the head
iv. Crowning of the head
v. Extension of the head
vi. Restitution of the head
vii. Internal rotation of the shoulders
viii. External rotation of the head
ix. Lateral flexion of the body
 Management of labour
• Is the care given through out the stages of labour
A) Admission procedure
 Well coming the mother and her partner
 On Arrival greet the mother
 Introduce your self
 Inform relatives to wait
• B. Admission criteria
Check - show
- rupture of membrane
- regular uterine contraction with progressive cervical dilatation
VE – it may be done first or last depending on how the woman presents
herself.
• History --past, present, med/surg and all other relevant history
• Information from the mother --gestational age,duration elapsed since
onset of labour pain, any drainage of liquor, any PV discharge noted
• Ask the mother on set of contraction
• Rupture of membranes / passage of liquor
• Show or any other bright red bleeding

Physical examination
• The general condition
• Exhausted, anemic, pain, dehydrated general edema
• Vital sign: Blood Pressure, Temperature, pulse, respiration
• Abdominal examination using c) Presenting by vertex
Leopold’s Manoeuvres d) Through the birth canal within a
a) Inspection reasonable time ( not less than 3 hrs
b) Palpation lie, presentation, )
attitude engagement, Fundal e) Without complications to the
height mother or to the foetus
c) Auscultation fetal heart rate &
rhythm Maternal Observations
Vaginal examination • Partograph is tool & initiated in
• Use sterile speculum & digital VE active phase of labour
at intervals of 4 hrs • The periodicity of intermittent
• Criteria to call it normal labour fetal heart auscultation is 30
a) spontaneous onset minutes
b) Spontaneous expulsion of a single
mature foetus
• Use of early ARM (Amniotomy) with early oxytocin for prevention of
delay in labour not routinely recommended as evidence is largely
lacking
• Amniotomy can be done with augmentation of labour.
• Increased risk of infection due to rupture of membranes

contraindications to Amniotomy
• Infections i.e Hepatities B, C, HSV & HIV to minimize the hazards to
the foetus of ascending infection
• Presenting part high and mobile …active mgt of labour, intrapartum
foetal surveillance
Examination during labor
• Palpate uterine contractions
• Assessment of the cervix dilatation
• Effacement of the cervix: thinning of the cervix (%) or length
(cm). The cervix is normally 3-5 cms.
If cervix is about 2 cm from external to internal os
Consistency of the cervix: soft vs. hard. During labor the cervix
becomes soft.

Position of the cervix: posterior vs. anterior. During labor the cervix
changes from posterior to anterior.

Membrane is intact or ruptured: assessed by fluid collection in the

vagina
 Care in the 1st stage
Investigations
• Hematology
- Hematocrit
- Hemoglobin
- Blood Group, Rh, cross- match
• Urine analysis
- Protein (Albumin)
- Sugar
- Ketone
• Write on patient chart and inform relatives. Use partograph
and record on it.
• NB – if the woman is in true labour i.e 4cm dilated start a partograph and
continue with care as follows.
• Note: Provide woman-centred individualized care.
• During the first stage of labour, encourage the woman to:
a) Empty her bladder regularly
b) Freely move about
c) Maintain oral intake of fluids and food as required
d) Exercise breathing techniques
e) Observe personal hygiene
f) Have a chosen companion with her.
• The health provider should:

a) Practice universal infection prevention and control protocols

b) Use partograph as appropriate for monitoring labour

c) Listen to, encourage, support and reassure the woman continually

d) Prepare for management for the other stages of labour

e) Ensure privacy and confidentiality

f) Make arrangements to accommodate the birth companion or male partner

g) Anticipate the need for neonatal resuscitation and prepare for it

 INFECTION PREVENTION
• Admit the woman in a clean environment.
• Control the no number of visitors in a birthing unit.
• Clean beds and rooms thoroughly after use.
• Encourage the woman to bathe and wash as she wishes.
• Wash your hands before and after attending the client.
• Wear gloves when handling used sanitary pads, blood stained linen or
body fluid.
• Invasive procedures should be kept to the minimum
• Artificial rupture of membranes should be avoided unless there is a
good indication of the same.
• Observe the aseptic technique every time you are doing a sterile
procedure
 Emotional support
• Encourage the birth companion to support the woman emotionally during
labor.

• Explain the process of labor to the woman and lay down expectations to
relieve anxiety.

• Keep on encouraging the woman.

• Express care and dependability to the client to boost her confidence.

• As a midwife, display tolerant non-judgemental attitude in provision of care.

 Observations/partograph
• Observations about the condition of the pregnant woman, her unborn
baby and progress of labor should be monitored regularly.
• Partograph should only be started when the mother is in active labor,
ie cervical dilatation of 4cm has been achieved.
• The following observations are done:-
• Pulse rate:-recorded every 30 minutes when the woman is in active
labor. Pulse rate of above 100b/m are indicative of anxiety, infections,
ketosis or hemorrhage.
• Temperatures:- should be recorded every 4 hours. Pyrexia is
indicative of infections or hypoglycemia.
• Blood pressure:- measured every four hours, unless it is abnormal.
Hypotension may be due to supine position, shock or epidural
anaesthesia.
• Blood pressures may be further aggravated by labor on women who
had hypertensive disorders in pregnancy.
• Urinalysis-- urine is tested for glucose, ketones and proteins. The
volume of the urine is also measured.
• Contractions-- assessed ½ hrly
• Descent of the presenting part- assessed 4 hourly
• Cervical dilatation-- assessed 4 hourly
• Fetal heart rate-- to assess fetal well being its assessed ½ hourly
• Amniotic fluid-- It also determines the fetal reaction to labour and
its assessed ½ hourly
• Observe the maternal general status and her fortitude.
 Care of the bladder
• Encourage the woman to empty her bladder every 1-2 hours.
• If the woman is not able to visit the toilet, offer privacy and
provide with a bed pan.
• A catheter is passed if the woman is unable to empty the
bladder completely.
Nutrition
• Offer the woman light foods rich in carbohydrates to provide energy
during labor eg. Biscuits, toast, yoghurt, breakfast cereal, fruit juice,
tea etc.
• Fluids intake will reduce the risk of dehydration during labor.
 Relieving pain and comfort
• Rub the woman’s back during contractions to increase sensory input
and thus reduce sensation of pain.

• Ensure the woman assumes a comfortable position.

• Encourage the woman to walk around to aid in descent and shorten

labor.

• Encourage the woman to anticipate positively the birth of her child.

• Control of pain may be achieved by:
i. Change of position/ moving around,
ii. Touch and back massage from a companion,
iii. Breathing techniques
iv. Verbal coaching and relaxation to help draw her attention away
from labour pain,
v. Warm bath or shower
vi. Use of pharmacological agents e.g. tramadol 100mg 1M or slow
IV 6-8 hourly, pethidine 50-100 mg 1M or IV slowly 6-8 hourly,
inhalational nitrous oxide combined with 50% oxygen (Entonox)
or epidural analgesia where available
 INDICATIONS FOR VE
 When in doubt about the presentation, dilatation, or position and
to assess progress.
 To assess the shape and size of the pelvis.

 To know the cause in fetal or maternal distress.

 When the membranes rupture and the head is high or there is

Malpresentation, to make sure there is no prolapsed cord
Information: To be got on Vaginal Examination
a) Presenting Part
Presentation
Level of presenting Part
Caput
Sutures and Fontanelles.
Overlapping or moulding
b) Membranes
Intact - Bulging or flat?
Ruptured - Color of liquor
c) Cervix:
• Ripe - firm or soft
• Effacement - long or short - taken up.
• Oedematous- thick or thin
• Applied to the presenting part- Loose or well applied.
• Dilation- Measure in cm.
d) Vagina: Lax or tight, Warm or hot, Moist or Dray
e) Pelvis:
a) Cavity, sacral promontory
b) Curve of the sacrum, ischeal spine
c) Lateral pelvic side walls- parallel or convergent
Now Co-relate your findings, after recording them and determine
the stage of labour.
 Progress of First stage of
labour
• Satisfactory progress in first stage of labour is indicated by: Regular
contractions progressively increasing in frequency and intensity,
cervical dilatation of at least 1cm per hour with the cervix well
applied to the presenting part

• Unsatisfactory progress of first stage of labour is when the

contractions are infrequent and irregular after the latent phase,
cervical dilatation is less than 1 cm per hour during the active phase
and the cervix is poorly applied to the presenting part.
Examples of Positions for Labour and Delivery
Contents of a delivery kit
 THE SECOND STAGE OF
LABOUR
• Definition:
It is the stage from full dilatation of the cervix (i.e no cervix felt on V.E) until
the Baby is born:-

• Duration:
Primigravida 45 min – 1 hour, as long as 2 hrs
Multigravida 1/2 hour can be as little as 5 minutes.

• N.B. there should always be advance or descent in this stage

Management of Second Stage of
Labour
Signs of 2 stage
nd

• Complete dilatation of the cervix

• Contractions of short intervals lasting for more than a minutes & are
occurring every 2-3 minutes
• Grunting or the urge to bear down
• Retching or vomiting
• Growing of the fetal head visible at the perineum
• The perineum bulging & the skin becoming tense and glistening
• The anal gaping and/or passage of faecal matter.
• Companionship of labour ( doula)
• Once the patient is in the second stage the nurse must not
leave her, and a constant and careful supervision must be kept on her:
a) General condition, pulse, uterine contractions & Vulva
b) Bladder should be empty
c) Fetal heart more frequently (after every contraction)
d) Descent of the presenting part and progress.
e) Membrane should be ruptured
• NB – see procedure manual for further care.
 Examples of positions for
childbirth
Birth
 why delay cord clamping/
cutting?
• There is a transfer from the placenta of about 80 ml of blood at 1 minute after birth,

• reaching about 100 ml at 3 minutes after birth

• These additional volumes of blood can supply extra iron amounting to 40–50 mg/kg
of body weight.

• When this extra iron is added to the approx. 75 mg/kg of body iron that a full-term
newborn is born with,

• The total amount of iron can reach 115–125 mg/kg of body weight, which may help
prevent iron deficiency during the first year of life.
 EPISIOTOMY
• Definition-- The making of an incision into the perinium to enlarge the
vaginal orifice.
Indications for Episiotomy
i. Delay due to rigid perineum, disproportion between fetus and
vaginal orifice.
ii. Fetal distress due to prolapsed cord in second stage.
iii. To facilitate vaginal or intra uterine manipulation Eg. Forceps,
breach delivery
iv. Preterm baby in order to avoid intracranial damage
v. Previous 3rd degree repair of the perineum.
vi. A history of Female Genital Mutilation(FGM)
Advantages of episiotomy

a) Fetal acidosis and hypoxia are reduced

b) Over stretching of the pelvic floor is lessened

c) Bruising of the urethra is avoided.

d) In sever pre - eclampsia or cardiac disease to reduce the effort

bearing down.

e) A previous third degree tear which may occur again because of the
scar tissue which does not stretch well is prevented.
Types of Episiotomy
i. Medio- lateral

ii. Median

iii. J- shaped

iv. Lateral
Types of Episiotomy
• 1. Medio – Lateral

• The incision is begun in the center of the fourchette and directed

posterio laterally, usually to the woman’s right.

• Not more than 3cm long & directed diagonally in straight line which
runs 2.5cm distance from the anus.

• Advantages –

- Barthlion glands are not affected

- Anal sphincters are not injured

• 2. Median:
• The incision begun in the center of the fourchette and directed
posteriorly for approximately 2.5cm in the midline of the perineum.
• Advantage:
 Less bleeding
 More easily and successfully repaired
Greater subsequent comfort for the women
3. J – Shaped

The incision is began in the center or the fourchette and directed

posteriorly in the midline for about 2cm and then directed towards
7 on the clock to avoid the anus.

• Disadvantage

- The suturing is difficult

- Shearing of the tissue occurs

- The repaired wound tends to be pucked.

• 4. Lateral:

• The incision is begun one or more cm in distant from the anus.

• Disadvantages

- Bartholins duct may be saved

- The levator-ani muscle is weakened

- Bleeding is more profuse

- Suturing is more difficult

- The woman experiences subsequent discomfort

Timing the incision

1. The head should be well down on the perineum, low enough to

keep it stretched and thinned

2. In breech presentation the posterior buttock would be distending

the perineum

3. It must be made neither too soon nor too late

• REMEMBER:
Do not tie the sutures too tightly
The last stitches are important for they prevent excessive Scar
formation
 Press firmly on suture line with a pad to see if bleeding has
stopped.
 Remove perineal pad or suture pack from vagina. Rub up fundus
put clean pad on perineum
 Put gloved finger in to the rectum – to make suture that no stitch
has gone through the rectum
 Make the women comfortable, clean and dry.
After care of episiotomy

a) Hot bath, cleanliness and wound care

b) If pus or foul smelling discharge develop report to health

personnel.

c) Advise not to strain and avoid constipation

 THIRD STAGE OF LABOUR
The Third Stage of Labour
• It begins immediately after the baby is born, until the placenta is
delivered.
• The 3rd stage lasts between 5-15 minutes but any period up to 1 hour is
normal.
• If it lasts more than 1 hr it is considered as retained placenta.

• Physiology of the third stage of labour

a) Separation of the placenta
b) Descent of the placenta
c) Expulsion of the placenta
d) Control of bleeding
NB:1. Separation of the placenta-placenta separates vin two ways

• Central separation-blood clot comes behind the placenta

• Lateral separation-there is a gush of blood ahead of the placenta

2. Control of bleeding-there is contraction and retraction of the oblique

muscles of the uterus to prevent bleeding from sinuses (living ligatures)

3. Expulsion of placenta-separates in two methods/ways

• Shultze method-fetal surface on the lead and membranes tail behind

• Mathew Duncan method-placenta expelled with its lateral border

coming through vulva like a button coming through a button hole.
• 1. Separation of the placenta
Mechanism of placental separation
It is brought by the contraction and retraction of the uterine muscles.
Separation usually begins in the center of the placenta.
At the area of the separation the blood sinuses are torn across.
30- 60ml of blood is connected between maternal surface of the
placenta and the decidual basalis.
The uterine contractions detaches the placenta from the uterus and
the placenta forced out of the upper uterine segment into the lower
uterine segment.
Signs for placental separation

• 1. Gush of blood

• 2. The fundus rises at the level of umbilicus

• 3. Uterus becomes globular

• 4. Cord lengthens and does not recend on supra-pubic pressure

• The uterus contracts during & after the birth of the baby.

• This causes the uterus to become smaller, the placenta remains the same
size & is pushed off the uterine wall.
2. Descent of the placenta
• When the placenta has completely separated, the
• contracting uterus pushes it down into the lower uterine segment and into
the vagina.
• The weight of the placenta itself pulls the chorion off the uterine wall.
Sign of placental descent
• 1. The uterus becomes hard, round and movable.
• 2. The fundus rises to the level of the umbilicus.
• 3. The cord seems to lengthen.
• 4. There is a gush of blood
• 5. When you apply suprapubic pressure the cord will not
• reced back
• 6. Placenta can be felt on vaginal examination.
3. Expulsion of the placenta

Method of placental expulsion

• a). Using the fundus as a piston

• The contracted fundus is used as apposition to push the placenta out.

• b) Controlled cord traction with out oxytocin drugs (Brandit Andrews

method)

• c) Fundal pressure

• d) Traditional method/Bearing down by the woman

 METHODS OF PLACENTA EXPLUSION
1. ACTIVE MANAGEMENT OF LABOUR
• An oxytocic drug is given, if pregnancy is not multiple as soon as
anterior shoulder is delivered.
• The cord is clamped and cut, wait for contraction.
• Do not wait for the sign of placental separation and
descent
• As soon as the uterus contracts the left hand is placed above the
symphysis pubis push and the uterus upwards
towards the umbilicus.
• At the same time the right hand grasps the umbilical cord and apply
traction in “a down ward direction” out ward when the placenta is
visible traction is exerted in an upward direction following the curves
of then birth canal and then deliver the placenta.
 AMTL
• If the membranes are not complete twisting the placenta to form the membranes
into a rope or grasping the membranes with artery forceps and moving gently up and
down to remove it.

• It is done for high risk mothers.

• Recommendations – When active management of the third stage is used clamp the
cord.

a) Prophylactic use of oxytocin

b) Controlled cord traction for delivery of the placenta

c) Uterine massage
• 2. Controlled cord traction without oxytocic drugs /Brandit
Andrews method/ passive management of third stage of
labour
• Signs of placental separation and descent are awaited.
• The left hand is placed above the symphysis pubis push the uterus
upwards towards the umbilicus.
• At the same time the right hand grasps the umbilical cord and apply
traction in “a down ward direction” out ward when the placenta is
visible traction is exerted in an upward direction following the
curves of the birth canal then deliver the placenta.
• Cord traction should not be applied when the fetus is macerated or
if the baby is preterm.
• Danger: Breaking of the cord. If the cord is snap manual removal is
indicated.
• Advantage: It allows the placenta to separate and descend with out
interference

• Danger: The third stage may be longer Haemorrhage and infection

may happen.
3. Maternal effort: When the uterus is well contracted ask the mother
to push as she did during the birth of the baby

• If she is not successful, the midwife or nurse may put a hand flat on
the abdomen while the mother pushes, thus provides counter
pressure to compensate the poor abdominal muscle tone3
• 4. Fundal pressure: The midwife or nurse puts her left hand
on the fundus of the well contracted uterus and pushes down
wards and back wards.
• The uterus is pushed against the placenta & the placenta emerges
from the vagina, receive the placenta, massage the uterus to make it
contract, and give Ergometrine.
• Indication:- Preterm labour, still birth
• Danger- Pain
• N.B : Fundal pressure and cord traction must never be combined
because of the risk of inversion of the uterus.
• 5. Traditional method
• Up right kneeling/ squatting positions should be recommended when
the third stage is passively managed.
• Gravity and intra abdominal pressure aid & speed the process
Advantage – Blood loss can be easily observed
• About 500-.800ml blood flows through the placental site each minute.
• Following delivery of the placenta the oblique muscle fibers of the
myometrium contract very strongly to compress
the blood vessels.
• All average blood loss after the delivery of the placenta is
150ml.
• Blood loss should never be more than 500ml.
• All blood should be measured including clots from the placental surface.
 PHYSIOLOGY OF 3rd STAGE ct….
• 4. Control of bleeding
Methods:-
• Contraction & relaxation of uterine muscles
• The actions of living ligatures
• Extra clotting power in the blood
The third stage is the shortest and easiest but the most dangerous stage.
Bleeding after third stage of labour stops spontaneously, because of:
• 1. “Living ligatures” The oblique muscles fibers of the uterus run in and out
between the blood vessels when the uterus is contracted they clump the
blood vessels very securely and the bleeding stops.
• 2. Extra clotting power: The mother has extra clothing power in her blood
at this time the clotting mechanism is very powerful.
• At the end of the third stage

1. The uterus should be hard, round and movable

2. The uterus should be mid way between the umbilicus and

symphysis pubis

3. There should be no excessive bleeding

4. The bladder should be empty

 THE OXYTOCIC DRUGS
• These drugs stimulate the uterus to contract. It is used before, during &
after the third stage of labour.
• Advantages:
1. It speeds up the delivery of the placenta
2. Lessen the blood loss
3. Contract the uterus
• The oxytocic drugs are:-
1. Syntocinon, orastinon, pitocin, oxytocin - one ampule contains 5 or 10
units
2. Ergometrine ampules – 0.5 mg or 0.25mg, Ergometrine 0.25 or 0.5mg
tablet form
3. Syntometrine - 1ml contains 0.5mg Ergometrine and 5
unites of oxytocin.
 4th STAGE OF LABOUR
• The recovery phase immediately after delivery of the placenta is
referred to as the 4th stage of labour.

• The 4th stage is critical time that begins after delivery of the
placenta and ends when the mother’s system has stabilized, usually
1 to 4 hours later.

• This is the stage of observation for both the mother and baby for at
least 1-2hrs after expulsion of the afterbirth.
 cont..
• The mother and the baby has to remain in the delivery room for an
hour after delivery.
• Immediate care of mother:
Give oxytocin 5-10 iu, massage the uterus and expel
the clots.
The vulva is swabbed and a sterile pad placed in position
Buttocks should be dry and any wet sheet is removed
 The sterile towel is removed over the lower abdomen and thighs
and cover with warm blanket.
 MOTHER
• Check/perform,
• Physical assessment; pallor, temperature, blood pressure, uterine
involution. Blood pressure is taken ½ hourly.
• Assess Pain –Type, location and intensity
• Inspect cervix, upper vaginal vault
• inspection of C/S wound- for bleeding
• inspect and evaluate the placenta, membranes and umbilical cord
• Breast examination for establishment of lactation
• Perineal cleaning and positioning
• Record in PNC register and MCH booklet
 Provide: Advice on
• Pain management • Danger signs to the mother
• Vitamin A • Personal hygiene
• Appropriate FP method • Breast care
• Give her a hot drink & place the • Exercises
baby on the breast • Care of perineum
• If HIV positive give ARVs • Use of insecticide treated mosquito
Counsel on: nets
• HIV counseling and testing • Return date
• FP counseling
 BABY
Check/perform
• Apgar score
• Temperature
• Check weight, height, head circumference and any drug (s) given to
the baby
• Head to toe exam
• Asses for danger signs for the baby
• Observe a breast feed
• Record in postnatal register
• Promote bonding and breast feeding
• Put on ID (identification) band
Provide
• Ensure warmth and put hat on the baby
• Delays baby’s first bath for the first 24 hours
• If pre term encourage skin to skin care
• Encourage early initiation of an exclusive breast feeding
• Tetracycline eye ointment 1%
• Vitamin k
• Immunization (BCG and birth polio)
• Infant HIV prophylaxis if indicated
• Encourage & facilitate birth registration
 Counsel on
• Cord care
• Hand washing for care giver
• Return date
 RECORD KEEPING
• Record your observations during labour
• Method of delivery- spontaneous or accelerated, forceps, cesarean
section or vacuum.
• Anaesthetic – General, epidural, local
• Blood loss- amount
• Placenta and membranes- complete, incomplete
• Perineum- laceration, episotomy
• Drugs given for the mother
• Baby – Sex, weight, APGAR score, alive or stillbirth. Date and time of
delivery
• N.B .The chart should present a clear, concise, reliable record.
• The legal aspect of record keeping is also important during labour.
 END

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