Normal labor and

delivery
Estela Abera
(BSc. MSc. MRHN)

By Estela 3/25/2025
1
By Estela
3/25/2025
 Objectives
 At the end of this session, you are expected to:
 Define labor and delivery
 Outline theories of labor initiation
 Outline determinants of labor
 Describe characteristics of uterine contractions in
labor
 Describe patterns of cervical dilatation in labor
 Describe normal patterns and durations of labor
 Describe stages of labour
Discuss on the management of each stage of labour
using partograph
Describe essential newborn care

By Estela
3/25/2025
 Definition
 Labor is a process regular uterine contraction results
in progressive dilatation effacement which ends in the
delivery of the fetus and placenta and membranes
 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.
( FMOH,2022)

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 Normal labor and delivery
Labor is considered normal when the following conditions
are fulfilled:
 Parturient without any risk (e.g., Pre-eclampsia, Previous
scar, etc.),
 Labor should start spontaneously and at term,
 Fetal presentation must be by vertex,
 Delivery should be by spontaneous vertex delivery, with
minimal aid,
 All stages of labor are lasting normal duration, and
 the neonate is alive, normal and the immediate postpartum
course is normal
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 Cause of onset of labour
 The exact reason for the causes of the onset of labour is
unknown but the various theories responsible for that
are hormonal , biochemical, and mechanical stretch
pathways, these are as follows;

(Vanora H. et al. ,2020)

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3/25/2025
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 1.Hormonal factors
1. Oestrogen Peak Theory
 It increases the release of oxytocin from the maternal pituitary.

 Promote the synthesis of myometrial receptors of

prostaglandin, oxytocin.
 Prostaglandin synthesizes from decidua & amnion by the
lysosomal disintegration.
 Synthesis of myometrial contractile protein, actin &
myosin.

By Estela 8
3/25/2025
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 1.Hormonal factors cont’d
1.2 Progesterone withdrawal theory
 During pregnancy, progesterone is secreted in high level
which has a sedative effect on the uterine muscle
making it remain relaxed.
 As pregnancy advances the level of progesterone
get reduced so the uterus becomes more active so
that a diminished amount leads to onset of labor.
 Progesterone has opposite effect to that of oestrogen,
making the myometrium less sensitive to stimuli.

By Estela 9
3/25/2025
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 1.Hormonal factors cont’d
1.3 Prostaglandins initiating theory
 Prostaglandins E2 and F2α are powerful stimulators
of uterine muscle activity.
 The site of synthesis is amnion, chorion, decidual
cell,
myometrium.
 Its release is influenced by rising estrogen, glucocorticoid,
stretching, separation of the ruptured membrane.
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 1.Hormonal factors cont’d
1.4 Oxytocin theory
 Large oxytocin receptors are present in the fundus in
comparison to the cervix which increases at the time
of labour & it stimulates the synthesis or release of
Prostaglandins E2 and F2α from amnion & decidua.

By Estela 11
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 1.Hormonal factors cont’d
1.5 Fetal placental theory
 There is interaction between the fetal adrenal gland and
the uterus. At term the fetal adrenal gland secret
corticoid steroid which is believed to trigger the
release of prostaglandin in the maternal decidua

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 2.Mechanical factors
1. Uterine distension theory
 Stretching effect by growing fetus at the time of onset
of labour increases gap junction, receptors of oxytocin
& contraction associated protein.
 The physical stretching of the uterus causes an influx of
ions, sodium, and calcium, that change the action
potential across myometrial cells. This facilitates the onset
of uterine contractions.
 The gap junctions between myometrial cells increase just
before labour, which allows coordinated muscle
contraction.

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 2.Mechanical factors
2.2 Pressure of the Presenting part
 On the cervical nerve endings is thought to stimulation
nerve plexus (known as cervical ganglion) which result
in secretion of oxytocin by the Posterior Pituitary Gland
(PTG). This gives the reason why labour is very fast with
engaged head.

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 3. Biochemical Factors
 Through the release of phospholipase A2 in the
lysosomes of fetal membranes at term which esterifies the
arachidonic acid (fatty acid) thus synthesizing
prostaglandins.
 This then diffuses into the sarcoplasmic reticulum and
the free calcium ion releases that bind to a contractile
protein in myometrium and the contraction begins

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 Hormonal change

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 Characteristics of uterine contractions

Relevance of Uterine anatomy to labor:

 Myometrial content is highest in the fundus and
decreases downward to the cervix
 the upper segment and body is dominant, while
the lower segment and cervix remain passive
 Gradient of uterine contractions is highest at the
fundus and decreases towards the cervix

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 Unique features of uterine contraction
Characteristic Description and relevance

Contraction and Following each contraction, the length of the myometrial cells
“retraction” is shorter than its original length thus gradually decreasing
uterine volume and pushing the fetus downwards through the
birth canal
Painful The only physiologic contraction that is painful. Cause of pain
– myometrial hypoxia; stretching of the cervix; stretching of
parametrial tissues; stretching of overlying serosa
Gradient of Three zones of activity with a highly active fundal segment;
activity moderately strong mid segment and an inactive lower
segment.
Ferguson’s Cervical dilatation and pressure on the cervix by the
reflex presenting part leads to more stronger contractions through a
local uterine reflex that leads to a more stronger contraction

By Estela 3/25/2025
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 DIAGNOSTIC CRITERIA OF TRUE
LABOR
 Regular, rhythmic uterine contractions (≥ 2 contractions in 10 minutes)
with one or more of the following:
 Rupture of the membranes.
 Cervical dilatation of 4 centimeters.
 Cervical effacement of ≥ 80 %.
 Bloody show (If fetal membranes are ruptured or if digital vaginal
examination was done within the past 48 hours, show shouldn’t be used
as diagnostic criteria.)
 NOTE: Always rule out false labor to avoid unnecessary interventions

By Estela 3/25/2025
 False Labor

 False labor is irregular contractions of the uterus prior to actual

labor pains resembling those of normal labor.

 Signs of false labor are

• Mild pain and irregular contractions.

• There is no mucous blood-stained discharge (show).

• No progressive cervical dilatation observed on follow up

By Estela 3/25/2025
 True Vs False labour
Factor True labor False labor
Contraction Produce progressive dilation Do not produce progressive
and effacement of the dilatation and effacement .are
cervix . Occur regularly and irregular and do not increase in
increase in frequency ,duration ,and
frequency ,duration , and intensity.
intensity
Show Is present Not present. May have brownish
discharge that may be from
vaginal exam if within the last
48 hours
Cervix Becomes effaced and dilate s Usually uneffaced and closed
progressively
Fetal No significant change , even May intensity for a short period
movement though fetus continues to or it may remain the same
move
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 ADMISSION CRITERIA

 For a woman without known risk and intact membrane if cervical

dilation is ≥ 4 cm.
Those women with ruptured membranes & known risk factor can be
admitted at any cervical dilatation.

By Estela 3/25/2025
 Cervical changes during labour
Pre-labor cervical ripening
• A few days to weeks before the onset of labor
the cervix ripens
• ( becomes softer; changes position from posterior
to middle and anterior; begins dilatation and
effacement)
Ripening is due to the hormonal effects of estrogen,
progesterone and relaxin leading to water absorption
and separation of dense connective tissue fibers

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 Changes during labor
. Cervical effacement- the progressive shortening and
thinning of the cervix during labour

oIt expressed in percentage so when we say

effacement is 80% it means that 80% of the cervical
canal has been taken up.

 Cervical dilatation—the increase in diameter of

the cervical opening measured in centimeters

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 Causes of cervical dilatation:
 Contraction and retraction of uterine musculature.
 Mechanical pressure by the forebag of waters, if
membranes still intact,
 the presenting part, if they had ruptured. This in
turn will release more prostaglandins which
stimulate uterine contractions and cervical
effacement
 Softness of the cervix which has occurred during
pregnancy facilitates dilatation and effacement of
the cervix
By Estela 22
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 Mechanism of labour
 The mechanics of labor describe the forces required for
fetal descent, and the movements that the fetus must
perform to overcome the resistance met by the maternal
bony pelvis and soft tissue.
Cardinal movements
Refers to the changes in position of fetal head during
its passage through the birth canal.
 Because of a symmetry in fetal head and maternal
pelvis, such rotations are needed for negotiation.

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 Mechanism of labour cont’d
 Seven cardinal movements:
Engagement, Descent, Flexion,
Internal rotation, Extension,
External rotation and Expulsion
1)Engagement: the passage of
widest diameter of presenting part to a
level below the plane of pelvic inlet
 In cephalic presentations, the
widest diameter is biparietal;
 in breech presentations, it is
intertrochanteric.

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 Mechanism of labour cont’d
2) Descent: downward passage
of presenting part through the
birth canal
 The greater the pelvic
resistance or the poorer the
contractions, the slower the
descent.
 Descent continues
progressively until the fetus is
delivered

By Estela 22
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 Mechanism of labour cont’d
3) Flexion
 In most cases, flexion is essential
for both engagement and descent
Passively as the head descends
owing due to:
• Shape of the bony pelvis
• Resistance offered by the soft
tissues of the pelvic floor
 Flexion to some degree in most
fetuses starts before labor, and
complete flexion usually occurs
during the course of labor

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 Mechanism of labour cont’d
4) Internal rotation
 Refers to rotation of the
presenting part from its orginal
position( usually transverse with
regard to the birth canal) to the
AP position .so that sagital suture
occupies the anteroposterior
diameter of the pelvis.
 Normally begins with the
presenting part at the level of the
ischial spines and its movement is
in the direction of levator ani
muscles (the main muscle of the
pelvic floor) i.e. downwards,
forwards and inwards.
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 Mechanism of labour cont’d
5) Extension:
 Occurs once fetus descended to a
level of introitus
 Is because of force of uterine
contraction versus muscles of the
pelvic floor.
 As the head continues its descent,
there is a bulging of the perineum
followed by crowning.
 Crowning occurs when the largest
diameter of the fetal head is
encircled by the vulvar ring.

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 Mechanism of labour cont’d
6) External rotation: also called as restitution
 Return of fetal head to the correct postion in
relation to fetal torso.
 Passive movement
 Results from maternal bony pelvis & its
musculature and basal tone of fetal musculature
7) Expulsion: Delivery of rest of fetus.

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By Estela
3/25/2025 30
 Classification of labor
Normal labor is classified / staged as:
1 First stage of labor: The period between onset of
regular uterine contractions to full cervical dilatation.
It is subdivided into two phases: -
 Latent phase: The phase of labor between the onset
of regular uterine contraction to 5 cm of cervical
dilatation (often slow & unpredictable rate of cervical
dilatation).
 Active phase: The phase of labor after 5 cm of
cervical dilatation to full cervical dilatation
(morerate of cervical dilatation).
rapid
( FMOH,2022)

By Estela
3/25/2025
 Classification of labor
2. Second stage of labor: The stage of labor between
full cervical dilatation and delivery of the last fetus
(often associated with involuntary bearing down urge
because of expulsive uterine contraction).
3. Third stage of labor: The stage of labor between
delivery of the last fetus and delivery of the placenta &
membranes.

( FMOH,2022)

By Estela
3/25/2025
 Determinants of Labor
 The powers
 Primary powers- uterine contractions
 Secondary powers- maternal valsalva maneuver
 The passage
 The bony pelvis
 The pelvic soft tissues
 The passenger(fetus)
 Fetal size(macrosomia)
 Attitude the relationship of fetal part
to each other.
 It can be flexed, deflexed, military
 Position
 Psychic
By Estela
3/25/2025
 Management of Normal Labor

By Estela
3/25/2025
Discuss Criteria for diagnosis of
true labor

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 Admission criteria

 For a woman without known risk and

intact membrane- cervix dilation is ≥ 4 cms.
 For those with ruptured membranes & known
risk factor could be admitted at any cervical
dilatation

( FMOH,2022)

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3/25/2025 40
 Admission procedure

 Warm and friendly acceptance

 Immediate assessment of the general

conditions of the mother and fetus:

 History taking

 Physical examination

 Laboratory investigation

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 Admission procedure cont’d
History taking
 Review antenatal records
 Detailed obstetric history as for any antenatal mother
 Detailed description of duration, onset, frequency and
characteristics of pain
 Fetal movements, leakage of liquor including timing
amount and color
 History of “show”- bloody mucoid scanty discharge
 Any other history of relevance should be detailed

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 Admission procedure cont’d
Physical examination
 Detailed physical exam as any obstetric client
 Additional exams during labor include:
Abdominal examination
 Assess Lie, presentation and position of the fetus
 Descent of fetal head – fifths above the pelvic brim
 Characterize of uterine in ten minute
contraction,
 Frequency/10 minute
 Duration in second strength/mild,
Intensity or
moderate, strong
By Fetal
Estela heart sound count 3/25/2025
for full minute 44
44
 Admission procedure cont’d
Pelvic examination
 Inspection- fluid, blood, discharge, circumcision scars, hand
or cord prolapse if any
 Cervix- dilatation, effacement, position, consistency
 Membranes – intact or ruptured, liquor – amount and degree
of meconium staining, cord presentation or prolapse
 Presenting part- vertex, face, breech, shoulder
 Station of presenting part
 Position of presenting part
 Caput, molding
 Clinical pelvimetry
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 Admission procedure cont’d
Laboratory evaluation
 Review antenatal records for essential laboratory and
other diagnostic workup of the pregnant mother-
hemoglobin, blood group, RH type, urinalysis, HIV,
HBV, VDRL, ultrasonography…etc
 Revise or order new investigations on individual
basis

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 Admission procedure cont’d

Team approach is
important, and all
abnormal clinical/
laboratory findings
should be informed to
the most senior
personnel in charge of
the labor ward activity.

By Estela
3/25/2025
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 Management during
first stage of
labor

First stage of labor: The period between

onset of regular uterine contractions to full
cervical dilatation
(FMOH, 2021)
By Estela
3/25/2025
 Management of latent
phase of first stage of
labor

By Estela
3/25/2025
 Latent phase of first stage of labor

 Latent phase: The phase of labor between the

onset of regular uterine contraction to 5 cm of
cervical dilatation (often slow & unpredictable
rate of cervical dilatation) (FMOH, 2021).

 If the client presents before cervical dilatation of

5cm & fulfils admission criteria follow her using
normal chart
 Approximately 5% to 6.5% of women are given
the diagnosis of prolonged latent phase of
labor(Betsy Greulich, 2017).
By Estela
3/25/2025
 Latent phase of first stage of labor cont’d

Latent phase of first stage of Labor Follow Up Chart

(Management protocol on selected obstetrics topics for hospitals. MOH, Ethiopia, 2021)
By Estela
3/25/2025
 Management during 1st stage
 The three components of first
stage monitoring and follow-up:-
 Maternal wellbeing
monitoring
 Fetal wellbeing monitoring

 Monitoring of progress of
labor
 NB: All observations and findings should
By Estela
3/25/2025
I) Maternal wellbeing monitoring
 Vital signs: Pulse- every ½ hourly, Temperature –every 2 hourly and
BP - every 4 hourly or more frequently if indicated
 Maternal position - Avoid supine position, Can assume any position
comfortable to her. Why??
 Nutrition - Encourage oral intake of liquid diet (tea, juice) but not
hard foods. Why??
 Companionship in labor - Encourage partner to accompany the
spouse who is in labor.
 Pain management - provide continuous emotional support

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 Recommended maternal positions
(Positions for Labor & Birth from Simkin & Anchetta, The Labor Progress Handbook)

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 Pain management during labour
Non pharmacologic
Pharmacological
 Provide continuous 1.Opioids alone
emotional support (pethidine, diamorphine and
 Inform laboring mothers fentanyl are options)
about the procedures to  Always check respiratory
which they will be subjected depressant effect of
during labor and delivery pethidine on the mother as
 Relaxation & Massaging well as the neonate.
(back rubbing) 2. Lumbar Epidural
 Hot compress (back) Analgesia (if available)
(FMOH, (FMOH,
2021) 2021)
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 Pain management during labour
 RCT study done using non‐opioid drugs compared with placebo
showed
insufficient evidence to support a role for non‐opioid drugs on their own
to manage pain during labour (Othman M , 2012).
 Another study suggests both non-pharmacological and pharmacological

methods resulted in a significant reduction in pain (p < 0.01).

 Water immersion and epidural anesthesia (gold standard) proved to be the

most effective non-pharmacological and pharmacological methods.

 Also suggest that women giving birth in hospitals have better control of

labor pain due to access to pharmacological methods (Pietrzak J,

By Estela 55
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2022). 55
 II) Fetal wellbeing monitoring
A) Fetal heart rate
 Auscultate immediately after a contraction for 1 min
 Every 30 min for a parturient without any risk and every 15 min for
with a risk condition
 Continuous electronic FHR monitoring for Known problem
 FHR 100-180 BPM is normal for term normal fetus.

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II) Fetal wellbeing monitoring cont’d

B) Status of liquor for meconium

 Clear liquor
 Grade I - Good volume of liquor, lightly meconium stained.
 Grade II - Reasonable volume with a heavy suspension of
meconium.
 Grade III - Thick meconium/particulate matter which is
undiluted.
NOTE: A newly appearing meconium is alarming sign.

By Estela 3/25/2025
II) Fetal wellbeing monitoring cont’d

C) Grading of Molding
 No molding: The cranial bones are separate along the
suture lines.
 Grade I: Fetal cranial bones are touching each other along
the sutures
 Grade II: Fetal cranial bones are overlapping but can be
separated.
 Grade III: Fetal cranial bones are overlapping & are not
separable.
By Estela 3/25/2025
III) Monitoring of progress of labor
1) Uterine contraction
 Frequency in 10 minutes, duration and intensity of

each contraction determined by palpation

 Monitored every 1 hr. for latent phase and every 30 min.

for active phase

2) Descent of fetal head

 Should be done by abdominal palpation before vaginal

examination
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III) Monitoring of progress of labor cont’d

3) Vaginal examination
 To evaluate cervical dilatation, station, position, status of liquor, molding

and caput
 Frequency of vaginal examination is every 4 hours

 But can be repeated after spontaneous rupture of membranes, when there is:

 Abnormal FHR or FHRP,

 Before giving analgesia and

 If symptoms are suggesting 2ndstage of labor(to confirm

the diagnosis).

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 Management of
Active phase of first
stage of labor

By Estela
3/25/2025
 Active phase of first stage of labor

 Active phase: The phase of labor after 5

cm of cervical dilatation to the full cervical
dilatation more rapid rate of cervical
dilatation)(FMOH, 2021).

 If the client presents cervical dilatation

of above 5cm follow her using
partograph

By Estela 3/25/2025 66
33
 Partograph
and its
management

By Estela
3/25/2025
 The WHO partograph
 Partograph is a graphical
record of the observations
made of a women in labour
 For progress of labour and
salient conditions of the
mother and fetus.
 In 1954,
Friedman’s
MODIFIED
introduced the concept of WHO
partograph by graphically PARTOGRAPH
plotting cervical dilatation
against time(Friedman’s,
1955).
By Estela
3/25/2025
 The WHO partograph cont’d
 A systematic review in Ethiopia evidenced that
a pooled prevalence of partograph utilization is
59.95%
 The highest in Addis Ababa (92%) while the
lowest one in Oromia region (6.9%)
 The factor to increase the use of partograph is
 Supportive supervision,
 Providing Basic Emergency Obstetric and Newborn Care
training,
 On-the-job refresher training on partograph, and
 Promoting midwifery profession.
(Ayenew, A.A,
By Estela
3/25/2025 2020)
 The WHO partograph cont’d

Components
 Patient information
 Fetal condition
 Progress of labor
 Maternal condition

By Estela
3/25/2025
 I. Patient

information:
Name,
 Gravid, Para,
 Hospital number,
 Date and time of admission, and
 Time of ruptured membranes

By Estela
3/25/2025
 II. Fetal condition
Fetal heart rates
Degree of molding
Color of amniotic fluid (I,C,M,A,B)

By Estela
3/25/2025
 Fetal condition
cont’d
Mrs X 3 2
12.12.07 04.35 am 03.10

Amniotic  I – membranes intact

liqour  C – clear amniotic fluid
 В – blood-stained amniotic fluid
“I”,  A – absence of amniotic fluid
“C”“M”  M – meconium-stained amniotic fluid
By Estela “B”, “A”
3/25/2025
 Fetal condition
cont’d

Mrs X 3 2
12.12.07 04.35 am 03.10

Moulding
I. : Sutures apposed;
“O”, “+” II. : Sutures overlapped but
“++”, “+++” reducible;
III. : Sutures overlapped
By Estela
an d
not7 1reducible. 71
 III. Progress of
labour
 Cervical dilatation
 Descent of presenting
part
 Contractions
 Frequency
 Duration
 Alert and action lines

By Estela
3/25/2025
 Progress of labour

cont’d
Cervical dilatation: Assessed at every vaginal examination
and marked with a cross (X). Begin plotting on the
partograph at 5 cm.
 Alert line: A line starts at 5 cm of cervical dilatation to the
point of expected full dilatation at the rate of 1 cm per hour.
 Action line: Parallel and 4 hours to the right of the alert
line.
 Descent assessed by abdominal palpation: Refers to the part
of the head (divided into 5 parts) palpable above the
symphysis pubis; recorded as a circle (O) at every vaginal
examination. At 0/5, the sinciput (S) is at the level of the
symphysis pubis.

By Estela
3/25/2025
 Progress of labour
cont’d

By Estela
3/25/2025
 Progress of labour
cont’d
 Hours: Refers to the time elapsed since onset of active
phase of labour (observed or extrapolated).
 Time: Record actual time.
 Contractions: Chart every half hour; palpate the
number of contractions in 10 minutes and their duration
in seconds.
 Less than 20 seconds:
 Between 20 and 40 seconds:
 More than 40 seconds:
 Oxytocin: Record the amount of oxytocin per volume
IV fluids in drops per minute every 30 minutes when
used in hospitals.
By Estela
3/25/2025
 Progress of labour
cont’d
Dilatation of
cervix

By Estela
3/25/2025
 Cervix dilatation –”speedy” vs. “normal” vs. “slow” progress

08.00

10.00

15.00
 Cervical dilatation of 1 cm/hour = progress of labour follows the alert line
 >1 cm/hour = progress line moves to the left of the alert line = ”speedy” progress
 < 1 cm/hour = progress line moves to the right of the alert line, moving towards
or passing the action line – slow or prolonged progress
By Estela
3/25/2025
 Progress of labour
cont’d
Descent of foetal
head

08.00

By Estela
3/25/2025
 Progress of labour cont’d
Recording the contractions’ strength i.e. duration in
seconds

< 20 secs duration

20-40 secs duration

> 40 secs duration

By Estela
3/25/2025
 IV. Maternal condition
 Pulse, Temperature, Blood pressure
 Urine (volume, ketones, protein)
 It has also space to chart administration of drugs,
IV fluids, and oxytocin

By Estela
3/25/2025
 Maternal condition
cont’d
Pulse: Record every 30 minutes and mark with a
dot
(●).
 Blood pressure: Record every 4 hours and mark with
arrows.
Temperature: Record every 2 hours.
 Protein, acetone and volume: Record every time
urine is passed.

By Estela
3/25/2025
 Maternal condition
cont’d

Pethidine 2%
2 ml

36,
7

Maternal
temperature
50
ml
By Estela
3/25/2025
 Sample
Partograph
for Normal
Labor

By Estela
3/25/2025
 Sample
Partograph
for Normal
Labor

By Estela
3/25/2025
Partograph
Showing
Obstructed
Labor

By Estela
3/25/2025
Partograph
Showing
Obstructed
Labor

By Estela
3/25/2025
Example 3:
Prolonged
active phase
of labour

By Estela
3/25/2025
 Management of labour
using the partograph

By Estela
3/25/2025
 Management of labour using the partograph
 Partograph plot start when
cervical dilatation are 5cm
 Progress in active phase remains
on or left of the alert line
 Do not augment with oxytocin if
active phases go normally
 Do not intervene unless
complications develop
 Artificial rupture of
membranes
 No ARM in latent
By Estela
phase
3/25/2025
 ARM at any time in
Management of labour using the partograph
cont’d
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
 In Hospital setting
• Continue routine observations
• ARM may be performed if membranes are
still intact
By Estela
3/25/2025
Management of labour using the partograph
cont’d
At or beyond action line
 Conduct full medical assessment
 Consider intravenous infusion /
bladder catheterization / analgesia
 Action options:-
 Deliver by cesarean section if there is
fetal distress or obstructed labour
 Augment with oxytocin by intravenous
infusion if there are no contraindications
By Estela
3/25/2025
Management of labour using the partograph
cont’d
Common cause abnormal progress of labor

 Polonged Active phase

 Secondary arrest of cervical diltation
 Secondary arrest of head descant

By Estela
3/25/2025
Management of labour using the partograph
cont’d
Prolonged Active
phase
 In the active phase of
labor , plotting of cervical
diltation will normally
remain on or to the left of
the alert line
 In some cases will move
to the right of the alert line
and this warns that labor
may be prolonged
 This will happen if the rate
of cervical diltation in the
active phase of labor is not
1 cm / hour
By Estela
3/25/2025
Management of labour using the partograph
cont’d
Secondary arrest
of cervical
dilatation
 Abnormal progress of
labor may occur in cases
with normal progress of
cervical dilatation then
followed by secondary
arrest of dilatation

By Estela
3/25/2025
 The partograph in the management of labor
following cesarean section(VBAC).

 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 (Benazir H et al, 2017)

By Estela
3/25/2025
 The effect of partograph on labour progress and
delivery outcome
 Different study evidenced that a parturient women who
use partograph have:
 Increased referral rate,
 Decreases in vaginal examinations performed, augmentation
and obstructed labor.
 There were fewer cesarean births and neonatal resuscitation
 Reduced the duration of active phase and second stage of
labour (Lavender T et al, 2018), (Benazir H et al, 2017), (Fahdhy M, et
al, 2015), (Windrim R, 2007),
 Conclusions: A parturient women monitored by partograph experienced a
better monitoring of labour progress as well as delivery outcome in the
form of a healthy mother and a healthy child

By Estela
3/25/2025
 Advantages of Partographic labor monitoring

 Easy documentation of findings

 Quick evaluation of findings
 Graphic representation of labor progress
 Time saving
 Easy handing over of many laboring mothers
 Can be easily understood by midlevel health workers (
clear and easy indicators for referral)
 Suitable for research purposes
 Clear landmarks to assess when labor progress is
delayed( alert and action lines)
By Estela
3/25/2025
Situations in which the partograph may not be used

 Inductions and augmentations – begin

filling the partograph when labor is
established
 Second stage of labor
 False labor is not ruled out

By Estela
3/25/2025
The New Updated WHO labour care guide(LCG)

Source: WHO labour care guide: user’s manual. Geneva: World Health Organization; 2020

By Estela
3/25/2025
 key points on starting to use the

LCGes
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.

By Estela
3/25/2025
 The New Updated WHO labour care guide

The seven component of WHO Labour care guide

By Estela
3/25/2025
 The New Updated WHO labour care guide

The seven component of WHO Labour care guide

By Estela
3/25/2025
 The New Updated WHO labour care guide

The seven component of WHO Labour care guide

By Estela
3/25/2025
MANAGEMENT DURING 2nd STAGE of labor

 DEFINITION: The second stage is the time from full dilation of the
cervix to delivery of the last fetus.
 MATERNAL CARE AND WELLBEING EVALUATION
 BP monitoring: every 1hour (if indicated more frequently).
 PR, temp., and RR: every 30 minutes.
 Evaluate general condition: fatigue, pain, physical depletion and state of
hydration.
 Evaluate for the presence of the urge to push and /or effort. Avoid early
push.
 She can attain any position until the presenting part is visible or delivery is
imminent.
 The woman should be encouraged to empty her bladder before delivery.

By Estela 3/25/2025
MANAGEMENT DURING 2nd STAGE of labor

 BIRTHING POSITIONS
 Women can assume any position (e.g. semi sitting, squatting, kneeling or left
lateral position)
 unless delivery is imminent or there is a need for operative vaginal delivery or
episiotomy.
 Prolonged recumbent position should be avoided.

 FHR / FETAL STATUS MONITORING

 Every 15 min for low-risk pregnancy.
 Every 5 min for high-risk pregnancy (continuous electronic monitoring is
preferred for fetal monitoring of high-risk pregnancies).
 Evaluate the status of liquor (progress of meconium staining) during pelvic
examination.
By Estela 3/25/2025
MANAGEMENT DURING 2nd STAGE of labor
cont’d
LABOR PROGRESS EVALUATION
 Evaluate the degree of descent and / or station every1 hour. Look for
extent of caput and degree of molding.
PREPARATION FOR DELIVERY
 Notify the labor ward staff that delivery is imminent.
 Take the woman to the delivery room (if it is a separate room).
 Make sure all the equipment for delivery and newborn care are
available at the delivery room.
 There should be a pre-warmed neonatal corner for neonatal care.

By Estela 3/25/2025
MANAGEMENT DURING 2nd STAGE of labor
cont’d
 The birth attendant should wash hands and wear complete personal
protection equipment (gloves, gown, apron, mask, cap and eye
protection).
 Sterile draping in such a way that only the immediate area around
the vulva is exposed.
 Perineal care: clean the vulva and perineum with antiseptics /tap
water (downward and away from the introitus). Wipe feces
downwards. Avoid routine vaginal cleansing.

By Estela 3/25/2025
MANAGEMENT DURING 2nd STAGE of labor
cont’d

ASSISTANCE OF SPONTANEOUS DELIVERY

 Goal : Reduction of maternal trauma, prevention of fetal injury and
initial support of the newborn.
 Perineal protection (hands on birth) Perineal guard to support
perineum is recommended during childbirth for reduction of perineal
trauma & facilitation of birth.

By Estela 3/25/2025
Assistance of spontaneous delivery

Episiotomy:
 Episiotomy is intended incision of the perineum.
 Its goal is enlargement of vaginal opening for birth.
 Routine performance of episiotomy should be avoided ( MOH,2021)
 Indications for episiotomy:
• threat for a perineal tear,
• perineal resistance for fetal head descent or
• presence of fetal/maternal indication for expedited delivery

06/25/2025 by Estela
Assistance of spontaneous delivery cont’d…

 Timing of episiotomy: when the presenting part distends the vulva 2-3
cms (unless early delivery is indicated).
• Biparietal stretches the vulval outlet or during crowning
Types of episiotomy
1. Medial episiotomy
2. Lateral episiotomy
3. Mediolateral episiotomy

06/25/2025 by Estela
Assistance of spontaneous delivery cont’d…

1. Medial episiotomy
 Incision begins at the fourchette, incises the perineal body in the
midline,and ends well before the external anal sphinicter is
reached.
 Incision length varies from 2 to 3 cm depending on perineal length

06/25/2025 by Estela
Assistance of spontaneous delivery cont’d…

2. Lateral episiotomy
 Incision starts from about 1 cm away from the center of the
fourchette and extends laterally.
 It has got many drawbacks including chance of injury to the
Bartholin’s duct.

06/25/2025 by Estela
Assistance of spontaneous delivery cont’d…

3. Mediolateral
 The incision is made downwards and outwards from the midpoint of
the fourchette either to the right or left.
 It is directed diagonally in a straight line which runs about 2.5 cm
away from the anus (midpoint between anus and ischial tuberosity).

06/25/2025 by Estela
Assistance of spontaneous delivery cont’d…

 Medio-lateral episiotomy is recommended because of its relative

safety from rectal involvement from extension
 Note that analgesia/anesthesia should be given before episiotomy
is performed and during repair.

06/25/2025 by Estela
Assistance of spontaneous delivery cont’d…

 Delivery of the head

 First there will be encirclement of the largest head diameter by
the vulvar ring – crowning
 The anus becomes greatly stretched, and the anterior wall of the
rectum may be easily seen through it.
 Then a gloved hand is used to support the perineum and the
other hand is used to guide and control the fetal head to avoid
expulsive delivery.

06/25/2025 by Estela
Assistance of spontaneous delivery cont’d…

 Delivery of the shoulders

 Following delivery of the fetal head, a finger should be passed
across the fetal neck.
 The fetus then undergoes external rotation bringing its bisacromial
diameter into the AP diameter of the pelvis
 Delivery of the trunk
 The trunk is delivered gently by lateral flexion.

06/25/2025 by Estela
Assistance of spontaneous delivery cont’d…
 Cord clamping
 Delayed umbilical cord clamping (not earlier than 1 minute
after birth) is recommended for improved maternal and infant
health and nutrition outcomes.(WHO,2018).
 Clamp the cord immediately if the baby is preterm, low birth
weight, neonatal asphyxia, Rh isoimmunized pregnancy or HIV.
(MOH, 2021)
 Clamp the cord 4-5 cm away from the umbilicus
 Take cord blood if indicated.(MOH, 2021)

06/25/2025 by Estela
 Third stage of labor
 The time interval between the delivery of the last fetus up to the
expulsion of the placenta.
 During this stage, there is a significant risk of hemorrhage. Therefore,
all mothers require close monitoring and routine prevention of
postpartum hemorrhage (PPH) through active management of third stage
of labor (AMTSL).
 If it lasts more than 30 min it is considered as retained placenta

(MOH,2021)
 Physiology of the third stage of labor

 Physiological management allows placental separation and

expulsion to occur spontaneously without intervention.
 This precludes the administration of oxytocic drugs.
 This process may take from fifteen minutes to one hour.

06/25/2025 by Estela
 Physiology of the third stage of labor

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

The uterine contractions detaches the placenta from the uterus

06/25/2025 by Estela
 Methods of separation

Schultz method Matthews Duncan’s method

 Separation begins centrally  separation starts at the edge

 retro placental clot is formed this may  No retro placental clot is found
further aid separation  trickling of blood seen
 Is associated with more complete  The placenta descends slipping
shearing of both placenta and sideways maternal surface first.
membranes and less blood loss  The process takes longer and is
associated with incomplete expulsion of
the membranes and a higher blood loss

by Estela 06/25/2025
 Physiology of the third stage of labour

Signs for placental separation

 small fresh blood loss
 lengthening of cord
 fundus becomes rounded and smaller

06/25/2025 by Estela
Physiology of the third stage of labor

2. Expulsion of the placenta

Allow the placenta and membranes to be expelled by

maternal efforts.
 Maternal positioning, such as squatting or sitting, by
utilizing the forces of gravity, will aid expulsion.

06/25/2025 by Estela
 Management of third stage

 Management of the third stage of labor may be expectant or active

 Expectant management refers to the delivery of the placenta without
any intervention
 Active management consists of early cord clamping, controlled cord
traction, and administration of a uterotonic agent

06/25/2025 by Estela
 Management of Third stage of labor

Expectant management
Involves waiting for placental separation signs
Allowing the placenta to deliver either spontaneously or aided by nipple
stimulation or gravity (World Health Organization, 2012)

06/25/2025 by Estela
 Active management of third-stage labor

 Active management of the third stage of labour consists of interventions designed

 to facilitate the delivery of the placenta by increasing uterine contractions and
 to prevent primary postpartum hemorrhage (PPH) by averting uterine atony.
 The usual components include: administration of uterotonic agents, controlled cord
traction and uterine massage after birth of the placenta, as appropriate
 The goal is to limit postpartum hemorrhage
(ICM/FIGO,2020)

06/25/2025 by Estela
 Active management of third-stage labor

 COMPONENTS OF AMTSL

1. Administer uterotonic medication within one minute of the

birth of the last baby.
2. Controlled cord traction.
3. Verification of uterine tone and if the uterus is not well
contracted, uterine massage
(MOH,2021)

06/25/2025 by Estela
 Active management of third-stage labor

1. Giving uterotonic agent

Palpate the abdomen and rule out the presence of an additional baby
Give oxytocin 10 units IM with in 1 minute of delivery of the baby
Oxytocin is preferred because it is effective 2 to 3 minutes after injection
has minimal side effects and can be used in all women

( MOH,2021)

06/25/2025 by Estela
Giving uterotonic agent

 If oxytocin is not available, administer other uterotonic agents

(within one minute of delivery):
 Carbetocin 100 micrograms IV or IM, or
Ergometrine 0.2 mg IM within 1 minute of the delivery or
Misoprostol 600 mcg oral

06/25/2025 by Estela
 2. Controlled cord traction ( CCT)

 In settings where skilled birth attendants are available, controlled

cord traction (CCT) is recommended for vaginal births if the 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. (WHO,2018)
 CCT has the advantage of reducing the risk of manual removal of the
placenta in some circumstances, and evidence suggest that CCT can be
routinely offered during the third stage of labor, provided the birth
attendant has the necessary skills.(cochrane database Syst Rev.2015)
06/25/2025 by Estela
 2. Controlled cord traction ( CCT)

Clamp the cord close to the perineum within 1-3 minutes after delivery or
after cord pulsation stops (either of the two which comes first).
Early cord clamping (< 1 min) is recommended if the neonate is asphyxiated
and needs resuscitation.
 Place the other hand just above the woman’s pubic bone and stabilize the
uterus by applying counter-pressure during controlled cord traction.
 Keep slight tension on the cord and wait for strong uterine contraction.

06/25/2025 by Estela
2. Controlled cord traction ( CCT)

With strong uterine contraction, gently pull the cord downwards to

deliver the placenta
Continue to apply counter-pressure on the uterus.
 If the placenta does not descend, wait until the uterus contracts and
repeat the controlled cord traction with the next contraction
 As the placenta delivers, hold the placenta in two hands and gently turn
it until the membranes are twisted.
( MOH,2021)

06/25/2025 by Estela
 Examination of Placenta

 Inspect both the placenta and fetal membranes for completeness

Examine fetal and maternal surfaces
Missing placental cotyledon or a membrane
If a portion of the maternal surface is missing or there are torn
membranes with vessels, suspect retained placental fragments

06/25/2025 by Estela
 Examination of Placenta

by Estela 06/25/2025
 Examination of Placenta

by Estela 06/25/2025
2. Controlled cord traction

 Never pull on the

cord without
pushing the uterus
up with the other
hand.

 CCT helps prevent

inversion of the
uterus

06/25/2025 by Estela
3. Uterine massage / checking of uterine tone
 Immediately check for contraction. If the uterus is soft, massage the
fundus of the uterus until the uterus is well contracted.
Assess uterine tone every 15 minutes for the first 2 hours after delivery.
If the uterus is atonic, massage the uterus.
Teach the woman how to assess uterine tone and massage her own
uterus.
Estimate and record blood loss.
(MOH,2021)

06/25/2025 by Estela
3. Uterine massage / checking of uterine tone
 Examine the woman carefully and repair any tears to the
cervix or vagina and repair episiotomy.
 Note that sustained uterine massage is not recommended as an
intervention to prevent postpartum hemorrhage in women who
have received a prophylactic uterotonic.(WHO, 2021)

06/25/2025 by Estela
Uterine massage / checking of uterine tone

A study conducted on the effect of uterine massage and emptying of

the urinary bladder on alleviation of afterpain among mothers in the
immediate post partum period; show that uterine massage and
emptying urinary bladder during immediate postpartum ware effective
in reducing the level of afterpains. Mothers should be encouraged to
use the methods as alternative techniques to relieve afterpains and
overcome the side effects of using analgesics.

(international journal of Africa nursing sciences.2021)

06/25/2025 by Estela
 Fourth stage of labor

 Fourth stage of labor is the first two hours after birth

It is the critical moments for both the mother and newborn
Close nursing observation and monitoring is necessary
This stage is a critical time for monitoring of vital signs and observe for blood
oss & uterine contractility and it is the time imitate post partum care.

06/25/2025 by Estela
post natal care

 Post-natal care is care that is provided to a mother and

newborn baby after delivery and within the first 42 days after
child birth.
CLASSIFICATION OF POSTNATAL CARE
1. Postpartum care: Care that is provided to a mother.
2. Postnatal care: Care that is provided to a newborn.

(MOH,2021)

06/25/2025 by Estela
 Immediate postpartum monitoring
Monitor mother every 15 min
 Measure and document BP, PR and temperature with in the first 2 hours.

• Check uterine tone

• Check for bleeding

• Check for pallor

(MOH,2021)

06/25/2025 by Estela
 Immediate postpartum monitoring

 Check for any perineal problem, inspect episiotomy site if done.

 Monitor urine output for 6 hours after delivery.
Encourage voiding of urine.
 Encourage for mobility / ambulation

(MOH,2021)

06/25/2025 by Estela
Immediate

postpartum monitoring
Counsel on breast feeding, encourage early initiation of breast
feeding
 Counsel on danger signs of the mother and newborn
Counsel on nutrition
 Advise on postpartum care and hygiene

(MOH,2021)

06/25/2025 by Estela
 Immediate postpartum monitoring

Check woman‘s supply of iron/folate and give 3 month‘s supplies.

 Advise on use of insecticide treated bed net
Give appropriate supportive care for mothers with stillborn or dead baby.
 Provide postpartum family planning based on counseling during ANC

(MOH,2021)

06/25/2025 by Estela
 Immediate postpartum monitoring
 world health organization recommend:
 Uterine tonus assessment for all women for early identification of
uterine agony
Routine postpartum maternal assessment for the first 24 hours starting
from the first hour after birth
healthy mothers and newborns should receive care in the facility for at
least 24 hours after birth.

(WHO,2018)

06/25/2025 by Estela
 Immediate postnatal monitoring

For the newborn

 Listen for grunting, look for chest in-drawing and fast breathing
Provide essential new born care.
 Warm baby by keeping mother and baby together, skin to skin
contact.
 Initiate breast feeding with in the first one hour.
(MOH,2021)

06/25/2025 by Estela
Immediate postnatal monitoring
Frequent observation of the baby
Check color, umbilical cord for oozing, sucking / feeding.
 Immunization with BCG, birth dose HBV and OPV0
Advise on cord care.
 Bathing should be delayed until 24 hours after birth. If this is not possible due
to cultural reasons, bathing should be delayed for at least six hours.(WHO,2018)

06/25/2025 by Estela
 management of fourth stage of labor

If heavy vaginal bleeding, palpate the uterus and manage as PPH
 If uterus not firm, massage the fundus to make it contract and expel any clots.
 If pad is soaked in less than 5 minutes, manage as bleeding after child birth.
If bleeding is from perineal tear, repair it

(MOH,2021)

06/25/2025 by Estela
 management of fourth stage of labor

If breathing with difficulty, grunting, chest in-drawing or fast breathing,

examine the newborn and manage as for asphyxia management
If feet are cold to touch or mother and newborn are separated:
• Ensure the room is warm, cover mother and newborn with a blanket
• Reassess in 1 hour. If still cold, measure temperature.
• If less than 36.50C, manage as for hypothermia management.

(MOH,2021)

06/25/2025 by Estela
 Immediate newborn care
Definition
immediate newborn care is the care given to the neonate after birth by
qualified personnel in the delivery room.
The care we give for most of the babies immediately after birth is simple
but very important to improve their survival and health.

06/25/2025 by Estela
 Immediate newborn care . . .

New born deaths

Globally, 2.4 million newborns died in the first month of life in 2020.
approximately a third of all neonatal deaths occurring within the first day after birth, and
close to three-quarters occurring within the first week of life.
Sub-Saharan Africa has the highest neonatal mortality rate in the world (27 deaths per 1000
live births) with of global newborn deaths, followed by central and southern Asia (23 deaths
per 1000 live births).
(WHO,2020)

06/25/2025 by Estela
 Immediate newborn care . . .
 A child born in sub-Saharan Africa is 10 times more likely to die in the first
month than a child born in a high-income country.
About 108,766 newborns die every year in Ethiopia.

According to EMDHS 2019, neonatal mortality rates were 33 deaths per 1,000
live births.
Causes of newborn deaths
Preterm birth, intrapartum-related complications (birth asphyxia or inability to
breathe at birth), infections and birth defects are the leading causes of most
neonatal deaths.[WHO,2020]
06/25/2025 by Estela
Immediate newborn care . . .
Children who die within the first 28 days of birth suffer from
conditions and diseases associated with lack of quality care at or
immediately after birth and in the first days of life
Significance of immediate new born care
47 % of total deaths among under five total in the first month of life,
are mostly preventable. [WHO and MCEE,2018]

06/25/2025 by Estela
Essential newborn care (ENC)

 Interventions in newborn care can be essential Newborn Care (routine)

or Basic Neonatal resuscitation
 Essential newborn care (ENC) is a package of basic care provided to newborns
to support their survival and wellbeing.
 ENC starts before birth (teaching of parents about the unborn child during
ANC) and extends to postnatal period.
 The initial steps in the care of the baby at birth, are similar for all babies .
(MOH,2021)

06/25/2025 by Estela
Essential newborn care (ENC)
Components of ENC at birth
 Prevent hypothermia.
 Observe for the first breath (spontaneous breathing).
 Cord and eye care.
 Provide vitamin k.
 Put the baby in skin to skin contact with the mother.
 Start exclusive breast feeding within one hour of life
 Measure newborn‘s weight.
 Vaccination of BCG, HBV and polio -0

06/25/2025 by Estela
 Essential newborn care (ENC)

Preparation for ENC during birth


Every delivery should be attended with the anticipation of need for

newborn resuscitation.
Personnel should always wash hands with soap and water and use PPE.


Keep the delivery room warm.
Prepare the newborn corner/ resuscitation area.

06/25/2025 by Estela
 Essential newborn care (ENC)
Turn on the radiant warmer until the baby is delivered.
Prepare functional self-inflating bag.
Prepare functional bulb suction or suction device with catheter.
Prepare stethoscope, clock and thermometer.

06/25/2025 by Estela
Procedures of ENC

Step 1: Dry and stimulate

 Deliver the baby on the mother‘s abdomen and dry the whole
body
 Stimulate by rubbing the back or flicking the soles of the feet.
 Let the baby stay in skin to skin contact on the mother‘s
abdomen.

06/25/2025 by Estela
 Procedures of ENC…

Step 2: Evaluate Breathing

 While drying and stimulating, check if the baby is breathing.
 If the baby cries or breathes well , continue routine essential newborn care.
 Normal breathing rate in a newborn baby is 30 to 60 breaths per minute.
 If the baby is not crying or breathing immediately cut the cord, call for help
and shift to the resuscitation corner.

06/25/2025 by Estela
Procedures of ENC…
N.B. Do not do suction of the mouth and nose as a routine.
 Do it only if there is thick meconium, mucus or blood obstructing the airway.
(WHO,2014)
The baby should not have any chest in-drawing or grunting.
Small babies (less than 2.5 kg at birth or born before 37 weeks gestation) may
have some mild chest in-drawing and may periodically stop breathing for a few
seconds.

06/25/2025 by Estela
Procedures of ENC…
While providing essential care; identify babies in need of
resuscitation according to the table below.
assessment Decision
Baby is crying No need for resuscitation or suctioning. Start
skin-to-skin contact and breastfeeding.

Baby is not crying but his chest is No need for resuscitation or suctioning. Start
rising regularly between 30 to 60 skin-to-skin contact and breastfeeding
times in a minute
Respiratory rate below 30 Start resuscitation immediately
Baby is gasping Start resuscitation immediately.
Baby is not breathing Start resuscitation immediately

06/25/2025 by Estela
Procedures of ENC…

Step 3: Cord care

Optimal cord care consists of the following:
 Clamping / tying the cord
 Cutting the cord
 Counseling on cord care:
Apply 4% chlorhexdine immediately after cutting the cord and continue
daily for 7 days.
 Watch out for complications

06/25/2025 by Estela
Procedures of ENC…
Step 4: Keep the newborn warm (Prevent
Hypothermia)
 Cover the baby‘s body and head
 Keep the newborn with the mother
 Support the mother to keep the baby warm by
placing skin-to-skin contact on her chest.
 Delay bathing for at least 24 hours

06/25/2025 by Estela
Procedures of ENC…
Step 5: Initiate breastfeeding in the first one hour
 Early initiation of breastfeeding with counseling for correct positioning.

Step 6: Administer eye ointment

 Give tetracycline eye ointment/drops within 1 hour of birth usually after
initiating BF.
Step 7: Administer vitamin K Intramuscularly (IM)
 1 mg for babies with gestational age of 34 weeks and above.
 0.5 mg for premature babies less than 34 weeks gestation

06/25/2025 by Estela
 Procedures of ENC…

Step 8: Weigh the newborn when it is stable and warm

Step 9: Record all observations and treatment provided in the
registers/appropriate.
Step 10: Immunization
BCG vaccinations .
Single dose of OPV at birth or in the two weeks after birth
HBV vaccination as soon as possible where perinatal infections are common

06/25/2025 by Estela
NEONATAL RESUSCITATION

by Estela 06/25/2025
1. Abnormal labor
2. Passage abnormality, contracted pelvis, soft tissue abnormality,
reproductive tract masses
3. Abnormalities of passenger, malposition, malpresentation, fetal
macrosomia, malformation
4. Non reassuring fetal HR
5. Obstructed labor
6. Induction and augmentation
7. Complication of 3rd stage of labor pph
8. Shoulder dystocia
9. Obstetrics shock
10. Cord prolapse
11. Uterine rupture
12. Preeclampsia
13. Instrumental delivery, vaccume forceps, vbac, cs
14. Tear
By Estela 3/25/2025
Neonatal resuscitation…
Birth asphyxia is the cause of one-quarter of all neonatal deaths globally.

Three to 5% of all newborns need resuscitation to initiate breathing. If

resuscitation is not done in a timely and effective manner, it will lead to

death or irreversible damage.

Many newborns who require resuscitation have no identifiable risk

factors before birth.

(WHO,2020)

06/25/2025 by Estela
Resuscitation…
Therefore, resuscitation must be anticipated at every birth, and preparation
must be made
Neonatal resuscitation is the process of reviving and stimulating a newborn
baby to breathe.
Proper breathing is essential for the baby's blood flow, circulation and body
temperature.
It is a lifesaving intervention for newborns who fail to initiate and maintain
spontaneous and adequate breathing at birth.

06/25/2025 by Estela
06/25/2025 by Estela
Golden rules of resuscitation

THE 3A’S:
1. Anticipation: Identify those newborns that are at high risk for birth
asphyxia.
2. Adequate preparation: Skilled manpower can undertake the steps of
resuscitation
3. Act on time: There should not be any delay in identifying newborns that
need resuscitation and action should be taken immediately.

06/25/2025 by Estela
PREPARATION FOR RESUSCITATION
 Change your gloves.
Tie and cut the cord first.
Tell the mother that her baby is having difficulty to breath and that you
are going to help the newborn. Tell her quickly but calmly.
Lightly wrap the baby in a warm dry towel or cloth.
 Leave the face and upper chest free for observation.
Immediately transfer the baby to a newborn corner which is warm,
clean and dry surface, under an overhead heat source.

06/25/2025 by Estela
Risk factors of neonatal resuscitation

Fetal compromise
Apgar score <5 at 1 minute
Meconium-staining of liquor
Urgent c/s
Elective c/s for
-Placenta previa
-Multiple birth
Vaginal breech delivery

06/25/2025 by Estela
Risk factors of neonatal resuscitation

Multiple pregnancy
Instrumental delivery(forceps or venous delivery)
Preterm delivery at <34 weeks gestation
Sever IUGR
Maternal insulin-dependent diabetes
Known serious fetal abnormality e.g diaphragmatic hernia, hydrops
fetalis

06/25/2025 by Estela
STEPS OF NEONATAL RESUSCITATION
Neonatal resuscitation can be done using the action plan developed by WHO.

► Dry the infant immediately

with a clean cloth.
► Keep warm by skin-to-skin
contact
Look for and covered.
 Breathing or crying Routine
 Good muscle tone or YEScare
vigorous movements
N
 Stimulate by rubbing
O the back 2
to 3 times.
 Suction only if had meconium Routine care and
Breath closely observe
stained liquor or the mouth or
breathing
nose is full of secretions ing

06/25/2025 by Estela
RESUSCITATION…
Not breathing or gasping
Transfer to newborn
resuscitation area. Breathi
►Position the head/neck ng well Observe
B closely if
slightly extended.
continues to
►Start positive pressure
breathe well
ventilation with mask and self-
inflating bag within 1 min of
birth *
►Make sure the chest is
moving adequately
After30–
60s
Check the heart rate (HR) with a stethoscope.

06/25/2025 by Estela
RESUSCITATION…
If HR ≥ 60/min If HR < 60/min
HR 60–100/min:  Chest compressions until HR ≥100/min
 Take ventilation corrective steps.
 Continue to ventilate at 40 breaths per min.  Give higher oxygen concentration.
 ConsiderC higher oxygen concentration.
 Suction, if necessary. If HR remains at < 60/min, consider:
 Reassess every 1–2 min.  Other ventilatory support.
HR > 100/min:  IV adrenaline.
 Continue to ventilate at 40 breaths per min.
 If breathing spontaneously.  If no HR for > 10 min or remains <60/min
 Stop ventilating when respiratory rate is >
for 20 min, discontinue
30 breaths per min.

by Estela 06/25/2025
Medications
Epinephrine ;
If HR remain less than 60bpm after 30 sec of compression
Via ETT or umbilical venous catheter
Dose-0.01-0.03mg/kg

NaHCO3
For metabolic acidosis
Only if ventilation is adequate
DOSE ;2mEq/kg IV

06/25/2025 by Estela
Medications

Naloxone
For respiratory depression 2ndry to maternal narcotic
administration within 4hrs of delivery
Dose; 0.4mg/kg IV
volume expansion
For hypervolemia
-saline
-ringer’s lactate

06/25/2025 by Estela
 Breast feeding
 All newborns, including low-birth-weight (LBW) babies who are able
to breastfeed, should be put to the breast as soon as possible after birth
when they are clinically stable, and the mother and baby are ready.
(WHO, 2018)
 Early initiation of breastfeeding: Breastfeeding within the first hour,
with counseling for correct positioning.(MOH,2021)
Exclusive breastfeeding means to feed the baby only the breast milk .

06/25/2025 by Estela
Benefits of early breast feeding
1.Colostrum is the first milk secreted from the breast and has many benefits
for the newborn.
 It is very high in vitamin A and antibodies, which protects the baby from
infection. It is often called the baby’s first “immunization.”
2. Early breastfeeding reduces the risk of postpartum hemorrhage for the
mother.
3. Skin to skin contact while feeding helps the baby to stay warm.
4. The more the baby sucks, the more milk the mother makes and produce
breast milk.

06/25/2025 by Estela
 Exclusive breast feeding
 Exclusive breastfeeding for the first 6 months is recommended throughout the
world because it helps a baby survive, grow and develop. (WHO,2018)
 According to EDHS 2019; exclusive breast feeding for the first 6 months is
59% per 1,000 live birth.
 But there is a contrary to WHO recommendations that babies should only
receive breast milk in the first six months. [Line E.2013]

06/25/2025 by Estela
Exclusive breast feeding…
A Norwegian study shows a link between vitamin B12 deficiency and
the delayed development of infants’ brains and nervous systems.
The quantities of B12 in breast milk, and how much of the vitamin the
infant has at birth, depend partly on whether the mother consumes
enough meat and fish.

• But after two to three months of nursing a child, concentrations of B12

in breast milk decline.

06/25/2025 by Estela
Benefits of breast feeding
 It is the healthiest way to feed a newborn.
Breast milk is a clean source of food.
Exclusive breastfeeding on demand provides all the nutrition a baby needs in
the first 6 months.
It provides nutrients ideally suited for growth and development.
it makes the immune system stronger.

06/25/2025 by Estela
Benefits of BF…
It is the easiest food for the baby to digest.
Strengthens the relationship between a mother and her baby. (Bonding and
attachment)
Breastfeeding delays the mother's return to fertility because of lactation.
Breastfed children perform better on intelligence tests, are less likely to be
overweight or obese and less prone to diabetes later in life. Women who
breastfeed also have a reduced risk of breast and ovarian cancers. [WHO,2018]

06/25/2025 by Estela
Benefits of BF…
 Breastfeeding helps to stabilize the baby’s temperature.
In a study done in Sitti Khadijah I Mother and Child Hospital of Makassar., those who gave
exclusive breastfeeding respondents baby were 100% in normal overall body temperature
in comparison to those who were not exclusively breastfed mostly 75.6%)
The statistical analysis results showed that there was an effect of breastfeeding with body
temperature in newborns 0–72 hr. (Gac Sanit. 2021)

06/25/2025 by Estela
Breast feeding counseling
Encourage mothers to breastfeed their babies :

Giving first breastfeed within one hour of birth

Early contact between mother and newborn enables breastfeeding
No prelacteal feeds or other supplement
No need for extra bottle feeds for normal babies
Correct positioning to enable good attachment of the newborn
Breastfeeding on demand
Psycho-social support to breastfeeding mother

06/25/2025 by Estela
Positions of breast feeding

There are a few different breastfeeding positions. these are 4 of the most
popular:
• Cradle hold

• Lying on side

• Laid-back nursing

• Rugby hold (or the ‘clutch’)

06/25/2025 by Estela
 Cradle hold
Sit in a comfy chair with arm rests, or a bed with
cushions or pillows around you.

1.lie the baby across the lap, facing to the mother

2.Place the baby's head on mother’s forearm nose

towards the nipple.

3.The hand should support the length of their

body.

4.Check to make sure the baby's ear, shoulder and

hip are in a straight line.

by Estela 06/25/2025
 Lying on side

This is a good position if a caesarean or

difficult delivery, or to feed in the middle of the
night.

1.The baby lies facing the mother (tummy to

tummy).

2.Put some cushions or pillows behind the

mother for support.

3.Tuck the arm the mother lying on under head

or pillow and use the free arm to support and
guide your baby's head to the breast.
by Estela 06/25/2025
 Laid-back nursing

Also known as "biological nursing"

is when the mother lie back in a comfortable semi

reclined position on a comfy sofa or bed

1.Lean back (but not flat) on a sofa or bed.

2.place your baby on front.

3.Their tummy should be resting on mothers

tummy – but if this is uncomfortable, lie them
to one side.

4.gently guide the baby to nipple.

by Estela 06/25/2025
 Rugby hold (or the ‘clutch

• Is a good position for twins as to feed them at the

same time, as well as caesarean babies.
1.Sit in a chair with a cushion or pillow along
the side.
2.Position the baby at the side, under arm, with
their hips close to mother’s hips.
3.baby's nose should be level with the nipple.
4.Support the baby's neck with the palm of hand.
5.Gently guide them to the nipple

by Estela 06/25/2025
Good Positioning

 The mother should be into a comfortable position Sitting up or Side-lying.

 Her back should be supported.
 The baby should close to the mother with both the head and the body turned to
face the breast.
 The baby is facing the breast with the baby’s nose opposite to the nipple.
 The baby’s whole body is fully supported.

06/25/2025 by Estela
 Signs of good attachment

The baby’s chin is touching the breast.

mouth is wide open.
The lower lip is turned outward.
more of the areola above the mouth than
below it.

by Estela 06/25/2025
 Breast feeding
Signs of good sucking
Slow deep sucks with some pauses. Frequency of feeding

Use both breasts.  Should not be less than 8 times in

The baby should emptying one
24 hours or about every 2-3 hours.
breast to get the rich hind milk before
If the baby is small (< 2,500 grams),
starting on the second breast.
wake the baby to feed every 3 hours.

by Estela 06/25/2025
 Psycho-social support to
Feed the Baby on Demand breastfeeding mother
Feed whenever the baby wants
With demand feeding, the mother’s milk
Successful breastfeeding
production adjusts to the baby’s needs, so
there is always enough milk. requires support for the
mother from the family
and health institutions.

by Estela 06/25/2025
Breast feeding guidelines

Globally (UNICEF, 2020)

 3 in 5 babies are not breastfed in the first hour of their life.
Nearly 2 out of 3 infants are not exclusively breastfed for the

recommended 6 months.
Less than two in three young children aged 12-23 months are

still breastfed during their second year of life or beyond..

06/25/2025 by Estela
Breast feeding guidelines

In Ethiopia there is an evidence that Exclusive breastfeeding in was

significantly lower than the global recommendations.
According to meta-analysis of 32 studies, The pooled prevalence of
EBF in Ethiopia was 59.3%. [Alebel et al. 2018]
WHO and UNICEF launched the Baby-friendly Hospital Initiative
(BFHI) to help motivate facilities providing maternity and newborn
services worldwide to implement the Ten Steps to Successful
Breastfeeding.

06/25/2025 by Estela
 Breast feeding guidelines
1. Critical management procedures
international code of marketing of breast-milk substitutes and relevant world
health assembly resolutions.
Have a written infant feeding policy that is routinely communicated to staff
and parents.
Establish ongoing monitoring and data- management systems.
2. Ensure that staffs have sufficient knowledge, competences and skills to
support breast feeding.

06/25/2025 by Estela
 Breast feeding guidelines
3. Discuss the importance and management of BF.
4.Facilitate immediate and uninterrupted skin to skin contact and support
mothers to initiate breastfeeding.
5. Support mothers to initiate and maintain breastfeeding and manage common
difficulties.
6.Do not provide breast fed newborn any food or fluids other than breast milk
unless medically indicated.

06/25/2025 by Estela
Breast feeding guidelines

7. Support mothers to recognize and respond to their infants’cues for feeding.

8. Enable mothers and their infant to remain together and to practice rooming
in 24 hours a day.
9. Counsel mothers to the use and risk of feeding bottles, teats and pacifiers.
10. Coordinate discharge so that parents and their infants have timely access
to ongoing support care.

06/25/2025 by Estela
 Reference
s
 FMOH, OBSTETRICS MANAGEMENT PROTOCOL, 2021

 WHO labour care guide: user’s manual. Geneva: World Health Organization;
2020

 Lavender T, Cuthbert A, Smyth RMD. Effect of partograph use on outcomes

for women in spontaneous labour at term and their babies. Cochrane
Database of Systematic Reviews 2018, Issue 8.

 Ayenew, A.A., Zewdu, B.F. Partograph utilization as a decision-making tool

and associated factors among obstetric care providers in Ethiopia: a
systematic review and meta-analysis. Syst Rev 9, 251 (2020).

By Estela
3/25/2025
 Article invitation

 Iravani M, Janghorbani M, Zarean E, Bahrami M. An overview of

systematic reviews of normal labor and delivery management. Iran
J Nurs Midwifery Res. 2015 May-Jun;20(3):293-303.
 Kauffman E, Souter VL, Katon JG, Sitcov K. Cervical Dilation on
Admission in Term Spontaneous Labor and Maternal and
Newborn Outcomes. Obstet Gynecol 2016; 127:481.
 Bugg GJ, Siddiqui F, Thornton JG. Oxytocin versus no treatment or
delayed treatment for slow progress in the first stage of
spontaneous labour. Cochrane Database of Systematic Reviews
2013, Issue 6.
 Lawrence A, Lewis L, Hofmeyr GJ, Styles C. Maternal positions
and mobility during first stage labour. Cochrane Database of
Systematic Reviews 2013, Issue 8.

By Estela
3/25/2025
 Any question please

THANK YOU !
By Estela
3/25/2025 106