NORMAL LABOUR

SN/TY (15TH JUNE 2020

LESSON 1
 A basic knowledge of physiology of normal pregnancy is
essential to understand the management of normal labour and
delivery.
The mechanism of labour will be discussed in another
module.
INTRODUCTION Labour is a physiological process which involves expulsion
of the fetus and placenta.
LABOUR itself is a clinical diagnosis with onset of regular,
intermittent uterine contractions which is associated with
progressive cervical effacement and dilatation accompanied
by descent of the fetal head (with vertex presentation).
 • At the end of this lesson you would be able to
1.2 LEARNING understand:
• The four stages of labour
OBJECTIVES • What is latent and active phase of labour
• Rate of cervical dilatation.
• Partograph charting and interpretation
 Conventionally there are THREE phases of labour i.e.
First stage, Second stage and Third stage.

1.3. THREE In order to ensure safety after completion of the third

AND FOUR stage, often we include the Fourth Stage of Labour
which is observation of the mother for ONE hour
PHASES OF after completion of Third Stage of Labour.
LABOUR
Others have extended this period to Four hours or
even longer so as to ensure mother and baby are safe.
STAGES OF LABOUR

First stage of labour

• Begins with regular uterine contraction and ends
with complete dilatation of cervix at 10 cm.
• The first stage is further divided into (i) Latent
Phase (ii) Active Phase
Second stage of Labour
• Begins from complete dilatation of cervix to
delivery of the fetus
Third stage of labour
• This the period after delivery of the fetus to
complete delivery of the placenta together with
membranes.
 Two phases are :
2.1.
MANAGEMENT
OF FIRST STAGE Latent phase
OF LABOUR

Active Phase
LATENT PHASE

• In this phase the patient perceives uterine

contractions which are regular associated
with softening and dilatation of the cervix.
• It is often difficult to determine precisely the
Latent phase Primigravida Multigravida
beginning of the latent phase and much of
(HOURS)
determination is based on patient’s history
and experience of the birth attendant. Average 8.6 5.3
Prolonged 20.0 14.0
• The latent phase may last 3-8 hours with
multigravidas having a shorter period
compared to primigravida
 Contractions become coordinated ,
stronger and efficient with time.

Cervix becomes softer, pliable and more

LATENT PHASE elastic .

The latent phase ends when the cervical

dilatation is 4 cm

Note that latent phase is not FALSE

LABOUR
II. ACTIVE • The active phase of labour has generally been
PHASE described when the cervical dilatation is 4 cm
associated with regular and progressive uterine
contractions which results in progressive effacement
and dilatation of the cervix
• Cervix becomes more responsive and dilation proceeds
rapidly
• Contractions are usually very strong and regular —
occurring every two to three minute
• Steady fetal descent begins in the later part of the active
phase with the greatest degree of descent near full
dilation
• Once descent begins it should be progressive
ACTIVE • Descent of less than 1 cm per hour in a primipara and 2 cm per
hour in a multipara is abnormal and investigation is indicated.
PHASE • Average active phase is 5.8 hours in primiparas and 2.5 hours in
multiparas.
• Current views in starting the partograph at 5 cm cervical
dilatation rather than 4 cm dilatation is based on evidence that
60 % women reach latent-active phase transition to 4 cm while
89% women reach this transition to 5 cm with no difference
between primigravida and multigravida.
• Conventional teaching is that the cervix dilates at a rate of 1
cm/hour in active phase of labour.
• There is a variation in this value in that primigravida take longer
at about 1.2 cm/hour while multigravida may dilate more rapidly
at 0.8 cm/hour
 Considering these differences, duration of
active phase in a primigravida is about 8
hours (average 5.2 hours).

ACTIVE PHASE
They are unlikely to labour over 18 hours.

In multiparous women active phase of

labour is about 5 hours (average 2.5 hours
) and should not exceed 12 hours.
 Time duration should not the only criteria for
making a diagnosis of delay in active phase
of labour
ACTIVE
PHASE : TIME
DURATION
The following factors need to be considered:
Changes in strength,
Cervical dilatation of
Descent and rotation duration, and
less than 2 cm in 4
of the fetal head frequency of uterine
hours
contractions
 • A better understanding of labour in otherwise
uncomplicated pregnancies has led practitioners to
observe labour for longer periods than those quoted as
ACTIVE PHASE long as the mother and fetus are well especially with
the use of regional analgesia and better maternal-fetal
monitoring
LESSON 2
INITIAL ASSESSMENT BY BIRTH ATTENDANT

If patients are brought into the delivery suite in established

labour after 4-5 cm cervical dilatation, they spend less
time in the delivery suite.
This reduces anxiety and pain, some extent.
The unfamiliar surroundings of the delivery suite should
be avoided by prior visits before the onset of labour.
ADVANCED
LABOUR
• Transfer to labour suite in
advanced labour
• Reduces anxiety and pain
• Shorter period spent in labour
suite
• Analgesia and role of the
accompanying person (like her
spouse) are matters to be
discussed prior to admission to Source:abmc.com.my
the delivery suite.
PARTOGRAPH

The partograph is a pictorial depiction of the progress of

labour and also includes fetal and maternal monitoring
parameters.

These include vital signs, urinalysis, assessing uterine

contractions i.e. intensity, duration, and frequency.

The fetal lie is determined and the descent of the fetal

head is stated in 5th above the pelvic brim.

The pelvic examination is performed FOUR hourly so as

to decrease the risk of infection taking aseptic measures
and recorded in the partograph.

Cervical dilatation and cervical effacement are

determined and plotted.

WHO Modified Partograph, 2013

POSITION TO BE TAKEN IN
DELIVERY SUITE:

• A mother should assume the position she

finds most comfortable
• Adoption of the upright position or
ambulation during first stage of labor may
be safe
• Considering the available evidence and its
consistency, it cannot be recommended as
an effective intervention to reduce duration
of the first stage of labor The results of an RCT ClinicalTrials.gov
Identifier: NCT03447015 (2019) is
awaited
 During labour mothers should
In women with no risk have:
factors, continuous CTG is • Family support or companionship
not indicated and intermittent • Intermittent auscultation of fetal heart
auscultation of the fetal heart after contraction for ONE minute at
would suffice. least at 15 minute intervals and the
findings should be recorded in the
partograph.

FETAL Continuous CTG is

recommended for: meconium
Apart from recording fetal
heart rate, maternal
MONITORING:
stained liquor, abnormal fetal
temperature is taken every
heart rate detected at
four hours, maternal pulse
intermittent auscultation,
and BP are taken hourly, and
augmentation of labour and if
uterine contractions are taken
the patient requests for such
half hourly.
monitoring.

Four hourly vaginal

examinations are done, more
frequent vaginal examination
must be justified.
LESSON 3
 • Active management of labour was introduced as a
measure to shorten labour and has been seen to shorten
ACTIVE
the first stage of labour and reduce febrile morbidity
MANAGEMENT but does not decrease the incidence of caesarean
OF LABOUR deliveries.
 • Organization of the system
• The patient and family are educated on the birthing process and the

TWO ASPECTS protocol the attending doctor is to follow.

• The value of emotional support is emphasized and provided in the
ARE MANAGED care of the mother in the labour suite.
IN ACTIVE • The process of care and outcomes of the deliveries are all audited so

MANAGEMENT as to improve quality and efficiency of intrapartum care.

• Clinical management
NAMELY • Patient selection is vital and only primigravida with no risk factors or
uncomplicated pregnancies are to undergo active management of
labour.
CLINICAL • Established labour

MANAGEMENT • Early amniotomy

OF ACTIVE • Note colour of liquor
PHASE • Oxytocin augmentation
CLINICAL MANAGEMENT
OF ACTIVE PHASE

• Strict diagnosis of established labour is made so as

to exclude those in latent phase of labour
• Early amniotomy is performed and colour of liquor
is ascertained together with presenting part and its
position. Early amniotomy reduces total labour by
about 50 minutes without increase in infection and
fetal heart abnormalities.
• Frequent evaluation and assessment of progress of
labour to detect labour dystocia. Oxytocin
augmentation is instituted if the labour progress is
slower than 1 cm/hour cervical dilatation.
 High dose oxytocin regimes are used in augmentation in such
cases beginning with 4-6 mIU /min increasing every 15 minutes
up to maximum of 35-40 mIU/min, trying to achieve frequency
of contractions of seven in 15 minutes.

CLINICAL Such regimes has been shown to result in more vaginal

MANAGEMENT deliveries without maternal and fetal compromise. Studies have
also shown lower maternal fever and reduction of neonatal
OF ACTIVE culture-proved sepsis.

PHASE
Epidural analgesia has been noted to prolong labour but is not a
contraindication.
LESSON
FOUR
5.1. PARTOGRAGH

• This is also termed PARTOGRAM.

• This chart records information about the
progress of labour, the condition of the
mother and her fetus.
• This is a legal document and should be
completely filled as the mother progresses.
Improved maternal and fetal outcomes
have been shown to be the result of
effective use of the partogram.
PARTOGRAM

• The alert and action lines are placed four hours apart and are used to make decisions on normal
and abnormal progress of labour. WHO developed an international agreed partogram which is
used for charting normal labour? It is also an effective tool for:
• i. Detecting failure to progress
• ii. Teaching
• iii. Pass over of labour progress between attendants
• iv. Audit of labour management
• v. Research of labour progress and complications
PARTOGRAM

• Women in established labour (cervical dilatation of 4 cm) should have a partogram initiated.
Should the patient be induced, the ALERT line is plotted with onset of active phase of labour.
• This line corresponds to cervical dilatation of 1 cm/hour.
• The ALERT line separates two groups of patients:
• Women with cervical dilatation equal to or greater than 1 cm/hour who are not likely to require
intervention of operative delivery
• Women with cervical dilatation slower than 1 cm/hour who may require intervention or operative
delivery.
WHO
PARTOGRAM
The WHO partograph begins only
in the active phase of labour, when
the cervix is 4 cm or more dilated
(see below).
However, it is a tool which is only
as good as the health-care
professional who is using it
PARTOGRAM

• The WHO Partogram does not differentiate between primigravida and multigravida in
labour.
• In summary, the PARTOGRAM provides objective data on which clinical decisions are
made. It also enhances communication between members of the team caring for the
patient in labour.
 WHO PARTOGRAM

A typical WHO PARTOGRAM used to chart labour is shown in

the figure. Take notice of the various sections of the chart from
top to bottom.
i. The top box shows the fetal heart rate where the heart rate
at 12 pm is 180 /minute.
ii. The second box shows AMNIOTIC FLUID colour charted
as clear © initially and becoming meconium (M) stained at 12
pm. Moulding of the fetal head is also recorded in this box
denotes as (0) (+) (++) etc. Moulding is graded from 0 to 3+. (0)
means no moulding, (1+) sutures are opposed (2+) sutures
overlap but reducible and (3+) sutures are overlapped and not
reducible Caput formation may also be recorded as none (0),
small caput ( 1+) , moderate caput ( 2+) and large caput ( 3+).
PARTOGRAM

iii. The third box relates to CERVICAL

DILATATION charted along the ALERT line with the
labour moving to the right to cross the ACTION line
by 12.30pm. This is a classic example of labour
progressing slower than the predicted 1 cm/hour.

iv. The decent of the fetal head is denoted by the

lower graph (with circles). There is no further descent
after 9 am. In such situations it is important to review
the vaginal findings and determine the presentation and
position of the head and also evidence of moulding.
These may indicate disproportion between the
fetal head and bony pelvis.
PARTOGRAM

v. The fourth box relates to how Uterine

Contractions are charted per 10 mins. .

vi. The various shades within the small boxes denote

intensity with the grey shading indicating
‘STRONG contractions”.

vi. The fifth box is for recording oxytocin if it used

for augmentation of labour.

vii. The sixth box is to chart fluid and drug

therapy and also maternal blood pressure and pulse
rates.

viii. The temperature and urine analysis are

charted in the lower two boxes respectively.
1.3.1. FETAL HEART RECORDING

• Note the fetal heart is recorded every 15-30 minutes.

Source: healthhub.sg
LESSON 5
 Both abdominal and vaginal examination is done every four hours in
the initial ACTIVE PHASE and the findings are plotted on the
cervicograph which is the section of the partogram representing
cervical dilatation.

It is begun when the patient is in active labour or established labour

with cervical dilatation of 4 cm.

EXAMINING
THE MOTHER Current thoughts are that we should begin the cervical graph at 5 cm.

IN LABOUR
This is plotted as (0) hour time.

The blue line denotes cervical dilatation of 1 cm/hour.

 The action line is drawn parallel to the alert line four
hours to the right.
If the cervical dilatation is less than 1 cm/hour a
repeat vaginal examination is done after TWO hours.
WATCHING FOR The DESCENT of the fetal head is also charted in the
Partogram/CERVICOGRAPH.
PROGRESS OF
It is denoted as fifths of the head palpable above the
LABOUR pelvic brim on abdominal examination.
The descent ranges from 0-5 i.e. 0/5, 1/5, 2/5, 3/5/,
4/5, 5/5.
The head is engaged when 2/5 or less is palpable per
abdomen.
1.4 DETERMINING CERVICAL DILATATION

• Before performing vaginal examination to determine cervical length and cervical

dilatation one should have an idea of length of one’s index and middle fingers.
• Figure 10.10 A B and C shows how cervical dilatation is estimated in cm after some
practice on model ( Diagram C). T
 ESTIMATING CERVICAL
DILATATION AT PELVIC
EXAMINATION

Cervical Index and middle finger breadth

dilatation
(CM)
1.5 cm On finger fits tightly through cervix
2.0 One finger fits loosely BUT cannot fit 2 fingers
3.0 Two fingers fits tightly inside cervix
4.0 Two fingers fir loosely with 1 cm gap between fingers
6.0 Middle and index fingers open 25-3.0 cm gap or 2cm of cervix palpable on both sides
of cervix
8.0 Only 1 cm of cervix still palpable on both sides of the cervix
9.0 Less than 1 cm cervical rim is palpable or is there is only an anterior lip of the cervix

Cervix is fully dilated and there is no cervix felt around the fetal head
10.0

Fig. 1: Moulded plastic models are available for training in estimating cervical
dilatation
CERVICAL EFFACEMENT AND DILATATION
MEMBRANE & LIQUOR

• The status of fetal membranes guides management .

• Colour of liquor once membranes rupture is noted.
• Risk of neonatal and maternal sepsis increases the longer the
membranes are ruptured.
• Spontaneous rupture of membranes may precede the onset of labour
( premature rupture of membranes).
• Alternatively membranes may be artificially rupture with an
amniohook.
• The figure below shows how an amniohook is used to rupture the
membranes.

Source: https://pregnancy.lovetoknow.com/wiki/Breaking_the_Water
 Liquor may be confirmed by
inspection of leakage through the
cervical os with vaginal speculum.
AMNIOTIC If this is not seen, fluid collecting in
FLUID the posterior fornix may be tested
with Nitrazine or pH tester.

Amniotic fluid will turn Nitrazine

paper dark blue as liquor is weakly
acidic.
1.6 RECORDING UTERINE CONTRACTIONS

• Figure 10.4 shows 5 vertical squares running across the partogram.

• Each square represents ONE contraction .

• Uterine contractions are timed for 10 minutes .

• If there are two contractions, then TWO squares are shaded.

• The pattern of shading represents the strength and duration of contractions.

Weak contraction are shaded with ‘dots’ lasting 20-40 seconds .
• Line shading is for moderate contractions lasting 20-40seconds and dark
shading is for strong contractions lasting > 40 seconds.
• Aim is to achieve 5 strong contractions over 10 minutes.
OXYTOCIN

• Oxytocin may be infused as an

induction agent or , more commonly
for augmenting labour so as to
achieve effective uterine
contractions.
• The rate of infusion should be
recorded .
• The table shows the dose infused in
units/ 500ml of intravenous fluids.
1.8. MATERNAL BP/PULSE AND INTRAVENOUS FLUID INFUSION

• These are recorded in the lower table of the partogram ( Fig. 10.6).
• All medication prescribed and administered to the patient are recorded in this section. It is
also important to record the amount of fluid administered.
• The last section in the partogram is for recording the maternal temperature ( every 4
hours) and urine analysis for protein and ketones. The volume of urine passed are also
recorded in the respective column.
1.9 DETERMINATION OF STATION

• Station is the degree of descent of the presenting part which is the lowermost
portion. An arbitrary line along the ischial spines forms the reference point for
determining station.
• When the presenting part is above this line a negative number is given while a
positive number is given for that below the line (ischial spine).
• When the presenting part is at the level of the ischial spine it is recorded as (0).

• When it is recorded as (+2) it means the presenting part has passed the level of
ischial spine for a distance of 2 cm .

Fig. 2: Station is ( - 3 )- above the level of the ischial

PROGRESS OF LABOUR
SHORT ANSWER QUESTIONS

• Give reasons why pelvic examination is avoided more frequently than FOUR hours
• What observations are done to assess normal progress of labour after labour is
established?
CHECK POINT: ANSWER THE FOLLOWING
QUESTIONS
• Why is pathophysiology behind meconium stained liquor ?
• Define station
• What part of the fetal skulls is ‘vertex’ ?
• How do you define ‘station’ at vaginal examination in first stage of labour?
• What is the clinical significance of finding a large caput and excessive moulding in
the course of first stage of labour?
LESSON 6
 • Summary point:
MANAGEMENT
• The second stage of labour begins from FULL dilatation
OF SECOND
of the cervix ( 10 cm) to delivery of the fetus.
STAGE OF • The second stage is complete with the expulsion of the
LABOUR fetus.
 When the second stage is reached fetal heart monitoring is
increased to every 5 minutes.
• Two phases are described in the second phase of labour:
PHASES OF 2ND • Propulsive phase
STAGE OF • Expulsive phase

LABOUR • Propulsive phase begins with full cervical dilatation up to the

descent of the presenting part to the pelvic floor .
• Expulsive phase ( active phase) is indicated by maternal bearing
down effort which ends with delivery of the baby
SECOND STAGE OF LABOUR

SECOND STAGE DESCRIPTION

Propulsive phase Full dilatation of cervix
Absence of expulsive contractions
Expulsive phase Onset of active second stage
1. Fetal head is visible
2. Expulsive contractions with full dilatation of cervix
3. Active maternal effort to push
DURATION OF SECOND STAGE OF LABOUR

• Time-duration is often quoted for the second stage to guide management.

• The NICE guidelines state that a delay in expulsive or active phase is present when it
exceeds TWO hours in primigravida.
• In parous women delay is suspected when the duration exceeds ONE hour into the active
phase .
• Most parous women are expected to deliver within TWO hours.
ACTIONS TO BE TAKEN SECOND STAGE OF LABOUR

• If feasible the patient should assume any position she is comfortable with.
• Avoid placing her in supine or semi-supine position.
• If pushing during contractions is ineffective, the following is advised:
• Provide support and encouragement
• Change position
• Empty the urinary bladder

• When the second stage is prolonged review uterine contractions, assess the mother and fetus for causes
of delay
• Fundal pressure should be avoided as it does not shorten second stage .
SEEKING CONSULTATION WHEN SECOND STAGE
IS PROLONGED
• Literature states that operative deliveries are higher in second stage of labour, hence a
senior or experienced colleague should be called in for re-evaluation of the situation
including exclusion of feto-pelvic disproportion.
• There is an increased risk of maternal morbidity, operative delivery, postpartum
haemorrhage , vaginal and perineal tears and infections especially in primigravidas.
MONITORING • ½ hourly BP/pulse

DURING • 15 min. uterine contractions

SECOND • 5 min. fetal heart rate monitoring-intermittent auscultation for ONE minute
after each contraction, compare with maternal pulse
STAGE • Review of maternal position, hydration, pain relief , coping strategies
• Frequency of bladder emptying
• Assessment of progress
• Maternal behaviour
• Effectiveness of pushing
• Fetal well being
• Fetal position,station
• Need for further vaginal examination
• Oxytocin augmentation may be indicated if uterine contractions are
inefficient
• Routine episiotomy is NOT done during spontaneous delivery
LESSON 7
NORMAL VAGINAL BIRTH

• Mechanism of Labour

• In normal vaginal birth with a cephalic presentation, the fetus goes through specific sequence
of manoeuvers as it traverses the birth canal. There are SIX phases to this process i.e.
• Engagement
• Descent of head and flexion
• Internal rotation
• Delivery by Extension
• Restitution
• Kindly watch this video before proceeding with the lesson
• https://elearning.rcog.org.uk/mechanisms-normal-labour-and-birth/mechanism-normal-la
bour-and-birth
ENGAGEMENT

• During engagement the fetal head

enters the pelvic inlet in a transverse
position with the face facing one of
other of the mother’s hips.
• The position is then stated as LOT
or ROT .
ENGAGEMENT

• The head is said to be engaged when the biparietal diameter (measuring ear tip to ear tip
across the top of the babys head, see Figure above) descends into the pelvic inlet, and the
occiput is at the level of the ischial spines in the mother’s pelvis
DESCENT OF HEAD & FLEXION

• With further propulsive action of uterine contractions the head descends .

• Fetal descent describes the progressive downward movement of the fetal presenting part
(commonly the head) through the pelvis.
• Flexion occurs during descent and is brought about by the resistance felt by the baby’s
head against the soft tissues (pelvic floor) and bones of maternal pelvis.
• Flexion occurs at the level pelvic floor muscles in mid-pelvis so as to present the
smallest diameter (suboccipitobregmatic ).
INTERNAL ROTATION, CROWNING AND
RESTITUTION
• At this point of resistance offered by the pelvic floor muscles, the fetal head undergoes internal
rotation (90 degrees) so as to present in the occipito-anterior position with the face towards to the
rectum. This typical rotation is s to accommodate the change in diameters of the maternal pelvis.
• The fetal head will then ‘crown’ with fetal head bowed , chin in chest, with the back or crown
leading the way through the birth passage , until the back of its head presses against the pubic bone ,
chin leaves the chest and extension of the head occurs. The rest of the head then passes the birth
canal.
• Restitution occurs as the fetal head turns 45 degrees to resume the normal relationship with the
shoulders as shown in the diagram below.
CROWNING,
EXTENSION AND
RESTITUTION

SOURCE: (Source: WHO, 2008, Midwifery Education Module: Managing Prolonged and
Obstructed Labour, 2nd edn., Figure 1.5, page 23
EXTERNAL ROTATION

• External rotation follows as the shoulder ‘repeats’ the cockscrew movement of the
head .
• This manoeuvre is not seen by the attendant.
• A quick overview of the birthing process with the corresponding changes in the position
of the head is shown in the diagram below.
MECHANISM
OF LABOUR
ASSISTING DELIVERY OF THE HEAD AND DELIVERY OF THE BABY

• As the head crowns the gloved hand should support the head .(Fig.1 )
• With further descent ( with uterine contractions) and distension of the perineum, the
fingers of the right hand are placed on the head while the left hand is placed below the
head to protect the perineum from tearing. (Fig 2)
2ND STAGE …

• With delivery of the head at the next contraction, protected by the right hand from sudden
extension, the fingers of the left hand leaves the perineum to check for any cord around
the baby’s head.
• If this is present and is loosely applied, it is gently slipped over the head.
• If tight, it may have to be divided between metal clamps before complete delivery of the
head ( Fig. 3)
• At this stage, the head will , in most instances restitute and rotate externally signifying the
anterior shoulder is ready to be borne. (fig. 4)
• The hands are now placed parallel to the baby’s head, avoiding any pressure to the face
and neck. ( Fig. 4,5,).
• With gentle downward and outward traction, the anterior shoulder is delivered. (Fig 6) .
• With the back of the axillary fold visible at this stage, lift the baby out of the birth canal
to deliver the posterior shoulder. (fig. 7)
• At this stage look for the axillary fold of the posterior shoulder and move the right hand
from below to grasp the shoulder and chest to enable lifting the baby out of the birth
canal.(Fig 9)
• After this stage the whole baby is delivered by moving the upper hand ( left) towards the
baby’s feet enabling grasping of the ankle ( Fig. 10,11, 12)
SPECIFIC • Apart from continued monitoring the fetal heart the birthing
attendant is required to anticipate complications during the
MEASURES second stage.
TO BE • The common complication is delay in the second stage and

TAKEN measures must be taken to determine cause for such delay so as

to institute suitable interventions which include:
DURING 2ND • Correction of hydration
STAGE OF • Position change
LABOUR • Emptying the bladder
• Analgesia
• Encouragement to push
• Augmentation with oxytocin
Steps that are essential to bear in mind during 2nd stage of labour are :
 

Place sanitary pad over perineum Sanitary pad placement at the Support of perineum and upper hand
Empty urinary bladder during conduct of labour to support perineum prevents faeces from the in the head also maintains flexion of
the perineum and avoid perineal tears rectum soiling the fetal head the head

Keep in mind risk of shoulder

dystocia when there is difficulty in
With fetal crowning , the vaginal Consider suction of meconium delivering the anterior shoulder
outlet is stretched , the fetal head Check for nuchal cord and attend to it stained liquor in oropharynx, if (turtle neck sign, fetal head does not
delivery must be controlled so as to , if present. noted before complete delivery of the undergo normal rotation, head
avoid sudden extension of the head. body retracts). Be prepared to perform
essential manoeuvres should
shoulder dystocia be diagnosed.
SUMMARIZING THE
DELIVERY OF BABY AND
PLACENTA
Source: wikipedia: childbirth
LESSON 8
 By definition, the third stage of labour begins
immediately after the delivery of the baby
and ends with delivery of the placenta.
MANAGEMENT
OF THIRD
STAGE OF
LABOUR The third stage of labour may be conducted
as :
Physiological
Active management of 3rd
management of 3rd stage
stage of labour
of labour
 In active management the following are done,
with the primary aim of preventing postpartum
haemorrhage , which is one of the leading
ACTIVE causes of maternal mortality in Malaysia.
MANAGEMENT • Administration of uterotonic agents after
delivery of the baby
OF 3RD STAGE OF
• Expulsion of the placenta by controlled cord
LABOUR traction
• Uterine massage after expulsion of the placenta
CONDUCT OF 3RD STAGE OF LABOUR

• Once the baby is delivered the attendant should palpate the uterus and exclude another
fetus.
• Then Oxytocin 10IU IM is administered.
• If an IV Line is present, IV Oxytocin may be given.
• Administer oxytocin slowly over 60 seconds.

• Then apply TWO clamps ( forceps) roughly in the middle of the cord leaving a 3cm
space . Divide the cord between clamps.
• Delay of one minute in clamping is advised.
ACOG, 2017
Number 684 (Replaces Committee Opinion Number 543, December 2012)
 If controlled cord traction is decided as opposed to
EXPECTANT ( physiological ) management of 3rd
CONTROLLED stage, wait for signs of placental separation:

CORD • The uterus contracts and rises

TRACTION • The cord lengthens

• A small gush of blood occurs
CONTROLLED CORD
TRACTION
• In controlled cord traction (CCT), one
hand is placed above the pubic bone
( feeling the uterus and supporting it at all
times) while the other hand keeps tension
on the cord, using the clamp to hold on.
• Pulling the cord is not advisable.
• Await for the next uterine contraction and
gently give downward traction to deliver
the placenta. (Fig. 10.19)

Source: https://www.glowm.com/pdf/AMTSL_Wallchart_Single_FINAL.pdf
 The WHO 2012 guidelines no longer recommends controlled cord traction
as the primary mode of delivery of the placenta but states that it is an
OPTION as adverse events like uterine inversion has been seen in
inexperienced hands.

CONTROLLED In settings where skilled birth attendants are available, controlled cord
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
TRACTION reduction in the duration of the third stage of labour as important.

Often controlled cord traction is employed during caesarean delivery

WHO recommendation on controlled cord tracti17 February 2018

POSSIBLE ADVERSE EFFECTS OF ACTIVE MANAGEMENT OF 3 RD
STAGE OF LABOUR

• Effects due to utero-tonic agents ( ergot alkaloids)

• Hypertension
• Nausea
• Vomiting

• Risk of retained placenta

• Neonatal risk of early cord clamping i.e. iron deficiency anemia, intraventricular
haemorrhage and hypotension
 Oxytocin ( Oxytocin 10 IU or Syntometrine is administered IM or IV
( preferred during caesarean delivery) just after delivery of the anterior
shoulder of the baby or expulsion of the placenta.

Syntometrine contains Oxytocin 5 IU and Ergometrine 0.5 mg .

UTERO-TONIC
AGENTS IN 3RD • The time of onset of uterine response is shorter than IM Ergometrine and duration of action is
several hours. Though more effective than oxytocin, its use is restricted in view of adverse profile
which include hypertension, nausea and vomiting.
STAGE OF
Misoprostol, a synthetic prostaglandin E1 derivative, may be administered in a
LABOUR single ORAL dose (600 µg misoprostol, oral or sublingual).

Both WHO and the International Federation of Gynaecology and Obstetrics

recommend its use in the third stage of labor to prevent PPH when a sterile
syringe and trained midwife were absent. It is less effective than Oxytocin 10
IU IM.
UTERINE FUNDAL MASSAGE AFTER PLACENTAL EXPULSION

• Uterine fundal massage after placental expulsion provides uterine contractions by stimulating endogenous
prostaglandin secretion.
• This method was recommended in the 2007 WHO guidelines, and was described as optional for the active
management of the third stage in the 2012 updated guidelines.
• One study by Chen et al , involving 2340 pregnancies, showed that the addition of fundal massage to
oxytocin did not decrease PPH
• Cochrane Review ( 2013) found inconclusive evidence for its benefit after oxytocin has been administred

Abdel-Aleem H, Abdel-Aleem MHofmeyr G, A https://www.cochrane.org/CD006431/PREG_uterine-massage-preventing-postpartum-haemorrhage

 The duration of 3rd stage of labour is
usually LESS than 30 minutes.
DURATION OF
3RD STAGE OF
LABOUR Prolonged third stage is diagnosed if the
duration exceeds 30 minutes with active
management of the 3rd stage and 60
minutes with expectant management.
ACTIVITY

• Kindly see the animation of delivery of placenta and manual removal of placenta.
• You are to enter these ( with links) in your log book .

• https://elearning.rcog.org.uk/mechanisms-normal-labour-and-birth/practical-manag
ement/third-stage-labour-0
 • 3rd stage of labour:
CONDUCT OF https://www.youtube.com/watch?v=WvKSKTahCss
THIRD STAGE
• Kindly watch this video
AND
• Discuss with your preceptor about physiological and
INSPECTION OF
active management of 3rd stage of labour ( delivery of
PLACENTA placenta)
SHORT ANSWER QUESTIONS

• Briefly distinguish active management of third stage of labour from physiological

management.
• What are the anticipated risks of active management of third stage of labour?
• In which maternal condition would you prefer oxytocin over syntometrine?
LESSON 9
CONCLUSIONS
FOLLOWING DELIVERY OF THE PLACENTA

• Massage of the uterus helps it to contract and reduce postpartum bleeding.

• Assess the APGAR score of the newborn and initiate breastfeeding
• Check perineum for haematoma and if an episiotomy has been done , it will need repair.
• Check the placenta for completeness and weigh the placenta.
• After mother and baby are determined to be well attend to documentation of events of labour i.e. duration of
each stage of labour, oxytocics and analgesics administered, status of mother and baby, weight and other
measures of the baby, time of delivery, ARM, episiotomy, blood loss, and any interventions done.
• Take vital signs of the mother .
3.4.5 TAKE HOME MESSAGES

• a. Uncertain if there is a difference between active and expectant management of 3 rd

Stage of Labour
• b. Delayed cord clamping is preferred
3.4.5 TAKE HOME MESSAGES

• a. Uncertain if there is a difference between active and expectant management of 3 rd Stage of

Labour
• A Cochrane Review ( 2019 ) summarises the reduction of PPH in those who bleed more than 1000
ml.
• In women at low risk of excessive bleeding, the authors summarise that it is uncertain whether
there was a difference between active and expectant management for severe PPH or maternal Hb
less than 9 g/dL (at 24 to 72 hours).
• Considering the facts , controlled cord traction and fundal massage are done in selected cases and
done only by experienced birth attendants
3.4.5 TAKE HOME MESSAGES

• b. Delayed cord clamping is preferred

• Early cord clamping reduces the risk of bleeding after birth (postpartum haemorrhage).
One review of 15 randomised trials (n= 3911 women and infant pairs) did not show
significant difference in postpartum haemorrhage rates when early and late cord clamping
(generally between one and three minutes) were compared
ADVANTAGE OF DELAYED
CLAMPING OF THE CORD

• Delayed cord clamping in health infants is

recommended as it has several
advantages:
• Higher birth weight
• Early haemoglobin concentration
• Increased iron reserves up to six months
after birth
• But there is a small additional risk of
neonatal jaundice requiring phototherapy
REFERENCES:

• Cecily M Begley, Gillian MI Gyte, Declan Devane, William Mc Guire et al, Active vs, expectant management of third
stage of labour. Cochrane Systematic Revie. 13, February 2019.
• https://doi.org/10.1002/14651858.CD007412.pub5
• WHO recommendations of the latent and active first stage of labour. 15 Februaury 2018.
• WHO recommendations on progress of the first stage of labour: application of slow-yet normal cervical dilatation
patterns for labour management.
• 15 February 2018
• https://extranet.who.int/rhl/topics/preconception-pregnancy-childbirth-and-postpartum-care/care-during-childbirth/care
-during-labour-1st-stage/who-recommendation-definitions-latent-and-active-first-stages-labour-0
• WHO recommendations Intrapartum care for a positive childbirth experience, 2018.
https://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf;jsessionid=7E800B590A164DC7FC
879E73B480D6FC?sequence=1
VIDEO LINKS

• In watching the videos you may find the procedures and conduct may vary from the
LESSONS seen in this Module. It is important to discuss variations from what is
conventionally described in the lessons with your preceptors so as to be aligned to current
clinical practice.
• The source of these videos are indicated in the links-these are duly acknowledged. All
videos are for internal use ( education) and not for commercial purposes.
VIDEO LINKS

• Conduct  vaginal delivery : https://www.youtube.com/watch?v=ROCTb1lKBVY

• Narration of conduct of labour :https://www.youtube.com/watch?v=w0iDfcAYZWc
• Vaginal   delivery https://brooksidepress.org/brooksidepress/?page_id=151