NORMAL LABOR

Adrian Goenawan, M.D.

References

Cunningham, F. Gary, et al. Williams

Obstetrics, 24th Edition. McGraw Hill
Education, 2014.
 Definition of labor
Is a physiologic process that begins with
the onset of rhythmic contractions which
bring about changes in the biochemical
connective tissue resulting in gradual
effacement and dilatation of the cervix and
end with the expulsion of the product of
conception.
 Definition of labor
o The criteria for the diagnosis of labor include:
1. Uterine contractions (at least 1 in 10 minutes or 4
in 20 minutes), documented by direct observation
or electronically using a cardiotocogram.
2. Documented progressive changes in cervical
dilatation and effacement as observed by one
observer.
3. Cervical effacement of > 70-80%.
4. Cervical dilatation > 3cm.
 2 Requirements for the ideal management of
labor & delivery:

1. Birthing is a normal physiological process

that most women experience without
complication

1. Intrapartum complications should be

anticipated.
 Admission Procedures

• Early admittance is important

 Admission Procedures
A. Identification of Labor
• True labor • False labor
– Contractions occur at – Contractions occur at
regular intervals irregular intervals
– Intervals gradually – Intervals remain long
shorten
– Intensity gradually – Intensity remains
increases unchanged
– Discomfort is in the – Discomfort is chiefly in
back & abdomen lower abdomen
– Cervix dilates – Cervix does not dilate
– Discomfort is not – Discomfort is usually
stopped by sedation relieved by sedation
 Admission Procedures
A. Identification of Labor
• Diagnosis of labor ? – observe patient for a longer
period of time.
– General condition of mother and fetus
– Quality of contractions
– Degree of discomfort shown by the mother
– Status of fetal membrane; leakage
– Vaginal bleeding
 Admission Procedures
B. Electronic Fetal Heart Rate Monitoring
• High risk pregnancies – electronic FHR monitoring is
routine starting from admission.
• Low risk pregnancies – electronic FHR monitoring on
admission (fetal admission test). If normal,
intermittent monitoring for the remainder of labor.
• Preadmission evaluation by external electronic FHR
monitoring for 1 hour before discharging patient with
a diagnosis of false labor.
 Admission Procedures
C. Vital Signs & Review of Pregnancy Record
• BP, PR, RR, Temperature on admission
• Review pregnancy record to identify complication
 Mechanism of Labor
• Fetal lie
• Fetal presentation
• Fetal position
• Fetal attitude
Mechanism of Labor
Mechanism of Labor
Mechanism of Labor
 Admission Procedures
D. Vaginal Examination
• Warning: no IE when there is vaginal bleeding
• Procedure: gloved hand (sterile gloves)
– Avoid anal region
– Complete examination before withdrawing the fingers
– Limit IE especially in early rupture of membrane
 Admission Procedures
D. Vaginal Examination
• Cervical effacement
– Express in terms of length of cervical canal compared with
that of uneffaced cervix
• Cervical dilatation
– Average diameter of the cervical opening in centimeters
– Fully dilated cervix = 10 cm when baby is term
• Cervical position
– Posterior, midposition or anterior
 Admission Procedures
D. Vaginal Examination
• Level of the presenting part in the birth canal in
relation to the ischial spine
• Station 0 = presenting part at the level of the ischial
spine
• Centimeters above or below the ischial spine
• +5 = presenting part visible at the introitus
 Admission Procedures
D. Vaginal Examination
• At station 0 fetal head is engaged
• If the head is unusually molded, or if there is an
extensive caput formation, or both, engagement
might not have taken place even though the head
appears to be at station 0
• Clinical Pelvimetry
 Passage
Parameters Adequate Contracted
assessed
Sacral Promontory Not reached Easily reached
Curvature of Concave Straight or flat
sacrum
Sacrosciatic notch Admits 2 fingers < 2 fingers
Ischial spine Blunt Prominent
Bispinous Not reached by 2 Reached by 2
diameter fingers fingers
 Passage
Parameters Adequate Contracted
assessed
Pelvic sidewalls Parallel or Convergent
divergent
Pubic arch Obtuse angle Acute angle
Ischial tuberosities > Closed fist < Closed fist
 Admission Procedures
E. Detection of Ruptured Membranes
• Significance of membrane rupture
1. Possibility of cord prolapse and cord compression is
increased if presenting part is not engaged
2. Labor is likely to begin as soon as pregnancy is at or near
term
3. Intrauterine infection is more likely if patient is
undelivered 24 hours or more after membrane rupture
 Admission Procedures
E. Detection of Ruptured Membranes
• Procedure:
– Insert sterile speculum and observe pooling of amniotic
fluid in the posterior fornix or clear fluid is seen coming
out of the cervical canal.
 Admission Procedures
E. Detection of Ruptured Membranes
• Diagnosis:
1. Visualization of amniotic fluid – conclusive
2. Nitrazine test – fairly reliable
• test pH of vaginal fluid
• basis for the test
– vaginal secretions pH 4.5 – 5.5
– amniotic fluid pH 7-7.5
– (+) test pH above 6.5
 Admission Procedures
E. Detection of Ruptured Membranes
• Diagnosis:
– Nitrazine test – fairly reliable
• False positive
– Coexistent blood
– Coexistent semen
– Coexistent bacterial vaginosis
• False negative
– Scanty fluid
 Admission Procedures
E. Detection of Ruptured Membranes
• Diagnosis:
3. Arborization or ferning of vaginal fluid in membrane
rupture
4. Detection of alpha-fetoprotein in fluid found in vaginal
vault
5. Injection of dye into the amniotic sac by abdominal
amniocentesis (Evan’s blue, methylene blue, indigo
carmine)
 Admission Procedures
F. Laboratory Studies
• Hemoglobin, hematocrit
– save blood for blood type, screening & routine serology
– urine albumin for hypertensive patients
– screen for syphilis, hepatitis B & HIV if not previously done
Management of the 1st Stage of Labor
• Complete general PE as soon as possible after
admission
• Assess after history, PE and laboratory exams
are reviewed
• Plan of management based on assessment
 Management of the 1st Stage of
Labor
A. Monitoring fetal well being during labor

Low Risk High Risk

1st stage of labor At least every At least every

30 mins 15 mins
2nd stage of labor At least every At least every
15 mins 5 mins
Management of the 1st Stage of Labor
B. Uterine contractions – frequency, duration
and intensity
• Determine time of onset of contraction
• Determine intensity of contraction by the
degree of firmness of the uterus
• Note the time that the contraction disappears
 Management of the 1st Stage of Labor
C. Maternal Vital Signs
• Temperature, pulse rate, respiratory rate and BP at
least every 4 hours
• Temperature every hour if ruptured bag of water or if
borderline elevation

D. Subsequent Vaginal Examinations

• Every 4 hours to check progress of labor
Management of the 1st Stage of Labor
E. Oral Intake

F. IV Fluids
Management of the 1st Stage of Labor
G. Maternal Position During Labor
• No need to be confined to bed early in labor
• Laboring woman should be allowed the most
comfortable position in bed
• Lateral recumbent position
• Walking neither enhanced nor impaired active
labor
Management of the 1st Stage of Labor
H. Amniotomy
• Fetal head must be well applied to the cervix and not be
dislodged from the pelvis
• May rupture bag of water during a contraction
• If vertex not well applied to the lower uterine segment,
amniotomy by several membrane punctures using a gauge 26
needle under direct visualization using a vaginal speculum
• Assess fetal heart tone before and immediately after amniotomy
Management of the 1st Stage of Labor
H. Amniotomy
• Advantage – shorter labor
• Disadvantage – increased incidence of
chorioamnionitis

I. Urinary Bladder Function

• Inspect suprapubic area. If full, encourage patient to
void. Catheterize if unable to void.
• Avoid bladder distention because it can
1. Hinder the descent of the presenting part
2. Lead to bladder hypotonia and infection
Management of the 2nd Stage of Labor
• Full cervical dilatation
• Woman bears down; urge to defecate with descent of the
presenting part
• Uterine contractions – 1½ min duration, interval of 1 min.
• Mean duration
– Primi – 50 mins
– Multi – 20 mins
• Fetal heart rate monitoring
– Low risk – at least every 15 mins
– High risk – at least every 5 mins
Management of the 2nd Stage of Labor
• Cardinal Movement of Labor:
1. Engagement
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External Rotation
7. Expulsion
Cardinal Movement
Cardinal Movement
Cardinal Movement
Cardinal Movement
Cardinal Movement
Cardinal Movement
Cardinal Movement
Cardinal Movement
Management of the 2nd Stage of Labor
A. Maternal Expulsive Effort
• Bearing down – spontaneous or may need coaching
• Legs half flexed
• Take a deep breath as soon as contraction begins, hold the
breath and push as though straining. Discontinue when
contractions disappear. Rest in between contraction.
• With descent of the presenting part the perineum begins to
bulge and the overlying skin becomes stretch. The scalp
becomes visible through the vulvar opening.
Management of the 2nd Stage of Labor
B. Preparation for Delivery
• Dorsolithotomy position
• Legs in stirrups
• Vulvar & perineal cleansing
• Apply sterile drapes
• Scrubbing, gowning and gloving by birth attendant to
protect the woman from introduction of infectious
agents and to protect the health care provider
 Spontaneous Delivery
A. Delivery of the Head
• Crowning – encirclement of the largest head diameter
by the vulvar ring
• Perineum thins out
• Anus becomes greatly streched and protuberant and
anterior wall of the rectum is seen
• Episiotomy
 Spontaneous Delivery
A. Delivery of the Head
• Ritgen or Modified Ritgen Manuever
• “Hands poised” Method
 Spontaneous Delivery
B. Clearing the Nasopharynx
• Wipe face and aspirate mouth and nares after head is
delivered to prevent aspiration of amniotic fluid,
particulate matter and blood once the thorax is
delivered and the baby can inspire.
 Spontaneous Delivery
C. Delivery of the Shoulder
• Restitution (external rotation) indicates that the
bisacromial diameter has rotated into the AP
diameter of the pelvis
• Shoulders may spontaneously come out or sides of
the head are grasped with 2 hands and gentle
traction downward is exerted until the anterior
shoulder appears under the pubic arch
• Suction nasopharynx and check for nuchal cord
• Deliver posterior shoulder by upward movement
 Spontaneous Delivery
D. Nuchal Cord
• Determine if umbilical cord is encircled in the fetal
neck after delivery of the anterior shoulder
• If cord is loose, slip over the head
• If cord is tight, cut loop between 2 clamps
 Spontaneous Delivery
E. Delivery of the Rest of the Body
• Always follows the shoulders without difficulty
• If delayed, apply moderate traction on the head and
moderate pressure on the fundus
• Do not hook fingers in the axilla because it may injure
the nerves of the upper extremities and may lead to
transient or permanent paralysis
• Traction should be along the long axis of the baby. Do
not bend the babies neck
 Spontaneous Delivery
F. Clamping the Cord
• Apply 2 clamps placed 4-5 cm from the fetal
abdomen and cut
• Apply umbilical cord clamp 2-3 cm from the fetal
abdomen

– Timing of Cord Clamping

• After delivery, place the newborn at or below the
level of the vaginal introitus
• Clamp cord after thoroughly clearing the airway (30
sec)
 Lacerations of the Vagina &
Perineum
1st 2nd 3rd 4th
degree degree degree degree
Fourchette    

Perineal skin    

Vaginal mucosa    

Fascia   

Muscles of the perineal   

body
Anal sphincter  

Rectal mucosa 
 Episiotomy
• Purposes:
1. Substitution of a straight surgical incision is
easier to repair than a ragged laceration. Post-
op pain is less and healing improved.
2. Prevents pelvic laceration
 Episiotomy
• Recommendation is that episiotomy should
not be performed routinely because of
increased risk of 3rd and 4th degree laceration
and fecal and flatus incontinence.
 Episiotomy
• Indications:
1. Shoulder dystocia
2. Breech delivery
3. Forceps or vacuum extraction delivery
4. Occiput posterior position
5. Instances when failure to perform an episiotomy
will result in perineal rupture
 Episiotomy
• Timing:
– Done when the head is visible during a
contraction to a diameter of 3-4 cm.
– If done in conjunction with forceps delivery,
should be made after application of the blades.
 Midline vs. Mediolateral
Episiotomy
Type of Episiotomy
Characteristic Midline Mediolateral
Surgical repair Easy More difficult
Faulty healing Rare More common
Postoperative Minimal Common
pain
Anatomic results Excellent Occasionally
faulty
Blood loss Less More
Dyspareunia Rare Occasional
Extensions Common Uncommon
 Episiotomy
• Factors associated with increase risk of 3rd &
4th degree laceration
1. Nulliparity
2. 2nd stage arrest of labor
3. Persistent OP position
4. Mid or low forceps
5. Use of local anesthesia
6. Asian race
 Episiotomy
• Complications:
1. Wound disruption
2. Infection alone
3. Infection with dehiscence

• Timing of Repair
1. After placenta is delivered
 Episiorrhapy
• Hemostasis and anatomical restoration
without excessive suturing is essential for
success of repair
 Episiorrhapy
• 4th degree laceration
– Stool softener necessary
– Avoid enema
– Prophylactic antibiotics
 Episiotomy
• Pain after episiotomy and repair maybe due to
a large vulvar, paravaginal or ischiorectal
hematoma or perineal cellulitis
• Examine carefully if pain is severe or
persistent
• In the absence of complications oral
analgesics is given