undergraduate course lectures in Obstetrics&Gynecology prepared by Dr Manal Behery.Professor of OB&GYNE Faculty of medicine Zagazig University

1. Management of Normal Labor

2. Management on Admission

3.  Full history:
1-Complete obstetric history.
2-History of the present pregnancy.
3-History of the present labor ( e.g.: labor pains, vaginal
bleeding, gush of fluid& fetal movement).

4.  General Examination:
Vital signs ( pulse , B.P. , temperature,…etc.)

5. 2-Abdominal examination


6. Fundal level

7. Fundal grip

8. Umbilical grip

10. Second pelvic grip

11. Palpation

12. Auscultation

13. 3-Pelvic examination:
 Cervix : dilatation (c.m.), effeacemet (%) ,
position & consistency.
 membrane: intact or ruptured ( if ruptured
exclude cord prolapse).
 -Amniotic fluid ( after R.O.M.): either clear
, meconium stained or blood stained.
 -Presenting part , position ,station &
moulding.
 -Assessment of pelvic capacity

14. Cervical dilatation
 It is the surest way to assess progress of labour

15. Assessment of pelvic capacity

19. Partograph
 a graphical record of the
observations made
of a women in labor
 For progress of labor and
conditions of the mother and
the fetus

20. History Of Partogram
 Friedman's partogram


21. latent phase
 Starts from onset of labour until the cervix reaches 3
cm dilatation
 lasts 8 hours or less
 Contractions at least 2/10 min contractions
 each lasting < 20 seconds

22. Active phase :
 The cervix should dilate at a rate of 1 cm / hour
or faster
 Contractions at least 3 / 10 min each lasting < 40
seconds

23. Closed cervix vs effeced vs dilated Cx

24. Components of the partograph
 Part 1 : fetal condition ( at top )
 Part 2 : progress of labour ( at middle )
 Part 3 : maternal condition ( at bottom )

25. Part 1 : Fetal condition
Recording fetal heart rate

26. Membranes and liquor
Dilated cervix with bag of fore water
I: intact
C : clear
M : muconium
B : blood stained

27. Molding the fetal skull bones
 . Increasing molding with the head high in the pelvis is an ominous
sign of Cephalopelvic disproportion.
 separated bones . sutures felt easily……….O
 bones just touching each other……………..+
 overlapping bones …………… …………...++
 severely overlapping bones ( notable ) ……..+++

28. Part 2 – progress of labour
. Cervical dilatation: it is divided into a latent phase and an active
phase
 Descent of the fetal head
 Uterine contractions

29. Descent of the fetal head
 The rule of fifth BY abdominal examination

30. Assessing descent of the fetal PV;
0 station is at the level of the ischial spine

32. Engagment

33. Normal progress in labor

34. Alert line ( health facility line )
 The alert line drawn from 3 cm dilatation
represents the rate of dilatation of 1 cm / hour
 Moving to the right or the alert line means
referral to hospital for extra care

35. Action line ( hospital line )
 The action line is drawn 4 hour to the right of
the alert line and parallel to it
 This is the critical line at which specific
management decisions must be made at the
hospital

36.  When labor goes from latent to active phase , plotting of the
dilatation is immediately transferred from the latent phase
area to the alert line

37. Normal labor progress
 At addmision
 Then after 4h

38. Abnormal labor progress

39. Recording uterine contraction

40. PART 3:Recording of maternal
condition

41. -


42. Management of the first
stage

43. Ambulating and position in labor
 Walking may be more comfortable than being supine
during early labor
 The left lateral position keeps the uterus off the
inferior vena cava; this prevent (supine hypotensive
syndrome)

46. Evaluation of fetal well-being
 Measurement of the fetal heart rate
 By hand-held Doppler, or By CTG

47. Late in first stage
 patients may report the urge to push.
 This may indicate significant descent of the fetal
head with pressure on the perineum.

48. Management of the second stage

49. Diagnosis of the onset of the 2nd stage
 Feeling a desire to evacuate the bladder or
rectum
 Reflex desire to bear down during
contractions.
 The uterine contractions are more prolonged
and vigorous.
 Full cervical dilatation
(the surest sign).

50. Transport the lady to the delivery
room.
 . (A)Position: - Lithotomy position or
Dorsal position.
 (B)Paint vulva & perineum with
antiseptic solution.
 (C)Apply sterile leggings and towels
 (D)Evacuate the bladder by catheter (if
not evacuated before)

51. Litotomy positionVS dorsal position

52.  F)Ask the lady to bear down during
uterine contractions and relax in between.
 J). V oxytocin drip in glucose solution 5%
may be given.

53. 4)The main task of the
obstetrician is to prevent
perineal lacerations, how?

54. When the labia start to
be separated by the head,
put a sterile dressing on
the perineum
 and press on it during
 uterine Contractions.

55.  A. Support of the perineum till
crowning occurs

56. Crowning: The B.P.D passes through the
vulval ring during contraction and the head
does not recede inbetween uterine
contractions.

57. Episiotomy
 when the perineum is maximally stretched
and about to tear

58. Problems arising from Episiotomy
58
 Pain
 Edema
 Bleeding
 Infection
 Defects in wound

59. Before Crowning After
59

60. B. After crowning,
 Prevent straining after crowning.
 Allow gradual and slow extension only
inbetween uterine contractions. by doing
"Rtigen maneuver“

61. Examine neck for looped umbilical cord
.
 If a loop of cord is coiled
around the neck Try to slip it.
 If several loops,
apply double clamping
and cut the cord
inbetween.

62. Support infant’s head as it rotates for
shoulder presentation
.
 Guide infant’s head downward to deliver
anterior shoulder

63. 7)Deliver posterior shoulder first ,
then the anterior shoulder
 when the anterior shoulder appears under the
pubic arch,the head is lifted upwards to deliver
the posterior shoulder, then downwards to
deliver the anterior shoulder.

64. The rest of the body usually slips
easily

65. 8)Hold the fetus from its feet
 Contraindications
1-Premature baby
2-Fetal asphyxia
 3-Suspected presence
of intracranial hemorrhage.

66. 9)Milking the cord
 Towards the fetal umbilicus add l00 cc of blood to
fetal circulation
 Alternatively, the infant is held about half minute
below the level of the vaginal introitus before
clamping the cord.

67. In cases of Rh incompatibility
 The cord should be clamped immediately
with no milking to avoid addition of more
bilirubin from destructed R.B.Cs to fetal
circulation →more hyperbilirubinaemia

68. 10)Clamp the cord by 2 ring
forceps and cut inbetween
After delivery and evaluation of infant, clamp and cut cord

69. D- Management of the 3rd
Stage:
Normally the placenta is expelled within 10
minutes, if expelled between 10- 30 minutes
(delayed delivery of placenta).
If not expelled within 30 minutes (Retained
placenta).

70. Active management of 3rd stage of labor.
A
CONTROLLED CORD TRACTION

71. Guarding the Uterus

72. Controlled cord traction

73. Delivering the Membranes

74. Physiological Management
 Passive or expectant management
 No prophylactic
oxytocics
 Cord clamped after
delivery of placenta
 No Controlled Cord Traction (CCT)

75. 11)Episiotomy repair

76. check placenta and membranes
for completeness
and normality

77. THANK YOU

78. Active Management Of
Labour

79. The aim of active management of
labour is to
 ensure that the primigravida will deliver a
healthy baby in less than 12 hours

80. Benefits of Active Management of
Labour
 It avoids prolonged labour which can lead
to:
 Maternal distress and emotional upset.
 Fetal hypoxia and distress.
 Exhaustion of the medical and nursing staff.

81. The Principles of Active
Management of Labour

82. 1-Antenatal education
 :The mother is informed about the physiology of labour and
assured that labour will take less than 12 hours. In this way, she
can cope better with the stress of labour.

83.  2-Strict diagnosis of onset of labour.
 Onset of regular involuntary coordinated,
painful uterine contractions associated with
cervical effacement and dilatation

84. 3-Regular follow-Up of the
Patient during Labour
 : PV is done on admission to the labor. This will be
repeated every 1-2 hours

85. Examination recoreded in
partograph

86. 4-Correction of Abnormal Progress
 The rate of cervical dilatation should not be less
than 1 cm per hour in the active phase of labour.
 If the cervix is not dilating properly, amniotomy
or pitocin drip

87. Normal vs.Prolonged latent
phase

88. 5-Personal Attention:
 one nurse face to face for each patient .

89. 6-Diet
 Nothing is allowed by mouth.

90. 7-Provision of suitable analgesia.