This presentation contains details on normal anatomy on female pelvis and fetal head, process of normal labour, abnormal labour, induction of labour and malpresentations.
2. CONTENTS
• Introduction
• Fetal and maternal anatomy relevant to labour
• The process of the labour
• Physiology of the labour
• Management of normal labour
• Pain relief in labour
• Abnormal labour
• Labour in special circumstances
• Induction of labour
• Clinical risk management
JMJ 2
3. Introduction
• There is a complex interaction between the
• “Powers of the uterus” –
• contractions
• “Passage” of the birth canal –
• bony pelvis and the soft tissues of the pelvic floor and perineum)
• “Passenger” –
• Fetus
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4. Fetal and maternal anatomy relevant to labour
• The pelvis
• Pelvic brim/inlet
• Pelvic mid cavity
• Pelvic outlet
• Pelvic floor
• Perineum
• The fetal skull
• Bones, sutures and frontenelles
• Diameter of the skull
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5. Pelvic brim of inlet
• Is bounded
JMJ 5
Anteriorly
Posteriorly
Each sides Each sides
Symphysis pubis (joint
separating the 2 pelvic bone)
• Upper margin of the
pubic bone
• Ileopecteneal line
• Ala of the sacrum
• Upper margin of the
pubic bone
• Ileopecteneal line
• Ala of the sacrum
Promontory of the sacrum
6. Pelvic brim of inlet
• Normal transverse diameter – 13.5 cm
• Normal AP diameter – 11cm
• Angle of the inlet normally 60º to the horizontal in the
erect position
• Increased angle - delay the head entering (Afro Carribean)
JMJ 6
9. Sagittal section of the
pelvis demonstrating
the AP diameter of
the inlet and outlet
JMJ 9Obstetrics by Ten Teachers 19th Edition
10. Pelvic mid cavity
• Is bounded
JMJ 10
Anteriorly
Posteriorly
Each sides Each sides
Middle of the pubic
symphysis
• Pubic bone
• Obturator fascia
• Inner aspect of the
ischeal bone
• Spines
Junction of the 2nd and
3rd sections of the sacrum
• Pubic bone
• Obturator fascia
• Inner aspect of the
ischeal bone
• Spines
11. Pelvic mid cavity
• Cavity is almost round
• Transverse and anterior diameter – 12 cm
• Ischeal spines are palpable vaginally
• Are used as a landmarks to
• assess the descend of head on vaginal examination (station)
• For providing an anesthetic block to the pudendal nerve
• Pudendal nerve passes behind and below the ischeal spine on
each side
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12. Pelvic outlet
• Is bounded
JMJ 12
Anteriorly
Posteriorly
Each sides Each sides
Lower margins of the pubic
symphysis
• Descending ramus of
the pubic bone
• Ischeal tuberosity
• Sacrotuberous
ligament
• Descending ramus of
the pubic bone
• Ischeal tuberosity
• Sacrotuberous
ligament
Last piece of the sacrum
13. Pelvic outlet
• AP diameter – 13.5 cm
• Transverse diameter – 11cm
• Transverse is the widest diameter at the inlet, but at the outlet it is the AP
• These measurements can be less in
• Maternal stature
• Previous pelvic fracture
• Metabolic bone diseases (rickets)
• During 3rd trimester these become loosen
• Pelvic ligaments at pubic symphysis
• Sacroiliac joint
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15. • GYNAECOID PELVIS
• Most favourable for labour
• Most common
JMJ 15Obstetrics by Ten Teachers 19th Edition
16. • ANDROID - TYPE
• Predisposes to deep transverse arrest
JMJ 16Obstetrics by Ten Teachers 19th Edition
17. • ANTHROPOID SHAPE
• Encourage an occipito-posterior position
JMJ 17Obstetrics by Ten Teachers 19th Edition
18. • PLATYPELLOID PELVIS
• Increase risk of obstructed labour
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19. Pelvic floor
• Formed by
• 2 lavetor ani muscles which,
• with their fascia,
• form a musculofascial gutter
during the 2nd stage of labour
JMJ 19Obstetrics by Ten Teachers 19th Edition
20. Perineum
• Perineal body
• Is a condensation of fibrous and muscular tissue
• lying between the vagina and the anus
• It receives attachments from
• Posterior end of the bulbocavenous muscles
• Medial ends of the superficial and deep transverse perineal muscles
• Anterior fibers of the external anal sphincter
• It is always involved in a 2nd degree perineal tear
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23. Fetal skull bones, sutures, frontenelles
• Fetal skull
• Vault
• Face
• Base
• At the time of labour,
• Sutures joining the bones of the vault are
• soft, unossifed membranes
• Sutures of the face and the skull base
• Firmly united
JMJ 23
24. JMJ 24
Fetal skull from superior
and lateral view
Obstetrics by Ten Teachers 19th Edition
25. Fetal skull bones, sutures, frontenelles
• Vault is formed by
• Parietal bones and parts of occipital
• Frontal and temporal bones
• Between these bones there are 4 membranous sutures
• Sagittal
• Frontal
• Coronal
• Lambdoidal sutures
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26. Fetal skull bones, sutures, frontenelles
• Anterior frontenelle (bregma)
• Diamond shaped
• At the junction of sagittal, frontal and coronal sutures
• Posterior frontenelle
• Triangular shape
• Lie at the junction of the sagittal suture & lamb
• The area of the fetal skull bounded by 2 parietal eminenses
& the anterior and posterior frontenelles – “vertex”
JMJ 26
27. Fetal skull bones, sutures, frontenelles
• Sutures allow these bones to move together and even to overlap
• Paratial bones usually slides over the frontal and occipital bones
• Bones are also compressible
• Together these characteristics of the fetal skull allow a process
called “moulding”
• Which effectively reduces the diameter of the fetal skull and
• encourages progress through the bony pelvis,
• without harming the underlying brain
• .
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29. Diameter of the skull
• Fetal head- ovoid in shape
• The attitude of the head
• Refers to the degree of flexion and extension at the upper cervical
spine
• Different longitudinal diameters are presented to the pelvis in
labour depending on the attitude of the fetal head
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32. PROCESS OF LABOUR
• The onset of labour
• Stages of labour
• 1st stage
• 2nd stage
• 3rd stage
• Duration of labour
• Mechanism of labour
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33. Onset of labour
• Can be defined as
• Regular contractions bringing about progressive cervical change
• Diagnosis is made retrospectively
• Following does NOT define as onset of labour
• Loss of ‘show’ ( blood-stained plug of mucus passed from the
cervix)
• Spontaneous rupture of membranes (SPOM)
JMJ 33
34. Stages of labour – 1st stage
• Time from the diagnosis of labour, to full dilatation of the
cervix (10 cm)
JMJ 34
1st stage
Latent phase Active phase
35. JMJ 35
Thick upper segment and the thin
lower segment of the uterus
at the end of the 1st stage of labour
Dotted lines indicate the position
assumed by the uterus during
contractions
Obstetrics by Ten Teachers 19th Edition
36. JMJ 36
Effacement
• Is the process by which the cervix shortens in length as it becomes
included into the lower segment of the uterus
• Begins during the weeks proceeding the onset of labour, but will
complete by the end of the latent phase.
• Cervical os usually cannot begin to dilate until effacement is complete
• Effacement and dilatation should be thought of as
• consecutive events in nulliparous women
• Simultaneous events in multiparous women
37. 1ST STAGE
LATENT PHASE
• Time between onset of labour
and 3-4 cm dilatation
• Cervix become fully effaced
• Usually lasts between 3 – 8
hours
• Being shorter in multiparous
women
ACTIVE PHASE
• Time between the end of
latent phase and full
dilatation (10cm)
• Usually lasting between 2-6
hours
• Shorter in multiparous women
• Cervical dilatation occurs at
1cm/hour –more in normal
labour
• Abnormal – less than
0.5cm/hour
JMJ 37
38. 2nd stage
• Time from full dilatation of the cervix to the delivery of the
fetus or fetuses
JMJ 38
2nd stage
Passive phase
Active 2nd
stage
39. 2nd STAGE
PASSIVE PHASE
• Time between full dilatation
and the onset of involuntary
expulsive contractions
• No maternal urge to push
• Fetal head is still relatively
high in the pelvis
ACTIVE 2ND STAGE
• There is maternal urge to push
• Fetal head is low (often visible)
• Causing a reflex need to ‘bear
down’
• Should last no longer than
• 2hr- primiparous lady
• 1hr- previous NVD
JMJ 39
40. Active 2nd stage
• If a woman never reaches a point of involuntary pushing,
• the active 2nd stage is said to begin
• when starts making voluntary active efforts
• directed by her midwife.
• Active 2nd stage – lasting more than 3 hours
• Associate with increase maternal and fetal morbidity
• Use of epidural anesthesia
• May influence the length & management of 2nd stage of labour
JMJ 40
41. 3rd STAGE
• Time from delivery of the fetus or fetuses until delivery of
the placenta
• Placenta usually delivered within few minutes of the birth of
the baby
• Lasting more than 30 minutes – Abnormal
• If women is under the ‘Physiological management’ – can last
for 60 minutes
JMJ 41
42. Duration of labour
• Morale of most women starts to deteriorate after 6 hours in labour
• After 12 hours the rates significantly accelerated
• Longer labours
• Greater incidence of fetal hypoxia
• Early Artificial Rupture of Membranes (ARM)
• Does shortens the length of labour,
• Does not necessarily alter the outcome
• Prolonged labour
• > 12 hours - nulliparous women
• > 8 hours – multiparous women
JMJ 42
43. Mechanisms of labour
• Refers to the series of changes in
• position & attitude
• that the fetus undergoes
• during its passage through the birth canal
• Here describes on vertex presentation in a gynaecoid pelvis
JMJ 43
44. Mechanisms of labour
Engagement Descent Flexion
Internal
rotation
ExtensionRestitution
External
rotation
Delivery of shoulders and
fetal body
JMJ 44
45. Engagement
• Head enters the pelvis – in transverse position
• Engagement is said to have occurred when,
• Widest part of the presenting part has passed successfully through the
inlet
• It has occurred
• In vast majority of nulliparous women prior to labour
• Not so majority in multiparous women
• If more than 2/5th of fetal head is palpable abdominally – head
not yet engaged
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46. Descent
• During 1st stage and 1st phase of the 2nd stage
• Descent is 2ry to uterine contractions
• During Active phase of 2nd stage
• Descent is helped by voluntary use of abdominal musculature &
• Valsalva manoeuvre (‘Pushing’)
JMJ 46
48. Flexion
• Head may not always be completely flexed when it enters
the pelvis
• When head enters then mid cavity flexion should occur
• This passive movements occurs, in part,
• Due to surrounding structures
• Important in minimizing the diameter of the fetal head
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49. Internal Rotation
• If head is well flexed, occiput will be the leading point
• On reaching the sloping gutter of the levator ani muscles it
will be encourage to rotate anteriorly
• So that the sagittal suture now lies in the AP diameter of the
pelvic outlet
• If babies head is in occipiti Posterior (OP) position-
• Labour duration can be increased
• May persist result in a ‘face to pubes’ delivery
• Obstructed labour
• Instrumental or Caesarean delivery
JMJ 49
50. Extension
• Following completion of the internal rotation
• Occiput is underneath the symphysis pubis &
• Bregma is near the lower boarder of the sacrum
• Soft tissue of perineum- still resistance, more prone to get damaged
• Well flexed head now extends,
• & the occiput escapes from underneath the symphysis pubis & distends
the vulva
• This is known as ‘Crowning’ of the head
• This will minimize the trauma to the soft tissues
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51. Restitution
• When head delivering – occiput is directly anterior
• As soon as it escapes from the vulva,
• the head aligns itself with the shoulders,
• which have enters the pelvis in the oblique position
• Slight rotation of the occiput through 1/8th of the circle is
called ‘restitution’
JMJ 51
52. External Rotation
• In order to be delivered
• Shoulders have to rotate into the direct AP plane
• When this occurs, the occiput rotates through a further
1/8th of a circle to the transverse position
JMJ 52
54. Delivery of the shoulders and fetal
body
• After restitution and external rotation occurred
• Shoulders will be in AP position
• Anterior shoulder
• Is under the symphysis pubis
• Delivers 1st
• Rest of the body will delivered easily
JMJ 54
56. Physiology of labour
• Myometrium
• Cervix
• Hormonal factors
• Mechanism responsible for initiating human parturition is
still unknown
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57. MYOMETRIUM
• Myometrium cells
• Contains filaments of actine and myosis
• Which interact and bring about contraction,
• In response to increase in intracellular calcium
• Prostaglandin and oxytocin
• Increase intracellular free calcium ions
• Beta adrenergic compounds, CCB
• Inhibits
• Separation of actin & myosin filaments brings about relaxation of
myocytes
JMJ 57
58. MYOMETRIUM
• Development of upper thick segment
• however, unlike in any other muscle cell of the body,
• this actin– myosin interaction occurs along the full length of the
filaments
• so that a degree of shortening occurs
• with each successive interaction.
• This progressive shortening of the uterine smooth muscle cells is
called retraction and
• occurs in the cells of the upper part of the uterus.
• Retraction – results in making upper segment (thick)
JMJ 58
59. MYOMETRIUM
• Development of lower thin segment
• It is more stretched
• This results in cervix being taken up into the lower segment of the
uterus
• Cervix effaces & then dilates,
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60. JMJ 60
Thick upper segment and the thin
lower segment of the uterus
at the end of the 1st stage of labour
Dotted lines indicate the position
assumed by the uterus during
contractions
Obstetrics by Ten Teachers 19th Edition
61. Myometrium
• Myocytes of the uterus contracts together
• Individual myometial cells are laid down in a mesh of collagen
• Cell-to-cell communication by gap junctions
• These gap junctions are absent for most of the pregnancy ,
but appears at term
• Prostaglandins stimulate the formation of gap junction
• Beta- adrenergic - opposite
JMJ 61
62. Myometrium
• Uterine contractions are involuntary in nature
• Minimal extrauterine neuronal control
• Majority of labour –
• occurs at intervals of 2-4 minutes
• Intensity or amplitude of the intrauterine pressure
generated with each contraction averages between 30 to 60
mmHg
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63. Cervix
• Contains muscles and fibroblasts,
• Separated by ‘ground substance’ made up of extracellular matrix
molecule
• Under the influence of prostaglandin and other humoral mediators
• There is an increase in proteotyric activity
• Reduction in collagen and elastin
• Interleukins bring about a pro-inflammatory change – with significant
invasion by neutrophils
• Dermatan sulphate is replaced by the more hydrophilic hyaluronic
acid
• Which results in increase in water content in cervix
• This causes cervical softening or ripening,
• So that contractions, when they begin, can bring about the process of
effacement and dilatation
JMJ 63
64. Hormonal factors
• Progesterone
• Maintains uterine quiescence by,
• Suppressing prostaglandin production
• Inhibiting communication between myometrial cells and
preventing oxytocin release
• Oestrogen
• Opposes the action of progesterone
• Prior to labour,
• there is a reduction in progesterone receptors and
• an increase in the concentration of oestrogen relative
to the progesterone
JMJ 64
65. Hormonal factors
• By chorion and decidua
• Increased prostaglandin synthesis
• Leading to increase in calcium influx into myometrial
cells
• Corticotrophin-releasing hormone (CRH)
• Produced by placenta
• Increase contractions towards term
• Potentiates the action of prostaglandin & oxytocin on
myometrial contractility
• Fetal pituitary oxytocin
• Fetal adrenals cortisol
JMJ 65
Stimulates the conversion
of progesterone to oestrogen
67. History
• Details of previous births & the size of previous babies
• Frequency, duration & perception of strength of the contractions
and when they began
• Whether the membranes have ruptures
• Colour and amount of amniotic fluid
• Presence of abnormal vaginal discharge or bleeding
• Recent activity of the fetus
• Any medical issues
• Special requirements (psychological needs)
JMJ 67
68. General Examination
• Body mass index
• Temperature
• Pulse
• Blood pressure
• Urine tests for
• Protein / blood / ketones/ glucose
JMJ 68
69. Abdominal Examination
• Inspection for scars
• Lie of the fetus
• Presenting part
• Cephelic or breech
• If cephalic, degree of engagement
• If 5/5 – do USS- to figure out the reason for high head
• OP position
• Deflexed head
• Placenta previa
• Fibroids
• Assessment of contractions – by palpation
• Can comment only on frequency and duration of contractions
• Not the strength
JMJ 69
70. Vaginal Examination
• Examine cervix for
• Dilatation
• Effacement
• Application of the presenting part
• Dilatation – comment by cm
• If cannot feel for the cervix- fully dilated
• Length of the cervix
• At 36 weeks – 3cm
• At about 4cm of dilatation, the cervix should be fully effaced
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71. Vaginal Examination
• Normal labour- presenting part is vertex
• Occiput is identified by feeling for triangular posterior
frontenelle
• Normally occiput will be
• Transvers (OT position)
• Anterior (OA position)
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72. Vaginal Examination
• Conditions of the membranes should be noted
• Copious amount of clear fluid –
• good prognosis
• Heavily blood stained or meconium stained fluid –
• warning sign for fetal compromise
• Women in labour should have their,
• Pulse measured – hourly
• Temp, & BP – 4 hourly
• Frequency of contractions – 30 minutes
• Vaginal examination – 4 hourly
JMJ 72
74. Fetal assessment in labour
With each
contraction
Low placental
blood flow
Low Oxygen to
fetus
Switch to
anaerobic
metabolism
More lactic acid
and H+
Metabolic
acidosis
Neuronal damage
Intrapartum fetal
death
JMJ 74
75. Passage of meconium
• Thin, very dark green or brown colour
• Healthy fetus
• Results of maturation of gastrointestinal physiology
• Thicker and much brighter green in colour
• Intrauterine hypoxia or acidosis
JMJ 75
76. Fetal assessment in labour takes four
forms
• Observation of the colour of the liquor
• Intermittent auscultation of fetal heart using Pinard
stethoscope or a hand held Doppler US
• Continuous external fetal monitoring (EFM)-by CTG
• Fetal scalp blood sampling (FBS)
JMJ 76
77. Fetal assessment in labour
• Women who bring labour with intermittent auscultation
• may be advised to change to continuous EFM
• if any of the following events occur during their labour
• Significant meconium staining to liquor
• Abnormal fetal heart rate detected by intermittent auscultation
• Maternal pyrexia
• Fresh vaginal bleeding
• Augmentation of contractions with oxytoxin
• At the request of the woman
JMJ 77
79. CTG
• Quality is poor
• Due to fetal position
• Maternal obesity
• Normal parameters
• Normal fetal heart rate pattern
• Baseline rate between 110-160 bpm
• Baseline variability between 5 and 25 bpm
• Absence of decelerations
• During 2nd stage of labour
• Absence of accelerations
• Presence of early decelerations tends to be normal
JMJ 79
80. CTG
• Each feature of CTG (baseline rate, variability, decelerations and
accelerations), should be assessed each time
• Should describe as ‘reassuring’ , ‘Non-reassuring’ or ‘abnormal’
(NICE guidelines)
• If all 4 features reassuring –
• Normal CTG
• If one is non-reassuring-
• Suspicious CTG
• If 2 or more non-reassuring or any abnormal –
• Pathological CTG
JMJ 80
81. Partogram
• Instance visual assessment of the rate of cervical dilatation
• Progression of the labour
• Frequency and strength of contractions
• Descent of the head in 5th palpable
• Amount and colour of the amniotic fluid draining
• Basic observation of maternal wellbeing
• BP/ Pulse rate/ Temprature
JMJ 81
83. Key management principles of 1st stage
of labour
• 1st stage – timed from the Δ of labour to full dilatation of cervix
• Provision of continuity care and emotional support
• Observation of progression of labour
• Monitor fetal well being
• Adequate and appropriate pain relief
• Adequate hydration to prevent ketosis
JMJ 83
84. management of 1st stage of labour
• Woman in latent phase –
• encourage to mobilize
• Encourage and reassure them
• Avoid interventions unless there is an identified risk factors
• Simple analgesics preferred over NO and epidurals
• No need to restrict eating and drinking (light food and clear fluid-
tolerable)
• Vaginal examination – in every 4 hours
JMJ 84
85. management of 1st stage of labour
• Woman in active phase – (Cervical d-4cm)
• Lower limit of normal progression – 1cm dilatation in every 2 hours
• Descend of the fetal part
• Full dilatation may be reached, but id descent is inadequate, vaginal
delivery will not occur
• During 1st stage
• Membranes may be intact, ruptured spontaneously or ruptured artificially
• Maintain a partogram- maternal and fetal observations
JMJ 85
86. management of 1st stage of labour
• Mobility during labour is encourage (standing upright encourage the progress
• Encourage drinking water
• If the woman is dehydrated- start IV fluids
• To prevent ketosis, which can impair uterine contractions
• Light diet is accepted -
• if no indication for GA
• If they have not had pethadine or diamorphine
• Shaving and enemas are unnecessary
• Antacids need only to women
• with risk factor for complications
• Those who have opioid analgesia
JMJ 86
87. Active management of labour
• Collections of interventions
• Which are routinely recommended to
• Nulliparous women
• To maximize the chances of a normal birth
• This includes
• 2 hourly vaginal examination
• Early artificial rupture of membranes
• Use of oxytocin augmentation if progress fell more than 2 hours
JMJ 87
89. • 1st sign of the 2nd stage-
• urge to push experienced by mother
• Full dilatation of cervix-
• Should be confirmed by a vaginal examination, if the head is
not visible
• The women will get an expulsive reflex with each
contraction, & will generally take
• Deep breath, hold it and strain down (Valsalva manoeuvre
• Woman should be discourage lying supine or semi supine
• Lying in the left lateral position & squatting are
particularly effective options
• Use of regional analgesia may interfere with normal urge
to push
• Pushing is usually delayed for at least an hour if an
epidural is in situ (‘passive phase’),
• However baby should be delivered within 4 hours after
full dilatation
JMJ 89
90. Descent and delivery of the head
1st there is a slight general bulge as the woman strains
When head stretches the perineum, anus will begin to
open
Soon after this babies head will be seen at the vulva
Between the contractions, elastic tone of the perineal
muscles will push the head back into pelvic cavity
Perineal body and vulva stretches more, until fetal head is
low enough to pass forward under the suprapubic arch
JMJ 90
91. Descent and delivery of the head…
cont
When head no longer recedes between contractions
(crowning) – indicated head had passed through pelvic
cavity
When crowning has occur, tell woman to take rapid,
shallow breaths (‘panting’)
An episiotomy cut is performed (from vaginal
fourchette in a Medio lateral direction – to right)
Episiotomy is performed during –
1. instrumental birth
2. suspected fetal compromise
JMJ 91
92. Delivery of the shoulders and the rest
of the body
Once fetal head is born, check whether the cord is wound tightly
around the neck
If yes, cord need to clamp before delivering the rest of the
body
With next contraction external rotation of the head and
shoulders can be delivered
To aid delivery of the shoulders, head should be pulled gently
downwards and forwards until A shoulder appears beneath the
pubis
Head then lifted gradually until the P shoulder appears over
the perineum
baby then swept upwards to deliver the body and legs
JMJ 92
93. Immediate care of the neonate
• After born, infant lies between mother’s legs
• Baby will usually take 1st breath within seconds
• No need for immediate clamping of the cord
• Nearly 80ml of blood will transferred from placenta to the baby, before
cord pulsation cease
• Reduces the chances of neonatal anemia and iron deficiency
• Oropharyngeal aspiration is only done if necessary
• After clamping & cutting cord – calculate APGAR score –
• 1 minute and
• 5 minutes
JMJ 93
94. Immediate care of the neonate
• Immediate skin to skin contact between mother & baby
• Help bonding
• Promote further release of oxytocin
• Baby should be dry and cover with warm blanket
• Initiation of breastfeeding – 1st ½ hour of life
• Newborn measurements – temperature, head circumference,
birth weight
• 1st dose of vitamin K should be given
JMJ 94
96. • Normally take 5 to 10 minutes
• Separation of placenta occurs because
• Reduction of volume of uterus
• Due to uterine contractions and retraction
• Signs of separation are
• Lengthening of the cord protruding from vulva
• A small gush of blood from the placental bed, which normally stops
quickly due to retraction of the myometrial fibers
• Rising of the uterine fundus to above the umbilicus
• Fundus becomes hard & globular compared to board
JMJ 96
98. Mx of 3rd stage
Active Mx
IM 10 IU of oxytoxin -
given as the A soulder of
the baby is deliverd /
immediately after delivery
Early clamping and
cutting of umbilical
cord
Controlled cord
traction
Physiological Mx
JMJ 98
99. Active Management
• Recommended to all women – to reduce risk of PPH
• When signs of placental separation are recognized
• Control cord traction is used
• When contractions are felt
• Left hand should be moved suprapubically
• & the fundus elevated with the palm facinf toward the mother
• Right hand should grasp the cord
• Use twisting motion
• Uterine inversion – rare complication
JMJ 99
101. Active Management
• 2% - placenta will not expelled
• If no bleeding occurs
• Further attempt at controlled cord traction should be made after 10
minutes
• If that fails manual removal under GA or regional anesthesia
• Direct injection of oxytocin into the umbilical vein – may bring
about delivery of the placenta
JMJ 101
102. Physiological Management
• Where the placenta is delivered by the maternal effort
• No uterine drugs are given to assist
• Associated with heavy bleeding
• Can wait up to 60 minutes
JMJ 102
103. • After completion of 3rd stage
• Inspect placenta for missing cotyledons or succenturiate
lobe
• If anything suspected -> manual removal (US guided)
• Inspect vulva for an tears extending into perineal
muscles
JMJ 103
104. Key features of normal labour are
• Spontaneous onset
• Single cephalic presentation
• 37- 42 weeks gestation
• No artificial interventions
• unassisted spontaneous vaginal delivery
• Dilatation of at least 1cm every 2 hrs in the active phase of 1st stage
• An active 2nd stage of no more than 2hr primiparous woman
no more than 60 minutes in multiparous woman
• 3rd stage lasting no more than 30 minutes with active management
JMJ 104
106. Abnormal Labour
Poor
progression of
labour
1st stage
Dysfunctional
uterine activity
Cepahlopelvic
disproportion
malpresentation
Anomalies of
birth canal
2nd stage
Patterns of
normal progress
of labour
Fetal
compromise in
labour
Recognition Management
JMJ 106
107. Poor progress of 1st stage of labour
• Defined as
• Cervical dilatation of less than 2cm in 4 hours
• Associate with failure of descent &
• Rotation of the fetal head
• Progress dependent on 3 variabilities
• Power
• The efficiency of the uterus
• Passenger
• Fetus (Size, presentation, position)
• Passage
• Uterus, cervix, bony pelvis
JMJ 107
108. Dysfunction of the uterine cavity
• Most common cause
• Common in primigravida & older women(weak contractions)
• Assessment done by
• Clinical examination
• External uterine tocography
• Intrauterine pressure catheter (more accurate)
• Frequency of 4-5 contractions per 10 minutes- ideal
JMJ 108
109. Dysfunction of the uterine cavity
• When poor labour suspected
• Repeat vaginal examination 2 hrly
• If confirmed
• ARM
• If still poor progress till 2 hours
• Oxytocin infusion- slow rate
• Increase carefully in 30 minutes
• Continuous EMF
• Multiparous women- less likely to experience poor progress (excepts
malposition or malpresentation)
JMJ 109
110. Dysfunction of the uterine cavity
• Excessive uterine contractions in a truly obstructed labour
• Results in uterine rupture in multiparous women
• Augmentation with oxytocin is contraindicated
• if there are concerns regarding the condition of the fetus
• If progress fails to occur despite 4-6 hours of augmentation
with oxytocin,
• a Caesarean section will usually be recommended
JMJ 110
111. Cephalopelvic disproportion (CPD)
• Anatomical disproportion between the fetal head and maternal pelvis
• Due to
• Large head
• Small pelvis
• Combination of the 2
• Women with short stature (<1.60m), with a large baby in their 1st pregnancy –
high risk
• Obstructive hydrocephalus – macrocephaly
• Fetal thyroid & neck tumors – extension of neck
• OP position – deflexion of the fetal head , presents a larger skull diameter to
the maternal pelvis
JMJ 111
112. Cephalopelvic disproportion (CPD)
• Cephalopelvic disproportion is suspected in labour
• Progress is slow or actually arrests despite efficient uterine
contractions
• The fetal head is not engaged
• Vaginal examination shows sever maulding & caput formation
• Head is poorly applied to the cervix
• Oxytocin can be given carefully to a primigravida with mild
to moderate CPD
• Oxytosin must never be used in a multiparous women where
CPD is suspected
JMJ 112
114. Malpresentations
• Vital good progress in labour
is the tight application of the
fetal presenting part on to
the cervix
• Face presentation
• May apply themselves poorly to
the cervix
• Vaginal birth is still possible
JMJ 114Obstetrics by Ten Teachers 19th Edition
116. Malpresentation
• Brow presentation
• Mento-verticle diameter
• Too large to fit through the bony pelvis, unless flexion occurs or
• hyperextension to a face presentation
• Shoulder presentation
• Cannot deliver vaginally
• Malpresentations are common in women with
• High parity
• Risk of uterine rupture
JMJ 116
118. Abnormalities of the birth canal
• Abnormalities of the uterus and cervix
• Unsuspeccted fibroids in the lower uterine segment –
prevent descend
• Delay can caused by cervical dystocia
• non-compliant cervix which effaces but fails to dilate because of
severe scarring, usually as a result of a previous cone biopsy.
JMJ 118
119. Poor progress in the 2nd stage of labour
• Birth is expected to take place within 3 hrs of the start of the
active 2nd stage
• Delay diagnosed if delivery is not immitent after
• 2 hr of pushing – nulliparous labour
• 1 hour of pushing – multiparous labour
• Causes for 2nd stage delay
• Abnormalities of power
• Passenger
• passage
JMJ 119
120. • 2ry uterine inertia –
• common cause of 2nd stage delay
• May be exacerbated by epidural analgesia
• Maternal dehydration causing ketosis
• Weak uterine contractions
• Tx-rehydration & IV oxytocin –if primi
• Persistent OP position – fetal head
• Either head has to undergo long rotation to OA
position
• Delivered in the OP position (face to pubes)
• When 2nd stage has been diagnosed,
• Never start oxytocin
JMJ 120
121. • Narrow – mid pelvis (android pelvis)
• Prevents internal rotation of fetal head
• This may result in the arrest of the descent of
the fetal head
• at the level of the ischial spines
• in the transverse position
• “DEEP TRANSVERSE ARREST”
• Instrumental birth should be considered for
prolonged 2nd stage
JMJ 121
123. Risk factors for poor prognosis in
labour
• Small woman
• Big baby
• Dysfunctional uterine activity
• Malpresentation
• Malposition
• Early membrane rupture
• Soft-tissue/pelvic malformation
JMJ 123
124. Patterns of abnormal progress in
labour
• Partogram
JMJ 124Obstetrics by Ten Teachers 19th Edition
125. • Prolonged latent phase
• More common in primiparous woman
• Primary dysfunctional labour
• Poor progress in the active phase of labour (<2cm
cervical dilatation/4 hourly)
• Common in primi women
• 2ry arrest
• When progress in the active phase of 1st stage is
initially good but then slows,
• stops altogether
• Typically after 7cm dilatation
JMJ 125
126. Poor progress in labour
• Different patterns +
• Insufficient uterine cavity – most common cause
• Fetal malposition, malpresentation, and true CPD are other causes
• May occur in isolation or in combination with inefficient uterine contractions
• ARM is a simple intervension which may shortens labour, but does not influence the overall
outcome
• Use of oxytocin – relatively safe in nulliparous women
• Use of oxytocin augmentation – less safe because of greater risk of uterine
hyperstimulation, fetal compromise & uterine rupture in the face of obstruction
• Oxytocin does not have a significant impact on the mode of delivery, but does shorten the
length of labour
JMJ 126
127. Fetal compromise in labour
• Reduction in placental blood flow associated with
contractions
• Lead to fetal hypoxia
• Eventually acidosis
• Fresh meconium staining to the amniotic fluid
• Abnormal CTG
• ‘Presumed fetal compromise’ more accurate than ‘fetal
distress’
JMJ 127
128. Risk factors for fetal compromise in
labour
• Placental insufficiency – fetal growth restriction and pre-eclampsia
• Prematurity
• Postmaturity
• Multiple pregnancy
• Prolonged labour
• Augmentation with oxytocin
• Uterine hyperstimulation
• Precipitated labour
• Intrapartum abruption
• Cord prolapse
• Uterine rupture / dehiscence
• Maternal diabetes
• Cholestasis of pregnancy
• Maternal pyrexia
• Chorioamnionitis
• Oligohydroamnios JMJ 128
129. Recognition of fetal compromise
• Meconium staining
• Thick or tenacious
• Dark green
• Bright green
• Black
• Thin & light meconium – is more likely to represent fetal gut maturity
• CTG changes
• Fetal tachycardia
• Fetal bradycardia
• Fetal heart rate deceleration
JMJ 129
136. CTG signs suggestive of fetal
compromise
• Fetal tachycardia (>160 bpm, or a steady rise over the
course of labour)
• Loss of baseline variability (<5bpm)
• Recurrent late decelerations
• Persistent variable decelerations
• Fetal tachycardia (<100 bpm for more than 3 minutes)
JMJ 136
137. Management of possible fetal
compramise
• Number of resuscitative manoeuvres
• Should be considered when a CTG is classified as ‘suspicious’
• If a CTG becomes pathological
• Do immediate vaginal examination to exclude malpresentation and cord
prolapse
• If cervix is fully dilated,
• Deliver baby vaginally
• If cervix is not dilated
• Instrumental delivery
• Caesarean section
JMJ 137
138. Resuscitating the fetus in labour
• Maternal dehydration and ketosis
• Can corrected with IV fluids
• Maternal hypotension
• 2ry to an epidural
• Can be reversed by a fluid bolus
• Although a vasoconstrictor such as ephedrine is occasionally necessary
• Uterine hyper stimulation
• From excess oxytocin can be treated by
• turning off the infusion temporarily and
• using tocolytic drugs (terbutaline)
• Venocaval compression and reduced uterine blood flow
• Can be eased by turning the woman into left lateral position
JMJ 138
140. Labour
Woman with a
uterine scar
Malpresentation
Breech
presentation
Face
presentation
Brow
presentation
Shoulder
presentation
Multiple
gestation
JMJ 140
141. Women with a uterine scar
• 20% deliveries are Caesarean sections
• Out of that 99% - lower segment of the uterus
• Blood loss is less
• Healing is better
• Low risk of uterine rupture
• Upper segment C- section “ classical”
JMJ 141
142. Signs of uterine rupture
• Severe lower abdominal pain
• Vaginal bleeding
• Hematuria
• Cessation of contractions
• Maternal tachycardia
• Fetal compramise
JMJ 142
143. • Uterine rupture likely to occur
• Late in 1st stage of labour
• With induction or accelerated labour
• In association with a large baby
• Labour after previous Caesarean section
• Vaginal birth after Caesarean section
JMJ 143
VBAC after
delivery
75%
C section
25%
PERCENTAGE OF
PERFORMING VBAC
144. • Contraindications for VBAC
• 2 or more previous Caesarean section scars
• Need for induction of labour (IOL)
• Previous labour progress and outcome suggestive of CPD
• Previous classical Caesarean section
• Absolute contraindication
• Previous myomectomy
• Minimal danger for rupture of membranes
JMJ 144
146. Breech presentation
• Increased risk of cord prolapse
• With footing breech presentation
• With flexed breech
• Increased risk of CTG abnormalities
• Cord compression
• Mechanical difficulties with delivery of the shoulder &/or
after coming head
• Damage to visceral organs
• Traction of brachial plexus
• Prolonged compression of umbilical cord & asphyxia
JMJ 146
147. Face presentation
• 1.500 labours
• Due to complete extension of fetal head
• Presenting diameter(submento-bregmatic) – 9.5cm
• Same diameter as suboccipito-bragmatic (vertex) presentation
• Engagement of the fetal head is late & progress is also slow.
• Because facial bones do not mould
• Diagnosed by palpating nose, mouth and eyes on vaginal
examination
• Forcep delivery is permitted for low mento-anterior face
presentations
JMJ 147
148. Face presentation
• Excellent prognosis if
• If chin remains meto anterior
• Possible vaginal delivery
• Head being delivered by flexion
• Poor prognosis if
• Chin is posterior (mento-posterior position)
• Extension over the perineum cannot occur
• C-section is performed
• Oxytocin should not be given
JMJ 148
149. Brow presentation
• Lesser extreme extension of the fetal neck that that with a
face presentation
• can be considered a midway position between vertex and
face
• 1:2000
• Brow presentation –
• As a result of exaggerated extension associated with OP position
• Presenting diameter (mento-vertical) – 13.5cm
• Incompatible with a vaginal delivery
JMJ 149
150. Brow presentation
• Diagnosed by palpating
• anterior frontenelle
• Supra-orbit ridges
• Nose
• If this presentation persist
• Delivery by Caesarian section
JMJ 150
151. Shoulder presentation
• 1:300
• Due to transverse oblique lie of the fetus
• Cause of this abnormal presentation include placenta Previa
• Delivery by Caesarean section
• Delay making the diagnosis have risk of
• Cord prolapse
• Uterine rupture
JMJ 151
152. Multiple Gestation
• 1:80
• Indications for elective Caesarian section in twin pregnancy
• Malpresentation of the 1st twin
• Second twin larger than the 1st
• Evidence of FGR in one or both twins
• Monoamniotic twins
• Placenta previa
• Maternal request
JMJ 152
154. Key points
• Most labours are uncomplicated and the outcomes are good.
• Labour can be a hazardous journey for the baby.
• Abnormalities of the uterine contractions (the ‘powers’), the fetus
(the ‘passenger’) and the pelvis and lower genital tract (the
‘passages’) can cause abnormal labour.
• The term ‘fetal distress’ is unhelpful and often misleading. If there
are concerns regarding fetal well-being in labour, the term
‘presumed fetal compromise’ should be used instead.
• Augmentation of labour with oxytocin will often correct poor uterine
contractions and may help to resolve fetal malposition.
• Augmentation of labour with oxytocin can be dangerous in
multiparous women, in those with a uterine scar, and in cases of
malpresentation
JMJ 154
156. Common indications for induction of
labour
• Prolonged pregnancy
• Fetal growth restriction
• Pre-eclampsia and other maternal hypertensive disorders
• Deteriorating maternal illnesses
• Prelabour rupture of membranes
• Unexplained antepartum haemorrhage
• Diabetes mellitus
• Twin pregnancy continuing beyond 38 weeks
• Intrahepatic cholestasis of pregnancy
• Maternal iso-immunization against red cell antigens
• ‘Social’ reasons
JMJ 156
157. induction of labour
• Recommended IOL between 41 & 42weeks
• Longer the time delay between delivery of the baby and
membrane rupture
• Greater risk of ascending infection (chorioamnionitis)
• Before 34 weeks
• Maternal infection, fetal compromise, growth restriction
• Between 34-37
JMJ 157
158. Methods
• Artificial rupture of membranes
• Synthetic syntocin (Syntocinon)
• Prostaglandin PGE2
• Inseted vaginally
• Posterior fornix – tablet or gel
• 2 doses given – 6hrs apart
• Controlled release pessery – 24hrs
• Prostaglandin recommends even if the cervix is favourable
JMJ 158
159. Methods
• Oxytosin given IV as a dilute solution
• Mifepristone (anti-progesterone)
• Misoprostol (prostaglandin)
• Membrane sweeping - ARM
JMJ 159
160. Bishop score
JMJ 160
High score - favourable cervix
Low score – unfavourable cervix
Obstetrics by Ten Teachers 19th Edition
161. Risk of induction of labour
• Greater pain in labour
• Uterine hyperstimulation
• Cord prolapse
• Greater risk of uterine rupture during VBAC
• Failure
• Increased need for Caesarean or instrumental delivery
• Fetal compromise
JMJ 161
163. Induction of labour and clinical risk management
• • Every induction of labour should have a valid indication.
• • The most common indication for induction of labour is prolonged pregnancy.
• • A high Bishop score predicts an easier induction of labour.
• • Clinical risk management aims to improve standards of intrapartum care and to
reduce the number and severity of poor obstetric outcomes.
JMJ 163