Normal labour and delivery

APRIL 2005

DEPARTMENT OF
OBST & GYNAE
RCMP

NORMAL LABOUR
AND
DELIVERY

Prof Dr MOHD AZHAR MN
ROYAL COLLEGE OF MEDICINE PERAK

APRIL 2005

NORMAL LABOUR
AND
DELIVERY

DEPARTMENT OF
OBST & GYNAE
RCMP

CONTENTS
1.
2.
3.
4.
5.
6.

Definition of normal labour
Factors influencing progress of labour
Diagnosis of labour
Stages of labour
Mechanisms of labour
Management of labour

Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY

WHAT IS
NORMAL LABOUR ?

APRIL 2005

DEPARTMENT OF
OBST & GYNAE
RCMP

NORMAL
LABOUR

DEFINITIONS
Labour is defined as the onset of regular painful contractions
with progressive cervical effacement and dilatation of the
cervix accompanied by descent of the presenting part.


NORMAL LABOUR
The following criteria should be present to call it normal labour
 Spontaneous expulsion,
 of a single,
 mature fetus (37 completed weeks – 42 weeks),
 presented by vertex,
 through the birth canal (i.e. vaginal delivery),
 within a reasonable time (not less than 3 hours or more than 18

hours),
 without complications to the mother,
 or the fetus

APRIL 2005

NORMAL LABOUR
IMPORTANCE
DEPARTMENT OF
OBST & GYNAE
RCMP

Understanding the process of
labour is importance
• problems can be identified
• correctly managed


WHAT FACTORS INFLUENCE
PROGRESS OF LABOUR ?


LABOUR AND DELIVERY
FACTORS THAT INFLUENCE
PROGRESS OF LABOUR
Power

Passenger

Passage


THE NORMAL FEMALE PELVIS
1. The female pelvis provides the basic framework of the
birth canal.
2. The obstetric pelvis is divided into false and true pelvis
by the pelvic brim or inlet

Inlet

3. The true pelvis is important, for it is through this
confined space that the fetus must pass on its journey
through the birth canal.
4. The true pelvis is composed of inlet, cavity and outlet.
5. Types of female pelvis – gynaecoid, anthropoid,
android and platypelloid

Cavity
Outlet


The ideal normal female gynaecoid pelvis:
1. The brim is slightly oval transversely.
2. The sacral promontory is not prominent.
3. The transverse diameter is slightly longer
than the anteroposterior.
4. The sidewalls are parallel and straight.
5. The ischial spines are not prominent.
6. The sacrosciatic notches are wide.
7. The sacrum has a good curve.
8. The pubic arch angle are wide, i.e. more than
90°
9. Inter tuberous diameter is wide


The important diameters of the female pelvis:
Diameters
(cm)
Anteroposterior
BRIM

11 – 11.5

Oblique

Transverse

12

12.5

CAVITY 12

12

12

OUTLET 12.5

12

11- 11.5


THE FETAL SKULL

1. Sutures
2. Diameters


THE FETAL SKULL
SUTURES
1.

Sagittal suture: - The sagittal suture lies between the
parietal bones. It runs in an anteroposterior direction
between the anterior and posterior fontanelles.

2.

Coronal sutures: - The suture uniting the parietal bones
to the frontal bones is called the coronal suture. It’s
extend transversely from the anterior fontanels and lies
between the parietal and frontal bone.

3.

Frontal suture: - The frontal suture is between the two
frontal bones. It is an anterior continuation of the
sagittal suture.

4.

Lambdoidal suture: - Is between the parietal and
occiptal bones.


THE FETAL SKULL
MOULDING OF THE FETAL SKULL

MOULDING’ is the ability of the fetal head
to change its shape and so to adapt itself
to the unyielding maternal pelvis during
the progress of labour.
This property is of the greatest value in the
progress of labour.


THE FETAL SKULL
Diameters of the fetal skull – anterior posterior diameters
A
G
D
E
AB ~ Suboccipto bregmatic – 9.5
AC ~ Submento bregmatic – 9.5
DE ~ Occipito frontal ~ 11.0

F
C

B

FG ~ Mento vertical – 13.5


POWER ► Contractions + Maternal
pushing
Uterine contractions:
1. Initiate by pacemakers ~ uterotubal junction
2. Contraction waves meet at the fundus
3. Contraction waves progress downward

Additional force
“maternal pushing”

 Shortening of muscle fibres
 Retractions
 intra uterine pressure

EXPULSION OF THE FETUS

Intra abdominal pressure


UTERINE CONTRACTION

Uterine contractions

NORMAL CONTRACTION
1.
2.
3.

Frequency ~ one in every 2 – 3 min with at least 1 minute interval
Intensity ~ strong (> 50 mmHg)
Duration ~ 45 – 60 sec


LABOUR AND DELIVERY

WHAT INITIATE LABOUR
“ONSET OF LABOUR”


NORMAL LABOUR
Causes of Onset of Labour:
- It is unknown but the following theories were postulated:


Hormonal factors
1) Estrogen theory
2) Progesterone withdrawal theory
3) Prostaglandins theory
4) Oxytocin theory
5) Fetal cortisol theory



Mechanical factors
1) Uterine distension theory
2) Stretch of the lower uterine segment by the presenting near
term


LABOUR AND DELIVERY

DIAGNOSIS OF LABOUR

Prof DR MOHD AZHAR – “NOMAL LABOUR & DELIVERY”

NORMAL LABOUR AND DELIVERY

SYMPTOMS AND SIGNS OF LABOUR

Before labour begins, women usually notice one or more premonitory, or
warnings, signs that labour is about to begin.
They are:

 Painful regular uterine contractions – as evidence by

contraction at least one in ten minutes
 Show – as evidence by mucus mixed with blood
 Rupture of membranes – as evidence by leaking liquor
 Progressive shortening and dilatation of the cervix


LABOUR AND DELIVERY

DESCRIBE THE STAGES OF
LABOUR



STAGES OF LABOUR

Labour can be divided into three stages, which are unequal in length.

FIRST STAGE

SECOND STAGE

THIRD STAGE

It begins with the onset of true
labour contractions and ends
when the cervix is fully dilated
(10 cm).

The second stage of labour
begins with complete dilatation
of the cervix and ends with the
birth of the baby.

The third stage is that of
separation and expulsion of
placenta and membranes and also
involves the control of bleeding.

Cervical
effacement
and
dilatation occur in the first stage

The duration is about 1 to 1½
hours in nulliparas and about 30
to 45 minutes in parous women.

It begins after the birth of the
baby and ends with the expulsion
of the placenta and membranes.

First stage of labour consists of
two phases:- latent and active.
The first stage of labour is the
longest for both nulliparous and
parous women.

This is the shortest stage, lasting
up to 30 minutes, with an
average length of 5 to 10
minutes. There is no difference
in duration for nulliparous and
parous.

APRIL 2005

DEPARTMENT OF
OBST & GYNAE
RCMP

FIRST STAGE OF
LABOUR



PHASES OF THE FIRST STAGE OF LABOUR
Divided into:

Latent phase – begins with onset of contracts and ends when cervix is 3 cm dilated and effaced
Active phase – begins after the cervix is 3 cm dilated



PHASES OF THE FIRST STAGE OF LABOUR
LATENT Phase
1.
2.
3.
4.
5.
6.

Begins with onset of contractions
Slow progress
Little cervical dilatation
Progressive cervical effacement
Ends once the cervix reaches 3
cm dilatation
Durations
~ 8 hours for nulliparae
~ 6 hours for multiparae

ACTIVE Phase
1.
2.
3.
4.
5.

Active process
Begins after 3 cm of cervical
dilatation
Period of active cervical dilatation
(average rate 1 cm/hr)
S-shaped curve which is used to
define progress of labour
It has 3 component
a) acceleration - slow
b) maximum - fast
c) deceleration - slow



WHAT HAPPEN DURING
THE FIRST STAGE OF LABOUR



WHAT HAPPEN DURING THE FIRST STAGE OF LABOUR
1. Contractions:
CONTRACTIONS
1: Regular
2: Increasing in frequency
3: Stronger



2. Cervical dilatation and effacement:
Causes of cervical dilatation:
Contraction and retraction of uterine musculature
Mechanical pressure by the bulging membrane (fore
water)
The descend of the presenting part

Phases of cervical dilatation
Latent phase – the first 3 cm of dilatation; a slow process
(8 hours in nulliparous and 3 hours
in
multiparous
Active phase – this is active process of cervical
dilatation; the normal rate is 1 cm/hour



3. Engagement of the presenting part:


FETAL HEART CHANGES
Do Uterine Contractions Affect Fetal Heart Rate?
Uterine contractions can affect fetal heart rate by increasing or
decreasing that rate in association with any given contraction.
The three primary mechanisms by which uterine contractions can
cause a decrease in fetal heart rate are compression of:
·
Fetal head
·
Umbilical cord
·
Uterine myometrial vessels


PROGRESS OF FIRST STAGE OF LABOUR
Findings suggestive of satisfactory progress in first stage of labour are:
- regular contractions of progressively increasing frequency and duration;
- rate of cervical dilatation at least 1 cm per hour during the active phase of
labour (cervical dilatation on or to the left of alert line);
Findings suggestive of unsatisfactory progress in first stage of labour
are:
- irregular and infrequent contractions after the latent phase;
- OR rate of cervical dilatation slower than 1 cm per hour during the active
phase of labour (cervical dilatation to the right of alert line);

APRIL 2005

DEPARTMENT OF
OBST & GYNAE
RCMP

SECOND STAGE OF
LABOUR


SECOND STAGE OF LABOUR
1. Begins with FULL DILATATION and ends with DELIVERY OF THE BABY.
2. It have TWO Phases
a) Propulsive phase – from full dilatation until presenting part has descended
to the pelvic floor
b) Expulsive phase which ends with the delivery of the baby
Features of expulsive phase – 1) mother’s irresistible desire to bear down
2) distension of perineum
3) dilatation of the anus

3. Average length
a) Primigravidae – 40 minutes
b) Multigravidae – 20 minutes


PROGRESS OF SECOND STAGE OF LABOUR
Findings suggestive of satisfactory progress in second stage of labour
are:
- steady descent of fetus through birth canal;
- onset of expulsive (pushing) phase.
Findings suggestive of unsatisfactory progress in second stage of labour
are:
- lack of descent of fetus through birth canal;
- failure of expulsion during the late (expulsive) phase.

APRIL 2005

DEPARTMENT OF
OBST & GYNAE
RCMP

THIRD STAGE OF
LABOUR


THIRD STAGE OF LABOUR
1. Begins after DELIVERY of the baby and ends with DELIVERY OF THE
PLACENTA / MEMBRANES.
2. It have TWO Phases
a) Separation phase
b) Expulsion phase
3. Duration – usually 15 minutes or less (if actively managed).
4. Average blood loss – 150 to 250 ml.


PHYSIOLOGICAL EFFECTS OF LABOUR
FIRST STAGE
1.

Minimal effects

SECOND STAGE
1.
2.

ON THE MOTHER

3.

ON THE FETUS

1.
2.

Pulse increases
Systolic BP
slightly increased
due to pain and
anxiety
Minor injuries to
the birth canal

THIRD STAGE
1.

2.

Blood loss from
the placental site
(200 ml)
Blood loss from
laceration and
perineum (100 ml)

Moulding – overlapping of the vault bones
Caput succedaneum – it is a soft swelling of the most dependent part of the
fetal head


AIMS IN THE MANAGEMENT OF LABOUR
The AIMS include:
 To achieve delivery of a normal healthy child
 To anticipate, recognize and treat potential abnormal

conditions before significant hazard develops for the
mother or the fetus.


PRINCIPLES IN THE MANAGEMENT OF LABOUR
The principles include:
 Diagnosis of labour
 Monitoring the progress of labour
 Ensuring maternal well-being
 Ensuring fetal well-being.



MANAGEMENT
FIRST STAGE OF
LABOUR


MANAGEMENT OF THE FIRST STAGE OF LABOUR1
 On admission:
When the women presents at hospital, the woman’s antenatal record is reviewed to discover
whether there have been any abnormalities during her pregnancy. When there are no
records of antenatal care a complete history must be taken.
 General examination of the mother
a) General conditions – evaluate the mother general health condition. Look for pallor,
edema, abdominal scar (LSCS) and maternal height.
b) Vital signs – Blood pressure, pulse, respiration and temperature are taken and recorded
c) Heart and lungs
d) Urine analysis – for protein, sugar and ketones


 Abdominal examination:
a) A detailed abdominal examination should be carried out and recorded.
b) Determine the presentation and position of the fetus and also the engagement
c) Auscultate the fetal heart
d) Evaluate the uterine contraction
 Vaginal examination – the purpose is to
a) To make a positive diagnosis of labour
b) To make a positive identification of presentation
c) To determine whether the fetal head is engaged in case of doubt
d) To ascertain whether the fore waters have ruptured or to rupture them artificially
e) To exclude cord prolapse after rupture of the fore waters
f) To confirm the degree of cervical dilatation and position of the presenting part
g) To assess progress of labour.
h) To assess the adequacy of the pelvis.


 Bowel preparation:
If there has been no bowel action for 24 hours or the rectum feels loaded on vaginal
examination an enema is given.
 Bladder care
A full bladder may initially prevent the fetal head from entering the pelvic brim and later
impede descent of the fetal head. It will also inhibit effective uterine action.
The woman should be encouraged to empty her bladder every 1½ - 2 hours during labour.
The quantity of urine passed should be measured and recorded and a specimen obtained for
testing.

 Nutrition in early labour
No food is permitted after labour is established – to prevent regurgitation and aspiration
It is important to maintain adequate hydration - via intravenous routes


 Position of labouring mother:
As long as the patient is healthy, the presentation normal, the presenting part engaged, and
the fetus in good condition, the patient may walk about or may be in bed, as she wishes
 Monitoring the progress of labour
Once labour has become established, all events during labour should be recorded on a
partogram.
a) The well-being of the fetus
b) The well-being of the mother
c) The progress of the labour
 Pain relief
When the pains are severe an analgesic preparation may be given.
a) Opiate drugs – e.g. Pethidine given intramuscularly every 4 hour
b) Inhalational analgesia – e.g. Entonox
c) Epidural analagesia


LABOUR PAIN – causes1
 Pain in labour
The pain experienced by the woman in labour is caused by the:
1): Uterine contractions and uterine ischaemia.
2): Cervical dilatation. Dilatation and stretching of the cervix and lower uterine
segment stimulate nerve ganglia and are a major source of pain.
3): Distention of the vagina and perineum. Marked distention of the vagina and
perineum occurs with fetal descent, especially during the second stage.


LABOUR PAIN – causes2
 Pain in labour
Table 1: PAIN DURING THE STAGES OF LABOUR

STAGES OF LABOUR
FIRST STAGE

SECOND STAGE

THIRD STAGE

SORCES OF PAIN
Pain is caused mainly by uterine contractions, thinning of
the lower segment of the uterus, and dilatation of the
cervix.
Pain result from two sources:
1.The stretching of the vagina, vulva and perineum.
2.The contraction of the myometrium.
Pain is caused by the passage of the placenta through the
cervix, plus that produced by the uterine contractions.


PAIN RELIEF IN LABOUR – types
Three methods are in common use during labour:
1. Analgesic drugs (narcotics, e.g. pethidine) which
are given by intramuscularly injection.
2. Inhalation analgesia (e.g. Entonox).
3. Regional anaesthesia (e.g. epidural, spinal) that
blocks the sensory pain pathways.



MONITORING FETAL HEART

How Do Uterine Contractions Affect Fetal Heart Rate?
Uterine contractions can affect fetal heart rate by increasing or
decreasing that rate in association with any given contraction.
The three primary mechanisms by which uterine contractions can
cause a decrease in fetal heart rate are compression of:
·
Fetal head
·
Umbilical cord
·
Uterine myometrial vessels




How To Monitor The Fetal Heart Rate?
 Auscultation methods
 Electronic monitoring ~ CTG



To detect fetal hypoxia

ABNORMAL

NORMAL

APRIL 2005

DEPARTMENT OF
OBST & GYNAE
RCMP

RECORDING THE
PROGRESS OF LABOUR


RECORDING THE PROGRESS OF LABOUR
PATIENT INFORMATION
FETAL INFORMATION
~ fetal well being

LABOUR INFORMATION
~ Dilatation
~ Descent
~ Contraction

MEDICATIONS

MATERNAL INFORMATION
~ Well being


RECORDING THE PROGRESS OF LABOUR - Partogram
Patient information: Fill out name,
gravida, para, hospital number, date and
time of admission and time of ruptured
membranes.
Fetal heart rate: Record every half hour.
Amniotic fluid: Record the colour of
amniotic
fluid
at
every
vaginal
examination:
I: membranes intact;
C: membranes ruptured, clear fluid;
M: meconium-stained fluid;
B: blood-stained fluid.
Moulding:
1: sutures apposed;
2: sutures overlapped but reducible;
3: sutures overlapped and not reducible.


Assess the progress of labour:
Cervical dilatation: Assessed at every
vaginal examination and marked with a
cross (X). Begin plotting on the partograph
at 3 cm.
Station : recorded as a circle (O) at every
vaginal examination.
Contractions: Chart every half hour;
palpate the number of contractions in 10
minutes and their duration in seconds.
Less than 20 seconds:
Between 20 and 40 seconds:
More than 40 seconds:


Progress of maternal well being:
Oxytocin: Record the amount of oxytocin
every 30 minutes when used.
Drugs given: Record any additional
drugs given – e.g. Pethidine
Pulse: Record every 30 minutes and
mark with a dot (●).
Blood pressure: Record every 4 hours
and mark with arrows ( )
Temperature: Record every 2 hours.
Protein, acetone and volume: Record
every time urine is passed.



MANAGEMENT
SECOND STAGE OF
LABOUR


MANAGEMENT OF THE SECOND STAGE OF LABOUR1
Once the onset of the second stage has been confirmed a woman should
not be left without attendance. Accurate observation of progress is vital,
for the unexpected can always happen.
 Maternal position:
With the exception of avoiding supine position, the mother may assume any comfortable
position for effective bearing down.
The semi-recumbent or supported sitting position, with the thighs abducted, is the posture
most commonly adopted

 Bearing down
With each contraction, the mother should be encouraged to bear down with expulsive
efforts


 Observation during the second stage:
Four factors determine whether the second stage may be safely continued and these must
be carefully monitored throughout the second stage of labour.
1.

Maternal conditions
Observation includes an appraisal of the mother’s ability to cope emotionally as well as an
assessment of her physical wellbeing. A maternal pulse rate is usually recorded quarterhourly and bloods pressure hourly

2.

Fetal conditions - During the second stage, the fetal heart should be monitored either
continuously or after each contraction. stage may be associated with fetal distress.
The liquor amnii is observed for signs of meconium staining.

3.

Uterine contractions - The strength, length and frequency of contractions should be
assessed continuously.

4.

The progress of descent - The progress should be recorded approximately every 30
minutes during the second stage.


 CONDUCTING THE DELIVERY1:
When delivery is imminent, the patient is usually placed in the dorsal position, and the skin
over the lower abdomen, vulva, anus and upper thigh is cleansed with antiseptic solution
and draped.

DELIVERY OF THE HEAD
1) Control the delivery of the head to prevent laceration
2) Performed episiotomy if requires
3) Performed Ritgen’s method
4) Cleared the airway after delivery of the had


 PERFORMING AN EPISIOTOMY:

EPISIOTOMY
"..is a surgical incision into the perineum to enlarge the space at the
outlet
IS EPSIOTOMY REALLY NEEDED?
Episiotomies are said to provide the following benefits:
1.
2.
3.
4.
5.

Speed up the birth
Prevent Tearing
Protects against incontinence
Protects against pelvic floor relaxation
Heals easier than tears

medical research has not proven
any of these benefits



Episiotomies are not always necessary
Episiotomy should be considered only in the case of:

• Complicated vaginal delivery (breech, shoulder dystocia, forceps,

vacuum);

• Scarring of the perineum;
• Fetal distress.


Incision of episiotomy

Episiotomy Types

Midline episiotomy

Mediolateral episiotomy

The three major types of
episiotomy

J-shaped episiotomy


Making an incision
Performing an episiotomy will
cause bleeding. It should not,
therefore, be done too early.
Wait until:
1)

the perineum is thinned
out;
and

2)

Infiltrate perineum with
local anaesthetic agent

3–4 cm of the baby’s head
is
visible
during
a
contraction.


DELIVERY OF THE SHOULDERS
Delivery of the anterior shoulder is aided by
gentle downward traction on the head.

The posterior shoulder is delivered by
elevating the head.


DELIVERY OF THE TRUNK
After the delivery of the shoulders the baby is grasped around the chest to aid the birth of
the trunk.
Finally, the body is slowly extracted by traction on the shoulders and lifts the baby towards
the mother’s abdomen.
The time of delivery is noted.
CUTTING THE UMBILICAL CORD
After delivery, it is therefore usual to wait 15 to 20 seconds before clamping and cutting the
umbilical cord.
After cutting the cord a plastic crushing clamp is placed on the cord 1 to 2 cm from the
umbilicus and the cord is cut again 1 cm beyond the clamp.


IMMEDIATE CARE OF THE NEW BORN
Once the baby is breathing normally he should be dried and warmly wrapped to prevent
cooling and handle to the mother to hold, cuddle and enjoy.
If spontaneous respiration is not established soon after birth, resuscitation is the immediate
priority.
The Apgar’s score of the baby should be noted and
recorded.


LABOUR AND DELIVERY

THE MECHANISMS OF
NORMAL LABOUR
- Occiput anterior -



Occiput anterior (OA)
Anterior

Occipital bone

Pubis

Right

Left

Sacrum
Posterior



Occiput anterior positions



MECHANISM OF LABOUR for occiput anterior
DEFINITION:
The “mechanism of labour” refers to the sequencing of
events related to posturing and positioning that allows the
baby to find the “easiest way out”.
For a normal mechanism of labour to occur, both the fetal
and maternal factors must be harmonious.



MECHANISM OF LABOUR for occiput anterior
Events of mechanism of labour:
F:
I:
C:
E:
R:
I:
E:
L:

Flexion and descent
Internal rotation of the fetal head
Crowning
Extension
Restitution
Internal rotation of the shoulders
External rotation of the fetal head
Lateral flexion of the body


MECHANISM OF LABOUR for occiput anterior (OA)
F
I
C
E
R
I
E
L

Internal rotation of shoulder

Descend

External rotation of head
LOA

LOA

LOT

Restitution
Flexion
LOA

Internal rotation

OA

Extension
Lateral flexion of body
OA

Crowning

OA
Delivery



MANAGEMENT
THIRD STAGE OF
LABOUR


MANAGEMENT OF THE THIRD STAGE OF LABOUR
 BIRTH OF THE PLACENTA1:
Delivery of the placenta occurs in two stages:
(1) separation of the placenta from the wall of the uterus and into the lower uterine segment
and/or the vagina, and
(2) actual expulsion of the placenta out of the birth canal.


THE THIRD STAGE OF LABOUR
 MECHANISM OF PLACENTA SEPARATION1:

Two mechanisms of placental separation occurs:
1- Mathews-Duncan mechanism

2- Schultz mechanism

The leading edge of the placenta
separates first and the placenta is
delivered with its raw surface
exposed.

If the placenta is inserted at the
fundus and central area separates
first, the placenta inverts and draws
the membranes after it, covering the
raw surface (inverted umbrella)


LABOUR AND DELIVERY

WHAT ARE THE SIGNS OF
PLACENTA SEPARATION


CLINICAL SIGNS OF PLACENTAL SEPARATION
Placental separation takes place within 5 minutes after the delivery of the infant. Signs
suggesting that detachment or separation has taken place include:
1.

The uterus becomes globular and hard. This sign is the earliest to appear.

2.

There is often a sudden gush of blood

3.

The uterus rises in the abdomen because the placenta,
having separated, passes down into the lower segment
and vagina, where its bulk pushes the uterus upward.

4.

Cord lengthening. This is the most reliable clinical sign
of placental separation.



After the placental separation takes place the placenta can be
delivered by the:
1. Passive management – wait for spontaneous expulsion of placenta
2. Active management


LABOUR AND DELIVERY

ACTIVE MANAGEMENT OF
THE THIRD STAGE OF LABOUR


ACTIVE MANAGEMENT OF THE THIRD STAGE
Active management of the third stage (active delivery of the placenta)
helps prevent postpartum haemorrhage.
Active management of the third stage of labour includes:
~ use of oxytocin
~ controlled cord traction, and
~ uterine massage.


ACTIVE MANAGEMENT OF THE THIRD STAGE
~ Use of oxytocin
Oxytocic drugs should be given with the birth of the anterior shoulder.
Syntocinon is the most used oxytocic known to be effective; the addition of
ergometrine may reduce blood loss.
SYNTOMETRINE (oxytocin 5 IU + ergometrine 0.5 mg) – widely used


EXPULSION OF THE PLACENTA BY ACTIVE MANAGEMENT
When these signs have appeared the placenta is ready for expression. If the patient is
awake, she is asked to bear down while gentle traction is made on the umbilical cord.
The popular and effective method of delivering the placenta is by Brandt-Andrews method.


BRANDT’S ANDREW METHOD
Once the signs of placental separation have occurred the obstetrician assists delivery of the
placenta by controlled cord traction as described by Brandt-Andrews’ method.

A) Placenta separation

B) Controlled cord traction

C) Delivery of the membranes


EXAMINATION OF THE PLACENTA
The placenta, membranes, and umbilical cord should be examined for completeness and for
anomalies.

EXAMINATION OF THE PERINEUM
At the same time, the perineal region, vulva outlet, vaginal canal, and the cervix should be
carefully examined for lacerations.
If the perineum has been torn or an episiotomy made, tear or incision should be repaired
immediately.


 REPAIR OF EPISIOTOMY:

Note: It is important that absorbable sutures be used for closure.
Vaginal mucosa
1.

Identify apex

2.

Begin suturing
1.0 cm above apex

3.

Continuous sutures

4.

Ends at the level of
vaginal opening

Continuous sutures

Interrupted sutures

Interrupted suture or
subcuticular

APRIL 2005

DEPARTMENT OF
OBST & GYNAE
RCMP

MANAGEMENT AFTER
DELIVERY


IMMEDIATE MANAGEMENT AFTER THE DELIVERY
 EARLY POSTPARTUM MANAGEMENT:
The hours immediately following delivery and the birth of the placenta are a critical period
as postpartum haemorrhage can occurs due the relaxation of the uterus.
The patient is kept in the delivery suite for 1 hour postpartum under close observation. She
is check for bleeding, the blood pressure is measured, and the pulse is counted.
Before discharging the patient from the delivery suit it is mandatory:
To check the uterus frequently to make sure it is firm and not relaxing.
To remove any presence of intrauterine blood clots. The presence of these clots will
interfere with retraction and the normal haemostatic mechanism of the uterus.
 To look at the introitus to see that there is no haemorrhage.
 To keep the bladder empties because full bladder can also interfere with uterine retraction.
 To examine the baby to be certain that it is breathing well and that the colour and tone are
normal.



Normal labour and delivery

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