This presentation describe in brief the labour and midwifery care

2. NORMAL LABOR
Labor is described as the process by which the fetus,
placenta and membranes are expelled through the
birth canal.
Normal labor occurs at term and is spontaneous in
onset with the fetus presenting by the vertex. the
process is completed within 18 hours and no
complications arise.
 These labor abnormalities are best described as protraction
disorders (ie, slower than normal progress) or arrest disorders
(ie, complete cessation of progress).

3. STAGES OF LABOR
1-The 1st stage is that of dilation of the cervix
2-The 2nd stage of labor and is the expulsion of the fetus.
3-The 3rd stage of labor icludes separation and expulsion
of placenta and membranes.
4-The 4th stage lasts from delivery of the placenta until the
postpartum condition of the woman has become stabilize
''usually 1-2 hour after delivery''

4. STAGES OF LABOR

5. THE 1ST STAGE CONSISTS OF 3 PHASES
A. Latent phase: cervical dilations is 0-3 cm
1- Begins with regular contractions (labor pains).
2- pains are similar to painful menstrual cramping and are usually
accompanied by low back pain.
3-Contractions during this phase are more than 5 minutes apart,
last 25 to 35 seconds, and are considered to be mild. usually, woman is
excited about labor and talkative.
B. Active phase: cervical dilation is 4-7 cm.
1- more active contractions.
2- The contractions become more frequent (every 3 to 5 minutes), last
longer (60 seconds), and are of a moderate to strong intensity.

6. THE 1ST STAGE CONSISTS OF 3 PHASES
3- Cervical dilation become advances more quickly
4- nulliparous women abut 1 cm of dilation per hour and
multiparas at 1.5cm of cervical dilation per hour
C. Transitional phase: cervical dilation is 7-10 cm
1- The transition phase is the most intense phase of labor.
Transition is characterized by frequent
2- strong contractions that occur every 2 to 3 minutes and
last 60 to 90 seconds on average.
3- That a woman may feel during transition include rectal
pressure, an increased urge to bear down, an increase in
bloody show, and spontaneous rupture of the membranes
(if they have not already ruptured).

7. True and false labor contractions
TRUE AND FALSE LABOR CONTRACTIONS

8. THE FIRST STAGE OF LABOUR
Duration:
primigravida = 8-12 h
multigravida = 6-8 h
Phases of the first stage:
Latent phase: started when the cervix dilatated slowly-
reached to about 3cm.
in primigravida = 4-6h
in multigravida = 4.8 h
- Active phase: rapid dilatation of the cervix to reach 10cm
in primigravda = 4h
in multigravida =2h

9.  Prolong Latent phase : A failure of thinning of the lower
segment, effacement and dilation of the cervix despite
several hours of painful contractions.
Management:
 Simple analgesia
 Encourage mobilization
 Reassurance
 AROM and oxytocin will cause poor progress
ABNORMAL LABOR INDICATORS
Nulliparous Multiparous
Latent phase 4.6 h 4.8 h
Abnormal 20 h 14 h

10. Protracted active phase ( Prolong active
phase)
Protracted active phase dilation is a common dysfunctional
labor pattern
 → Most common in first labour.
 → Implies slow progress during the active phase of
labour.
 → Usually with inefficient uterine contractions.
 → Abnormalities of passenger
 It seems to be associated with mild cephalopelvic
disproportion.
ABNORMAL LABOR INDICATORS

11. Arrest of labor
absence of progress of active labor (as defined by cervical
dilation and descent of the presenting part) for 2 hours or
longer.
There is a well-recognized relationship of arrest with
fetopelvic disproportion.
It has been suggested that the diagnosis not be made
unless labor is active,
The cervix is dilated greater than 4 cm, and there has
been 2 hours of no cervical change with 200
Montevideo units or more per 10-minute interval.
ABNORMAL LABOR INDICATORS

12. LABOR INDICATORS
Idication Nullipara Multipara
Prolonged latent phase >20 h >14 h
Average second stage 50 min 20 min
Prolonged second stage without
(with) epidural
>2 h (>3 h) >1 h (>2 h)
Protracted dilation < 1.2 cm/h < 1.5 cm/h
Protracted descent < 1 cm/h < 2 cm/h
Arrest of dilation* >2 h >2 h
Arrest of descent* >2 h >1 h
Prolonged third stage >30 min >30 min
*Adequate contractions >200 Montevideo units [MVU] per 10 minutes for 2 hours. (Please refer to the
Pathophysiology for information regarding adequate contractions.)

13. DIAGNOSIS OF LABOR
The determination of whether a woman is in labor is made within
one hour of admission .
Diagnosis of labor is made only when painful contractions are
accompanied by any one of the following :
 Bloody show
 Rupture of the membranes
 Full cervical effacement.
 Cervical dilatation is not part of the criteria
Meet the criteria
Rest &
observation
Until next day
Antenatal
ward
Didn’t meet the
criteria

14. MANAGEMENT OF LABOUR
The management of labour should be
commenced during the antenatal period
the women should be classified as high or low
risk pregnancy.
The medical or surgical problems should be
corrected as in case of (anaemia,
hypertension, urinary tract infection) and all
investigations should be performed and
prepared such as (HIV, HCV, Hbs Ag, blood
grouping…….etc).

15. AIM OF FIRST STAGE MANAGEMENT:
1- achieve delivery of normal healthy child with with minimal
physical and psychological maternal effect.
2- early anticipation, recognition and management of any
abnormalities during labour.

16. ADMISSION TO LABOUR
 Welcoming the woman
 Review the referral note or pregnancy card to review history.
 Check and record the vital sign: BP-RR-Temp
 Auscultate fetal heart sound.
 Assess uterine contraction.
 Ask to woman to empty bladder and give urine spacemen.

17. MIDWIFERY CARE
 Nutrition and fluid :
1- encourage intake of oral fluid and come candies.
2- Encourage voiding every 2 hr.
 Ambulation and position:
1- encourage ambulation if continues monitoring is not required.
2- encourage woman to avoid lying on her back.
3- if lying back encourage to be on left lateral position.
 Hygiene:
1- offer to woman have a shower upon admission if she desire.
2-encourage and assess having warm shower if woman is not active
phase.
3- assist woman to keep Perineal clean after vaginal examination.
4-change wet linen whatever possible .

19. MIDWIFERY CARE (CONT.)
 Artificial rupture of membrane:
1- perform artificial rupture of membrane if woman is 4 cm or more.
2- head is well applied.
3- Head is engaged
The AROM is don by physician at MOH hospital and it can be don my
midwife under doctor supervision or if the woman is 6 cm or more
 Follow-up
1- follow the progress of labour utilizing the partogram.
2- conduct vaginal examination in following condition:
a. Upon admotion.
b. After AROM
c. Q 2-4 hr
Document all of procedure, assessment finding on partogram.

20. MIDWIFERY CARE (CONT.)
cervical examination should be kept to a
minimum to avoid promoting intraamniotic
infection.
In general, vaginal examinations are
performed:
• On admission
• At one to four hour intervals in the first stage and at one hour intervals in the second stage
• At rupture of membranes to evaluate for cord prolapse
• Prior to intrapartum administration of analgesia
• When the parturient feels the urge to push to determine whether the cervix is fully dilated
• If the FHR falls, to evaluate for conditions such as cord prolapse or uterine rupture.

21. MIDWIFERY CARE (CONT.)
A. Establish good rapport and trust beginning with the first contact and maintain it
throughout the woman’s stay.
B. Follow the woman’s wishes on including her husband or relatives.
C. Explain all procedures and processes.
D. Keep the woman informed about all decisions.
E. Listen respectfully to questions and answer her calmly and reassuringly.
F. Respect the woman’s privacy.
G. Provide continuous emotional support.
H. Allow the woman to drink fluids, eat light meals and walk.

22. PAIN RELIEVE FOR WOMAN IN ACTIVE
PHASE
 Changing of body positions: lying down, walking, sitting etc.
 Vocalization: reading Quran and chanting.
 Breathing exercise
 Touch and massage.
 Hot/cold packs.
 Warm shower: if possible may relieve her pain & increase her
labour contraction.
 Relaxation techniques.
 Document alternative measures & any medication given.

23. PARTOGRAM
Definition:
it is graphical record of key data of labor progress
with both maternal and fetal data.
it is the process by which normal and abnormal
progress of labor and also fetal response in labor
can be defined.

24. IMPORTANCE
It allows an instant visual assessment of the rate
of
Cervical dilatation and comparison with an
expected
Norm , so that slow progress can be recognized
Early and appropriate actions taken to correct it
Where possible.

25. it is a graphic representation of cervical
dilatation and descent of the presenting part .
* it is an essential part of the partogram .
it offers the chance of early detection of slow progress of
labor
* first ,we set an alert line at 1cm/h. for the active
phase dilatation to represent the ideal progress.
then.
PART 1 : PROGRESS OF LABOR CERVICOGRAM ):

26. Starting a Pantograph
A pantograph should be started only when a
woman is in active phase of labour
Contractions must be 1 or more in 10mins, each
lasting for 20secs or more
Cervical dilatation must be 4cms or more
PART 1 : PROGRESS OF LABOR CERVICOGRAM ):

27.  The plot of first digital examination should be put on alert line
 It should be at alert line or at the left of it
 If it moves to the right of the alert line, labour may be prolonged
Normal Latent and Active Phases
Latent phase is less than 8 hrs. and active phase
remains to the left of or on the alert line
Do not augment with oxytocin or intervene unless
complications develop
ARM may be done at any time in the active phase
PART 1 : PROGRESS OF LABOR CERVICOGRAM ):

28. Between Alert and Action lines ( moving to the right)
 It is 4 hours to the right of Alert line
 Assess the cause of slow progress and take action
 Action should be taken in a place with facility for dealing with obstetric
emergencies is available
It indicate prolong active phase of labour
In a Health Centre:
1- Transfer to hospital with facilities for Cesarean section, unless Cervix is almost
fully dilated
2- ARM may be performed if membranes are still intact and observe labour for a short
period before transfer
In Hospital:
Perform ARM if membranes are intact and continue routine observations
PART 1 : PROGRESS OF LABOR CERVICOGRAM ):

29. PART 1 : PROGRESS OF LABOR CERVICOGRAM ):
At or Beyond Active Phase Action Line
Full medical assessment
Consider IV infusion/bladder catheterization/analgesia
Options:
Delivery if fetal distress or obstructed labour
Oxytocin augmentation if no contraindication
digital examination after 3 hr , then in 2 or more hr: then in 2
or more hr
failure to have progress which mean delivery is indicated

30. Under supervision of physician:
Undersupervioin of doctor:
Perform Aminotomy if the membrane is
intact
Augment uterine contraction by oxytocin
in absence of contraction
Perform vaginal examination Q2 hr
If no progress after 6 hr of augmentation
, LSCS is indicated
30‫كانون‬،‫األول‬14
APPLICATION OF PARTOGRAM

31. PARTOGRAM IN FIRST STAGE
OF LABOUR
 Star partogram for every woman in active phase of labour.
 Record fetal condition include:
Assess fetal heart Q 30 mint.
 Use the following keys in documentation:
I= intact membrane.
C= clear
B= blood staining
M= meconium
 Moulding:
0= bon are normally separated.
+ = bon touching each other.
++ = bone overlapping but easily separated.
+++ = bone overlapping but can not separated.

32. PARTOGRAM IN FIRST STAGE OF
LABOUR
BP= 2 hr
Puls=30 minutes
Temp= 2 hr
Check and record all rein passed for albumin
Drug administration include oxytocin
IV fluid.
 Record progress of labour:
Cx dilatation = Q2-4 hr
Uterine contraction if is week, moderate or strong
It should to be assessed about frequency and duration.

33. 30‫كانون‬،‫األول‬14

34. USE OF OXYTOCIN:
 The midwife will obtain the physician order before
initiating and oxytocin infusion:
1- perform vaginal examination.
2- commence oxytocin via dropper machine
3- follow the following standard of oxytocin initiation.
6- add 5 unit to 500 ml R/l
7- increase the drip rate according to IOL protocol at 30
minutes interval until contraction lasting until
contraction lasting for 40- 45 sec. and occurring 3-4/10
minute.
8- the license maximum dose is 20 milliunits per
minutes i.e. 24 dpm ( 72ml/hr)

35. USE OF OXYTOCIN
Keep woman under continues fetal monitoring.
Reduce oxytocin if good contractions have been
established to prevent hyper stimulation
Reassess progress by vaginal examination q/2 hr
 Discontinue oxytocin in case of:
1- hypertonic uterine contraction.
2- Prolong fetal deceleration
3- Persistent fetal bradycardia.
4- Document .