Management of Normal Labour
World Health Organization defined normal birth as
Spontaneous in onset
Low-risk at the start of labour and remaining so throughout labour and delivery
The infant is born spontaneously in the vertex position between 37 and 42 completed
weeks of pregnancy
After birth, mother and infant are in good condition
True Labour Pain
A clinical diagnosis is based upon
Regular phasic uterine contractions
Increasing in intensity and frequency and
Progressive cervical effacement and dilatation
Braxton Hicks Contractions
Irregular and sporadic
Painless practice contractions
Stages of Labour
1st stage (dilatation up to 10 cm); includes the latent phase and active phase
2nd stage (fully dilated); passive (not pushing) and active (pushing) ends with delivery of
baby
3rd stage; delivery of placenta and membranes
1st Stage
Latent phase; gradual cervical change, dilatation < 4 cm
Softening, shortening and effacement of cervix
Not yet in established or active labour, may stop and start
Usually no more than 8 – 12 hours
Can be prolonged if fetal malposition; e.g., occipital posterior
Low-risk women, recommend staying at home/war, bath/mobilization/simple analgesia
Active phase rapid cervical change
Progressive cervical dilatation of ≥ 4 cm – 10 cm
Normal progress is minimum of 0.5 cm/hour dilatation
Assess descent and rotation as well as dilatation
Effacement
Station
Bishop score
Partogram
Figure – Descent of the Fetal Head in relationship to Ischial spines
The higher scores show ripening of the cervix which means
Labour is closer
Induction of labour more likely to be easier, shorter and successful
The Partogram
Used since the 1950 s
Graphical chart used to monitor active labour which is recommended by WHO
But, recent Cochrane review suggested no evidence of decreasing fetal/ maternal
mortality
Includes sets of data on;
Maternal BP, pulse and temperature
Fetal heart rate
Cervical opening (dilatation)
Descent of the fetal head in relation to ischial spines
Provides easy way to assess progress of labour and identify need for intervention
Why monitor progress in labour?
The sun should not rise or set twice on a woman in labour – African proverb
Prolonged labour
Fetal hypoxia
Poor perinatal outcomes
Pelvic floor damage
Obstetric fistula
PPH
Maternal death
Infection
Uterine rupture
Management of Labour
Management of 1st stage of labour
Monitoring vital signs
Maternal blood pressure; heart and respiratory rates; temperature; frequency
Fetal heart rate (FHR)
Fetal lie, presentation and position
Progress of labour by VEs (after excluding placenta praevia and PROM)
Use of partogram in the 1st stage
Pain control and comfort measures
Gas and air (Entonox)
Oral/injection opiates (oral morphine, injection pethidine/diamorphine)
Epidural anaesthesia
CSE (combined spinal epidural)
CTG (Cardiotocography)
Continuous electronic monitoring of the fetal heart rate and uterine contractions
Used to assess fetal wellbeing
Non-Pharmacological Control
Self-soothing activities – e.g., slow breathing, breathing technique
Change comfortable positions
Birth ball
War, shower and water bath, touch and message, music, yoga
Support from partner or doula
Transcutaneous electrical nerve stimulation (TENS)
Aromatherapy, acupuncture, hypnotherapy
Management of 2nd Stage
From full dilatation to delivery of the baby
Need to understand the mechanism of delivery with knowledge of the anatomy of the
pelvis and fetal head
Passive stage (no pushing)
Active stage (pushing)
Nulliparous woman
Birth should be expected to take place within 3 hours of the start of active pushing
Multiparous woman
Birth should take place within 2 hours of the start of active pushing
Mechanism of Delivery (For Revision)
Head at pelvic brim Occipital transverse (OT) position
Flexion of neck
Head descends and engages
Head reaches pelvic floor – rotates to Occipital anterior
Head delivers by extension
Shoulders rotate into anterior/posterior diameter of pelvis
Head restitutes (comes in line with the shoulders)
Anterior shoulder delivered by lateral flexion from downward pressure on baby’s head
Posterior shoulder by upward lateral flexion
Episiotomy
Performed to enlarge the birth outlet and facilitate delivery of the fetus
Routine use of episiotomy has become unfavour due to increased complications with use
Episiotomy is considered when the patient at high risk of a third or fourth degree perineal
tears or when the fetal heart tracing is of concern
Mediolateral episiotomy is associated with a lower risk of third and fourth degree
laceration than a median episiotomy
Management of the Third Stage
From the birth of the newborn to expulsion of the placenta
Active management of 3rd stage – shorten the 3rd stage, less blood loss and prevent PPH
Administration of a paraphylactatic uterotonic drugs such as IM/IV syntocinon 10 units
or IM Syntometrine (Oxytocin 5 units and ergometrine 0.5 mg) just after delivery of the
anterior shoulder or after birth of the newborn
Followed by gentle controlled traction of the cord
Physiological management – no drugs
3rd stage can be long upto 1 hour more blood loss risk of PPH
Which is malpresentation?
The vertex is not coming first
Face
Brow
Breech
Shoulder
Transverse lie
Summary
Normal labour is spontaneous onset, infant is born spontaneously in the vertx position
between 37 and 42 completed weeks of pregnancy
After birth, mother and infant are in good condition
1st stage (dilatation up to 10 cm)
2nd stage – full dilatation till the fetus is born
3rd stage – delivery of placenta and menbranes
1st Stage
Nulliparous woman – minimum of 0.5 cm/hour dilatation
Multiparous woman – minimum of 1 cm/hour dilatation
2nd Stage
Nulliparous woman – birth should be expected to take place within 3 hours of the start of
active pushing
Multiparous woman – birth should take place within 2 hours of the start of active pushing
Operative Vaginal Delivery of Instrumental Delivery
OVD
Forceps or vacuum extractor (ventouse)
Goal – expedite delivery with minimal maternal or neonatal morbidity
Safety criteria have been met
Benefits outweigh risks
RCOG – obstetricians should achieve experience in spontaneous vaginal delivery prior to
commencing training in OVDs
Obstetrician must have competency in chosen procedure
Trainees under direct supervision of an experienced trainer
Incidence
UK – 10 % and 15 % of deliveries
Nulliparous women - 30 %
Widely varies within/between countries, and this impacts on rates of 2nd stage CS
Strategies to lower rates of OVD including
One to one midwifery care in labour
Presence of a birth partner
Delayed pushing in 2nd stage of labour, especially with epidural
Oxytocin use to enhance expulsive contractions in 2nd stage
Maternal repositioning to enhance the effects of gravity and maternal urge to push
History
History of forceps delivery is fascinating
Use of birth instruments was initially limited to the extraction of dead fetuses via
destructive techniques, from as early as 1500 BC
There exist reports of successful deliveries of live infants in obstructed labour
Modern obstetric forceps by the Chamberlen, a Huguenot family practicing in England,
dramatically changed the role of assisted delivery in favour of a live infant
William Smellie, a Scottish doctor
Indication
Fetal
Suspected fetal compromise (CTG pathological, abnormal pH or lactate on fetal blood
sampling, thick meconium)
Maternal
Nulliparous women – no progress for 3 hours with regional anaesthesia or 2 hours
without regional anaesthesia
Multiparous women – no progress for 2 hours with regional anaesthesia or 1 hour without
regional anaesthesia
Maternal exhaustion/vomiting/distress
Medical indications to avoid prolonged pushing or Valsalva (e.g., cardiac disease,
hypertensive crisis, cerebral vascular disease, particularly uncorrected cerebral vascular
malformations, myasthenia gravis, spinal cord injury)
Combined
Fetal and maternal indications often coexist
Classification of Operative Vaginal Delivery
Outlet
Fetal scalp visible without separating the labia
Fetal skull has reached the pelvic floor
Sagittal suture is in the antero-posterior diameter or right or left occiput anterior or
posterior position (rotation does not exceed 45’)
Fetal head is at or on the perineum
Low
Leading point of the skull (not caput) is at station plus 2 cm or more but not on the pelvic
floor
Two subdivisions: rotation of 45 ‘ or less, rotation more than 45’
Mid
Fetal head is no more than 1/5 palpable per abdomen, usually 0/5 leading point of the
skull is above station plus 2 cm but not above the ischial spines (station 0 to + 1)
High
Not appropriate, therefore not included in classification (station -1 or above)
Contraindications
Both instruments
Breech presentation
Before full dilatation of the cervix (exceptions > vaccum delivery of 2nd twin where
cervix has contracted in interval between delivery of 1st and 2nd twins)
Inexperienced operator
Ventouse
Face presentation
Less than 34 weeks > risk of cephalhaematoma and intracranial haemorrhage
Relatively CI if 35 – 36 weeks
Significant degree of caput – preclude correct placement of cup or more sinisterly,
indicate a substantial degree of CPD
Minimal risk of fetal haemorrhage after following fetal blood sampling (FBS) or
application of a fetal scalp electrode (FSE)
Safety Criteria for Operative Delivery
Full abdominal and vaginal examination
Head ≤1/5 palpable per abdomen (in most cases 0/5 palpable)
Cervix is fully dilated and membranes ruptured
Station at level of ischial spines or below (0/ +1/ +2/ =3)
Exact position of the head has been determined so correct placement of the instrument
can be achieved
Caput and moulding is no more than moderate
Pelvis is deemed adequate
Safety Criteria for Operative Vaginal Delivery
Preparation of mother
Clear explantation and informed consent
Trust has been established and woman offers full co-operation
Appropriate anaesthesia;
Midpelvic rotational delivery > regional block;
A pudendal block may be appropriate in urgency;
Low-pelvic or outlet delivery > perineal block
Bladder – emptied recently
Indwelling catheter has been removed or balloon deflated
Aseptic technique
Preparation of staff
Operator – knowledge, experience and skill
Adequate facilities are available (appropriate equipment, bed, lighting) and access to OT
Back-up plan in place if fail
For midpelvic deliveries, theatre staff should be available immediately to allow CS to be
performed (< 30 minutes);
Senior obstetrician should be present if a junior obstetrician is conducting delivery
Anticipation of complications that may arise (e.g., shoulder dystocia, perineal trauma,
postpartum haemorrhage)
Personnel present that are trained in neonatal resuscitation
Vacuum vs Forceps
Vacuum
Significantly more likely to be associated with;
Failure to achieve a vaginal delivery
Cephalohaematoma (subperisteal bleed)
Retinal haemorrhage
Maternal worries about the baby
Forceps
Significantly less likely to be associated with;
Use of maternal regional/general anaesthesia
Significant maternal perineal and vaginal trauma
Severe perineal pain at 24 hours
Similar in terms of:
Delivery by caesarean section (where failed vacuum is completed by forceps)
5 minute Apgar scores
Expediting Birth
Assessments should include;
Degree of urgency
Clinical findings on abdominal and vaginal examination
Choice of mode of birth (and whether to use forceps or ventouse if an instrumental birth
is indicated)
Anticipated degree of difficulty, including the likelihood of success if instrumental birth
is attempted
Location
The need for additional analgesia or anaesthesia
The woman’s preferences
Place of Delivery
Prospective cohort study (UK)
CS in 2nd stage
Women > major haemorrhage
Babies > less likely to have trauma, but more likely to admission for ICU
Experience of operator was directly related to major haemorrhage whatever mode of
delivery
Subsequent pregnancies, 70 % who had 2nd stage CS > repeat CS in the next pregnancy
compared to only
10 % of women who ad a successful OVD
Aim to deliver vaginally, unless there are CI or woman expresses a clear preference for
CS
Psychological consequences of transferring a patient to OT in 2nd stage of labour should
not be underestimated
Most midpelvic procedures, which by their nature have a higher rate of complications
than outlet or low deliveries, should be performed in OT with immediate resource to CS
Positioning
Lithotomy position
Angle of traction needed requires that bottom part of the bed removed
Limited abduction (such as those with symphysis pubis dysfunction), it mat be necessary
to limit abduction of the thighs to a minimum
Instrument Types Ventouse/Vacuum Extractors
Vacuum extraction – suction cup, of a silastic or rigid construction, is connected, via
tubing to a vacuum source
Either directly through tubing or via a connecting chain, direct traction can then be
applied to the presenting part
Recent – removed need for cumbersome external suction generators and have
incorporated the vacuum mechanism into hand-held pumps (e.g., OmniCup)
Success rates similar to that of standard vacuum devices
Figure – Metal Ventouse Cup
Figure – Silicone Cup Vacuum
Figure – OmniCup
Forceps/ Types of Forceps
Two blades with shanks, joined together at a lock, with handles to provide a point for
traction
Blades may be fenestrated (open), pesudofenestrated (open with a protruding ridge) or
solid
Lock (convergent, divergent or sliding)
Fashioning of the handles are instrument specific
Forceps
Non-rotational forceps – head is OA < 45’ deviation (LOA, ROA)
Examples such as Neville Barnes or Simpson forceps have a pelvic curve and an English
or non-sliding lock
If head is positioned > 45’ from the vertical, rotation must be accomplished before
traction
Forceps designed for rotation, such as Kielland forceps have minimal pelvic curve to
allow rotation around a fixed axis
Roles of Episiotomy
Controversial
RCT – routine approach was neither protective nor associated with increased risk of
severe perineal tearing
Most obstetricians cut routinely for forceps delivery, especially in nulliparous deliveries
where anal sphincter damage is more likely
Parous women, particularly those requiring ventouse delivery, an episiotomy may not be
necessary
Failure of Chosen Instrument
Choice is wrong
Application of instrument is wrong (e.g., ventouse application over the anterior
fontanelle)
Position – wrongly defined (most commonly OP – OA errors) > inappropriately large
diameters
More common if fetus is large or maternal effort is poor
Observational studies – outcomes for babies are worse with multiple or sequential use of
instruments
Rates of third and fourth degree tears are higher when a second instrument is used
Cup detachment, OA and on perineum > low pelvic or liftout forceps to complete
delivery is less traumatic than 2nd stage CS
No descent with first pull of a correctly applied instrument with raction in the correct axis
of the pelvis > delivery must be by CS as the likely CPD
If instrument failed because position was incorrectlt defined
> rotational instrumental delivery
> CS
Uncertainty, senior help should be sought immediately and a full re-evaluation should
take place, ideally in OT
CS will be the safer option for fetus
Complications
Short and long term morbidity of maternal pelvic floor injury
Third and forth degree perineal tears > fecal incontinence
Underestimation of blood loss
PPH > spontaneously, but less common than delivered by CS in 2nd stage
Increase in litigation
Forceps
Fetal trauma due to forceps delivery, particularly rotational > long established
Vacuum
Maternal deaths due to cervical tearing before full dilatation
Infant fatality secondary to intracranial haemorrhage (cephalhaematoma, subgaleal
haemorrhage)
Risk of trauma to the baby correlate with duration of traction exposed to multiple
attempts
