By: Dr. Ayman Bukhari
House officer
Obstetrics & Gynaecology
Contents:
 Introduction
 Stages of labor
 Diagnosis
 Management on admission
 Active management of labor
 Monitoring
 Partogram
 Abnormalities
 Pain control
Introduction
 Labor : Uterine contractions resulting in progressive
dilation and effacement of the cervix and accompanied
by descent and expulsion of the fetus.
 Abnormal labor, dystocia, and failure to progress are
terms used to describe a difficult labor pattern
 Approximately 20 % of labors involve dystocia
Stages of labor
NORMAL LABOR — divided into Four stages
 First stage: time from the onset of labor until complete
cervical dilatation
 Second stage: time from complete cervical dilatation to
expulsion of the fetus
 Third stage: time from expulsion of the fetus to
expulsion of the placenta
 Fourth stage: the 1st post partum hour..
Recommendations on definitions of
the first stage of labor:
The first stage is further subdivided into the latent and
active phases.
active phase subdivided into three additional phases:
1.
acceleration phase
2.
phase of maximum slope
3.
deceleration phase
Recommendations on definitions of
the first stage of labor:
 Latent phase — The existence of a latent phase and
subphases of active labor are somewhat controversial.
 Latent phase is typically characterized by mild,
infrequent, irregular contractions with gradual change
in cervical dilation (usually <1 cm / h) and effacement.
Nulliparous
Multiparous
Latent phase
6.4 h
4.8 h
Abnormal
20 h
14 h
• Not influenced by maternal age, birth weight, or obstetric abnormalities
Recommendations on definitions of
the first stage of labor:
 Active phase — begins at 3 to 4 centimeters when
cervical dilatation is plotted against time: this is the
beginning of the active phase.
 characterized by painful contractions of increasing
frequency, intensity, and duration accompanied by
more rapid (usually >1 cm /h) cervical change.
Recommendations on definitions of
the first stage of labor:
Recommendations on definitions of
the first stage of labor:
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 painfull 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
Didn’t meet the
criteria
Antinatal
ward
Rest &
observation
Until next day
Diagnosis of labor
 The correct diagnosis of labor is considered to be the
single most important determination in the
management of labor because an incorrect diagnosis
of active labor will lead to inappropriate interventions
and an increased likelihood of cesarean delivery.
Management on admission
 Patient preparation — There is no evidence that
routine enemas or perineal shaving is beneficial .
 A urinary catheter is not necessary unless the woman
is unable to void, but she should be encouraged to
empty her bladder regularly as a full bladder can
impede fetal descent.
 Fluids and oral intake — There is no consensus on
acceptable maternal oral intake during
uncomplicated labor
Management on admission
 Placement of an intravenous line or a hep-lock at
the time admission is recommended.
 Interestingly, one randomized trial found that women
who received intravenous hydration at 250 mL/h had
fewer labors persisting for over 12 hours and less need
for oxytocin augmentation than those who received 125
mL/h
Management on admission
 Antibiotic prophylaxis : (in some centers)
to prevent early-onset neonatal infection is
appropriate patients;
the agent of choice is intravenous penicillin. A
minimum of four hours of intrapartum therapy has
been recommended prior to delivery
 Although normal labor and vaginal delivery is not an
indication for prophylaxis against infective
endocarditis, some centers generally administer
antibiotic prophylaxis during labor to pregnant women
with underlying valvular heart disease.
Management on admission
 Monitoring — All pregnant women require
surveillance (eg, monitoring of vital signs and FHR)
since 20 to 25 % of all perinatal morbidity and
mortality occurs in pregnancies with no underlying
risk factors for adverse outcome .
 Assessment of the quality of the uterine contractions
and cervical examinations are repeated at appropriate
intervals to follow the progress of labor.
Management on admission
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.
The results can be noted on a partogram
Management on admission
Active management of labor
It refers to active control, rather than passive observation,
over the course of labor by the obstetrical provider.
It includes three essential elements
I. Careful diagnosis of labor by strict criteria
II. Constant monitoring of labor with specific standards
for normal progression
III. Prompt intervention (eg, amniotomy, high dose
oxytocin) according to established guidelines if progress
is unsatisfactory .
Active management of labor
The active management of labor is generally limited to
women who meet the following criteria:
1) Nulliparous
2) Term pregnancy
3) Singleton infant in cephalic presentation
4) No pregnancy complications
5) Experiencing spontaneous onset of labor.
Active management of labor
 Nulliparous labor tends to be more subject to failure
to progress .
 administration of oxytocin, sometimes at high
dosages, is one of the interventions involved in active
management. This is safer in nulligravid women since
the nulligravid uterus is virtually immune to rupture
(except as a result of manipulation or previous surgery)
Active management of labor
Recommendation on routine amniotomy

Limited evidence showed no substantial benefit for
early amniotomy and routine use of oxytocin
compared with conservative management of labor.
 In normally progressing labor, amniotomy should
not be performed routinely.

Combined early amniotomy with use of oxytocin
should not be used routinely.
Active management of labor
Interventions with amniotomy and/or high dose
oxytocin are initiated if progress does not proceed
according to the defined standards.
 Rutpure of the fetal membranes provides information
about fetal status, but does not appear to significantly
accelerate labor . In the Dublin protocol, rupture must
be performed before treatment with oxytocin, which is
administered only in the presence of clear amniotic
fluid .
Active management of labor
 If membranes are ruptured when there is
polyhydramnios or an unengaged fetal presenting part,
it is prudent to use a small gauge needle, rather than a
hook, to puncture the fetal membranes in one or more
places, and to perform the procedure in the operating
room. This "controlled amniotomy“ permits
emergency cesarean delivery in the event of an
umbilical cord prolapse .
 Routine amniotomy should not be performed in
women with active hepatitis B & C or HIV in order to
minimize exposure of the fetus to ascending infection.
Active management of labor
 So usually, Amniotomy is indicated to further evaluate
fetal status (eg, placement of a fetal scalp electrode) or
uterine contractions (eg, placement of an intrauterine
pressure catheter).
Active management of labor
 Slower progress in the nulliparous patient is most
often the result of inefficient uterine action .
 In the absence of medical contraindications, labor
that fails to progress is treated with oxytocin
Monitoring
 It is desirable that all examinations
be performed by a single individual
to minimize interobserver
variations
 A vaginal examination during labor
often raises anxiety and interrupts
the woman’s focus & if there is
(PRoM), increasing numbers of VEs
have been found to be associated
with neonatal sepsis ….
Monitoring:
Recommendations on monitoring during the
established first stage of labor
 A pictorial record of labor (partogram) should be used once labor is established.

4 hourly temperature and blood pressure

hourly pulse

half-hourly documentation of frequency of contractions

frequency of emptying the bladder

vaginal examination offered 4 hourly, or when there is concern about progress
 Intermittent auscultation of the fetal heart after a contraction should occur for at least
1 minute, at least every 15 minutes, and the rate should be recorded as an average.
Monitoring:
Recommendations on initial monitoring:
1) Psychological & Emotional
2) Vitals & Urinalysis
3) Uterine contractions
4) Abdominal examination_Leopold manouvers
5) Vaginal loss – show, liquor, blood
6) Vaginal examination....when necessary
7) Pain control
8) FHR
Monitoring:
Explain
Monitoring:
 Fetal heart rate —
fetal heart rate assessment has
become a standard of care for all
women in the United States
because patients and clinicians are
reassured by normal results and
believe there is some value in
detecting abnormal patterns.
Monitoring:
 The American College of Obstetricians and
Gynecologists suggests that electronic fetal monitoring
tracings to be reviewed :
First stage
Second stage
Low risky
30 min
15 min
High risky
15 min
5 min
 In general, continuous intrapartum FHR monitoring
is suggested for high-risk patients and when FHR
below 110 or over 160 BPM
Monitoring:
 Intermittent auscultation of the F.H is recommended
 Once a woman is in established active labor,
intermittent auscultation of the fetal heart after a
contraction should be continued
 Intermittent auscultation can be undertaken by either
Doppler ultrasound or Pinard stethoscope.
Monitoring:
 Uterine contractions
simple observation of the mother
ii. palpation of the fundus
iii. CTG
iv. direct measurement of intrauterine
pressure via internal manometry or
pressure transducers
i.
 95% of women in active labor will have
3-5 contractions per 10 minutes.
Partogram:
 Maternal status
 Fetal heart rate
 Dilatation & descent
 Uterine contractions
Partogram:
 a graphical representation that clearly shows the patient's
labor compared to the expected lower limit of "normal
progress
 Some clinicians employ a partogram with alert and action
lines. The alert line represents the rate of dilatation of the
slowest 10 % of labors in primigravidae. Crossing the alert
line suggests that the patient should be transferred to a
hospital if she is laboring in a rural setting. The action line
is parallel and four hours to the right of the alert line;
crossing the action line suggests the need for intervention
(eg, artificial rupture of the membranes, administration of
oxytocics).
Abnormalities
 Cervix
 Uterus
 Maternal pelvis
 Fetus
i.e ( power, passenger, or pelvis).
 Hypocontractile uterine activity — is the most common cause
of protraction or arrest disorders in the first stage of labor. This
entity refers to uterine activity that is either not sufficiently
strong or not appropriately coordinated to dilate the cervix and
expel the fetus. It occurs in 3-8 % of parturients and can be
quantified as uterine contraction pressures less than 200
Montevideo units.
Abnormalities
 Augmentation — Hypocontractile uterine activity is
treated with oxytocin in the United States. Oxytocin is the
only medication approved by the US Food and Drug
Administration (FDA) for labor stimulation in the active
phase
Abnormalities
Active phase arrest is diagnosed when a protraction
disorder persists despite oxytocin therapy to achieve ≥ 200
Montevideo units for greater than two hours; cesarean
delivery is typically performed at this point.
 The National Institute for Health and Clinical Excellence
(NICE) also recommended starting oxytocin and
monitoring the progress of labor over the next four hours.
If less than 2 cm of cervical dilatation occurred, they
recommended consideration of cesarean delivery
Abnormalities
Cephalopelvic disproportion — A disproportion between
the size of the fetus relative to the mother can lead to a
diagnosis of dystocia . This diagnosis is based upon
observation of slow or arrested labor during the active
phase. However, it is usually duo to fetal malposition (eg,
extended or asynclitic fetal head) or malpresentation
(mento- posterior, brow), rather than a true disparity
between fetal and maternal pelvic dimensions
Abnormalities
Diagnosis of POSITION can generally be made by
digital examination, but if there is uncertainty,
ultrasound examination is useful and accurate
 (OA)… (left 2/3)
 (Transverse positions are unstable)…
 (OP) …mostly spontaneously rotate to (OA) during the
course of labor.
However, approximately 5 % experience malposition with
persistent OP position or transverse arrest.
Pain Control:
 The pain of childbirth is likely to be the most severe
pain that a woman experiences during her lifetime.
Pain Control:
 women should be involved in the decision of pain
relief, to increase maternal satisfaction.
 This can be accomplished by educating women about
pain relief techniques during pregnancy, prior to the
onset of labor, as rational decision-making is difficult
during times of emotional & physical stress .
 Furthermore, using patient-controlled epidural
analgesia (PCEA) empowers the parturient by giving
her direct control of her pain relief, and this may
increase maternal satisfaction .
Pain Control:
First stage of labor
 Visceral or cramp-like
 source :
uterus and cervix, produced by distention of uterine and
cervical mechanoreceptors and by ischemia of uterine and
cervical tissues///. The pain signal enters the spinal cord
after traversing the T10, T11, T12, and L1 .
abdominal wall, lumbosacral region, iliac crests, gluteal
areas, and thighs.///
 Transition refers to the shift from the late first stage (7 to 10
cm cervical dilation) to the second stage of labor.
Transition is associated with greater nociceptive input as
the parturient begins to experience somatic pain from
vaginal distention.
Pain Control:
 Hyperventilation — consistently accompanies labor
pain. Arterial CO2 partial pressures less than 20
mmHg are not uncommon, and profound hypocarbia
may inhibit ventilatory drive between contractions and
result in maternal hypoxemia, lightheadedness, and
loss of consciousness . respiratory alkalosis, which
impairs oxygen transfer from the maternal to fetal
circulation, may occur.
Pain Control:
 Psychological effects — unrelieved pain may also be a
factor that contributes to the development of
postpartum psychological trauma. This may negatively
influence the mother's postpartum adjustment, and in
its most severe form, result in post-traumatic stress
disorder (PTSD) which shouldn’t be underestemated.
ANALGESIA FOR THE FIRST STAGE
OF LABOR :
classified as either
 systemic
 locoregional
Systemic:
 Intravenous
 Intramuscular
 inhalation routes
 most popular agents are opioids (eg, morphine,
fentanyl, meperidine)
Systemic:
 Newer opioid analgesics — Fentanyl, a synthetic
opioid, and its congeners (eg, sufentanil, alfentanil,
and remifentanil) have also been used to provide labor
pain relief. These drugs have a short duration of
action, so they are best administered using the
intravenous, rather than the intramuscular route.
Systemic
 Inhalation agents — Nitrous oxide . The parturient
self-administers the anesthetic gas using a hand-held
face mask. The safety of this technique is that the
parturient will be unable to hold the mask if she
becomes too drowsy. A systematic review on nitric
oxide for relief of labor pain concluded it was
inexpensive, easy to administer, and safe for both
mother and fetus. The analgesic effect was better than
that produced by opioids, but less than with epidural
analgesia
Regional techniques:
Epidurals and Spinals are the most popular modalities
Regional techniques are widely acknowledged to be
the only consistently effective means of relieving the
pain of labor and delivery. Local injection may also be
administered to achieve paracervical or pudendal
nerve block.
Pain control:
 Epidural analgesia provided better pain relief
than parenteral opioids. However, opioids were
associated with a shorter duration of labor, less
oxytocin augmentation, and fewer instrumental
deliveries compared to epidural analgesia.
 Side effects- epidural: Nausea, vomiting, and
sedation & Respiratory depression which was the
major neonatal concern
References:
 Up-to-Date
 Clinical Guideline, September 2007,Funded to produce guidelines for

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the NHS by NICE
Royal College of Obstetricians and Gynaecologists: Clinical
Effectiveness Support Unit. The Care of Women Requesting Induced
Abortion. Evidence-based guideline No. 7. London: RCOG
Government Statistical Service and Department of Health. NHS
Maternity Statistics, England: 2002–03. Statistical Bulletin 2004/10.
London: Department of Health; 2004.
National Assembly for Wales. Maternity Statistics, Wales: Methods of
Delivery, No. SDR 40/2004. Cardiff: National
Assembly for Wales
National Collaborating Centre for Women’s and Children’s Health,
Intrapartum care of healthy women and their babies dur ing
childbirth