Obstetrics Simplified - Diaa
Active Management of Normal Labour
- To achieve delivery of a normal healthy child with minimal physical
and psychological maternal effects.
- Early anticipation, recognition and management of any abnormalities
during labour course.
- Maternal education: about the physiology of labour and symptoms
of impending labour.
- Breathing exercise: adapt the mother to breathing during labour
to guard against respiratory alkalosis caused by hyperventilation.
First Stage of Labour
- Complete obstetric history.
- History of present pregnancy:
- Duration of pregnancy.
- Medical disorders during this pregnancy.
- Complications during this pregnancy as antepartum
- History of present labour:
- Labour pains: onset, frequency and duration.
- Passage of "show", fluid or blood per vaginum.
- Sensation of foetal movement.
- General examination:
- Height and built.
- Maternal vital signs: pulse, temperature and blood pressure.
- Chest and heart examination.
- Lower limbs for oedema.
- Abdominal examination:
- Fundal level.
- Fundal grip.
- Umbilical grip.
- Pelvic grips.
- Scar of previous operations (e.g. C.S, myomectomy or hysterotomy).
- Pelvic examination:
- Dilatation: the diameter of the external os is measured
by the finger (s) during P/V examination and expressed in
cm, one finger = 2 cm, 2 fingers = 4 cm and the distance
resulted from their separation is added to the 4 cm in more
- Position (posterior, midway, central).
- Membranes: ruptured or intact. If ruptured exclude cord
prolapse and meconium stained liquor.
- Presenting part and its position.
- Station: of the presenting part.
- Pelvic capacity.
- Investigations: If not done before or if indicated:
- Blood group-Rh typing.
- Urine for albumin and sugar.
- Active procedures:
- Evacuation of the rectum by enema to;
- avoid uterine inertia,
- help the descent of the presenting part,
- avoid contamination by faeces during delivery.
- Evacuation of the bladder:
- ask the patient to micturate every 2-3 hours, if she cannot
use a catheter.
- It prevents uterine inertia and helps descent of the presenting
- Preparation of the vulva:
- Shave the vulva, clean it with soap and warm water from
above downwards, swab it with antiseptic lotion and apply a
- When labour is established no oral feeding is allowed,
but sips of water.
- 15 ml magnesium trisilicate is given every 2 hours as an
oral antacid to guard against bronchospasm occurs if the acid
vomitus is inhaled during general anaesthesia "Mendelson’s
syndrome". Antacid injections may be used instead.
- If labour is delayed more than 8 hours, IV drip of glucose
5% or saline-glucose solution is given.
- Patient is allowed to walk during the early first stage
particularly with intact membranes.
- If rest is needed the patient lies on her left lateral position
to prevent inferior vena cava compression and hence placental
insufficiency and foetal distress.
- Pethidine 100 mg IM,
- trilene inhalation, or
- epidural anaesthesia are the most common use.
- N.B. Patient should not bear down during the first stage
as this is useless, exhausts the patient and predisposes to
- The partogram:
- It is the graphic recording of the course of labour including
the following observations:
- The mother:
- Pulse every 30 minutes,
- blood pressure every 2 hours,
- temperature every 4 hours,
- uterine contractions: frequency, strength
and duration every 30 minutes by manual palpation or
better by tocography if available,
- cervical dilatation,
- fluid input and output,
- drugs including oxytocins.
- The foetus
- FHR every 15 minutes by Pinard’s stethoscope
or better by doptone,
- descent of the presenting part,
- degree of moulding.
- Cardiotocography if available is more valuable for continuous
monitoring of both uterine contractions and FHR particularly
in high risk pregnancy.
- The advantages of the partogram:
- Allows right intervention in the proper time e.g. oxytocin
usage, instrumental delivery or C.S.
- Allows different staff shifts to manage the case successively.
- A document for labour events.
Second Stage of Labour
Its beginning is identified by:
- The patient feels the desire to defecate.
- The contractions become more prolonged and painful.
- Reflex desire to bear down during the contractions.
- The expulsive effort is accompanied by sustained expiratory grunt.
- Rupture of membranes, although this is not specific as it may occur
earlier even before start of labour " prelabour rupture of membranes"
or later even to the degree that the foetus is delivered in an intact
- Full dilatation of the cervix (10 cm) in between uterine contractions
is the most sure sign.
- The patient is transferred on a wheel or trolley to the delivery
- Put her in the lithotomy position.
- The lower abdomen, upper parts of the thighs, vulva and perineum
are swabbed with antiseptic lotion.
- Sterile legs and towels are applied.
Ask the patient to bear down during contractions and relax in between.
Delivery of the head
The main aim during delivery of the head is to prevent perineal lacerations
through the following instructions:
- i) Support of the perineum:
- When the labia start to separate by the head, a sterile pad
is placed over the perineum and press on it with the right hand
during uterine contractions. This is continued until crowning occurs
to maintain flexion of the head.
- is the permanent distension of the vulval ring by the foetal
head like a crown on the head. The head does not recede back in
between uterine contractions.
- This means that the biparietal diameter is just passed the vulval
ring and the occipital prominence escapes under the symphysis pubis.
- After crowning, allow slow extension of the head so the vulva
is distended by the suboccipito frontal diameter 10 cm.
- If the head is allowed to extend before crowning the vulva will
be distended by the occipito-frontal 11.5 cm increasing the incidence
of perineal lacerations.
- Ritgen manoeuvre: upward pressure on the perineum by the right
hand and downward pressure on the occiput by the left hand to control
the extension of the head.
- It is done at crowning when the perineum is stretched to the
degree that it is about to tear.
- Swab and aspirate:
- the mouth and nose once the head is delivered before respiration
is initiated and the liquor, meconium or blood is inhaled.
- Coils of the umbilical cord:
- if present around the neck are slipped over the head but if
tight or multiple they are cut between 2 clamps.
Delivery of the shoulders
Gentle downward traction is applied to the head till the anterior shoulder
slips under the symphysis pubis. The head is lifted upwards to deliver the
posterior shoulder first then downwards to deliver the anterior shoulder.
Delivery of the remainder of the body
Usually slips without difficulty otherwise gentle traction is applied
to complete delivery.
Clamping the cord
The baby is held by its ankles with the head downwards at a lower level
than its mother for few seconds. This is contraindicated in:
- Preterm babies.
- Erythroblastosis foetalis.
- Suspicion of intracranial haemorrhage.
This may be enhanced by milking the cord towards the baby, to add about
100 ml of blood to its circulation.
The cord is divided between 2 clamps to avoid bleeding from a possible
2nd uniovular twin.
Third Stage of Labour
Delivery of the placenta
- Put the ulnar border of the left hand just above the fundus at the
level of the umbilicus to detect any bleeding inside the uterus known
by rising level of the atonic uterus.
- Wait for signs of placental separation and descent but do not massage
- As soon as they are detected massage the uterus to induce its contraction,
ask the patient to bear down and push the uterus downwards to deliver
- Hold the placenta between the two hands and roll it to make the
membranes like a rope in order not to miss a part of it.
- Give ergometrine 0.5 mg or oxytocin 5 units IM after delivery of
the placenta to help uterine contraction and minimise blood loss. These
may be given before delivery of the placenta.
Signs of placental separation and descent:
- The body of the uterus becomes smaller, harder and globular.
- The fundal level rises as the upper segment overrides the lower
uterine segment which is now distended with the placenta.
- Suprapubic bulge due to presence of the placenta in the lower uterine
- Elongation of the cord particularly on pressing on the uterine fundus
and it does not recede back into the vagina on relieving the pressure.
- Gush of blood from the vagina.
The active method (Brandt- Andrews method):
- With delivery of the anterior shoulder, 0.5 mg ergometrine or syntometrine
(0.5 mg ergometrine + 5 units oxytocin) is given IM.
- When the uterus contracts, put the left hand suprapubic and push
the uterus upwards while gentle downward and backward traction is applied
on the cord by the right hand when the placenta is delivered it is rolled
as in the conservative method.
- Advantage: reduction of the blood loss.
- Constriction ring may occur with retention of the placenta.
- Avulsion of the cord if undue pressure is applied.
- Inversion of the uterus if fundus is pressed while the uterus
- Examination of the placenta and membranes:
- by exploring it on a plain surface to be sure that it is complete.
If there is missed part, exploration of the uterus is done under
- Explore the genital tract:
- For any lacerations that should be immediately repaired.
Repair of episiotomy
Fourth Stage of Labour
Observation for the patient particularly atony of the uterus and vaginal
Care of The Newborn
Clearance of the air passages
- The newborn is placed in supine position with the head lower down.
A metal, rubber or better disposable plastic catheter is used to aspirate
the mucus from the pharynx and mouth directly by the physician’s mouth
or by attach it to an electric suction pump.
- Crying of the baby is usually occurs within seconds, if delayed
slapping its soles, flexion and extension of the legs and rubbing the
back usually stimulate breathing.
Is calculated at 1 and 5 minutes and further steps of resuscitation are
arranged according to it (see later).
The umbilical cord
- A disposable plastic umbilical clamp is applied about 5 cm from
the umbilicus to avoid the possibility of tying an umbilical hernia
then cut about 1.5 cm distal to the clamp. Inspect for bleeding and
paint it with alcohol.
- If the plastic umbilical clamp is not available, 2 ligatures of
silk are applied instead of it.
- The umbilical stump is painted daily with an antiseptic till its
fall within 10 days.
The newborn is examined for injuries or congenital anomalies as
anus, hypospadias (not to be circumcised as the cut skin will be used in
the repair later on), cyanotic heart diseases.... etc.
the newborn and record it.
Dressing as well as all previous procedures should be done in a warm
place better under radiant warmer to prevent heat loss which occurs rapidly
after delivery increasing the metabolism and acidosis.
Care of the eyes
An antibiotic eye drops as chloramphenicol are instilled into the eyes
as a prophylaxis against ophthalmia neonatorum.
of the baby by a plastic bracelet on which its mother’s name is written.
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Edited by Aldo Campana,