SBA - Presentation 4

Care during labor

and delivery

Maternal Health Division

Ministry of Health & Family Welfare
Government of India
 Session Objectives
To learn about:
• Difference between true and false labour
• Stages of labour
• Supplies required for normal delivery
• Monitoring the first stage of labour using partograph
• How to conduct and manage the second stage of labour

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True labour pains False labour pains
Regular and predictable Irregular
Felt first in lower back & sweeps Remains confined to lower
towards lower abdomen abdomen
Not relieved by rest Often relieved by rest
Increase in duration, intensity and Does not increase in duration,
frequency with time intensity or frequency
“Show” blood stained mucus “Show” absent
discharge present

Accompanied by cervical changes Not accompanied by cervical

changes
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 Stages of labour
First stage: From onset of labor till full dilatation of cervix

• Latent Phase
– Cervix < 4 cms
– Contractions are weak
– Less than 2 contractions per ten minutes

• Active phase
– Cervix > or = 4 cms
– Contractions >3 per 10 min lasting 45 - 50 sec
– Rate of dilatation 1cm / hour or more
– Descent present
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 Stages of labour
Second stage: From full dilatation of cervix
till delivery of baby

• Full cervical dilatation

• Bulging thinned out perineum
• Gaping anus and vagina
• Head visible at the perineum

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 Stages of labour
Third stage:
From delivery of baby to delivery of placenta

Fourth stage:
For 2 hrs after delivery of the baby

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 Monitoring of first stage of labour:
Latent phase

• Monitor every 1 hour

– Contractions:
– Frequency: How many contractions in 10 min
– Duration: Each lasting for how many seconds
– Fetal Heart Rate (FHR):
• Monitor the following every 4 hours:
– Temperature, pulse, blood pressure
• Record time of rupture of membranes and color of
amniotic fluid.
• Look for presence of any emergency signs
Difficulty in breathing, shock, vaginal bleeding, convulsions
or unconsciousness
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 Monitoring of first stage of labour:
Latent phase

In Latent Phase
After 8 hours

Contractions stronger, No increase in intensity / frequency /

more frequent, no change duration of contractions, membranes
in dilatation or effacement not ruptured and no progress in
ROM +/- cervical dilatation

Prolonged latent phase Ask woman to relax

REFER to FRU
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 Monitoring of first stage of labour:
Active phase

• Monitor the following every 30 minutes:

– Maternal pulse, uterine contractions, FHR
– Look for presence of -
– Meconium or blood stained liquor or cord prolapse

• Monitor the following every 4 hours:

– Cervical dilatation (in cm) by P/V
– Temperature
– Blood pressure

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 Monitoring of first stage of labour:
Active phase

In Active Phase
• Never leave the woman alone
• Start maintaining a partograph when the women reaches
active labour
• Ensure adequate hydration, avoid solid foods
• Encourage upright position and walking
• Monitor intensively using Partograph
• Refer immediately if no progress

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 Partograph
What is a partograph?
• Graphic recording of the progress of labor & condition
of mother and fetus
• Labor record , thus reduces paper work
• Tool to identify complications of labor and make
timely referrals

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 Filling a Partograph

Identification data
• Name
• Age,
• Parity,
• Date and time of admission
• Registration number;
• Time of rupture of membranes.
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 Filling a Partograph

Fetal Condition
• Count fetal heart rate every half hour
• Count for one full minute, immediately following a uterine
contraction
• Fetal distress:
FHR <120 beats/minute or >160 beats/minute; Arrange for referral
• Each of small boxes in the vertical column of partograph represents
a half hour interval
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 Filling a Partograph

Record status of membranes and amniotic fluid

in Partograph as follows:
• Membranes intact (mark ‘I’)
• Membranes ruptured (mark ‘R’)
– Clear liquor (mark ‘C’)
– Meconium stained liquor (mark ‘M’)

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 Plotting a Partograph

Labor
• Begin plotting in active labor
• Cervical dilatation > 4 cms and > 2 contractions / 10 minutes
• Plot the initial finding on alert line. Note the time.
• Repeat P/V after 4 hours and plot the cervical dilatation
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 Plotting a Partograph
Chart the contractions every half an hour
• Number of contractions in 10 mins
• Duration in seconds.
– Less than 20 seconds
– Between 20 and 40 seconds
– More than 40 seconds

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 Plotting a Partograph

Interventions
• Mention dose, route and time of administration of any drug
• Mention the food items and liquids consumed

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 Plotting a Partograph

Maternal Condition
• Record maternal pulse every half hour and mark with a dot ( . )
• Record maternal BP every 4 hours using a vertical arrow,
with upper end signifying systolic BP and lower end diastolic BP
• Record the temperature every 4 hours and note on
temperature graph
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 Plotting a Partograph

• If Alert line is crossed (the plotting moves to the right of the alert
line) it indicates abnormal labour : prolonged/ obstructed labour
• Note the time
• Refer to FRU
• Ensure Provision of transport
• Send partograph with patient
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 Plotting a Partograph
• Crossing of the Action line (the plotting moves to the
right of the Action line) : indicates the need for
intervention

• By the time the action line is crossed the woman

should ideally have reached the FRU for the
appropriate intervention to take place

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 What are the indications for referral to FRU –
on the basis of partograph ?

• FHR is <120 beats / min or > 160 beats / min

• Meconium and /or blood stained amniotic fluid
• When cervical dilatation plotting crosses the alert line
(moves towards the right side of the alert line)
• Contractions not increasing in duration, intensity and
frequency (e.g. < 2 contractions lasting for < 20 sec in
10 min)

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Case studies

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 Monitoring of second stage of labour

• Monitor frequency and duration of contractions

half hourly

• Monitor fetal heart every 15 minutes

• Watch for any emergency signs : excessive

bleeding, convulsions

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 Monitoring of second stage of labour

• Watch for signs of imminent delivery

– Gaping of vulva
– Thinning and bulging of perineum
– Pouting of anus
– Head of the baby seen at vulva

• Encourage the woman to push during contractions

when she has an urge to do so while taking deep
breaths

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 Delivery of Head
• Ensure a controlled delivery of the head by keeping
one hand gently on the head and other supporting
the perineum

• Feel gently around the baby’s neck for presence of

umbilical cord
– If it is loose around the neck, deliver the baby
through the loop of the cord, or slip the cord over
the baby’s head
– If it is tight around the neck, doubly clamp and cut
in between

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 Delivery of shoulders and rest of the body

• Wait for the spontaneous rotation and delivery of the

shoulders. This usually happens within 1-2 minutes
• Apply gentle pressure downwards to deliver the top
(anterior) shoulder
• Then lift the baby up, towards the mother’s abdomen,
to deliver the lower (posterior) shoulder
• Rest of the baby’s body follows smoothly
• Note the time of birth

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 Key messages
• Let the woman choose a comfortable position
during labour and delivery
• Maintain a partograph
• Ensure timely referral

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Thank you

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