Chapter 02

Normal Pregnancy
• Labor and Delivery
• Normal Labor
• Phases of labor
• Mechanism of labor
• Types of pelvis
• Cardinal movements of labor
• Stages of labor
• Management principles
 Chapter 02: Normal Pregnancy
Labor and Delivery
Labor is a process where regular uterine contraction results in progressive cervical dila-
tation and effacement which ends in the delivery of the fetus, placenta and membranes.
Labor can be classified as TRUE or FALSE labor And Normal and Abnormal labor. Each of
the above clinical entities are discussed in the subsequent sections of this book.
True Labor
Regular, rhythmic uterine contractions (≥ 2 contractions in 10 minutes) with one or
more of the following:
• Rupture of the membranes.
• Cervical dilatation of 4 centimetres.
• Cervical effacement of ≥ 80 %.
• Bloody show (DON’T use this as a criteria if Digital vaginal examination has been
done or membranes have ruptured in the past 48 hours.)
False Labor
Irregular contractions of the uterus prior to actual labor pain. Signs of false labor are
• Mild pain and irregular contractions.
• There is no mucous blood-stained discharge (show).
• No progressive cervical dilatation observed on follow up.
Normal Labor
Labor is considered normal when the following conditions are fulfilled.
• Without any risk (e.g. previous scar, pre-eclampsia)
• Labor should start spontaneously and at term,
• Fetal presentation must be by vertex,
• Delivery should be by spontaneous vertex delivery,
• Each stage lasts for normal duration
• Neonate is alive and well and the mother has uncomplicated puerperal
Abnormal Labor
(Discussed in separate section)
Phases of Labor
• Uterine quiescence: it is a prelude to pregnancy and begins before implantation. It
is characterized by smooth muscle tranquillity with maintenance of cervical struc-
tural integrity. During this phase, the myometrium is unresponsive to contraction.

• Activation phase: prepares the myometrium for labor contractions. Expression of

different proteins including receptors for uterotropins and uterotonics increase
uterine irritability and responsiveness to uterotonics. It occurs during the last 6-8
weeks of pregnancy.

• Stimulation phase: is synonymous with active labor.

• Involution phase: it is the phase of the uterine state in which the uterus returns to
its pre-pregnancy state.
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Mechanism of Labor
The ability of the fetus to successfully negotiate the pelvis during labor and delivery
depends on the complex interactions of three variables(The Three Ps): uterine activity
(Power), the fetus (Passenger), and the maternal pelvis (Passage).
1. Uterine activity (POWER): frequency, amplitude intensity, and duration of contrac-
tions.
• Adequate contractions are defined as having three to five contractions, lasting
for 40-60 seconds in 10 minutes.
• If uterine contractions are adequate to effect vaginal delivery, one of two
things will happen:
• The cervix will efface and dilate, and the fetal head will descend
• Caput succedaneum (scalp edema) and moulding of the fetal head
without cervical effacement and dilation in the cephalopelvic dispro-
portion (CPD)
2. Fetus (PASSENGER)
The following fetal characteristics will affect how labor progresses: -
• Fetal size: Estimated clinically by abdominal palpation or ultrasound.
• Fetal macrosomia (birth-weight greater than or equal to the 90th percentile for
a given gestation age or greater than 4500g for any gestational age) has higher
association with labor dystocia.
• Small for gestational age (birth-weight less than or equal to the 10th percentile
for a given gestation age) is also associated with higher complication during
labor and delivery.
• Fetal lie: refers to the longitudinal axis of the fetus relative to the longitudi-
nal axis of the mother. It can be longitudinal, transverse, or oblique. Trans-
verse and oblique lie pose a risk for vaginal delivery.

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 • Presentation: refers to the fetal part that directly overlies the pelvic inlet. In
a fetus presenting in the longitudinal, The fetus should have cephalic (Vertex)
presentation to fill full criteria for normal labor.
• Misrepresentation that is any presentation other than vertex, is seen in
approximately 5% of all term labors.
• Attitude: The relationship of fetal head with the fetal spine (the degree of flex-
ion and/or extension of the fetal head).
• When the fetal chin is optimally flexed onto the chest, the subocciptobreg-
matic diameter (9.5cm), presents at the pelvic inlet. This is the smallest
possible presenting diameter in the cephalic presentation.
• Deflection of the head will result in increment of the diameter presenting
to the pelvic inlet and may contribute to failure to progress in labor.

Position: is the relation of the fetal presenting part to the maternal pelvis.
• Markers for position are:
• Occiput for vertex presentation
• Sacrum for breech presentation
• Mentum (chin) for face presentation
• Acromion for shoulder presentation
• The designated fetal bony point is related to the maternal pelvis right or left and
anterior, posterior, or transverse. For example, right occiput anterior.
• Station: is a measure of descent of the bony presenting part of the fetus through
the birth canal. It is measured by vaginal examination using the maternal ischial
spine as the midpoint (station 0).
• The measurement ranges from -5 to +5 based on the distance of the present-
ing part in centimetres from the ischeal spines.
• “–” is used when the bony presenting part is above the ischial spine whereas
the “+” is used when it is below the ischial spine

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 3. The Bony Pelvis (PASSAGE)
• It is divided into the false (greater) and true (pelvis) by the pelvic brim.
• The true pelvis has the pelvic inlet, mid-pelvis, and pelvic outlet.
• The diagonal conjugate is a measure from the sacral promontory to the anterior
inferior pubic symphysis and on average measures 12.5cm.
• Obstetric (true) conjugate is the length from the sacral promontory to the posteri-
or pubic symphysis.
• This measurement cannot be measured clinically and is determined by subtract-
ing 1.5 to 2 cm from the diagonal conjugate.
• The obstetrical conjugate is the shortest anterior posterior diameter through
which the fetal head must pass.

Types of Pelvis
• Gynecoid (Round): is the most common type and is the classic female shape.
• Anthropoid (long and oval): The AP diameter is greater than the transverse; promi-
nent ischial spines; narrow pubic arch
• Android (Heart Shaped): Male type pelvis.
• Platypelloid: least frequent; flattened shape with short AP diameter and wide trans-
verse diameter.

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 Adequate Pelvis
•
• Pelvic brim is round
• Diagonal Conjugate ≥ 11.5 cm
• Sacrum is hollow with average inclination
• Side walls are straight
• Ischeal spines are blunt
• Diameter ≥ 10.5 cm
• Sacrosciatic notch is 3 finger breadth
• Sub-pubic Angle 900
• Bi tuberous diameter fits a knuckle
• Coccyx mobile
• AP diameter of the outlet ≥ 10.5 cm

Cardinal Movements of Labor

1. Engagement:
• It is the passage of the bi parietal diameter of the head, the greatest transverse
diameter of the head, in occiput presentations through the pelvic inlet.
• It occurs when the lowest point of the presenting part is at the level of station 0
(ischial spines).
• Engagement is likely to occur weeks before the onset of labor in primigravida,
while it occurs later or in the course of labor in the multigravida.
2. Descent: downward passage of the presenting part through the pelvis.
3. Flexion: With this movement, the chin is brought into more intimate contact with
the fetal thorax.
4. Internal rotation:
• It refers to rotation of the presenting part from its original position as it enters the
pelvic inlet (usually occiput transverse) to the AP position as it passes through the
pelvis.
• As the head descends, the occiput of the fetus rotates toward the symphysis pubis
anteriorly, or less commonly, toward the hollow of the sacrum posteriorly - thereby
allowing the widest portion of the fetus to negotiate the pelvis at its widest dimen-
sion.
5. Extension:
• It occurs once the fetus has descended to the level of the introitus.
• The birth canal curving upward, at this point descent brings the base of the occiput
into contact with the inferior margin at the symphysis pubis.
6. External rotation (restitution): refers to the return of the fetal head to the correct
anatomic position in relation to the fetal torso.
7. Expulsion: refers to delivery of the rest of the fetus.

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Stages of Labor
A. The first stage:
• Latent phase: is the period from the onset of labor to 5 cm cervical dilation
• We say the latent phase is prolonged when it takes more than 20 hours for the
primigravida and more than 14 hours for the multigravida.
• Active phase: is the period from the end of the latent period to full cervical
dilation and is the period with rapid rate of cervical change (>=1.2 cm/hr for
primigravida and >=1.5 cm/hr for multigravida).
B. The second stage: is from full cervical dilation until the delivery of the baby.
• The duration of the second stage is normally 2 hours for multigravida and 3 hours
for primigravida. It may be prolonged by factors such as epidural analgesia (pro-
longs the seconds stage by 1 hour for both primigravida and multigravida).
C. The third stage: begins with the delivery of the baby and ends with delivery of the
placenta. It involves the separation and expulsion of the placenta.
D. The fourth stage: is the two-hour period after the delivery of the placenta.

Management Principles
• Differentiate true labor from false labor
• Admit all women with diagnosis of labor with known risk or ruptured membranes.
Admit a women at 4 cm cervical dilation with no known risk.
Management during first stage
• Use WHO partograph to record progress of labor
• Maternal well-being monitoring:
• V/S Monitoring
• Maternal position: Avoid supine position to prevent hypo tension due to ven-
acaval compression by the uterus. Encourage the mother to move around.
• Nutrition: Encourage oral intake of liquid diet (tea, juice)
• Companionship: encourage partner to accompany the mother.
• Pain management
• Non-pharmacologic:Back massaging, moving around
• Pharmacologic: Pethidine ,Spinal Anaesthesia
• Fetal well-being monitoring
• Fetal heart rate (FHR): Use pinnard stethoscope for women with no known
risk factor. Auscultation is done every 30 minutes for a parturient without risk
factor and every 15 minutes for a parturient with risk factor immediately after a
contraction for 1 min. Use continuous electronic fetal heart rate monitoring for
high risk mothers.
• Status of the liquor (Amniotic fluid):
Grade I: Lightly meconium stained
Grade II: Heavy suspension of meconium
Grade III – Thick meconium which is undiluted
• Monitoring of progress of labor
• Uterine contraction: Frequency ,duration and intensity of each contraction is
determined by palpation and tocodynamometer. Monitor every one hour for
latent phase and every 30 minutes for active phase.
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 • Descent of fetal head: Should be done by abdominal palpation before vaginal
examination
• Per vaginal examination: Done every 4 hour to see rate of cervical dilation, sta-
tion, position, and degree of moulding. It may also be done under the following
conditions
• After spontaneous rupture of membranes
• When there is abnormal FHR pattern
• Before giving analgesia
• Symptoms suggesting second stage (urge to push, sweating, increased pain and
rectal pressure) to confirm the diagnosis.
Management During Second Stage
• Vital signs
• Evaluate general condition: Fatigue, pain, physical depletion and state of hydration
• Maternal care and well-being evaluation
• Evaluate the presence of the urge to push and/or effort
• Avoid early push
• Encourage to empty bladder
• Respect maternal preferred position for delivery
• FHR monitoring: Every 15 min for low-risk and every 5 min or continuous electron-
ic monitoring for high-risk
• Labor progress evaluation: evaluate the degree of descent every 1hr
• Goals of assistance of spontaneous delivery:
I. Reduction of maternal trauma
II. Prevention of fetal injury
III. Initial support of the newborn
Episiotomy:
Episiotomy is an incision of the perineum made to enlarge the pelvic outlet to facilitate
delivery.This procedure should be individualized and routine performance should be
avoided. Episiotomy should be done when there is:
• Threat for a perineal tear
• Perineal resistance for fetal head descent
• Fetal/maternal distress to expedited delivery
Types
Medial episiotomy: Is cut vertically in the midline of the perineal body. It has advantages
of having less blood loss, being easier to repair and more comfortable during healing but
there is possible occurrence of inadvertent incision or extension into the anal sphincter
and rectum.

Mediolateral episiotomy: Is made at a 45-degree angle to the hymenal ring. It provides

more room with less risk of injury to the rectum and sphincter but also has more blood
loss, is more difficult to repair and has more discomfort during healing.

Note: Episiotomy should be performed when fetal head has distended the vulva 2-3cms
unless early delivery is indicated. Local anesthesia should be used when making and
repairing episiotomy.

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 • Delivery of the head
• Prevent rapid delivery and assist extension of the head.
• If extension does not occur, place hand protected with sterile towel on the peri-
neum and palpate the fetal chin to press it up ward gently to result in extension.
• Check for cord around the neck and disentangle it from around the head or
clamp it at two sites and cut in between if not reducible.
• Complete delivery of the rest of the body
• After securing complete delivery, wipe the newborn’s body with dry clean towels,
remove the wet towel and wrap them with a dry towel.
• Cord clamping: 4-5 cm from fetal umbilicus. Delayed Cord clamping (Wait for 2-3
minutes or until the pulsation of the umbilical vessels stop before clamping) should
be applied
Management of the Third Stage of Labor
• Active management of third stage of labor is the administration of uterotonic agent
(preferentially oxytocin – 10 IU intramuscularly) shortly after the delivery of the
baby but prior to delivery of the placenta, followed by controlled cord traction and
countertraction to support the uterus until the placenta is separated and delivered
and uterine massage after delivery of the placenta. Benefits of AMTSL includes
• Shorter duration
• Less maternal blood loss
• Reduced incidence of PPH

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 Chapter 03
Abnormal Pregnancy
• Abnormal Labor
• Disorders of the Latent Phase
• Disorders of the Active Phase
• Disorders of the Second Phase
 Chapter 03: Abnormal Pregnancy
Abnormal Labor
Any deviation from the normal progress of labor makes the labor abnormal. It is caused
by abnormalities of one or more of the 3Ps.
Types
• Latent phase disorders
• Protraction disorders
• Arrest disorders
• Precipitate labor (delivery which spans less than 3 hours from onset of contrac-
tions)
For discussion purposes, disorders of labor are classified as latent phase, active phase and
2nd stage disorders.

I. Disorders of the latent phase

Prolonged latent phase: When the latent stage spans beyond 20 hours for nulliparous
women and 14 hours for multiparous women. In the hospital setting, this is diagnosed
after 8 hours of diagnosis of true labor for any laboring women.
Principles of management for latent phase prolongation
• First assess whether the labor is true labor or not.
• Supportive care
• Adequate rest
• Rehydration

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II. Disorders of the Active Phase
Etiologies:
• Inadequate uterine activity
• Abnormal positioning of the fetal presenting part
• Cephalopelvic disproportion
1. Protraction disorder: it is a condition in which the active phase progresses slower than
in the normal labor. The most common cause is inadequate uterine activity.
• Protracted active-phase dilation: Characterized by slow rate of dilation (<1.2cm/h
in nulliparas or <1.5cm/h in multiparas). When using the partograph, this is diag-
nosed when there is < 1cm cervical dilatation in an hour.
2. Arrest disorder: it is a condition in which the progress of the active has completely
ceased. It is defined as the absence of cervical change for 2 hours or more in the pres-
ence of adequate uterine contractions and cervical dilation of at least 4 cm.

Principle of management for active phase abnormalities

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III. Disorders of the Second Stage
Protraction of descent: although fetal descent begins before the cervix becomes fully
dilated, the majority of fetal descent occurs once full cervical dilation is achieved. Pro-
traction of descent is defined as descent of the presenting part during the second stage of
labor that occurs at < 1cm/ hr in the nullipara and < 2cm/ hr in the multipara.
Arrest of descent refers to complete failure of progress in descent.
Prolonged second stage of labor: when the duration of the second stage of labor exceeds
2 hours in nulliparas or 1 hour in multiparas without epidural anesthesia and 3 and 2
hours respectively with epidural anaesthesia.

Principles of Management
Assess the cause and manage accordingly
• Maternal Exhaustion: rest and re-hydrate with glucose containing solution
• Malposition/ Misrepresentation or CPD: Use specific maneuvers or C/S
• Inefficient uterine contraction: Augment labor

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 Chapter 04
Induction and Augmentation of Labor
• Complications of IOL
• Augmentaion of Labor
Chapter 04: Induction and Augmentation of Labor
• Induction of labor (IOL) means initiating labor by artificial means after the period
viability to effect a vaginal delivery;
• Augmentation is the artificial stimulation of labor that has begun spontaneously
but is inadequate.
• Evaluation of the cervical status in terms of effacement and softening is important
in predicting success of induction and is highly recommended before any elective
induction.
Bishop Score

Interpretation of the Bishop’s score:

• Score ≥ 6: Favourable - cervical condition and induction is likely to succeed. There
is no need for cervical ripening. Induction using oxytocin can be planned.
• Score ≤ 5: Unfavourable - cervix is unlikely to yield for induction; cervical ripening
is needed for success with induction; postpone induction for next week if possible
or use cervical ripening and plan induction for next day
Indications for Induction
The following are common indications for induction of labor:
• Maternal—obstetric complications like hypertensive disorders of pregnancy in-
cluding Preeclampsia/eclampsia, poly/oligohydramnios and maternal medical con-
ditions like diabetes mellitus, heart disease, chronic pulmonary diseases.
• Fetal—, Post term pregnancy, Rh incompatibility, chorioamnionitis, premature rup-
ture of membranes (PROM), placental insufficiency, suspected intrauterine growth
restriction (IUGR), Intra uterine fetal death (IUFD).
Contraindications
Absolute contraindications to induction of labor include
• Contracted pelvis;
• Cephalopelvic disproportion(CPD),
• Placenta/vasa previa;
• Pelvic tumor,
• Cord prolapse,
• Multiple gestation
• Uterine scar because of previous caesarean section,
• Significant prior uterine surgery eg. Full thickness myomectomy and transverse lie.
Relative contraindications include grand multiparity, bad obstetric history, macrosomia
and extreme prematurity.

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General Principles / Prerequisites for IOL
• Get informed, written, and understood consent.
• Ascertain fetal lung maturity
• Make sure that there are no contraindications,
• Do pelvic (Bishop) scoring
• IOL should only be done when there is a clear indication and expected benefits
should outweigh its potential harms and document the indication.
• Whenever possible IOL should be carried out in facilities where caesarian delivery
can be performed.
• Failed induction does not necessarily indicate caesarean section.
• There should be close monitoring since IOL carries a risk of
• uterine hyperstimulation (≥6 contractions in 10 min), uterine rupture and fetal
distress.
Methods of Cervical Ripening
Cervical ripening is the process of catalyzing physical softening and distensibility of the
cervix in preparation of labor and delivery. Ripening cervix before IOL could facilitate the
onset and progression of labor and increase the chance of vaginal delivery, particularly in
primigravid patients.

Methods include
• Pharmacologically
Prostaglandins:
• Side-effect: nausea, vomiting, fever, and peripartum infection, fetal heart rate
deceleration, fetal distress, emergency caesarean section, uterine hypertonicity.
• Previous caesarean section (risk of uterine hyperstimulation and rupture) is a
Contraindication.
1. PGE2(Dinoprostone): asthma, glaucoma, or myocardial infarction (risk of
hypo tension and arrhythmia),
2. PGE1(Misprostone):
Mechanically
1. Transcervical balloon catheters
2. Hygroscopic dilators (Laminaria)
3. Membrane stripping(sweeping)

Trans cervical Balloon catheter

A Foley catheter is introduced through the cervix above the internal os. The balloon is
then inflated with NS and pulled gently to the level of the internal os, where it is left for
12 hours or until spontaneous expulsion occurs. The mechanical pressure directly on the
cervix causes ripening and dilatation.
Hygroscopic Dilators
Laminaria tents are made from the seaweed Laminaria or from synthetic equivalents. It
works by extracting water from cervical tissues once it’s put in the cervical canal expands
cervical canal Prodtaglandins are released.

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Membrane Stripping (Sweeping)
The membranes are stripped by inserting the examining finger through the internal OS
and moving it in a circular direction to detach the inferior pole of the membranes from
the lower uterine segment.

This mechanically dilates the cervix which releases PGs. Risks include patient discom-
fort, infection, bleeding from undiagnosed placenta previa, and ROM.

Methods of Induction of Labor

Amniotomy (ARM or Artificial Rupture of Membranes. Aka Surgical Induction)
Release of amniotic fluid shortens the muscle bundles of the myometrium; the strength
and duration of the contractions are thereby increased.

Requirement: Cervix must be at least one finger dilated

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 Hazards: Cord prolapse may occur if head hasn’t engaged to prevent the cord from ‘fall-
ing out’. Other risks include increase perinatal HIV transmission, rupture of vasa previa,
chorioamnionitis.
Oxytocin
Effective in inducing uterine contraction in the 3rd trimester.

The smallest possible effective dose must be determined for each patient and then used
to initiate and maintain labor. Constant observation and following up is required when
this method is used. Must be given as infusion because of short half-life.

Complications of IOL
• Maternal:
• Failed induction: is failure to achieve regular (e.g. every 3 minutes) uterine
contractions and cervical change after at least 6 - 8 hours of the maintenance
dose of oxytocin administration, with artificial rupture of membranes if feasi-
ble.
• Tetanic uterine contraction,
• Uterine rupture,
• Precipitated labor resulting in genital tear
• PPH,
• Water intoxication (Oxytocin has ADH-like properties)
• Fetal:
• Iatrogenic prematurity if EDD is inaccurate
• Precipitous delivery may result in physical injury,
• Prolapse of the cord may follow amniotomy,
• Injudicious administration of oxytocin fetal distress

Augmentation of Labor
(See definition above)
Indications: labor dystocia due to inadequate contractions eg. Prolonged latent phase of
first stage of labor, prolonged active phase of first stage of labor, Prolonged second stage
secondary to poor contraction.

NB: contraindications, dosage, follow up and complications are the same as that of in-
duction.

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