Case 13.1 – Normal Vs Abnormal Labour

Diagnosis of Labour

Labour is diagnosed by the presence of painful regular uterine contractions producing changes in the cervix:

• Effacement: Thinning out of the cervix
• Dilatation: Opening of the cervix

Clinical Assessment

• History: Careful documentation of contraction frequency, duration, and intensity
• Initial vaginal examination: Assess cervical effacement and dilatation
• Confirmation: If the cervix has not dilated on initial examination, a second vaginal examination should be performed 2-4 hours later to confirm progressive cervical changes

Important: The diagnosis of labour cannot be made from a single examination if the cervix has not yet begun to dilate. Progressive cervical change on serial examinations is essential for diagnosis.

Confirming Spontaneous Rupture of Membranes (SROM)

Clinical Assessment

• History:
  • Sudden gush of fluid or continuous leaking
  • Timing of fluid loss
  • Color and odor of fluid
• Examination:
  • Pooling of fluid in posterior vaginal fornix on speculum examination
  • Observe for continued leaking

Confirmatory Tests

Test	Method	Interpretation
Sterile speculum examination	Visualize pooling of amniotic fluid in posterior fornix	Most reliable clinical method
Nitrazine test	pH paper turns blue-green in presence of amniotic fluid (pH 7.0-7.5)	Positive: Blue-green color Can be false positive (blood, semen, alkaline urine)
Ferning test	Dried amniotic fluid on slide shows fernlike crystallization pattern under microscopy	Highly specific for amniotic fluid Due to salt content creating crystallization
Ultrasound	Assess amniotic fluid volume	Oligohydramnios suggests membrane rupture Not diagnostic alone
Commercial tests	PAMG-1, IGFBP-1 detection	High sensitivity and specificity Expensive

Assess Amniotic Fluid Characteristics

• Clear: Normal
• Blood-stained: May indicate placental abruption or cervical bleeding
• Meconium-stained: Green/brown; may indicate fetal distress
• Offensive odor: Suggests chorioamnionitis

Important Considerations After SROM

• Document time of rupture: Risk of infection increases >18-24 hours
• Assess fetal heart rate: Risk of cord prolapse, especially if presenting part not engaged
• Digital vaginal examination should be avoided until labor is established if membranes are ruptured (to reduce infection risk)
• Speculum examination preferred for initial assessment

Stages of Labour

First Stage of Labour

From the onset of regular painful contractions with progressive cervical change to full cervical dilatation (10cm).

Subdivisions of First Stage

Phase	Definition	Duration	Expected Progress
Latent Phase	Onset of labour until cervix is 3-4cm dilated	Variable duration • Primipara: Up to 20 hours • Multipara: Up to 14 hours	• Cervical effacement (thinning) • Dilatation to 3cm • In multiparous women, dilatation may occur before complete effacement
Active Phase	From 3-4cm dilatation to full dilatation (10cm)	• Primipara: Average 1cm/hour • Multipara: Average 2cm/hour	• Regular, progressive cervical dilatation • Descent of presenting part • Strong, regular contractions (3-4 per 10 minutes)

Second Stage of Labour

From full cervical dilatation (10cm) to delivery of the baby.

Subdivisions of Second Stage

Phase	Definition	Duration	Characteristics
Passive Phase	Full dilatation without urge to push	Variable (up to 1-2 hours with epidural)	• Allows fetal descent through pelvis • No active maternal pushing • Fetal head rotates and descends with contractions
Active Phase	Active maternal pushing efforts	• Primipara: Up to 3 hours (4 hours with epidural) • Multipara: Up to 2 hours (3 hours with epidural)	• Mother feels urge to push • Active bearing down with contractions • Presenting part visible at introitus • Crowning and delivery

Third Stage of Labour

From delivery of the baby to delivery of the placenta and membranes.

Management	Active Management (Recommended)	Physiological Management
Definition	Use of uterotonic drugs and controlled cord traction	Await spontaneous placental separation and delivery
Duration	Usually <10 minutes Abnormal if >30 minutes	Usually <60 minutes Abnormal if >60 minutes
Process	1. Give oxytocin IM/IV with delivery of anterior shoulder 2. Clamp and cut cord 3. Await signs of placental separation 4. Controlled cord traction with counter-pressure on uterus 5. Deliver placenta and membranes	1. No oxytocin given 2. Await signs of separation 3. Allow spontaneous delivery with maternal effort 4. Cord clamped after pulsation ceases
Advantages	• Reduced risk of PPH • Reduced blood loss • Shorter duration • Less need for transfusion	• More physiological • Delayed cord clamping possible • No medication side effects

Signs of Placental Separation

• Cord lengthening: Umbilical cord descends further from vagina
• Gush of blood: Small amount of blood loss as placenta separates
• Uterus contracts and rises: Fundus becomes firmer and rises in abdomen
• Change in uterine shape: From discoid to globular

Important Notes

• Active management is recommended as it significantly reduces the risk of postpartum hemorrhage
• Controlled cord traction should only be applied after signs of placental separation to avoid uterine inversion
• Fundal pressure ("guarding") during cord traction helps prevent uterine inversion
• Retained placenta is diagnosed if not delivered within 30 minutes of active management or 60 minutes of physiological management

The Three P's of Labour

Assessment of labour progress requires evaluation of the "three P's" - factors that determine whether vaginal delivery can occur:

1. POWERS - Uterine Contractions

Assessment of Contractions

Parameter	Normal/Adequate	Inadequate
Frequency	3-4 contractions per 10 minutes in active labour	<2 contractions per 10 minutes
Duration	40-60 seconds	<40 seconds
Intensity	Strong (unable to indent uterus during contraction)	Weak (can easily indent uterus)
Resting tone	Soft, relaxed uterus between contractions (at least 60 seconds rest)	Hypertonic uterus or tachysystole (\>5 contractions in 10 minutes)
Coordination	Regular, coordinated contractions propagating from fundus	Incoordinate contractions (different parts of uterus contracting separately)

Types of Inadequate Powers

• Hypotonic contractions: Weak, infrequent contractions; most common
• Hypertonic contractions: Painful but ineffective; elevated baseline tone
• Incoordinate contractions: Uncoordinated uterine activity; painful but not productive
• Uterine exhaustion: Contractions decrease in frequency and strength after prolonged labour

Clinical Assessment

• Palpation: Feel contractions abdominally
• CTG monitoring: External tocodynamometry shows frequency and duration (not intensity)
• Intrauterine pressure catheter (IUPC): Gold standard for measuring intensity (rarely used)
• Serial vaginal examinations: Lack of cervical change despite contractions indicates inadequate powers

2. PASSENGER - The Fetus

Components to Assess

A. Fetal Size

• Estimated fetal weight: Clinical estimation or ultrasound
• Macrosomia: Birth weight >4000g (4500g if diabetic mother)
• Excessive head size: Hydrocephaly
• Clinical assessment: Abdominal palpation, symphysis-fundal height

B. Fetal Position

Position of the fetal occiput in relation to the maternal pelvis:

Position	Abbreviation	Presenting Diameter	Implications
Occipito-anterior (OA)	LOA, ROA, OA	Suboccipito-bregmatic: 9.5cm (smallest)	• Most favorable • Easiest vaginal delivery • Left OA most common (LOA)
Occipito-transverse (OT)	LOT, ROT	Variable	• Common at engagement • Usually rotates to OA • If persistent, may require rotation
Occipito-posterior (OP)	LOP, ROP, OP	Occipito-frontal: 11.5cm (larger)	• Presents larger diameter • Longer, more painful labour • Higher risk of operative delivery • Back pain prominent

C. Fetal Presentation

Presentation	Frequency	Management
Cephalic (vertex)	96%	Normal vaginal delivery
Breech	3-4%	External cephalic version (ECV) or planned cesarean section
Shoulder (transverse lie)	\<1%	Emergency cesarean section
Face	Rare	May deliver vaginally if mento-anterior; CS if mento-posterior
Brow	Very rare	Usually requires cesarean section (largest diameter: 13.5cm)

D. Degree of Flexion

• Well flexed: Smallest diameter presents (suboccipito-bregmatic: 9.5cm)
• Deflexed: Larger diameter presents
• Extended: Face or brow presentation

Assessment Techniques

• Abdominal palpation:
  • Leopold's maneuvers to determine lie, presentation, position
  • Assess engagement (fifths palpable above pelvic brim)
• Vaginal examination:
  • Identify sutures and fontanelles
  • Determine position and station
  • Assess caput and moulding
• Ultrasound: Confirm lie, presentation, estimate weight

3. PASSAGE - The Pelvis

A. Pelvic Anatomy

Pelvic Type	Shape	Frequency	Suitability for Labour
Gynaecoid	Round inlet, adequate dimensions	50% of women	Most favorable
Android	Heart-shaped inlet, narrow	20% of women	Unfavorable - associated with CPD
Anthropoid	Oval, long AP diameter	25% of women	Usually favorable; OP position common
Platypelloid	Flat, wide transverse diameter	5% of women	Unfavorable - transverse arrest common

B. Factors Affecting Pelvic Adequacy

• Previous pelvic fractures: May distort pelvic anatomy
• Pelvic injuries: Trauma affecting bony pelvis
• Skeletal disorders: Rickets, kyphoscoliosis
• Pelvic tumors: Fibroids, ovarian masses obstructing passage
• Short stature: May be associated with smaller pelvis

C. Clinical Assessment of Pelvis

Abdominal Examination

• Engagement: How many fifths of fetal head palpable above pelvic brim
  • 5/5 palpable: Completely above brim
  • 3/5 palpable: Sinciput at pelvic brim
  • 0/5 palpable: Fully engaged
• Note: In primigravidas, engagement usually occurs before labor; in multiparas, may occur during labour

Vaginal Examination

• Station: Relationship of presenting part to ischial spines
  • -3 to -1: Above spines (cm above)
  • 0: At spines (engaged)
  • +1 to +3: Below spines (cm below)
• Pelvic diameters:
  • Diagonal conjugate (\>11.5cm)
  • Ischial spines (should not be prominent)
  • Subpubic angle (\>90 degrees)
  • Sacral curve (should be concave)
• Moulding: Overlap of skull bones
  • 0: No overlap (bones separated)
  • +: Bones touching
  • ++: Bones overlapping but reducible
  • +++: Bones severely overlapping and irreducible (suggests CPD)
• Caput: Scalp edema
  • 0: None
  • +: Small amount
  • ++: Moderate (concerning if present early in labour)
  • +++: Severe (suggests obstruction)

D. Soft Tissue Considerations

• Cervix: Should efface and dilate progressively
• Perineum: Should be elastic and stretch during delivery
• Pelvic floor muscles: Tone and ability to relax

Integration: Diagnosing Cephalopelvic Disproportion (CPD)

CPD is diagnosed when there is failure of labour to progress despite adequate uterine contractions (adequate "powers").

Clinical Signs Suggesting CPD

• Lack of descent despite adequate contractions
• Lack of cervical dilatation despite adequate contractions
• Persistent occipito-posterior or occipito-transverse position
• Increasing caput and moulding without descent
• Oedematous, poorly applied cervix
• Signs of obstructed labour (maternal tachycardia, fever, fetal distress)

Management

• If CPD diagnosed after trial of labour with adequate augmentation → Cesarean section

Management of Prolonged Labour

Scenario: G1P0, 38 years old, active labour for 6 hours (since 2pm), no progress in cervical dilatation for 3 hours (stuck at 5cm since 5pm), now developing caput ++. This represents prolonged first stage of labour.

Step 1: Immediate Assessment of Mother and Fetus

Maternal Assessment

Parameter	What to Check	Significance
Vital signs	• Temperature • Pulse rate • Blood pressure • Respiratory rate	• Fever/tachycardia: Chorioamnionitis, dehydration • Hypotension: Epidural, dehydration, hemorrhage • Hypertension: Pre-eclampsia
Hydration status	• Oral intake • IV fluid intake • Urine output • Signs of dehydration	• Dehydration can reduce uterine contractility • Ketosis may develop
Pain/exhaustion	• Adequacy of analgesia • Maternal exhaustion • Coping ability	• Inadequate pain relief may prevent maternal cooperation • Exhaustion reduces pushing effectiveness
Bladder	• Time of last void • Bladder distension	Full bladder can obstruct descent and reduce uterine contractility

Fetal Assessment

• Fetal heart rate monitoring:
  • Continuous CTG monitoring
  • Assess for signs of fetal distress (late decelerations, reduced variability, bradycardia)
• Liquor:
  • Color (clear, blood-stained, meconium)
  • Amount
  • Meconium staining may indicate fetal compromise

Step 2: Detailed History

• Labour history:
  • Onset of contractions
  • Progression of labour (partogram review)
  • Membrane status (intact or ruptured, when, fluid color)
  • Pain relief used so far
• Obstetric history:
  • Parity (primigravida more likely to have prolonged labour)
  • Previous deliveries (mode, complications)
  • Previous cesarean sections
• Antenatal history:
  • Estimated fetal weight (ultrasound or clinical)
  • Any fetal abnormalities detected
  • Maternal complications (diabetes → macrosomia; pre-eclampsia)
• Risk factors for CPD:
  • Previous pelvic injury or fracture
  • Maternal short stature
  • Suspected large baby

Step 3: Systematic Examination

A. Abdominal Examination

• Fetal lie and presentation: Confirm cephalic presentation
• Position: Identify fetal back position (LOA vs LOP vs LOT)
• Engagement: How many fifths of head palpable above pelvic brim
• Estimated fetal weight: Size appropriate for gestational age?
• Contractions:
  • Frequency (count over 10 minutes)
  • Duration (time each contraction)
  • Strength (palpate for intensity)

B. Vaginal Examination - Assess the 3 P's

POWERS

• Assess uterine contractions (frequency, duration, intensity)
• Review CTG tocograph

PASSENGER

• Position: Identify position by palpating sutures and fontanelles
  • Sagittal suture orientation
  • Anterior fontanelle (diamond-shaped, larger)
  • Posterior fontanelle (triangular, smaller)
  • LOA, ROA most favorable; OP positions more difficult
• Station: Relationship to ischial spines (-3 to +3)
• Caput: 0 to +++ (++ is significant, suggests obstruction)
• Moulding: 0 to +++ (assess for excessive/irreducible moulding)
• Presentation: Confirm vertex (exclude face, brow, breech)

PASSAGE

• Cervix:
  • Dilatation (currently 5cm, no change in 3 hours)
  • Effacement
  • Consistency (oedematous/thickened cervix suggests obstruction)
  • Application to presenting part (poorly applied suggests malposition)
• Pelvis:
  • Pelvic capacity (diagonal conjugate, ischial spines prominence, subpubic angle)
  • Any bony abnormalities
• Membranes: Intact or ruptured?
• Liquor: Color and amount if ruptured

Signs of Obstructed Labour (Concerning Findings)

• Oedematous/thickened cervix
• Poorly applied cervix to fetal head
• Significant caput (++ or +++)
• Irreducible moulding (+++)
• Lack of descent despite adequate contractions
• Maternal tachycardia, fever
• Fetal tachycardia or distress

Step 4: Investigations

• Urinalysis: Check for ketones (suggests dehydration/exhaustion)
• CTG monitoring: Continuous fetal heart rate monitoring
• Partogram review: Plot findings on partogram
  • Cervical dilatation crossing "action line" indicates need for intervention
  • Lack of progress for 2-4 hours in active labour is abnormal
• Bloods (if indicated):
  • FBC if signs of infection
  • Group and hold if anticipating operative delivery
• Ultrasound (if available and needed):
  • Confirm presentation and position
  • Estimated fetal weight

Step 5: Management Plan

Immediate Interventions

1. Encourage mobilization and position changes:
   • Upright positions, walking (if able)
   • Lateral positions can help with rotation
   • All-fours position may help with OP position
2. Ensure adequate hydration:
   • IV fluids if dehydrated or ketotic
   • Encourage oral fluids if tolerated
3. Bladder care:
   • Encourage voiding
   • Consider catheterization if unable to void
4. Optimize pain relief:
   • Consider epidural analgesia (especially if augmentation planned)
   • Alternative: parenteral opioids (morphine, pethidine)
   • Good analgesia important before starting syntocinon

Augmentation of Labour (After Ensuring Adequate Analgesia)

1. Amniotomy (Artificial Rupture of Membranes)

• Indication: Membranes intact in active labour with slow progress
• Prerequisite: Presenting part should be engaged (to avoid cord prolapse)
• Effect: Increases prostaglandin release, strengthens contractions
• Assess liquor: Note color (clear, blood, meconium)
• Re-assess in 2-3 hours: If no progress, consider syntocinon

2. Syntocinon (Oxytocin) Infusion

• Indication: Inadequate uterine contractions (hypotonic labor)
• Prerequisites:
  • Cephalic presentation
  • No evidence of CPD or obstructed labour
  • Continuous CTG monitoring
  • Adequate pain relief
  • No contraindications (previous uterine scar is relative contraindication)
• Administration:
  • Start low dose, gradually increase (titration protocol)
  • Aim for 3-4 contractions per 10 minutes
  • Each contraction lasting 40-60 seconds
  • At least 1 minute rest between contractions
• Monitoring:
  • Continuous CTG
  • Monitor contraction frequency and uterine tone
  • Vaginal examination every 2-4 hours to assess progress
• Complications of syntocinon:
  • Uterine hyperstimulation (tachysystole)
  • Fetal distress (from excessive contractions)
  • Uterine rupture (rare, especially with previous scar)
  • Water intoxication (if high doses, prolonged use)

Decision Points After Augmentation

If Labour Progresses

• Continue augmentation and supportive care
• Reassess regularly
• Anticipate vaginal delivery

If Labour Fails to Progress Despite Adequate Augmentation

Diagnosis: Failure to progress / Cephalopelvic disproportion (CPD)

• Definition: No cervical change after 2-4 hours of adequate contractions (with or without syntocinon)
• Management: Cesarean section (LSCS)
• Rationale: Once adequate uterine activity has been established and there is still no progress, the problem is either with the passenger or passage (CPD), not the powers

If Fetal Distress Develops

• Immediate assessment
• Intrauterine resuscitation (maternal position change, IV fluids, oxygen)
• Stop syntocinon
• Expedite delivery (cesarean section or instrumental delivery if fully dilated)

Step 6: Use of Partogram

A partogram is a graphical record of labour progress that helps identify abnormal labour:

• X-axis: Time (hours)
• Y-axis: Cervical dilatation (cm)
• Alert line: Expected rate of progress (1cm/hr for primigravida)
• Action line: 2-4 hours to the right of alert line
• Crossing action line: Indicates need for intervention (augmentation or CS)

Summary Management for This Case

1. Assess: Mother (vitals, hydration, pain) and fetus (CTG, liquor)
2. Examine: Abdomen (contractions, position) and vaginal (3 P's, looking for signs of obstruction)
3. Investigations: Urinalysis for ketones, continuous CTG, partogram
4. Supportive measures: Mobilization, hydration, bladder care, pain relief
5. Augmentation:
   • Amniotomy (if membranes intact)
   • Syntocinon infusion (if inadequate contractions)
6. Reassess in 2-4 hours:
   • If progress → continue
   • If no progress despite adequate augmentation → Cesarean section for CPD
   • If fetal distress → Emergency cesarean section

Key Point

In this case, the presence of significant caput (++) without progress suggests possible early obstruction/CPD. After ensuring adequate analgesia and attempting augmentation, if there is no progress, the safest option is cesarean section to avoid maternal and fetal morbidity.

Mechanism of Normal Labour

The mechanism of labour refers to the series of movements that the presenting part (usually the fetal head) undergoes to navigate through the pelvis and achieve vaginal delivery. These movements are necessary because the fetal head must adapt to the changing dimensions and shape of the birth canal.

The Seven Cardinal Movements

1. Descent

• Definition: Downward movement of the fetal head through the pelvis
• Timing:
  • Primigravidas: Usually begins before labour (engagement in late pregnancy)
  • Multigravidas: Often occurs during labour
• Mechanism: Driven by uterine contractions, maternal pushing efforts, and gravity
• Clinical assessment: Measured by fifths palpable abdominally or station on vaginal examination
• Note: Descent occurs throughout all subsequent movements

2. Engagement

• Definition: The maximum diameter (biparietal diameter: 9.5cm) of the fetal head has passed through the pelvic inlet (pelvic brim)
• Clinical criteria:
  • Head at or below ischial spines (station 0 or below)
  • OR ≤2/5 head palpable abdominally
• Position at engagement: Head typically enters in occipito-transverse (OT) position
  • Left occipito-transverse (LOT) most common
  • This is because the pelvic inlet is widest in the transverse diameter

3. Flexion

• Definition: The fetal head flexes so that the chin approaches the chest
• Timing: Occurs throughout labour, increasing as head descends
• Mechanism: Resistance from pelvic floor and cervix causes flexion
• Importance: Flexion presents the smallest diameter to the pelvis
  • Well-flexed: Suboccipito-bregmatic diameter (9.5cm)
  • Deflexed: Larger diameters present (less favorable)
• Landmark: Posterior fontanelle becomes more easily palpable on VE

4. Internal Rotation

• Definition: The fetal head rotates so that the occiput moves from transverse toward the anterior (or occasionally posterior) position
• Common rotation: OT → OA (occipito-transverse to occipito-anterior)
  • LOT → LOA → OA (most common)
  • ROT → ROA → OA
• Occasional rotation: OT → OP (persistent occipito-posterior)
  • Occurs in ~5-10% of labours
  • Associated with longer, more painful labour
• Mechanism: Rotation occurs due to:
  • Shape of pelvis (pelvic mid-cavity widest in AP diameter)
  • Shape of pelvic floor muscles (levator ani)
  • Gutter-shaped pelvic floor directs occiput anteriorly
• Important note: The head rotates in relation to the fetal shoulders (shoulders remain transverse)
• Clinical assessment: Position of sagittal suture changes from transverse to anterior-posterior on VE

5. Extension

• Definition: The fetal head extends as it passes under the pubic symphysis and delivers through the vaginal introitus
• Mechanism:
  • As the head reaches the perineum, it encounters resistance
  • The occiput pivots under the pubic symphysis (fulcrum)
  • The head extends to deliver
• Delivery sequence:
  • Occiput appears and remains under pubic arch
  • Head "crowns" (widest diameter passes through introitus)
  • Forehead, face, and chin sweep over perineum
• Visualization: In OA position, baby is "looking down at the floor" as head delivers
• Clinical significance: Controlled delivery of head prevents perineal trauma

6. External Rotation (Restitution)

• Definition: After delivery, the head rotates back (externally) to realign with the fetal shoulders
• Direction: Head turns from OA position back to transverse (OT)
  • If was LOA, head rotates to left
  • If was ROA, head rotates to right
• Mechanism: Shoulders are still in transverse position in pelvis; head "untwists" to return to natural alignment with shoulders
• Clinical observation: After head delivers, it spontaneously turns to face mother's thigh
• Next step: Shoulders undergo internal rotation (to AP diameter)

7. Lateral Flexion (Delivery of Shoulders and Body)

• Shoulder delivery:
  • Anterior shoulder appears first under pubic symphysis
  • Gentle downward traction facilitates anterior shoulder delivery
  • Posterior shoulder then delivers over perineum
  • Gentle upward lift after anterior shoulder
• Trunk delivery:
  • Body delivers by lateral flexion
  • Rest of body follows easily once shoulders delivered
• Completion: Baby lifted onto mother's abdomen

Additional Steps (Third Stage)

8. Cord Clamping

• Timing:
  • Delayed cord clamping recommended (30-180 seconds) if baby vigorous
  • Benefits: Improved iron stores, reduced anemia
  • Immediate clamping if baby requires resuscitation
• Procedure: Apply two clamps to umbilical cord and cut between them

9. Active Management of Third Stage

• Administer oxytocic: With delivery of anterior shoulder or immediately after birth
  • Oxytocin 10 units IM or 5 units slow IV
  • Or Syntometrine (ergometrine + oxytocin) if no contraindications
• Await signs of placental separation:
  • Cord lengthening (descends from vagina)
  • Gush of blood
  • Uterus rises up and becomes firm (contracts)
  • Uterus changes from discoid to globular shape
• Controlled cord traction:
  • Apply steady, gentle traction on cord
  • Counter-pressure on uterus ("guarding") with other hand above pubic symphysis
  • This prevents uterine inversion
• Deliver placenta and membranes:
  • As placenta delivers, twist gently to encourage membrane delivery
  • Inspect placenta for completeness
  • Inspect membranes
• Examine:
  • Check perineum for tears
  • Estimate blood loss
  • Palpate uterus to ensure contracted

Summary Table: The Seven Cardinal Movements

Movement	What Happens	Why It Happens
1. Descent	Head moves down through pelvis	Contractions, pushing, gravity
2. Engagement	Biparietal diameter enters pelvic inlet (OT position)	Pelvic inlet widest transversely
3. Flexion	Chin to chest (smaller diameter presents)	Resistance from cervix/pelvic floor
4. Internal rotation	OT → OA (head twists, shoulders stay transverse)	Pelvic mid-cavity widest AP; shape of pelvic floor
5. Extension	Head extends, pivoting under pubic symphysis	Resistance from perineum; pubis acts as fulcrum
6. External rotation (restitution)	Head turns back to transverse	Realigns with shoulders (which are still transverse)
7. Lateral flexion	Shoulders and body deliver	Anterior shoulder under pubis, posterior over perineum

Key Principles

• The fetal head adapts to the pelvis, not vice versa
• Each movement facilitates the next
• Movements occur in response to pelvic architecture
• Understanding mechanism helps diagnose abnormal labour (e.g., failure of rotation, deflexion)

Routine Observations in Normal Labour

Monitoring during labour is typically recorded on a partogram, which provides a graphical representation of labour progress over time.

Key Parameters Monitored

Parameter	Frequency	Method/Details	Normal Findings	Concerning Findings
Fetal Heart Rate (FHR)	• Every 15 min in 1st stage • Every 5 min in 2nd stage • Continuous CTG if risk factors	• Intermittent auscultation with Pinard or Doppler • OR continuous CTG monitoring • Listen for 1 minute after contraction	• Baseline: 110-160 bpm • Moderate variability (5-25 bpm) • Accelerations present • No decelerations	• Tachycardia (\>160 bpm) • Bradycardia (\<110 bpm) • Late or prolonged decelerations • Reduced variability (\<5 bpm) • Sinusoidal pattern
Uterine Contractions	Every 30 minutes in active labour	• Frequency: Count per 10 minutes • Duration: Time each contraction (seconds) • Strength: Palpate intensity • CTG tocograph shows frequency and duration	• Active labour: 3-4 per 10 minutes • Duration: 40-60 seconds • Strong (unable to indent uterus) • At least 60 sec rest between	• <2 per 10 minutes (inadequate) • >5 per 10 minutes (tachysystole) • <60 sec rest between (tetanic) • Weak or irregular
Cervical Dilatation	• Every 4 hours in latent phase • Every 2-4 hours in active phase	• Vaginal examination • Measured in centimeters (0-10cm) • Plot on partogram	• Primipara: ≈1 cm/hr in active labour • Multipara: ≈2 cm/hr in active labour • Progress along or left of alert line	• No change over 2-4 hours in active labour • Cervical dilatation crosses action line on partogram • Oedematous cervix
Fetal Descent	• Every 4 hours (with VE) • OR every 2 hours abdominally	Abdominal palpation: • Fifths of head palpable above pelvic brim (0-5/5) Vaginal examination: • Station relative to ischial spines (-3 to +3)	• Progressive descent • Engagement (≤2/5 abdominally or station 0) • Descent with dilatation	• No descent despite contractions • Head remains high (\>2/5 palpable) • Increasing caput without descent
Position of Fetal Head	With each VE (every 2-4 hours)	• Palpate sutures and fontanelles • Identify sagittal suture orientation • Locate anterior and posterior fontanelles	• OT at engagement • Progressive rotation to OA • OA for delivery	• Persistent OT (transverse arrest) • OP position (especially if not progressing) • Deflexed attitudes
Caput & Moulding	With each VE	Caput: Scalp oedema (0 to +++) Moulding: Overlap of skull bones (0 to +++)	• Minimal or no caput • 0 or + moulding • Develops gradually in late labour	• Significant caput (++) early in labour • Severe irreducible moulding (+++) • Suggests obstruction/CPD
Amniotic Fluid	• At membrane rupture • With each VE • Continuous observation	• Color • Amount • Odor • Presence of meconium or blood	• Clear • Adequate volume • No odor • No blood or meconium	• Meconium-stained (green/brown) • Heavy blood staining • Offensive odor (infection) • Scant/absent (oligohydramnios)
Maternal Blood Pressure	Every 4 hours (more frequently if hypertension or epidural)	Measure with sphygmomanometer	• Systolic <140 mmHg • Diastolic <90 mmHg	• ≥140/90 (hypertension) • ≥160/110 (severe hypertension) • Hypotension (\<90/60)
Maternal Pulse	Every 30-60 minutes	Radial pulse for 1 minute	60-100 bpm	• Tachycardia (\>100 bpm): infection, dehydration, hemorrhage, pain • Bradycardia (\<60 bpm)
Maternal Temperature	Every 4 hours (every 2 hours if membranes ruptured >18 hrs)	Oral or tympanic thermometer	<37.5°C	• ≥37.5°C: Consider chorioamnionitis, UTI, dehydration • ≥38°C: Likely infection
Maternal Urinalysis	• On admission • Every 4 hours or with each void	• Protein • Ketones • Glucose	• No protein (trace acceptable) • No ketones • No glucose	• Protein: Pre-eclampsia, UTI • Ketones: Dehydration, starvation • Glucose: Diabetes
Fluid Balance	Continuous recording	Input: • Oral fluids • IV fluids Output: • Urine • Vomit • Blood loss	• Adequate hydration • Voiding regularly • Urine output >30 mL/hr	• Oliguria (\<30 mL/hr) • Unable to void (bladder distension) • Ketones in urine (dehydration)
Medications/Interventions	Continuous recording	• Document all medications given • Time, dose, route • Analgesia administered • IV fluids • Oxytocin infusion rate	N/A	Ensure accurate documentation for safety
Vaginal Bleeding	Continuous observation	• Amount (spotting, small, moderate, heavy) • Character (mixed with mucus, clots, fresh)	• Small amount of blood-stained mucus (bloody show) • Minimal bleeding	• Heavy bleeding: placental abruption, vasa praevia • Fresh blood: consider abruption, cervical/vaginal trauma
Maternal Well-being	Continuous observation	• Pain level and coping • Anxiety/emotional state • Exhaustion • Ability to mobilize • Support person present	• Coping well • Mobilizing if able • Adequate pain relief • Supported	• Severe pain unrelieved by analgesia • Extreme anxiety or distress • Exhaustion • Requesting intervention

Partogram Components

The partogram is a single-page graphical record of labour that typically includes:

• X-axis: Time (hours)
• Fetal parameters:
  • Fetal heart rate (plotted)
  • Liquor color and amount
  • Moulding and caput
• Labour progress:
  • Cervical dilatation (plotted on alert and action lines)
  • Descent of head (abdominally and station)
  • Position of head
• Contractions: Frequency and duration (plotted)
• Maternal parameters:
  • BP, pulse, temperature
  • Urine output and analysis
• Interventions:
  • Drugs administered (analgesia, oxytocin)
  • IV fluids
  • Procedures (VE, amniotomy)

Alert and Action Lines

• Alert line: Represents expected rate of cervical dilatation (usually 1cm/hr for primigravida)
• Action line: Typically 2-4 hours to the right of alert line
• Interpretation:
  • Progress to left of alert line = normal labour
  • Crossing alert line = slower than expected (monitor closely)
  • Crossing action line = requires intervention (augmentation or CS)

Benefits of Systematic Monitoring

• Early detection of abnormal labour
• Identification of maternal or fetal compromise
• Guides clinical decision-making
• Improves communication between healthcare providers
• Medicolegal documentation

Episiotomy

An episiotomy is a surgical incision of the perineum made to enlarge the vaginal opening during delivery.

Types of Episiotomy

Type	Description	Advantages	Disadvantages
Mediolateral	Incision from posterior fourchette directed laterally (45-60° angle from midline)	• Less risk of anal sphincter injury • Less risk of extension to rectum • Preferred in most countries	• More blood loss • More painful healing • More difficult to repair
Median (midline)	Incision in midline from posterior fourchette toward anus	• Less blood loss • Easier to repair • Better healing • Less postpartum pain	• Higher risk of extension to anal sphincter (3rd degree) or rectum (4th degree) • Not routinely recommended

Indications for Episiotomy

Fetal Indications

• Expedited delivery required for fetal distress:
  • Persistent fetal bradycardia
  • Severe variable or late decelerations
  • Pathological CTG requiring urgent delivery
• Preterm delivery: To protect fragile premature head
• Breech delivery: To facilitate delivery of head

Maternal Indications

• Rigid, non-stretching perineum:
  • Tight perineal tissue not stretching adequately
  • Risk of severe uncontrolled tear
  • Primigravida with tight perineum
  • Previous perineal scarring (FGM, previous 3rd/4th degree tear)
• Maternal exhaustion: Prolonged 2nd stage, unable to push effectively
• Maternal medical conditions:
  • Cardiac disease (avoid prolonged Valsalva)
  • Severe hypertension
  • Other conditions where pushing should be limited

Operative Delivery

• Instrumental delivery:
  • Forceps delivery (usually requires episiotomy)
  • Vacuum delivery (episiotomy if inadequate space)

Delivery Complications

• Occipito-posterior (OP) position: Larger diameter presenting, increased perineal stretch
• Shoulder dystocia: May need episiotomy to create space for maneuvers

Timing of Episiotomy

• Performed during a contraction when perineum is thinned and stretched
• When presenting part is visible and distending perineum (crowning)
• Local anaesthetic infiltration if no epidural (1% lidocaine)
• Cut made with scissors in one deliberate cut

Situations Where Episiotomy is NOT Routinely Indicated

• Routine use is NOT recommended: Evidence shows no benefit to routine episiotomy
• Most women can deliver without episiotomy with adequate perineal support and controlled delivery
• Natural tears are often smaller and heal better than episiotomy

Principles of Episiotomy Repair

Timing and Setting

• Repair as soon as possible after placental delivery
• Ensure adequate lighting
• Comfortable position for both patient and operator
• Aseptic technique

Anaesthesia

• Ensure adequate pain relief before starting repair
• Options:
  • Epidural top-up (if epidural in situ)
  • Pudendal block
  • Local infiltration with lidocaine 1% (up to 20mL)
• Test anaesthesia is adequate before starting

Assessment Before Repair

• Thorough examination:
  • Extent of episiotomy
  • Any additional tears
  • Depth of wound (vaginal mucosa, muscle, skin)
• ESSENTIAL: Digital rectal examination
  • Check anal sphincter integrity
  • Check rectal mucosa (ensure no buttonhole tear)
  • If 3rd or 4th degree tear identified → specialist repair in theatre required

Classification of Perineal Tears

Degree	Definition	Management
1st degree	Injury to perineal skin and/or vaginal mucosa only	May not require suturing if edges well-approximated and no bleeding
2nd degree	Injury to perineum involving perineal muscles but not anal sphincter	Requires repair in layers (see below)
3rd degree	Injury to perineum involving anal sphincter complex: • 3a: \<50% external anal sphincter (EAS) torn • 3b: >50% EAS torn • 3c: Internal anal sphincter (IAS) also torn	Specialist repair in theatre under regional/general anaesthesia by experienced obstetrician
4th degree	Injury to perineum involving anal sphincter complex AND rectal mucosa	Specialist repair in theatre by experienced obstetrician ± colorectal surgeon

Suture Material

• Absorbable sutures: Rapidly absorbed synthetic sutures preferred
  • Polyglactin 910 (Vicryl Rapide) 2-0 or 3-0
  • Associated with less pain and less need for suture removal
• Continuous technique preferred over interrupted sutures
  • Faster
  • Less painful
  • Better anatomical results

Layered Repair Technique (2nd Degree Tear or Episiotomy)

1. Vaginal Mucosa (First Layer)

• Start: At apex of vaginal trauma (above hymenal ring)
• Important: Identify apex first to prevent missed bleeding points
• Technique:
  • Anchor suture at apex
  • Continuous suture down to hymenal ring
  • Close vaginal mucosa with continuous suture
  • Ensure haemostasis

2. Deep Perineal Muscles (Second Layer)

• Structures: Bulbocavernosus and transverse perineal muscles
• Technique:
  • Continuous or interrupted sutures
  • Approximate muscle layers
  • Minimize dead space: Dead space increases risk of hematoma and infection
  • Ensure good apposition but avoid excessive tension

3. Perineal Skin (Third Layer)

• Technique options:
  • Continuous subcuticular suture (preferred - less painful, better cosmesis)
  • OR interrupted sutures
• Start at posterior end and work forward
• Ensure skin edges are everted and well-approximated
• Avoid tight sutures (causes pain and necrosis)

Key Principles of Repair

1. Achieve Haemostasis

• Identify and ligate bleeding vessels
• Ensure no ongoing bleeding before completing repair
• Reduces risk of hematoma formation

2. Minimize Dead Space

• Approximate tissue layers carefully
• Avoid gaps between layers where blood/fluid can collect
• Dead space → hematoma → infection → wound breakdown

3. Anatomical Reconstruction

• Restore normal anatomy layer by layer
• Match corresponding tissue edges
• Avoid distortion of vaginal opening or perineum

4. Avoid Excessive Tension

• Sutures should approximate tissue, not strangle it
• Excessive tension → tissue ischemia → necrosis → breakdown
• Can cause significant postpartum pain

5. Ensure Adequate Anaesthesia

• Patient comfort essential for cooperation
• Allows proper examination and meticulous repair

After Repair

Examination

• Rectal examination:
  • Ensure no sutures penetrated rectal mucosa
  • Check repair is satisfactory
• Vaginal examination:
  • Check for retained swabs/instruments
  • Perform swab and instrument count
• Assess bleeding: Ensure haemostasis achieved

Documentation

• Degree of tear/episiotomy
• Layers repaired
• Suture material used
• Estimated blood loss
• Any complications
• Swab and instrument count correct
• PR examination findings

Postpartum Care

• Analgesia:
  • Regular simple analgesia (paracetamol, NSAIDs)
  • Opioids if needed for first 24-48 hours
• Perineal care:
  • Keep area clean and dry
  • Change pads frequently
  • Warm baths or cold packs for comfort
• Laxatives: Prevent constipation (stool softeners)
• Antibiotics: Consider if 3rd/4th degree tear or contaminated wound
• Follow-up:
  • Routine postnatal follow-up
  • 6-12 week check
  • If 3rd/4th degree: Specialist follow-up, consider physiotherapy, assess continence

Complications of Episiotomy

• Short-term: Pain, bleeding, hematoma, infection, wound breakdown
• Long-term: Dyspareunia (painful intercourse), scarring, anal incontinence (if sphincter injury)

Special Circumstances: 3rd and 4th Degree Tears

If anal sphincter involvement identified:

• DO NOT attempt repair at bedside
• Transfer to operating theatre
• Regional or general anaesthesia
• Repair by experienced obstetrician (or under direct supervision)
• Specialist technique:
  • End-to-end or overlapping sphincter repair
  • Separate repair of internal and external anal sphincter
  • Rectal mucosa repair if 4th degree (rectal side first)
• Postoperative:
  • Broad-spectrum antibiotics
  • Laxatives (avoid constipation)
  • Physiotherapy referral
  • 6-12 week specialist follow-up
  • Assess anal continence
  • Counsel regarding future deliveries