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Obstetrics

Normal Labour and Delivery Management

Management of the physiological process of labour and vaginal delivery at term, including monitoring progress, supporting the mother, and immediate care of mother and newborn.

Also known as: Vaginal Birth, Childbirth

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Referral and warning signs

When to refer

Refer if: Progress crosses Alert Line, Fetal distress, Maternal distress/complications, Need operative delivery, Meconium liquor, Malpresentation.

Red flags

  • Abnormal FHR (<110/>160/decelerations)
  • Thick meconium
  • Progress crosses Action Line
  • Maternal exhaustion/ketosis
  • Bleeding > show
  • Severe hypertension/eclampsia
  • Signs of uterine rupture

Signs and symptoms

  • Onset of Labour: Regular painful contractions (increasing strength/frequency/duration), Show, Rupture of membranes.
  • First Stage (0-10cm): Latent Phase (slow dilatation to 4-6cm), Active Phase (faster dilatation >=1cm/hr nullipara). Descent.
  • Second Stage (Full dilatation to baby): Expulsive contractions, Urge to push, Crowning.
  • Third Stage (Baby to placenta): Placental separation signs (gush blood, cord lengthens, uterus rises), Placental expulsion.

Risk factors

  • Not applicable for normal labour.

Diagnosis

Clinical assessment

Labour onset: Regular painful contractions +/- show/ROM. Progress assessment: Abdo palpation (contractions, descent), Vaginal Exam (dilatation, effacement, station, position, membranes).

Investigations

  • Review ANC record.
  • Vital signs.
  • Abdominal palpation.
  • Vaginal Examination (on admission, Q4H in active phase).
  • Partograph plotting.

Diagnostic criteria

Regular painful contractions + progressive cervical change.

Management

Non-pharmacological management

  • First Stage: Supportive care (companion), Mobility/position changes, Hydration/light nourishment, Monitor vitals (hourly active), FHR (Q30min active), Contractions, Partograph plotting, Privacy.
  • Second Stage: Confirm full dilatation, Encourage effective pushing, Monitor FHR (Q5-15min), Prepare for delivery, Perineal support, Controlled delivery of head/shoulders, Immediate newborn drying/assessment.
  • Third Stage (Active Management - AMTSL): Rule out 2nd baby, Oxytocin 10 IU IM (<1min), Delayed cord clamping (1-3min), Controlled Cord Traction (CCT), Uterine massage.
  • Fourth Stage (Immediate Postpartum 1-2h): Examine for tears/repair, Monitor vitals/uterus/bleeding (Q15min x 2h), Encourage skin-to-skin & breastfeeding (<1h), Ensure urination, Comfort.

Pharmacological treatment

  • Pain Relief (1st Stage): Pethidine/Morphine IM (judiciously). Paracetamol.
  • AMTSL: Oxytocin 10 IU IM (Standard). Alternatives: Heat-stable Carbetocin 100mcg IM/IV; Misoprostol 600mcg PO.
  • Episiotomy (Restrictive): Local anaesthetic (Lignocaine 1%).
  • Tear Repair: Local anaesthetic, Sutures.
  • Newborn: Vitamin K 1mg IM, Tetracycline eye ointment.

Monitoring

Partograph use essential (Cervix, Descent, Contractions, Maternal/Fetal condition). Frequent FHR and maternal vital signs.

Complications

  • Failure to progress/Obstructed labour.
  • Fetal distress.
  • Postpartum haemorrhage (PPH).
  • Perineal tears.
  • Puerperal sepsis.
  • Uterine rupture.
  • Amniotic fluid embolism.

Prevention

  • Good ANC.
  • Skilled birth attendance.
  • Correct Partograph use.
  • Active Management of Third Stage (AMTSL).

Patient education

  • Stages of labour.
  • Pain coping.
  • Hydration/nutrition.
  • Birth companion role.
  • Delivery process/newborn care.
  • AMTSL benefits.
  • Postpartum care.
  • Early breastfeeding.

Uganda-specific notes

Partograph use standard. AMTSL standard. Skilled attendance key. Referral crucial for poor progress.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 16, Section 16.4.1

  • Partograph Chart, MOH Uganda

    (Standard tool)

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