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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 

 


Section 1 - Clinical Principles


Normal labour and childbirth

NORMAL LABOUR

  • Make a rapid evaluation of the general condition of the woman including vital signs (pulse, blood pressure, respiration, temperature).

  • Assess fetal condition:

- Listen to the fetal heart rate immediately after a contraction:

- Count the fetal heart rate for a full minute at least once every 30 minutes during the active phase and every 5 minutes during the second stage;

- If there are fetal heart rate abnormalities (less than 100 or more than 180 beats per minute), suspect fetal distress.

- If the membranes have ruptured, note the colour of the draining amniotic fluid:

- Presence of thick meconium indicates the need for close monitoring and possible intervention for management of fetal distress 

- Absence of fluid draining after rupture of the membranes is an indication of reduced volume of amniotic fluid, which may be associated with fetal distress.

SUPPORTIVE CARE DURING LABOUR AND CHILDBIRTH

  • Encourage the woman to have personal support from a person of her choice throughout labour and birth:

- Encourage support from the chosen birth companion;

- Arrange seating for the companion next to the woman;

- Encourage the companion to give adequate support to the woman during labour and childbirth (rub her back, wipe her brow with wet cloth, assist her to move about).

  • Ensure good communication and support by staff:

- Explain all procedures, seek permission and discuss findings with the woman;

- Provide a supportive, encouraging atmosphere for birth, respectful of the woman’s wishes;

- Ensure privacy and confidentiality.

  • Maintain cleanliness of the woman and her environment:

- Encourage the woman to wash herself or bathe or shower at the onset of labour;

- Wash the vulval and perineal areas before each examination;

- Wash your hands with soap before and after each examination;

- Ensure cleanliness of labouring and birthing area(s);

- Clean up all spills immediately.

  • Ensure mobility:

- Encourage the woman to move about freely;

- Support the woman’s choice of position for birth.

  • Encourage the woman to empty her bladder regularly.

Note: Do not routinely give an enema to women in labour.

  • Encourage the woman to eat and drink as she wishes. If the woman has visible severe wasting or tires during labour, make sure she is fed. Nutritious liquid drinks are important, even in late labour.

  • Teach breathing techniques for labour and delivery. Encourage the woman to breathe out more slowly than usual and relax with each expiration.

  • Help the woman in labour who is anxious, fearful or in pain:

- Give her praise, encouragement and reassurance;

- Give her information on the process and progress of her labour;

- Listen to the woman and be sensitive to her feelings.

  • If the woman is distressed by pain:

- Suggest changes of position (Fig C-2);

- Encourage mobility;

- Encourage her companion to massage her back or hold her hand and sponge her face between contractions;

- Encourage breathing techniques;

- Encourage warm bath or shower;

- If necessary, give pethidine 1 mg/kg body weight (but not more than 100 mg) IM or IV slowly or give morphine 0.1 mg/kg body weight IM.

Figure C-2  

Positions that a woman adopt during labour 

 

DIAGNOSIS

  • Diagnosis of labour includes:

  • diagnosis and confirmation of labour;

  • diagnosis of stage and phase of labour;

  • assessment of engagement and descent of the fetus;

  • identification of presentation and position of the fetus.

An incorrect diagnosis of labour can lead to unnecessary anxiety and interventions

 

DIAGNOSIS AND CONFIRMATION OF LABOUR

  • Suspect or anticipate labour if the woman has:

- intermittent abdominal pain after 22 weeks gestation;

- pain often associated with blood-stained mucus discharge (show);

- watery vaginal discharge or a sudden gush of water.

  • Confirm the onset of labour if there is:

- cervical effacement—the progressive shortening and thinning of the cervix during labour; and

- cervical dilatation—the increase in diameter of the cervical opening measured in centimetres (Fig C-3 A–E).

Figure C-3  

Effacement and dilatation of the cervix 

 

Table C-8 

Diagnosis of stage and phase of labour a 

Symptoms and Signs

Stage

Phase

• Cervix not dilated 

False labour/Not in labour

• Cervix dilated less than 4 cm

First

Latent

• Cervix dilated 4–9 cm

• Rate of dilatation typically 1 cm per hour or more

• Fetal descent begins

First

Active

• Cervix fully dilated (10 cm)

• Fetal descent continues

• No urge to push

Second

Early (non-expulsive)

• Cervix fully dilated (10 cm)

• Presenting part of fetus reaches pelvic floor

• Woman has the urge to push

Second

Late(expulsive)

 

a The third stage of labour begins with delivery of the baby and ends with expulsion of placenta.

 

DESCENT

Abdominal palpation

  • By abdominal palpation, assess descent in terms of fifths of fetal head palpable above the symphysis pubis (Fig C-4 A–D):

- A head that is entirely above the symphysis pubis is five-fifths (5/5) palpable 
(Fig C-4 A–B);

- A head that is entirely below the symphysis pubis is zero-fifths (0/5) palpable.

FIGURE C-4

 Abdominal palpation for descent of the fetal head 

Vaginal examination

  • If necessary, a vaginal examination may be used to assess descent by relating the level of the fetal presenting part to the ischial spines of the maternal pelvis (Fig C-5).

Note: When there is a significant degree of caput or moulding, assessment by abdominal palpation using fifths of head palpable is more useful than assessment by vaginal exam.

FIGURE C-5  

Assessing descent of the fetal head by vaginal examination; 0 station is at the level of the ischial spine (Sp). 

 

Presentation and position

Determine the presenting part

  • The most common presenting part is the vertex of the fetal head. If the vertex is not the presenting part, manage as a malpresentation (Table S-12).

  • If the vertex is the presenting part, use landmarks on the fetal skull to determine the position of the fetal head in relation to the maternal pelvis (Fig C-6).

FIGURE C-6

 Landmarks of the fetal skull 

 

Determine the position of the fetal head

  • The fetal head normally engages in the maternal pelvis in an occiput transverse position, with the fetal occiput transverse in the maternal pelvis (Fig C-7).

FIGURE C-7

Occiput transverse positions 

      

 

FIGURE C-8 

Occiput anterior positions 

   

 

  • An additional feature of a normal presentation is a well-flexed vertex (Fig C-9), with the occiput lower in the vagina than the sinciput.

 

FIGURE C-9

Well-flexed vertex 

 

Assessment of progress of labour

Once diagnosed, progress of labour is assessed by:

  • measuring changes in cervical effacement and dilatation (Fig C-3 A–E) during the latent phase;

  • measuring the rate of cervical dilatation and fetal descent (Fig C-4, and Fig C-5) during the active phase;

  • assessing further fetal descent during the second stage.

Progress of the first stage of labour should be plotted on a partograph once the woman enters the active phase of labour. A sample partograph is shown in Fig C-10.  Alternatively, plot a simple graph of cervical dilatation (centimetres) on the vertical axis against time (hours) on the horizontal axis.

Vaginal examinations

Vaginal examinations should be carried out at least once every 4 hours during the first stage of labour and after rupture of the membranes. Plot the findings on a partograph.

  • At each vaginal examination, record the following:

- colour of amniotic fluid;

- cervical dilatation;

- descent (can also be assessed abdominally).

  • If the cervix is not dilated on first examination it may not be possible to diagnose labour.

- If contractions persist, re-examine the woman after 4 hours for cervical changes. At this stage, if there is effacement and dilatation, the woman is in labour; if there is no change, the diagnosis is false labour.

  • In the second stage of labour, perform vaginal examinations once every hour.

USING THE PARTOGRAPH

The WHO partograph has been modified to make it simpler and easier to use. The latent phase has been removed and plotting on the partograph begins in the active phase when the cervix is 4 cm dilated. A sample partograph is included (Fig C-10). Note that the partograph should be enlarged to full size before use. Record the following on the partograph:

Patient information: Fill out name, gravida, para, hospital number, date and time of admission and time of ruptured membranes.

Fetal heart rate: Record every half hour.

Amniotic fluid: Record the colour of amniotic fluid at every vaginal examination:

  • I: membranes intact;

  • C: membranes ruptured, clear fluid;

  • M: meconium-stained fluid;

  • B: blood-stained fluid.

Moulding:

  • 1: sutures apposed;

  • 2: sutures overlapped but reducible;

  • 3: sutures overlapped and not reducible.

Cervical dilatation: Assessed at every vaginal examination and marked with a cross (X). Begin plotting on the partograph at 4 cm.

Alert line: A line starts at 4 cm of cervical dilatation to the point of expected full dilatation at the rate of 1 cm per hour.

Action line: Parallel and 4 hours to the right of the alert line.

Descent assessed by abdominal palpation: Refers to the part of the head (divided into 5 parts) palpable above the symphysis pubis; recorded as a circle (O) at every vaginal examination. At 0/5, the sinciput (S) is at the level of the symphysis pubis. 

Hours: Refers to the time elapsed since onset of active phase of labour (observed or extrapolated).

Time: Record actual time.

Contractions: Chart every half hour; palpate the number of contractions in 10 minutes and their duration in seconds.

  • Less than 20 seconds: 

  • Between 20 and 40 seconds:

  • More than 40 seconds:

Oxytocin: Record the amount of oxytocin per volume IV fluids in drops per minute every 30 minutes when used.

Drugs given: Record any additional drugs given.

Pulse: Record every 30 minutes and mark with a dot (●).

Blood pressure: Record every 4 hours and mark with arrows.

Temperature: Record every 2 hours.

Protein, acetone and volume: Record every time urine is passed.


Figure C-10  The modified WHO Partograph


 

Figure C-11 is a sample partograph for normal labour: 

  • A primigravida was admitted in the latent phase of labour at 5 AM:

- fetal head 4/5 palpable;

- cervix dilated 2 cm;

- 3 contractions in 10 minutes, each lasting 20 seconds;

- normal maternal and fetal condition.

Note: This information is not plotted on the partograph.

  • At 9 AM:

- fetal head is 3/5 palpable;

- cervix dilated 5 cm;

Note: The woman was in the active phase of labour and this information is plotted on the partograph. Cervical dilatation is plotted on the alert line. 

- 4 contractions in 10 minutes, each lasting 40 seconds;

- cervical dilatation progressed at the rate of 1 cm per hour.

  • At 2 PM:

- fetal head is 0/5 palpable;

- cervix is fully dilated;

- 5 contractions in 10 minutes each lasting 40 seconds;

- spontaneous vaginal delivery occurred at 2:20 PM.

Figure C11  Sample partograph for normal labour

Progress of first stage of labour

  • Findings suggestive of satisfactory progress in first stage of labour are:

- regular contractions of progressively increasing frequency and duration;

- rate of cervical dilatation at least 1 cm per hour during the active phase of labour (cervical dilatation on or to the left of alert line);

- cervix well applied to the presenting part.

  • Findings suggestive of unsatisfactory progress in first stage of labour are:

- irregular and infrequent contractions after the latent phase; 

- OR rate of cervical dilatation slower than 1 cm per hour during the active phase of labour (cervical dilatation to the right of alert line);

- OR cervix poorly applied to the presenting part.

Unsatisfactory progress in labour can lead to prolonged labour (Table S-10).

 

Progress of second stage of labour

  • Findings suggestive of satisfactory progress in second stage of labour are:

- steady descent of fetus through birth canal;

- onset of expulsive (pushing) phase.

  • Findings suggestive of unsatisfactory progress in second stage of labour are:

- lack of descent of fetus through birth canal; 

- failure of expulsion during the late (expulsive) phase.

 

Progress of fetal condition

Progress of maternal condition

Evaluate the woman for signs of distress:

 

NORMAL CHILDBIRTH

General methods of supportive care during labour are most useful in helping the woman tolerate labour pains 

  • Once the cervix is fully dilated and the woman is in the expulsive phase of the second stage, encourage the woman to assume the position she prefers (Fig C-12) and encourage her to push.

Figure C-12

Positions that a woman may adopt during childbirth 

 

Note: Episiotomy is no longer recommended as a routine procedure. There is no evidence that routine episiotomy decreases perineal damage, future vaginal prolapse or urinary incontinence. In fact, routine episiotomy is associated with an increase of third and fourth degree tears and subsequent anal sphincter muscle dysfunction.

 

Episiotomy  should be considered only in the case of:

  • complicated vaginal delivery (breech, shoulder dystocia, forceps, vacuum);

  • scarring from female genital mutilation or poorly healed third or fourth degree tears;

  • fetal distress.

 

Delivery of the head

  • Ask the woman to pant or give only small pushes with contractions as the baby’s head delivers.

  • To control birth of the head, place the fingers of one hand against the baby’s head to keep it flexed (bent).

  • Continue to gently support the perineum as the baby’s head delivers. 

  • Once the baby’s head delivers, ask the woman not to push.

  • Suction the baby’s mouth and nose.

  • Feel around the baby’s neck for the umbilical cord: 

- If the cord is around the neck but is loose, slip it over the baby’s head;

- If the cord is tight around the neck, doubly clamp and cut it before unwinding it from around the neck.

Completion of delivery

  • Allow the baby’s head to turn spontaneously.

  • After the head turns, place a hand on each side of the baby’s head. Tell the woman to push gently with the next contraction.

  • Reduce tears by delivering one shoulder at a time. Move the baby’s head posteriorly to deliver the shoulder that is anterior. 

Note: If there is difficulty delivering the shoulders, suspect shoulder dystocia.

  • Lift the baby’s head anteriorly to deliver the shoulder that is posterior.

  • Support the rest of the baby’s body with one hand as it slides out. 

  • Place the baby on the mother’s abdomen. Thoroughly dry the baby, wipe the eyes and assess the baby’s breathing:

Note: Most babies begin crying or breathing spontaneously within 30 seconds of birth.

- If the baby is crying or breathing (chest rising at least 30 times per minute) leave the baby with the mother;

- If baby does not start breathing within 30 seconds, SHOUT FOR HELP and take steps to resuscitate the baby.

Anticipate the need for resuscitation and have a plan to get assistance for every baby but especially if the mother has a history of eclampsia, bleeding, prolonged or obstructed labour, preterm birth or infection. 

  • Clamp and cut the umbilical cord.

  • Ensure that the baby is kept warm and in skin-to-skin contact on the mother’s chest. Wrap the baby in a soft, dry cloth, cover with a blanket and ensure the head is covered to prevent heat loss.

  • If the mother is not well, ask an assistant to care for the baby.

  • Palpate the abdomen to rule out the presence of an additional baby(s) and proceed with active management of the third stage.

ACTIVE MANAGEMENT OF THE THIRD STAGE

Active management of the third stage (active delivery of the placenta) helps prevent postpartum haemorrhage. Active management of the third stage of labour includes:

  • immediate oxytocin;

  • controlled cord traction; and 

  • uterine massage.

Oxytocin

  • Within 1 minute of delivery of the baby, palpate the abdomen to rule out the presence of an additional baby(s) and give oxytocin 10 units IM.

  • Oxytocin is preferred because it is effective 2 to 3 minutes after injection, has minimal side effects and can be used in all women. If oxytocin is not available, give ergometrine 0.2 mg IM or prostaglandins. Make sure there is no additional baby(s) before giving these medications.

Do not give ergometrine to women with pre-eclampsia, eclampsia or high blood pressure because it increases the risk of convulsions and cerebrovascular accidents. 

 

Controlled cord traction

  • Clamp the cord close to the perineum using sponge forceps. Hold the clamped cord and the end of forceps with one hand.

  • Place the other hand just above the woman’s pubic bone and stabilize the uterus by applying counter traction during controlled cord traction. This helps prevent inversion of the uterus.

  • Keep slight tension on the cord and await a strong uterine contraction (2–3 minutes). 

  • When the uterus becomes rounded or the cord lengthens, very gently pull downward on the cord to deliver the placenta. Do not wait for a gush of blood before applying traction on the cord. Continue to apply counter traction to the uterus with the other hand. 

  • If the placenta does not descend during 30–40 seconds of controlled cord traction (i.e. there are no signs of placental separation), do not continue to pull on the cord:

- Gently hold the cord and wait until the uterus is well contracted again. If necessary, use a sponge forceps to clamp the cord closer to the perineum as it lengthens;

- With the next contraction, repeat controlled cord traction with counter traction.

Never apply cord traction (pull) without applying counter traction (push) above the pubic bone with the other hand. 

  • As the placenta delivers, the thin membranes can tear off. Hold the placenta in two hands and gently turn it until the membranes are twisted.

  • Slowly pull to complete the delivery.

  • If the membranes tear, gently examine the upper vagina and cervix wearing high-level disinfected gloves and use a sponge forceps to remove any pieces of membrane that are present.

  • Look carefully at the placenta to be sure none of it is missing. If a portion of the maternal surface is missing or there are torn membranes with vessels, suspect retained placental fragments.

  • If uterine inversion occurs, reposition the uterus.

  • If the cord is pulled off, manual removal of the placenta may be necessary.

Uterine massage

  • Immediately massage the fundus of the uterus through the woman’s abdomen until the uterus is contracted.

  • Repeat uterine massage every 15 minutes for the first 2 hours.

  • Ensure that the uterus does not become relaxed (soft) after you stop uterine massage.

Examination for tears

INITIAL CARE OF THE NEWBORN

  • Check the baby’s breathing and colour every 5 minutes. 

  • If the baby becomes cyanotic (bluish) or is having difficulty breathing (less than 30 or more than 60 breaths per minute), give oxygen by nasal catheter or prongs.

  • Check warmth by feeling the baby’s feet every 15 minutes:

- If the baby’s feet feel cold, check axillary temperature;

- If the baby’s temperature is below 36.5�C, rewarm the baby.

  • Check the cord for bleeding every 15 minutes. If the cord is bleeding, retie cord more tightly.

  • Apply antimicrobial drops (1% silver nitrate solution or 2.5% povidone-iodine solution) or ointment (1% tetracycline ointment) to the baby’s eyes. 

Note: Povidone-iodine should not be confused with tincture of iodine, which could cause blindness if used.

  • Wipe off any meconium or blood from skin.

  • Encourage breastfeeding when the baby appears ready (begins “rooting”). Do not force the baby to the breast.

Avoid separating mother from baby whenever possible. Do not leave mother and baby unattended at any time.

Top of page

Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support

Emergencies

General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages

Symptoms

Shock

Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems

Procedures

Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia

Ketamine

External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section

Symphysontomy

Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy

Episiotomy

Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy

Appendix

 

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