www.slcog.

lk/sljog CLINICAL GUIDELINE

Management of Labour
Management of normal labour 3. Management of labour
3.1. General considerations
1. Introduction 3.1.1. Communication between women and healthcare
The aim of this guideline is to provide recommendations professionals/workers
to care providers in the management of a healthy woman • Greet the mother with a smile and a personal
with a single fetus in labour at term (37-42weeks). It does welcome
not cover the care of women with complicated
• Treat her with respect and dignity
pregnancies.
• Assure privacy
The objective of this guideline is to ensure optimal
management of women in labour, detect any abnormality, • Establish a good rapport with the labouring
take appropriate action, prevent complications and woman asking her about her wants and concerns
consequently make childbirth safer; and also to make and address them
sure that these women are treated with respect and • Maintain a calm and confident approach which
compassion, kept well informed and well supported will reassure women that the situation is under
throughout labour. control
• Assess the woman’s knowledge of strategies for
2. Diagnosis of labour coping with pain and provide balanced infor-
mation to find out which available approaches
Labour is diagnosed by the presence of regular, painful are acceptable to her
intermittent contractions, which are of increasing
frequency, duration and intensity, leading to progressive • Ask her permission before all procedures and
cervical effacement and dilatation. observations, focusing on the woman rather than
technology or the documentation
Note: for the purpose of this guideline, labour is also
diagnosed in the presence of painful contractions 3.1.2. Preparation of mothers to transfer to labour room
occurring at a frequency of 2 in 10 minutes or more.
• Shaving or trimming of perineal hair may be
necessary to facilitate unhindered performance
and repair of the episiotomy.
Definitions: • Efforts must be made to minimize faecal soiling.
Latent phase of the first stage of labour – from the Where an enema is deemed necessary, a medicated
commencement of labour to a cervical dilatation of enema is recommended.
up to 4 cm. (This is a period of time, not necessarily (These two steps should not be considered mandatory)
continuous, when there are painful contractions • Women should be encouraged to have a com-
and some cervical changes including cervical panion of her choice during labour, depending
effacement and dilatation up to 4cm take place) on the facilities and clinical situation.
Active phase of the first stage of labour –
commences at a cervical dilatation of 4cm and ends 3.1.3. Documentation
with full dilatation. (There are regular painful
contractions and progressive cervical dilatation • Admit the mother to the labour room and
from 4cm up to full dilatation) complete the ‘handing over’ form.
• Keep relevant notes on the BHT and start a
partograph.

If the diagnosis of labour is uncertain, observation should

• Review clinical notes and reassess risk factors.
continue and reassessment made in four hours. • Accurate documentation of all observations and
interventions must be made, with timing.
Any woman who is diagnosed as not being in labour,
but continues to complain of pain, would require careful • All obstetric examinations and procedures carried
reassessment by an experienced medical officer. Possible out must be documented in the clinical notes.
diagnoses of placental abruption and non-obstetric Each entry must be accompanied by a plan for
causes should be considered. Fetal compromise should management and be signed by the responsible
be excluded. person.

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3.1.4. Mobilization and positioning • Check the fetal heart and maternal pulse half
• Women should be encouraged and helped to move hourly;
about and adopt whatever positions they find • Check temperature four hourly;
most comfortable throughout labour. • Consider vaginal examination four hourly,
• They need to be encouraged to void urine depending on the contraction pattern and initial
regularly. cervical dilatation;
• Document the colour of amniotic fluid if the
3.1.5. Eating and drinking in labour membranes rupture;
• Mothers must be encouraged to consume clear, • Use of a sanitary pad may indicate early the
non-fizzy liquids during labour. Isotonic presence of meconium.
solutions such as oral rehydration fluid and
coconut water are more beneficial than water. • Consider the requirement for analgesia.
• In addition to clear fluids, women in the latent It is important to inform the mother and reassure her that
phase may consume light solids e.g. biscuits and it is common to have slow progress in the latent phase.
fruits. The latent phase is considered prolonged when it lasts
more than 12 hours in a primigravida and 8 hours in a
3.1.6. Hygiene during labour multigravida. In these situations an experienced medical
• Strict asepsis must be maintained during labour. officer (with a minimum one year of experience in
the field) must reassess the mother with a view to
• Instruments should be available in packets. augmentation of labour.
• Use proper hand washing technique.
• Use of double gloves and disposable gloves is 3.2.1.2. Active phase
encouraged. 3.2.1.2a. Admitting women to the labour room
All pregnant women diagnosed as being in active phase
3.1.7. Pain relief in labour of the first stage of labour need to be admitted to the labour
Relief of pain should be a major consideration (please room.
refer guideline on pain relief during labour). The initial assessment of a woman at the labour room
should include:
• Listening to her story, considering her emotional
3.2. Management of the three stages of labour
and psychological needs and reviewing her
clinical records
• Physical observation: temperature, pulse, blood
The practice of maintaining a labour, room ‘notice pressure
board’ – a ‘white board’ in which the status of all • Length, strength and frequency of contractions
women in labour is summarized and updated
regularly is encouraged. This would convey at a • Abdominal palpation: fundal height, lie, presen-
glance to all care providers women who require tation, position and station
additional attention. The age, parity status, risk • Vaginal loss: show, liquor, blood
factors, salient findings at each assessment and any
• Assessment of woman’s pain including her
abnormalities noted must be included in this.
wishes for coping with labour along with the
range of options for pain relief
• The fetal heart rate (FHR) should be auscultated
3.2.1. Management of the first stage of labour preferably with a hand held Doppler for a mini-
mum of 1 minute immediately after a contraction
3.2.1.1. Latent phase
• The maternal pulse should be recorded to
It is important to recognize the latent phase of labour, differentiate between maternal pulse and FHR
since its prolongation could lead to maternal exhaustion,
dehydration and acidosis, leading to fetal compromise • A vaginal examination should be offered
and dysfunctional labour. Health care professionals who conduct vaginal
Women in the latent phase of labour would be best examination should:
managed in the antenatal ward. • Be sure that there is a valid indication for vaginal
Women in the latent phase of labour must be assessed on examination that it will add important infor-
a regular basis, as follows: mation to the decision making process

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• Be aware that for many women who may already • Significant meconium staining of amniotic fluid,
in pain, highly anxious and in an unfamiliar • Abnormal fetal heart rate detected by intermittent
environment, vaginal examination can be very auscultation (< 110 beats per minute; > 160 beats
distressing per minute; any decelerations after a contraction)
• Ensure the woman’s consent, privacy, dignity and • Fresh vaginal bleeding and
comfort
• Maternal pyrexia
• Explain the reason for examination and what will
be involved, and
• Explain the findings and their impact sensitively In women with spontaneous labour progressing
to the woman normally; routine early amniotomy and, use of
oxytocin is not recommended.

3.2.1.2b. Management of active phase of first stage

Monitoring must be conducted as instructed in the 3.2.1.3. Delayed progress of first stage of labour
partogram and findings recorded accordingly.
Use of a sanitary pad may indicate early presence of
Delayed progress is diagnosed when there is
meconium.
progress of less than two cm in four hours.
Women in the active phase of labour must be assessed Slowing of progress in a woman who has previously
on a regular basis, as follows: been progressing satisfactorily must also be
• Check the fetal heart and maternal pulse every 15 considered as a delay.
minutes;
• Check temperature and blood pressure four
hourly; It is extremely important that delay in progress is assessed
by an experienced medical officer. This assessment must
• Vaginal examination four hourly or earlier, take into account:
depending on the clinical situation;
• the uterine contractions,
• Frequency of contractions should be monitored
as follows: • descent and position of the fetal head
The interval between two contractions should be • features of early obstruction of labor (caput and
assessed by palpation of the abdomen. During moulding), and
active labor usually there are at least three • The fetal condition
contractions per ten minutes. In other words the In women with delay in the active phase of the first stage,
interval between two contractions should be three every effort must be made to find a cause for the delay.
minutes This may either be due to inadequate contractions or
• Document the colour of amniotic fluid if the obstruction due to CPD, malpresentation or malposition
membranes rupture; (such as occipito-posterior position), or a combination of
• Consider the requirement for analgesia, (which these.
now becomes more important). In cases of inadequate contractions:
• Amniotomy must be performed if membranes are
still intact.
Intermittent auscultation of the fetal heart is best • Following that, the woman must be reassessed in
performed using hand-held Doppler devices. The two hours.
fetal heart rate must be counted for one minute
beginning immediately after a contraction. • In case there is inadequate progress, augmen-
tation with oxytocin must be considered.
• The situation must be reassessed after four hours
or earlier if required.
The mother may continue to consume clear fluids in the
active phase. Multiparous women with delayed progress:
She must be encouraged to assume any position that she • Must be viewed with extreme caution.
is comfortable in and to avoid the dorsal position. • It is very important to exclude mechanical causes
Women who have the following conditions are of delay before considering oxytocin.
recommended to be have to continuous electronic fetal • Use of oxytocin in multipara with obstructed
monitoring: labour could be extremely dangerous.

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In all cases where progress is slow in spite of adequate Multigravida:

contractions a careful assessment must be made to • Birth would be expected to take place within 1
exclude obstruction of labour. hour of the start of the active second stage in most
Attention must be paid to effective pain relief and to women.
correcting dehydration in these situations.
• A diagnosis of delay in the active second stage
After paying attention to the above, cesarean section must should be made when it has lasted 30 minutes
be considered where the progress continues to be slow and requires advice from a health professional
after four hours (less than two cm) of commencing trained in assisted/ operative vaginal birth if birth
oxytocin. is not imminent.
• Delay in the second stage in a multiparous
3.2.2. Management of second stage of labour woman must raise suspicion of disproportion or
malposition.
3.2.2.1. Passive second stage of labour (descent phase)
One further hour is permitted for women in each category
• Is diagnosed when full cervical dilatation is for women with epidural analgesia.
reached in the absence of involuntary expulsive
efforts by the mother.
• Bearing down must be discouraged at this stage. 3.2.2.3. Observations for women and babies in the
second stage of labour:
• Intermittent auscultation of the fetal heart should
be done immediately after a contraction for at least All observations should be documented on the
one minute, at least every 10 minutes. The partograph.
maternal pulse should be palpated if there is • Chart blood pressure and pulse hourly
suspected fetal bradycardia or any other FHR
• Continue four hourly temperature recording
anomaly to differentiate the two heart rates.
• Vaginal examination must be offered after an hour
• Presence of meconium must be noted. in the active second stage after abdominal
palpation and assessment of vaginal loss
3.2.2.2. Active second stage of labour (expulsive phase) • Half hourly documentation of frequency of
• Is diagnosed when the mother gets the urge to contractions
bear down with full dilatation. • Consideration of the woman’s emotional and
psychological needs
• Intermittent auscultation of the fetal heart should
be done immediately after a contraction for at least In addition:
one minute, at least every 5 minutes. The maternal
pulse should be palpated if there is fetal brady-
• Assessment of progress should include maternal
behavior, effectiveness of pushing and fetal
cardia or any other FHR anomaly.
wellbeing, taking into account fetal position and
• Presence of meconium must be noted. station at the onset of the second stage. These
Use of a hand-held Doppler device is recommended (in factors will assist in deciding the timing of further
preference to a Pinnard stethoscope) for fetal heart rate vaginal examination and the need for obstetric
monitoring in the second stage. review.
Women must be encouraged to continue consuming clear • Ongoing consideration should be given to the
fluids during the second stage. woman’s position, hydration, coping strategies
and pain relief throughout the second stage.
Support by the labour companion must be continued.
Total time durations allowed for the second stage of
labour are as follows: 3.2.2.4. Women’s position and pushing in the second
stage of labour:
Primigravida: Although most deliveries in Sri Lanka are conducted in
• Birth would be expected to take place within 2 the dorsal/McRobert’s position, women may be
hours of the start of the active second stage in encouraged to adopt squatting, semi upright or lateral
most women. positions to aid the expulsion phase.
• A diagnosis of delay in the active second stage Women should be informed that in the second stage, they
should be made when it has lasted 1 hour and should be guided by their own urge to push.
need to seek the advice from a health professional If pushing is ineffective, strategies to assist birth such as
trained in the assisted/operative vaginal birth if support and encouragement and change of position can
birth is not imminent. be used.

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In primigravida in whom contractions have become Delayed clamping of the cord allows for placental
weak and there is no evidence of fetal compromise transfusion, which reduces neonatal and infant iron
deficiency and anemia. This policy should be
or obstruction, oxytocin may be administered as an
followed unless the baby is born in a poor condition
infusion. In this case, the expulsive phase may be
or if the mother is bleeding or is Rhesus iso-
continued under close observation for a further 30
immunized.
minutes. Delivery must be considered at the end of
this period.
• Followed by controlled cord traction.
• This must be followed by uterine massage.
3.2.2.5. Intrapartum interventions to reduce perineal
trauma Clamp and cut the cord close to the perineum. A hand
should be placed above the symphysis pubis to stabilize
Either the ‘hands on’ (guarding the perineum and flexing the uterus by applying counter traction during controlled
the baby’s head) or the ‘hands poised’ (with hands off cord traction. Application of cord traction when the
the perineum and baby’s head but in readiness) uterus is relaxed could lead to acute inversion of the
techniques can be used to facilitate spontaneous birth. uterus.
A routine episiotomy should not be carried out during After delivery, the placenta must be placed on a flat
spontaneous vaginal birth. surface and the maternal surface examined for
Episiotomy should only be performed selectively, in completeness. On the fetal surface the blood vessels must
women in whom there is a clinical need such as be traced to exclude a succenturiate lobe. Completeness
instrumental birth or suspected fetal compromise or a of the fetal membranes must be ensured.
high chance of perineal tears. Observations in the immediate postpartum period
Where episiotomy is performed, mediolateral episiotomy, include:
performed at 45 - 60 degrees from the midline directed to • Inspect for continued fresh bleeding
the right side, beginning at the vaginal fourchette is
preferred to the median episiotomy. It should be • Check pulse, blood pressure, uterine contraction
performed at the time of crowning of the fetal head. and the level of the fundus every 15 minutes up to
2 hours
Episiotomy should be performed after infiltration of 1%
lignocaine (up to 20 ml may be used). • Her general physical condition, as shown by her
colour, respiration and her own report of how
3.2.2.6. Delivery her feels
The fetal head should not be allowed to extend till occiput Experienced medical personnel should be informed in
is felt below the symphysis pubis. The perineum should any one the following instances:
be supported during delivery of the head. Once the head
• Continuing fresh bleeding;
is delivered the woman should be discouraged from
bearing down. Following restitution and external • Elevation of the level of the fundus;
rotation, shoulders must be delivered with appropriately • Increase of pulse rate above 100 or by 30 beats per
directed traction on the fetal head. The baby must be minute;
delivered onto the mother’s abdomen. Breastfeeding
should be initiated within 30 minutes of birth.
• Drop in systolic blood pressure below 100 or by
30 mmHg.

3.2.3. Third stage of labour The level of the fundus must be marked on the skin using
a marker to make observations more objective.
The third stage of labour is the period from complete
delivery of the baby to the complete delivery of the 3.2.3.2. Delayed third stage
placenta and membranes. Delayed third stage is diagnosed if the placenta is not
3.2.3.1. Active management of the third stage of labour delivered within 30 minutes of active management.

Active management of the third stage of labour is The first step in managing delayed third stage of labour
recommended for all mothers. This includes; is:

• Routine use of uetrotonic drugs: Oxytocin 5 IU • To proceed to intraumbilical vein oxytocin, in a

intravenously soon after the delivery of the baby dose of 50 IU in 30 ml of 0.9% sodium chloride
or 10 IU intramuscularly solution.
• Delayed cord clamping (2 minutes after the birth) • A period of 30 minutes is allowed and controlled
and cutting of the cord cord traction is attempted again.

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• If the placenta is not delivered by this method, The Apgar score at 1 and 5 minutes should be recorded
manual removal of placenta is proceeded to. for all births.
Initiation of breastfeeding should be aimed for within 1
4. Care for the newborn baby hour after birth.
Effective care at birth is needed for anticipation of Head circumference, birth weight, length and other
problems with the transition from in utero dependent measurement should be carried out once the first feed is
life to extra utero independent existence and to provide complete. A health care professional should examine the
support to ensure stabilization. baby to detect any physical abnormality and to identify
• Skilled birth attendant (Medical Officers, Nursing any problems that require referral.
Officers and Midwives) is responsible for the care.
• The care at birth is the same irrespective of birthing 5. Perineal care
place or person attending to the birth.
Perineal or genital trauma caused by either episotomy or
• At least one health care provider trained in tearing need to be repaired.
neonatal resuscitation must be physically
available at time of birth of all infants irrespective Before assessing for genital trauma:
of risk status. • Explain to the woman what you are going to do
• This person must be present in the delivery room and why
before the birth of the baby. • Offer analgesia
• The attending personnel should document the • Ensure good lighting
baby details such as time of birth, weight, gender
and any other relevant information in all cases. • Position the woman so that she is comfortable
and the genital structures can be seen clearly.
The aims of neonatal care following birth include the
following: The initial assessment should be performed gently and
with sensitivity and may be done in the immediate period
• Establishment of respiration (as per NRP
following birth preferably as soon as the placenta is
guidelines)
delivered.
• Prevention of hypothermia (Refer Newborn
Guideline)
• Establishment of breast feeding (Refer Newborn
Guideline) Classification of perineal trauma
• Prevention of infection (Refer Newborn Guideline) First degree: Injury to skin only
• Detection of danger signs (Refer Newborn Second degree: Injury to the perineal muscles but
Guideline) not the anal sphincter
Following basic steps should be followed at the time of Third degree: Injury to the perineum involving the
birth; anal sphincter complex
1. Call out the time of birth Fourth degree: Injury to the perineum involving the
2. Deliver the baby onto the mother’s abdomen or anal sphincter complex and anal epithelium
into her arms
3. Dry baby with a warm towel or a warm piece of
cloth
Perineal repair should only be undertaken with tested
4. Wipe baby’s eyes effective analgesia in place using infiltration with up to
5. Assess baby’s breathing while drying 20 ml of 1% lignocaine or equaling, or by topping up the
epidural, as soon as possible by a medical officer.
6. Make sure that there is no second baby
The preferred suture material is rapidly absorbed
7. Change gloves or remove the first layer of gloves
polyglycolic acid.
8. Clamp and cut the umbilical cord
The following basic principles should be observed when
9. Put the baby between mother's breast for skin to performing perineal repairs:
skin care
• Perineal trauma should be repaired using aseptic
10. Place the identity label on the baby techniques.
11. Cover mother and baby with warm cloth • Equipment should be checked and swabs and
12. Put a hat on baby’s head needles counted before and after the procedure.

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• Good lighting is essential to see and identify the completing the repair to ensure that suture
structures involved. material has not accidently been inserted through
• Difficult injuries should be repaired by an the rectal mucosa.
experienced medical officer in theatre under • Following completion of repair, an accurate
regional or general anaesthesia. An indwelling detailed account should be documented covering
catheter should be inserted for 24 hours to prevent the extent of the trauma, the method of repair and
urinary retention. the materials used.
• Good anatomical alignment of the wound should • Information should be given to the woman
be achieved, and consideration given to the regarding the extent of the trauma, pain relief, diet,
cosmetic result. hygiene and the importance of pelvic floor
• Rectal examination should be carried out after exercises.

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