Management of Normal & Abnormal Labor: Complete Guide for BHMS/MBBS Students

1. Management of Normal Labor

A. First Stage of Labor (Latent & Active Phase)

Admission & Initial Assessment:

• Confirm labor diagnosis (Regular contractions + Cervical changes).
• Vitals Monitoring: BP, Pulse, Temperature.
• Fetal Monitoring: Fetal Heart Rate (FHR) with CTG.
• Vaginal Exam: Cervical dilation, effacement, station.

Supportive Care:

• Encourage mobility, hydration, pain relief.
• Analgesia Options:
• Non-pharmacological: Breathing techniques, Massage.
• Pharmacological: Epidural, IV Opioids (Pethidine).

Monitoring:

• Use of Partograph to assess progress (Dilation ≥1 cm/hr in primigravida).

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B. Second Stage of Labor (Delivery of Baby)

Pushing Efforts: Encourage maternal pushing with contractions.
Episiotomy (If Needed): Performed in cases of prolonged labor, shoulder dystocia, instrumental delivery.
Delivery of the Baby: Controlled head delivery to prevent perineal tears.

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C. Third Stage of Labor (Placental Expulsion)

Active Management (Reduces PPH Risk):

• Oxytocin 10 IU IM (To prevent uterine atony).
• Controlled Cord Traction (CCT).
• Uterine Massage after placenta expulsion.

Monitor for Postpartum Hemorrhage (PPH):

• If heavy bleeding, administer additional uterotonics (Misoprostol, Ergometrine).

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2. Abnormal Labor (Dystocia) & Its Management

A. Prolonged Labor

Definition: Labor progression slower than normal.

Stage	Criteria for Prolongation
First Stage (Active Phase)	Cervical dilation <1 cm/hr (Primi), <1.5 cm/hr (Multi)
Second Stage	>2 hrs (Primi), >1 hr (Multi)

Causes:

• Power: Weak uterine contractions.
• Passenger: Malposition (Occiput Posterior, Breech).
• Passage: Cephalopelvic Disproportion (CPD).

Management:

• Oxytocin Augmentation (If contractions are weak).
• Amniotomy (Artificial Rupture of Membranes - ARM).
• Cesarean Section (If CPD or fetal distress).

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B. Obstructed Labor

Definition: Failure of labor progression despite strong uterine contractions due to mechanical obstruction.
Causes:

• CPD (Cephalopelvic Disproportion).
• Fetal Malposition (Brow, Face, Shoulder).
• Pelvic Abnormalities (Contracted pelvis, Fibroids).

Signs:

• Bandl’s Ring Formation (Pathological retraction ring).
• Severe maternal exhaustion, fetal distress.

Management:

• Immediate Cesarean Section.
• IV Fluids, Antibiotics (If infection suspected).

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C. Precipitate Labor

Definition: Extremely rapid labor & delivery <3 hours from onset of contractions.
Risks:

• Maternal: Uterine rupture, Perineal tears, Postpartum hemorrhage (PPH).
• Fetal: Birth trauma (Intracranial hemorrhage, Shoulder dystocia).

Management:

• Controlled delivery to prevent perineal trauma.
• Monitor mother & baby closely postpartum.

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D. Fetal Distress in Labor

Signs:

• Abnormal CTG (Late decelerations, Bradycardia).
• Meconium-stained amniotic fluid.
• Decreased fetal movements.

Management:

• Intrauterine Resuscitation:
• Left lateral position.
• Oxygen therapy (10 L/min via mask).
• IV fluids.
• Stop Oxytocin if hyperstimulation.
• Immediate Cesarean Section if distress persists.

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E. Shoulder Dystocia

Definition: Failure of fetal shoulders to deliver after the head due to impaction on the pubic symphysis.
Risk Factors:

• Fetal Macrosomia (>4 kg).
• Maternal Diabetes.
• Post-term pregnancy.

Management (HELPERR Mnemonic):

1. H – Call for Help.
2. E – Episiotomy if needed.
3. L – Legs in McRoberts Maneuver (Flex thighs onto abdomen).
4. P – Pressure (Suprapubic).
5. E – Enter Vaginal Manoeuvres (Rubin, Woods Screw).
6. R – Remove Posterior Arm.
7. R – Roll the patient to All-Fours (Gaskin Maneuver).

Emergency: If maneuvers fail → Zavanelli Maneuver (Push head back in & perform C-section).

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3. Instrumental & Operative Delivery

A. Indications for Assisted Vaginal Delivery (Forceps/Vacuum)

• Prolonged Second Stage (>2 hrs in Primi, >1 hr in Multi).
• Fetal Distress in Second Stage.
• Maternal Exhaustion (Inability to push).

B. Cesarean Section (C-Section) Indications

• Fetal Distress.
• Cephalopelvic Disproportion (CPD).
• Placenta Previa, Placental Abruption.
• Failed Induction of Labor.

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4. Summary Table: Management of Abnormal Labor

Condition	Definition	Management
Prolonged Labor	Slow cervical dilation	Oxytocin, Amniotomy, C-section if needed
Obstructed Labor	No progress despite strong contractions	Emergency C-section
Precipitate Labor	Delivery <3 hours	Controlled delivery, Monitor for PPH
Fetal Distress	Abnormal CTG, Meconium	Intrauterine resuscitation, C-section if needed
Shoulder Dystocia	Shoulders stuck after head	McRoberts Maneuver, Suprapubic Pressure
C-Section Indications	Fetal distress, CPD, Previous C-section	Planned or Emergency Cesarean

5. Key Takeaways

• Normal labor is managed with monitoring, pain relief, & active third-stage management.
• Prolonged labor requires Oxytocin or C-section if progress is inadequate.
• Obstructed labor & fetal distress need emergency Cesarean Section.
• Shoulder dystocia is managed with maneuvers (McRoberts, Suprapubic Pressure).
• Instrumental delivery is used for maternal exhaustion or fetal distress in the second stage.