Bishop's Score & Induction of Labour & Stages of Labor😍

Management of Labour at Admission

Stage 1 of Labour: Supportive Care (Labour Care Guide)

• Early Labour: Ambulation allowed

• Late Labour: Lie in left lateral position

• Oral intake:
• Solids are not allowed
• Clear fluids can be given orally
• IV fluids can be given for C-section
• Liquid stopped: 2 hours before surgery
• Solid stopped: 6 hours before surgery

• Bladder function: Encouraged

• Pain relief: Epidural/opioids/massage etc. (allowed)

• Companion: Allowed

Monitoring (Maternal)

• Uterine contractions: Every 30 mins

• Pulse & BP: Hourly

• Temperature: 4 hourly (Hourly if membranes have ruptured)

• P/V: 4 hourly

FHR Monitoring

Robson Classification

Bishop's Score & Induction of Labour

Bishop's Score:

• Purpose: To assess susceptibility of cervix for Induction of Labour (IOL).

• Mnemonic: Delhi police employed special commanders.

Scoring:

• Mnemonic: Pink DESK

In Modified Bishop score,

• Cervical effacement is replaced by cervical length

Simplified Bishop Score:

• Max score: 9.

• Calculated by: DES
• Dilatation of cervix.
• Effacement of cervix.
• Station of fetal head.

Pre-Labour State

1. Lightening/Welcome sign

• 36 weeks:
• Respiratory discomfort
• Uterus reaches xiphisternum level

• 40 weeks:
• Relief of respiratory discomfort
• After descent of fetal head into pelvis
• Uterine height corresponds to 32 weeks

2. False Labour Pains

• Non-progressive uterine contractions

• No cervical dilation

3. Cervical Ripening

• Cervix softens and dilates

• Mediated by prostaglandins

• Cause – Connective tissue changes:
• ↓ Cross-linking of collagen fibers
• ↑ Water content
• ↑ Hyaluronic acid

Laminaria Tents

• Intracervical laminaria tents
• Hygroscopic dilators
• Mechanism:
• Absorb moisture
• Expand and dilate
• Used for cervical ripening
• Before labor induction
• Before D & C
• Made from dried Laminaria seaweed stems

Induction of Labour

Mechanical methods:

• Foley catheter filled with 30-50 mL NS/Extra amniotic saline infusion
• Best for IOL in CS

• Stripping of membranes.

Medical methods:

Contraindications of IOL: 🗸🗸

• Severe cephalopelvic disproportion.

• Contracted pelvis.

• Transverse lie, Brow presentation, Face (mentoposterior) position.

• Placenta previa / Vasa Previa / Placenta accreta

• Cord Prolapse

• Category 3 FHR.

• Ca Cervix

• Active genital herpes infection.

• Classical C-section.

• Previous hysterotomy.

• Previous myomectomy.

Normal Labour

At Onset:

• Estrogen levels: ↑

• Progesterone: ↓ (Functional withdrawal)

• Oxytocin receptors: ↑

• Prostaglandins: ↑

• GAP junctions: ↑

Labour Pain:

• Adequate Contractions:
• Frequency: ≥3 in 10 mins.
• Duration: ≥45 secs.
• Intensity: 65-75 mm Hg (200-350 mvu).
• Origin: Cornua of uterus.

• Tachysystole:
• 5 contraction in 10 mins (With fetal distress: Hyperstimulation).
• Cause: Augmentation of labour with misoprost/oxytocin.

Prolonged Deceleration (2-10 mins)

• Between 2 major red line is 1 min

• Management:
• Stop oxytocin.
• Left lateral position.
• O2 by mask.
• Terbutaline.

Cardinal Movements

• Mnemonic: Every decent female I employ rises extremely late.

• Movements:
• Engagement
• Descent
• Flexion of fetal head
• Internal rotation (IR)
• Crowning
• Extension: Head of baby delivered.
• Restitution
• External rotation: Internal rotation of shoulders.
• Lateral flexion: Body of baby delivered.

• Note:
• Crowning: 
• Occurs after IR.
• Not a cardinal movement.
• Delivery of head:
• Vertex presentation: By extension.
• Breech & face: By flexion.
• Delivery of shoulder
• 1st anterior → by downward lateral flexion
• 2nd posterior → by upward lateral flexion

Engagement:

• Definition: When largest transverse diameter of fetal head crosses pelvic brim
  (biparietal diameter: 9.5 cm).

• Time:
• Primi: → 38 weeks.
• Multi: → Onset of labour.

• Assessment:
• P/A: → ≤2/5th head palpable.
• P/V: → 0 station or below.

• Cause for unengaged (Free floating) at term in primi:
• Deflexed/OP position > CPD > Placenta previa.

Partogram

Modified WHO Partogram

• Based on earlier WHO recommendations:
• Latent phase: Till 3 cm.
• Active phase: 4-10 cm.
• Active phase minimum dilation: 1 cm/hr
• (Based on this alert line is drawn).

• Time duration b/w alert & action line: 4 hrs.

• Latent phase: Not represented.

• Active phase: Represented.

• Second stage of labour: Not represented.

Upper Part (Fetal Condition Assessment)

• FHR:
• FHR represented by a circle.
• FHR: 110-160 bpm.
• FHR plotted every 30 minutes.
• Each square is 30 mins.

• Amniotic Fluid: ICBMA
• I: Intact.
• A: Absent liquor.
• C: Clear liquor.
• B: Blood stained.
• M: Meconium stained.

• Moulding: If present or not.

Middle Part (Cervicogram)

• X axis: Time.

• Y axis: Cervical dilatation (x).

• Descent of fetal head (O).

• Big square: 1 hr.

• Small square: 30 mins.

• 2 parallel lines:
• Alert & action line.
• Duration b/w: 4 hrs.

Lower Part (Maternal Condition Assessment)

• Uterine contractions:
• Every 30 mins.
• Placing palm on fundus of uterus.
• No of contractions in 10 mins.

• Each square: 1 contraction.

• Contraction Representation:
• <20 s: Dots
• 20-40 s: Stripes
• 40 s: Solid

• Following charted:
• Oxytocin.
• Drugs.
• Pulse, BP, temperature of mother.
• Urine output.

• Not charted:
• Respiratory rate.
• Oxygen saturation.
• Oral intake.

Labor Care Guide (LCG)/Next Generation Partogram

• Mnemonic: Supporting Baby & Woman in Labour is a Medical Decision

Based on new WHO guidelines (2020):

• Active phase: Begins at 5 cm.

• If mother and baby are fine:
• Cervical dilatation can be <1 cm/hr.

• In LCG:
• Latent phase: Not represented.
• No alert & action line.
• Active phase: At 5 cm.
• Plotting should begin: At 5 cm.
• 2nd stage of labour: Is represented.

• Used for: All females who are delivering (Especially low risk).

• Used at: At all levels of health care.

Labour Management

Stages of Labour

Stage 1: Latent Phase

• Begins: Onset of regular uterine contractions

• Ends:
• ACOG: Cervical dilation 5 cm
• Modified WHO: Cervical dilation 4 cm
• Earlier WHO: Cervical dilation 3 cm

• Function: Prepares cervix for dilation

• Duration/rate:
• Primi: <20 hours
• Multi: <14 hours

Stage 1: Active Phase

Stage 2: Management of Second Stage of Labour

• Prevention of perineal tear:
• Perineal massage
• Warm compress at perineum
• Controlled delivery of head
• Perineal support
• Fetal head: modified Ritgen maneuver
• First flexed, then extended with one hand
• other hand should support perineum

• Not Recommended
• Routine episiotomy
• Lithotomy
• Fundal pressure

• Fetal distress
• In second stage of labour (Dilatation is 10 cm):
• If station of fetal head above +2: C-section
• If station of fetal head at +2 or below +2:
• Instrumental delivery
• Wrigley Forceps > Vacuum
• (Low forceps delivery)

Stage 3: Third Stage of Labour

Stage 4: Fourth Stage of Labour

Augmentation of Labour

• Definition: Accelerating the progress of labour

• Indication: Protracted active phase after ruling out occipitoposterior position and CPD

Methods:

• Artificial Rupture of Membranes (ARM) done by Kocher forceps

• Oxytocin: Given at 6 mU/min, increased at interval of 20-40 minutes by 6 mU

Contraindications of ARM:

• Maternal HIV infection

• Genital Herpes infection

• Vasa previa

• Intrauterine death of fetus

Note:

• In polyhydramnios → Controlled rupture of membranes is done

Abnormal Stages of Labour Management

1. Prolonged Latent Phase

• Definition:
• Latent phase ≥20 hours in primi
• Latent phase ≥14 hours in multi

• Cause:
• Occipitoposterior position/deflexed head
• Unfavourable cervix - CPD
• False labour pains

• Management:
• Therapeutic rest
• C-section is never done for prolonged latent phase

2. Protracted Active Phase (Slow Progression)

Definition:

• Dilatation of cervix is <1 cm/hr

• Descent of fetal head is
• <1 cm/hr in primi
• <2 cm/hr in multigravida

Do P/A and P/V examination

3. Arrest of Active Phase

• Definition:
• Diagnosed if membranes are ruptured and cervical dilatation has not changed:
• For 4 hrs with adequate uterine contraction
• For 6 hrs if oxytocin is given with inadequate uterine contraction

• Management:
• C-section
• Note: If fetal distress → Emergency C-section

4. Second Stage Arrest/Prolonged

Management:

Obstructed Labor

• Cause: Transverse lie, Conjoint twin, etc.

Clinical features:

• Maternal dehydration

• exhaustion,

• tachypnea,

• tachycardia

• On P/A:
• Bandl's ring (Depression/groove felt & seen between UUS & LUS)
• Upper uterine segment (UUS): Thick, tender and tonically contracted
• LUS: Thinned and stretched

• On P/V:
• Hot and dry vagina
• Caput (+)
• Moulding (+)
• Hematuria +/-

Management:

• C-section immediately.

• Do not give oxytocin/forceps/vacuum.

Complication:

• Rupture of uterus

• Vesicovaginal fistula:
• Developed Countries:
• Hysterectomy
• Developing Countries:
• Obstructed Labour

Notes on Rings in Labour

Bandl's ring

• Retraction ring

• Due to obstructed labour

• Between UUS and LUS

• Seen in 2nd stage of labor

• Felt and seen P/A

• Associated with maternal dehydration and fetal distress

• Relieved by C-section

• Mnemonic: BRil (Bandl → Retraction) Obstruct (Obstructed labor) cheyth vach

Constriction ring/Schroeder ring

• Constriction ring

• Due to injudicious use of oxytocin → localised spasm of uterus

• Can be seen anywhere
• Felt P/V

• 1st or 2nd stage of labor

• Mother and fetus are normal

• Relieved by sedation;

• If ring reappears then do a lower vertical C-section (Only indication)

Vagitus uterinus

• Late pregnancy: Fetus can produce vocalizations.

• Audible fetal sounds heard as cry
• During ultrasound
• Sometimes heard by the mother herself

Management of Fetal Distress in Labour

• In first stage of labor (Dilatation <10 cms):
• Management: C-section

Instrumental Delivery

• Types: Forceps delivery & vacuum delivery.

Note:

• Forceps and vacuum can be applied only if:
• Cervix: Fully dilated
• Station of fetal head: ≥+2

Prerequisites for Forceps Delivery (FORCEP):

• Favourable position & station (≥+2).

• OS: fully dilated.

• Ruptured membranes.

• Contracted uterus.

• Episiotomy to be given, empty bladder.

• Pelvis: Adequate.

Forceps & Vacuum applied in:

1. Fully dilated (10 cm) cervix.

2. Station of head ≥+2.

Forceps vs Vacuum

C/I for both Forceps and Vacuum

• Presentation
• Mentoposterior
• Brow presentation
• Transverse lie

• Mother
• CPD
• Contracted Pelvis
• HIV positive

• Baby
• Osteogenesis imperfecta
• Coagulopathy in baby → Thrombocytopenia

Vulval hematoma

• Devascularisation of Internal Pudendal Art

Forceps Correct Application Identification

• Lock
• Closed properly

• Blades
• Equidistant from sagittal suture

• Forceps applied along
• Occipitomental diameter

Vacuum Application:

• Site: Flexion point (FP).

• Anterior fontanelle

• Rim of vacuum cup

• Vacuum cup (Diameter : 6 cm)

• Posterior fontanelle

Complications

Forceps Lock Types

• Mnemonic: Tuck () in Foreceps through Pipe () → may Wrinkle () or Kill ()

• Mnemonic:
• 3 parts → Tuck and kill
• 2 parts → Wrinkled Pipe
• Solid blade → Tucker
• Short Wringed child (short → wrigley)

• But Wrigley’s forceps
• Classified as Outlet forceps

Wrigley Forceps

• Outlet forceps

• Short and light

• Length: 27.5 cm

• Shank: 2.5 cm

Piper's Forceps

• Longest forceps

• English lock

• Delivers after-coming breech head

Fetal distress

Active Management of Third Stage of Labor (AMTSL)

WHO Recommendations as it

• Decreases duration of third stage (5-10 minutes)

• Decreases blood loss

• Decreases chances of PPH

• Best method to prevent PPH

Steps in AMTSL

• Inject uterotonic:
• (most important step)
• Within 1 minute of delivery of baby or
• Immediately after delivery of anterior shoulder of baby

• Delayed cord clamping:
• Clamping cord in ≥ 1 min of delivery

• Delivery of placenta:
• By controlled cord traction
• Modified Brandt Andrews technique

• Intermittent assessment of uterine tone:
• (Earlier: uterine massage)

• Note: Early cord clamping is not part of AMTSL

• U (uterotonics) can (cord clamping) control (CCT) tone (intermittent tone assessment)

Uterotonics

• Recommended by WHO:
• Oxytocin:
• t 1/2 = 3 mins
• DOC for AMTSL
• DOC for PPH
• No IV Bolus
• Hypotension on IV bolus
• S/E:
• Water Intoxication
• ADH like action

• If Oxytocin is unavailable, the following can be given:
• Methylergometrine (Methergine):
• 0.2 mg IM
• Never given IV (can lead to hypertension)
• Used in AMTSL, PPH
• NOT IOL
• Avoid in
• Cardiac and hypertensive patients,
• Twins, Rh negative, HIV positive mother on PIs, PVD
• NOTE: After delivery of 1st twin → Methergine can be given
• Mnemonic: Methyl kidathath are? → Rich people, tension people, cardiac patients, twins ne
• For IOL
• Misoprost (PGE 1):
• Can be given in asthma

Uses	Doses	ㅤ
MTP T1	800 mcg	ㅤ
MTP T2	400 mcg every 3 - 4 hrly (max: 6 doses)	ㅤ
IOL	Tab. 25 mcg Q4H P/V (max: 6 doses)	Not given in Prev CS for IOL
AMTSL	600 mcg Oral	ㅤ
PPH	800 - 1000 SL or PR	ㅤ

• Misoprost
• Baby miss (Abortion) avumbo misoprost
• Baby Miss avumbo Fever and hypotension
• WHO recommends misoprostol distribution to pregnant females
• To prevent PPH.
• S/E: Fever with chills

• Dinoprostone (PGE2):
• Only for IOL
• Time gap with Oxytocin = 6 hrs
• Maximum does: 3
• Cerviprime: Gel 0.5 mg Q6H (max: 4 doses).
• Cervidil: 10mg dinoprostone placed in posterior vaginal fornix (Slow release).
• NOTE: Dinoprost (Carboprost/ Hemabate): PGF2α
• S/E: Hyperstimulation
• Only as gel

• Syntometrine:
• Fixed dose combination of
• 5 IU oxytocin and 0.5 mg methyl ergometrine
• NOT GIVEN FOR PPH
• Carbetocin:
• Synthetic oxytocin with longer T½
• 100 mcg slow IV
• NOT GIVEN FOR PPH
• C/I: Asthma

• Note: 
• Dinoprost/Carboprost/ Hemabate
• PGF2α is used for management of PPH
• Not for AMTSL
• C/I: Asthma
• S/E: Diarrhea
• MgSO4

Cord Clamping

Conditions of Early Cord Clamping (Within 1 minute of delivery)

• Absolute Indication:
• Birth asphyxia
• If neonatal resuscitation is needed
• Known congenital heart disease
• If in Rh negative female: Indirect coombs test is negative
  (Non-isoimmunized pregnancy)

Delayed Cord Clamping Indications

• HIV positive pregnant females

• In Rh negative pregnancy:
• If indirect Coombs test is positive, maternal antibodies already formed against fetal Rh antigen.
• Early cord clamping is of no use.

• In preterm infants

• In COVID-19 positive patients

• Macrosomic babies

• In post-term cases

• Note: Extra 80 ml of blood goes to fetus, which prevents neonatal anemia.

Drugs Used in AMTSL & PPH

Oxytocin

• Synthesis:
• Paraventricular nucleus of the hypothalamus synthesizes natural oxytocin (nonapeptide)
• Stored in posterior pituitary.

• Function:
• Milk ejection & for after pains.

• Half-life: 3-5 mins.

• Route: IM/IV infusion (prepared in Ringer lactate/normal saline).

• Contraindications/Cautions:
• IV bolus: HypOtension/cardiac arrest.
• Dextrose 5% preparation: Water intoxication.

If Oxytocin Unavailable

• Note: Drugs not used in PPH management in hypertensive patients:
• Methyl ergometrine > Carboprost.

Signs & Methods of Placental Separation

Signs

• Surest sign: Feel of placenta in vagina

• Apparent + permanent cord lengthening (2nd best sign)

• Gush of blood per vaginally

• Suprapubic bulge

• Height of uterus rises slightly

Methods

ㅤ	Fetal side	Maternal side
Placenta formation	Chorion frondosum	Decidua basalis
Appearance	Smooth, shiny	Dull
During Placental separation	Central separation	Peripheral separation
Method	Schultze method	Duncan method
ㅤ	Better, M/c ↳ Retroplacental clot formed ↳ Decreased bleeding	ㅤ

Retained Placenta & Placenta Accreta Spectrum

Retained placenta/prolonged 3rd stage

• Not delivered within 30 minutes of delivery of baby

Trapped placenta :

• Placenta separated from uterus but not expelled (closed internal os).

• Management:
• All signs of placental separation present.
• Rule out: empty bladder.
• If uterus relaxed / No significant bleeding
• Give oxytocin + Controlled Cord Traction (CCT)
• If uterus contracted + closed os / Significant bleeding
• Manual Removal of Placenta (MRP)
• Usually done ↓ GA > Spinal/Epidural

Note: 

• At any point while doing CCT → cord breaks → MRP

• If there is inadequate separation of Placenta by CCT → MRP

Placenta attached to uterus:

• Does not invade myometrium
• No signs of placental separation.
• Management: Oxytocin + CCT.
• If fails: Manual Removal of Placenta (MRP)

• Invades myometrium
• Placenta Accreta Spectrum
• Hysterectomy

Placenta Accreta Spectrum (PAS)IOC →

IOC

Condition	Screening	IOC	ㅤ
Vasa Previa	ㅤ	USG Doppler	ㅤ
Placenta Previa	TAS (PP vs. AP)	TVS	Best Time for USG • T3 (32 - 36 weeks)
Placenta accreta	TVS	MRI	ㅤ

Signs on USG Placenta Accreta Spectrum:

• Placental lakes/moth-eaten appearance.

• Heterogenous Placenta

• Thinning of myometrium behind Placenta

• Loss of clear space behind Placenta

• Loss of Bladder line

• Absence Of hypoechoic area
• behind placenta representing decidua basalis

• Absence Of Continuous white line reflecting
• bladder - uterine serosa interface.

Types:

Types	Featuures
Placenta accreta (M/c)	Chorionic villi superficially attached to myometrium
Placenta increta	Villi invade myometrium
Placenta percreta	Villi penetrate → attached to serosa

Pathology:

• Absent decidua basalis.

• Absent Nitabuch layer.

Risk factors:

• Placenta previa +

• Previous history of C-section.

C/F

• Cord snapping on traction

• PPH

Management (Mx):

• Classical CS + Hysterectomy

 

Episiotomy

• WHO recommendation: 
• Does not recommend routine episiotomy in all vaginal delivery.

• Types:

Median Episiotomy	Mediolateral Episiotomy
Less preferred	Angle : 45°-60° M/C preferred
Involves anal sphincter if extended	Does not involve anal sphincter when extended
• ↓Bleeding, healing quicker • ↓Chances of dyspareunia wound gaping	• ↑Bleeding, healing delayed • ↑Chances of dyspareunia wound gaping

• Episiotomy Scissors: 
• Rounded ends, angulated.

• Muscles involved:
• Muscles attached in the mid-line/to perineal body are cut.
• Muscles not cut during episiotomy:
• Ischiococcygeus/coccygeus,
• ischiocavernosus,
• anal sphincter,
• obturator internus.
• Muscles cut
• Pubococcygeous
• Deep transverse perinium
• Superficial Transverse perinium
• Bulbospongiosus

Grading of Perineal Tear:

• Avoid pregnancy: 1 year (At least 6 months after repair).

• Mode of delivery:
• Can have vaginal delivery.
• If h/o ≥2 times anal sphincter injury → C-section.