admission procedures dr. f mostajeran md admission procedures urged to report early in labor early...
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Admission procedures
Dr. F Mostajeran MD
Admission procedures
Urged to report early in laborEarly admittance to labar , delivery unit especially high risk pregnancyaccurat diagnosis of labarFalsely diagnosed , inappropriate in terrentionNot diagnosed (remot from medical personnel medical facilities)
Definition of labor
Uterine contractions that bring effacement and dilatation of cervix.
Painful contractions become regular
onset of labor as beginning at the time of admission to the labor unit
Admission for labor based on dilatations accompanied by painful contractions .
D. Diagnasis between false and true labor is difficult
Contractions of true labor
Regular intervals
Intervals gradually shorten
Intensity gradually increases
Discomfort back , abdomen
Cervix dilates
Discomfort is not stopped by sedation
Contractions of false labor
Irregular intervals
Intervals long
Intensity unchanged
Discomfort lawer abdomen
Cervix not dilate
Relieved by sedation
Pregnant woman who is having
Cantractions
Emergency condition
Labor is defined as process of childbirth beginning
Latent phase delivery placenta
Electronic admission testing
Recommend NST or CST on all patient
(labar – delivery unit)
Fetal admission test
identify unsuspected cases
Vaginal examination1. Amnionic fluid effacement2. Cervix dilatation position3. Presenting part4. Station5. Pelvic architecture
Detection of ruptured membranes
Leakage of fluidProlapse cordLabor occurSerious intra uterine infectionNitrazine paper (PH= 7.0 – 7.5)Arborization or ferningAlpha – fetoproteinInjection various dyes
Vital signs and review of pregnancy recordPhysical examinationPreparation of vulva and perineumInspection and cleaning of the vulva , perineum , mini – shave - enema
Friedman Three functional divisions of labor Preparatory division:
Little cervical dilatation Considerable change
Dilatational division : Most rapid rate
pelvic division: Deceleration phase of cervix - dilatation Cardinal fetal movements
Latent phase (14-20h)
Active phase:
acceleration ,phase of maximum slope
, deceleration phase
Cervical dilatationCervical dilatation
Management first stage of labor
Remainder of general physical exam is completed
HCT HB protein - glocose
average duration first stage of labor
7 hours in nulliparous w
4 hours in parous w
Fetal monitoring during labar
Contractions and response FH
Suitable stethoscopc , doppler ultrasonic devices
FH should be checked after contractions
every 30 minutes (15)
Second stage every 15 minutes (5)
Cantinous electronic monitoring
MATERNAL MONITORING
Vital signs
T , pulse , BP every 4/h
PROM temprature every 1/h
18 h of PROM antimicrobial
Subsequent vaginal examinations
When membrans rupture if head was not Defenetly engaged
fetal H immediately and during the next uterine contraction
(occult umbilical cord compression)
periodic examinations at 2-3 hours interval
Oral intakeGastric emptying time prolanged
(food – medication remain in the stomach – not absorbed may be vomited)
Food should be withheld
Intravenous fluidsInfusion system routine early labar (IV line)
Longer labors glucose sodium water 60-120 ml/hr
Maternal position during labornormal laboring woman
Not be confined to bed
Comfortable chair
In bed position most comfortabl (lateral recumbend)
AnalgesiaIs initiated on the basis of maternal
discomfortvaginal examination befor administration of analgesia
(delivering a depressed infant)Timing , method and size of initial and subsequent dose , interval of time until delivery
Amniotomy
There is a great temptationBenefits: rapid labor detection of meconium staining Internal fetal MAseptic techniqueHead must be well applied to the cerxin
Urinary bladder functionBladder distention avoid
Abstracted labor
Subsequent bladdes hypotonia, infection
Suprapubic region shauld be visualized , palpated detect filling bladder
If could not void on a bedpan
Intermittent catheterization
Management of second stage labor
Full dilatation of the cervix
Begins to bear dawn
50 minutos in nulliparous
20 minutos in multiparous
Higher parity 2-3 expulsive efforts may suffice Complete the delivery of the infant
FHRLow – risk 15 H.risk 5
Fetal H.R
Contraction – maternal expulsive efforts
FHR are not consequence of head compression
Descent fetus and reduction in uterine volume
some degree of premature separation placenta
tighten a loop or loops of umbilical cord
Around the fetus umbilical blood flow
Prolonged uninterrupted maternal expulsive efforts dangerous to the fetus
Preparation for deliveryVariety of positions
Dorsal lithotomy position
For beter exposure legholders stirrups
Cramps in the legs (brief massage – changing position)
Preparation for delivery entails vulvar and perineal cleansing
Spontaneous delivery
Delivery of the headContraction perineum bulgesVulvovaginal opening becomes more dilatedGradually circular opening This encirclement of the largest headBy the vulvar ring is known as crowning
Perineum is extremely thin
Episiotomy , laceration
Episiotomy risk tear external anal – rectum
Episiotomy - anterior tear urethra , labia
Ritgen manover
Vaginal introitus 5 cm
Towel – draped , gloved hand forward pressure
on the chin of the fetus
other hand exerts pressure superiorly against occiput
Cleaning the nasopharynxMinimize aspiration AF – debris , bloodonce thorax is delivered face quickly wiped nause , mouth are aspirated
Following delivery of anterior shoulder
Finger should be passed to the neck
Nuchal cords 25% +
Drawn down , loose – slipped over the head
Clamping the cord4-5 cm , 2-3 cm fetal abdomen two clamps
Plastic cord clamp
Timing of cord clamping
Infant is placed at or below vaginal interoitus 3 , 80ml of blood shifted from placenta to infant80ml 50mg Iron , Iron deficiency
anemiaMaternal alloimmunization our policy after cleaning airway 30" cord clamp
Management of the third stage
After delivery of the infantHeight uterine fundusUterus firm , no unusual bleedingWaiting until placentac separat – no massageHand rest on the fundus (atonic – filled with blood)
Signs of placental separation
1. uterus becames globular firm
2. Sudden gush of blood
3. Uterus rises (placenta separated , passes dawn to lower u-segment
4. Its balk pushes uterus upward
5. Umbilical cord protrudes forther out
delivery of the placentaTraction on the umbilical cord must not be used inversion
Manaol removal of placentaoccasionally placenta will not separatAt any time brisk bleeding and , placenta can not be deliveredActive management of the third stage5 units oxytocin +0.5 ergometrine reductian in the length of third stage
Fourth stage of labor
Exam placenta , membranes , umbilical cord
Completeness , anomalies
Hour immediately fallowing delivery
Critical fourth stage of labor
uterine atony , BP , pulse every 15
Oxytocic AgentsOxytocin (pitocin , syntocinon)
Methylergo novine maleat (methergine)
Reduce blood loss by stimuloting myometrial contraction
Iml 10IU half – lifc IV 3
Inapropriate dose kill the fetus ,rupture uterus
Cardiovascular effectsDeleterious effects follow IV bolusAntidiuresisrare maternal convulsion antidiuretic actionWater intoxication (20,40mu/minut )Concentration should be increared rather than rate of flowNormal saline are lactated ringer solution
Ergonovine and methylergonavine
IV – IM – orally no differenc in actions
Sensitivity of pregnant uterus is very great
In pregnancy 0.1my IV , 0.25my oral tetanic Uterine contraction
Tetanic effect prerention , control PPH
IV administration sometimes
tram sient , severe hypertension
ProstaglandinsNot used routinely
Manage ment PPH
PG F2x 250ng IM (15-90" ) 8does 88% successful
20% side effects diarrhea ,hypertension vomiting , Fever , flushing , tachycandia
PG E2 20-mg suppositories
Lacerat ons of the Birth canal
ClassifiedFirst fourchette , perineal skin vaginal mucousSecond fascia and muscles of perineal bodyThird anal sphincterFourth retal mucosa
Episiotomy and repair
Incision of pudendaPerineotomy incision of perineuEpisiotamy synonymously with penineotomyBegin in midline :Directed laterally mediolateralDirected down ward midline
Timing of episiotomyPerform when head is visible during contraction 3-4After application of bladesTiming of repairMost common practice repair until placenta deliveredTechniqueHemostasisAnatomical restoration without excessive suturingChromic catgut 3-0
Fourth – degree laceration
Various techniques remcommend
Esential approximat torn edges rectal mucosa
With muscularis sutures 0.5cm apart
Muscular layer covered with a layer of fascia
Labor with occiput presentations
95% fetus occiput or vertex presentationMost commonly ascertained ab – examConfirmed V.Examination before or at the onset of laborSagitlal suture in the transrevse pelvic diameterLOT , ROT , LOA , ROAROP , LOP (narrow forepelvis , anterior placentation
OCCCIPUT ANTERIOR PRESENTATION
Irregular shape pelvic canal
Large dimensions fetal head
Adoptation or accommodation of suitable
Portions of head to the varius segment of the pelvis is required
Cardinal movements of labar
Engagement
Descent
Flexion
Internal rotation
Extension
External rotation expulsion
Concomitantly , uterine cantractions
Important modifications in fetal attitude
straightening of the fetus loss dorsal convexity , closer application of the extremities to the body , fetal ovoid cylinder
EngagementBiparietal diameter – greatest transverse diameter F.Head passes thraugh the pelvic inlet
Lost few weeks of pregnancy
Until after cammencement of labor
In many multiparous , some nulliparous
At onset of labor head freely movable above inlet
Referred “floating”
Asynclitism
Sagittal suture remaining parallel to transverse axis may not lie exactly midway
Between symphysis and sacral promontory
Sagitlal suture deflected posteriorly or anteriorly
Asynclitism anteror or posterior
Moderat degree of asynclitism are the rule in normal labor
Severe asynclitism may lead to cephalopelvic disproportion even with an normal – sized pelvis
DESCENT
First requisit for birth infant In nulli parus take place befor the onset of laborFurther descent until onset of the second stageIn multiparous descent usually begins with engagement
Descent is brought by one or more of four forces
1. Pressure of amnionic fluid
2. Direct pressure of fondus with cont ractions
3. Bearing down efforts abdominal muscles
4. Extension and straightening of fetal body
FLEXION
As soon as descending head meets resistanceCervix , walls of the pelvis , pelvic floorThe chin is braught into more intimate contact Fetal thorox suboccipitobreg matic occipitafrontal
Internal rotation
occiput gradually moves from original position toward symphysis pubisLess commonly posteriorlyInternal rotation essential completion of laborIt always associated with descent and acomplished after engagement
ExtensionAfter in-rotation sharply flexed head reaches the vulvaUndergoes extension which essential to birthVulvar outlet directed upward , for wardExtension must occur before head can pass through it
Head born by further extension
occiput , bregma , fore head , nose mouth
Finally chin pass
Head drops down ward chin lies over anal region
External rotationdelivered head under goes restitution
occiput toward the left rotates left ischial tuberosity
occiput toward the right rotates right ischial tuberosity
Bisacromial diameter in to relation anteroposterior diameter of the pelbic outlet shoulders (anteriar – posterior)
ExpulsionImmediatly after external rotation
Anterior shoulder under symphysis pubis
Posterior shoulder distended perineum
After delivery of the shoulders
Rest of body quickly extruded
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