labour mx 2016

LABOUR MANAGEMENT

GOALS

1. To get correct diagnosis of labour2. To learn regarding intrapartum

management3. To be able to identify abnormal labour

and manage accordingly

CORRECT DIAGNOSIS OF LABOUR

Contraction occur at regular interval Interval gradually shortens Intensity of pain gradually increase Duration of contraction increase

There is progressive cervical effacement and dilatation

Progress of labour not stopped by sedation

WHY IMPORTANT??

Proper monitoring Prevent unnecessary intervention

ARM Wrong diagnosis of prolonged latent phase Admission

SALSO 2015

“FALSE” LABOUR !!

Uterine contractions impalpable/ infrequent

Misdiagnosis unnecessary induction/ augmentation higher risk of failure with an increased risk of Caesarean section & chrioamnionitis

DEFINITION

1st Stage: Start of labour Full dilatation of cervix

2nd Stage: Full dilatation delivery of baby

3rd Stage: Birth of baby delivery of placenta

LATENT PHASE ACTIVE PHASE

1ST STAGE 2ND STAGE 3RD STAGE

POINTS TO OBSERVE FOR…

Active phase: On or at the left of an alert line

2nd Stage: Need proper assessment of the maternal expulsion & descend of fetus

3rd Stage : Retained placenta if not delivered by 30 minutes

LABOUR: PRINCIPLES OF MANAGEMENT

1. Initial assessment2. Diagnosis and intervention of abnormal labour3. Close monitoring of fetal and maternal

condition4. Adequate pain relief5. Adequate hydration6. Emotional support/ supportive companion

INITIAL ASSESSMENT

Define risk Degree of monitoring needed Level of staff to manage the patient

• Depends on maternal coding and antenatal risk factors

• Don’t forget to monitor vital signs

OBSERVATIONS OF MOTHER*IF ANY OF THE FOLLOWING ARE OBSERVED, NEED IMMEDIATE ATTENTION

Blood pressure (BP)- SBP > 140 and DBP > 90 mmHg in non hypertensive patient

Pulse rate (PR)- > 120 bpm on 2 occasions 30 mins apart Temperature (T)- > 38 degree celcius Proteinuria in a non hypertensive patient Any fresh vaginal bleeding Rupture of membranes more than 24 hours Presence of significant meconium Pain that differs from normal contraction (TRO rupture

uterus)

OBSERVATIONS OF FETUS*IF ANY OF THE FOLLOWING ARE OBSERVED, NEED IMMEDIATE ATTTENTION

Any abnormal presentation, including cord presentation Any abnormal lie Floating head per abdomen Suspected anhydramnions or polyhydramnions Abnormal fetal heart rate

PARTOGRAPH

Diagrammatic representation of the progress of labour

“Story of a patient in labour” Main components:

Progress of labourMaternal conditionFetal conditionDrugs given

MONITORING ON PARTOGRAM

Maternal vital signs- BP, PR, T 4hly (unless high risk) 4hly urine ketone Monitor contraction (TCM) every 1/2hly Descend of fetal head Vaginal examination (VE) every 4hly- progress of cervical

dilatation, degree of moulding & liqour colour Fetal heart rate monitoring

PARTOGRAPH

PARTOGRAM X 2 PAGES = PERINATAL MORTALITY

PARTOGRAM X 3 PAGES= MATERNAL MORTALITY

PARTOGRAPH

Patient came in active phase of labour normal/ good progress

PARTOGRAPH

Patient came in latent phase normal progress

PARTOGRAPH

Patient came in latent phase normal progress

PARTOGRAPH

Patient came in latent phase normal/good progress

ABNORMAL PARTOGRAPH (POOR PROGRESS)

Latent phase > 8 hours Cervical dilatation to the right of alert line Cervical dilatation at or beyond action line

PARTOGRAPHDilatation < 4 cm despite 8 hours of regular contraction

Patient with prolonged latent phase

NON PROGRESSIVE LABOUR:THE THREE P’S

1. Power2. Passage3. Passenger

* Position* Size* Attitude

1. POWER

Adequate contractions are needed for adequate progress of labour

Usually 3-4 in 10 min Usually 40-60s duration

PARTOGRAPH

PARTOGRAPH

Dilatation < 1cm/ hour in active phase due to ineffective uterine contractions < 3:10 < 40sec

Patient came in active phase Primary dysfunctional labour

AUGMENTATION

Oxytocin (Pitocin) Correct dose and titration To achieve “efficient “/”adequate” contraction. Prevent hyperstimulation Careful consideration in multipara and previous

scar

HYPERSTIMULATION

Prolonged contractions (> 2 mins) Frequent contractions (<1:2) Tetanic contractions (continuous)

2. PASSAGE

Clinical @ x-ray pelvimetry – not used in modern obstetrics

Adequacy of pelvis can only be ascertain through labour and delivery

Passage may be adequate but might not be for a big baby!!

EVIDENCE OF OBSTRUCTED LABOUR

Secondary arrest Large caput 3rd degree moulding Poorly applied cervix to presenting part Odematous cervix Maternal/ fetal distress

SECONDARY ARREST

Arrest of cervical dilatation and descent of presenting part despite good uterine contraction

ABSOLUTE CPD RELATIVE CPD

BIG BABY/ SMALL PELVIS FETAL MALPOSITION

PARTOGRAPH

Patient came in active phase Secondary arrest

3. PASSENGER

Size of baby Congenital abnormalities e.g. hydrocephalus Malposition (e.g. OP), malpresentation (e.g.

breech, brow)

FHR MONITORING Pinard stethoscope or Daptone

In latent phase: Intermittent auscultation* Low risk : Hourly* High risk : Every 15-30 min : CTG In active phase: Intermittent auscultation* Low risk: Every 30 min* High risk: Every 15 min CTG

FHR MONITORING

During second stage: Intermittent auscultation

* Low risk : Every 15 min

* High risk: Every 5 min or after each contraction/pushing

: CTG

Cardiotocography Management of suspicious tracing is not to

wait or repeat the CTG until it become normal/reactive

The stressor to the fetus is the contraction not the degree of cervical dilatation

FHR MONITORING

FHR MONITORING

If patient in labour (contracting)FETAL HEART HEARD!!! NOT ENOUGH

**palpate the maternal HR to differentiate between maternal & fetus

SALSO 2015

ADEQUATE ANALGESIA Every patient have a right for good analgesia in

labour “ TARIK NAFAS” is not an analgesia at all Breathing exrecises, immersion in water & massage

may reduce pain in latent phase of labour IM Pethidine 1-2mg/kg + Phenergan 0.5mg/kg 6

hourly Entonox inhalation (50% O2 and 50% Nitrous oxide)

at the start of contraction Continuous epidural analgesia

EPIDURAL ANALGESIA Available in SGH More effective pain relief than opiods Not associated with long term backache or

paralysis Not associated with a longer 1st stage of labour

or increased caesarean section rate Associated with longer 2nd stage and increased

chance of instrumental delivery

HYDRATION Good hydration is important for satisfactory

labour progress Review hydration status regularly (Don’t just

concentrated on VE finding) Urine volume and urine ketones assessed Allow low residual diet / oral fluids in labour

except for high risk cases

CONTROLLING GASTRIC ACIDITY

Either H2 – receptor antagonist or antacids should be considered for women who receive opiods develop risk factors that make general

anaesthetic more likely

COMPANIONSHIP / DOULA

Provides reassurance to patient Shown to:

Reduce analgesia requirements Reduce Caesarean section & instrumental Improve vaginal delivery rates

PARTNER

PARTNER ARE IMPORTANT, ESPECIALLY SUPPORTIVE AND HELPFUL ONES

SECOND STAGE OF LABOUR… STILL NEED TO CLOSELY MONITOR1. Maternal vital signs- BP, PR2. Progress of pushing and descend of fetal head3. CTG monitoring** NEED ATTENTION if 2nd stage more than 1H in nulliparous and 1/2H in multiparous** If contraction is INADEQUATE can consider to use oxytocin

Intrapartum interventions to reduce perineal trauma

1. DO NOT perform perineal massage in the second stage2. ’Hands on’ to guard the perineum & flexing baby’s head3. DO NOT carry out routine episiotomy4. If episiotomy needed, the recommended technique is

mediolateral episiotomy

DELAYED CORD CLAMPING

Do not clamp the cord earlier than 1 min from the birth of baby,unless resuscitation of newborn is needed

Clamp the cord before 5 min in order to perform CCT

THIRD STAGE OF LABOUR Active management of 3rd stage1. Usage of uterotonics2. Delayed cord clamping and cutting (up till 5 minutes)3. CCT after signs of placenta separation Monitoring during 3rd stage1. Maternal vital signs2. Degree of vaginal bleeding** NEED ATTENTION if 3rd stage delayed more than 30 mins

QUESTIONS??