labour management
TRANSCRIPT
Management of
normal labour
Prof. Aboubakr Elnashar Benha university Hospital, Egypt
Contents Introduction Definitions
Mechanism
Aims
Principles
1st stage
2nd stage
3rd stage
4th stage
Definitions Labour:
Regular involuntary coordinated, painful uterine contractions associated with cervical effacement and dilatation
• Regular frequent uterine contractions
+ • Cx changes (dilatation & effacement)
or • SROM
Delivery:
Expulsion of the product of the conception after fetal viability.
Anterior
Pubis
Right Left
Occipital bone
MECHANISMS OF NORMAL LABOUR
Occiput anterior
Occiputo anterior positions
D: Descent
F: Flexion
I: Internal rotation of the fetal head
C: Crowning
E: Extension
R: Restitution
I : Internal rotation of the shoulders
E: External rotation of the fetal head
L: Lateral flexion of the body
Descend
Flexion
Internal rotation
Crowning
Extension
Restitution
Internal rotation of shoulder
External rotation of head
Lateral flexion of body
LOA
LOA
OA
LOA
OA
OA
LOT
Delivery
D
F
I
C
E
R
I
E
L
Cardinal movements of Labor
Cardinal movements of labour (LOA)
Head is delivered
by Extension Restitution
External rotation
9
CROWNING OF THE HEAD
Head is delivered by EXTENSION
RESTITUTION
EXTERNAL ROTATION
• Delivery of a normal healthy child
• To anticipate, recognize and treat potential abnormal conditions before significant hazard develops for the mother or the fetus.
AIMS
• Diagnosis of labour
• Monitoring the progress of labour • Ensuring maternal well-being • Ensuring fetal well-being.
PRINCIPLES
MANAGEMENT 1st STAGE
OF LABOUR
I. Assessment
II. Preparation and care
III. Partogram
I. Assessment 1. History: 1. Woman’s antenatal record is reviewed
2. No records of antenatal care: complete history .
2. Examination
a. General a) Pallor, edema, abdominal scar (LSCS)
b) Vital signs: BP, pulse, RR and T
c) Heart and lungs
b. Abdominal examination:
a. Presentation and position and engagement
b. Auscultate the fetal heart
c. Evaluate the uterine contraction
c. Vaginal examination –
i) PP:
Presentation
Engagement, station
Position
ii) Membranes
Intact or absent: exclude cord prolapse after ROM
iii) Cx
Consistency, position
Dilatation
Effacement,
iv) Pelvis Adequacy.
Do not do vaginal examination:
vaginal bleeding before the placenta previa is
excluded.
Sterile speculum examination:
suspected ROM, if the woman is not in labour.
Admission to labour ward:
Active labour:
Regular painful contractions and
cervical dilatation 3 cm
{less time in the labor ward
less intrapartum oxytocics
less analgesia}
3. Investigation Urine: Protein Sugar ketones Blood: CBC RBS Grouping cross match for high risk patients.
II. Preparation and care 1. Bowel preparation:
Indicated:
No bowel action for 24 h or
Rectum feels loaded on vaginal examination
similar length of labor and most maternal and
neonatal outcomes
generates discomfort in women
2. Bladder care Encourage to empty bladder /1½ - 2 h. {A full bladder: prevent the fetal head from entering the pelvic brim impede descent of the fetal head. inhibit effective uterine action}. The quantity of urine should be measured and recorded
and a specimen obtained for testing.
3. Nutrition No food is permitted after labour is established {prevent regurgitation and aspiration} Small amount of clear fluid or frozen pineapple, Ice chips
to moisten the mouth
Maintain adequate hydration via intravenous routes
4. Perineal shaving
No
{is associated with similar maternal febrile
morbidity, wound infection, and neonatal
infection compared with just selective clipping of
hair}
Routine early ARM
Not recommended
{decrease duration of labor( 60 min, mostly
because of shorter 1st stage),
decrease use of oxytocin,
similar incidence of NRFHR monitoring
similar neonatal outcomes compared with
selective (later or no) AROM
26% increase in CD}
should be reserved for failure to progress
5. Position:
Walk about or
in bed, as she wishes
As long as the
patient is healthy
presentation normal
presenting part engaged
fetus in good condition
6. Pain relief Severe: an analgesic
a) Opiate drugs. e.g. Pethidine IM/4 h
b) Inhalational analgesia e.g. Entonox
c) Epidural analagesia
III. Monitoring the progress of labour
Once labour has become established, all events during labour should be recorded on a partogram. a) Well-being of the fetus b) Well-being of the mother c) Progress of the labour
Patient information:
name, gravida, para, hospital number, date and time
of admission and time of ruptured membranes.
PATIENT INFORMATION FETAL INFORMATION FHR Am fluid Moulding LABOUR INFORMATION Dilatation Descent Contraction MEDICATIONS syntocinon drugs IV fluids MATERNAL INFORMATION Pulse, BP, T Urine: alb, ketones, vol
A. Condition of the fetus
I. FHR: every half hour.
II. Memb & Liq: every vaginal examination
I= intact,
A= abscent
C= clear,
M= meconium
B= blood,
III. Moudling:
0 (separated)
+ (touching)
++(overlap)
+++ (severe overlap)
Monitor FHR Auscultation methods Electronic monitoring: CTG
NORMAL
ABNORMAL
B. Progress of labour
I. Cervical dilatation (cm).
every vaginal examination
Plot x
In active phase
Alert line: drawn at a rate of 1 cm /h cervical dil
The mean rate of the slowest 10% of normal PG Action line: drawn 4 h to the right of alert line. Intervention should take place II. Descend:
every vaginal examination Plot O (amount of head palpable
above pelvic brim) and Position
III. Contractions:
every half hour
Frequency/10 m, Duration & Intensity:
stippled (<20 sec, weak);
striped (20-40 sec, moderate);
complete (>40 sec, strong).
Recording the progress of labour
frequency of cervical examinations.
Most studies: every 2 h.
{risk of chorioamnionitis increases with the increasing
number of examinations}.
C. Condition of the mother
I. Medications:
Oxytocin: amount /30 min
Drugs
IV Fluids
II. V/S:
B.P: /4 h
mark with arrows ( )
P: /30 min
mark with a dot (●).
T: /2 hours.
III. Urine:
every time urine is passed.
Vol, alb, ketones
WHO partogram, 2002
Simple & easy to use.
The latent phase has been removed .
Plotting on begins in the active phase when the cervix
is 4 cm dilated.
MANAGEMENT 2nd
STAGE OF
LABOUR I. Preparation
II. Observation
III. Conduct of delivery
I. Preparation 1. Maternal position: With the exception of avoiding supine position, the
mother may assume any comfortable position for effective bearing down.
Semi-recumbent or
Supported sitting position, with the thighs abducted
2. PERINEAL CLEANSING
When delivery is imminent skin over the lower abdomen, vulva, anus and upper thigh is cleansed with antiseptic solution and draped.
POSITIONING FOR DELIVERY
PERINEAL CLEANSING
Need 6 swab balls
Clean sequentially
as shown by the
numbers
Clean according to
the direction
shown by the
Arrows
CREATE A STERILE FIELD
AROUND THE VAGINAL OPENING
II. Observation 1.Maternal conditions
Emotional condition
pulse quarter-hourly
bloods pressure hourly
2.Fetal conditions
FHR: either continuously or after each contraction.
Liquor: meconium staining.
3.Uterine contractions
Strength
Duration
Frequency, assessed continuously.
4.The progress of descent
every 30 minutes
III. CONDUCTING THE DELIVERY 1. DELIVERY OF THE HEAD
1) Control the delivery of the head to prevent laceration
2) Episiotomy if required
3) Ritgen’s method
4) Clear the airway after delivery of the had
Modified Ritgen Maneuver
As crowning occurs: exert forward pressure on the chin of the
fetus through the perineum just in front of the coccyx.
Concurrently, the other hand exerts pressure superiorly against
the occiput
• Instruct the mother to focus on her breathing. Have her
“breathe heavily” to help her stop pushing and prevent a
forceful birth.
• Ask the woman to pant or give
only small pushes with
contractions as the baby’s
head delivers
• To control birth of the head,
place the fingers of one hand
against the baby’s head to
keep it flexed (bent)
• Continue to gently support the
perineum as the baby’s head
delivers
DELIVERY OF THE HEAD
Head is delivered by extension
• Once the baby’s
head delivers, ask
the woman not to
push
• Suction the baby’s
mouth and nose
CORD AROUND THE NECK
Feel around the baby’s
neck for the umbilical cord
If the cord is around the
neck, attempt to slip it over
the baby’s head
If the cord is tight around
the neck, doubly clamp
and cut it before unwinding
it from around the neck
As the head emerges,
the baby will turn to one
side (for easier passage
of shoulders through
birth canal)
Note the time, if
possible
• Allow the baby’s head to turn spontaneously.
• After the head turns, place a hand on each side of the baby’s head.
• Tell the woman to push gently with the next contraction.
• Reduce tears by delivering one shoulder at a time
DELIVERY OF FETAL HEAD WITH
ROL POSITION
2. Delivery of the anterior shoulder by gentle downward traction on the head.
In the direction of the axis of the body
3. DELIVERY OF POSTERIOR SHOULDER
by elevating the head.
Support the rest of the baby’s body with one hand as
it slides out
4. DELIVERY OF THE TRUNK
After the delivery of the shoulders the baby is
grasped around the chest to aid the birth of the
trunk.
Finally, the body is slowly extracted by traction
on the shoulders and lifts the baby towards the
mother’s abdomen.
The time of delivery is noted.
BABY DELIVERED
FIRST BODY CONTACT OF MOTHER AND
BABY AND CORD CLAMPING
5. CLAMING AND CUTTING THE UMBILICAL CORD
After delivery
wait 15 to 20 seconds before
clamping and cutting the
umbilical cord.
After cutting the cord a plastic
crushing clamp is placed on
the cord 1 to 2 cm from the
umbilicus and the cord is cut
again 1 cm beyond the clamp.
Clamping, cutting and tying Of
umbilical cord
EPISIOTOMY Surgical incision into the perineum to enlarge
the space at the outlet
Benefits:
1.Speed up the birth
2.Prevent Tearing
3.Protects against incontinence
4.Protects against pelvic floor relaxation
5.Heals easier than tears
Not proven
No decrease
perineal damage
future vaginal prolapse
urinary incontinen
Increase 3rd & 4th degree tears
anal sphincter muscle dysfunction.
Indications Not routine
1. Sizeable babies with anticipation of shoulder
dystocia.
2. Shoulder dystocia.
3. Instrumental delivery (according to judgement)
4. Breech
5. Scarring from female genital mutilation or poorly
healed third or fourth degree tears
6. Fetal distress.
Types
Mediolateral rather than midline
(less 3rd and 4th degree perennial tear).
Good analgesia
(infiltration with xylocain )
Timing:
cause bleeding: not be
done too early. Wait
until perineum is
thinned out and
3–4 cm of the baby’s
head is visible during
contraction.
IMMEDIATE CARE OF THE NEW BORN
Once the baby is breathing normally he should be dried and warmly wrapped to prevent cooling and handle to the mother to hold, cuddle and enjoy.
If spontaneous respiration is not established soon after birth, resuscitation is the immediate priority.
The Apgar’s score of the baby should be noted and recorded.
Nonoperative interventions to decrease
operative birth in systematic reviews (FIGO, 2012):
1. Continuous support for women during
childbirth by one-to-one birth attendants
2. Use of upright or lateral positions during
delivery compared with supine or lithotomy
3. Delaying pushing for 1–2 hours or until the
woman has a strong urge to push reduces the
need for rotational and midcavity interventions
Recommendations FIGO (2012)
• Delivery facilities must offer everywoman
privacy and allow her to be accompanied by her
choice of a supportive person (husband, friend,
mother, relative, TBA)
• Psychosocial support, education,
communication, choice of position,
and pharmacological methods appropriately
used during the first stage are all useful in
relieving pain and distress in the second stage
of labor.
• Monitoring of FHR must be continued during
2nd stage to allow early detection of bradycardia.
• Routine episiotomy is harmful and should not
be practiced.
• Women should not be forced or encouraged to
push until they feel an urge to push.
• Fetal heart auscultation after every contraction.
• Local anesthetic should always be given for
any episiotomy, episiotomy/ laceration repair, or
forceps delivery.
MANAGEMENT 3rd
STAGE OF
LABOUR I. Delivery of placenta
II. Examination of placenta and perineum
III. Repair of episeotomy
I. Delivery OF THE PLACENTA
two stages:
(1) Separation of the placenta from the wall of the uterus and into the lower uterine segment
and/or the vagina, and
(2) Actual expulsion of the placenta out of the birth canal.
MECHANISM OF PLACENTA SEPARATION1:
1-Mathews-Duncan
mechanism
The leading edge of
the placenta separates
first and the placenta
is delivered with its
raw surface exposed.
2- Schultz mechanism
If the placenta is inserted
at the fundus and central
area separates first, the
placenta inverts and
draws the membranes
after it, covering the raw
surface (inverted
umbrella)
SIGNS OF PLACENTALSEPARATION
within 5 minutes after the delivery of the infant.
1.The uterus becomes globular and hard. =earliest
to appear.
2.Sudden gush of blood
3.The uterus rises in the abdomen because the
placenta, having separated, passes down into
the lower segment and vagina, where its bulk
pushes the uterus upward.
4.Cord lengthening.
=most reliable clinical
. . . Physiological Management
Active Management
Uterotonic None or after placenta delivered
With delivery of anterior shoulder or baby
Uterus Assessment of size and tone
Assessment of size and tone
Cord traction None Application of controlled cord traction* when uterus contracted
Cord clamping Variable Early
*Gentle downward cord traction with countertraction on the uterine body
ACTIVE MANAGEMENT OF THE THIRD STAGE
Helps prevent postpartum haemorrhage.
includes:
1. use of oxytocin
2. controlled cord traction, and
3. uterine massage.
Once the signs of placental separation have occurred the obstetrician assists delivery of the placenta by controlled cord traction as described by Brandt-Andrews’ method.
If the patient is awake, she is asked
to bear down while gentle
traction is made on the umbilical
cord.
A) Placenta separation
B) Controlled cord traction
C) Delivery of the membranes
II. EXAMINATION 1. OF THE PLACENTA
The placenta, membranes, and umbilical cord should be examined for completeness and for anomalies.
2. OF THE PERINEUM
At the same time, the perineal region, vulva outlet, vaginal canal, and the cervix should be carefully examined for lacerations.
If the perineum has been torn or an episiotomy made, tear or incision should be repaired immediately.
III. REPAIR OF EPISIOTOMY Suture as soon as possible after delivery to avoid bleeding and infection (RCOG) Start just above the apex Use 3 layer technique, vaginal mucosa, perennial muscle and perineal skin Synthetic, absorbable (rapidly absorbable polyglactin 910) VICRYL RAPIDE begins to fall off 7-10 days post-operatively reduced post partum perineal pain, dyspareunia, although increased suture removal up to 3/12 For each layer use loose continuous non locking suturing this will reduce pain and dyspareunia.
1. Identify apex
2. Begin suturing
1.0 cm above apex
3. Continuous sutures
4. Ends at the level of
vaginal opening
Continuous sutures Interrupted sutures Interrupted suture or
subcuticular
MANAGEMENT 4th stage of labour
I. Observe II. Check
The 2 hours after delivery
critical period {postpartum haemorrhage can
occurs due the relaxation of the uterus}.
I. Observation in delivery suite
Bleeding
blood pressure
pulse .
II. Check before discharging the patient from the
delivery
1. Uterus:
Frequently to make sure it is firm and not relaxing.
Remove any presence of intrauterine blood clots. {clots
interfere with retraction and the normal haemostatic
mechanism of the uterus}.
2. Introitus
to see that there is no hge.
3. Bladder
empty {full bladder can also interfere with uterine retraction}.
4. Baby
breathing well and that the colour and tone are normal.
Thank you Aboubakr elnashar