Management of normal labour

Definition-Normal labour can be defined as The spontaneous delivery of a single living term

fetus with vertex, occipito-anterior position without:-

1-any surgical intervention (except episiotomy).

2-any fetal or maternal complication.

STAGES OF LABOUR ARE 4

• First stage cervical dilatation and effacement• Second stage is the expulsion of the fetus• Third stage is the delivery of the placenta• Fourth stage is the early recovery

The first stage of labour:

The first stage of labour begins with the onset of true labour pains and ends with full cervical dilatation.

This can be divided into two phases:-The latent phase (from 0-3 cm).-The active phase (from 3- full cervical

dilatation) and the cervix should dilate at a rate of 1 cm/ h.

The latent phase:

-Starts from onset of labour until the cervix reaches 3cm dilatation.-Lasts about 8 hours or less.-Contractions occurs at least twice every 10 minutes with each lasting > 20

seconds.

The active phase:-Starts when the cervix reaches 3 cm dilatation.-Contractions occurs 3 times every 10 minutes, with each lasting > 40

seconds.-The cervix should dilate at a rate of 1cm / hour or faster.

Cervix

• Dilatation: How far has the cervix opened (in cm)

• Effacement: How thin is the cervix (in cm or %)

DIAGNOSIS OF THE ONSET OF LABOUR

SUSPECT OR ANTICEPATE THE ONSET OF LABOUR IF the woman has:

•Blood stained mucus discharge per vagina (show ). • Watery vaginal discharge.

Confirm the onset of labour if there are the following: • True labour pains. • Progressive cervical dilatation. • Progressive cervical effacement. • Formation of the bag of fore water which bulges through the

cervix and becomes tenser during uterine contractions.

TRUE LABOUR VX FALES LABOUR

• Regular contractions• Increase in frequency and intensity• Cervix dilate• No relive with sedation• Abd and back pain

• Irregular• Remain the same

• Unchanged• relive

• Lower abd

Management of Normal Labour

• Monitor maternal well-being• Monitor fetal well-being• Monitor the progress of labour

FRIEDMAN’S CURVE

Management of labourThe management of labour should be commenced during the antenatal period, and the women should be classified as high or low risk pregnancy. The medical or surgical problems should be corrected as in case of (anaemia, hypertension, urinary tract infection), vaccination should be given if necessary, and all investigations should be performed and prepared such as (HIV, HCV, Hbs Ag, blood grouping…….etc).

Also the patient should be advised to attend the antenatal class (parenterful class) and visit the hospital including the labour ward to be familiar to the place and staff. Once labour is commenced and the patient arrived to the admission room the following to be done:

A. -Taking history or reviewing the antenatal file. 1-Last menstrual period – expected date of

confinement. 2-Time of onset of labour. 3-Frequency and duration of contraction (3-4

/10min). 4-Presence or absence of amniotic fluid leakage. 5-Presence or absence of show or vaginal bleeding. 6-Past obstetric history especially mode of previous

delivery, presentation, mode of delivery, and weight of previous children.

7-Past medical or surgical history that may affect labour or delivery, especially diabetes, heart disease, respiratory disease allergies, and any medication.

B-Examination:1. .General: a-pallor, oedema, varicosities, height, and

built. b-Vital signs (BP, P, T) c-Examination of heart, lungs, breast and

other organs if necessary 2. .Abdominal Examination: a-To determine fundal height in cm using

tape measure (to determine gestational age clinically), fetal lie, presentation, engagement in fifths, size of the fetus, amount of liquor, fetal heart rate.

b-The frequency and duration of the contraction.

Orientation of Fetus• Vertex, breech or transverse lie• Palpate vaginally• Leopold’s Maneuvers

Monitor the Fetal Heart

3. .Vaginal Examination: to assess the following.

a-Cervical dilatation in cm and effacement in %.

b-Length of the cervix.c-Consistency of the cervixd-Position of the cervixe-State of the membranes, amount and colour

of liquor.f-fetal presentation, position and station.g-pelvic architecture.

The partogram used by most maternity

units, is an easy, graphical method of assessing

the progress of labour and helps facilitate handover

between midwives.

Purpose of the partograph:

*To detect abnormal progress of labour as early as possible.

* To prevent prolonged labour.

* To recognize CPD long before obstructed labour.

* To assist in early decision on augmentation or termination of labour.

* To increase the quality and regularity of all observations of the mother and fetus.

* To recognize maternal or fetal problems as early as possible.

Component of the partograph:

-Part I assessment of fetal condition.-Part II progress of labour.-Part III assessment of maternal condition.-Part IV outcome of labour.

Arrival to the labour ward:

I-first stage of labour:1-Ensure patient’s privacy by covering her

with sheaths or blankets.2-Reassure and show great sympathy and

interest.3-Record maternal vital signs every hour (BP,

P, T).4-Take blood for grouping and cross match for

high risk patients.5-Monitor:a-high risk patients should have a continuous

electronic fetal heart monitoring.

b-low risk patients should have brief electronic fetal heart monitoring if NORMAL, to be followed by intermittent auscultation:

-first stage every 15min-second stage every 5min6-Limit oral intake to small amount of clear

fluid or frozen pineapple.7-Give all patients in active labour Ranitidine

(Zentac) 150mg orally / 6hourly.8-Nurse the patient in:a-left lateral position for mediated patients.b-sitting or semi-reclining for unmediated

patients.

9-Encourage spontaneous voiding, catheterization may be necessary.

10-Test all urine specimen for proteins, sugar, and acetone.

11-Give IV fluids during labour to avoid dehydration

a-0.9% Nacl or hartmann’s solution at 80-125ml/hr

b-Supplementation with 5% dextrose to prevent ketosis and hypoglycemia.

12-Give analgesia/anesthesia as required.a-Pethidine (50-150mg)IM.b-Diamorphin (5-10mg)IM. Every 3-4 hours.*avoid giving it too early in labour < 3-4cm

cervical dilation or too late when the delivery is expected within 1-2hours.

*if given too late:-inform the pediatrician-give Naloxon (Narcon) 0.02mg IM to the neonate.c-Use Entonox (NO2 50%+O2 50%) by mask if available.d-Use epidural analgesia in selected cases if available such as Breech, Twins, preterm delivery.e-Give anti-emetics such as Metoclopromide (5-10mg)IM if necessary, but should not be routine.13-Do vaginal examination to:a-assess progress of labour every 2-4hrb-or immediately after rupture of membranesc-FHR abnormalities.

14-Recall all the observations in labour in Partogram.15-Consider augmentation with rupture of membrane then with syntocinon if progress of labour is slow (partogram).-1000 ml Hartmann’s solution or normal saline + 10 units syntocinon (pitocin) -Begin the infusion using a pump at 4 milliunits per minute and double the dose every 20 minutes to a maximum of 32 milliunits/min.-Or begin with 15 drops / min and increase the rate by 10 drops every 30 minutes untill adequate contractions.

Risks in using oxytocin

-Uterine hyperstimulation which may lead to fetal distress and / or uterine rupture.

-Abruptio placenta.

-Hyponatremia and water intoxication.

-Neonatal hyperbilirubinemia.

Assessment of the fetal condition:• Assess the amniotic fluid (color and amount).

• If cardiotocography is available:-Perform an admission test for all labouring women (a 20 minute period of

external electronic fetal monitoring upon admission.

-In high risk cases and cases with borderline cardiotocography , apply continuous electronic fetal heart monitoring.

-In low risk cases , perform intermittent electronic fetal heart monitoring( e.g. 15 minutes every hour).

• If no cardiotocography available: -Perform intermittent auscultation every 15 minutes in high risk cases and every

30 minutes in low risk cases ( listening for one minutes after uterine contraction).

-If there is fetal distress, stop oxytocin, place the patient on her left side and administer oxygen via a mask.

• Artificial rupture of the membranes.• Liq Fig. 3 Artifi

Fig. 4 Sweeping the membranes.

Risks of amniotomy:

-Pain and discomfort.

-Bleeding.

-Infection.

-Abruptio placenta.

-Cord prolapse.

II-second stage of labour:

Once the patient reach the second stage of labour and have the desire to push down then:

1-Put the patient in lithotomy position or other positions clean the vulva, and perineum with antiseptic solution.

2-Encourage organized pushing down which she is feeling to do so

3. -Monitor the uterine contraction and fetal heart more frequent.

4. -Use syntocinon if progress is slow and no contractions.

5. -When the head appears at the vulva, the perineum is supported during uterine contraction by sterile pad to promote flexion and prevent premature extension of the head by pressing up on the sinciput until crowning occur.

6. -After crowning the head is allowed to be delivered by extension slowly in between the contractions by sliding the perineum over the face.

7. -DO episiotomy if necessary under local anaesthetic ( 10-20 ml) of 1% lignocain, but should not be routine.

8. -Wait for the next contraction to deliver the shoulder and trunks.

9. -Clamp the cord and deliver and baby to be handled to pediatrician.

Episiotomy:

-There is no evidence to support claims that routine use of episiotomy reduces the risk of sever perineal trauma, improves perineal healing, prevent fetal trauma, or reduce the risk of urinary incontinence after delivery.

-Episiotomy should be used only to relieve fetal or maternal distress or to achieve adequate progress when it is the

perineum that is responsible for lack of progress.

Fig. Performing an episiotomy.(a) Episiotomy incisions, (b) Local anaesthetic isinfiltrated before the incision is made.(c) Midline episiotomy does not protect thesphincter.

Duration of the second stage:

• It is about 1hour for primigravida and half an hour for multigravida.

• Many factors influence the duration of the 2nd stage of labour:-Parity.-Epidural analgesia.-Fetal position-Strength of contractions.-Fetal size.-Perineal resistance.• A conservative approach will allow a spontaneous delivery or a safer

instrumental delivery at a lower station.• Terminating the 2nd stage of labour electively on the bases of duration, will

increase the incidence of unnecessary instrumental delivery and CS.

III-Third stage of labour:The management of third stage is

aimed at:1-Complete delivery of the after birth

(placenta and membranes).2-Prevention of acute inversion of the

uterus.3-prevention of postpartum

haemorrhage

Active management of the third stage :

1.Early clamping of the cord ( within 30 second of delivery) should be carried out ( clamp the cord close to the perineum)

- The cord should be immediately clamped in the following cases:

*Rh incompatibility.

*Preterm labour.

*Cases with possible Polycythemia of the fetus (maternal DM, IUGR).

2.Massage of the uterus abdominally

3.When the uterus contracts, deliver the placenta by controlled cord traction with a hand pushing the uterus upward to prevent uterine inversion.

Check the placenta and membranes for any missing parts.

A-Delivery of the placenta and membranes:a-Conservative method: the left hand is placed over the abdomen to detect any change in the level of the fundus or sign of placental separation and decent are detected, the patient is asked to bear down to deliver the placenta spontaneously. Ergometrine 0.5mg or Syntometrine(5 units syntocinon + 0.5mg Ergometrine) to be given intravenouslly.

Signs of separation and decent of the placenta:

1. -The body of the uterus becomes smaller, harder, and globular.

2. -The fundal level rises in the abdomen because the lower segment becomes distended by the placenta.

3. -Suprapubic bulge may appear due to presence of the placenta in the lower segment.

4. -Elongation of the cord out side the vulva.5. -Sudden gush of blood from the vagina.

b-Active methods(prophylaxis against postpartum haemorrhage)

1-Give Methargine 0.5 mg IM or Syntometrine (5units oxytocin+0.5mg Methargine), at the time of the anterior shoulder is free from symphysis pubis or as soon as possible thereafter.

2-Deliver the placenta and membranes by control cord traction by right hand, and the left hand is placed on the suprapubic region, pushing the uterus upwards.

N.B. USE SYNTOCINON RATHER THAN METHARGINE IN CARDIAC AND HYPERTENSIVE CASES.

Inspect the Placenta

• Make sure it is complete• Look for missing pieces• Look for malformations• Look for areas of adherent

blood clot

IV-Post Delivery:1-examine the placenta for their

completeness, anomalies, length, and number of vessels in the cord and record the placental weight.

2-Suture the episiotomy or any laceration.3-Estimate blood loss, count swabs, and take

cord blood for Hb, blood group, Rh, bilirubin, and coomb’s test for Rh negative mother.

4-Check BP, P, T, Lochia and firmness of the uterus before transferring the patient.

5-Continue an infusion of syntocinon through the first hour if necessary.

6-Allow no food during the first hour, sips of water may be taken, encourage nursing.

V-Care of the new born infant:1. -Clearance of the new passages.2. -Determine the Apgar score one and five

minutes- heart rate- respiratory rate- muscle tone- colour- reflex irritability3-Care of the umbilical cord stump4-General assessment of the infant to exclude

any congenital anomalies.5-Identification of weight, estimate the

gestational age, dress it and put a mask to identify it.

6-Protect the baby against cold.

Thank you