managment of labor for undergraduate
DESCRIPTION
undergraduate course lectures in Obstetrics&Gynecology prepared by Dr Manal Behery.Professor of OB&GYNE Faculty of medicine Zagazig UniversityTRANSCRIPT
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Management of Normal Management of Normal LaborLabor
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Management on Management on AdmissionAdmission
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Full historyFull history::1-Complete obstetric history.1-Complete obstetric history.
2-History of the present pregnancy.2-History of the present pregnancy.
3-History of the present labor ( e.g.: labor 3-History of the present labor ( e.g.: labor pains, vaginal bleeding, gush of fluid& fetal pains, vaginal bleeding, gush of fluid& fetal movement).movement).
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General Examination:General Examination:Vital signs ( pulse , B.P. , temperature,Vital signs ( pulse , B.P. , temperature,
…etc.)…etc.)
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2-Abdominal 2-Abdominal examinationexamination
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Fundal levelFundal level
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Fundal gripFundal grip
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Umbilical gripUmbilical grip
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Second pelvic gripSecond pelvic grip
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PalpationPalpation
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AuscultationAuscultation
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3-Pelvic examination:3-Pelvic examination:
CervixCervix : dilatation (c.m.), effeacemet (%) , : dilatation (c.m.), effeacemet (%) , position & consistency.position & consistency.
membrane:membrane: intact or ruptured ( if intact or ruptured ( if ruptured exclude cord prolapse).ruptured exclude cord prolapse).
--Amniotic fluidAmniotic fluid ( after R.O.M.): either ( after R.O.M.): either clear , meconium stained or blood stained.clear , meconium stained or blood stained.
-Presenting part -Presenting part , , position ,station & moulding.position ,station & moulding.
--Assessment of pelvic capacity Assessment of pelvic capacity
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Cervical dilatationCervical dilatation It is the surest way to assess progress of labourIt is the surest way to assess progress of labour
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Assessment of pelvic Assessment of pelvic capacitycapacity
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PartographPartograph a graphical record of the a graphical record of the
observations made observations made
of a women in labor of a women in labor
For progress of labor and For progress of labor and conditions of the mother conditions of the mother and and
the fetus the fetus
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History Of PartogramHistory Of Partogram Friedman'sFriedman's partogram partogram
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latent phase latent phase
Starts from Starts from onset of labour onset of labour until the until the cervix cervix reaches 3 cm dilatationreaches 3 cm dilatation
lasts 8 hours or lesslasts 8 hours or less
Contractions Contractions at least 2/10 min at least 2/10 min contractionscontractions
each lastingeach lasting < < 20 seconds20 seconds
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Active phase :Active phase :
The cervix should dilate at a rate of 1 The cervix should dilate at a rate of 1 cm / hour or fastercm / hour or faster
Contractions at least 3 / 10 min each Contractions at least 3 / 10 min each lasting lasting << 40 seconds 40 seconds
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Closed cervix vs Closed cervix vs effecedeffeced vs vs dilated Cxdilated Cx
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Components of the Components of the partographpartograph
Part 1 : fetal condition Part 1 : fetal condition ( at ( at top )top )
Part 2 : progress of labour Part 2 : progress of labour ( at ( at middle )middle )
Part 3 : maternal condition ( at Part 3 : maternal condition ( at bottom )bottom )
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Part 1 : Fetal condition Part 1 : Fetal condition Recording fetal heart Recording fetal heart
raterate
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Membranes and liquorMembranes and liquor
Dilated cervix with bag of fore water
I: intactC : clearM : muconiumB : blood stained
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Molding the fetal skull Molding the fetal skull bonesbones
. Increasing molding with the head high in the pelvis . Increasing molding with the head high in the pelvis is an ominous sign of Cephalopelvic disproportion.is an ominous sign of Cephalopelvic disproportion.
separated bones . sutures felt easilyseparated bones . sutures felt easily……………….O.O bones just touching each otherbones just touching each other…………………………..+..+ overlapping bones …………… overlapping bones …………… ……………………...++...++ severely overlapping bones ( notable ) severely overlapping bones ( notable ) …………..+++..+++
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Part 2 – progress of labourPart 2 – progress of labour . . Cervical dilatation: it is divided into a latent Cervical dilatation: it is divided into a latent
phase and an active phasephase and an active phase Descent of the fetal headDescent of the fetal head Uterine contractions Uterine contractions
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Descent of the fetal Descent of the fetal headhead
The rule of fifth BY abdominal The rule of fifth BY abdominal examinationexamination
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Assessing descent of the fetal PV;Assessing descent of the fetal PV; 0 station is at the level of the 0 station is at the level of the
ischial spine ischial spine
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Engagment Engagment
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Normal progress in Normal progress in labor labor
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Alert line ( health facility Alert line ( health facility line )line )
The alert line drawn from 3 cm The alert line drawn from 3 cm dilatation represents the rate of dilatation represents the rate of dilatation of 1 cm / hour dilatation of 1 cm / hour
Moving to the right or the alert line Moving to the right or the alert line means referral to hospital for extra means referral to hospital for extra carecare
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Action line ( hospital Action line ( hospital line )line )
The action line is drawn 4 hour to the The action line is drawn 4 hour to the right of the alert line and parallel to right of the alert line and parallel to itit
This is the critical line at which This is the critical line at which specific management decisions must specific management decisions must be made at the hospitalbe made at the hospital
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When labor goes from latent to active phase , When labor goes from latent to active phase , plotting of the dilatation is immediately plotting of the dilatation is immediately transferred from the latent phase area to the transferred from the latent phase area to the alert linealert line
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Normal labor progress Normal labor progress
At At addmision addmision
Then after Then after 4h 4h
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Abnormal labor progress Abnormal labor progress
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Recording uterine Recording uterine contractioncontraction
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PART 3:Recording of PART 3:Recording of maternal conditionmaternal condition
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--
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Management of the Management of the first stagefirst stage
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Ambulating and position in Ambulating and position in labor labor
Walking may be more comfortable than Walking may be more comfortable than being supine during early laborbeing supine during early labor
The left lateral position keeps the uterus The left lateral position keeps the uterus off the inferior vena cava; off the inferior vena cava; this prevent this prevent (supine hypotensive syndrome)(supine hypotensive syndrome)
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Evaluation of fetal well-Evaluation of fetal well-beingbeing
Measurement of the Measurement of the fetal heart fetal heart raterate
By hand-held Doppler, or By CTGBy hand-held Doppler, or By CTG
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Late in first stageLate in first stage patients may report the urge to patients may report the urge to
push.push. This may indicate significant descent This may indicate significant descent
of the fetal head with pressure on of the fetal head with pressure on the perineum.the perineum.
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Management of the Management of the second stagesecond stage
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Diagnosis of the onset of the Diagnosis of the onset of the 2nd stage2nd stage
Feeling a desire to evacuate the Feeling a desire to evacuate the bladder or rectumbladder or rectum
Reflex desire to bear down during Reflex desire to bear down during contractions. contractions.
The uterine contractions are more The uterine contractions are more prolonged and vigorous. prolonged and vigorous.
Full cervical dilatation Full cervical dilatation
(the surest sign).(the surest sign).
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Transport the lady to the Transport the lady to the delivery room.delivery room.
. . (A)Position(A)Position:: - Lithotomy - Lithotomy position or Dorsal position.position or Dorsal position.
((B)Paint vulva & perineumB)Paint vulva & perineum with antiseptic solution.with antiseptic solution.
((C)Apply sterile leggings and C)Apply sterile leggings and towelstowels
((D)Evacuate the bladderD)Evacuate the bladder by by catheter catheter (if not evacuated before)(if not evacuated before)
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Litotomy positionVS dorsal Litotomy positionVS dorsal positionposition
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F)Ask the lady to bear down F)Ask the lady to bear down during uterine contractions and during uterine contractions and relax in between.relax in between.
J). V oxytocin drip J). V oxytocin drip in glucose in glucose solution 5% solution 5% may be given.may be given.
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4)The main task of 4)The main task of the obstetrician is the obstetrician is to prevent perineal to prevent perineal lacerationslacerations, , how?how?
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When the labia start toWhen the labia start to
be separated by the head, be separated by the head,
put a sterile dressing on put a sterile dressing on
the perineum the perineum and press on it during and press on it during uterine Contractions.uterine Contractions.
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A. Support of the perineum A. Support of the perineum till crowning occurstill crowning occurs
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Crowning: Crowning: The B.P.D passes The B.P.D passes through the vulval ring during through the vulval ring during
contraction and the head does not contraction and the head does not recede inbetween uterine recede inbetween uterine
contractionscontractions..
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EpisiotomyEpisiotomy
when the perineum is when the perineum is maximally stretched and about maximally stretched and about to tearto tear
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Problems arising from Problems arising from EpisiotomyEpisiotomy
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PainPain EdemaEdema BleedingBleeding InfectionInfection Defects in woundDefects in wound
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Before Crowning Before Crowning After After
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B. After crowningB. After crowning,, Prevent straining after Prevent straining after
crowning.crowning. Allow gradual and slow extension Allow gradual and slow extension
only inbetween uterine contractions. only inbetween uterine contractions. by doing by doing ""Rtigen maneuver“Rtigen maneuver“
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Examine neck for looped umbilical cordExamine neck for looped umbilical cord
.. If a loop of cord is coiled If a loop of cord is coiled
around the neck Try to slip it.around the neck Try to slip it. If several loops, If several loops,
apply double clampingapply double clamping
and cut the cord and cut the cord
inbetween.inbetween.
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Support infant’s head as it rotates for Support infant’s head as it rotates for shoulder presentationshoulder presentation
..
Guide infant’s head downward to deliver Guide infant’s head downward to deliver anterior shoulderanterior shoulder
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7)Deliver posterior 7)Deliver posterior shoulder first , then the shoulder first , then the
anterior shoulder anterior shoulder when the anterior shoulder appears when the anterior shoulder appears under the pubic arch,the head is under the pubic arch,the head is lifted upwards to deliver the lifted upwards to deliver the posterior shoulder, then downwards posterior shoulder, then downwards to deliver the anterior shoulder.to deliver the anterior shoulder.
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The rest of the body The rest of the body usually slips easilyusually slips easily
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8)Hold the fetus from its 8)Hold the fetus from its feetfeet
ContraindicationsContraindications
1-Premature baby1-Premature baby
2-Fetal asphyxia2-Fetal asphyxia 3-Suspected presence3-Suspected presence
of intracranial hemorrhage.of intracranial hemorrhage.
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9)Milking the cord9)Milking the cord TTowards the fetal umbilicus add l00 cc owards the fetal umbilicus add l00 cc
of blood to fetal circulation of blood to fetal circulation Alternatively, the infant is held about Alternatively, the infant is held about
half minute below the level of the half minute below the level of the vaginal introitus before clamping the vaginal introitus before clamping the cord. cord.
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In cases of Rh In cases of Rh incompatibilityincompatibility
The cord should be clamped The cord should be clamped immediately with no milking to immediately with no milking to avoid addition of more bilirubin avoid addition of more bilirubin from destructed R.B.Cs to fetal from destructed R.B.Cs to fetal circulation →more circulation →more hyperbilirubinaemiahyperbilirubinaemia
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10)Clamp the cord by 2 10)Clamp the cord by 2 ring forceps and cut ring forceps and cut
inbetweeninbetweenAfter delivery and evaluation of infant, clamp and cut cord
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D- D- Management of Management of the 3rd Stage:the 3rd Stage:
Normally the placenta is expelled within 10 minutes, if expelled between 10- 30 minutes (delayed delivery of placenta). If not expelled within 30 minutes (Retained placenta).
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Active management of 3Active management of 3rdrd stage stage of labor.of labor.
AA
CONTROLLED CORD TRACTION
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Guarding the UterusGuarding the Uterus
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Controlled cord tractionControlled cord traction
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Delivering the Delivering the MembranesMembranes
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Physiological Physiological ManagementManagement
Passive or expectant managementPassive or expectant management No prophylactic No prophylactic oxytocicsoxytocics
Cord clamped afterCord clamped afterdelivery of placentadelivery of placenta
No Controlled Cord Traction (CCTNo Controlled Cord Traction (CCT))
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11)Episiotomy repair 11)Episiotomy repair
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check placenta and check placenta and membranesmembranes
for completeness for completeness
and normalityand normality
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THANK YOUTHANK YOU
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Active Management Active Management Of LabourOf Labour
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The aim of active The aim of active management of labour is management of labour is
toto ensure that the primigravida will ensure that the primigravida will
deliver a healthy baby in less than deliver a healthy baby in less than 12 hours12 hours
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Benefits of Active Benefits of Active Management of LabourManagement of Labour
It avoids prolonged labour which It avoids prolonged labour which can lead to: can lead to:
Maternal distress and emotional Maternal distress and emotional upset.upset.
Fetal hypoxia and distress.Fetal hypoxia and distress.
Exhaustion of the medical and Exhaustion of the medical and nursing staff.nursing staff.
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The Principles of Active The Principles of Active Management of LabourManagement of Labour
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1-Antenatal education1-Antenatal education ::The mother is informed about the physiology of The mother is informed about the physiology of
labour and assured that labour will take less than labour and assured that labour will take less than 12 hours. In this way, she can cope better with 12 hours. In this way, she can cope better with the stress of labour.the stress of labour.
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2-Strict diagnosis of onset of 2-Strict diagnosis of onset of labour.labour.
Onset of regular involuntary Onset of regular involuntary coordinated, painful uterine coordinated, painful uterine contractions associated with cervical contractions associated with cervical effacement and dilatationeffacement and dilatation
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3-Regular follow-Up of 3-Regular follow-Up of the Patient during the Patient during
LabourLabour : PV is done on admission to the labor. : PV is done on admission to the labor.
This will be repeated every 1-2 hoursThis will be repeated every 1-2 hours
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Examination recoreded in Examination recoreded in partographpartograph
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4-Correction of Abnormal 4-Correction of Abnormal ProgressProgress
The rate of cervical dilatation should The rate of cervical dilatation should not be less than 1 cm per hour in the not be less than 1 cm per hour in the active phase of labour. active phase of labour.
If the cervix is not dilating properly, If the cervix is not dilating properly, amniotomy or pitocin dripamniotomy or pitocin drip
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Normal vs.Prolonged Normal vs.Prolonged latent phaselatent phase
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5-Personal Attention:5-Personal Attention:
one nurse face to face for each one nurse face to face for each patient patient ..
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6-Diet6-Diet
Nothing is allowed by mouth.Nothing is allowed by mouth.
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7-Provision of suitable 7-Provision of suitable analgesia.analgesia.