04 NORMAL LABOUR.pptx

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1. OBSTETRICS AND MIDWIFERY CARE NORMAL LABOUR Mrs. ngoma

2. LECTURE OUTLINE Introduction Definition of terms Factors regulating onset of labour Premonitory signs of labour Signs of true labour Differences between True and False labour conclusion

3. INTRODUCTION Labour and child birth herald another developmental phase in the life of the woman and her family. The processes that occur are both physiological and psychological and women anticipate labour differently and so behave differently during labour .

4. .. Labour and child birth have a special meaning for every culture; the woman herself, the partner and family. In some cultures labour and child birth are accompanied by particular rituals. Therefore, the midwife should be sensitive to the individual woman’s needs so as to render holistic care that is cultural sensitive. In addition, The role of the midwife is supportive and intervening only when circumstances demand it.

5. .. The transition from pregnancy to motherhood is enormous and unique physiological and psychological change in each woman . Women experience stress and physical pain so midwives need to provide an environment that allows the woman to go through labour and the birthing process safely and with dignity . The woman should be provided with adequate and relevant information which allows her to make informed decisions.

6. OBJECTIVES General Objective At the end of the presentation student midwives should be able to acquire knowledge and an understanding on Normal labour and its management.

7. .. Specific objectives At the end of this presentation students should be able to: Define the terms labour and Normal Labour State the factors that regulate the on set of labour. Explain the premonitory signs of labour. List the signs of true labour.

8. .. What is labour? What is normal labour?

9. DEFINITIONS Labour : It is the process by which the fetus, placenta and its membranes are expelled through the birth canal after 28 weeks of gestation (Frazer,2009).

10. .. Normal Labour Is the process by which the fetus is born at term and presents by vertex , the process is completed spontaneously within 18hours of labour with no complications to either the mother or baby (Frazer, 2009)

11. …. NORMAL LABOUR is labour in which the foetus is born at term (between 37 and 42 weeks’ gestation), presents by vertex , the process is completed spontaneously and does not exceed 18hours and labour is completed with no complications and by unaided natural maternal effort.

12. .. What causes labour? Or what factors that regulates labour to start?

13. FACTORS REGULATING THE ONSET OF LABOUR The cause of labour is not known or fully understood but a combination of factors which are hormonal and mechanical are said to cause the onset of labour.

14. Hormonal Certain hormones are involved in the onset of labour. The placenta produces progesterone and oestrogen during pregnancy. Progesterone has a relaxing effect on the uterine muscles there by inhibiting contractions . As pregnancy reaches term, biochemical changes cause a decrease in the availability of progesterone to the uterine muscles and there is an increase in oestrogen , which has an effect on uterine contractions.

15. .. Oestrogen increases the sensitivity of myometrium to oxytocin and stimulates production of prostaglandins which in turn will cause irritability and contractions.

16. .. Prostaglandins are wide spread in the body. They play a central role in the initiation of labour. They are released by lysosomes of the decidual and myometrial cells. This process is further stimulated by the contractions , probably setting in motion a cycle of events (Sellers, 2013). It is produced in response to sharp rise of maternal oestrogen during the last week of pregnancy. They inhibit the effects of progesterone and initiate uterine contractions hence the onset of labour.

17. Mechanical factors Increased Uterine activity : occurs as a result of stimulation of the uterus and cervix. Smooth muscles usually contract when stretched, Therefore the uterine muscles become sensitive to distension and end up contracting . The increased stretching of the uterine muscles by the increased intra-amniotic volume (enlarging fetus, placenta and the increased amniotic amount of amniotic fluid ) has effects as pregnancy progresses. Towards term, the braxtone hicks contractions comes in and increase in intensity and frequency as pregnancy advances contributing to onset of labour.

18. .. Overstretching or over distension of the uterus The uterine muscles become more sensitive in the case of multiple pregnancy, poly- hydramnious or when the presenting part is well applied to the cervix. Twins are usually born 2-3 weeks earlier than a single fetus. This is due to the increased stretch of the smooth muscles of the uterine.

19. .. Cervical irritation and stretch It is thought that cervical irritation and stretch of the lower segment play an important part in initiating uterine contractions. When the presenting part is pressing on the cervix and dilatation of the cervix is taking place, impulses are conducted to the neuro -hypothesis, causing the release of oxytocin . A well-fitting presenting part, exerting an even pressure and therefore, a greater area of pressure on the cervix causes the best stimulation of uterine contractions.

20. PREMONITORY SIGNS OF LABOUR These signs occur 2-3 weeks before labour starts and include the following: Lightening This is the sinking of the uterus 2-3 weeks before term. The fundus no longer clouds to the lungs and breathing is easier. It occurs as a result of the following :

21. .. Softening of pelvic ligaments and widening of the symphysis pubis The softened and relaxed pelvic floor allows the uterus to descend further into the true pelvis. When this occurs: There is a feeling of relief because the diaphragm comes to its normal position

22. .. The lower segment becomes softened and the fetus sinks further downwards causing vague discomfort in a woman. The woman may experience discomfort in the lower abdomen, groins and thighs and she may experience pain when walking. She may also experience increased venous stasis leading to eodema in the lower extremities.

23. .. Frequency of micturition Mild incontinence of urine occurs due to weakened bladder control because of pelvic floor muscles relaxation. This reduces sphincter function Pressure of the fetal head on the bladder limits its capacity requiring to be emptied at all times. Sometimes there is a state of mild incontinence or poor control o f the sphincter due to relaxed conditions of the softened pelvic floor.

24. False pain/Braxton Hicks contractions Braxton Hicks contractions are more intense but are erratic and irregular. These contraptions occurs throughout pregnancy, however, they may become uncomfortable. The pain seems to be in the abdomen and groin but may feel like the “drawing “sensation experienced by some women with dysmenorrhoea. When these contractions are strong enough for the woman to believe she is in labour but she is said to be in false labour.

25. Taking up of the cervix to be part of the lower uterine segment The cervix is drawn up and emerges into the lower uterine segment and becomes part of the uterus. This is possible because of the softened pelvic floor. In primigrada , taking up of the cervix occurs before dilation of external OS (before labor) while in multigravida it occurs in labour as dilation of the cervix begins. This is due to differences in muscle tonicity (frazer,2009).

26. SIGNS OF TRUE LABOUR Presence of show This is due to the plugging off of the operculum ; it will be with blood and appears as blood stained mucus. Dilation of the cervix This is due to upward retraction exerted by muscle fibers in the upper uterine segment pulling on the cervix making it to enlarge. Dilation is further aided by a well-fitting presenting part .

27. … Painful rhythmic uterine contractions These are felt by the woman as tightening discomfort or actual pain and they increase in intensity until they reach the climax after which they diminish gradually. They have a pattern of being mild, moderate and strong.

28. DIFFERENCES BETWEEN FALSE AND TRUE LABOUR True labour In true labour the uterine contractions are regular, rhythmic and painful and increase in intensity As contractions increase in intensity the interval between contractions shorten gradually.

29. .. Contractions intensify when the woman is up and about. Effacement of the cervix takes place, accompanied by progressive dilation of the cervix and the membranes feel tense during a contraction Show is present as the operculum is shed.

30. .. False labour Uterine contractions may be painful but not regular and do not increase in intensity. The interval between contractions varies Pain from the uterine contractions is relieved by walking. Show is absent. Effacement of the cervix takes place but there is no accompanying dilation of the cervix The membranes do not become tense.

31. SUMMARY Labour is a process in which the fetus, placenta and its membranes are delivered through the birth canal. The cause of labour is idiopathic but there are factors that initiate the onset. These are hormonal and mechanical factors. There are premonitory signs that occurs 2-3 weeks before labour begins such as lightening and frequency of micturation.

32. … It is also important to know the true signs of labour such as show, cervical dilatation and continuous painful rhythmic uterine contraction. The midwife should be able to distinguish true labour from false labour.

33. REFERENCES Fraser D.M & Cooper M.A (2009). Myles textbook for midwives . 15 th Edition, Churchil Livingstone Sellers P.M, (1993), Sellers Midwifery; volume 1 , Capetown , South Africa

34. STAGES OF LABOUR …

35. STAGES OF LABOUR First stage of labour or the stage of dilation This stage starts with the initiation of painful, regular and rhythmic uterine contractions to full dilation of the cervix (10 cm). This is the longest stage of labour. Lasts about 11 to 14 hours in a Primigavida . Should not exceed 16 hours Lasts 6 to 8 hours in a multi gravida woman and should not exceed 12 hours .

36. .. Three sub-stages (Phases) of the first stage of labour According to Fraser and Cooper (2005), the first stage is divided into the : Latent Active and Transitional phases

37. Latent phase (0-4 cm dilatation) This begins with the onset of regular contractions. During this phase the cervix dilates from 0-4 cm. The duration of latent phase should not be longer than 8 hours. Active phase (4-10 cm) The active stage is the time when the cervix undergoes more rapid dilatation. This begins when the cervix is 4 cm and in presence of rhythmic contraction and is complete when the cervix if fully dilated (10 cm). During this phase cervical dilation should be 1cm per hour in

38. .. The transitional phase The transitional phase is the stage of labour when the cervix is from around 8 cm dilated until it is fully dilated . There is brief lull (brief time of quiet) in the intensity of the uterine activity at this time. When the woman enters this phase, she may demonstrate significant anxiety, restlessness and frequently changing positions, leg tremor, nausea and vomiting.

39. .. Second stage of labour The second stage of labour begins from full dilatation of the cervix to complete delivery of the baby. It lasts 15-30 minutes in a multiparous woman. It lasts 40-45 minutes in a Primigavida . There are two phase Perineal phase and descent phase

40. .. Third stage of labour It begins from the complete birth of the baby to the complete expulsion of the placenta and its membranes including control of vaginal bleeding. Phases include the following Separation of the placenta Descent of the placenta Control of bleeding

41. DURATION OF LABOUR Parity FIRST STAGE SECOND STAGE THIRD STAGE Primigravida 12-14 Hours Not more than 16hrs 30-45 Minutes Not more than 1hr 5-15 Minutes Not more than 1hr Active mgt-5min Multigravida 7-9 Hours Not more than 11hrs 5-30 Min Not more than 30min 5-15 Min Same as above

42. Factors influencing the progress of labour There are four important factors influencing the progress of labour commonly known as the ‘5Ps ’

43. 1. Passage The maternal bony pelvis(true pelvis) soft tissues of the cervix, the muscles of the pelvic floor, vagina, vaginal introitus and the elasticity of the perineum form the passage through which the foetus must pass during labour and delivery. The pelvis is divided into three parts the outlet, inlet and cavity.

44. Cont…. Although the soft tissues, particularly the muscular layers of the pelvic floor, contribute to vaginal birth of the foetus, the maternal pelvis plays a far greater role in the labour process because the foetus must successfully accommodate itself to this relatively rigid passage way. Therefore, the size and shape of the pelvis must be determined before labour begins.

45. 2. Passenger Refers to foetus, placenta and membranes. The number of foetuses can affect the duration of labour e.g. a singletone is shorter than multiple pregnancy.

46. Cont…. The attachment of the placenta and membranes in the fundal region with an average size umbilical cord will not delay descent of the presenting part while as the placenta in the same position with a short cord can delay descent and duration of labour the head of the foetus is the largest part of the foetus made of several bones. If the head is too big it will affect the progress of labour. The presentation of the foetus also affects the progress of labour. Immediately the head is born the rest of the body is rarely delayed.

47. 3. Powers the powers of labour are divided into two parts, the primary and secondary powers . The primary powers are the uterine contractions which effect the changes of the first stage of labour (complete effacement and dilatation of the cervix ). The secondary powers are the abdominal and diaphragm musculature contractions, which add to the primary powers after full dilatation has occurred. When a pregnant woman is in established labour contractions begin in the uterine fundus and radiate downwards to the body of the uterus.

48. 4. Position This affects the woman’s anatomic and physiologic adaptations to labour. Frequent changes in position relieve fatigue, increase comfort and improve circulation. (Gupta and Nikodem , 2001) Therefore a labouring woman should be encouraged to find positions that are most comfortable for her i.e. walking, sitting, kneeling or squatting.

49. 5 . Psychological preparation The woman’s psychological preparation plays a major role in the progress of labour. Many women fear the pain of contractions. They worry about their ability to withstand the pain and self-control. Those women who attend antenatal clinics may be less anxious. Support at bedside during labour the husband/partner, a family member or friend can help reduce anxiety and promote comfort

50. PHSIOLOGY OF FIRST STAGE OF LABOUR The length of labour varies widely and influenced by parity, birth interval, psychological state, presentation and position of the fetus. Maternal pelvic shape and size and the character of uterine contractions also affect the duration of labour. The following physiological changes take place in the first stage of labour:

51. A. UTERINE ACTION 1. Fundal dominance Each uterine contraction starts in the fundus near one of the cornua and spreads across and downwards . The contraction lasts longest in the fundus where it is also most intense but the peak is reached simultaneously over the whole uterus and the contraction fades from all parts together. This partten permits the cervix to dilate and the strongly contracting fundus to expel the fetus.

52. 2. Polarity Polarity is the term used to describe the neuromuscular harmony that prevails between the two poles or segments of the uterus throughout labour. During each uterine contraction, the two poles act harmoniously. The upper pole contracts strongly and retracts to expel the fetus while The lower pole contracts slightly and dilates to allow expulsion to take place. If polarity is disorganized the progress of labour is inhibited.

53. 3. Contraction and Retraction Uterine muscle has a unique property . During labour the contraction does not pass off entirely, but muscle fibers retain some of the shortening of contraction instead of becoming completely relaxed. This term is called retraction. This assists in the expulsion of the fetus because the cavity of the uterus is reduced as the upper uterine segment becomes shorter and thicker

54. 4. Formation of Upper and Lower Uterine Segments By the end of pregnancy, the body of the uterus is described as having divided into two segments. The upper uterine segment , having been formed from the body of the fundus is mainly concerned with contraction and retraction, it is thick and muscular. The lower uterine segment is formed of the isthmus and the cervix . The lower segment is prepared for distension and dilatation .

55. … Although there is no clear and strict division of the upper and lower uterine segments, the muscle content reduces from the fundus to the cervix where it is thinner. When labour begins, the retracted longitudinal muscle fibers in the upper uterine pull on the lower segment causing it to stretch; This is aided by the force applied by the descending pressing part.

56. 5. Formation of a Retraction Ring This refers to the physiological ridge which develops as a result of retraction of the upper uterine segment, producing progressive thickening of the walls of the upper segment at the same time progressive thinning of the walls of the lower segment. In normal labour it is not visible, but when it becomes exaggerated and visible above the symphysis pubis it is referred to as the bandl’s ring.

57. .. This may be mistaken for a full bladder and it may be an indication of obstructed labour pending uterine rupture. The physiological ring rises gradually as the upper uterine segment contracts and retracts and the lower uterine segment thins out to accommodate the descending fetus. Once the cervix is fully dilated and the fetus is expelled through the birth canal, the retraction ring rises no further.

58. 6. Cervical Effacement Effacement of the cervix may occur later in pregnancy in Primigavida and in multigravida the external os may begin to dilate before effacement. Effacement and dilatation of the cervix occurs simultaneously in multigravida women.

59. … The muscle fibers surrounding the internal os are drawn upwards and merge into the lower uterine segment . The cervical canal widens at the level of the internal os . The external os which is now called the os uteri is dilated by the continuing traction exerted by the retracting upper segment.

60. 7. Dilatation of the Cervix Dilatation of the cervix is a process of enlargement of the external os from a tightly closed aperture to an opening larger enough to allow for passage of the fetal head. Dilatation occurs as a result of uterine action and counter pressure applied by the bag of membranes and the presenting part on the cervix.

61. … Pressure applied evenly to the cervix stimulates the uterine fundus to respond by contracting e.g. a well flexed fetal head closely applied to the cervix favours efficient cervical dilatation. Cervical dilatation is assessed on vaginal examination and is measured in centimeters from 0 to 10.

62. 7. Show When effacement and dilatation of the cervix takes place, the operculum which formed the cervical plug during pregnancy is displaced or lost from the cervical canal and is shade through the vagina as show. The blood comes from rupture of capillaries in the deciduas vera where the chorion has become detached.

63. … The woman sees blood stained mucoid discharge within a few hours after labour starts. Frank bleeding is considered abnormal while red blood may herald the second stage of labour.

64. B. MECHANICAL FACTORS 1. Formation of fore waters As the lower uterine segment stretches, the chorion becomes detached from it and it becomes loose. The intra-uterine pressure causes the loosed part of the sac to bulge downwards into the internal os to the depth of 6-12 mm.

65. .. The well-flexed fetal head fits well into the cervix and cuts off the fluid in front of the head from that which surrounds the body. The fluid in front of the head is called the fore-waters while that which surrounds the rest of the body are called hind waters. The effect of separation of the fore waters prevents the pressure that is applied to the hind waters during uterine contractions from being applied to the fore waters. This helps to keep the membranes intact in the first stage of labour and be a natural defense against ascending infections .

66. .. 2. General fluid pressure This term is used to describe the pressure that is exerted by the uterine contractions on the amniotic fluid during labour. As the pressure is applied, the fluid cannot be compressed ; hence this pressure is equalized throughout the uterus and over the fetal body.

67. … When the membranes rupture and a significant amount of fluid is lost during uterine contractions the placenta and umbilical cord are compressed between the uterine wall and the fetus causing diminished blood supply to the fetus. Intact membranes during labour enhance oxygen supply to the fetus and also to prevent intra-uterine infection if prolonged labour occurred.

68. … 3. Fetal axis pressure This is the force of contraction that is transmitted to the upper pole of the fetus and down the long axis of the fetus and applied to the cervix by the presenting part. This occurs when the uterus rises forward during each contraction and is more significant after the rupture of membranes and during the second stage of labour.

69. MANAGEMENT OF THE 1ST STAGE OF LABOUR ADMISSION OF A CLIENT/PATIENT IN LABOUR Objectives To confirm if the patient is in labour To reassure the patient and allay anxiety To detect any abnormalities and take appropriate action To prepare the woman for delivery

70. History and initial examination and investigations. Prepare a clean and well dump dusted room with all necessary equipment. Greet the woman as she comes into the admission room. Introduce yourself in a friendly and reassuring manner in order to ally anxiety and give her confidence.

71. Quickly assess the general condition of the woman as she comes in by observing her behaviour- gait, facial expressions and appearance. Inquire about the labour and how she is feeling. Ask if she has a support person and whether she wants the support person present during the examination. Explain to the mother and the support person what is going to happen.

72. Review the antenatal card noting: Age to confirm what is indicated on the antenatal card Number of pregnancies Mode of delivery for previous pregnancies; whether normal vaginal delivery, caesarian section and what caused it. problems during last deliveries Current HIV status If RPR and Hb were done and the results Urine analysis for protein and sugar.

73. Check the medical history, anything unusual about the pregnancy and relevant data. (In an unbooked client/patient a full social history, medical/surgical obstetrical history must be taken). Obtain details concerning the present labour. Time and onset of regular uterine contractions. History of any show

74. Any vaginal bleeding observed, if so no vaginal examination. Does she have any danger signs; severe headache, blurred vision, dizziness, fever. If the membranes have ruptured and if so at what time. Colour of the liquor.

75. Check the temperature, pulse and blood pressure and record. Obtain a clean specimen of urine and test especially noting the presence of albumin, sugar or acetone to rule out pre- eclampsia , diabetes mellitus and starvation. Measure the amount and record.

76. Ask the woman to lie on the couch, ask her to remove her pants and adopt the supine position. Cover her with a bed sheet or gown. She should not lie in this position for a long time to prevent supine hypotension.

77. Stand on the woman’s right side; maintain rapport with her by talking to her, at the same time observe carefully her facial expression during the procedure for any indication discomfort. Carry out a head to toe examination taking particular note of such abnormalities as anaemia, oedema, varicose veins, lymphadenopathy , any vaginal discharge or vulva sores.

78. The physical examination will help to find out any problems that might have been missed during antenatal care. Explain the procedure to the mother. Ask her to empty her bladder if not yet done. Next carry out an abdominal examination.

79. ABDOMINAL EXAMINATION Inspection Size of the abdomen in relation to calculated gestational age Shape and contour of the abdomen Any scars or skin changes Uterine contractions, type, frequency and duration Fetal movements and activity

80. Palpation Estimate the height of uterine fundus to confirm the gestational age Fundal palpation for the part lying in the upper pole Lateral palpation for the lie of the fetus Pelvic palpation to assess the presentation and descent of the presenting part in fifths. Auscultation Auscultation of the fetal heart rate noting the rate and rhythm. Record the findings of the abdominal examination.

81. After physical examination, if the mother is in labour, perform a sterile vaginal examination if she is not in labour, then do a quick inspection of the vulva to check on the following: Cleanliness Presence of any sores, chancre or condylomatalata , any warts Vaginal bleeding or abnormal discharge, varicose vein oedema If membranes are ruptured, note the type of liquor- colour, odour, and any meconium .

82. Any scar tissue which may indicate a previous episiotomy, tears or female circumcision. Inform the woman of the findings, if she is not in labour, then a doctor should see her Strict privacy should be maintained at all times If the woman is in labour, then a vaginal examination should be carried out under strict aseptic technique as described below:

83. VAGINAL EXAMINATION DURING LABOUR This is a sterile procedure Indications for vaginal examination To assess the progress or delay in labour To confirm second stage of labour To rule out cord prolapsed when membranes rupture To determine whether the head is engaged in case of doubt To confirm that the woman is labour To make a positive identification of the presentation

84. To determine the state of the membranes, whether ruptured or not To assess progress of labour before giving any analgesia

85. Contraindications for vaginal examination Where there is history of previous vaginal bleeding during pregnancy or where there is present vaginal bleeding. Where membranes have ruptured for more than 24 hours and there is an abnormal discharge. In cord prolapsed as more fidgeting can lead to spasms of the cord resulting in hypoxia and fetal death. NB:If the cord presents, feel for pulsations and put the mother in knee-chest position and refer to the hospital.

86. On vaginal examination not the following: Vulva Presence of blood, cleanliness, oedema, varicose veins, ulcers, warts and scars Vagina Direct the fingers along the anterior wall and note the degree of warmth and moisture and vaginal texture. It should feel warm and moist, not dry (a sign of obstructed labour) soft and distensible.

87. Cervix When the examining reach the end of the vagina, palpate along the furnaces and proximity of the presenting part with two examining fingers, feel the cervix and note the following. Degree of effacement: How much of the cervix has been taken up. Dilatation of the external cervical so :The dilatation is assessed by fingers, each finger is 2 cm. Application of the presenting part to cervix,whether ill or well-fitting.

88. Whether membranes are intact or not, if ruptured feel for the cord. The presentation and feel for the land marks- sagital suture, lambda or bregma , when you go in and find the sagital suture , follow it with your finger until you reach the posterior fontanelle .

89. Assess the location of the occiput in relation to the maternal pelvis. Assess the degree of moulding noting: When the bones of the fetal head are separated and sutures could be easily felt it indicated no molding (recorded as 0).

90. When bones are touching each other or are in apposition (recorded as +) When bones are overlapping but can be separated easily on finger pressure ( recorded as ++) When bones are overlapping and cannot be separated easily on finger pressure ( recorded as +++). This is a problem as the fetal head is under pressure and may lead to injuries of the internal structures of the skull. Assess the adequacy of the pelvis especially

91. Feel for the sacro -promontory , which should not be reached Feel the prominence of the ischial spines and they should be smooth and not prominent Assess the sub pubic arch which should accommodate 2 fingers comfortably/easily Assess the inter tuberous space by removing the examining fingers and make a fist, then place the knuckles between the ischial tuberositie s . It should accommodate 4 knuckles.

92. After removal of the fingers from the vagina assess the degree of discharge- which should be show. Remove gloves after rising them in jik 1:6 and dispose them in the appropriate container Wash hands with soap and dry them Make the patient comfortable

93. Auscultate the fetal heart, record the findings and clear away the equipment. Inform the patient of the findings and discuss her birth plan. If the woman is in the active phase open the partograph .

94. PARTOGRAPH