active management of labour

mx of labour

1. Management Of 1 st ,2 nd &3 rd Stages Of Labour

2. Definition Labour : Regular involuntary coordinated, painful uterine contractions associated with cervical effacement and dilatation • Regular frequent uterine contractions •cervical changes (dilatation & effacement ) ,or • SROM Delivery : Expulsion of the product of the conception after fetal viability.

3. MECHANISMS OF NORMAL LABOUR

4. MECHANISMS OF NORMAL LABOUR The following criteria should be present to call it normal labour Spontaneous expulsion, of a single, mature fetus (37 completed weeks – 42 weeks), presented by vertex, through the birth canal (i.e. vaginal delivery), within a reasonable time (not less than 3 hours or more than 18 hours), without complications to the mother, or the fetus

5. What are the stages of labour? The first stage: begins when start having contractions that cause progressive changes in the cervix and ends when the cervix is fully dilated. This stage is divided into two phases: Latent phase (~8H): Point at which woman perceives regular uterine contractions until 4cm dilatation. Prolonged if >20H in a nulliparous; >16H if multipara. Active phase (~8H nullipara , 6H multipara): 4cm dilatation to fully dilated and regular contractions. Rate of dilatation should be >1cm per hour if nulliparous; >1.5cm per hour if multipara.

6. The second stage of labor begins when the cervix is fully dilated and ends with the birth of the baby. This is sometimes referred to as the "pushing" stage. The third stage: begins right after the birth of the baby and ends with the delivery of the placenta. This is the shortest stage, lasting up to 30 minutes, with an average length of 5 to 10 minutes. There is no difference in duration for nulliparous and parous .

7. Stages Of Labour

8. Aims in the management of labour To achieve delivery of a normal healthy child To anticipate, recognize and treat potential abnormal conditions before significant hazard develops for the mother or the fetus.

9. MANAGEMENT Of 1st STAGE OF LABOUR Assessment Preparation and care Partogram

10. I. Assessment 1. History: 1. Woman’s antenatal record is reviewed 2. No records of antenatal care: complete history . 2. Examination General Pallor , edema, abdominal scar Vital signs: BP, pulse, RR and Temp. Abdominal examination: a. Presentation and position and engagement b. Auscultate the fetal heart c. Evaluate the uterine contraction

11. Vaginal examination Presentation, Engagement, Position Membranes: Intact or absent: exclude cord prolapse after ROM Cervix: Consistency, position Dilatation Effacement, A ssess the adequacy of the pelvis. 3. Investigation Urine: Protein, Sugar, ketones Blood: CBC ,RBS, Grouping ,cross match for high risk patients.

12. II. Preparation and care 1. Bowel preparation: Indicated when there is No bowel action for 24 h or Rectum feels loaded on vaginal examination . 2. Bladder care: Encourage to empty bladder1½ - 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

13. 4.Position of labouring mother: As long as the patient is healthy, the presentation normal, the presenting part engaged, and the fetus in good condition, the patient may walk about or may be in bed, as she wishes. 5 . Pain relief : for Severe pain : Opiate drugs: e.g. Pethidine IM/4 h Inhalational analgesia: e.g. Entonox Epidural analagesia . III. Monitoring the progress of labour : Once labour has become established, all events during labour should be recorded on a partogram . a) fetal Well-being. b) maternal Well-being. c) Progress of the labour .

14. Partogram:

15. MONITORING FETAL HEART

16. How To Monitor The Fetal Heart Rate?    Auscultation methods Electronic monitoring ~ CTG } === To detect fetal hypoxia

17. Progress of labour I. Cervical dilatation (cm).every vaginal examination. Causes of cervical dilatation: Contraction and retraction of uterine musculature. Mechanical pressure by the bulging membrane . The descend of the presenting part. Phases of cervical dilatation Latent phase – the first 3 cm of dilatation; a slow process (8 hours in nulliparous and 3 hours in multiparous Active phase – this is active process of cervical dilatation; the normal rate is 1 cm/hour II. Descend : every vaginal examination (amount of head palpable above pelvic brim).

18. III. Contractions: 1: Regular 2 : Increasing in frequency 3 : Stronger

19. MANAGEMENT 2nd STAGE OF LABOUR I. Preparation II.Observation III.Conduct of delivery

20. 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.

21. PERINEAL CLEANSING Need 6 swab balls Clean sequentially as shown by the numbers Clean according to the direction shown by the Arrows

22. 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

23. III. CONDUCTING THE DELIVERY 1. DELIVERY OF THE HEAD Control the delivery of the head to prevent laceration that occur when the head born suddenly,& the head must be flexed until the largest diameter has passed vulval outlet. Once the head has crowned , the women should be discouraged from bearing down by telling her to take shallow breaths. The head now delivered by pressure through perineum on to the forehead , the fingers & thumb placed on each side of the anus , pushing the head forward slowly before it is allowed to extend and complete its delivery, & control the rate of escape with the other hand.

24. 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

25. •Instruct the mother to focus on her breathing. Have her “breathe heavily” to help her stop pushing and prevent a forceful birth.

26. Once the baby’s head delivers, ask the woman not to push Suction the baby’s mouth and nose

27. 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

28. As the head emerges, the baby will turn to one side (for easier passage of shoulders through birth canal) Note the time, if possible

29. 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

30. DELIVERY OF FETAL HEAD WITH ROL POSITION

31. 2. Delivery of the anterior shoulder by gentle downward traction on the head. In the direction of the axis of the body

32. 3. DELIVERY OF POSTERIOR SHOULDER by elevating the head. Support the rest of the baby’s body with one hand as it slides out

33. Delivery Of Shoulders

34. 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.

35. 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.

36. Clamping, cutting and tying Of umbilical cord

37. EPISIOTOMY Surgical incision into the perineum to enlarge the diameter of vulval outlet & assist childbirth. Benefits : 1.Speed up the birth 2.Prevent Tearing 3.Protects against incontinence 4.Protects against pelvic floor relaxation 5.Heals easier than tears

38. No decrease of : perineal damage future vaginal prolapse urinary incontinence Increase: 3rd & 4th degree tears anal sphincter muscle dysfunction.

39. Indications : 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. 7.Prevent perineal tear or excessive stretching of muscles ,tear may involve anal sphincter and stretching may lead to prolapse in later years 8.Prevent damage from abnormal presenting part e.g face presentation .

40. Complication s 1.haemorrhage 2.infection 3.dyspareunia 4.extension to anal sphincter(third ,fourth degree tears)

41.  Types Mediolateral rather than midline (less 3rd and 4th degree perennial tear).

42. 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.

43. MANAGEMENT 3nd STAGE OF LABOUR I. Delivery of placenta II. Examination of placenta & perineum III. Repair of episiotomy

44. 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 SEPARATION : 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)

45. SIGNS OF PLACENTAL SEPARATION 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 clinically.

46. ACTIVE MANAGEMENT OF THE THIRD STAGE Helps prevent postpartum haemorrhage . includes: 1. use of oxytocin 2. controlled cord traction, 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.

47. 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.