Management of normal labour Final yr.pptx

For Under and Postgrad Medical students

1. Management of Normal Labor Prof. Dr. Iram Chaudhry FCPS ( Obs & Gynae) MHPE Bahawalpur, Pakistan

2. OUTLINE Definition of Labor Stages of Labor Mechanism of Labor Management of Normal Labor

3. La b o ur It is a physiological process by which the fetus, placenta and membrane s are expelled out through the birth canal after twenty four week of pregnancy Parturition is the process of giving birth

4. Normal labour Normal labour is physiological process by which the fetus ,placenta and membrane are expelled through the birth canal after full term pregnancy (3 7 -42 weeks of gestation)

5. Labour is called normal when it fulfill s the following criteria : Spontaneous onset at term With vertex presentation Without prolongation Natural termination with minimal aids

6. NORMAL LABOUR FIRST STAGE SECOND STAGE THIRD STAGE LATENT PHASE: 0- 6 cm ACTIVE PHASE: 6 -10cm FULL DILATION TO EXPULSION OF FETUS BIRTH TO EXPULSION OF PLACENTA Expectant (physiological) vs Active (CCT + OT)

7. Mechanism of Labor 19 In the normal labor; there are series of changes in position and attitude of the fetus to accommodate himself to the pelvic to pass easily through the birth canal: Engagement Descent Flexion Internal rotation Extension External rotation Expulsion

8. Fetal Station 12

9. 1. Engagement 20 o f the fetal head passes The greatest diameter through the pelvic inlet. 2. Descent Movement of the fetus through the birth canal during the first and second stages of labor 3. Flexion The chin of the fetus moves toward the fetal chest which reduce the fetal head diameter from nearly 12 to 9.5 cm.

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11. 4. Internal rotation The rotation of the fetal head until the longest diameter of the fetal head match the longest diameter of the maternal pelvic. 11

12. 5. Extension The fetal head passes beneath the sy mphysis pubis and passes out of the birth canal making the crowning. 12

13. 6. Restitution & External rotation After the head has del i ver e d, the sh o uld e rs rotate internally to fit the pelvis. 13

14. 7. Expulsion The shoulders and remainder of the body are delivered 14

15. Management of Normal Labor: Birthing should be recognized as a normal physiological process that most women experience without complications Intrapartum complications, often arising quickly and unexpectedly, should be anticipated.

16. 1st Stage of Labour Assessment Preparation and care Partogram  

17. 1- Regular Uterine Contractions 2- Show 3- Leaking

18. HISTORY Woman’s antenatal record is reviewed  Previous births and size of babies. Previous caesarean section. Onset, frequency, duration, strength of contractions. M embranes have ruptured and, if so, colour and amount of amniotic fluid.

19. Presence of abnormal vaginal discharge or bleeding. F etal movements. Medical or obstetric issues of note (e.g. diabetes, hypertension, fetal growth restriction [FGR]). Any special requirements (an interpreter or particular emotional/psychological needs). Maternal expectations of labour and delivery?

20. GENERAL & PHYSICAL EXAMINATION Identify women with a raised BMI Pallor, edema etc. Vital signs: BP, pulse, RR and Heart Lungs

21. Abdominal examination Abdominal examination: Presentation, position and engagement Auscultate fetal heart Evaluate uterine contractions

22. Vaginal examination Presentation Engagement, station Position, attitude and the presence of caput or moulding . P osition can be determined by locating occiput. Membranes Intact or absent: exclude cord prolapse Cx : Consistency, Position Dilatation Effacement Pelvis Adequacy

23. No vaginal examination : I n case of vaginal bleeding ( before placenta previa is excluded) Sterile speculum examination: suspected ROM, if the woman is not in labour .

24. Admission to labour ward: In Active labour : less time in the labor ward less intrapartum oxytocics , less analgesia Investigation: Urine: Protein Sugar ketones Blood: CBC RBS Grouping cross match for high risk patients.

25. Preparation and care Bowel preparation: Indication: No bowel action for 24 h or Rectum loaded Bladder care: Encourage to empty bladder /1½ - A full bladder inhibits fetal head descent and effective uterine action. Nutrition.

26. Position of the woman: Walk about or in bed, As long as the patient is healthy, presentation is normal, presenting part has engaged and fetus in good condition. Pain relief: Opiates. e.g. Pethidine (IM/4 h b) Inhalational analgesia ( Entonox) Epidural analagesia

27. Factors affecting Labor (5 P’s) I n e v e r y l a bo r ; there are fi v e e s s e n t i a l fa ct ors a f f e ct t he process. 5 P’s: Passenger : the fetus Passageway : the pelvis and birth canal Powers : the uterine contractions ph y s i cal Positio n : mate r nal po s tu r es and positions Psyche : the response of the mother 7

28. 1 . Passenger (Th e Fetus ) : T h e fe t us rel a ti o n s h i p to t h e pas s agew a y i s the m a jor factor in the birthing process. The relationship includes: Fetal skull and size Number of fetuses Position of feus Fet a l li e : r e la t i o n s hip o f fetal spine t o ma t e r nal spi n e ; longitudinal (vertical) or transverse (horizontal) Fetal presentation: part of fetus that enters pelvis first Fet a l a t ti t ud e : r e la t ion s h i p o f f e ta l b o d y p a r t s to e a c h o t h e r ; flexion (normal) or extension (abnormal) Fetal position: fetal direction in the pelvis Fetal station: position of the baby's head relative to the lower bone of pelvis called the ischial spines 8

29. MANAGEMENT OF FIRST STAGE OF LABOUR: First stage : I nterval from diagnosis of labour to full dilatation of the cervix. One-to-one midwifery care. Additional emotional support from a birth partner. Obstetric and anaesthetic care . Maternal and fetal wellbeing should be monitored. Vaginal examinations are performed 4 hourly or as clinically indicated. Progress of labour , using a partogram . Appropriate pain relief . A dequate hydration and light diet to prevent ketosis.

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31. Condition of the fetus FHR: every half hour. Intermittent auscultation using a Pinard stethoscope or a Doppler ultrasound. Continuous external electronic fetal monitoring (EFM) using CTG. Membranes & Liquor: On every vaginal examination. Moudling : 0 (separated) + (touching) ++(overlap) +++ (severe overlap) Continuous internal electronic fetal monitoring using a fetal scalp electrode ( FSE) and CTG. Fetal scalp blood sampling (FBS).

32. PROGRESS OF LABOUR Monitoring the progress of labour : A ll events during labour should be recorded on a PARTOGRAM. Well-being of the fetus Well-being of the mother Progress of the labour Patient information: name, gravida, para, hospital number, date and time of admission and time of ruptured membranes.

33. PARTOGRAM A graphic record of labour A n instant visual assessment of the progress of labour based on the rate of cervical dilatation compared with an expected norm, according to the parity of the woman. frequency and strength of contractions D escent of the head in fifths palpable , station, the amount and colour of the amniotic fluid B asic observations of maternal wellbeing ( blood pressure, heart rate and temperature )

34. Second stage of labour : stage of delivery of the fetus. Definition: the second stage refers to the period from complete cervical dilatation to the birth of the fetus. Duration: primigravida = 2 h multigravida = 1 h H owever the duration of second stage is controversial

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36. Management during second stage First sign of the second stage is an urge to push. Full dilatation of the cervix: Confirm by vaginal examination if the head is not visible. Use of regional analgesia (epidural or spinal) may interfere with the normal urge to push and pushing can be delayed for 1 to 2 hours. In all cases the baby should be delivered within 4 hours after full dilatation. Descent and delivery of the head Delivery of the shoulders and rest of the body

37. 34 clamp and cut of the umbilical cord

38. Third stage of labour : The stage of expulsion of placenta and membranes. Duration: up to 30 minutes, average time is 10 minutes

39. Management of third stage Interval between delivery of the baby and the complete expulsion of the placenta and membranes. T akes between 5 and 10 minutes Considered prolonged after 30 minutes SIGNS OF PLACENTAL SEPARATION: Apparent lengthening of the cord. A small gush of blood from the placental bed. Rising of the uterine fundus above the umbilicus Uterus feels firm globular mass on palpation.

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41. Active management of the third stage R ecommended for all women, as it reduces the incidence of PPH from 15% to 5%. Intramuscular injection of 10 IU oxytocin, given immediately after delivery of the baby. D elayed cord clamping between 1 and 3 minutes. Controlled cord traction Uterine massage after the placenta is delivered After completion of the third stage, the placenta should be inspected. The vulva should be inspected for any tears or lacerations.

42. Immediate care of the neonate Head should be kept dependent to drain mucus Oropharyngeal suction: only if really necessary. Calculate Apgar score at 1 minute and 5 minutes after cutting the cord. Immediate skin-to-skin contact between mother and baby The baby should be dried and covered with a warm towel Initiation of breastfeeding: within the first hour of life, N ewborn measurements of head circumference, birthweight and temperature . The first dose of vitamin K. General examination for abnormalities and a wrist label for identification.

43. KEY LEARNING POINTS Features of normal labour : Spontaneous onset at 37–42 weeks’ gestation. Singleton pregnancy. Cephalic vertex presentation. No artificial interventions. Spontaneous vaginal delivery. Cervical dilatation of at least 1 cm every 2 hours in the active phase of first stage. Active second stage no more than 2 hours in primiparous and 1 hour in multiparous. Third stage lasting no more than 30 minutes with active management.

44. Stage of labour Definition Duration Stage I latent phase (affacment) Begins from the onset of regular contractions. Ends with acceleration of cervical dilatation Prepares cervix for dilatation. <20 hours in PG <14 hours MG Stage 1 active phase (dilatation) Begins with acceleration of cervical dilatation. Ends at 10 cm dilatation Rapid cervical dilatation <2/hours in PG <1.5/ hrs in MG Stage 2 ( d e s c e n t ) Begins from 10cm dilatation Ends with delivery of the baby Descent of the fetus <2 hours in PG <1 hours in MG Add 1 hour in epi Stage 3 ( e x p u l s i o n) Begins with delivery of the baby. Ends with delivery of the placenta Delivery of the placenta <30 min.

45. Thank you THANK YOU