MANAGEMENT OF NORMAL LABOUR IN WOMEN IN HOSPITALS

management of labour in women

1. MANAGEMENT OF NORMAL LABOUR Presented by chiamaka nneka nwoke Supervised by Dr nsor Department of obstetrics and gynaecology federal medical centre bida 24 th February,2023. 3/5/2023 1

2. OUTLINES INTRODUCTION DEFINITION STAGES OF LABOUR MATERNAL BONY PELVIS AND FETAL SKULL PHYSIOLOGY OF LABOUR MECHANISM OF LABOUR MANAGEMENT OF DIFFERENT STAGES OF LABOUR SUMMARY REFERENCES 3/5/2023 2

3. INTRODUCTION Labour is the physiological process that results in the birth of neonate, delivery of the placenta and a signal for lactation to begin. An understanding of the physiological and anatomical principles involved in labour is best summarized using ‘3 Ps’ which are powers, the passages and the passenger. The powers refers to the forces, firstly the uterine contractions that result in the passage of the foetus through the birth canal and secondly the maternal effort of pushing, the passage refers to the birth canal itself made up of bony pelvis, muscles of the pelvic floor and soft tissues of the perineum. The passenger refers to the foetus in terms of size, presentation and Position. 3/5/2023 3

4. DEFINITION Labour is defined as the onset of painful, palpable regular uterine contractions of progressively increasing frequency and intensity associated with progressively increasing cervical effacement and cervical os dilatation and descent of the presenting part leading to the delivery of the foetus and placenta per vagina with minimal risk to both mother and baby. Normal labour is retrospective diagnosis made after a woman in labour has delivered. it entails a spontaneous onset of labour with low risk at start and remining so resulting in the delivery of single vertex neonate born between 37 to 42 completed weeks of gestational age. 3/5/2023 4

5. STAGES OF LABOUR Labour can be divided into 3 stages First stage This is the time from diagnosis of labour to full dilatation of the cervix. It is divided into 2 phases, latent phase and active phase. The latent phase. This is the phase in which the cervix is progressively effaced and cervical os dilated from 0 to 5cm. it lasts a maximum duration of 8 hours ACTIVE PHASE This is the period from cervical dilatation of 5cm to full dilation of 10cm. It lasts for a maximum period of 12hours. 3/5/2023 5

6. STAGES OF LABOUR CONTINUED SECOND STAGE This is the stage from full cervical os dilatation to of 10cm to the delivery of the baby. it’s duration is usually 1 hour, It is composed of 2 phases. The passive phase which is the time from full cervical os dilatation till the time the leading part of the foetus on the pelvic floor. It is usually associated with strong uterine contractions and decent of the presenting part. The active phase of the 2 nd stage is associated with strong maternal urge to push because the foetal head is low causing a reflex need to ‘bear down’ 3/5/2023 6

7. STAGES OF LABOUR CONTINUED 3 RD STAGE This is the time from delivery of the foetus to complete delivery of the placenta and membranes. The hallmark is strong uterine contractions, easy separation and expulsion of the placenta. The normal duration of 3 rd stage is usually about 5 -10minutes. If longer than 30 minutes, its prolonged 3/5/2023 7

8. BRIEF DESCRIPTION OF THE BONY MATERNAL PELVIS The pelvic inlet or brim bounded anteriorly by upper border of the pubic symphysis, laterally by the upper margin of the pubic bone, the iliopectineal line and the ala of the sacrum. It has an ovoid shape and a wider transverse diameter of 13.5cm and anterior posterior diameter of 11.0cm 3/5/2023 8

9. 3/5/2023 9

10. The midpelvis or midcavity that is the area bounded anteriorly by the middle of the symphysis pubis, the obturator fascia and inner aspect od the ischial bone and spines and posteriorly by the 2 nd and 3 rd sections of the sacrum. It is almost round in shape with diameters of 12cm in both transverse and anterior posterior diameters. The pelvic outlet: this is the area bounded anteriorly by the lower border of the symphysis pubis, laterally by the descending ramus of the pubic bone, the ischial tuberosity and posteriorly by the last piece of the sacrum. The anteroposterior diameter of the pelvic outlet is 13.5cm and the transverse diameter is 11cm 3/5/2023 10

11. 3/5/2023 11

12. At the time of labour, the sutures joining the bones of the foetal vault are soft and unossified. This allows the bones to move together and even overlap in a process called moulding which reduces the diameter of the foetal head and encourages progress through the bony pelvis. In normal labour, the vertex of the of the foetal head is the presenting part and the posterior fontanelle which is triangular in shape is usually felt during a Vaginal examination and used to define the position of the foetal head in relation to the pubic symphysis 3/5/2023 12

13. The foetal head is ovoid in shape. The attitude of the foetal head refers to the degree of flexion and extension at the upper cervical spine. The longitudinal diameter that presents with a flexed attitude of the foetal head in occipital-anterior position is the suboccipito-bregmatic diameter and is usually 9.5cm The longitudinal diameter that presents in a less well flexed head in an occipito-posterior position, is the suboccipito-frontal diameter and is 10cm With further extension of the head, the occipito-frontal diameter presents (deflexed OP) and is 11.5cm The greatest diameter that may present is the is the mento-vertical diameter also known as the brow presentation and is 13cm . 3/5/2023 13

14. PHYSIOLOGY OF LABOUR The process that initiates labour is poorly understood. There are number of important elements HORMONAL FACTORS Progesterone maintains uterine relaxation by suppressing prostaglandin production, inhibiting communication between myometrial cells and preventing oxytocin release. Oestrogen opposes this action of progesterone Prior to labour, there is reduction in progesterone receptors and an increase in the concentration of oestrogen Prostaglandin synthesis by the chorion and decidua is enhanced leading to calcium influx into the myometrial cells 3/5/2023 14

15. PHYSIOLOGY CONTINUED There is increased gap junction formation between individual myometrial cells, creating a functional syncytium which is necessary for coordinated uterine activity The production of corticotropin releasing hormone by the placenta increases in concentration towards term and potentiates the action of prostaglandin and oxytocin on myometrial cells Also the foetal pituitary secretes oxytocin and the foetal adrenal gland produce cortisol which stimulates the conversion of progesterone to oestrogen However it is unclear which of these hormonal changes initiate labour 3/5/2023 15

16. PHYSIOLOGY OF LABOUR CONTINUED CERVIX The cervix initially long, firm and closed, with protective plug must soften, shorten, thin out and dilatate for labour to progress The cervix contains myocytes and fibroblast, interaction between collagen, fibronectin and dermatan sulphate ( a proteoglycan) keep the cervix firm and closed during earlier stages of pregnancy At term, the proteoglycan is replaced by the more hydrophilic hyaluronic acid which results in an increase in water content of the cervix. This causes cervical ripening or softening. 3/5/2023 16

17. PHYSIOLOGY OF LABOUR CONTINUED UTERUS The uterus changes from a state of relaxation to active state of regular, strong and frequent contraction to facilitate transit of foetus through the birth canal. Each contraction must be followed by a resting phase in order to maintain placental blood flow and adequate perfusion of the foetus. Myometrial cells of the uterus contain filaments of actin and myosin which interact and bring about contraction in response to an increase in intracellular calcium. Prostaglandins and oxytocin increase intracellular free calcium ions 3/5/2023 17

18. PHYSIOLOGY OF LABOUR CONTINUED Actin and myosin interaction occurs along the full length of the filament so a degree of shortening occurs with each successive interaction This progressive shortening is called retraction and it occurs in cells of the upper part uterus This results in development of a thicker actively contracting upper segment At the same time, the lower segment becomes thinner and more stretched This results in the cervix being ‘taken up’(effacement) and dilatation 3/5/2023 18

19. MECHANISM OF LABOUR This refers to the series of changes in position and attitude that the foetus undergoes as it passes through the birth canal . It consists of the following process ENGAGEMENT The foetal head enters the pelvis oriented in a transverse diameter in keeping with the wider transverse diameter of the pelvic inlet. Engagement is said to have occurred when the widest part of the presenting part has successfully through the pelvic inlet DESCENT This is continuous movement throughout the process of delivery. During the 1 st stage and passive phase of 2 nd stage, it occurs as a result of uterine contractions. In the active phase of the 2 nd stage, descent of the foetus is assisted by voluntary pushing efforts of the mother. 3/5/2023 19

20. MECHNISM OF LABOUR CONTINUED FLEXION The foetal head may not be completely flexed when it enters into the pelvic cavity, but once in the midpelvis, the rigid pelvic floor muscles force the chin contact with the foetal thorax. This in reduces the presenting diameter of the foetal head INTERNAL ROTATION As the head is flexed in its descent into the pelvic gutters, with the chin being brough into close contact with thorax, so also it has to rotate from the lateral plane it came into the pelvis into the anterior posterior direction which has a wider diameter in the pelvic outlet. 3/5/2023 20

21. MECHANISM OF LABOUR CONTINUED EXTENSION Following the internal rotation and with further descent, the sharply, flexed head descend into the vulva. With further push and descent, the head extends because the pubic rami act as a pivot and the head begins to crown and the delivery of the head occurs with the occiput often directly anterior RESTITUTION When the head is delivering, the occiput is directly anterior. As soon as it crosses the perineum, the foetal head realigns itself back to the direction of the shoulders by rotating to the oblique plane of the shoulders through one eight of the circle. which is in an anteroposterior plane in the pelvic outlet 3/5/2023 21

22. MECHANISM OF LABOUR CONTINUED EXTERNAL ROTATION Following the restitution of the foetal head, the foetal head rotates through a further one eighth of a circle into the transverse position DELIVERY OF THE SHOULDERS AND FETAL BODY When restitution and external rotation have occurred, the shoulders will be in an Anterior posterior position. The anterior shoulder is under the pubic symphysis and delivers first and the posterior shoulder delivers subsequently. The foetal body aided by lateral movement is then easily delivered. 3/5/2023 22

23. 3/5/2023 23

24. MANAGEMENT MANAGEMENT OF LATENT PHASE Take a detailed history about the patient, BIODATA, LMP, EDD, EGA, presenting complaint, duration, any drainage of liquor, passage of bloody mucous or vaginal bleeding, foetal movement, past obstetric history, index pregnancy, Do a general examination; check for pallor, dehydration,, patients height and weight Abdominal examination; inspection for presence of scars, Linea nigra and striae gravidarum, measure the symphysiofundal height, then ascertain the lie and presenting part for this case it is longitudinal lie and cephalic presentation, position and degree of engagement. 3/5/2023 24

25. MANAGEMENT CONTINUED Vaginal examination; obtain verbal consent and explain what you want to do and why to the patient. If she concedes, you screen properly and ask her to lie on her back, and flex her knees. You examine the cervix for dilatation, effacement, position, consistency and station. The condition of the membranes should be noted, if ruptured the colour Educate the woman about her diagnosis and the intension to watch till active phase occurs. Set an intravenous access using a wide bore canula 3/5/2023 25

26. MANAGEMENT CONTINUED encourage to move about or stay in bed as she wishes Do PCV test, Urinalysis, group and crossmatch 1 unit of blood Encourage her to empty her bladder allow fluids and light food Give pain relief Monitor fetomaternal vital signs hourly or 2 hourly as deemed fit Repeat vaginal examination after 4 hours to assess cervical effacement and dilatation 3/5/2023 26

27. MANAGEMENT CONTINUED MANAGEMENT OF ACTIVE PHASE A vaginal examination confirms the diagnosis of active phase of labour, inform and reassure the woman that she is now in the active phase of labour Open a partograph and record the patient’s information, foetus (FHR, state of the membranes, Moulding) about the labour( contractions, cervical os dilatation, head descent. The woman may be encouraged to walk around the labour ward if she is in early active phase Adequate pain relief using narcotics such as IM pethidine 100mg, it can be given with antiemetics to counter the side effect of nausea and vomiting 3/5/2023 27

28. MANAGEMENT CONTINUED Adequate hydration with 5% DW 500mls every 4 hours. This will maintain adequate fluid and calorie balance as oral feeding is not allowed Monitor the contraction and ensure it’s adequate that is a maximum of 3 contractions lasting for more than 40seconds in 10minutes Monitor the foetal heart rate every 15 minutes using the pinnard fetoscope preferably at the end of each contraction Monitor the patient’s blood pressure every 30minutes, Repeat urinalysis each time the patient voids urine 3/5/2023 28

29. MANAGEMENT CONTINUED MANAGEMENT OF 2 ND STAGE OF LABOUR Once the diagnosis is made, you inform your patient about the diagnosis, reassure her and provide emotional support Put on personal protective equipment, assemble your necessary equipment wash your hands thoroughly and put on put on your sterile gloves and drape your patient. Swab the vulva area with antiseptic solutions Ask patient to bear down with contraction control the delivery of the head with the fingers of one hand to maintain flexion and use the other hand to guard the perineum. 3/5/2023 29

30. Give episiotomy if required Once the head is delivered, ask the woman not to push, clean the face and suction the baby's nose with and mouth Feel around the baby’s neck for cord, if any try to slip it over the head, if its too tight, you can gently double clamp and cut 3/5/2023 30

31. MANAGMENT CONTINUED Allow restitution to take place With both hands on either side of the baby’s head, deliver the anterior shoulder by a gentle downward traction of the head Then lift the head upward to deliver the posterior shoulders by upward traction Support the rest of the baby’s body as it slides out and place the baby on the mothers abdomen Clamp and cut the umbilical cord 3/5/2023 31

32. MANAGEMENT CONTINUED Management of the 3 rd stage Separation of the placenta occurs due to reduction of uterine volume following delivery of the baby. This leads to shearing off placenta from the decidua basalis layer. Subsequent contraction and retraction pushes the placenta into lower uterine segment. Signs of placenta separation Lengthening of the umbilical cord Gush of blood from the placenta bed Rise of the uterine fundus above the umbilicus Uterus assuming a more globular shape and becoming hardened 3/5/2023 32

33. MANAGEMNT CONTINUED Traditionally, we wait for signs of separation then expel by pressing down on the fundus. But this is associated with primary post partum haemorrhage. The modern management is active management of the 3 rd stage of labour which entails Administration of an oxytocic immediately after the delivery of the baby. Oxytocic used include IM Ergometrine 0.5mg ( peak action time is 2 mins, or IM syntometrine (a mixture of 0.5mg of ergometrine and 5IU of oxytocin) peak action time is 3 mins or IM 10 IU oxytocin. Early clamping and cutting of the umbilical cord without awaiting cessation of cord pulsation Controlled cord traction by putting traction on the cord and counter traction on the suprapubic region of the abdomen 3/5/2023 33

34. MANAGEMENT CONTINUED Examine the placenta and membranes for completeness Examine the genital tract and perineum for lacerations/tears, if any repair. Clean up the patient and apply a perineal pad Fourth Stage This is a stage of observation for at least 1 hour after delivery. During this phase, you monitor the general condition of the patient closely( for bleeding, uterine contractions and bleeding. You monitor for 5 minutes, every 15 mins. 3/5/2023 34

35. SUMMARY A woman in labour usually presents with complain of lower abdominal pain, drainage of liquor or passage of bloody mucoid . A detailed History and thorough examination will a correct diagnosis of labour Monitoring of fetomaternal vital signs and proper management will result in a positive outcome 3/5/2023 35

36. THANK YOU FOR LISTENING. 3/5/2023 36

37. REFERENCES TEXT BOOK OF OBSTERICS AND GYNEACOLOGY BY AKIN AGBOOLA OBSTETRICS BY TEN TEACHERS MEDSCAPE 3/5/2023 37