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How to manage it

1. Normal labour 1

2. NORMAL LABOUR Labour is defined as the onset of painful, regular uterine contractions with progressive cervical dilatation accompanied by descent of presenting part. Physiological process during which the products of conceptus are expelled from the uterus 2

3. COMPONENTS OF NORMAL LABOUR Powers Passage Passenger 3

4. passage-the female pelvis 4

5. Pelvic inlet 13cm 11cm Mid cavity 12cm 12cm Pelvic outlet 11cm 13cm 5 transverse Anterior- Posterior diameter

6. DIAMETERS OF THE PELVIC INLET ANTEROPOSTERIOR DIAMETERS Anatomical conjugate 11cm - From the tip of sacral promontary to upper border of S.P. Obstetric conjugate 10,5 cm - From the tip of promontary to the most bulging point of the back S.P. Diagonal conjugate 12,5 cm - From the tip of promontary to lower border of S.P. 6

7. Diameters of the pelvic inlet Transverse diameter - Between the widest points of the pelvic brim 13 cm. Oblique diameters 12cm -From sacroiliac joint of one side to the iliopectinal eminence of the opposite side 7

8. III PELVIC OUTLET Diameters of pelvic outlet. -Anteroposterior diameters -Anatomical 11cm -Obstetric 13 cm Transverse diameters Between ischial tuberosities 11 cm 8

9. THE PASSENGER 9

10. THE FETAL SKULL Sutures: Saggital suture -----  separates parietal bones Frontal suture------- separates frontal bones. Coronal suture------ separates frontal & parietal bones. Lambdoid suture--- separates parietal & occipital bones Fontanelles Anterior fontanelle( Bregma) : Meeting of frontal,coronal& saggital sutures Posterior fontanelle: Meeting of saggital & lambdoid sutures 10

11. 1. Moulding It is over riding of the bones of the vault over each other to allow some reduction of the diameters. First degree : Approximation of skull bones Second degree : Overriding of bones but reducible Third degree: Irreducible overriding of skull bones, sign of obstructed labour and may lead to intracranial hemorrhage 11

12. DIAMETERS OF THE FETAL SKULL SUBOCCIPITO-Bregmatic 9.5 cm From posterior junction of head& neck to center of anterior fontanelle. Frontal 10cm From posterior junction of head, neck to anterior end of bregma- Occipital-frontal 11,5 cm From occiput to root of the nose- Mento vertical 13,5 cm tip of chin to furthest point on sagittal suture 12

13. The power The uterine contractions True uterine contractions are characterized by being: - Involuntary Intermittent ,Increase in frequency & duration as labour advances. Associated with Fore water bulging Effective contractions are : 3-5/10min in frequency 40-60 sec in duration 13

14. Stages of labour First stage Onset from true labour pain End :full cervical dilatation Duration : Prim gravida 12-16hrs Multigravida 6-8 hrs. Second stage Onset : Full cervical dilatation End : Delivery of the fetus Duration : Prim gravida 1hour Multigravida 30 min Third stage Onset : delivery of the fetus End: delivery of placenta Duration: < 30 min. 14

15. Diagnosis of the onset of labour Symptoms: True labour pain (backache) Passage of show : passage of cervical mucous plug as the cervix dilates Signs: Dilatation& Effacement of the cervix Formation of bag of fore water 15

16. Mechanism of normal labour First stage of labour Uterine contractions Cervical dilatation : It is due to uterine contractions & retractions. Fetal pressure and also pressure of the bag of fore water Cervical effacement : It is progressive taking up of the cervix and its incorporation into lower uterine segment It is detected clinically by the progressive thinning of the cervix. 16

17. 17 FMJ- Fibromascular junction

18. Cervical effacement 18

19. Second stage of labour Diagnosis of onset of the second stage of labour: Symptoms: Involuntary bearing down, desire of defecate Signs: Perineal bulge. Full cervical dilatation 10 cm delivery of the baby 19

20. Mechanism of labour Descent - It is constant movement throughout delivery Engagement - Passage of the widest diameters of Presenting Part below pelvic inlet Diagnosis of engagement : 2/5 head palpable abdominally Vaginally- Head station at zero. . 20

21. Mechanism of labour flexion- is due to resistance from the bony pelvis and the pelvic floor soft tissues as the head descends Internal rotation Aim to bring the longest diameter of Presenting Part to the longest diameter of the pelvic outlet The occiput meets the pelvic floor then rotates to lie behind S.P. 21

22. Mechanism of labour Extension It is movement of which the fetal head is expelled outside of vulva. Mechanism: The suboccipital region hings under S.P. then head extends to be delivered. Restitution Occiput rotates 1/8 of a circle in direction opposite to that of internal rotation 22

23. External rotation It is rotation of the head after its delivery Secondary to internal rotation of shoulders Delivery of shoulders : The biacromial diameter enters the opposite obligue diameter to that of the head.Then anterior shoulder meets the pelvic floor first rotates 1/8 of circle,with further descent its hinges below SP 23

24. Placental separation SCHULTZ 80% DUNCAN 20% Separation Centrally Lower pole Presents By fetal surface By lower pole Bleeding Less More Retained parts Less risk More risk 24

25. Maternal surface of placenta 25

26. Third stage of labour Placenta descent to lower uterine segment Signs of placental separation: 1. Gush of dark blood 2. Apparent cord elongation 3. Suprapubic bulge 4. Fundus rises,becomes firm 27

27. Active management of labour (AMTSL) IM oxytocin 10IU with one minute of delivery of baby Support suprapubic area with one hand Controlled cord traction Massage of uterus Inspection for tears Reduces PPH by 60% Caution of ergometrin in Cardiac disease, hypertension 28

28. Fetal surface of placenta 26

29. End Any questions? 29