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Management of normal labour Final yr.pptx

Medical Doctor at QAMC à QAMC
29 Mar 2023
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Management of normal labour Final yr.pptx

  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. Labour • It is a physiological process by which the fetus, placenta and membranes are expelled out through the birth canal after twenty four week of pregnancy • Parturition isthe process of givingbirth
  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 (37-42 weeks ofgestation)
  5. • Labour is called normal when it fulfills 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: 0-6cm 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: 1. Engagement 2. Descent 3. Flexion 4. Internal rotation 5. Extension 6. External rotation 7. Expulsion
  8. Fetal Station 12
  9. 1. Engagement 20 of 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 symphysis pubis and passes out of the birth canal making the crowning. 12
  13. 6. Restitution & External rotation After the head has delivered, the shoulders 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 I. Assessment II. Preparation and care III. 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. Membranes have ruptured and, if so, colour and amount of amniotic fluid.
  19.  Presence of abnormal vaginal discharge or bleeding. Fetal movements. Medical or obstetric issues of note (e.g. diabetes, hypertension, fetal growth restriction [FGR]). Anyspecial 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. Position can be determined by locating occiput. Membranes Intact or absent: exclude cord prolapse Cx: Consistency, Position Dilatation Effacement Pelvis Adequacy
  23. • No vaginal examination: • In 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
  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) In every labor; there are five essential factors affect the process. 5 P’s: 1. Passenger: the fetus 2. Passageway: the pelvis and birth canal 3. Powers: the uterine contractions physical 4. Position: maternal postures and positions 5. Psyche: the response of the mother 7
  28. 1.Passenger (The Fetus): The fetus relationship to the passageway is the major factor in the birthing process. The relationship includes: • Fetal skull and size • Number of fetuses • Position of feus – Fetal lie: relationship of fetal spine to maternal spine; longitudinal (vertical) or transverse (horizontal) – Fetal presentation: part of fetus that enters pelvis first – Fetal attitude: relationship of fetal body parts to each other; 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: Interval from diagnosis of labour to full dilatationof 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.  Adequate 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 : All events during labour should be recorded on a PARTOGRAM. a) Well-being of the fetus b) Well-being of the mother c) Progress of the labour d) Patient information: name, gravida, para, hospital number, date and time of admission and time of ruptured membranes.
  33. PARTOGRAM • A graphic record of labour • An instant visual assessment of theprogress of labour based on the rate of cervical dilatation compared with an expected norm, according to the parity of the woman. • frequency and strengthof contractions • Descent of the head in fifths palpable, station, the amountand colour of the amniotic fluid • Basic observations of maternal wellbeing (blood pressure, heart rate and temperature)
  34. Secondstage of labour: stage of delivery of the fetus. Definition: the second stage refers to the period from complete cervical dilatation to the birth of thefetus. Duration: primigravida =2h multigravida =1h However the duration of second stage is controversial
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  36. Management during second stage First sign of the second stage is anurge 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: upto30minutes,averagetimeis10 minutes
  39. Management of third stage Interval between delivery of the baby and the complete expulsion of the placenta and membranes. Takes 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 • Recommended 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. • Delayed 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, • Newborn 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 firststage.  Active second stage no more than 2 hours in primiparous and 1 hour inmultiparous.  Third stage lasting no more than 30 minutes with active management.
  44. Stage of labour Definition Duration StageI latent phase (affacment) •Beginsfrom the onset of regularcontractions. •Endswith acceleration of cervicaldilatation •Prepares cervix for dilatation. <20hours in PG <14hours MG Stage1 active phase (dilatation) •Beginswith acceleration of cervicaldilatation. •Endsat 10 cmdilatation •Rapid cervical dilatation <2/hours in PG <1.5/ hrs inMG Stage2 (descent) •Beginsfrom 10cmdilatation •Endswith delivery of thebaby •Descent of the fetus <2hours in PG <1hours in MG Add 1 hour inepi Stage3 (expulsion) •Beginswith delivery of thebaby. •Endswith delivery of theplacenta •Delivery of the placenta <30min.
  45. Thank you THANK YOU
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