Normal labour presentation by UM


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Normal labour presentation by UM

  1. 1. Iskandar dzulkarnain Nurul syuhadah
  2. 2. <ul><li>LABOUR </li></ul><ul><ul><li>Event that take place in the uterus and birth canal to expel the viable fetus through the vagina. </li></ul></ul><ul><ul><li>The onset is painful, regular contractions, more than one every ten minutes </li></ul></ul><ul><ul><li>with progressive cervical effacement and dilatation </li></ul></ul><ul><ul><li>accompanied by descent of the head of fetus . </li></ul></ul><ul><li>DELIVERY </li></ul><ul><ul><li>T he expulsion of a viable fetus out of the uterus . </li></ul></ul><ul><li>NORMAL LABOUR (EUTOCIA) </li></ul><ul><ul><li>Labour is consider normal when mature fetus presenting by vertex </li></ul></ul><ul><ul><li>delivers by natural efforts </li></ul></ul><ul><ul><li>without prolongation of labour. </li></ul></ul><ul><li>DYSTOCIA </li></ul><ul><ul><li>A difficult labour, which refers to a labour not progressing satisfactorily with possible undue consequences to mother and fetus. </li></ul></ul>
  3. 3. Primary force – actions of the uterine muscles Secondary force – involuntary contraction of muscles of diaphragm and anterior abdominal wall (bearing down effort) Formed by the soft tissues covering the bony pelvis through which the fetus is expelled during labour *pelvic inlet *pelvic cavity *pelvic outlet POWER PASSAGE PASSENGER <ul><li>Refers to fetal </li></ul><ul><ul><li>Attitude </li></ul></ul><ul><ul><li>Lie </li></ul></ul><ul><ul><li>Presentation </li></ul></ul><ul><ul><li>Denominator </li></ul></ul><ul><ul><li>Position </li></ul></ul>
  4. 4. <ul><li>Onset </li></ul><ul><li>regular contraction bringing about progressive cervical changes </li></ul><ul><li>Duration </li></ul><ul><li><12hrs – nulliparous </li></ul><ul><li><8hrs – multiparous </li></ul>
  5. 5. <ul><li>1 st stage </li></ul><ul><li>from onset of labour to full dilatation of cervix (10cm) </li></ul><ul><li>Latent Phase </li></ul><ul><li>from onset to dilatation (3-4cm) </li></ul><ul><li>cervix fully effaced </li></ul><ul><li>3-8hrs </li></ul><ul><li>Active Phase </li></ul><ul><li>end of LP </li></ul><ul><li>full dilatation (10cm) </li></ul><ul><li>2-6hrs </li></ul><ul><li>cervix dilates 1cm/hr </li></ul><ul><li>2 nd Stage </li></ul><ul><li>from full dilatation of cervix (10cm) to delivery of fetus </li></ul><ul><li>Passive Phase </li></ul><ul><li>no maternal urge to push </li></ul><ul><li>fetal head is still high in the pelvis </li></ul><ul><li>sagittal suture in transverse diameter </li></ul><ul><li>Active Phase </li></ul><ul><li>should not last </li></ul><ul><li>- 2hrs in nulliparous </li></ul><ul><li>- 1hr in multiparous </li></ul><ul><li>3 rd stage </li></ul><ul><li>from delivery of fetus to delivery of placenta </li></ul><ul><li>more than 30min is considered prolonged </li></ul>
  6. 6. <ul><li>Lightening </li></ul><ul><ul><li>as the baby settles into lower uterine segment, causing lowering of the fundal height; a sense of relief for the mother. </li></ul></ul><ul><li>Increased vaginal secretion. </li></ul><ul><li>Cervix become soft and effaced. </li></ul><ul><li>False labour pain occur with variable frequency. </li></ul>
  7. 7. <ul><li>There are 2 phase: </li></ul><ul><li>Latent Phase: time between the onset of the labour and 3-4cm dilatation. Lasted between 3-8 hours(lesser in multiparous) </li></ul><ul><ul><li>Uterine contractions </li></ul></ul><ul><ul><ul><li>Regular in frequency. </li></ul></ul></ul><ul><ul><ul><li>4-5 in 10 min, each contraction may last 40-45s. </li></ul></ul></ul><ul><ul><li>Show (blood stained mucus discharge) </li></ul></ul><ul><ul><ul><li>Evidence of start of effacement and dilatation . </li></ul></ul></ul><ul><ul><li>E ffacement of cervix (thinning of cervix: 2.5cm-paperly thin) </li></ul></ul><ul><ul><li>Dilatation of cervix </li></ul></ul><ul><li>Active Phase : time between the end of latent phase(3-4cm dilate) until full dilatation(10cm) </li></ul>
  8. 9. <ul><li>There are 2 phases: </li></ul><ul><li>Passive phase - no maternal urge to push and the fetal head is still relatively high in the pelvis </li></ul><ul><li>Active second stage </li></ul><ul><li>Accomplished by downward thrust offered by </li></ul><ul><ul><ul><li>↑ uterine contractions </li></ul></ul></ul><ul><ul><ul><li>voluntary contraction of abdominal muscles </li></ul></ul></ul><ul><li>Bearing down efforts </li></ul><ul><ul><ul><li>Breath hold; strain down as in defecation desire </li></ul></ul></ul><ul><li>Descent of the head. </li></ul>
  9. 10. <ul><li>Series of changes in position and attitude that the fetus undergoes during it passage through the birth canal </li></ul><ul><li>Engagement </li></ul><ul><li>Descent </li></ul><ul><li>Flexion </li></ul><ul><li>Internal rotation </li></ul><ul><li>Extension </li></ul><ul><li>Restitution </li></ul><ul><li>External rotation </li></ul><ul><li>Lateral flexion ( Expulsion ) </li></ul>
  10. 11. <ul><li>Head normally enters pelvis in the transverse position. </li></ul><ul><li>Engagement occurred when the widest part of the presenting part has passed successfully through the inlet. </li></ul><ul><li>More than two-fifth palpable abdominally, the head is not engaged. </li></ul>
  11. 12. <ul><li>A continuous movement </li></ul><ul><li>Brought by: </li></ul><ul><ul><li>uterine contraction </li></ul></ul><ul><ul><li>pressure of amniotic fluid </li></ul></ul><ul><ul><li>contractions of abdominal muscles </li></ul></ul><ul><li>In primigravida – engagement occur before onset of labour, descent continues in the second stage of labour </li></ul><ul><li>In multigravida – descent follows engagement </li></ul>
  12. 13. <ul><li>At the beginning of labour, head of fetus is possible for some degree of flexion. </li></ul><ul><li>Presenting diameter (11.5cm) </li></ul><ul><li>As labour progresses , the head of fetus meet the resist a nce of lower uterine segment. </li></ul><ul><li>Presenting diameter: </li></ul><ul><li>O ccipitobregmatic (9.5cm) </li></ul><ul><li>Flexion has advantage of bringing the shortest diameter of the head into descent. </li></ul>
  13. 14. <ul><li>Important factor: Resistance of pelvic floor </li></ul><ul><li>Occiput r if head is well flexed  occiput will be leading point  encouraged to rotate anteriorly  sagittal suture now lies in AP diameter </li></ul><ul><li>Rotates from LOT(L eft occipitotransverse (90 0 ) /LOA- Left occipitoanterior (45 0 ) position to lie under the subpubic arch. </li></ul><ul><li>Head now in occipito-anterior (OA) position </li></ul><ul><li>Shoulders is in left oblique of the brim </li></ul><ul><li>The internal rotation cause a slight twist in the neck of the fetus (the head is no longer in direct alignment with the shoulder). </li></ul>
  14. 16. <ul><li>Occiput is below symphysis pubis. </li></ul><ul><li>2 forces: </li></ul><ul><ul><ul><li>Uterine contraction – posterior & downward </li></ul></ul></ul><ul><ul><ul><li>Resistance of pelvic floor - upward and forward </li></ul></ul></ul><ul><li>The well flexed head now extends and the occiput escapes from underneath the symphisis pubis and distends the vulva. </li></ul><ul><li>Crowning </li></ul><ul><ul><li>That stage of childbirth when the fetal head has negotiated the pelvic outlet and the largest diameter of the head is encircled by the vulvar ring . </li></ul></ul><ul><li>Occiput is delivered followed by bregma, brow and face. </li></ul>
  15. 17. <ul><li>Rotation of the head 45° to restore the position of the head of fetus - to correct the twist in the neck that occurred during internal rotation. </li></ul>
  16. 18. <ul><li>In order to be delivered, the shoulders have to rotate into the direct AP plane(the widest diameter) </li></ul><ul><li>External rotation cause rotation of the head 45 ° towards mother left thigh in the same direction as restitution. </li></ul><ul><li>Thereby relationship of head with shoulder is restored.(same alignment) </li></ul>
  17. 19. <ul><li>Shoulders will be in the anterior-posterior position </li></ul><ul><li>Anterior shoulder is under symphysis pubis, delivers first and subsequently posterior shoulder. </li></ul><ul><li>Aided by lateral movement: </li></ul><ul><li>The rest of the body is born by lateral flexion with arms folded on the chest and hands under the chin . </li></ul>
  18. 22. <ul><li>A computerised tracing of fetal heart rate pattern and also measure the uterine contraction. </li></ul><ul><li>Can be used antenatally & during labour </li></ul><ul><li>able to detect fetus in distress </li></ul><ul><li>It reflects any physiological & pathological changes to the heart rate in response to stimuli, the most important which is hypoxia </li></ul>
  19. 23. <ul><li>Basically there are 4 parameters: </li></ul><ul><li>1)Baseline heart rate : </li></ul><ul><li>Normally 110 – 150bpm </li></ul><ul><li>160 bpm upper limit of normal. </li></ul><ul><li><110 bpm = bradycardia (fetal hypoxia) </li></ul><ul><li>>160 bpm = tachycardia (fetal compromise) </li></ul><ul><ul><ul><ul><ul><li>Congenital tachycardia. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Maternal and fetal infections. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Acute fetal hypoxia. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Fetal anaemia. </li></ul></ul></ul></ul></ul>
  20. 24. <ul><li>2)fetal heart rate variability </li></ul><ul><li>normal baseline indicate normal autonomic nervous system of the fetal. </li></ul><ul><li>The range of the normal variability is about 10-25 beats/min </li></ul><ul><li>Baseline is modified by fetal sleep states and activity,hypoxia,fetal infection and drugs that supressing the CNS such as opioids and hypnotics. </li></ul>
  21. 25. <ul><li>Fetal heart rate (FHR) acceleration . </li></ul><ul><li>Increased baseline FHR at least 15 bpm lasting at least 15 seconds. </li></ul><ul><li>Within 20 – 30 minutes CTG, 2 or more accelerations present define as reactive trace. </li></ul><ul><li>The importance of accelerations is that there are a good sign for fetal health. </li></ul>
  22. 26. <ul><li>FHR deceleration </li></ul><ul><ul><li>Transient reduction fetal heart rate of 15 bpm or lasting more than 15 seconds. </li></ul></ul><ul><ul><li>E.g. fetal hypoxia. </li></ul></ul><ul><li>related to uterine contraction . </li></ul><ul><li>What happened during uterine contraction?? </li></ul><ul><li>Reduction in blood flow to the placenta => reduces fetal oxygenation => alter fetal heart rate (decelaration) </li></ul><ul><li>However, normal fetus can withstand the temporary reduction in blood flow to placenta (no hypoxia) </li></ul><ul><li>-due to sufficient exchange of oxygen </li></ul>
  23. 28. <ul><ul><li>Type 1 deceleration(early deceleration) </li></ul></ul><ul><ul><li> Not associated with fetal distress </li></ul></ul><ul><ul><li>onset, maximum fall and recovery of FHR are coincident with the onset, peak and end of the uterine contraction </li></ul></ul><ul><ul><li>engagement of fetal head =>compression of the fetal head </li></ul></ul><ul><ul><li>Pressure on the fetal head leads to increased ICP that elicit a vagal response (parasympathetic). </li></ul></ul>
  24. 29. <ul><ul><li>Type 2 deceleration (late deceleration) </li></ul></ul><ul><ul><li>onset, maximal decrease, and recovery that are shifted to the right in relation to the contraction </li></ul></ul><ul><ul><li>nadir of deceleration lags behind and persist even after the peak of uterine contraction. – fetal distress </li></ul></ul><ul><ul><li>Severe deceleration: hypoxia and acidosis are more pronounced </li></ul></ul><ul><ul><li>Variable deceleration pattern </li></ul></ul><ul><ul><li>nadir variable in depth and timing peak of contraction </li></ul></ul><ul><ul><li>May be due to the umbilical cord compression. </li></ul></ul>