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Normal labour presentation by UM
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Normal labour presentation by UM


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  • 1. Iskandar dzulkarnain Nurul syuhadah
  • 2.
    • LABOUR
      • Event that take place in the uterus and birth canal to expel the viable fetus through the vagina.
      • The onset is painful, regular contractions, more than one every ten minutes
      • with progressive cervical effacement and dilatation
      • accompanied by descent of the head of fetus .
      • T he expulsion of a viable fetus out of the uterus .
      • Labour is consider normal when mature fetus presenting by vertex
      • delivers by natural efforts
      • without prolongation of labour.
      • A difficult labour, which refers to a labour not progressing satisfactorily with possible undue consequences to mother and fetus.
  • 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
    • Refers to fetal
      • Attitude
      • Lie
      • Presentation
      • Denominator
      • Position
  • 4.
    • Onset
    • regular contraction bringing about progressive cervical changes
    • Duration
    • <12hrs – nulliparous
    • <8hrs – multiparous
  • 5.
    • 1 st stage
    • from onset of labour to full dilatation of cervix (10cm)
    • Latent Phase
    • from onset to dilatation (3-4cm)
    • cervix fully effaced
    • 3-8hrs
    • Active Phase
    • end of LP
    • full dilatation (10cm)
    • 2-6hrs
    • cervix dilates 1cm/hr
    • 2 nd Stage
    • from full dilatation of cervix (10cm) to delivery of fetus
    • Passive Phase
    • no maternal urge to push
    • fetal head is still high in the pelvis
    • sagittal suture in transverse diameter
    • Active Phase
    • should not last
    • - 2hrs in nulliparous
    • - 1hr in multiparous
    • 3 rd stage
    • from delivery of fetus to delivery of placenta
    • more than 30min is considered prolonged
  • 6.
    • Lightening
      • as the baby settles into lower uterine segment, causing lowering of the fundal height; a sense of relief for the mother.
    • Increased vaginal secretion.
    • Cervix become soft and effaced.
    • False labour pain occur with variable frequency.
  • 7.
    • There are 2 phase:
    • Latent Phase: time between the onset of the labour and 3-4cm dilatation. Lasted between 3-8 hours(lesser in multiparous)
      • Uterine contractions
        • Regular in frequency.
        • 4-5 in 10 min, each contraction may last 40-45s.
      • Show (blood stained mucus discharge)
        • Evidence of start of effacement and dilatation .
      • E ffacement of cervix (thinning of cervix: 2.5cm-paperly thin)
      • Dilatation of cervix
    • Active Phase : time between the end of latent phase(3-4cm dilate) until full dilatation(10cm)
  • 8.  
  • 9.
    • There are 2 phases:
    • Passive phase - no maternal urge to push and the fetal head is still relatively high in the pelvis
    • Active second stage
    • Accomplished by downward thrust offered by
        • ↑ uterine contractions
        • voluntary contraction of abdominal muscles
    • Bearing down efforts
        • Breath hold; strain down as in defecation desire
    • Descent of the head.
  • 10.
    • Series of changes in position and attitude that the fetus undergoes during it passage through the birth canal
    • Engagement
    • Descent
    • Flexion
    • Internal rotation
    • Extension
    • Restitution
    • External rotation
    • Lateral flexion ( Expulsion )
  • 11.
    • Head normally enters pelvis in the transverse position.
    • Engagement occurred when the widest part of the presenting part has passed successfully through the inlet.
    • More than two-fifth palpable abdominally, the head is not engaged.
  • 12.
    • A continuous movement
    • Brought by:
      • uterine contraction
      • pressure of amniotic fluid
      • contractions of abdominal muscles
    • In primigravida – engagement occur before onset of labour, descent continues in the second stage of labour
    • In multigravida – descent follows engagement
  • 13.
    • At the beginning of labour, head of fetus is possible for some degree of flexion.
    • Presenting diameter (11.5cm)
    • As labour progresses , the head of fetus meet the resist a nce of lower uterine segment.
    • Presenting diameter:
    • O ccipitobregmatic (9.5cm)
    • Flexion has advantage of bringing the shortest diameter of the head into descent.
  • 14.
    • Important factor: Resistance of pelvic floor
    • Occiput r if head is well flexed  occiput will be leading point  encouraged to rotate anteriorly  sagittal suture now lies in AP diameter
    • Rotates from LOT(L eft occipitotransverse (90 0 ) /LOA- Left occipitoanterior (45 0 ) position to lie under the subpubic arch.
    • Head now in occipito-anterior (OA) position
    • Shoulders is in left oblique of the brim
    • The internal rotation cause a slight twist in the neck of the fetus (the head is no longer in direct alignment with the shoulder).
  • 15.  
  • 16.
    • Occiput is below symphysis pubis.
    • 2 forces:
        • Uterine contraction – posterior & downward
        • Resistance of pelvic floor - upward and forward
    • The well flexed head now extends and the occiput escapes from underneath the symphisis pubis and distends the vulva.
    • Crowning
      • 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 .
    • Occiput is delivered followed by bregma, brow and face.
  • 17.
    • 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.
  • 18.
    • In order to be delivered, the shoulders have to rotate into the direct AP plane(the widest diameter)
    • External rotation cause rotation of the head 45 ° towards mother left thigh in the same direction as restitution.
    • Thereby relationship of head with shoulder is restored.(same alignment)
  • 19.
    • Shoulders will be in the anterior-posterior position
    • Anterior shoulder is under symphysis pubis, delivers first and subsequently posterior shoulder.
    • Aided by lateral movement:
    • The rest of the body is born by lateral flexion with arms folded on the chest and hands under the chin .
  • 20.  
  • 21.  
  • 22.
    • A computerised tracing of fetal heart rate pattern and also measure the uterine contraction.
    • Can be used antenatally & during labour
    • able to detect fetus in distress
    • It reflects any physiological & pathological changes to the heart rate in response to stimuli, the most important which is hypoxia
  • 23.
    • Basically there are 4 parameters:
    • 1)Baseline heart rate :
    • Normally 110 – 150bpm
    • 160 bpm upper limit of normal.
    • <110 bpm = bradycardia (fetal hypoxia)
    • >160 bpm = tachycardia (fetal compromise)
            • Congenital tachycardia.
            • Maternal and fetal infections.
            • Acute fetal hypoxia.
            • Fetal anaemia.
  • 24.
    • 2)fetal heart rate variability
    • normal baseline indicate normal autonomic nervous system of the fetal.
    • The range of the normal variability is about 10-25 beats/min
    • Baseline is modified by fetal sleep states and activity,hypoxia,fetal infection and drugs that supressing the CNS such as opioids and hypnotics.
  • 25.
    • Fetal heart rate (FHR) acceleration .
    • Increased baseline FHR at least 15 bpm lasting at least 15 seconds.
    • Within 20 – 30 minutes CTG, 2 or more accelerations present define as reactive trace.
    • The importance of accelerations is that there are a good sign for fetal health.
  • 26.
    • FHR deceleration
      • Transient reduction fetal heart rate of 15 bpm or lasting more than 15 seconds.
      • E.g. fetal hypoxia.
    • related to uterine contraction .
    • What happened during uterine contraction??
    • Reduction in blood flow to the placenta => reduces fetal oxygenation => alter fetal heart rate (decelaration)
    • However, normal fetus can withstand the temporary reduction in blood flow to placenta (no hypoxia)
    • -due to sufficient exchange of oxygen
  • 27.  
  • 28.
      • Type 1 deceleration(early deceleration)
      • Not associated with fetal distress
      • onset, maximum fall and recovery of FHR are coincident with the onset, peak and end of the uterine contraction
      • engagement of fetal head =>compression of the fetal head
      • Pressure on the fetal head leads to increased ICP that elicit a vagal response (parasympathetic).
  • 29.
      • Type 2 deceleration (late deceleration)
      • onset, maximal decrease, and recovery that are shifted to the right in relation to the contraction
      • nadir of deceleration lags behind and persist even after the peak of uterine contraction. – fetal distress
      • Severe deceleration: hypoxia and acidosis are more pronounced
      • Variable deceleration pattern
      • nadir variable in depth and timing peak of contraction
      • May be due to the umbilical cord compression.
  • 30.  
  • 31.  
  • 32.  
  • 33.