Your SlideShare is downloading. ×
0
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Labour management
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Labour management

1,410

Published on

1 Comment
13 Likes
Statistics
Notes
No Downloads
Views
Total Views
1,410
On Slideshare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
150
Comments
1
Likes
13
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Management of normal labour Prof. Aboubakr Elnashar Benha university Hospital, Egypt elnashar53@hotmail.com
  • 2. Contents Introduction Definitions Mechanism Aims Principles 1st stage 2nd stage 3rd stage 4th stage
  • 3. Definitions Labour: Regular involuntary coordinated, painful uterine contractions associated with cervical effacement and dilatation • Regular frequent uterine contractions + • Cx changes (dilatation & effacement) or • SROM Delivery: Expulsion of the product of the conception after fetal viability.
  • 4. Anterior Pubis Right Left Occipital bone MECHANISMS OF NORMAL LABOUR Occiput anterior
  • 5. Occiputo anterior positions
  • 6. D: Descent F: Flexion I: Internal rotation of the fetal head C: Crowning E: Extension R: Restitution I : Internal rotation of the shoulders E: External rotation of the fetal head L: Lateral flexion of the body
  • 7. Descend Flexion Internal rotation Crowning Extension Restitution Internal rotation of shoulder External rotation of head Lateral flexion of body LOA LOA OA LOA OA OA LOT Delivery D F I C E R I E L
  • 8. Cardinal movements of labour (LOA) Head is delivered by Extension Restitution External rotation 9
  • 9. CROWNING OF THE HEAD
  • 10. Head is delivered by EXTENSION
  • 11. RESTITUTION
  • 12. EXTERNAL ROTATION
  • 13. • Delivery of a normal healthy child • To anticipate, recognize and treat potential abnormal conditions before significant hazard develops for the mother or the fetus. AIMS
  • 14. • Diagnosis of labour • Monitoring the progress of labour • Ensuring maternal well-being • Ensuring fetal well-being. PRINCIPLES
  • 15. MANAGEMENT 1st STAGE OF LABOUR I. Assessment II. Preparation and care III. Partogram
  • 16. I. Assessment 1. History: 1. Woman’s antenatal record is reviewed 2. No records of antenatal care: complete history . 2. Examination a. General a) Pallor, edema, abdominal scar (LSCS) b) Vital signs: BP, pulse, RR and T c) Heart and lungs
  • 17. b. Abdominal examination: a. Presentation and position and engagement b. Auscultate the fetal heart c. Evaluate the uterine contraction
  • 18. c. Vaginal examination – i) PP: Presentation Engagement, station Position
  • 19. ii) Membranes Intact or absent: exclude cord prolapse after ROM iii) Cx Consistency, position Dilatation Effacement,
  • 20. iv) Pelvis Adequacy.
  • 21. Do not do vaginal examination: vaginal bleeding before the placenta previa is excluded. Sterile speculum examination: suspected ROM, if the woman is not in labour. Admission to labour ward: Active labour: Regular painful contractions and cervical dilatation 3 cm {less time in the labor ward less intrapartum oxytocics less analgesia}
  • 22. 3. Investigation Urine: Protein Sugar ketones Blood: CBC RBS Grouping cross match for high risk patients.
  • 23. II. Preparation and care 1. Bowel preparation:  Indicated: No bowel action for 24 h or Rectum feels loaded on vaginal examination  similar length of labor and most maternal and neonatal outcomes generates discomfort in women
  • 24. 2. Bladder care  Encourage to empty bladder /1½ - 2 h. {A full bladder: prevent the fetal head from entering the pelvic brim impede descent of the fetal head. inhibit effective uterine action}.  The quantity of urine should be measured and recorded and a specimen obtained for testing. 3. Nutrition  No food is permitted after labour is established {prevent regurgitation and aspiration}  Small amount of clear fluid or frozen pineapple, Ice chips to moisten the mouth  Maintain adequate hydration via intravenous routes
  • 25. 4. Perineal shaving No {is associated with similar maternal febrile morbidity, wound infection, and neonatal infection compared with just selective clipping of hair}
  • 26. Routine early ARM Not recommended {decrease duration of labor( 60 min, mostly because of shorter 1st stage), decrease use of oxytocin, similar incidence of NRFHR monitoring similar neonatal outcomes compared with selective (later or no) AROM 26% increase in CD} should be reserved for failure to progress
  • 27. 5. Position:  Walk about or in bed, as she wishes  As long as the patient is healthy presentation normal presenting part engaged fetus in good condition 6. Pain relief Severe: an analgesic a) Opiate drugs. e.g. Pethidine IM/4 h b) Inhalational analgesia e.g. Entonox c) Epidural analagesia
  • 28. III. Monitoring the progress of labour Once labour has become established, 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 Patient information: name, gravida, para, hospital number, date and time of admission and time of ruptured membranes.
  • 29. PATIENT INFORMATION FETAL INFORMATION FHR Am fluid Moulding LABOUR INFORMATION Dilatation Descent Contraction MEDICATIONS syntocinon drugs IV fluids MATERNAL INFORMATION Pulse, BP, T Urine: alb, ketones, vol
  • 30. A. Condition of the fetus I. FHR: every half hour. II. Memb & Liq: every vaginal examination I= intact, A= abscent C= clear, M= meconium B= blood, III. Moudling: 0 (separated) + (touching) ++(overlap) +++ (severe overlap)
  • 31. Monitor FHR  Auscultation methods  Electronic monitoring: CTG
  • 32. NORMAL ABNORMAL
  • 33. B. Progress of labour I. Cervical dilatation (cm). every vaginal examination Plot x In active phase Alert line: drawn at a rate of 1 cm /h cervical dil The mean rate of the slowest 10% of normal PG Action line: drawn 4 h to the right of alert line. Intervention should take place II. Descend: every vaginal examination Plot O (amount of head palpable above pelvic brim) and Position III. Contractions: every half hour Frequency/10 m, Duration & Intensity: stippled (<20 sec, weak); striped (20-40 sec, moderate); complete (>40 sec, strong).
  • 34. Recording the progress of labour frequency of cervical examinations. Most studies: every 2 h. {risk of chorioamnionitis increases with the increasing number of examinations}.
  • 35. C. Condition of the mother I. Medications: Oxytocin: amount /30 min Drugs IV Fluids II. V/S: B.P: /4 h mark with arrows ( ) P: /30 min mark with a dot (●). T: /2 hours. III. Urine: every time urine is passed. Vol, alb, ketones
  • 36. WHO partogram, 2002 Simple & easy to use. The latent phase has been removed . Plotting on begins in the active phase when the cervix is 4 cm dilated.
  • 37. MANAGEMENT 2nd STAGE OF LABOUR I. Preparation II. Observation III. Conduct of delivery
  • 38. I. Preparation 1. Maternal position: With the exception of avoiding supine position, the mother may assume any comfortable position for effective bearing down. Semi-recumbent or Supported sitting position, with the thighs abducted 2. PERINEAL CLEANSING When delivery is imminent skin over the lower abdomen, vulva, anus and upper thigh is cleansed with antiseptic solution and draped.
  • 39. POSITIONING FOR DELIVERY
  • 40. PERINEAL CLEANSING Need 6 swab balls Clean sequentially as shown by the numbers Clean according to the direction shown by the Arrows
  • 41. CREATE A STERILE FIELD AROUND THE VAGINAL OPENING
  • 42. II. Observation 1.Maternal conditions Emotional condition pulse quarter-hourly bloods pressure hourly 2.Fetal conditions FHR: either continuously or after each contraction. Liquor: meconium staining. 3.Uterine contractions Strength Duration Frequency, assessed continuously. 4.The progress of descent every 30 minutes
  • 43. III. CONDUCTING THE DELIVERY 1. DELIVERY OF THE HEAD 1) Control the delivery of the head to prevent laceration 2) Episiotomy if required 3) Ritgen’s method 4) Clear the airway after delivery of the had Modified Ritgen Maneuver As crowning occurs: exert forward pressure on the chin of the fetus through the perineum just in front of the coccyx. Concurrently, the other hand exerts pressure superiorly against the occiput
  • 44. • Instruct the mother to focus on her breathing. Have her “breathe heavily” to help her stop pushing and prevent a forceful birth.
  • 45. • Ask the woman to pant or give only small pushes with contractions as the baby’s head delivers • To control birth of the head, place the fingers of one hand against the baby’s head to keep it flexed (bent) • Continue to gently support the perineum as the baby’s head delivers
  • 46. DELIVERY OF THE HEAD Head is delivered by extension
  • 47. • Once the baby’s head delivers, ask the woman not to push • Suction the baby’s mouth and nose
  • 48. CORD AROUND THE NECK Feel around the baby’s neck for the umbilical cord If the cord is around the neck, attempt to slip it over the baby’s head If the cord is tight around the neck, doubly clamp and cut it before unwinding it from around the neck
  • 49. As the head emerges, the baby will turn to one side (for easier passage of shoulders through birth canal) Note the time, if possible
  • 50. • Allow the baby’s head to turn spontaneously. • After the head turns, place a hand on each side of the baby’s head. • Tell the woman to push gently with the next contraction. • Reduce tears by delivering one shoulder at a time
  • 51. DELIVERY OF FETAL HEAD WITH ROL POSITION
  • 52. 2. Delivery of the anterior shoulder by gentle downward traction on the head. In the direction of the axis of the body
  • 53. 3. DELIVERY OF POSTERIOR SHOULDER by elevating the head. Support the rest of the baby’s body with one hand as it slides out
  • 54. 4. DELIVERY OF THE TRUNK  After the delivery of the shoulders the baby is grasped around the chest to aid the birth of the trunk.  Finally, the body is slowly extracted by traction on the shoulders and lifts the baby towards the mother’s abdomen.  The time of delivery is noted.
  • 55. BABY DELIVERED
  • 56. FIRST BODY CONTACT OF MOTHER AND BABY AND CORD CLAMPING
  • 57. 5. CLAMING AND CUTTING THE UMBILICAL CORD After delivery wait 15 to 20 seconds before clamping and cutting the umbilical cord. After cutting the cord a plastic crushing clamp is placed on the cord 1 to 2 cm from the umbilicus and the cord is cut again 1 cm beyond the clamp.
  • 58. Clamping, cutting and tying Of umbilical cord
  • 59. EPISIOTOMY Surgical incision into the perineum to enlarge the space at the outlet  Benefits: 1.Speed up the birth 2.Prevent Tearing 3.Protects against incontinence 4.Protects against pelvic floor relaxation 5.Heals easier than tears Not proven
  • 60.  No decrease perineal damage future vaginal prolapse urinary incontinen  Increase 3rd & 4th degree tears anal sphincter muscle dysfunction.
  • 61. Indications Not routine 1. Sizeable babies with anticipation of shoulder dystocia. 2. Shoulder dystocia. 3. Instrumental delivery (according to judgement) 4. Breech 5. Scarring from female genital mutilation or poorly healed third or fourth degree tears 6. Fetal distress.
  • 62. Types Mediolateral rather than midline (less 3rd and 4th degree perennial tear).
  • 63. Good analgesia (infiltration with xylocain ) Timing: cause bleeding: not be done too early. Wait until perineum is thinned out and 3–4 cm of the baby’s head is visible during contraction.
  • 64.  IMMEDIATE CARE OF THE NEW BORN Once the baby is breathing normally he should be dried and warmly wrapped to prevent cooling and handle to the mother to hold, cuddle and enjoy. If spontaneous respiration is not established soon after birth, resuscitation is the immediate priority. The Apgar’s score of the baby should be noted and recorded.
  • 65. Nonoperative interventions to decrease operative birth in systematic reviews (FIGO, 2012): 1. Continuous support for women during childbirth by one-to-one birth attendants 2. Use of upright or lateral positions during delivery compared with supine or lithotomy 3. Delaying pushing for 1–2 hours or until the woman has a strong urge to push reduces the need for rotational and midcavity interventions
  • 66. Recommendations FIGO (2012) • Delivery facilities must offer everywoman privacy and allow her to be accompanied by her choice of a supportive person (husband, friend, mother, relative, TBA) • Psychosocial support, education, communication, choice of position, and pharmacological methods appropriately used during the first stage are all useful in relieving pain and distress in the second stage of labor. • Monitoring of FHR must be continued during 2nd stage to allow early detection of bradycardia.
  • 67. • Routine episiotomy is harmful and should not be practiced. • Women should not be forced or encouraged to push until they feel an urge to push. • Fetal heart auscultation after every contraction. • Local anesthetic should always be given for any episiotomy, episiotomy/ laceration repair, or forceps delivery.
  • 68. MANAGEMENT 3rd STAGE OF LABOUR I. Delivery of placenta II. Examination of placenta and perineum III. Repair of episeotomy
  • 69. I. Delivery OF THE PLACENTA two stages: (1) Separation of the placenta from the wall of the uterus and into the lower uterine segment and/or the vagina, and (2) Actual expulsion of the placenta out of the birth canal.
  • 70. MECHANISM OF PLACENTA SEPARATION1: 1-Mathews-Duncan mechanism The leading edge of the placenta separates first and the placenta is delivered with its raw surface exposed. 2- Schultz mechanism If the placenta is inserted at the fundus and central area separates first, the placenta inverts and draws the membranes after it, covering the raw surface (inverted umbrella)
  • 71. SIGNS OF PLACENTALSEPARATION within 5 minutes after the delivery of the infant. 1.The uterus becomes globular and hard. =earliest to appear. 2.Sudden gush of blood 3.The uterus rises in the abdomen because the placenta, having separated, passes down into the lower segment and vagina, where its bulk pushes the uterus upward. 4.Cord lengthening. =most reliable clinical
  • 72. . . . Physiological Management Active Management Uterotonic None or after placenta delivered With delivery of anterior shoulder or baby Uterus Assessment of size and tone Assessment of size and tone Cord traction None Application of controlled cord traction* when uterus contracted Cord clamping Variable Early *Gentle downward cord traction with countertraction on the uterine body
  • 73. ACTIVE MANAGEMENT OF THE THIRD STAGE Helps prevent postpartum haemorrhage. includes: 1. use of oxytocin 2. controlled cord traction, and 3. uterine massage.
  • 74. Once the signs of placental separation have occurred the obstetrician assists delivery of the placenta by controlled cord traction as described by Brandt- Andrews’ method. If the patient is awake, she is asked to bear down while gentle traction is made on the umbilical cord. A) Placenta separation B) Controlled cord traction C) Delivery of the membranes
  • 75. II. EXAMINATION 1. OF THE PLACENTA The placenta, membranes, and umbilical cord should be examined for completeness and for anomalies. 2. OF THE PERINEUM At the same time, the perineal region, vulva outlet, vaginal canal, and the cervix should be carefully examined for lacerations. If the perineum has been torn or an episiotomy made, tear or incision should be repaired immediately.
  • 76. III. REPAIR OF EPISIOTOMY Suture as soon as possible after delivery to avoid bleeding and infection (RCOG) Start just above the apex Use 3 layer technique, vaginal mucosa, perennial muscle and perineal skin Synthetic, absorbable (rapidly absorbable polyglactin 910) VICRYL RAPIDE begins to fall off 7-10 days post- operatively  reduced post partum perineal pain, dyspareunia, although increased suture removal up to 3/12 For each layer use loose continuous non locking suturing this will reduce pain and dyspareunia.
  • 77. 1. Identify apex 2. Begin suturing 1.0 cm above apex 3. Continuous sutures 4. Ends at the level of vaginal opening Continuous sutures Interrupted sutures Interrupted suture or subcuticular
  • 78. MANAGEMENT 4th stage of labour I. Observe II. Check
  • 79. The 2 hours after delivery critical period {postpartum haemorrhage can occurs due the relaxation of the uterus}. I. Observation in delivery suite Bleeding blood pressure pulse .
  • 80. II. Check before discharging the patient from the delivery 1. Uterus: Frequently to make sure it is firm and not relaxing. Remove any presence of intrauterine blood clots. {clots interfere with retraction and the normal haemostatic mechanism of the uterus}. 2. Introitus to see that there is no hge. 3. Bladder empty {full bladder can also interfere with uterine retraction}. 4. Baby breathing well and that the colour and tone are normal.
  • 81. Thank you Aboubakr elnashar

×