Normal labour

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Normal labour

  1. 1. Normal labourNormal labour Definition of labour:-Definition of labour:-  series of events that take place in theseries of events that take place in the genital organs in an effort to expel thegenital organs in an effort to expel the viable fetus out of the uterus through theviable fetus out of the uterus through the vagina in to the outer world.vagina in to the outer world. Definition of delivery:-Definition of delivery:- Is the expulsion or extraction of a viableIs the expulsion or extraction of a viable fetus out of the uterusfetus out of the uterus.. www.doctor.sdwww.doctor.sd
  2. 2. NormallabourNormallabour  Labour is normal when it isLabour is normal when it is 1.1. Spontaneous in onsetSpontaneous in onset 2.2. At termAt term 3.3. single fetussingle fetus 4.4. vertex presentationvertex presentation 5.5. Without undue prolongationWithout undue prolongation 6.6. With no maternal complications orWith no maternal complications or 7.7. Fetal complicationsFetal complications - Any deviation from this definition is abnormal- Any deviation from this definition is abnormal www.doctor.sdwww.doctor.sd
  3. 3. OnOnset of labourset of labour  Based on naegel’s formula labour startsBased on naegel’s formula labour starts approximately as follow.approximately as follow.  In the expected date of delivery in 4% ofIn the expected date of delivery in 4% of casescases  One week on either side in 50% of casesOne week on either side in 50% of cases  Two weeks earlier and one week later onTwo weeks earlier and one week later on 80% of cases80% of cases  At 42 weeks in 10% of casesAt 42 weeks in 10% of cases  At 43 weeks plus in 4% of casesAt 43 weeks plus in 4% of cases www.doctor.sdwww.doctor.sd
  4. 4. Causes of the onset of labourCauses of the onset of labour  Unknown the following theories wereUnknown the following theories were postulatedpostulated 1.1. Optimal distension theoryOptimal distension theory - When the uterus is distended to a certainWhen the uterus is distended to a certain limit, it starts to contract to evacuate itslimit, it starts to contract to evacuate its contents (multiple preg. Polyhydramnios)contents (multiple preg. Polyhydramnios) 2.2. feto- placental theoryfeto- placental theory - Due to unknown factors fetal pituitary is- Due to unknown factors fetal pituitary is stimulated with increase release ofstimulated with increase release of ACTH that stimulate theACTH that stimulate the www.doctor.sdwww.doctor.sd
  5. 5. fetal adrenal to produce cortisol which act infetal adrenal to produce cortisol which act in the placenta to produce estrogen andthe placenta to produce estrogen and prostaglandins.prostaglandins. 3-3- estrogen theory:-estrogen theory:- during the last trimester more free estrogenduring the last trimester more free estrogen appears increasing the excitability of theappears increasing the excitability of the myometrium and prostaglandin synthesismyometrium and prostaglandin synthesis www.doctor.sdwww.doctor.sd
  6. 6. 4- progesterone:4- progesterone:  Increase fetal production ofIncrease fetal production of dehydroepiandro-sterone sulphate withdehydroepiandro-sterone sulphate with cortisol may inhibit the conversion of fetalcortisol may inhibit the conversion of fetal pregnenolone to progesterone there bypregnenolone to progesterone there by altering the estrogen progesterone ratio.altering the estrogen progesterone ratio. 5- prostaglandins5- prostaglandins:-:- - Attracted much attention in recent years- Attracted much attention in recent years produced by-placenta –membrane –produced by-placenta –membrane – decidual cells and myometriumdecidual cells and myometrium www.doctor.sdwww.doctor.sd
  7. 7. Synthesis is triggered bySynthesis is triggered by  Rise in estrogen levelRise in estrogen level  Altered estrogen. Progesterone ratioAltered estrogen. Progesterone ratio  Mechanical stretching in later pregnancyMechanical stretching in later pregnancy  Infection or separation of membranesInfection or separation of membranes ↑↑ oxytocin receptorsoxytocin receptors 6. Oxytocin theory:-6. Oxytocin theory:- although oxytocin is a powerful stimulator of uterinealthough oxytocin is a powerful stimulator of uterine contraction its natural role in onset of labour iscontraction its natural role in onset of labour is doubtful .doubtful . www.doctor.sdwww.doctor.sd
  8. 8. Diagnosis of labour :-Diagnosis of labour :- Pre labour (premonitory stage :-Pre labour (premonitory stage :- - May begins two to three weeks before the- May begins two to three weeks before the onset of true labour in PG. and few daysonset of true labour in PG. and few days before in multi gravida and may consist ofbefore in multi gravida and may consist of the following .the following . www.doctor.sdwww.doctor.sd
  9. 9. 1)Lightening :-1)Lightening :- A sense of relief from theA sense of relief from the upper abdominal pressure symptoms suchupper abdominal pressure symptoms such as dyspnoea or dyspepsia due to sink ofas dyspnoea or dyspepsia due to sink of the presenting part into the true pelvis .the presenting part into the true pelvis . 2.Pelvic pressure symptoms such as2.Pelvic pressure symptoms such as frequency of micturition due tofrequency of micturition due to engagement of the presenting part .engagement of the presenting part . 3.Cervical changes (ripening of the cervix)3.Cervical changes (ripening of the cervix) become soft , less than 1.3cm in lengthbecome soft , less than 1.3cm in length ,Admit tip of the finger and is dilatable .,Admit tip of the finger and is dilatable . 4.Appearance of false pain .4.Appearance of false pain . www.doctor.sdwww.doctor.sd
  10. 10. True LabourTrue Labour  Features of true labour areFeatures of true labour are :-:- 1)1) Labour pain:-Labour pain:- - Intermittened painful and regular .Intermittened painful and regular . - Increase progressively in frequency,Increase progressively in frequency, duration and intensity .duration and intensity . - Felt in the abdomen and radiate to theFelt in the abdomen and radiate to the back and thighback and thigh .. www.doctor.sdwww.doctor.sd
  11. 11. 2)The show2)The show Expulsion of the cervical mucusExpulsion of the cervical mucus plug mixed with blood –may occur fewplug mixed with blood –may occur few days before the onset of labour .days before the onset of labour . 3) Progressive effacement and dilatation of3) Progressive effacement and dilatation of the cervix .the cervix . 4) Formation of the bag of forewater ,the4) Formation of the bag of forewater ,the lower pole of the fetal membraneslower pole of the fetal membranes become unsupported and tend to bulgebecome unsupported and tend to bulge through the cervical canal .through the cervical canal . www.doctor.sdwww.doctor.sd
  12. 12. Stages of labourStages of labour  Labour is divided into fourLabour is divided into four stages:-stages:- 1-1- First stage of labour:-First stage of labour:- - It is the stage of cervicalIt is the stage of cervical dilatation .dilatation . - Starts with the onset of labourStarts with the onset of labour pain and ends with fullpain and ends with full dilatation of the cervix .dilatation of the cervix . - It takes about 12 hours in aIt takes about 12 hours in a Primipara, and 8hrs in aPrimipara, and 8hrs in a multipara .multipara . - It’s composed of two phases .It’s composed of two phases . www.doctor.sdwww.doctor.sd
  13. 13. A) Latent phase:A) Latent phase: Starts from the onset of labour and endsStarts from the onset of labour and ends when the cervix is (2 to3 cm) dilated . Itwhen the cervix is (2 to3 cm) dilated . It occurs because the thinning of the loweroccurs because the thinning of the lower segment and cervix take a lot of uterinesegment and cervix take a lot of uterine work before rapid dilatation can begin . Itwork before rapid dilatation can begin . It takes about (6 to 8 hrs) .takes about (6 to 8 hrs) . www.doctor.sdwww.doctor.sd
  14. 14. B) Active phase :-B) Active phase :- It is the phase of rapid dilatation of the cervixIt is the phase of rapid dilatation of the cervix from 3cm dilatation up to full dilatation it alsofrom 3cm dilatation up to full dilatation it also take (6hrs) with a rate of cervical dilatation oftake (6hrs) with a rate of cervical dilatation of (1.2cm/hour)in PG and (1.5cm/hour)in(1.2cm/hour)in PG and (1.5cm/hour)in multigravidamultigravida .. It has three components:-It has three components:- i) Accelerated phase of dilatation fromi) Accelerated phase of dilatation from (2.5cmto4cm).(2.5cmto4cm). ii) Phase of maximum slope of (4to9cm) dilatation .ii) Phase of maximum slope of (4to9cm) dilatation . iii) Phase of deceleration of (9-10cm) dilatationiii) Phase of deceleration of (9-10cm) dilatation .. www.doctor.sdwww.doctor.sd
  15. 15. www.doctor.sdwww.doctor.sd
  16. 16. Causes of cervical dilation:-Causes of cervical dilation:- 1.1. Contraction and retraction of uterineContraction and retraction of uterine musculature (primary force)musculature (primary force) - Normal uterine contraction occur with- Normal uterine contraction occur with frequency of one every 2-3 minutes withfrequency of one every 2-3 minutes with at least 1min between contraction. Withat least 1min between contraction. With a duration of 40-70 seconds and ana duration of 40-70 seconds and an intensity of around 50 mmHg & a restingintensity of around 50 mmHg & a resting tone less than 15 mmHgtone less than 15 mmHg www.doctor.sdwww.doctor.sd
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  18. 18.  The contraction begins in two paceThe contraction begins in two pace makers near the utrotubal junction –onlymakers near the utrotubal junction –only one pace maker is operative in eachone pace maker is operative in each contraction. It spread like a wave over thecontraction. It spread like a wave over the whole uterus- strong in the funds (fundalwhole uterus- strong in the funds (fundal dominance) less strong in the mid zonedominance) less strong in the mid zone and relatively in the lower segment.and relatively in the lower segment.  Relaxation begins simultaneously in allRelaxation begins simultaneously in all areas of the uterus.areas of the uterus.  The force generated by each contractionThe force generated by each contraction is applied to the amniotic fluid and directlyis applied to the amniotic fluid and directly www.doctor.sdwww.doctor.sd
  19. 19. Against the pole of the infant that occupiesAgainst the pole of the infant that occupies the upper segment therefore each time thethe upper segment therefore each time the muscle contracts the uterine cavitymuscle contracts the uterine cavity becomes smaller and the presenting part orbecomes smaller and the presenting part or the fore bag of water lying a head of it isthe fore bag of water lying a head of it is pushed down ward in to the cervix thispushed down ward in to the cervix this tends to force it to open or dilatetends to force it to open or dilate..  A more potent factor in cervical dilatationA more potent factor in cervical dilatation however is the retraction of the upperhowever is the retraction of the upper segment. As this area of the uterussegment. As this area of the uterus becomes shorter and thicker it pulls thebecomes shorter and thicker it pulls the lower segment and the dilating cervixlower segment and the dilating cervix upward around the presenting part at theupward around the presenting part at the same time thesame time the www.doctor.sdwww.doctor.sd
  20. 20. uterus contracting directly against theuterus contracting directly against the infant tends to push it through theinfant tends to push it through the cervicalcervical opening .opening .  Cervical dilatation in primigravidaCervical dilatation in primigravida occurs from above down wardoccurs from above down ward causing progressive shortening ofcausing progressive shortening of the cervix.( effacement).the cervix.( effacement).  In multigravida effacement andIn multigravida effacement and dilatation occurs simultaneously.dilatation occurs simultaneously. www.doctor.sdwww.doctor.sd
  21. 21. 2. Second stage of labour2. Second stage of labour  It is the stage of expulsion of the fetusIt is the stage of expulsion of the fetus  Begins with full cervical dilatation andBegins with full cervical dilatation and ends with delivery of the fetusends with delivery of the fetus  Its duration is about one hour inIts duration is about one hour in primigravida and ½ an hour inprimigravida and ½ an hour in multigravida.multigravida.  Delivery of the fetus is affected in additionDelivery of the fetus is affected in addition to the uterine contraction( primary force)to the uterine contraction( primary force) by voluntary contraction of the abdominalby voluntary contraction of the abdominal muscles with the diaphragm fixed aftermuscles with the diaphragm fixed after forced inspirationforced inspiration .. www.doctor.sdwww.doctor.sd
  22. 22. This will increase intra abdominalThis will increase intra abdominal pressure (secondary force).pressure (secondary force).  This secondary forces have no effectThis secondary forces have no effect on cervical dilatation but they are ofon cervical dilatation but they are of considerable importance in aiding theconsiderable importance in aiding the expulsion of the infant from the uterusexpulsion of the infant from the uterus and vagina after the cervix isand vagina after the cervix is completely dilated.completely dilated. www.doctor.sdwww.doctor.sd
  23. 23. 3- third stage of labour:-3- third stage of labour:- comprises the phase of placental separationcomprises the phase of placental separation its descent to the lower segment and finallyits descent to the lower segment and finally its expulsion with the membrane.its expulsion with the membrane. www.doctor.sdwww.doctor.sd
  24. 24.  It begins after delivery of the fetus and endIt begins after delivery of the fetus and end with expulsion of the placenta andwith expulsion of the placenta and membrane.membrane.  Duration is about 10__20 minutes in bothDuration is about 10__20 minutes in both primigravide and multigravida.primigravide and multigravida.  Placental separation is due to markedPlacental separation is due to marked uterine muscle retraction which reducesuterine muscle retraction which reduces the surface area at the placental site tothe surface area at the placental site to about its half but as the placenta isabout its half but as the placenta is inelastic a shearing force in institutedinelastic a shearing force in instituted bringing about its separation. the plane ofbringing about its separation. the plane of separation runs through the deep spongyseparation runs through the deep spongy www.doctor.sdwww.doctor.sd
  25. 25. Layer of the decidua basalisLayer of the decidua basalis  There are two mechanism of placentalThere are two mechanism of placental separation.separation. 1- central separation (Schultz) occur in 80%1- central separation (Schultz) occur in 80% of cases- detachment of placenta from itsof cases- detachment of placenta from its uterine attachment starts at the centre.uterine attachment starts at the centre. 2- marginal separation( Mathews –Duncan)2- marginal separation( Mathews –Duncan) occurs in 20% of cases. Separation startsoccurs in 20% of cases. Separation starts at the margin as it is mostly un supportedat the margin as it is mostly un supported www.doctor.sdwww.doctor.sd
  26. 26.  After complete separation of the placenta itAfter complete separation of the placenta it is delivered by effective uterine contractionis delivered by effective uterine contraction and retraction and expelled out by eitherand retraction and expelled out by either voluntary contraction of abdominal musclevoluntary contraction of abdominal muscle (bearing down effort) or by manipulative(bearing down effort) or by manipulative procedures.procedures.  After placental delivery the uterine sinusesAfter placental delivery the uterine sinuses and arterioles are occluded by effectiveand arterioles are occluded by effective uterine contraction and retraction which isuterine contraction and retraction which is the principle mechanism of haemostasis,the principle mechanism of haemostasis, however thrombosis also occurs and ishowever thrombosis also occurs and is facilitated by the hypercoagulable status offacilitated by the hypercoagulable status of pregnancy.pregnancy. www.doctor.sdwww.doctor.sd
  27. 27. 4-fourth stage of labour4-fourth stage of labour  Begins immediately after expulsion of theBegins immediately after expulsion of the placenta and membranes and last for oneplacenta and membranes and last for one hour.hour.  Careful observation of the patient for signsCareful observation of the patient for signs of postpartum hemorrhage is essential.of postpartum hemorrhage is essential. www.doctor.sdwww.doctor.sd
  28. 28. Mechanism of normal labour:-Mechanism of normal labour:-  It refers to the series of changes in positionIt refers to the series of changes in position and attitude which the fetus under goes duringand attitude which the fetus under goes during its passage through the birth canalits passage through the birth canal And it consist of the following.And it consist of the following. 1)1) Descent of the fetus is a continuous movementDescent of the fetus is a continuous movement it is slow or insignificant in the first stage ofit is slow or insignificant in the first stage of labour but pronounced in the second stage. itlabour but pronounced in the second stage. it is completed with the expulsion of the fetus. Itis completed with the expulsion of the fetus. It is due to contraction and retraction of uterineis due to contraction and retraction of uterine muscle (primary force). Added in the secondmuscle (primary force). Added in the second stage by bearing down efforts (secondarystage by bearing down efforts (secondary force).force). www.doctor.sdwww.doctor.sd
  29. 29. 2- flexion:-2- flexion:-  As the head meet the resistance of theAs the head meet the resistance of the birth canal during descent full flexion isbirth canal during descent full flexion is achieved to bring the shortest sub-occipitoachieved to bring the shortest sub-occipito bregmatic diameter. Of the head(9.5cm).bregmatic diameter. Of the head(9.5cm).  Flexion is essential for descent since itFlexion is essential for descent since it reduces the shape and size of the plane ofreduces the shape and size of the plane of the advancing diameter of the head.the advancing diameter of the head.  www.doctor.sdwww.doctor.sd
  30. 30. 3- internal rotation3- internal rotation In the second stage of labour the forcesIn the second stage of labour the forces propel the fetus progressively down thepropel the fetus progressively down the birth canal, when the head meets thebirth canal, when the head meets the resistance of the pelvic floor the occiputresistance of the pelvic floor the occiput rotates forward to lie under the sub pubicrotates forward to lie under the sub pubic arch with the sagittal suture in the antero-arch with the sagittal suture in the antero- posterior diameter of the pelvic out let . Thisposterior diameter of the pelvic out let . This internal rotation of the head occursinternal rotation of the head occurs because with a well flexed head the occiputbecause with a well flexed head the occiput is leading and meets the slopping gutter ofis leading and meets the slopping gutter of thethe www.doctor.sdwww.doctor.sd
  31. 31. Lavatores ani muscles which by their shapeLavatores ani muscles which by their shape direct it anteriorly.direct it anteriorly. 4. extension:-4. extension:-  further advances of the head lead to itsfurther advances of the head lead to its passage through the vulva by a process ofpassage through the vulva by a process of extension. Once the occiput has escapedextension. Once the occiput has escaped from under the symphysis pubis the headfrom under the symphysis pubis the head extends with the nape of neck pressedextends with the nape of neck pressed firmly against the public arch. Thefirmly against the public arch. The successive parts of the fetal head to bornsuccessive parts of the fetal head to born through the stretched vulval .out let arethrough the stretched vulval .out let are vertexvertex , brow and face., brow and face. www.doctor.sdwww.doctor.sd
  32. 32. 5- restitution:-5- restitution:-  As soon as the head is completely born itAs soon as the head is completely born it resumes its natural position with regard toresumes its natural position with regard to the shoulders by rotating 1/8the shoulders by rotating 1/8thth of a circle inof a circle in the direction opposite to that of internalthe direction opposite to that of internal rotation. The neck becomes untwisted androtation. The neck becomes untwisted and the head is restored to its natural relationthe head is restored to its natural relation to the shoulder.to the shoulder. www.doctor.sdwww.doctor.sd
  33. 33. 6.6. External rotationExternal rotation  It is the movement of rotation of the headIt is the movement of rotation of the head visible externally due to internal rotation ofvisible externally due to internal rotation of the shoulders it carries the head in athe shoulders it carries the head in a movement through 1/8movement through 1/8thth of a circle in theof a circle in the same direction as restitution.same direction as restitution. 7- Birth of shoulders and trunk:-7- Birth of shoulders and trunk:- - Further descent takes place the anterior- Further descent takes place the anterior shoulder escapes below the symphysisshoulder escapes below the symphysis pubis and by lateral flexion of the spine thepubis and by lateral flexion of the spine the posterior shoulder sweeps over theposterior shoulder sweeps over the perineum. Rest of the trunk is thereperineum. Rest of the trunk is there expelled outexpelled out www.doctor.sdwww.doctor.sd
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  35. 35. Management of normal labourManagement of normal labour First stage:-First stage:-  On admission a complete history must beOn admission a complete history must be takentaken  Antenatal record is reviewed to discoverAntenatal record is reviewed to discover whether there have been any abnormalitieswhether there have been any abnormalities during pregnancyduring pregnancy  The women general condition is assessedThe women general condition is assessed her pulse-blood pressure and temperatureher pulse-blood pressure and temperature are recordedare recorded www.doctor.sdwww.doctor.sd
  36. 36.  on abdominal examination theon abdominal examination the presentation and position of the fetus andpresentation and position of the fetus and the relation of the presenting part to thethe relation of the presenting part to the brim of the pelvis are determinedbrim of the pelvis are determined  Abdominal examination will also show theAbdominal examination will also show the frequency and strength of uterinefrequency and strength of uterine contraction .contraction .  The location, rate and regularity of theThe location, rate and regularity of the fetal heart tones are also determined.fetal heart tones are also determined.  A vaginal examination will show theA vaginal examination will show the degree of cervical dilation, whether thedegree of cervical dilation, whether the membranes are intact or rupture and themembranes are intact or rupture and the www.doctor.sdwww.doctor.sd
  37. 37. Position with station of the presenting part.Position with station of the presenting part.  A urine specimen is examined for proteinA urine specimen is examined for protein and glucose and a hemoglobin orand glucose and a hemoglobin or haematocrit determination is made.haematocrit determination is made. Enema:-Enema:-  It’s routine use is unnecessary and hasIt’s routine use is unnecessary and has no particular benefit.no particular benefit.  Usually given early in the first stage ofUsually given early in the first stage of labour to empty the rectum to preventslabour to empty the rectum to prevents soiling of the perineum during the secondsoiling of the perineum during the second stage.stage. www.doctor.sdwww.doctor.sd
  38. 38.  Shaving or clipping of theShaving or clipping of the vulval hairvulval hair  Is not necessaryIs not necessary  Awarm bath or shower is both hygienicAwarm bath or shower is both hygienic and pleasant.and pleasant.  Rest:-Rest:-  there is no need for the women to remainthere is no need for the women to remain in bed during early labour. She is allowedin bed during early labour. She is allowed to walk about and to sit. This attitudeto walk about and to sit. This attitude prevents venacaval compression andprevents venacaval compression and encourage descent of the presenting part.encourage descent of the presenting part. www.doctor.sdwww.doctor.sd
  39. 39. Oral intakeOral intake  The major risk to be avoided is aspirationThe major risk to be avoided is aspiration of gastric contents, this only occurs in theof gastric contents, this only occurs in the context of general anesthesia.context of general anesthesia.  Intake of solid food must be avoided, lowIntake of solid food must be avoided, low fat, low residuce food and drink can befat, low residuce food and drink can be given.given.  If dehydration needs to be correctedIf dehydration needs to be corrected normal saline should be infused.normal saline should be infused. www.doctor.sdwww.doctor.sd
  40. 40. Bladder care:-Bladder care:-  The patient should be encouraged to emptyThe patient should be encouraged to empty her bladder frequently as full bladder oftenher bladder frequently as full bladder often inhibits uterine contraction.inhibits uterine contraction.  If the patient fails to pass urine specially inIf the patient fails to pass urine specially in late first stage catheterization is to be donelate first stage catheterization is to be done with strict aseptic precautionwith strict aseptic precaution.. Relief of pain:-Relief of pain:-  Pethidine (100) mg intramuscularly can bePethidine (100) mg intramuscularly can be given when the pains are well estabished. It.given when the pains are well estabished. It. www.doctor.sdwww.doctor.sd
  41. 41. should not be given if delivery is anticipatedshould not be given if delivery is anticipated within two hourswithin two hours  Epidural analgesia is very effective & doEpidural analgesia is very effective & do not cause depression of fetal respirationnot cause depression of fetal respiration  If epidural is not used towards the end ofIf epidural is not used towards the end of first stage a mixture of nitrous oxide &first stage a mixture of nitrous oxide & Oxygen (Entonox) may be started with theOxygen (Entonox) may be started with the onset of each contraction.onset of each contraction. Partogram:-Partogram:-  One labour has become established allOne labour has become established all events during labour should be recordedevents during labour should be recorded on the partogram.on the partogram. www.doctor.sdwww.doctor.sd
  42. 42.  Cervical dilatation marked in centimeters atCervical dilatation marked in centimeters at the time of admission to ward and at everythe time of admission to ward and at every subsequent examination(2 hourly)subsequent examination(2 hourly)  Descent of head (in cm above or below theDescent of head (in cm above or below the lschael spine).lschael spine).  Frequency, duration and strength of uterineFrequency, duration and strength of uterine contration in (10)min. each half an hour.contration in (10)min. each half an hour.  Fetal heart rate every ½ an hour.Fetal heart rate every ½ an hour.  Condition of liquor and time and manner ofCondition of liquor and time and manner of membranes rupture.membranes rupture.  moulding of the fetal skullmoulding of the fetal skull www.doctor.sdwww.doctor.sd
  43. 43.  Dosage of Oxytocin if usedDosage of Oxytocin if used  Maternal status (BP- pulse- temp-Maternal status (BP- pulse- temp- urinalysis).urinalysis).  Medication (including epidural block ifMedication (including epidural block if usedused www.doctor.sdwww.doctor.sd
  44. 44. www.doctor.sdwww.doctor.sd
  45. 45. Management of the secondManagement of the second stage:-stage:-  The transition from the first stage to theThe transition from the first stage to the second stage is evidenced by thesecond stage is evidenced by the following features.following features. - Appearance of bearing down effortsAppearance of bearing down efforts - Complete dilatation of the cervix onComplete dilatation of the cervix on vaginal examination.vaginal examination. Principles of management are:-Principles of management are:- 1. To assist in the natural expulsion of the1. To assist in the natural expulsion of the fetus slowlyfetus slowly www.doctor.sdwww.doctor.sd
  46. 46. 2- to prevent perineal injuries2- to prevent perineal injuries  General measuresGeneral measures:: o FHR every 5 minutesFHR every 5 minutes o Maternal pulse and blood pressure everyMaternal pulse and blood pressure every 15mins15mins o If epidural block is not used to administerIf epidural block is not used to administer inhalation analgesia (entonox) to relieve paininhalation analgesia (entonox) to relieve pain during contractionduring contraction o Vaginal examination to confirm the on set of theVaginal examination to confirm the on set of the second stage – to detect cord prolapse and tosecond stage – to detect cord prolapse and to know the position and station of the headknow the position and station of the head o Nothing is given by mouthNothing is given by mouth www.doctor.sdwww.doctor.sd
  47. 47. Preparation for delivery:-Preparation for delivery:-  Bearing down efforts, bulging of theBearing down efforts, bulging of the perineum and gaping of the anal openingperineum and gaping of the anal opening during contraction signify that delivery isduring contraction signify that delivery is imminent so the patient should be shiftedimminent so the patient should be shifted to the labour tableto the labour table Position of the patientPosition of the patient Dorsal position is more widely preferred withDorsal position is more widely preferred with the thighs flexed and separated . Somethe thighs flexed and separated . Some however prefer delivery in lateral orhowever prefer delivery in lateral or lithotomy positionlithotomy position www.doctor.sdwww.doctor.sd
  48. 48.  Toileting the external genitalia and innerToileting the external genitalia and inner Side of the thighs with cotton swabsSide of the thighs with cotton swabs soaked in savlon . And the area is coveredsoaked in savlon . And the area is covered with sterile sheet. Keeping only thewith sterile sheet. Keeping only the external genitalia uncoveredexternal genitalia uncovered  The delivery attendant should scrub put onThe delivery attendant should scrub put on sterile gown ,mask and glovessterile gown ,mask and gloves  To catheterize the bladder if it is full.To catheterize the bladder if it is full. www.doctor.sdwww.doctor.sd
  49. 49. Conduction of the deliveryConduction of the delivery  The patient is encourage to intensify theThe patient is encourage to intensify the bearing down efforts during contractions.bearing down efforts during contractions.  When the scalp is visible for about 5cmWhen the scalp is visible for about 5cm diameter flexion of the head is maintaineddiameter flexion of the head is maintained during contraction by pushing the occiputduring contraction by pushing the occiput down wards and back wards by usingdown wards and back wards by using thumb and index fingers of the left handthumb and index fingers of the left hand while pressing the perineum by the rightwhile pressing the perineum by the right palm with a sterile vulval pad. Thispalm with a sterile vulval pad. This process is repeated during subsequentprocess is repeated during subsequent www.doctor.sdwww.doctor.sd
  50. 50. contraction until crowing of the head occurscontraction until crowing of the head occurs (biparietal diameter stretches the vulval(biparietal diameter stretches the vulval out let without any recession of the headout let without any recession of the head even after the contractions is over).even after the contractions is over).  When the perineum is fully stretched andWhen the perineum is fully stretched and threatens to tear specially in PGthreatens to tear specially in PG episiotomy is done at this stage after priorepisiotomy is done at this stage after prior infiltration with 10/ml of 1% lignocaine.infiltration with 10/ml of 1% lignocaine.  Slow delivery of the head is accomplishedSlow delivery of the head is accomplished by pushing the chin with sterile gauze .byby pushing the chin with sterile gauze .by covered fingers of the right hand placedcovered fingers of the right hand placed over the anococcygeal regionover the anococcygeal region www.doctor.sdwww.doctor.sd
  51. 51.  While the left hand exerts pressure on theWhile the left hand exerts pressure on the occiput. the forehead, nose, mouth andocciput. the forehead, nose, mouth and the chin are thus born successively overthe chin are thus born successively over the stretched perineum by extension.the stretched perineum by extension.  The mucus and blood in the mouth andThe mucus and blood in the mouth and pharynx should be wiped with sterilepharynx should be wiped with sterile gauze or alternatively mechanical suckergauze or alternatively mechanical sucker may be used.may be used.  The neck is then palpated to exclude theThe neck is then palpated to exclude the presence of any loop of cord if it is found itpresence of any loop of cord if it is found it should be slipped over the head or if it isshould be slipped over the head or if it is sufficiently tight it is cut in between twosufficiently tight it is cut in between two pairs of kocher’s forceps.pairs of kocher’s forceps. www.doctor.sdwww.doctor.sd
  52. 52.  Wait for uterine contractions to come and for theWait for uterine contractions to come and for the movements of restitution and external rotation ofmovements of restitution and external rotation of the head to occur, the anterior shoulder is bornthe head to occur, the anterior shoulder is born behind the symphysis. If there is delay the headbehind the symphysis. If there is delay the head is grasped by both hands and is gently drawnis grasped by both hands and is gently drawn posteriorly until the anterior shoulder is releasedposteriorly until the anterior shoulder is released from under the pubis. by drawing the head infrom under the pubis. by drawing the head in upward direction the posterior shoulder isupward direction the posterior shoulder is delivered out of the perineum.delivered out of the perineum.  After delivery of the shoulders the fore fingers ofAfter delivery of the shoulders the fore fingers of each hand are inserted under the axillae and theeach hand are inserted under the axillae and the trunk is delivered gently by lateral flexion.trunk is delivered gently by lateral flexion. www.doctor.sdwww.doctor.sd
  53. 53.  Some delay in clamping and cutting theSome delay in clamping and cutting the umbilical cord probably is beneficial to theumbilical cord probably is beneficial to the infant. As much as a 75 to 100ml increaseinfant. As much as a 75 to 100ml increase in fetal blood volume can be anticipated.in fetal blood volume can be anticipated.  The infant is placed in a heated crib withThe infant is placed in a heated crib with its head slightly lower than its body. Its airits head slightly lower than its body. Its air passage should be cleared of Mucus bypassage should be cleared of Mucus by sucker before vigorous respiratory effortssucker before vigorous respiratory efforts are established.are established.  Apgar rating at 1 minute an at 5 minute isApgar rating at 1 minute an at 5 minute is to be recordedto be recorded www.doctor.sdwww.doctor.sd
  54. 54.  A sterile cotton thread is applied to theA sterile cotton thread is applied to the cord 2.5cm away from the navel & thecord 2.5cm away from the navel & the cord is divided with scissors about 1 cmcord is divided with scissors about 1 cm beyond the ligature.beyond the ligature. Episiotomy:-Episiotomy:-  Defined as a planned surgical incision ofDefined as a planned surgical incision of the perineum made to increase thethe perineum made to increase the diameter of the vulval outlet duringdiameter of the vulval outlet during childbirth (perineotomy)childbirth (perineotomy) www.doctor.sdwww.doctor.sd
  55. 55. Types of episiotomyTypes of episiotomy  1-midline:-1-midline:- the cut is made vertically from the fourchettethe cut is made vertically from the fourchette down towards the anus.down towards the anus.  Advantages of this incision are less blood loss,Advantages of this incision are less blood loss, is easier to repair, the wound heals quicker, andis easier to repair, the wound heals quicker, and less postpartum pain and dyspareunia. Theless postpartum pain and dyspareunia. The major disadvantage it carries a higher risk tomajor disadvantage it carries a higher risk to extend to involve the anal sphincter.extend to involve the anal sphincter.  2-mediolateral:-2-mediolateral:-  This incision starts in the midline of theThis incision starts in the midline of the fourchette and then directed outwards to avoidfourchette and then directed outwards to avoid the anal sphincterthe anal sphincter www.doctor.sdwww.doctor.sd
  56. 56.  management of themanagement of the third stage:third stage: Two methods of management are currentlyTwo methods of management are currently in practicein practice 1.1. Watchful expectancy:-Watchful expectancy:- - In this management the placental- In this management the placental separation and its descent into theseparation and its descent into the vagina are allowed to occurvagina are allowed to occur spontaneously. When the features ofspontaneously. When the features of placental separation at its descent intoplacental separation at its descent into www.doctor.sdwww.doctor.sd
  57. 57. the lower segment are confirmed the patientthe lower segment are confirmed the patient is asked to bear down simultaneouslyis asked to bear down simultaneously with uterine contraction. The raised intra-with uterine contraction. The raised intra- abdominal pressure is often adequate toabdominal pressure is often adequate to expel the placenta. If the patient fail toexpel the placenta. If the patient fail to expel the placenta. controlled cord tractionexpel the placenta. controlled cord traction (Brandt- Andrews method) can be tried.(Brandt- Andrews method) can be tried. The palmer surface of the fingers of theThe palmer surface of the fingers of the left hand is placed approximately at theleft hand is placed approximately at the junction of upper and lower uterinejunction of upper and lower uterine segment the body of the uterus issegment the body of the uterus is displaced upwards and backwardsdisplaced upwards and backwards towards the umbilicus while by the righttowards the umbilicus while by the right hand steady tension is given inhand steady tension is given in www.doctor.sdwww.doctor.sd
  58. 58. Downwards and backward direction until theDownwards and backward direction until the placenta comes outside .placenta comes outside .  Signs of placental separation:-Signs of placental separation:- 1. A show of blood appears as the uterus1. A show of blood appears as the uterus contracts.contracts. 2. Lengthening of the cord2. Lengthening of the cord 3. The fundus become globular in shape,3. The fundus become globular in shape, rises above the umbilicus, becomerises above the umbilicus, become palatable.palatable. www.doctor.sdwww.doctor.sd
  59. 59. 2. Active management:-2. Active management:-  Is associated with reduced blood loss.Is associated with reduced blood loss.  I.V ergometrine or syntometrineI.V ergometrine or syntometrine (syntocinon 5 units +ergometrine 0.5mg)(syntocinon 5 units +ergometrine 0.5mg) is given with delivery of the anterioris given with delivery of the anterior shoulder.shoulder.  The placenta is immediately deliveredThe placenta is immediately delivered after delivery of the baby by controlledafter delivery of the baby by controlled cord traction after insuring uterinecord traction after insuring uterine contractioncontraction www.doctor.sdwww.doctor.sd
  60. 60.  As soon as the placenta passes through theAs soon as the placenta passes through the introitus it is grasped between the hands andintroitus it is grasped between the hands and twisted around and round with gentle traction sotwisted around and round with gentle traction so that the membranes are stripped intact.that the membranes are stripped intact.  The placenta and the membranes should beThe placenta and the membranes should be examined following their expulsionexamined following their expulsion  Vulva-vagina and perineum are inspectedVulva-vagina and perineum are inspected carefully for injuries and to be repaired if any.carefully for injuries and to be repaired if any. the episiotomy is sutured. The vagina isthe episiotomy is sutured. The vagina is evacuated from blood clots . The area isevacuated from blood clots . The area is cleaned and a dry sterile vulval pad is placed.cleaned and a dry sterile vulval pad is placed. www.doctor.sdwww.doctor.sd
  61. 61.  The maternal condition –pulse –bloodThe maternal condition –pulse –blood pressure. Behavior of the uterus and anypressure. Behavior of the uterus and any abnormal vaginal bleeding is to beabnormal vaginal bleeding is to be watched at least for one hour after deliverywatched at least for one hour after delivery (fourth stage of labour).(fourth stage of labour).  When fully satisfied that the generalWhen fully satisfied that the general condition is good pulse and bloodcondition is good pulse and blood pressure are steady the uterus is wellpressure are steady the uterus is well contracted and there is no abnormalcontracted and there is no abnormal vaginal bleeding the patient is sent to thevaginal bleeding the patient is sent to the ward.ward. www.doctor.sdwww.doctor.sd

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