stages and management of labor
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stages and management of labor Presentation Transcript

  • 1. LABOR
  • 2.  Labor is the process that begins with repeated, forceful uterine contractions. Uterine contractions supply the power that makes birth possible. Contractions cause the cervix to dilate and help move the baby through the birth canal3.
  • 3.  Defined as effective onset of uterine contractions leading to progressive effacement and dilatation of cervix resulting in expulsion of fetus, placenta and membranes.
  • 4. Labor is called normal if it fulfils the following Criteria  Spontaneous in onset at term  With vertex presentation  Without undue prolongation  Natural termination with minimal aids  Without having any complication
  • 5. Any deviation from the definition of Normal Labor is called Abnormal Labor.
  • 6.  First stage  Second stage  Third stage  Fourth stage
  • 7. It starts from the onset of true labor pain, and ends with the full dilatation of the cervix. Its average duration is 12 hrs. in primigravidae and 6 hrs in multiparae1. FIRST STAGE comprises of 3 phases • • • Latent phase Active phase Transitional phase
  • 8.  Latent phase : is prior to active first stage of labor and may last 6-8 hrs. in first time mothers when the cervix dilates from 0 cm to 3-4 cm dilated and cervical canal shortens from 3 cm to less then 0.5 cm long2.  Active phase : is the time when cervix undergoes more rapid dilatation. This begins when the cervix is 3-4 cm dilated2.  Transitional phase : is the stage of labor when the cervix is around 8cm dilated until it is fully dilated2.
  • 9.  The second stage is that of expulsion of the fetus. It begins when the cervix is fully dilated and the women feels urge to expel the baby. It is complete when baby is born2.  It has got two phases : 1) Propulsive phase : starts from full dilatation up to the descent of the presenting part to the pelvic floor. 2) Expulsive phase : is distinguished by maternal bearing down efforts and ends with the delivery of baby. Its average duration is 2 hours in primigravida and 30 min utes in muliparae.
  • 10.  The third stage is that of separation and expulsion of placenta and membranes ; it also involves control of bleeding. It lasts from the birth of the baby until the placenta and membranes have been expelled2.
  • 11.  It is the stage of observation for at least one hour after expulsion of the after-births. During this period, general condition of the patient and the behaviour of the uterus are to be carefully watched1.
  • 12.  Recognition of spontaneous labor is not always easy. Both the woman midwife being aware of the latent phase of the labor and allowing this time to pass with no intervention  Spurious labor: many woman experience contractions before the onset of labor , causing the women to think that labor has started.
  • 13. The 2 features of true labor that are absent here, 1} Effacement 2} Cervical dilatation
  • 14.  Duration  Uterine actions (a) Fundal dominance (b) Polarity (c) Contractions and retraction (d) Formation of upper and lower uterine segment (e) The retraction ring (f) Cervical effacement (g) Cervical dilatation
  • 15.  Mechanical factors (a) Formation of the forewaters (b) Rupture of the membranes (c) Fetal axis pressure
  • 16.  Length of labor is influenced by parity, birth interval, psychological state, presentation and position, maternal pelvic shape and size, character of uterine contractions.  In primipara women, average duration is 12 hours.  In multipara women it is 6 hrs.
  • 17.  FUNDAL DOMINANCE Each uterine contraction starts in the fundus near one of the cornua and spreads across and downwards. contraction lasts longest in the fundus where it is also more intense and contraction fades from all parts together.
  • 18.  POLARITY Polarity is the term used to describe the neuromuscular hormony that prevails between the two poles or segments of the uterus through out the labor. polarity disorganized = labor inhibited
  • 19. Contraction is the temporary reduction in the length of the fibers . Uterine muscles have unique property. During labour the contraction does not pass off entirely ,but muscle fibers retain some of the shortening of contraction instead of becoming completely relaxed, this termed as retraction . .
  • 20.  Intensity : gradually increases with advancement of labor until it become maximum in the second stage during delivery of the baby.  Intrauterine pressure raised to 40-50 mm Hg in first stage.  Duration : In the first stage the, the contraction last for about 30 sec., but gradually increase in duration with the progress of labour.  Frequency : in early stage, the contraction come at intervals of 10-15 mints. By the end of the second stage they occur at 2-3 mints. Intervals, last for 50-60 seconds and are very powerful 1.
  • 21.  Is the phenomenon of the uterus in labour in which the muscle fibers are permanently shortened.  Effects of retraction  Help in formation of lower segment  Maintains advancement of presenting part  Favouring separation of placenta  Haemostasis
  • 22.  By the end of the pregnancy body of the uterus is described as having divided in to two segments.  The upper segment, have been formed from the body of fundus, and is mainly concerned with concerned with contraction and retraction, it is thick and muscular.  The lower segment is formed of the isthmus and cervix, about 8-10 cm.  The lower segment is prepared for distention and dilatation.
  • 23.  The wall of the upper segment become progressively thickened with progressive thinning of the lower segment.  Distinct ridge is produced at the junction of two, called physiological retraction ring.  Physiological retraction ring should not be confused with pathological retraction ring also called as Bandl’s ring1 .  Once the cervix is fully dilated and the fetus can leave the uterus, the retraction ring rises no further 2 .
  • 24.  Here cervix is drawn up and gradually merges in to the lower uterine segment.  In the primiparous women it may result in complete effacement.  In multiparous women perceptible canal may remain.
  • 25. Effacement is the gradual thinning, shortening, and drawing up of the cervix, This is measured in percent. DESCRIPTION percentages from 0 to 100 EFFACEMENT OF CERVIX No changes to cervix 0% Effaced Cervix is half of the normal thickness 50% Effaced Cervix is completely thinned out 100% Effaced
  • 26.  Cervical dilation (or cervical dilatation) is the opening of the cervix, the entrance to the uterus, during childbirth, miscarriage, induce d abortion, or gynaecological surgery. Cervical dilation may occur naturally, or may 6 be induced by surgical or medical means . General guidelines for cervical dilation:  Latent phase: 0-3 centimeters  Active Labor: 4-7 centimeters  Transition: 8-10 centimeters  Complete: 10 centimeters. Delivery of the infant takes place shortly after this stage is reached
  • 27.  Latent phase: 0-3 centimeters  Active Labor: 4-7 centimeters  Transition: 8-10 centimeters  Complete: 10 centimeters. Delivery of the infant takes place shortly after this stage is reached.
  • 28.  During pregnancy, the os (opening) of the cervix is blocked by a thick plug of mucus to prevent bacteria from entering the uterus. During dilation, this plug is loosened. It may come out as one piece, or as thick mucus discharge from the vagina. When this occurs, it is an indication that the cervix is beginning to dilate.  Bloody show : is another indication that the cervix is dilating. Bloody show usually comes along with the mucus plug, and may continue throughout labor, making the mucus tinged pink, red or brown.
  • 29.  The sac of amniotic fluid is described as having two sections – the forewaters (in front of baby’s 4 head) and the hind waters (behind baby’s head).  During labor forewaters are formed as the lower segment of the uterus stretches and the chorion (the external membrane) detaches from it4.  The well flexed baby’s head fits into the cervix and cuts off the fluid in front of the head (forewaters) from the fluid behind (hind waters)4.
  • 30.  Pressure from contractions cause the forewaters to bulge downwards into the dilating cervix and eventually through into the vagina. This protects the forewaters from the high pressure applied to the hind waters during a contraction and keeps the membranes intact 4.  The forewaters transmit pressure evenly over the cervix which aids further dilatation 4 .
  • 31. 4
  • 32.  During a contraction the pressure is equalised throughout the fluid rather than directly squeezing the baby, placenta and umbilical cord.  This protects the baby and his/her oxygen supply from the effects of the powerful uterine contractions .
  • 33.  The optimum physiological time for the membranes to rupture spontaneously is at the end of the first stage of labor after the cervix become fully dilated and no longer supports the bag of forwaters 2.  When the baby is in an OP position the head may not flex as well to block off the hind waters = pressure is able to move into the forewaters and they may rupture. Early rupture of membranes if often a feature of an OP labour 2.
  • 34.  In longitudinal lie, there is a tendency of straightening out of fetal vertebral column.  This allow the fundal contraction to transmit through the podalic pole in to the fetal axis and hence allow mechanical stretching of lower segment and opening up of cervical canal .  In transverse lie fetal axis pressure is absent
  • 35.  PRINCIPLES  Non interference with watchful expectancy so as to prepare the patient for natural birth.  To monitor carefully – the progress of labour, maternal conditions, and fetal behaviour so as to detect any intrapartum complication early.
  • 36.  Management of normal labor aims at maximal observation with minimal intervention. The idea is to maintain the normalcy and to detect any deviation from the normal at the earliest possible moment.
  • 37.  This consist of basic evaluation of the current clinical condition.  Enquiry is to be made about the onset of labor pains or leakage of liquor, if any.  Thorough general and obstetrical examinations including vaginal examinations are to be carried out and recorded.  Records of antenatal visits, investigation reports and any specific treatment given, if available, are to be reviewed.
  • 38.  Environment Women may choose to give birth in their own home where they control the environment and feel comfortable in their own surroundings or they wish the security of a hospital birth where facilities are readily available for prompt and efficient action should an emergency occurs. A trusting atmosphere between a women and her caregivers, a feeling of being among friend’s and a knowledge of the skills required to cope with the stresses of labor set the scene for a positive childbirth experience.
  • 39. Emotional support consist of helping the mother to feel in control of herself to feel accepted whatever her reactions and behaviour may be and to complete her labor feeling that she is success, even if the outcome was not what she hoped for.
  • 40.  Consent and information giving Any individual who puts herself in the hands of professional attendants deserves to be kept fully informed about their actions and observations. The Midwife must takecare not only to talk to the mother but to ask for her consent to what she plans to do and to invite her comments and questions.
  • 41.  Prevention of infection The very nature of the care given during labor may expose both mother and fetus to the risk of infection. This is the responsibility of midwife to acquaint herself with the risks, prepare the woman physically during the antenatal period and to maintain hygiene and asepsis in order to prevent infection occuring, this include :
  • 42.  Blood : The haemoglobin level should be adequate and anemia should be corrected if necessary. WBCs are needed to fight invading organism and usually their ability to do so correlates with the general health and absence of fatigue.  Nutritional status: poverty may lead to malnurition. Education in using economic yet nutritious food, including how to prepare them may be an invaluable contribution from the midwife.
  • 43.  Skin and membranes : An intact skin provides an excellent barrier to organisms and it is important to protect its integrity. This involves the aviodance of surgical wounds whenever possible including how to prepare them may be an invaluable contribution from the midwife.  Hygiene : A clean body and environment will reduce the organisms which have assess to mother. This implies the need for barrier methods to be used.
  • 44.  Rest : A tired, exausted women will not be able to combat infection and if the mother has been deprived of sleep and rest prior to admission of during labor, the widwife may need to create an opportunity for sleeping if necessary by mild sedative drug.  General health and care of environment : A modern maternity unit should be constructed so as to limit the spread of infection. It should be sighted from a distance from any source of pathogenic organisms and should be designed for easy and effective cleaning and in a way which will reduce the transfer of air born organisms.
  • 45.  It is the responsibility of midwife to ensure that high standards of cleanliness are maintained even if she does not have managerial control over domestic services.  Antiseptics and asepsis: The midwife must always use sterile equipments and aseptic technique in order to avoid introduction foreign organism in to the genital tract.
  • 46.  several consideration govern the choice of position during the first stage of labor, of these the most important is that of maternal preference. In early labor, ambulation can be encouraged and during a contraction the woman often finds it comforting to lean forward, supporting her weight on a table or on her partner’s shoulder. lateral position will be the best as this avoids compression of the inferior venacava and consequent hypotension. changing position not only improves comfort but also help progress.
  • 47.  Remaining upright and leaning forward reduces this pressure while allowing your baby’s head to constantly bear down on your cervix. The result? Dilation tends to occur more quickly.
  • 48.  Nutrition : Advice prior to admission : the women’s need in labor is for energy and it is carbohydrates which provide. She should choose food that are light and easily digested such as bread and butter, fluids may be taken freely, although fizzy and very sweet drinks may induce vomiting. Intake in early labor : in some centers, no food is permitted after labor is established, on the basis that anesthesia could be needed. Policies in advance labor : most obstetric units withhold food in advanced labor. Some also discourage drinking but allow the women to have sips of water to keep her mouth comfortable.
  • 49.  Bladder care : The woman should be encouraged to empty her bladder every 1-2 hrs during labor.  The quantity of urine passed should be measured.  If the bladder remains full, the bladder neck can become nipped between the fetal head and the symphysis pubis. This may give rise to bruising which can slough during the perineum leaving a vesico-vaginal fistula. 
  • 50.  Vital signs : Pulse rate : A steady pulse rate is an indication that the women is in good condition. If the rate increases mare than 100 beats/min. it may indicative of infection, haemorrhage, ketoacidosis.  Temperature : this should remain with in the normal range. It should be recorded every 4 hrs.  Blood pressure : the effect of labor may be to further elevate a raised blood pressure. 
  • 51.  Bimanual or PV examinations are performed for a number of clinical reasons e.g. problems relating to menstruation, irregular bleeding, dyspareunia, abnormal vaginal discharge, pelvic pain, and here we are going to examine for early detection of any abnormality in labor process.
  • 52.  Toileting – hands and forearms should be washed, a scrubbing brush should be used for fingernails.  Sterile pair of gloves is to be put on.  Vulval toileting should be performed and same solution is poured over the vulva by separating the labia minora by the fingers of left hand.  Gloved middle and index finger of the right hand smeared with antiseptic cream introduced in to vagina after separating the labia by two fingers of the left hand.
  • 53.  Complete examination should be done before fingers are withdrawn.  Vaginal examination should be kept as minimum as possible.
  • 54.  Degree of cervical dilatation in centimeters  Degree of effacement of cervix  Status of membranes and if ruptured –color and liquor.  Presenting part and its position by noting the fontanelles and sagittal suture in relation to to the quadrants of the pelvis.  Caput and moulding of head  Station of the head in relation to ishchial spines.
  • 55.  Fetal condition during labor can e assessed by obtaining information about the fetal heart rate and patterns. The pH of the fetal blood and the amniotic fluid.  The doppler ultrasound apparatus can be used for measuring fetal heart rate and rate should be between 120-160 beats/min.
  • 56.  Non- pharmacological methods :  Transcutaneous electrical nerve stimulation (TENS) : It work be interrupting pain transmission along the sensory pathway.  Hypnosis : Is also a pain relieving technique. Women are usually taught self hypnosis and in suitable subject it may be successful.
  • 57.  Pharmacological methods : Sedative and analgesics : The sedative given were usually the chloral derivatives. Analgesics which are used in early labor are in mild to moderate analgesic range e.g. paracetamol.  Narcotics : A narcotic is a strong analgesic drug with some sedative properties. These include pethidine, morphine, naloxone, pentazocine.  Inhalation analgesia : They offer effective pain relief for the majority, of women with the adnvantage that all their effects are short lived and they donot give rise to any complication in the neonate. The agent used is Entonox. Entonox is the trade name used to describe an equal mixture of oxygen and nitrous oxide. 
  • 58. Physiology in the second stage of labor
  • 59.  Second stage of labor begins when the cervix is fully dilated and ends with the baby’s birth, it is a time when the whole tempo of activity changes. The mother’s passive control during the long hours of the first stage is replaced by intense physical effort and exertion for a comparatively short period. Both parents require stamina, courage and confidence in the skill of attendant midwife.
  • 60.  2 hours in Primi-gravida  30 minutes in multi- gravida
  • 61. 1) Uterine action 2)Soft tissue replacement
  • 62. 1. Uterine actions : contractions becomes stronger and longer but may be less frequent affording mother and fetus a recovery period during the resting phase. There are progressive, continued contractions and retractions of the upper uterine segment while the lower segment and cervix passively dilate and thin. The membrane often rupture spontaneously at the onset of second stage.
  • 63. The consequent drainage of liquor allows the hard , round fetal head to be directly applied to the vaginal tissues and aid distension. Fetal axis pressure increases flexion of the head which results in smaller presenting diameters, more rapid progress and less trauma to both mother and fetus The nature of the contraction changes. They become more expulsive as pressure is exerted on the rectum and pelvic floor.
  • 64. 2) Soft tissue replacement : As the fetal head descends, the soft tissue of the pelvic become displaced. Anteriorly the bladder is pushed upwards in to the abdomen where it is at less risk of injury during descent . Posteriorly the rectum becomes flattened in to the sacral curve and the pressure of the advancing head expels any residual fecal matter. The fetal head become visible at the vulva, advancing with each contraction and receding during the resting phase untill crowing takeplace and the head is born
  • 65.  Presumptive signs :  Expulsive uterine contractions : it is possible for a women to feel a strong desire to push before the cervix is fully dilated, specially if the fetus is in an occipto-posterior position.  Rupture of the fore-water : this may occur at anytime during labor.  Dilation and gaping of the anus: Deep engagement of the presenting part and premature maternal effort may produce this sign.
  • 66. Appearance of the presenting part : Excessive moulding may result in the formation of a large caput succedaneum which can protrude through the cervix prior to the full dilatation . Similarly a breech presentation may be visible when the cervix only 7 to 8 cm dilated.  Show : This must be distinguished from bleeding due to partial separation of the placenta or that caused by ruptured vasa previa.  Congestion of the vulva : Enthusiastic premature pushing may also cause this. 
  • 67.  As the fetus descends soft tissue and bony structures exert pressure which force fetus to negotiate the birth canal by a series of passive movements. Collectively these movements are called the mechanism of labor.  Principles common to all are : Descent take place throughout.  Whatever part leads and first meets the resistance of the pelvic floor will rotate forward untill it comes under the symphysis pubis  Whatever emerges from the pelvis will pivot around the pubic bone. 
  • 68.  During the mechanism of normal labor the fetus turns slightly to take advantage of the widest available space in each plane of the pelvis The lie is longitudinal.  The presentation is cephalic  The position is right or left occipitoanterior  Attitude is good flexion  Denominator is occiput  The presenting part is the posterior part of the anterior parietal bone 
  • 69. CARDINAL MOVEMENTS OF LABOR i
  • 70. Engagement Flexion Internal rotation Descent Crowning Extension External rotation Expulsion
  • 71.  In a first-time pregnancy descent is usually slow but steady; in subsequent pregnancies descent may be rapid. Progress in descent of the presenting part is determined by abdominal palpation until the presenting part can be seen at the introitus.
  • 72.  i. ii. iii. iv. v. Descent refers to the progress of the presenting part through the pelvis. Descent depends on at least four forces: Pressure exerted by the amniotic fluid. Direct pressure exerted by the contracting fundus on the fetus. Force of the contraction of the maternal diaphragm and abdominal muscles in the second stage of labor. Extension and straightening of the fetal body. The effects of these forces are modified by the size and shape of the maternal pelvic planes and the size of the fetal head and its capacity to mold.
  • 73.  The degree of descent is measured by the station of the presenting part As mentioned, little descent occurs during the latent phase of the first stage of labor. Descent accelerates in the active phase when the cervix has dilated to 5 to 7 cm. It is especially apparent when the membranes have ruptured.
  • 74.  When the bi-parietal diameter of the head passes the pelvic inlet, the head is said to be engaged in the pelvic inlet .  In most nulliparous pregnancies this occurs before the onset of active labor because the firmer abdominal muscles direct the presenting part into the pelvis.  In multiparous pregnancies, in which the abdominal musculature is more relaxed, the head often remains freely movable above the pelvic brim until labor is established.
  • 75. FIFTH’S FORMULA
  • 76.  Asynclitism : The head usually engages in the pelvis in a synclitic position, one that is parallel to the anteroposterior plane of the pelvis. Frequently asynclitism occurs (the head is deflected anteriorly or posteriorly in the pelvis), which can facilitate descent because the head is being positioned to accommodate to the pelvic cavity. However, extreme asynclitism can cause cephalopelvic disproportion, even in a normal-size pelvis, because the head is positioned so that it cannot descend.
  • 77.  As soon as the descending head meets resistance from the cervix, pelvic wall, or pelvic floor, it normally flexes so that the chin is brought into closer contact with the fetal chest Flexion permits the smaller suboccipito-bregmatic diameter (9.5 cm) rather than the larger diameters to present to the outlet.  Flexion has advantage of bringing the shortest diameter of the head into descent.
  • 78.  The maternal pelvic inlet is widest in the transverse diameter.  Therefore the fetal head passes the inlet into the true pelvis in the occipito-transverse position.  The outlet is widest in the antero-posterior diameter, however.  Therefore, for the fetus to exit, the head must rotate.  Internal rotation begins at the level of the ischial spines but is not completed until the presenting part reaches the lower pelvis.
  • 79.  As the occiput rotates anteriorly, the face rotates posteriorly. With each contraction the fetal head is guided by the bony pelvis and the muscles of the pelvic floor.  Eventually, the occiput will be in the midline beneath the pubic arch. The head is almost always rotated by the time it reaches the pelvic floor.  Both the levator ani muscles and the bony pelvis are important for achieving anterior rotation. A previous childbirth injury or regional anesthesia may compromise the function of the levator sling.
  • 80.  Theories which explains the anterior rotation of occiput are : # Slope of pelvic floor # Pelvic shape # Law of unequal flexibility
  • 81. Slope of pelvic floor : two halves of levator ani form a gutter & viewed from above, the direction of fibres is downwards, backwards and towards the midline. Thus with each contraction, the head, occiput in particular, in a well flexed position, stretches the levator ani, particularly that half which is in relation to occiput. # after contraction passes off, elastic recoil of the levator ani occur, bringing the occiput forwards toward the midline. The process is repeated untill the occiput is placed anteriorly “this is called rotation by Law of pelvic floor” 
  • 82.  Pelvic shapes : forward inclination of the side walls of the cavity, narrow bispinous diameter and ant.-Post. Diameter of the outlet results in putting the long axis of the head to accommodate in the maximum available diameter  Law of unequal flexibility : the internal rotation is primarily due to inequalities in the flexibility of the component parts of the fetus.
  • 83.  In O.T. position ,there will be anterior rotation by 2/8 of a circle of the occiput.  In oblique anterior position ( O. A.), the rotation will be 1/8 of a circle forward, placing the occiput behind the symphysis pubis.  There is always accompanying movement of descent with internal rotation
  • 84.  Pre-requisites i. ii. iii. iv. of internal rotation : Well flexed head Efficient uterine contractions. Favourable shape of pelvis Good tone of levator ani mucles.
  • 85.  Crowning is when baby’s head remains visible at vaginal outlet without slipping back in as mother is pushing continuously during birth
  • 86.  This is the torsion because of the internal rotation, and it depends upon the location of the occiput in-relation to pelvis.  In LOA or ROA torsion will be of 1/8th of circle.  In LOT or ROT torsion will be of 2/8th of the circle.  And torsion is corrected on restitution.
  • 87.  When the fetal head reaches the perineum for birth, it is deflected anteriorly by the perineum. The occiput passes under the lower border of the symphysis pubis first, then the head emerges by extension: first the occiput, then the face, and finally the chin.
  • 88.  After the head is born, it rotates briefly to the position it occupied when it was engaged in the inlet. This movement is termed restitution.  The 45-degree turn realigns the infant's head with her or his back and shoulders. The head can then be seen to rotate further.
  • 89.  This external rotation occurs as the shoulders engage and descend in maneuvers similar to those of the head.  Bisacromial diameter had rotated into the anterio-posterior dimeter of the pelvis  The posterior shoulder is guided over the perineum until it is free of the vaginal introitus.
  • 90. downward traction : ant. shoulder under the pubis.  upward movement: post. shoulder is delivered   and the trunk of the baby is born by flexing it laterally in the direction of the symphysis pubis.  When the baby has completely emerged, birth is complete, and the second stage of labor ends.
  • 91.  The onset: full dilatation of the cervix  bear down : descent of the presenting part the urge of defecate  uterine contraction & expulse force
  • 92. Duration - 50 min in nulliparous - 20 min in multiparous -become abnormally long if
  • 93. A contracted pelvis
  • 94. A large fetus
  • 95.  Impaired expulsive effort from conduction analgesia or intense sedation
  • 96.  Fetal heart rate -low risk: 15 min -high risk: 5 min -slowing of the FHR : due to fetal head compression : reduce placental perfusion : recovery after the contraction and expulsive effort cease
  • 97. Descent of the fetus obstruct umbilical cord blood flow (tighten loop or cord neck) ->uninterrupted maternal expulsive effort can be dangerous to the fetus   Maternal tachycardia in second stage :common, must not be mistaken for a normal FHR
  • 98. leg : half-flexed deep breath & breath held exert downward pressure  She should not be encouraged to “push” beyond the time of completion of each uterine contraction.  In increasing bulging of the perineum encouragement is very important.  FHR is likely to be slow  Feces is frequently expelled perineum begins to bulge , tense and glistening scalp may be visible 
  • 99.  Preparation for delivery -The dorsal lithotomy position : increase the diameter of the pelvic outlet : using leg holder and stirrup -> result in spontaneous tear or fourth degree -vulvar and perineal cleansing : sterile drape and gowning, gloving
  • 100.  Delivery of the head : crowning encirclement of the largest head diameter by the vulval ring. - one hand: a towel-draped, gloved hand may be exert forward pressure on the chin of the fetus through the perineum just in front of the coccyx - with other hand: exerts pressure superiorly against the occiput.
  • 101.  Delivery of shoulder The occiput : Turns toward one of the maternal thigh Fetal head: Transverse position sucking the nasopharynx or checking for a cord.
  • 102.  Clearing the nasopharynx : prevent of aspiration of amnionic fluid, debris, blood  The face: quickly wiped  Nares and mouth : aspirated  Nuchal cord after head dilevered, ascertain the umbilical cord -occur 25%, ordinarily do no harm -drawn down or cut (too tightly)
  • 103.  Between two clams: 4 or 5cm and later 2 or 3cm from the fetal abdomen
  • 104.  Timing of cord clmaping After delivery, the infant is placed at the level of vagina for 3 min, the fetoplacental circulation is not occluded 80 ml of blood – shift to the fetus (50mg of Fe) After first clearing the airway (30 second) -> then clamps the cord
  • 105.  After the baby has been born the placenta, which has sustained baby throughout pregnancy, is no longer needed; mother need to push it out along with the remaining part of the umbilical cord that runs between the placenta and baby.
  • 106. With no intervention the normal process is that baby is born and you can greet and hold her while she remains attached to the umbilical cord. The cord supplies oxygenated blood which supports her until she starts to breathe on her own. The cord runs from her tummy to the placenta, which is still attached to the inside of the womb until the placenta detaches and mother push it out.
  • 107.  Immediately after delivery of the infant, the height of the uterine fundus and its consistency are ascertained.  As long as the uterus remains firm and there is no unusual bleeding, watchful waiting until the placenta is separated is the usual practice.  No massage is practiced; the hand is simply rested on the fundus frequently, to make certain that the organ does not become atonic and filled with blood behind a separated placenta.
  • 108.  Vaginal Delivery  < 500 mL  Cesarean Section  < 1000 mL
  • 109.  When the placenta has separated, it should be ascertained that the uterus is firmly contracted.  The mother may be asked to bear down, and the intra-abdominal pressure so produced may be adequate to expel the placenta.  If these efforts fail, or if spontaneous expulsion is not possible
  • 110. In 2010 ICM/FIGO formed a Multidisciplinary expert taskforce to define the components of physiological management. ICM conducted a survey of current best practice and 39 ICM Member Association Countries responded. There was consensus on; 1) Signs of separation 2) How to support women to expel the placenta 3) The first two hours after the birth
  • 111.  1) Signs of separation Change in the size, shape and position of the uterus – A small gush of blood – The cord lengthens – The woman becomes uncomfortable, get contractions or feel that she wants to change position or bear down –  Most placentas will be delivered in one hour.
  • 112. 2) Supporting women to expel the placenta, after signs of separation Encourage woman into upright position  The placenta may be expelled spontaneously or  Encourage maternal effort to expel placenta  The birth attendant catches the placenta in cupped hands or a bowl  If the membranes are slow then assist by holding the placenta in two hands and gently turning it until the membranes are twisted then exert gentle tension 
  • 113.  Physiologic    Oxytocics are not used Placenta is delivered by gravity and maternal effort Cord is clamped after delivery of the placenta  Active     (“expectant”) management Management Oxytocic is given Cord is clamped Placenta delivered by controlled cord traction (CCT) with counter-traction on the fundus Fundal massage or pressure
  • 114.  Oxytocin  Within 1 minute of birth, palpate abdomen to rule out presence of another baby  Give oxytocin  CCT  Await strong uterine contraction (2–3 minutes)  Apply controlled cord traction while applying counter-traction above pubic bone  If placenta does not descend, stop traction and await next contraction
  • 115.  Try not to give oxytocic  Try not to use CCT or any manual interference with uterus at fundus  Try to encourage mother to concentrate on feeling for next contraction or urge to push  When mother feels contraction or urge or there are signs of separation, encourage mother and help her change posture  If placenta does not deliver spontaneously, wait, try putting baby to breast and encourage maternal effort
  • 116.  Try to give one ampule of oxytocic (5 units oxytocin and 0.5 mg ergometrine routinely or 10 units synthetic oxytocin if mother has high BP) immediately after delivery of anterior shoulder  Clamp cord 3 mints. after delivery of baby  When uterus has contracted, try to deliver placenta by CCT with protective hand on abdomen helping to shear off placenta and preventing uterine inversion  Try not to give any special instructions about posture
  • 117. Physiological Management Active management Uterotonic agent None or after placenta With delivery of delivered anterior shoulder or baby Uterus Assessment of size Assessment of size and tone after delivery and tone after delivery Cord traction None controlled cord traction when uterus contracted Cord clamping Variable Early
  • 118.  Use   oxytocin, when available: If oxytocin is not available, use syntometrine or ergometrine If oxytocic drugs are not available, use nipple stimulation  Do not use ergometrine in women with hypertension or heart disease  Store oxytocics in refrigerator (2–8ºC) and away from light  Misoprostol rectally has advantages.
  • 119.  Advantages    Causes uterus to contract Acts within 2.5 minutes when given IM Generally does not cause side effects  Disadvantages    More expensive than ergometrine IM or IV preparations only Not heat stable
  • 120.  Advantages   Low price Effect lasts 2–4 hours  Disadvantages      Takes 6–7 minutes to become effective when given IM; oral form insufficiently effective Causes tonic uterine contraction Increased risk of hypertension, vomiting, headache Contraindicated in women with hypertension or heart disease Not heat stable
  • 121.  Nipple stimulation has not been shown to reduce risk of PPH  Randomized controlled trial of suckling immediately after birth with over 4,000 subjects in Malawi showed no significant difference in frequency of PPH, mean blood loss or retained placenta  When oxytocics are not available, CCT and fundal massage should be performed  Advantages of early breastfeeding and nipple stimulation:   Stimulates natural production of oxytocin May maintain tone of contracted uterus Benefits baby  Bullough, Msuku and Karonde 1989.
  • 122.  Determine the fundal position and size of the uterus.  Ensure that the uterus is contracted (can be enhanced with oxytocin and uterine massage).  Examine the placenta for completeness and detection of abnormalities.  Suturing of lacerations. - Is justified in patients with bleeding originating high in the genital tract.
  • 123. Uterine exploration: - No longer recommended for normal deliveries or those following previous cesarean delivery. - Is justified in patients with bleeding originating high in the genital tract. - The cervix should be visualized after all forceps deliveries
  • 124.  Observe the vital signs.  Palpate the abdomen to assess and monitor uterine tone and size.  Do uterine massage.  Ensure continuous infusion of oxytocin.  Encourage early breastfeeding to promote endogenous oxytocin release.  assess the lower genital tract for bleeding.  repair of an episiotomy or any lacerations.  Close observation every 15 minute for the next hour.
  • 125.  http://en.wikipedia.org/wiki/Cervical_dilati on  Dutta DC textbook of obstetrics. edition sixth.2013  http://healthpages.org/pregnancy/pretermbirth-self-monitoring-contractions/  http://midwifethinking.com/2010/08/20/indefence-of-the-amniotic-sac/  http://www.studentmidwife.net/fob/bandlsring.72868/
  • 126. Q. Normal labour is the process by which contractions of the gravid uterus expel the fetus and the other products of conception A-between 37 and 42 weeks from the last menstrual period B- Before 37 weeks gestation C-After 42 weeks gestation D- After 24 weeks gestation
  • 127. Q. Fetal lie refers to ??? A. longitudinal axis of the fetus in relation to the oblique axis of the maternal uterus longitudinal axis of the fetus in relation to the transverse axis of the maternal uterus longitudinal axis of the fetus in relation to the long axis of the maternal uterus longitudinal axis of the fetus in relation to the long axis of the maternal pelvis B. C. D.
  • 128. Q. True onset of labor is defined by which one of the following A. Passage of bloody show Occurance of uterine contraction Excessive fetal movement Cervical dilation and effacement Gush of vaginal fluid B. C. D. E.
  • 129. Q. False contractions characteristics (Braxton-Hicks) all true Except A. Occur At Irregular Intervals Intensity doesn't change Pain primarily in lower abdomen Pain usually relieved with sedation Cervix dilate B. C. D. E.
  • 130. Q. Which is true about retraction A. Relaxion after uterine contraction Intensity of uterine contraction in upper and lower segment The myometrium of the upper uterine become shorter after contraction the pacemaker in the right cornu of the uterus B. C. D.