intrapartum care

1. 2/29/20
1
Labour Care
By
Ahmed Elbohoty MD, MRCOG
Assistant professor of obstetrics and gynecology
Ain Shams University
1
Preparation
2/29/20
ELBOHOTY
2

2. 2/29/20
2
Child Birth Choices
???
Prepared/Natural
Water Birth
3
Antenatal
education
about the
signs of
labour:
• how to differentiate between
• Braxton Hicks contractions and
active labour contractions
• the expected frequency of
contractions and how long they last
• recognition of amniotic fluid (‘waters
breaking’)
• description of normal vaginal loss.
• how to contact their midwifery care
team and what to do in an
emergency.
• what to expect in the latent first
stage of labour
• how to work with any pain they
experience
4

3. 2/29/20
3
Obstetric care
• Consultant led unit
• Midwifery led unit – stand alone/co-located
•Home births
5
• The Midwife - midwives are the experts in normal birth.
• She is responsible for taking a clinical risk assessment, recognising
and promoting normality and determining and reacting when
labour deviates from normal and referring for an obstetric
opinion.
• She will encourage open communication with the obstetrician.
• The Obstetrician will support the midwife in providing care to low
risk women and responding to deviations from normal.
• Maternity Support Worker - may be involved in the care of the
women working under the direction of the midwife
29/02/2020 ELBOHOTY
6

4. 2/29/20
4
Where ???
2/29/20 ELBOHOTY
7
•Where possible women should default to
midwifery led care and be encouraged to give
birth on the Birth Centre or at home.
•The benefits to women of having midwife led
care include increased feelings of control in
labour, increased chance of normal birth,
increased likelihood of initiating breast feeding
and reduced risk of interventions.
•For women with substantial medical/obstetric
complications obstetric led care is
recommended.
29/02/2020 ELBOHOTY
8

5. 2/29/20
5
• All healthcare professionals should ensure that there is a culture of respect for
each invidulaized woman and talk with her and her companions about birth and
the choices to be made when giving birth.
• one-to-one care in labour for all women
• Commissioners and providers should ensure that there are:
• robust protocols in place for transfer of care between settings
• clear local pathways for the continued care of women who are transferred from one
setting to another
29/02/2020 ELBOHOTY
Standardization of care In all birth settings
9
Give the woman the following information about all local
birth settings:
•Access to midwives, including:
• the likelihood of receiving one-to-one care throughout labour (not necessarily being cared
for by the same midwife for the whole of labour)
•Access to medical staff (obstetric, anaesthetic and neonatal).
•Access to pain relief, including birthing pools, Entonox, other
drugs and regional analgesia.
•The likelihood of being transferred to an obstetric unit (if this
is not the woman's chosen place of birth), the reasons why
this might happen and the time it may take.
29/02/2020 ELBOHOTY
10

6. 2/29/20
6
Team
29/02/2020 ELBOHOTY
Independent practitioners
Advanced skills: cannulation, suturing, prescribing
Midwives:
Variable level of skills: ST1-2/FY1-2/GP/ST3-7
Need to be explicit in instructions for delegation
ST 1-7 :
Epidural, spinal and GAs
Input in managing critically ill obstetric patients e.g. Severe PET,
massive obstetric haemorrhage
Anaesthetis
t:
Consultant/
trainees
40 hour cover (or more)
Consultant
–
11
29/02/2020 ELBOHOTY
Birth settings
12

7. 2/29/20
7
Options
29/02/2020 ELBOHOTY
higher rate of spontaneous vaginal birth
There is a small increase in the risk of an adverse outcome for the baby for lowrisk nuliparous only
(1/100) however for multiparous (3/1000) ; there is no additional risk.
Home birth
higher rate of spontaneous vaginal birth
The outcome for the baby is no different compared with an obstetric unit.
Free standing
midwifery unit
Lesser rate of spontaneous vaginal birth than home or free standing but more than obstetric unit
Alongside
midwifery unit
higher rate of interventions, such as instrumental vaginal birth, caesarean section and episiotomy
Direct access to obstetricians, anaesthetists,, neonatologists and epidural analgesia
A pre-existing medical condition or has had a previous complicated birth .
obstetric unit
13
29/02/2020 ELBOHOTY
14

8. 2/29/20
8
29/02/2020 ELBOHOTY
15
29/02/2020 ELBOHOTY
16

9. 2/29/20
9
29/02/2020 ELBOHOTY
17
29/02/2020 ELBOHOTY
18

10. 2/29/20
10
29/02/2020 ELBOHOTY
19
29/02/2020 ELBOHOTY
20

11. 2/29/20
11
29/02/2020 ELBOHOTY
21
conditions indicating individual assessment when
planning place of birth
• Atypical antibodies not putting the baby at risk of haemolytic disease
• Sickle-cell trait
• Thalassaemia trait
• Anaemia – haemoglobin 85–105 g/litre at onset of labour
• Previous complications
• Stillbirth/neonatal death with a known non-recurrent cause
• Pre-eclampsia developing at term
• Placental abruption with good outcome
• History of previous baby more than 4.5 kg
• Extensive vaginal, cervical, or third- or fourth-degree perineal trauma
• Previous term baby with jaundice requiring exchange transfusion
• BMI 30-35
• ……..
29/02/2020 ELBOHOTY
22

12. 2/29/20
12
Intrapartum transfer
•Maternal causes
•Fetal causes
29/02/2020 ELBOHOTY
23
Transfer when Observations of the unborn baby:
•any abnormal presentation, including cord
presentation, transverse or oblique lie
•high (4/5-5/5 palpable) or free-floating head in a
nulliparous woman
•suspected fetal growth restriction or macrosomia
•suspected anhydramnios or polyhydramnios
•fetal heart rate below 110 or above 160
beats/minute
•a deceleration in fetal heart rate heard on
intermittent auscultation
•reduced fetal movements in the last 24 hours
reported by the woman.29/02/2020 ELBOHOTY
24

13. 2/29/20
13
Transfer when Observations of the woman:
• pulse over 120 beats/minute on 2 occasions 30 minutes apart
• a single reading of either raised diastolic blood pressure of 110 mmHg or
more or raised systolic blood pressure of 160 mmHg or more
• either raised diastolic blood pressure of 90 mmHg or more or raised systolic
blood pressure of 140 mmHg or more on 2 consecutive readings taken 30
minutes apart
• a reading of 2+ of protein on urinalysis and a single reading of either raised
diastolic blood pressure (90 mmHg or more) or raised systolic blood pressure
(140 mmHg or more)
• temperature of 38°C or above on a single reading, or 37.5°C or above on 2
consecutive readings 1 hour apart
• any vaginal blood loss other than a show
• rupture of membranes more than 24 hours before the onset of established
labour
• the presence of significant meconium
• pain reported by the woman that is differs from the pain normally associated
with contractions
29/02/2020 ELBOHOTY
25
Other indication
• Delay in the first or second stages of labour
• Obstetric emergency –
• Retained placenta
• Third- or fourth-degree tear or other complicated perineal trauma requiring
suturing.
29/02/2020 ELBOHOTY
26

14. 2/29/20
14
Consultant led care
29/02/2020 ELBOHOTY
27
The labour ward team
•Midwives:
• Independent practitioners
• Advanced skills: cannulation, suturing, prescribing
•ST 1-2
• Variable level of skills
• Need to be explicit in instructions for delegation
•Anaesthetist
• Epidural, spinal and GAs
• Input in managing critically ill obstetric patients e.g. Severe PET, massive
obstetric haemorrhage
•Consultant – 40 hour cover (or more)
28

15. 2/29/20
15
Diagnosis of labour?
29/02/2020 ELBOHOTY
29
Initial assessment
•Listen to the woman.
•Review clinical records
•Ask about vaginal loss and contractions
•Check temperature, pulse, BP, urinalysis
•Observe contractions, fetal heart rate (FHR)
•Palpate abdomen
•Offer vaginal exam
29/02/2020 ELBOHOTY
30

16. 2/29/20
16
Assessment
• Consider an early assessment of labour by telephone triage provided by a
dedicated triage midwife for all women.
• Consider a face-to-face early assessment of labour for all low-risk nulliparous
women, either:
• at home (regardless of planned place of birth) or
• in an assessment facility in her planned place of birth (midwifery-led unit or obstetric unit), comprising one-to-
one midwifery care for at least 1 hour.
29/02/2020 ELBOHOTY
31
•Include the following in any early or triage assessment of
labour:
•ask the woman how she is, and about her wishes,
expectations and any concerns she has
•ask the woman about the baby’s movements, including
any changes
•give information about what the woman can expect in
the latent first stage of labour and how to work with
any pain she experiences
•give information about what to expect when she
accesses care
•The triage midwife should document the guidance of care
that she gives to the woman.
29/02/2020 ELBOHOTY
32

17. 2/29/20
17
definitions of labour:
•Latent first stage of labour:
•a period of time, not necessarily continuous,
when: there are painful contractions and there is
some cervical change, including cervical
effacement and dilatation up to 4 cm.
•Established first stage of labour when:
•there are regular painful contractions and there is
progressive cervical dilatation from 4 cm.
•Cervical dilatation of 6 cm should be threshold
for active phase of labor! ACOG
29/02/2020 ELBOHOTY
33
Women not in established
labour
•If initial assessment normal, offer individualised support and
analgesia if needed
• Encourage these women to remain at/return home , unless
doing so leads to a significant risk that she could give birth
without a midwife present or become distressed.
• Recognise that a woman may experience painful contractions without cervical
change, and although she is described as not being in labour, she may well think
of herself as being ‘in labour’ by her own definition
29/02/2020 ELBOHOTY
34

18. 2/29/20
18
Management of latent first stage of labour.
•Advise the woman and her birth
companion(s) that breathing exercises,
immersion in water and massage may
reduce pain
29/02/2020 ELBOHOTY
35
Prolonged latent phase
• There is no standard definition for a prolonged latent phase of labour.
• Mal positions may lead to prolonged latent phase. Between 10 – 30%
of all fetuses in early labour present in the occipito posterior (OP)
position but most subsequently rotate spontaneously .
• On suspicion of OP position early support and advice to women from
the midwife on how to cope may be of benefit.
• A prolonged latent phase of labour can be a discouraging and
exhausting experience for women.
• If a woman attends the unit for a THIRD time and remains in latent
phase of labour after clinical assessment of maternal and fetal
wellbeing (consider CTG) a review by a senior midwife is
recommended where an individualised plan of care incorporating the
woman’s preferences can be created.
29/02/2020 ELBOHOTY
36

19. 2/29/20
19
•If any of the following signs or symptoms are present
at any assessment, referral to the duty obstetrician is
recommended
•Maternal exhaustion, pyrexia, tachycardia or
dehydration
•Fetal distress
•Failure of descent of the presenting part or failure
of cervical dilation despite, regular uterine
contractions
29/02/2020 ELBOHOTY
37
* Personal
* Dating
* Detailed Obstetric history
* Past & Family history
* Any recommendation?
* ………………………………………..
Review clinical records:
29/02/2020 ELBOHOTY
38

20. 2/29/20
20
Physical Examination:
29/02/2020 ELBOHOTY
39
Abdominal Examination:
•Obstetrical Grips:
(The 4 maneuvers of Leopold)
•Fundal Grip
•Umbilical Grip
•Pelvic Grips
29/02/2020 ELBOHOTY
40

21. 2/29/20
21
•Lie
•Presentation
•Position of the back
•Attitude of the fetus
•Amount of liquor
•Expected [Estimated] Fetal Weight
•Engagement
•Obstetrical Grips will allow you identify:
29/02/2020 ELBOHOTY
41
Estimation of the symphesiofundal level
29/02/2020 ELBOHOTY
42

22. 2/29/20
22
Leopold maneuver
29/02/2020 ELBOHOTY
43
Leopold maneuver
29/02/2020 ELBOHOTY
44

23. 2/29/20
23
Do not perform cardiotocography on admission for low-risk women in
suspected or established labour in any birth setting as part of the initial
assessment.
Auscultate the fetal heart rate for a minimum of 1 minute immediately
after a contraction. Palpate the woman’s pulse to differentiate between
the heart rates of the woman and the baby.
29/02/2020 ELBOHOTY
45
Head engagement
29/02/2020 ELBOHOTY
46

24. 2/29/20
24
ASSESSMENT OF CONTRACTIONS BY PALPATION
Assess contractions for frequency and duration,by placing one hand on
the uterine fundus
Determine frequency-note the time from the beginning of the
contraction to beginning of next contraction
29/02/2020 ELBOHOTY
47
1. Vulva & vagina :
2. Cervix :
• Consistency
• Position
• Effacement
• Dilatation
3. Presenting part :
Type (vertex ,face,brow, breech or
shoulder).
Position and Station.
4. Condition of membranes
5. Pelvic capacity ???
(inlet,cavity& outlet)
3. Pelvic examination :
29/02/2020 ELBOHOTY
48

25. 2/29/20
25
29/02/2020 ELBOHOTY
When conducting a vaginal examination:
•be sure that the examination is necessary to the
decision-making process
•recognise that a vaginal examination can be very
distressing for a woman
•explain the reason for the examination and what
will be involved
•ensure the woman’s informed consent, privacy,
dignity and comfort
•explain sensitively the findings of the
examination
49
29/02/2020 ELBOHOTY
•If the woman appears to be in
established labour.
•If there is uncertainty about
whether the woman is in
established labour, it may be helpful
after a period of assessment.
When to offer Vaginal examination :
50

26. 2/29/20
26
29/02/2020 ELBOHOTY
51
29/02/2020 ELBOHOTY
52

27. 2/29/20
27
29/02/2020 ELBOHOTY
53
Multipara
Primipara
•Cervical Dilatation and Effacement:
•Effacement precedes dilatation in primiparas
•Effacement and dilatation occur simultaneously in
multiparas
29/02/2020 ELBOHOTY
54

28. 2/29/20
28
29/02/2020 ELBOHOTY
• Indication:
• If it is uncertain whether prelabour rupture of
the membranes has occurred, offer the
woman a speculum examination to
determine whether the membranes have
ruptured.
• Avoid digital vaginal examination in the
absence of contractions.
• Do not carry out it
• if it is certain that the membranes have
ruptured.
Speculum Vaginal examination :
55
4. Investigations :
NOT NEEDED
29/02/2020 ELBOHOTY
56

29. 2/29/20
29
The partogram
•It is a pictorial assessment of the progress of normal
labour.
•WHO partogram use in the standard method resulted in
a reduction in
• the incidence of prolonged labour,
• the need for augmentation
• the caesarean section rate.
29/02/2020 ELBOHOTY
57
Should we use it?
• The partogram has been in use for over 20 years and its use has been
shown to be associated with a reduction in prolonged labour,
reduction in the augmentation of labour and a reduction in sepsis.
• However, the continued use of the partogram in resource-rich
settings has been questioned.
• A Cochrane review has demonstrated that routine use of a partogram
does not convey any effect on caesarean section rate nor other
aspects of care in labour. Some reduction of caesarean sections rates
were demonstrated with partogram usage in settings with poorer
access to healthcare resources. The authors conclude that, in the
absence of stronger evidence, the routine use of the partogram
should be locally determined.
29/02/2020 ELBOHOTY
58

30. 2/29/20
30
The Partogram
•An action line of 4 hours should be used, as
earlier action lines increase interventions.
•If progress is to the right of the action line,
then it is considered to be prolonged and
action should be taken.
•The NICE guidance on caesarean section states
that a 4 hour action line reduces the rate of
caesarean sections.
29/02/2020 ELBOHOTY
59
Components of the partograph
•Details
•Diagnosis
•Fetal condition
•Progress of labour
•Maternal condition
•Outcome: ………………
29/02/2020 ELBOHOTY
60

31. 2/29/20
31
Fetal condition
• this part of the graph is used to monitor and assess fetal condition
• 1 - Fetal heart rate
• 2 - membranes and liquor
• 3 - moulding the fetal skull bones
• 4- Caput
29/02/2020 ELBOHOTY
61
moulding the fetal skull bones
•separated bones . sutures felt easily ……………….….O
•bones just touching each other ………………………..+
•overlapping bones ( reducible 0 ……………………...++
•severely overlapping bones ( non – reducible ) ……..+++
29/02/2020 ELBOHOTY
62

32. 2/29/20
32
progress of labour
• Cervical dilatation
• Descent of the fetal head
• Fetal position
• Uterine contractions
29/02/2020 ELBOHOTY
63
Action line
• The action line is drawn 4 hour to the right of the alert line and
parallel to it
29/02/2020 ELBOHOTY
64

33. 2/29/20
33
29/02/2020 ELBOHOTY
65
Uterine contractions
29/02/2020 ELBOHOTY
66

34. 2/29/20
34
Palpate number of contraction in ten minutes
and duration of each contraction in seconds
•Less than 20 seconds:
•Between 20 and 40 seconds:
•More than 40 seconds:
29/02/2020 ELBOHOTY
67
maternal condition
Name / DOB /Gestation
Medical / Obstetrical issues
Assess maternal condition regularly by monitoring :
• drugs , IV fluids , and oxytocin , if labour is augmented
• pulse , blood pressure
• Temperature
• Urine volume , analysis for protein and acetone
29/02/2020 ELBOHOTY
68

35. 2/29/20
35
29/02/2020 ELBOHOTY
69
Intrapartum care
29/02/2020 ELBOHOTY
70

36. 2/29/20
36
First stage of Labor
29/02/2020 ELBOHOTY
71
1st stage
[From the onset of true labor pains Till full cervical dilatation.]
29/02/2020 ELBOHOTY
72

37. 2/29/20
37
29/02/2020 ELBOHOTY
Management of the First stage
of labour
Do not offer or advise clinical
intervention if labour is
progressing normally and the
woman and baby are well.
73
• Use a partogram once labour is established
• If a partogram action line is used, this should be a 4-
hour action line
• Every 15 min after a contraction: check FHR
• Every 30 min: document frequency of contractions
• Every hour: check pulse
• Every 4 hours: check BP, temperature and offer
vaginal exam
• Regularly: check frequency of bladder emptying
• Consider the woman’s emotional and psychological
needs
29/02/2020 ELBOHOTY
First stage of labour
74

38. 2/29/20
38
29/02/2020 ELBOHOTY
•Encourage and help the woman to move and
adopt whatever positions she finds most
comfortable throughout labour
•Provide a woman in established labour with
supportive one-to-one care.
•Do not leave a woman in established labour on
her own except for short periods or at the
woman's request.
•Encourage the woman to have support from birth
companion(s) of her choice.
75
29/02/2020 ELBOHOTY
•Tap water may be used if cleansing is required before vaginal
examination.
•Routine hygiene measures taken by staff caring for women in
labour, including standard hand hygiene and single-use non-
sterile gloves, are appropriate to reduce cross-contamination
between women, babies and healthcare professionals.
•Selection of protective equipmentf must be based on an
assessment of the risk of transmission of microorganisms to the
woman, and the risk of contamination of the healthcare worker's
clothing and skin by women's blood, body fluids, secretions or
excretions
Infection control
Harmful Practices:
Pubic shaving causes discomfort with regrowth of hair, does not reduce
infection, may increase transmission of HIV and hepatitis
76

39. 2/29/20
39
Fetal monitoring
29/02/2020 ELBOHOTY
77
Low risk women
29/02/2020 ELBOHOTY
78

40. 2/29/20
40
29/02/2020 ELBOHOTY
79
• intermittent auscultation
• Offer cardiotocography if intermittent auscultation indicates possible
fetal heart rate abnormalities, and explain to the woman why this is
necessary. Remove the cardiotocograph if the trace is normal after 20
minutes.
29/02/2020 ELBOHOTY
Low risk fetus
80

41. 2/29/20
41
29/02/2020 ELBOHOTY
Measuring fetal heart rate as part of initial
assessment
Auscultate the fetal heart rate at first contact with the
woman in labour, and at each further assessment.
Auscultate the fetal heart rate for a minimum of 1 minute
immediately after a contraction and record it as a single
rate.
Palpate the maternal pulse to differentiate between
maternal heart rate and fetal heart rate.
Record accelerations and decelerations if heard.
Do not perform cardiotocography on admission for low-
risk women in suspected or established labour in any
birth setting as part of the initial assessment.
81
PINARD’S FETAL STETHOSCOPE
29/02/2020 ELBOHOTY
82

42. 2/29/20
42
High risk fetus
• Electronic fetal monitoring
29/02/2020 ELBOHOTY
Do not make any decision about a woman’s care in labour on the basis of
cardiotocography findings alone.
83
29/02/2020 ELBOHOTY
84

43. 2/29/20
43
fetal death is suspected
•If fetal death is suspected despite the presence of an
apparently recorded fetal heart rate, offer real-time
ultrasound assessment to check fetal viability.
29/02/2020 ELBOHOTY
85
Presence of meconium
•This is defined as dark green or black amniotic fluid that is
thick or tenacious, or any meconium-stained amniotic fluid
containing lumps of meconium.
•If significant meconium is present, ensure that:
•healthcare professionals trained in fetal blood sampling
are available during labour
•healthcare professionals trained in advanced neonatal life
support are readily available for the birth.
•If significant meconium is present, transfer the woman to
obstetric-led care provided that it is safe to do so and the
birth is unlikely to occur before transfer is completed.
29/02/2020 ELBOHOTY
86

44. 2/29/20
44
Evacuation of the Rectum
Harmful practices:
Use of enema: uncomfortable, may damage bowel, does not change
duration of labor, increased incidence of neonatal infection or perinatal
wound infection
Evacuation of the bladder.
Voluntary urination
Harmful practices: Catheterization ???
29/02/2020 ELBOHOTY
To do or not
87
Position of the Mother
during Normal
Labor:
Harmful practices:
Routine use of supine
position during labor
Routine use of lithotomy
position
29/02/2020 ELBOHOTY
88

45. 2/29/20
45
29/02/2020 ELBOHOTY
The benefits of delivering in an upright position, compared with the supine position
Slight reduction in second stage duration 4.28 min (95% CI, 2.93–5.63 minutes)
Reduction in assisted deliveries RR 0.80 (95% CI, 0.69–0.92)
Reduction in episiotomies RR 0.83 (95% CI, 0.75–0.92)
Fewer abnormal FHR patterns RR 0.31 (95% CI, 0.08–0.98)
Less severe pain RR 0.73 (95% CI, 0.60–0.90)
For women with epidural anaesthesia, the use of upright positions is associated with significantly less pain, fewer operative
vaginal deliveries, fewer deliveries by caesarean section, and a reduction in second stage duration.
89
Ideal practice :
• Encourage and help women to move and adopt whatever positions they find
comfortable throughout labour.
• Encourage upright positions as these are associated with a reduction in the
length of the first stage of labour and a reduction in the use of epidural
analgesia.
• Avoid the recumbent position especially in second stage, it may lengthen labour;
encourage women to opt for positions to aid descent of the fetal head such
kneeling, all fours position. Lithotomy position is associated with severe perineal
trauma and should never be encouraged.
• Encourage those women requiring continuous electronic fetal monitoring (where
available use the wireless monitoring equipment) and/or epidural analgesia to
adopt various upright positions.
• Inform women who choose an epidural of the risk of pressure ulcers and
encouraged to change position at least hourly during the first stage of labour and
at least every 30 minutes in the second stage (see Appendix 2 – Pressure area
care in labour).
• When using the birthing stool, encourage women to stand up every 10 minutes
to reduce tissue congestion to the perineal area
29/02/2020 ELBOHOTY
90

46. 2/29/20
46
Fluid and electrolyte management
during labor
29/02/2020 ELBOHOTY
91
Assessing Fluid Balance
•Intake :
•Food and drinks
•Output:
•Mainly urine
•Sweat
•Respiratory tract
29/02/2020 ELBOHOTY
• Clinical assessment
• Input and output
measurement
92

47. 2/29/20
47
Why are we worried about giving food and
fluids in labour?
•Physiological changes
•Gastroesophageal reflux is more
•Decrease in sphincter tone
•Predisposition to aspiration
•Delayed gastric emptying time
•Reflux + narcotics use
29/02/2020 ELBOHOTY
93
Changes in Obstetric Anaesthesia
Practice
•GA rates are declining approximately 3%
of all deliveries.
•Many women take epidural or spinal
•Reduction in aspiration related deaths
29/02/2020 ELBOHOTY
94

48. 2/29/20
48
Restriction of Food and Drink
•Accelerated Starvation
•Ketosis
•Reduction in plasma glucose levels
•Reduced insulin levels
29/02/2020 ELBOHOTY
95
Glucose Infusions in Labour
• Decrease in fetal pH
• Hypoglycemia in neonates
• Electrolyte imbalance (hyponatremia)
29/02/2020 ELBOHOTY
Dextrose infusions should
not be used.
If DNS is used – not more than 120 ml / hour
96

49. 2/29/20
49
•Encourage women to drink during labour and inform them
that isotonic drinks (non-fizzy sports drinks) may be more
beneficial than water.
•Encourage women to eat a light diet in established labour, if
they wish, unless they receive opioids or develop risk factors
that make a general anaesthetic more likely, in this instance
recommend water, isotonic sports drinks.
•The ideal foodstuff is a high calorie food which does not slow
gastric emptying. It should be low fat, have neutral pH and
be easily absorbed.
•Suggestions include: Plain biscuits: not digestives as
these have a very high fat content, Toast with minimal
butter, Cereal with skimmed milk, Low fat yoghurt,
glucose tablets29/02/2020 ELBOHOTY
Recommendations:
97
Recommendations:
•Neither H2-receptor antagonists nor antacids should
be given routinely to low-risk women.
•Either H2-receptor antagonists or antacids should be
considered for
•who receive opioids or
•who have or develop risk factors that make a
general anaesthetic more likely.
29/02/2020 ELBOHOTY
Inappropriate practice:
Restriction of food and fluids during labor
98

50. 2/29/20
50
In High Risk Mothers for GA
• When oral intake is not given
• IV infusion rate should be 2 ml / kg / hour
• 60 kg mother
• 120 ml per hour of lactated ringer
29/02/2020 ELBOHOTY
99
Pain Control during Labor
•Women are usually ready to accept some degree of pain during
labor, but nobody is ready to accept overwhelming pain.
29/02/2020 ELBOHOTY
100

51. 2/29/20
51
Pain Pathways of labor
29/02/2020 ELBOHOTY
First
stage
Second
stage
101
29/02/2020 ELBOHOTY
102

52. 2/29/20
52
29/02/2020 ELBOHOTY
103
LABOUR PAIN
↑ pain
& anxiety
↑ Catecholamines
$Uterine
blood flow
$Uterine
Contraction
strength
Dystocia
104

53. 2/29/20
53
• Hyperventilation:
• profound hypocarbia and Respiratory alkalosis
• impair oxygen transfer to fetus
29/02/2020 ELBOHOTY
• Neurohumoral effects
– Increased circulating
catecholamines
– Decreased blood flow to the
uterus.
– Relaxing uterine muscles
causing longer labor
105
Psychological Effects
§Psychological trauma
§Postpartum depression
§Posttraumatic stress disorder
(PTSD).
29/02/2020 ELBOHOTY
106

54. 2/29/20
54
29/02/2020 ELBOHOTY
107
An IDEAL intrapartum analgesic would:
•Provide complete analgesia
•Act rapidly
•Be non-invasive
•Have no harmful maternal or fetal effects
•Not be sedative or cause motor
dysfunction
•Have no effect on progress of labor
•Be inexpensive
29/02/2020 ELBOHOTY
108

55. 2/29/20
55
Non-
Pharmacologic
• Continuous labor support
• Maternal movement
• Water immersion
• Sterile water injection
• TENS
• Hypnosis
• Message and Acupuncture
29/02/2020 ELBOHOTY
• Neuraxial
– Epidurals
– Combined spinal-epidurals
• Local
– Pudendal nerve block
– Paracervical
– Perineal infiltration
• Systemic administration
– Inhalation medications
– Opioids
Pharmacologic
109
29/02/2020 ELBOHOTY
110

56. 2/29/20
56
Non-pharmacological Pain Management
•Non-invasive
•Appear to be safe for mother and baby
•Their efficacy is unclear, due to limited high
quality evidence except for:
•Continuous labor support
•Maternal movement and positioning
•Water immersion
29/02/2020 ELBOHOTY
111
Water immersion
•The temperature of the pool should be checked hourly to
ensure the woman is comfortable and not becoming
pyrexial.
•The water temperature should also not exceed 37.5°C.
•There is a lack of evidence on the timing of water use in
labour and on hygiene measures for water birth
29/02/2020 ELBOHOTY
112

57. 2/29/20
57
Neuraxial Labor Analgesia
• Use either epidural or combined spinal–
epidural analgesia for establishing regional
analgesia in labour.
• The most effective method
• It facilitates Operative vaginal delivery.
• It blunts the hemodynamic effects of uterine
contractions and the associated pain response
in patients with medical complications e.g
Mitral regurge, preeclampsia and Sickle cell
disease
• It can be used in Planned VBAC with adequate
monitoring .
29/02/2020 ELBOHOTY
113
Epidural analgesia:
• It is available only in obstetric units.
• It provides more effective pain relief than opioids.
• It is not associated with long-term backache.
• It is not associated with a longer first stage of labour
• It is not associated with increased risk of a caesarean birth
• It is associated with a longer second stage of labour
• It is associated with instrumental birth.
29/02/2020 ELBOHOTY
114

58. 2/29/20
58
Practical recommendations:
• Royal College of Anaesthetists recommends that time from epidural request
to the anaesthetist attending should not exceed 30 minutes
• Use low-concentration local anaesthetic and opioid solutions (0.0625–0.1%
bupivacaine or equivalent combined with 2.0 micrograms per ml fentanyl) for
maintaining epidural analgesia in labourIntravenous access prior to
commencing regional analgesia
• Do not administer routine preloading and maintenance fluid
• Check blood pressure every 5 minutes for 15 minutes during establishment
or after further boluses
• Anaesthetic review after 30 minutes if woman not pain-free
• Check sensory block hourly
• Continuous electronic fetal monitoring for 30 minutes during establishment
or after boluses of 10 ml or more
• Maternal pushing in the second stage of labour should be delayed, if
possible, until the presenting part is visible, or until 1 h after reaching full
cervical dilatation.
29/02/2020 ELBOHOTY
115
29/02/2020 ELBOHOTY
116

59. 2/29/20
59
Undertake the following additional observations for women
with regional analgesia:
• During establishment of regional analgesia or after further boluses (10 ml or
more of low-dose solutions), measure blood pressure every 5 minutes for 15
minutes.
• If the woman is not pain-free 30 minutes after each administration of local
anaesthetic/opioid solution, recall the anaesthetist.
• Assess the level of the sensory block hourly.
29/02/2020 ELBOHOTY
117
epidural Spinal
Usually used for labour and delivery Usually used for caesarean section
Placement of an epidural catheter in
the epidural space so that the drug can
be repeatedly added to the space
A one-off injection of anaesthetic into
the intrathecal space
Supplementation ('top-ups') allows
longer duration of action
Fixed duration, typically one hour of
good surgical anaesthesia
May be patchy. Unilateral, sacral
coverage often poor
More reliable, with denser block
Larger doses of local anaesthetic, thus
greater risk of toxicity
Less risk of failure and toxicity – much
smaller drug doses
Motor block can be reduced by using
fentanyl (an opiate) with a reduced
dose of local anaesthetic
Its disadvantage is that it causes
marked vasodilatation (due to effect of
the local anaesthetic on lumbar
sympathetic nerves) with consequent
hypotension.
A block height of T10 is sufficient for
labour.
The desired height of block for
caesarean section is to the T4 level
(nipple)29/02/2020 ELBOHOTY
118

60. 2/29/20
60
Contraindications
• Bleeding tendency e.g.(platelets < 80000/ml or
INR > 1.4)
• Local or systemic Infection
• low fixed cardiac output (tight MS)
• Uncorrected hypovolemia
• Increased intracranial pressure
• Certain spinal abnormalities
• Lack of trained supervised staff
29/02/2020 ELBOHOTY
119
Epidural Analgesia
•It can be done with:
• A higher concentration (HC) of local
anesthetics
• A Low concentration (LC) of local
anesthetics combined with other
neuraxial opioids (fentanyl)
29/02/2020 ELBOHOTY
120

61. 2/29/20
61
Combined Spinal Epidural Analgesia (CSE)
• This combines:
• The rapid, reliable onset of intrathecal injection along
• Longer duration due to epidural administration.
29/02/2020 ELBOHOTY
121
INTERVENTIONS DON’T CHANGE
OUTCOME WITH EPIDURAL ANALGESIA
• Early or late initiation of epidural analgesia
• Oxytocin for reducing operative births
• Upright or recumbent positions
• Discontinuation of epidural analgesia late in labor
29/02/2020 ELBOHOTY
122

62. 2/29/20
62
(2/100)
29/02/2020 ELBOHOTY
Complications of
epidural analgesia
Common
Under treatment:
persistent pain
Overtreatment:
transient motor
affection
Uncommon
Post punct.
Headache <1/100
Pruritus
Rare & Very Rare < 1/1000
Infection
Total spinal
Hematoma
Nerve injury
1: 50000
Hypotension/
Nausea /
Vomiting
123
Inhalational analgesia
• It increases the release of endogenous endorphins, corticotrophins
and dopamine, which activate descending pain pathways.
• Nitrous oxide has a short half-life of 2–3 minutes and is cleared rapidly
via the lungs.
• Ensure that Entonox (a 50:50 mixture of oxygen and nitrous oxide) is
available in all birth settings as it may reduce pain in labour, but inform
the woman that it may make her feel nauseous and light-headed.
• Is currently the most common labour analgesic used in UK delivery
units.
• The gas is self-administered via a mouthpiece
• Entonox takes 30 seconds to act and its effect continues for
approximately 60 seconds after inhalation has ceased
29/02/2020 ELBOHOTY
124

63. 2/29/20
63
Disadvantages of entonox
• drowsiness, disorientation, nausea
• Increase respiratory rate and decrease tidal volume
• Mild increase in sympathatic activity/ mild myocardial depression
• unlikely to be the only analgesic required
• contraindicated in conditions with 'air spaces', such as pneumothorax
and middle ear disease
• Prolonged nitrous oxide exposure for more than 5 hours per week in
some healthcare workers has been linked to decreased fertility,
preterm birth and vitamin B12 deficiency, although such side effects
have not been reported with its use in labour
29/02/2020 ELBOHOTY
125
Opioids
• Act on Mu receptors
• Ensure that pethidine, diamorphine or other opioids are available in all birth
settings.
• Inform the woman that these will provide limited pain relief during labour
and may have significant side effects for both her (drowsiness, nausea and
vomiting) and her baby (short-term respiratory depression and drowsiness
which may last several days).
• Inform the woman that pethidine, diamorphine or other opioids may
interfere with breastfeeding.
• If an intravenous or intramuscular opioid is used, also administer an
antiemetic.
• Women should not enter water (a birthing pool or bath) within 2 hours of
opioid administration or if they feel drowsy.
29/02/2020 ELBOHOTY
126

64. 2/29/20
64
Pethidine
29/02/2020 ELBOHOTY
127
29/02/2020 ELBOHOTY
128

65. 2/29/20
65
Diamorphine
29/02/2020 ELBOHOTY
129
29/02/2020 ELBOHOTY
130

66. 2/29/20
66
Patient-controlled analgesia
• PCA is the delivery of drugs through a preprogrammed pump.
• The programming usually involves clinician input plus self-administered boluses
by the patient.
• It offers an alternative to regional analgesia where regional anaesthesia is
unavailable, unsuccessful, contraindicated or refused.
• Although a number of opioids have been reported for their use in PCA, the only
one widely used in the UK for labour pain is remifentanil.
29/02/2020 ELBOHOTY
131
Remifentanil
• One-third of labour units in the UK now offer remifentanil PCA as a form of
analgesia
• It is a newer, synthetic opioid. While it shares many of the effects associated with
other opioids its metabolism is unique in this class of drugs.
• Due to an ultra-short duration of action half life 3-10 minutes, nausea and
vomiting seem less common.
• It is rapidly broken down by non-specific plasma and tissue esterases to an
essentially inactive metabolite excreted in urine.
29/02/2020 ELBOHOTY
132

67. 2/29/20
67
29/02/2020 ELBOHOTY
Remifentanil
133
Disadvantages of opioids
•woman requires supervision
•not a self-administration technique
•fetal side-effects, which can manifest as reduced CTG
variability & accelerations due to a prolonged ‘sleep phase’
pattern
•cross the placenta and will be present in the baby after
delivery – may cause reduced Apgars
• A neonate may take up to 6 days to eliminate pethidine from its
system, with respiratory depression, hypothermia, poor feeding,
altered crying and decreased alertness as recognised adverse effects
•secreted in breast milk (although not usually in sufficient
doses to cause problems)
•maternal adverse effects of: drowsiness, hypoventilation,
urine retention, nausea/vomiting and an increase in
gastrointestinal transit time (with a risk of aspiration),
pruritis & miosis
•the effects of opioids are reversed (temporarily) by
naloxone29/02/2020 ELBOHOTY
134

68. 2/29/20
68
29/02/2020 ELBOHOTY
135
Pudendal
nerve
block
Caudal
block
Spinal
block
Epidural
29/02/2020 ELBOHOTY
136

69. 2/29/20
69
29/02/2020 ELBOHOTY
137
General anaesthesia
• In the UK, only 9% of elective caesarean sections and 23% of
emergency cases are performed under GA.
Difficulties associated with GA in obstetrics
changes in blood volume and haemodynamic circulation
• intubation – pharyngeal wall oedema can progress acutely and
make intubation difficult
• reflux and gastric contents aspiration – this is increased because of
the pressure of the gravid uterus on the stomach
Indications for GA in labour and delivery
• Category I caesarean section for rapid delivery, e.g. fetal distress or
cord prolapse
• where regional blockade is contraindicated (bleeding tendency,
sepsis, hemodynamic instability)
• to convert to if the regional block proves inadequate
• placenta praevia is not normally an indication for general
anaesthesia29/02/2020 ELBOHOTY
138

70. 2/29/20
70
Bladder Care
• Encourage the woman to void at least 2-3hourly
• It is good practice to routinely palpate for a bladder prior to any vaginal
examination
• If the woman is unable to pass urine, discuss the importance of bladder care and
consider urinary catheterisation
29/02/2020 ELBOHOTY
139
Cathetrization is recommended
•There is concern regarding maternal fluid balance,
for example in severe pre- eclampsia
•Women choosing epidural analgesia ?
•Technique
•Catheterise with Ch 12 gauge Foley inflating the
balloon with maximum of 5ml water using aseptic
technique
•Remove the catheter at the onset of 2nd stage to
prevent trauma to the urethra29/02/2020 ELBOHOTY
140

71. 2/29/20
71
29/02/2020 ELBOHOTY
141
Oxytocin infusion
29/02/2020 ELBOHOTY
142

72. 2/29/20
72
29/02/2020 ELBOHOTY
143
Multiparous
augmentation
If a delay in progress is suspected in a multiparous
woman, an experienced obstetrician (middle
grade obstetrician (ST3–7 or equivalent) should
assess her and an abdominal and vaginal
examination performed prior to any decision
regarding the use of oxytocin.
If there is no evidence of cephalopelvic
disproportion, then cautious use of oxytocin may
be appropriate.
If there is still failure to progress despite
augmentation, then an early decision regarding
mode of delivery should be made.
144

73. 2/29/20
73
If previous
caesarean
section
29/02/2020
• discuss use of oxytocin with obstetric consultant.
ELBOHOTY
145
Management of the Second stage of Labor
29/02/2020 ELBOHOTY
146

74. 2/29/20
74
[From full cervical dilatation Till complete delivery of the Fetus.]
29/02/2020 ELBOHOTY
147
It is difficult to ascertain exactly when full
dilatation of the cervix occurs as it is an event in
the continuum of the labour process.
It is diagnosed by either routine vaginal
examination during labour or when the patient
reports experiencing the sensation to bear down.
Diagnosis of the 2nd
stage
29/02/2020 ELBOHOTY
148

75. 2/29/20
75
Maternal pushing
• the use of sustained valsalva bearing down efforts is associated with adverse maternal
and fetal effects.
• Delaying active pushing until the woman has an involuntary urge or the fetal head is
visible on the perineum has been shown to reduce the incidence of forceps delivery, the
need for caesarean section and shortens the active bearing down phase of the second
stage.
29/02/2020 ELBOHOTY
Fetal
Lower fetal pH
Lower fetal pO2
Higher fetal pCO2
More frequent occurrence of non-reassuring fetal heart rate (FHR)
patterns
Delayed recovery of FHR decelerations
Maternal
Increased maternal stress and fatigue
Increased perineal trauma
Increased risk of subsequent urogynaecological dysfunction
Newborn
Newborn acidaemia
Lower Apgar scores
149
1. A passive phase that begins with full dilatation of the
cervix and ends when bearing down efforts begin.
2. An expulsive phase when the mother feels the
sensation of bearing down due to pressure of the
presenting part on the rectum and active maternal
pushing occurs.
The second stage of labour has two phases.
29/02/2020 ELBOHOTY
150

76. 2/29/20
76
The onset of active second stage is when:
•the baby is visible,
•or there are expulsive contractions with other signs of or a
finding of full dilatation of the cervix,
•or active maternal effort following confirmation of full
dilatation of the cervix in the absence of expulsive
contractions.
29/02/2020 ELBOHOTY
151
For women with an epidural, delay pushing for at least
an hour, unless the woman has an urge to push or the
head is visible. After this time, actively encourage
pushing.
For women without an epidural, pushing should be
guided by the woman’s own urges with the support and
encouragement of her Midwife.
Women should be discouraged from lying supine or
semi-supine in the second stage of labour and should be
encouraged to adopt any other position that they find
most comfortable.
29/02/2020 ELBOHOTY
152

77. 2/29/20
77
Second stage of labour
1. Every 5 min after a contraction: check FHR
2. Every 30 min: document frequency of contractions
3. Every hour: check BP, pulse, offer vaginal exam
4. Every 4 hours: check temperature
5. Regularly: check frequency of bladder emptying
6. Assess progress, including fetal position and station
7. If woman has full dilatation but no urge to push, assess after 1
hour
8. Consider the woman’s position, hydration and pain-relief
needs.
9. Provide support and encouragement
29/02/2020 ELBOHOTY
153
Assessment during the second stage
1. 1st stage progress
2. General Condition
• Pulse rate, respiratory rate
• Degree and character of pain
2. Uterine contractions:
• Duration, intensity, frequency
3. Fetal heart beats:
• Immediately after each contraction
• Rate, abnormal patterns
4. Vaginal examinations:
• Presenting part:
• Station
• Rate of descent
• Internal Rotation
• Caput formation.
• Amniotic fluid
• Vaginal bleeding
29/02/2020 ELBOHOTY
154

78. 2/29/20
78
Women should be informed that in the
second stage they should be guided by their
own urge to push.
If full dilatation of the cervix has been
diagnosed in a woman without epidural
analgesia, but she does not get an urge to
push, further assessment should take place
after 1 h.
29/02/2020 ELBOHOTY
155
29/02/2020 ELBOHOTY
156

79. 2/29/20
79
29/02/2020 ELBOHOTY
157
Diagnosis and management of delay
1. For a multiparous woman, suspect delay if progress (in terms of rotation
and/or descent of the presenting part) is inadequate after 30 minutes of
active second stage. Offer vaginal examination and then offer amniotomy if
the membranes are intact.
2. birth would be expected to take place within (3h in PG or 2 h in MP) of the
start of the active second stage in most women;
3. a diagnosis of delay in the active second stage should be made when it has
lasted 2h in PG or 1 h in MP and women should be referred to a healthcare
professional trained to undertake an operative vaginal birth if birth is not
imminent.
4. Intervention in the second stage of labour because an arbitrary time limit
has been exceeded must be balanced with the risks of an adverse outcome
for the mother or her baby as a result of a prolonged second stage of
labour.
5. Consideration should be given to the use of oxytocin, with the offer of
regional analgesia, for nulliparous women if contractions are inadequate at
the onset of the second stage.
29/02/2020 ELBOHOTY
158

80. 2/29/20
80
Infection Prevention Practices
i. Use disposable materials
ii. Wear gloves
iii. Wear protective clothing
29/02/2020 ELBOHOTY
159
29/02/2020 ELBOHOTY
160

81. 2/29/20
81
29/02/2020 ELBOHOTY
161
•Allow bearing down only after full cervical dilatation, when the
mother feels the urge to bear down.
•Ask the patient to bear down with contractions & relax in
between.
Harmful Practices:
•Sustained, directed bearing down efforts during the second stage
of labor
•Massaging and stretching the perineum during the second stage
of labor (no evidence)
•Fundal pressure during labor
2.Bearing Down
29/02/2020 ELBOHOTY
162

82. 2/29/20
82
Perineal Care
29/02/2020 ELBOHOTY
Antenatal perineal massage carried out in the third trimester is an
effective approach in reducing perineal trauma especially in nulliparous
women.
Applying warm compresses to the perineum in the second stage of
labour may reduce perineal trauma and is acceptable to women.
Hands on or hands poised techniques can be used to facilitate
spontaneous birth.
There is no evidence to support routine episiotomy; it is associated
with severe perineal trauma.
163
•Warm compression during the second stage of labour reduces
the risk of OASIS
•Support the perineum during contraction to keep the head flexed till
crowning occurs .
•Delivery of the head by extension slowly in between uterine contractions
and sliding of the perineum over the face (Ritgen’s maneuver).
•Mother NOT pushing when head is crowning
•No routine episiotomy as the evidence for the protective effect of
episiotomy is conflicting.
3.Perineal Support & protection
29/02/2020 ELBOHOTY
164

83. 2/29/20
83
manual perineal protection/‘hands on’ techniques
Left hand slowing
down the delivery
of the head.
1
Right hand
protecting the
perineum.
2
Mother NOT
pushing when head
is crowning
(communicate).
3
Think about
episiotomy (risk
groups and correct
angle).
4
165
Support the perineum
Delivery by extention
2/29/20 ELBOHOTY
166

84. 2/29/20
84
Medio Lateral
Episiotomy
It should be considered in instrumental deliveries. :
Other indications:
•Complicated vaginal birth:
• Breech
• Shoulder dystocia
•Extensive perineal scarring (in FGM 3: anterior episiotomy can be
done)
•Fetal distress
167
1. Protect the baby head
by two fingers placed
between the baby
head and the
perineum.
2. Make a cut in the
perineum 3-4cm long
at the height of
contraction.
3. The angle is 60
degrees away from the
midline when the
perineum is distended
originating at the
vaginal fourchette and
usually directed to the
right side.
168

85. 2/29/20
85
Wait to perform episiotomy until:
- The perineum is thinned out; and
-3–4 cm of the baby’s head is visible during a contraction
[Crowning].
Performing an episiotomy will cause bleeding. It should
not be done too early.29/02/2020 ELBOHOTY
169
2/29/20 ELBOHOTY
170

86. 2/29/20
86
ELBOHOTY 29/02/2020
171
29/02/2020 ELBOHOTY
172

87. 2/29/20
87
Essential Newborn Care Interventions
29/02/2020 ELBOHOTY
173
174

88. 2/29/20
88
CLAMPING & CUTTING THE UMBILICAL CORD
29/02/2020 ELBOHOTY
umbilical cord scissors
175
Management of the second stage
Instructions and Active Procedures:
Essential Newborn Care Interventions
Apgar scoring
•At 1 and 5 minutes.
•Score of 0,1 or 2 for each of
the 5 items
•8-10 means newborn is OK
•Heart beats per minute
•Respiratory Effort
•Color
•Muscle Tone
•Reflexes
29/02/2020 ELBOHOTY
176

89. 2/29/20
89
29/02/2020 ELBOHOTY
177
29/02/2020 ELBOHOTY
178

90. 2/29/20
90
Management of the Third Stage of Labor
29/02/2020 ELBOHOTY
179
Third stage of labour
Observe physical health
Check vaginal loss
29/02/2020 ELBOHOTY
180

91. 2/29/20
91
Active management
Physiological management: if requested by
low-risk woman.
• no routine use of uterotonic drugs
• Observation for signs of placental
separation
• no clamping of the cord until pulsation
has stopped
• delivery of the placenta by maternal
effort.
• Breast feeding
Third stage of labour
29/02/2020 ELBOHOTY
Changing from physiological to active management in the third stage is indicated in the
presence of:
• Haemorrhage;
• Placenta not delivered after 1 hour;
• The woman’s desire to artificially shorten the third stage.
181
• Active management of third stage:
– 10 IU IM Oxytocin administration with delivery of the
anterior shoulder (Ensure there is no multiple pregnancy)
– Do not clamp the cord earlier than 1 minute from the birth
of the baby unless there is concern about the integrity of the
cord or the baby has a heartbeat below 60 beats/ minute
that is not getting faster.
– Clamp the cord before 5 minutes in order to perform
controlled cord traction as part of active management.
– Perform controlled cord traction as part of active
management only after administration of oxytocin and signs
of separation of the placenta.
• Routine examination of the placenta and membranes
• Routine examination of vagina and perineum for
lacerations and injury
29/02/2020 ELBOHOTY
182

92. 2/29/20
92
29/02/2020 ELBOHOTY
•shortens the third stage compared with physiological
management
•is associated with nausea and vomiting in about 100 in
1000 women
•is associated with an approximate risk of 13 in 1000 of
a haemorrhage of more than 1 litre
•is associated with an approximate risk of 14 in 1000 of
a blood transfusion.
Explain to the woman that active
management:
183
29/02/2020 ELBOHOTY
•is associated with nausea and vomiting in
about 50 in 1000 women
•is associated with an approximate risk of
29 in 1000 of a haemorrhage of more than 1
litre
•is associated with an approximate risk of
40 in 1000 of a blood transfusion.
•Explain to the woman that
physiological management:
184

93. 2/29/20
93
•Signs of placental separation:
•Abdominal
•Uterus becomes smaller & harder
•Fundus rises upwards & becomes more globular
•Supra-pubic bulge
•Vaginally
•Elongation of the cord
•A gush of blood per vulva
•Loss of transmitted pulsations
29/02/2020 ELBOHOTY
185
Brandt-Andrews maneuver for delivery of the placenta.
Firm traction is applied to the umbilical cord with one hand while the other
applies suprapubic counter pressure.
29/02/2020 ELBOHOTY
186

94. 2/29/20
94
The third stage of labor: delivery of the placenta.
29/02/2020 ELBOHOTY
BREECH PRESENTATION
187
The placenta and membranes
are examined
after delivery for any abnormalities
29/02/2020 ELBOHOTY
188

95. 2/29/20
95
Rationale for examination of the placenta
• A thorough inspection must be undertaken to ensure that no part of the placenta
or membranes have been retained as this may result in a postpartum
haemorrhage and/or infection.
• Inspection of the placenta should be performed as soon as possible after birth.
• The Placenta
• A fresh, term, healthy placenta is approximately 15 – 20 cm in diameter and 2.0 to 2.5 cm
thick.
• It generally weighs approximately 5-600gms (1/6 of the baby’s birth weight).
• The maternal surface of the placenta should be dark maroon in colour and should consist
of around 20 cotyledons.
• The fetal surface of the placenta should be shiny, grey and translucent so that the colour of
the underlying maroon villous tissue may be seen.
• The Umbilical cord At term
• the typical umbilical cord is 55 to 60 cm in length, with a diameter of 2.0 to 2.5 cm. The
cord vessels are suspended in Wharton's jelly.
• The normal cord contains two arteries and one vein.
• The Membranes
• The membranes consist of two layers; the amnion and the chorion.
29/02/2020 ELBOHOTY
189
29/02/2020 ELBOHOTY
190

96. 2/29/20
96
29/02/2020 ELBOHOTY
IV Co-amoxiclav 1.2g Stat
IV, then PO Co-amoxiclav
625mg 8 hourly x3 days
(Penicillin allergic PO
Clarithromycin 500mg 12
hourly x3 days)
191
29/02/2020 ELBOHOTY
192

97. 2/29/20
97
Before assessing for genital trauma, healthcare
professionals should:
• explain to the woman what they plan to do and why
• offer inhalational analgesia
• ensure good lighting
• position the woman so that she is comfortable and so that the genital structures
can be seen clearly.
• confirmation by the woman that effective local or regional analgesia is in place
• visual assessment of the extent of perineal trauma to include the structures
involved, the apex of the injury and assessment of bleeding
• a rectal examination to assess whether there has been any damage to the
external or internal anal sphincter if there is any suspicion that the perineal
muscles are damaged.
193
Repair
• 85% of women sustain perineal trauma following vaginal
delivery, of which 60-70% require suturing.
• First-degree trauma: suture skin unless well opposed
• Second-degree trauma: suture vaginal wall and muscle
for all second-degree tears.
• Use continuous non-locked technique for suturing
vaginal wall and muscle
• Use continuous subcuticular technique for suturing skin
• Offer rectal NSAIDs following perineal repair
• Start from just about 1 cm above the apex
• Use Polyglycolic sutures 2 0 (vicyl rapide) .
• Rectal examination
• Count needle and swabs.
194

98. 2/29/20
98
FOURTH STAGE OF LABOR
29/02/2020 ELBOHOTY
195
immediate postnatal care
• Routine practices after birth should not interfere with the opportunity for
mother and her baby to be together
• Skin to skin contact positively impacts on bonding and breastfeeding
• All women should be supported to breast feed their baby as soon as possible.
• Wherever possible the woman should pass urine before being transferred to the
ward.
• If unable to void, assess the fluid balance and consider an in-out catheter.
• The time and volume of the first void should be recorded in the woman’s
records.
29/02/2020 ELBOHOTY
196

99. 2/29/20
99
Post delivery care
29/02/2020 ELBOHOTY
197
Urinary
retension
198

100. 2/29/20
100
Care after birth Woman:
observe general physical condition, colour, respiration, how
she feels;
check temperature, pulse, BP, uterine contractions, lochia,
bladder voiding.
Examine cord, placenta and membranes. Assess maternal
emotional/psychological condition
Baby: record Apgar score at 1 and 5 min; keep warm
Encourage skin-to-skin contact between woman and baby as
soon as possible
Don’t separate the woman and baby in the first hour
Initiate breastfeeding within the first hour
After 1 hour, record baby’s head circumference, body
temperature and weight29/02/2020 ELBOHOTY
199
29/02/2020 ELBOHOTY
200

101. 2/29/20
101
29/02/2020 ELBOHOTY
201
29/02/2020 ELBOHOTY
202

102. 2/29/20
102
Perineal problems
29/02/2020 ELBOHOTY
203
2/29/20 ELBOHOTY
204

103. 2/29/20
103
Management of breastfeeding
29/02/2020 ELBOHOTY
205
Baby Friendly Initiative.
• Mothers and babies should not be separated within the first hour of life.
• Early skin to skin contact should be encouraged and continued into the puerperium.
• Breastfeeding should be encouraged in the first hour of life.
• Breastfeeding support, including positioning, attachment etc should be offered.
• Extra support should be offered to those women who have had narcotic analgesia, caesarean
section or delayed contact with their baby.
• Ensure that breastfeeding is unrestricted in frequency and duration.
• Ensure that the breastfeeding environment is private and that adequate rest is ensured with
minimum interruptions due to institutional routine.
• Reassure women about breast milk supply and that the baby will stop feeding when satisfied.
This is often after feeding from only one breast.
• Discomfort (or even pain) in the early days of breastfeeding is not uncommon, especially at
the start of a feed but will not persist.
• Supplementation with fluids other than breast milk is not recommended.
• Advise women that the signs of successful breastfeeding are:
• swallowing is audible and visible
• there is a sustained rhythmic suck
• the arms and hands are relaxed
• the mouth is moist
• nappies are regularly soaked.
• Advise women that the signs of successful attachment and positioning at the breast are:
• mouth wide open
• less areolar visible underneath the chin than above the nipple
• chin touching the breast, lower lip rolled down and nose free
• no pain.
29/02/2020 ELBOHOTY
206

104. 2/29/20
104
•Thank you
2/29/20 BSOG
207
29/02/2020 ELBOHOTY
208

105. 2/29/20
105
D
• A low-risk 27-year-old G1P0 woman at 40+4 weeks of gestation presents to
the labour ward with regular abdominal uterine contractions. Her
observations are normal. On examination the uterus is soft and non-tender
between palpable contractions with cephalic presentation. Vaginal
examination reveals a 5 cm dilated, fully effaced cervix with intact
membranes, and the presenting part is at –2 station above the spines.
• She requests to use the birthing pool and pethidine as pain relief.
• Regarding the use of pethidine, which of the following statements is correct?
a. Her baby may have short-term respiratory depression but this never lasts
for more than 4 hours
b. Pethidine offers poor pain relief
c. Women might feel drowsy but there are no other side effects associated
to pethidine
d. Women should not enter water (a birthing pool or bath) within 2 hours of
opioid administration
e. Women should not enter water (a birthing pool or bath) within 4 hours of
opioid administration
29/02/2020 ELBOHOTY
209
D
• A 25-year-old low-risk para 1 woman is admitted to the low risk
birthing unit in established labour. She progresses well and is now
fully dilated with no concerns on intermittent auscultation of the
fetal heart. She has significant lower back pain, which is improved by
adopting a standing position.
• Which of the following statements is associated with the upright
position?
a. Does not affect FHR patterns
b. Increases the rate assisted deliveries but reduces caesarean
section rates
c. More severe pain unless using epidural
d. Reduces the need for an episiotomy
e. Reduction of the 1st stage of labour
29/02/2020 ELBOHOTY
210

106. 2/29/20
106
e
• A 26-year-old G1P0 at 40+5 weeks of gestation presents to the labour ward
with regular painful contractions for the past 3 hours. On examination, she is
contracting 4 in every 10 minutes and the contractions are strong.
Abdominal examination reveals that the fetus is in a cephalic presentation
with the fetal head 3/5 palpable. Initial vaginal examination reveals an
effaced cervix, which is 4 cm dilated. The fetal membranes are intact and the
head is at station -1 to the spines with no caput or moulding. The position is
not defined. At 4 hours later, a second examination reveals that the head
remains at station –1 and the cervix is still 4 cm dilated despite ongoing
adequate contractions.
• Which is the most appropriate management intervention?
a. Amniotomy and re-examine 2 hours later
b. Amniotomy and re-examine 4 hours later
c. Caesarean section
d. Oxytocin infusion titrated to five contractions in every 10 minutes and
repeat assessment in 2 hours
e. Oxytocin infusion titrated to five contractions in every 10 minutes and
repeat assessment in 4 hours
29/02/2020 ELBOHOTY
211