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Normal Labour by Dr Salman

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obstetrics & gynecology

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Normal Labour by Dr Salman

  1. 1. NORMAL LABOUR SALMAN KHAN BATCH _L 08_206
  2. 2. WHAT ISWHAT IS NORMAL LABOUR ?NORMAL LABOUR ?
  3. 3. NORMALNORMAL LABOURLABOUR Labour is defined as the onset of regular painful uterine contractions with progressive cervical effacement and dilatation of the cervix accompanied by descent of the presenting part. DEFINITIONSDEFINITIONS
  4. 4. NORMAL LABOURNORMAL LABOUR • Spontaneous expulsion, • of a single, • mature fetus (37 completed weeks – 42 weeks), • presented by vertex, • through the birth canal (i.e. vaginal delivery), • within a reasonable time (not less than 3 hours or more than 18 hours), • without complications to the mother, • or the fetus The following criteria should be present to call it normal labour
  5. 5. WHAT FACTORS INFLUENCEWHAT FACTORS INFLUENCE PROGRESS OF LABOUR ?PROGRESS OF LABOUR ?
  6. 6. LABOUR AND DELIVERYLABOUR AND DELIVERY FACTORS THAT INFLUENCEFACTORS THAT INFLUENCE PROGRESS OF LABOURPROGRESS OF LABOUR Passenger Passage Power
  7. 7. THE NORMAL FEMALE PELVISTHE NORMAL FEMALE PELVIS The important diameters of the female pelvis: AnteroposteriorAnteroposterior ObliqueOblique TransverseTransverse BRIMBRIM 11 – 11.511 – 11.5 1212 12.512.5 CAVITYCAVITY 1212 1212 1212 OUTLETOUTLET 12.512.5 1212 11- 11.511- 11.5 DiametersDiameters (cm)(cm)
  8. 8. POWERPOWER ►► Contractions + Maternal pushing Uterine contractions: 1. Initiate by pacemakers ~ uterotubal junction 2. Contraction waves meet at the fundus 3. Contraction waves progress downward  Shortening of muscle fibres  Retractions  intra uterine pressure EXPULSION OF THE FETUS Additional force “maternal pushing” Intra abdominal pressure
  9. 9. UTERINE CONTRACTIONUTERINE CONTRACTION NORMAL CONTRACTION 1. Frequency ~ one in every 2 – 3 min with at least 1 minute interval 2. Intensity ~ strong (> 50 mmHg) 3. Duration ~ 45 – 60 sec Uterine contractions
  10. 10. LABOUR AND DELIVERY WHAT INITIATE LABOURWHAT INITIATE LABOUR ““ONSET OF LABOUR”ONSET OF LABOUR”
  11. 11. NORMAL LABOURNORMAL LABOUR • Hormonal factors 1) Estrogen theory 2) Progesterone withdrawal theory 3) Prostaglandins theory 4) Oxytocin theory 5) Fetal cortisol theory • Mechanical factors 1) Uterine distension theory 2) Stretch of the lower uterine segment by the presenting near term Causes of Onset of Labour: - It is unknown but the following theories were postulated:
  12. 12. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • Painful regular uterine contractions – as evidence by contraction at least one in ten minutes • Show – as evidence by mucus mixed with blood • Rupture of membranes – as evidence by leaking liquor • Progressive shortening and dilatation of the cervix SYMPTOMS AND SIGNS OF LABOUR Before labour begins, women usually notice one or more premonitory, or warnings, signs that labour is about to begin. They are:
  13. 13. “STAGES OF LABOUR”
  14. 14. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY PHASES OF THE FIRST STAGE OF LABOUR Divided into: Latent phase – begins with onset of contracts and ends when cervix is 3 cm dilated and effaced Active phase – begins after the cervix is 3 cm dilated
  15. 15. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY LATENT PhaseLATENT Phase ACTIVE Phase 1. Begins with onset of contractions 2. Slow progress 3. Little cervical dilatation 4. Progressive cervical effacement 5. Ends once the cervix reaches 3 cm dilatation 6. Durations ~ 8 hours for nulliparae ~ 6 hours for multiparae 1. Active process 2. Begins after 3 cm of cervical dilatation 3. Period of active cervical dilatation (average rate 1 cm/hr) 4. S-shaped curve which is used to define progress of labour 5. It has 3 component a) acceleration - slow b) maximum - fast c) deceleration - slow PHASES OF THE FIRST STAGE OF LABOUR
  16. 16. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY Do Uterine Contractions Affect Fetal Heart Rate? Uterine contractions can affect fetal heart rate by increasing or decreasing that rate in association with any given contraction. The three primary mechanisms by which uterine contractions can cause a decrease in fetal heart rate are compression of: · Fetal head · Umbilical cord · Uterine myometrial vessels
  17. 17. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY SECOND STAGE OF LABOUR 1. Begins with FULL DILATATION and ends with DELIVERY OF THE BABY. 2. It have TWO Phases a) Propulsive phase – from full dilatation until presenting part has descended to the pelvic floor b) Expulsive phase which ends with the delivery of the baby Features of expulsive phase – 1) mother’s irresistible desire to bear down 2) distension of perineum 3) dilatation of the anus 3. Average length a) Primigravidae – 40 minutes b) Multigravidae – 20 minutes
  18. 18. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY PROGRESS OF SECOND STAGE OF LABOUR Findings suggestive of satisfactory progress in second stage of labour are: - steady descent of fetus through birth canal; - onset of expulsive (pushing) phase. Findings suggestive of unsatisfactory progress in second stage of labour are: - lack of descent of fetus through birth canal; - failure of expulsion during the late (expulsive) phase.
  19. 19. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY THIRD STAGE OF LABOUR 1. Begins after DELIVERY of the baby and ends with DELIVERY OF THE PLACENTA / MEMBRANES. 2. It have TWO Phases a) Separation phase b) Expulsion phase 3. Duration – usually 15 minutes or less (if actively managed). 4. Average blood loss – 150 to 250 ml.
  20. 20.  MANAGEMENT OF LABOUR
  21. 21. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • To achieve delivery of a normal healthy child • To anticipate, recognize and treat potential abnormal conditions before significant hazard develops for the mother or the fetus. AIMS IN THE MANAGEMENT OF LABOUR The AIMS include:
  22. 22. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • Diagnosis of labour • Monitoring the progress of labour • Ensuring maternal well-being • Ensuring fetal well-being. PRINCIPLES IN THE MANAGEMENT OF LABOUR The principles include:
  23. 23. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY MANAGEMENT FIRST STAGE OF LABOUR
  24. 24. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • On admission: When the women presents at hospital, the woman’s antenatal record is reviewed to discover whether there have been any abnormalities during her pregnancy. When there are no records of antenatal care a complete history must be taken. • General examination of the mother a) General conditions – evaluate the mother general health condition. Look for pallor, edema, abdominal scar (LSCS) and maternal height. b) Vital signs – Blood pressure, pulse, respiration and temperature are taken and recorded c) Heart and lungs d) Urine analysis – for protein, sugar and ketones MANAGEMENT OF THE FIRST STAGE OF LABOUR1
  25. 25. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • Abdominal examination: a) A detailed abdominal examination should be carried out and recorded. b) Determine the presentation and position of the fetus and also the engagement c) Auscultate the fetal heart d) Evaluate the uterine contraction • Vaginal examination – the purpose is to a) To make a positive diagnosis of labour b) To make a positive identification of presentation c) To determine whether the fetal head is engaged in case of MANAGEMENT OF THE FIRST STAGE OF LABOUR2
  26. 26. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • Bowel preparation: If there has been no bowel action for 24 hours or the rectum feels loaded on vaginal examination an enema is given. • Bladder care A full bladder may initially prevent the fetal head from entering the pelvic brim and later impede descent of the fetal head. It will also inhibit effective uterine action. The woman should be encouraged to empty her bladder every 1½ - 2 hours during labour. The quantity of urine passed should be measured and recorded and a specimen obtained for testing. MANAGEMENT OF THE FIRST STAGE OF LABOUR3
  27. 27. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • Pain in labour The pain experienced by the woman in labour is caused by the: 1): Uterine contractions and uterine ischaemia. 2): Cervical dilatation. Dilatation and stretching of the cervix and lower uterine segment stimulate nerve ganglia and are a major source of pain. 3): Distention of the vagina and perineum. Marked distention of the vagina and perineum occurs with fetal descent, especially during the second stage. LABOUR PAIN– causes1
  28. 28. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY PAIN RELIEF IN LABOUR – types Three methods are in common use during labour: 1. Analgesic drugs (narcotics, e.g. pethidine) which are given by intramuscularly injection. 2. Inhalation analgesia (e.g. Entonox). 3. Regional anaesthesia (e.g. epidural, spinal) that blocks the sensory pain pathways.
  29. 29. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY How To Monitor The Fetal Heart Rate?  Auscultation methods  Electronic monitoring ~ CTG
  30. 30. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY MONITORING FETAL HEART To detect fetal hypoxia NORMAL ABNORMAL
  31. 31. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY RECORDING THE PROGRESS OF LABOUR PATIENT INFORMATION FETAL INFORMATION ~ fetal well being LABOUR INFORMATION ~ Dilatation ~ Descent ~ Contraction MEDICATIONS MATERNAL INFORMATION ~ Well being
  32. 32. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY RECORDING THE PROGRESS OF LABOUR - Partogram Patient information: Fill out name, gravida, para, hospital number, date and time of admission and time of ruptured membranes. Fetal heart rate: Record every half hour. Amniotic fluid: Record the colour of amniotic fluid at every vaginal examination: I: membranes intact; C: membranes ruptured, clear fluid; M: meconium-stained fluid; B: blood-stained fluid. Moulding: 1: sutures apposed; 2: sutures overlapped but reducible; 3: sutures overlapped and not reducible.
  33. 33. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY RECORDING THE PROGRESS OF LABOUR - Partogram Cervical dilatation: Assessed at every vaginal examination and marked with a cross (X). Begin plotting on the partograph at 3 cm. Station : recorded as a circle (O) at every vaginal examination. Contractions: Chart every half hour; palpate the number of contractions in 10 minutes and their duration in seconds. Less than 20 seconds: Between 20 and 40 seconds: More than 40 seconds: Assess the progress of labour:
  34. 34. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY RECORDING THE PROGRESS OF LABOUR - Partogram Oxytocin: Record the amount of oxytocin every 30 minutes when used. Drugs given: Record any additional drugs given – e.g. Pethidine Pulse: Record every 30 minutes and mark with a dot (●). Blood pressure: Record every 4 hours and mark with arrows ( ) Temperature: Record every 2 hours. Protein, acetone and volume: Record every time urine is passed. Progress of maternal well being:
  35. 35. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • Maternal position: With the exception of avoiding supine position, the mother may assume any comfortable position for effective bearing down. The semi-recumbent or supported sitting position, with the thighs abducted, is the posture most commonly adopted • Bearing down With each contraction, the mother should be encouraged to bear down with expulsive efforts MANAGEMENT OF THE SECOND STAGE OF LABOUR1 Once the onset of the second stage has been confirmed a woman should not be left without attendance. Accurate observation of progress is vital, for the unexpected can always happen.
  36. 36. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • Observation during the second stage: Four factors determine whether the second stage may be safely continued and these must be carefully monitored throughout the second stage of labour. 1. Maternal conditions Observation includes an appraisal of the mother’s ability to cope emotionally as well as an assessment of her physical wellbeing. A maternal pulse rate is usually recorded quarter- hourly and bloods pressure hourly 2. Fetal conditions - During the second stage, the fetal heart should be monitored either continuously or after each contraction. stage may be associated with fetal distress. The liquor amnii is observed for signs of meconium staining. 3. Uterine contractions - The strength, length and frequency of contractions should be assessed continuously. 4. The progress of descent - The progress should be recorded approximately every 30 minutes during the second stage. MANAGEMENT OF THE SECOND STAGE OF LABOUR2
  37. 37. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • CONDUCTING THE DELIVERY1 : When delivery is imminent, the patient is usually placed in the dorsal position, and the skin over the lower abdomen, vulva, anus and upper thigh is cleansed with antiseptic solution and draped. DELIVERY OF THE HEAD 1) Control the delivery of the head to prevent laceration 2) Performed episiotomy if requires 3) Cleared the airway after delivery of the had MANAGEMENT OF THE SECOND STAGE OF LABOUR3
  38. 38. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • CONDUCTING THE DELIVERY2 : DELIVERY OF THE SHOULDERS Delivery of the anterior shoulder is aided by gentle downward traction on the head. The posterior shoulder is delivered by elevating the head. MANAGEMENT OF THE SECOND STAGE OF LABOUR3
  39. 39. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • CONDUCTING THE DELIVERY3 : DELIVERY OF THE TRUNK After the delivery of the shoulders the baby is grasped around the chest to aid the birth of the trunk. Finally, the body is slowly extracted by traction on the shoulders and lifts the baby towards the mother’s abdomen. The time of delivery is noted. CUTTING THE UMBILICAL CORD After delivery, it is therefore usual to wait 15 to 20 seconds before clamping and cutting the umbilical cord. After cutting the cord a plastic crushing clamp is placed on the cord 1 to 2 cm from the umbilicus and the cord is cut again 1 cm beyond the clamp. MANAGEMENT OF THE SECOND STAGE OF LABOUR3
  40. 40. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • CONDUCTING THE DELIVERY4 : IMMEDIATE CARE OF THE NEW BORN Once the baby is breathing normally he should be dried and warmly wrapped to prevent cooling and handle to the mother to hold, cuddle and enjoy. If spontaneous respiration is not established soon after birth, resuscitation is the immediate priority. The Apgar’s score of the baby should be noted and recorded. MANAGEMENT OF THE SECOND STAGE OF LABOUR3
  41. 41. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY MECHANISM OF LABOUR for occiput anterior The “mechanism of labour” refers to the sequencing of events related to posturing and positioning that allows the baby to find the “easiest way out”. For a normal mechanism of labour to occur, both the fetal and maternal factors must be harmonious. DEFINITION:
  42. 42. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY MECHANISM OF LABOUR for occiput anterior Events of mechanism of labour: F: Flexion and descent I: Internal rotation of the fetal head C: Crowning E: Extension R: Restitution I : Internal rotation of the shoulders E: External rotation of the fetal head L: Lateral flexion of the body
  43. 43. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY MECHANISM OF LABOUR for occiput anterior (OA) Flexion Internal rotation Crowning Extension Restitution Internal rotation of shoulder External rotation of head Lateral flexion of body Delivery F I C E R I E L
  44. 44. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY MANAGEMENT THIRD STAGE OF LABOUR
  45. 45. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • BIRTH OF THE PLACENTA1 : Delivery of the placenta occurs in two stages: (1) separation of the placenta from the wall of the uterus and into the lower uterine segment and/or the vagina, and (2) actual expulsion of the placenta out of the birth canal. MANAGEMENT OF THE THIRD STAGE OF LABOUR
  46. 46. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • MECHANISM OF PLACENTA SEPARATION1 : THE THIRD STAGE OF LABOUR Two mechanisms of placental separation occurs: 1- Mathews-Duncan mechanism The leading edge of the placenta separates first and the placenta is delivered with its raw surface exposed. 2- Schultz mechanism If the placenta is inserted at the fundus and central area separates first, the placenta inverts and draws the membranes after it, covering the raw surface (inverted umbrella)
  47. 47. LABOUR AND DELIVERYLABOUR AND DELIVERY WHAT ARE THE SIGNS OFWHAT ARE THE SIGNS OF PLACENTA SEPARATIONPLACENTA SEPARATION
  48. 48. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • BIRTH OF THE PLACENTA2 : CLINICAL SIGNS OF PLACENTAL SEPARATION Placental separation takes place within 5 minutes after the delivery of the infant. Signs suggesting that detachment or separation has taken place include: 1. The uterus becomes globular and hard. This sign is the earliest to appear. 2. There is often a sudden gush of blood 3. The uterus rises in the abdomen because the placenta, having separated, passes down into the lower segment and vagina, where its bulk pushes the uterus upward. 4. Cord lengthening. This is the most reliable clinical sign of placental separation. MANAGEMENT OF THE THIRD STAGE OF LABOUR
  49. 49. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • BIRTH OF THE PLACENTA2 : After the placental separation takes place the placenta can be delivered by the: 1. Passive management – wait for spontaneous expulsion of placenta 2. Active management MANAGEMENT OF THE THIRD STAGE OF LABOUR
  50. 50. LABOUR AND DELIVERYLABOUR AND DELIVERY ACTIVE MANAGEMENT OFACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOURTHE THIRD STAGE OF LABOUR
  51. 51. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY MANAGEMENT OF THE THIRD STAGE OF LABOUR ACTIVE MANAGEMENT OF THE THIRD STAGE Active management of the third stage (active delivery of the placenta) helps prevent postpartum haemorrhage. Active management of the third stage of labour includes: ~ use of oxytocin ~ controlled cord traction, and ~ uterine massage.
  52. 52. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY MANAGEMENT OF THE THIRD STAGE OF LABOUR ACTIVE MANAGEMENT OF THE THIRD STAGE ~ Use of oxytocin Oxytocic drugs should be given with the birth of the anterior shoulder. Syntocinon is the most used oxytocic known to be effective; the addition of ergometrine may reduce blood loss. SYNTOMETRINE (oxytocin 5 IU + ergometrine 0.5 mg) – widely used
  53. 53. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • BIRTH OF THE PLACENTA3 : EXPULSION OF THE PLACENTA BY ACTIVE MANAGEMENT When these signs have appeared the placenta is ready for expression. If the patient is awake, she is asked to bear down while gentle traction is made on the umbilical cord. The popular and effective method of delivering the placenta is by Brandt-Andrews method. MANAGEMENT OF THE THIRD STAGE OF LABOUR
  54. 54. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • BIRTH OF THE PLACENTA4 : BRANDT’S ANDREW METHOD Once the signs of placental separation have occurred the obstetrician assists delivery of the placenta by controlled cord traction as described by Brandt- Andrews’ method. MANAGEMENT OF THE THIRD STAGE OF LABOUR A) Controlled cord traction B) Delivery of the membranes
  55. 55. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • BIRTH OF THE PLACENTA5 : EXAMINATION OF THE PLACENTA The placenta, membranes, and umbilical cord should be examined for completeness and for anomalies. EXAMINATION OF THE PERINEUM At the same time, the perineal region, vulva outlet, vaginal canal, and the cervix should be carefully examined for lacerations. If the perineum has been torn or an episiotomy made, tear or incision should be repaired immediately. MANAGEMENT OF THE THIRD STAGE OF LABOUR
  56. 56. MANAGEMENT AFTER DELIVERY
  57. 57. NORMAL LABOUR AND DELIVERYNORMAL LABOUR AND DELIVERY • EARLY POSTPARTUM MANAGEMENT: The hours immediately following delivery and the birth of the placenta are a critical period as postpartum haemorrhage can occurspostpartum haemorrhage can occurs due the relaxation of the uterus. The patient is kept in the delivery suite for 1 hour postpartum under close observation. She is check for bleeding, the blood pressure is measured, and the pulse is counted. Before discharging the patient from the delivery suit it is mandatory: • To check the uterus frequently to make sure it is firm and not relaxing. • To remove any presence of intrauterine blood clots. The presence of these clots will interfere with retraction and the normal haemostatic mechanism of the uterus. • To look at the introitus to see that there is no haemorrhage. • To keep the bladder empties because full bladder can also interfere with uterine retraction. • To examine the baby to be certain that it is breathing well and that the colour and tone are normal. IMMEDIATE MANAGEMENT AFTER THE DELIVERY

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