Gynaecology & Obstetrics

1. Management of
1st
,2nd
and 3rd
stages of
labor

2. Normal LaborNormal Labor
 Process by which ……Process by which …… regularregular
uterine contractionsuterine contractions —›—› progressiveprogressive
effacement and dilatationeffacement and dilatation of theof the
cervixcervix —›—› deliverydelivery of theof the fetusfetus andand
thethe placentaplacenta at or beyond age ofat or beyond age of
fetal viability.fetal viability.

3. 1 LNMP 24 W 28 W 37 W 40W 42W
PTL
Term
Labour
Labour can occur at:Labour can occur at:
prolongedprolonged

4. Stages of laborStages of labor
StageStage 11stst
22ndnd
33rdrd
44thth
OnsetOnset Onset ofOnset of
truetrue
uterineuterine
contractiocontractio
nsns
Full cxFull cx
dilatationdilatation
FetalFetal
expulsionexpulsion
PlacentalPlacental
deliverydelivery
EndEnd Full cxFull cx
dilatationdilatation
FetalFetal
expulsionexpulsion
PlacentalPlacental
deliverydelivery
2h2h
observatioobservatio
ns forns for
PPHgePPHge
and anyand any
complicaticomplicati
onsons
TimeTime oPG =12-14PG =12-14
hh
oMG = 6-8 hMG = 6-8 h
oPG = 1-2 hPG = 1-2 h
oMG = ½- 1MG = ½- 1
hh
PG &MGPG &MG
= 10-30= 10-30
minmin

5. Management of stages of labor
How to deal
Diagnosis
Preparations
Monitoring
Procedures

6. Management of the FirstManagement of the First
Stage of LabourStage of Labour

7. DiagnosisDiagnosis {{made within one hour of admission}made within one hour of admission}
A.A. symptoms:symptoms:
1.1. True labour painsTrue labour pains – colicky pain in the abdomen and back– colicky pain in the abdomen and back
are characterized byare characterized by::
charactercharacter True labour painTrue labour pain False labour painFalse labour pain
contractionscontractions regularregular IrregularIrregular
Interval betweenInterval between
contractions andcontractions and
intensityintensity
Progressive (increaseProgressive (increase
in frequency andin frequency and
intensity)intensity)
Short duration, notShort duration, not
progressiveprogressive
Changes in the cervixChanges in the cervix Associated withAssociated with
effacement andeffacement and
dilation of thedilation of the
cervixcervix
Not associated withNot associated with
effacement and dilationeffacement and dilation
of the cervixof the cervix
MembranesMembranes Associated withAssociated with
bulging ofbulging of
membranesmembranes
Not associated withNot associated with
bulging of membranesbulging of membranes
Response to analgesiaResponse to analgesia Not relieved byNot relieved by
sedationsedation
Relieved by sedationRelieved by sedation
LabourLabour Followed by labourFollowed by labour Not followed by labourNot followed by labour

8. Patient preparations:Patient preparations:
 FullFull historyhistory and clinicaland clinical examinationexamination
 PositionPosition: Encourage any non-supine: Encourage any non-supine
position and movement throughoutposition and movement throughout
labor and childbirth.labor and childbirth.
 DietDiet:: nothing by mouth, IV fluid, ornothing by mouth, IV fluid, or
light diet but fat ,proteins are notlight diet but fat ,proteins are not
allowed at all.allowed at all.
 IV lineIV line : recommended.: recommended.

9. Patient preparations:Patient preparations:
 Rectum:Rectum: no evidence that routine enema isno evidence that routine enema is
beneficial .beneficial .
 BladderBladder::
– Encouraged patient to empty her bladderEncouraged patient to empty her bladder
regularly.regularly.
– Urinary catheter only when woman is unable toUrinary catheter only when woman is unable to
void.void.
 Pain Control:Pain Control: antenatal women educationantenatal women education
about pain relief techniques- epidural anesthesiaabout pain relief techniques- epidural anesthesia
―› satisfaction.―› satisfaction.

10. 2.2. Show – blood stained mucous.Show – blood stained mucous.
3.3. SROMSROM
B.B. Signs:Signs:
o palpable or recorded uterine contractionpalpable or recorded uterine contraction
o effacement and dilation of the cervixeffacement and dilation of the cervix
o formation of forewaterformation of forewater

11. What is a partogram
(partograph) ?

12. PARTOGRAMPARTOGRAM
 Def:Def: diagrammatic record of the events ofdiagrammatic record of the events of
labour.labour.
 Advantages:Advantages:
– MonitoringMonitoring
 the progress of labour,the progress of labour,
 maternal and fetal wellbeingmaternal and fetal wellbeing
– Early detectionEarly detection and management ofand management of
labour abnormalities.labour abnormalities.

13. FetalFetal
cervicalcervical
DescentDescent
UterineUterine
MaternalMaternal

14. Timing observations of different parameters of
partogram in the the1st stage of labor
Parameter
Ideal
in both
phases
)hrs(
Minimum acceptable
Latent
phase
Active
phase
Vaginal examination 4 8 4
Descent of head 4 8 4
Contractions ½ 4 2
Fetal heart beats ½ 4 1
Temperature, PR, BP, urine 4 4 4

15. Phases of cervical dilatationPhases of cervical dilatation

16. • The alert line:The alert line:
• DrawnDrawn from 3 cm dilatationfrom 3 cm dilatation ( at rate of dilatation of 1 cm( at rate of dilatation of 1 cm
/ hour)./ hour).
• Represents the rate of dilatation of the slowest 10 % ofRepresents the rate of dilatation of the slowest 10 % of
labours in primigravidae.labours in primigravidae.
• Crossing the alert lineCrossing the alert line suggests that the patient should besuggests that the patient should be
transferred to a hospital for extra care.transferred to a hospital for extra care.
• The action lineThe action line ::
• parallel and 2 (4) hours to the right of the alert line;parallel and 2 (4) hours to the right of the alert line;
• crossing the action linecrossing the action line suggests the need for interventionsuggests the need for intervention
(eg, artificial rupture of the membranes, administration of(eg, artificial rupture of the membranes, administration of
oxytocics.oxytocics.

17. Vaginal examination:Vaginal examination:
single individual to minimize interobserversingle individual to minimize interobserver
variationsvariations
 Indications:Indications:
• On admissionOn admission
• At one to four hour intervals in theAt one to four hour intervals in the first stagefirst stage
• AtAt rupture of membranesrupture of membranes to evaluate for cord prolapseto evaluate for cord prolapse
• Feeling theFeeling the urge to pushurge to push to determine whether theto determine whether the
cervix is fully dilatedcervix is fully dilated
• If theIf the FHRFHR falls, to evaluate for conditions such as cordfalls, to evaluate for conditions such as cord
prolapse or uterine rupture.prolapse or uterine rupture.

18. Vaginal examination:Vaginal examination:
 Disadvantages:Disadvantages:
– Increases woman’s anxiety.Increases woman’s anxiety.
– Increasing numbers vaginal examinations inIncreasing numbers vaginal examinations in
(PROM) increases neonatal sepsis(PROM) increases neonatal sepsis

19. Effacement and dilation of the cervixEffacement and dilation of the cervix

20. Assessing descent of the fetal head byAssessing descent of the fetal head by
vaginal examination;vaginal examination;
0 station is at the level of the ischial0 station is at the level of the ischial
spine (Sp).spine (Sp).

21. 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:

22. Fetal heart rateFetal heart rate
 Intermittent auscultation of the fetal heartIntermittent auscultation of the fetal heart ( for low( for low
risk patients): after a contraction should occur for atrisk patients): after a contraction should occur for at
least 1 minute, at least every 15 minutes.least 1 minute, at least every 15 minutes.
– Method : Doppler ultrasound or Pinard stethoscope.Method : Doppler ultrasound or Pinard stethoscope.
 Continuous intrapartum FHR monitoringContinuous intrapartum FHR monitoring for :for :
((External and InternalExternal and Internal))
– High-risk patients ,High-risk patients ,
– When FHR below 110 or over 160 BPMWhen FHR below 110 or over 160 BPM

23. Active management ofActive management of
laborlabor
 AmniotomyAmniotomy
 OxytocinOxytocin
administrationadministration
for dilation ratesfor dilation rates
of <1 cm/hourof <1 cm/hour

24. Management of second stage
of labour

25. Onset of second stageOnset of second stage
 Full cervical dilatation (sure)Full cervical dilatation (sure)
 Involuntary Bearing downInvoluntary Bearing down
 The urge to defecate and urinate.The urge to defecate and urinate.
 Contractions becomes more prolonged.Contractions becomes more prolonged.
 Expiratory grunting with expulsive efforts.Expiratory grunting with expulsive efforts.
 Rupture of membranes (suggestive)Rupture of membranes (suggestive)

26.  Position:Position: Patient is put in dorsal Lithotomy position andPatient is put in dorsal Lithotomy position and
the legs are half-flexedthe legs are half-flexed
 Patient is properlyPatient is properly drapeddraped
 AsepsisAsepsis::
 DietDiet
 Bladder and rectumBladder and rectum
 Pain reliefPain relief
 Patient is asked to takePatient is asked to take deep breathdeep breath & breath held then& breath held then
exerts downward pressure at the time of uterineexerts downward pressure at the time of uterine
contraction and relax in betweencontraction and relax in between
Preparation for deliveryPreparation for delivery

27. Fetal heart rate monitoringFetal heart rate monitoring
 Low risk:Low risk: every 15 minevery 15 min
 High risk:High risk: every 5 minevery 5 min
Slowing of the FHR may occur due toSlowing of the FHR may occur due to
fetal head compressionfetal head compression

28. Obstetrical roleObstetrical role
 Bearing down only during contraction.Bearing down only during contraction.
 Delivery of the headDelivery of the head
– CrowningCrowning
– The main role of obstetrician is theThe main role of obstetrician is the
prevention of perineal tearsprevention of perineal tears
 Before crowningBefore crowning
 After crowningAfter crowning)) Ritgen maneuver )Ritgen maneuver )
 EpisiotomyEpisiotomy
– Once head delivered clear upper air way.Once head delivered clear upper air way.

29. Ritgen maneuverRitgen maneuver

30. Posterior shoulderPosterior shoulderAnterior shoulderAnterior shoulder
Delivery of shoulderDelivery of shoulder
The rest of the body almost always follows the shoulderThe rest of the body almost always follows the shoulder
without difficultywithout difficulty

31. Management of third stage of
labour

32. aimed at:
1-Complete delivery of the after birth
(placenta and membranes).
2-Prevention of acute inversion of the uterus.
3-prevention of postpartum haemorrhage
Management of third stage of labour

33. a-Conservative method:
•The left hand is placed just above the fundus to detect any
change in the fundal level, shape and consistency of the
uterus which indicate atony.
• Wait for signs of placental separation and decent,
•Massage uterus to contract
•The patient is asked to bear down to deliver the placenta
spontaneously.
• Ergometrine 0.5mg or Syntometrine(5 units syntocinon +
0.5mg Ergometrine) to be given intravenouslly.
Delivery of the placenta and membranes: uterus should
be examined for the presence of second baby

34. Signs of separation and decent of the
placenta:
1. -The body of the uterus becomes smaller, harder, and
globular.
2. -The fundal level rises in the abdomen because the
lower segment becomes distended by the placenta.
3. -Suprapubic bulge may appear due to presence of the
placenta in the lower segment.
4. -Elongation of the cord out side the vulva.
5. -Sudden gush of blood from the vagina.

35. b-Active methods (prophylaxis against postpartum haemorrhage)
1-Give Methargine 0.5 mg IM or Syntometrine (5units
oxytocin+0.5mg Methargine), at the time of the anterior
shoulder is free from symphysis pubis or as soon as possible
thereafter.
2-Deliver the placenta and membranes by control cord traction by
right hand, and the left hand is placed on the suprapubic
region, pushing the uterus upwards.
N.B. USE SYNTOCINON RATHER THAN METHARGINE
IN CARDIAC AND HYPERTENSIVE CASES.

36. ControlledControlled
cord tractioncord traction
Delivery ofDelivery of
the placentathe placenta

37. IV-Post Delivery:
1-examine the placenta for their completeness, anomalies,
length, and number of vessels in the cord and record the
placental weight.
2-Suture the episiotomy or any laceration.
3-Estimate blood loss, count swabs, and take cord blood for
Hb, blood group, Rh, bilirubin, and coomb’s test for Rh
negative mother.

38. IV-Post Delivery:
4-Check BP, P, T, Lochia and firmness of the uterus before
transferring the patient.
5-Continue an infusion of syntocinon through the first hour if
necessary.
6-Allow no food during the first hour, sips of water may be
taken, encourage nursing.

39. Seven Cardinal MovementsSeven Cardinal Movements
 EngagementEngagement
– descent of BPD to a level below the plane of thedescent of BPD to a level below the plane of the
pelvic inletpelvic inlet
 DescentDescent
 FlexionFlexion
 Internal rotationInternal rotation
 ExtensionExtension
 RestitutionRestitution
 External rotationExternal rotation
 ExpulsionExpulsion

41. InductionInduction
 Assess adequacy of pelvis and cervicalAssess adequacy of pelvis and cervical
examexam
 Bishop scoreBishop score

42. Bishop scoreBishop score

43. THANKTHANK
YOUYOU