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normal laboor & delivery.pptxi
1. Normal labor
and delivery
Definition of normal labour
Factors influencing progress of labour
Diagnosis of labour
Stages of labour
Mechanisms of labour
Management of labour
2. LABOUR
◦ Event that take place in the uterus and birth canal to expel the viable fetus
through the vagina.
◦ The onset is painful, regular contractions, more than one every ten minutes
◦ with progressive cervical effacement and dilatation
◦ accompanied by descent of the head of fetus.
DELIVERY
◦ The expulsion of a viable fetus out of the uterus.
NORMAL LABOUR (EUTOCIA)
◦ Labour is consider normal when mature fetus presenting by vertex
◦ delivers by natural efforts
◦ without prolongation of labour.
DYSTOCIA
◦ A difficult labour, which refers to a labour not progressing satisfactorily with
possible undue consequences to mother and fetus.
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3. Normal labor
The following criteria should be present to call it normal 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
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3
4. POWER
PASSAGE
PASSENGER
Refers to fetal
• Attitude
• Lie
• Presentation
• Denominator
• Position
Primary force –
actions of the uterine
muscles
Secondary force –
involuntary
contraction of
muscles of
diaphragm and
anterior abdominal
wall (bearing down
effort)
Formed by the soft tissues covering
the bony pelvis through which
the fetus is expelled during
labour
*pelvic inlet
*pelvic cavity
*pelvic outlet
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5. THE NORMAL FEMALE PELVIS
1. The female pelvis provides the basic framework of the
birth canal.
2. The obstetric pelvis is divided into false and true
pelvis by the pelvic brim or inlet
3. The true pelvis is important, for it is through this
confined space that the fetus must pass on its journey
through the birth canal.
4. The true pelvis is composed of inlet, cavity and outlet.
5. Types of female pelvis – gynaecoid, anthropoid,
android and platypelloid
Outlet
Cavity
Inlet
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6. THE NORMAL FEMALE PELVIS
1. The brim is slightly oval transversely.
2. The sacral promontory is not prominent.
3. The transverse diameter is slightly longer
than the anteroposterior.
4. The sidewalls are parallel and straight.
5. The ischial spines are not prominent.
6. The sacrosciatic notches are wide.
7. The sacrum has a good curve.
8. The pubic arch angle are wide, i.e. more than
90
9. Inter tuberous diameter is wide
The ideal normal female gynaecoid pelvis:
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7. THE NORMAL FEMALE PELVIS
The important diameters of the female pelvis:
Anteroposterior Oblique Transverse
BRIM 11 – 11.5 12 12.5
CAVITY 12 12 12
OUTLET 12.5 12 11- 11.5
Diameters
(cm)
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8. 1. Sagittal suture: - The sagittal suture lies between the
parietal bones. It runs in an anteroposterior direction
between the anterior and posterior fontanelles.
2. Coronal sutures: - The suture uniting the parietal bones
to the frontal bones is called the coronal suture. It’s
extend transversely from the anterior fontanels and lies
between the parietal and frontal bone.
3. Frontal suture: - The frontal suture is between the two
frontal bones. It is an anterior continuation of the sagittal
suture.
4. Lambdoidal suture: - Is between the parietal and
occiptal bones.
SUTURES
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9. MOULDING OF THE FETAL SKULL
MOULDING’ is the ability of the fetal head
to change its shape and so to adapt itself
to the unyielding maternal pelvis during
the progress of labour.
This property is of the greatest value in
the progress of labour.
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10. • Attitude: position of the head with regard to fetal spine
• Complete flexion best position, presents the smallest
diameter of cephalic presentation,
suboccipitobregmatic diameter (9.5cm.) to pelvic inlet
A--Complete flexion. B-- Moderate flexion. C--Poor flexion. D—Hyperextension
(military)
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11. • Position: relationship of a nominated site of presenting
part to a denomonating location on internal pelvis
• For vertex presentations, the occiput is used in relation
to the maternal side
• Identify the posterior fontanelle, it is smaller than the
anterior fontanelle
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13. • OA:occiput anterior position OP: occiput posterior
• LOT: left occiput transverse ROT: right occiput transverse
• LOA: left occiput anterior ROA: right occiput anterior
• ROP:right occiput posterior LOP: left occiput posterior
Lippincott Manual of Nursing Practice
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14. • Station: measure of descent of presenting part of
fetus through birth canal (-4 to +4) to quantify in
cm. distance of bony parts from ischial spines,
that is midposition or 0 station
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15. Diameters of the fetal skull – anterior posterior diameters
A
B
C
D
E
F
G
AB ~ Suboccipto bregmatic – 9.5
AC ~ Submento bregmatic – 9.5
DE ~ Occipito frontal ~ 11.0
FG ~ Mento vertical – 13.5
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16. THE FETAL SKULL
• Basal–Vertical
Base of skull to most distant point of vertex 9.0 cm.
• Occipital–Frontal
Root of nose to occipital protuberance 11.5 cm.
• Biparietal
Between the two parietal eminences * 9.5 cm.
• Bitemporal
Greatest distance between
two halves of coronal suture 8.5 cm.
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17. 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
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18. 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
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19. 70mmhg + 60mmhg + 55mmhg = 185 MVU’s
Center for experimental learning, Quillen College of Medicine, East Tennessee State University
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21. 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
”
SYMPTOMS AND SIGNS OF LAB
Before labour begins, women usually notice one or more premonitory, or
warnings, signs that labour is about to begin.
They are:
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22. 1st stage
• from onset of labour
to full dilatation of
cervix (10cm)
Latent Phase
• from onset to
dilatation (3-4cm)
• cervix fully effaced
• 3-8hrs
Active Phase
• end of LP
• full dilatation
(10cm)
• 2-6hrs
• cervix dilates
1cm/hr
2nd Stage
from full dilatation of
cervix (10cm) to
delivery of fetus
Passive Phase
• no maternal urge
to push
• fetal head is still
high in the pelvis
• sagittal suture in
transverse
diameter
Active Phase
should not last
- 2hrs in nulliparous
- 1hr in multiparous
3rd stage
from delivery of fetus
to delivery of placenta
• more than 30min is
considered prolonged
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23. Lightening
◦ as the baby settles into lower uterine segment, causing
lowering of the fundal height; a sense of relief for the
mother.
Increased vaginal secretion.
Cervix become soft and effaced.
False labour pain occur with variable frequency.
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24. There are 2 phase:
1) Latent Phase: time between the onset of the labour and 3-4cm
dilatation. Lasted between 3-8 hours(lesser in multiparous)
a) Uterine contractions
Regular in frequency.
4-5 in 10 min, each contraction may last 40-45s.
b) Show (blood stained mucus discharge)
Evidence of start of effacement and dilatation.
c) Effacement of cervix (thinning of cervix: 2.5cm-paperly thin)
d) Dilatation of cervix
2) Active Phase : time between the end of latent phase(3-4cm dilate)
until full dilatation(10cm)
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25. LATENT 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
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27. There are 2 phases:
1) Passive phase - no maternal urge to push and the fetal head is still
relatively high in the pelvis
2) Active second stage
a) Accomplished by downward thrust offered by
↑ uterine contractions
voluntary contraction of abdominal muscles
b) Bearing down efforts
Breath hold; strain down as in defecation desire
c) Descent of the head.
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28. Series of changes in position and attitude that the fetus
undergoes during it passage through the birth canal
1. Engagement
2. Descent
3. Flexion
4. Internal rotation
5. Extension
6. Restitution
7. External rotation
8. Lateral flexion (Expulsion)
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29. Head normally enters pelvis in the transverse position.
Engagement occurred when the widest part of the presenting
part has passed successfully through the inlet.
More than two-fifth palpable abdominally, the head is not
engaged.
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30. A continuous movement
Brought by:
◦ uterine contraction
◦ pressure of amniotic fluid
◦ contractions of abdominal muscles
In primigravida – engagement occur before onset
of labour, descent continues in the second stage of
labour
In multigravida – descent follows engagement
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31. At the beginning of labour,
head of fetus is possible for
some degree of flexion.
Presenting diameter
(11.5cm)
As labour progresses, the
head of fetus meet the
resistance of lower uterine
segment.
Presenting diameter:
Occipitobregmatic (9.5cm)
Flexion has advantage of
bringing the shortest
diameter of the head into
descent.
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32. Important factor: Resistance of pelvic floor
Occiput rif head is well flexed occiput will be leading point
encouraged to rotate anteriorly sagittal suture now lies in AP
diameter
Rotates from LOT(Left occipitotransverse (900)
/LOA-Left occipitoanterior (450) position to lie
under the subpubic arch.
Head now in occipito-anterior (OA) position
Shoulders is in left oblique of the brim
The internal rotation cause a slight twist in the
neck of the fetus (the head is no longer in direct
alignment with the shoulder).
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36. Occiput is below symphysis pubis.
2 forces:
Uterine contraction – posterior & downward
Resistance of pelvic floor - upward and forward
The well flexed head now extends and the occiput
escapes from underneath the symphisis pubis and
distends the vulva.
Crowning
◦ That stage of childbirth when the fetal head has negotiated the pelvic
outlet and the largest diameter of the head is encircled by the vulvar ring.
Occiput is delivered followed by bregma, brow and
face.
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37. Rotation of the head 45°
to restore the position of
the head of fetus - to
correct the twist in the
neck that occurred
during internal rotation.
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38. In order to be delivered, the
shoulders have to rotate into
the direct AP plane(the
widest diameter)
External rotation cause
rotation of the head 45°
towards mother left thigh in
the same direction as
restitution.
Thereby relationship of
head with shoulder is
restored.(same alignment)
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39. Shoulders will be in the anterior-posterior position
Anterior shoulder is under symphysis pubis, delivers
first and subsequently posterior shoulder.
Aided by lateral movement:
The rest of the body is born by lateral flexion with
arms folded on the chest and hands under the chin.
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41. (From delivery of the fetus until delivery of the placenta and membranes.)
Placenta separation due to
Effective uterine contraction and retraction
↓
Descent into the lower segment of the uterus
↓
Expulsion
Abdominal discomfort due to uterine contraction
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42. FIRST STAGE SECOND STAGE THIRD STAGE
ON THE MOTHER
1. Minimal effects 1. Pulse increases
2. Systolic BP
slightly increased
due to pain and
anxiety
3. Minor injuries to
the birth canal
1. Blood loss from
the placental site
(200 ml)
2. Blood loss from
laceration and
perineum (100 ml)
ON THE FETUS
PHYSIOLOGICAL EFFECTS OF LABOUR
1. Moulding – overlapping of the vault bones
2. Caput succedaneum – it is a soft swelling of the most dependent part of the
fetal head
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43. 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:
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44. 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:
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45. 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
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46. 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 doubt
d) To ascertain whether the fore waters have ruptured or to rupture them artificially
e) To exclude cord prolapse after rupture of the fore waters
f) To confirm the degree of cervical dilatation and position of the presenting part
g) To assess progress of labour.
h) To assess the adequacy of the pelvis.
MANAGEMENT OF THE FIRST STAGE OF LABOUR2
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47. 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.
Nutrition in early labour
No food is permitted after labour is established – to prevent regurgitation and aspiration
It is important to maintain adequate hydration - via intravenous routes
MANAGEMENT OF THE FIRST STAGE OF LABOUR3
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48. Position of labouring mother:
As long as the patient is healthy, the presentation normal, the presenting part engaged, and
the fetus in good condition, the patient may walk about or may be in bed, as she wishes
Monitoring the progress of labour
Once labour has become established, all events during labour should be recorded on a
partogram.
a) The well-being of the fetus
b) The well-being of the mother
c) The progress of the labour
Pain relief
When the pains are severe an analgesic preparation may be given.
a) Opiate drugs – e.g. Pethidine given intramuscularly every 4 hour
b) Inhalational analgesia – e.g. Entonox
c) Epidural analagesia
MANAGEMENT OF THE FIRST STAGE OF LABOUR4
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49. MONITORING FETAL HEART
How 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
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50. MONITORING FETAL HEART
How To Monitor The Fetal Heart Rate?
Auscultation methods
Electronic monitoring ~ CTG
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52. RECORDING THE PROGRESS OF LABOUR
PATIENT INFORMATION
FETAL INFORMATION
~ fetal well being
LABOUR INFORMATION
~ Dilatation
~ Descent
~ Contraction
MEDICATIONS
MATERNAL INFORMATION
~ Well being
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53. 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.
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54. 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
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55. 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) Performed Ritgen’s method
4) Cleared the airway after delivery of the had
MANAGEMENT OF THE SECOND STAGE OF LABOUR3
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56. PERFORMING AN EPISIOTOMY:
MANAGEMENT OF THE SECOND STAGE OF LABOUR3
"..is a surgical incision into the perineum to enlarge the space
at the outlet
EPISIOTOMY
IS EPSIOTOMY REALLY NEEDED?
Episiotomies are said to provide the following benefits:
1. Speed up the birth
2. Prevent Tearing
3. Protects against incontinence
4. Protects against pelvic floor relaxation
5. Heals easier than tears
medical research has not proven
any of these benefits
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57. PERFORMING AN EPISIOTOMY:
MANAGEMENT OF THE SECOND STAGE OF LABOUR3
Episiotomies are not always necessary
Episiotomy should be considered only in the case of:
• Complicated vaginal delivery (breech, shoulder dystocia, forceps,
vacuum);
• Scarring of the perineum;
• Fetal distress.
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58. PERFORMING AN EPISIOTOMY:
MANAGEMENT OF THE SECOND STAGE OF LABOUR3
Episiotomy Types
Midline episiotomy Mediolateral episiotomy J-shaped episiotomy
Incision of episiotomy
The three major types of
episiotomy
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59. PERFORMING AN EPISIOTOMY:
MANAGEMENT OF THE SECOND STAGE OF LABOUR3
Infiltrate perineum with
local anaesthetic agent
Making an incision
Wait until:
1) the perineum is thinned
out;
and
2) 3–4 cm of the baby’s
head is visible during a
contraction.
Performing an episiotomy will
cause bleeding. It should not,
therefore, be done too early.
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60. 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
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61. 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
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62. 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
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63. 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
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64. 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)
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65. 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
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66. 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
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67. 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.
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68. 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
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69. 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
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70. 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) Placenta separation B) Controlled cord traction C) Delivery of the membranes
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71. 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
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72. REPAIR OF EPISIOTOMY:
MANAGEMENT OF THE THIRD STAGE OF LABOUR
Note: It is important that absorbable sutures be used for closure.
Continuous sutures Interrupted sutures Interrupted suture or
subcuticular
Vaginal mucosa
1. Identify apex
2. Begin suturing
1.0 cm above apex
3. Continuous sutures
4. Ends at the level of
vaginal opening
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73. EARLY POSTPARTUM MANAGEMENT:
The hours immediately following delivery and the birth of the placenta are a critical
period as postpartum 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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74. • If we have mastered the information to appropriately manage a patient in labor
• Recognize complications of labor and institute the proper management
• Develop a personal and professional relationship with mother and baby
• ……..Then
……….you have truly become an Obstetrician
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