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Spontaneous Vertex Delivery - Normal Childbirth

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Spontaneous Vertex Delivery - Normal Childbirth

  1. 1. Normal Labour & Delivery Adam Collins – Year 4, Medicine, The University of Edinburgh
  2. 2. 1 NORMAL LABOUR • A series of uterine contractions • Progressive dilation and effacement of the cervix • Divided into three recognised stages
  3. 3. 2 STAGES OF LABOUR • First Stage – Latent Phase – Irregular contractions with gradual effacement and dilation up to 4cm – Active Phase – More frequent contractions, foetal descent, faster dilation to a full 10cm • Second Stage – Passive Stage – Full dilation of cervix but without expulsive contractions – Active Stage – Onset of expulsive contractions through to delivery of the neonate
  4. 4. 3 STAGES OF LABOUR • Third Stage – Physiological – No drugs, cord clamping or assistance with placental delivery – May be tried for up to 60 minutes before active management is commenced – Active – 10iu IM Oxytocin, either when anterior shoulder is delivered or upon commencement of active management – Cord clamping or cutting, delivery of the cord by placental traction
  5. 5. 4 POSSIBLE SIGNS OF LABOUR • Lightening • Movement of foetal head deeper into pelvis causing observable drop in abdomen and relieving DiB • Weeks to Hours from onset • Bloody Show • Bloody or brown discharge – the mucus plug of the cervix being released • Days to Hours from onset • Ruptured Membranes • “Waters Breaking” – PV fluid indicating rupture of the amniotic sac • Labour within 24 hours or induced • Contractions • Labour begins when the cervix is effaced and 3-4cm dilated • This usually coincides with regular contractions
  6. 6. 5 FIRST STAGE – DILATION • Cervix effaced and dilated 3-4cm • Uterine muscles contract pushing the foetus downwards • The cervix begins to dilate to accommodate the foetal head • Typically the cervix will dilate to 10cm, to allow the passage of the foetal head • Contractions increase in regularity and discomfort • Initially <45 second contractions >5 minutes apart • By late Active Phase, ~60sec contractions 2-3 minutes apart
  7. 7. 6 FIRST STAGE CARE • One to one midwifery led care in a private, relaxed setting • Facility to eat and drink as desired • Full discussion of birth plans and options • Regular obs and intermittent FHR • Abdominal exams for descent and position 4hrly • Vaginal exam only where clinically necessary to see cervical effacement and dilation • Assessment of PV discharge including “bloody show”, blood and amniotic fluid • 0.5cm/hr dilation rate is lower limit of normal in para 0 • 1cm/hr in para >0
  8. 8. 7 SECOND STAGE – FOETAL DELIVERY • Begins when cervix is fully dilated to 10cm • Foetal head is fully descended into the pelvic brim • Pressure on the cervix gradually increases • Expulsive contractions push the foetus from the uterus • Assisted by maternal pushing, which should be spontaneous rather than directed • Upright postures are associated with higher quality of contractions and faster labour
  9. 9. 8 FOETAL MOVEMENTS DURING DELIVERY • Descent takes places throughout labour • Leading aspect of the foetus descends through the pelvic canal, twisting to take advantage of the widest parts • Rotates forwards under the symphysis pubis, guided by the pelvic floor • Normal foetal progress is a vertex presentation
  10. 10. 9 FOETAL MOVEMENTS DURING LABOUR • Flexion increases throughout labour • As pressure along the longitudinal axis of the foetus increases the head is flexed forwards • This position presents the smallest diameter to the pelvic canal • Rotation of the head • As the head and then the shoulders pass through the pelvic canal they twist to pass match the widest axes • Typically the foetus crowns with a 45° rotation of the head relative to the shoulders which resolves as they follow • Shoulders • Shoulders are born sequentially, anterior first, twisting and passing out under the pubic symphysis
  11. 11. 10 SECOND STAGE CARE • 4 hourly obs, FHR after each contraction for 1 minute • Abdo and or PV exams as required to assess descent and position • Descent should begin within 1 hour of commencement of pushing for para 0 or 30 mins for para >0 • Descent of foetal head and quality of contractions are the most reliable progress indicators • Episiotomy is not routinely indicated unless there are signs of foetal distress or clear evidence of perineum obstructing progress
  12. 12. 11 THIRD STAGE – PLACENTAL DELIVERY • Begins after the delivery of the neonate and lasts until the placenta has been delivered • Active management of third stage is recommended (NICE) – Routine use of uterotonic drugs (oxytocin) – Early clamping and cutting of the cord – Controlled cord traction with uterine counterpressure • Physiological management may be supported in low risk women if requested – Convert if haemorrhage, >1 hr duration, requested by mother – Consult obstetrics if not resolved with 30 mins active management or 1 hr physiological management
  13. 13. 12 KCND • Keeping Childbirth Natural & Dynamic (KCND) • Scottish Govt Program led by consultant midwives • Aims to provide women with as natural a birth as possible by: – Providing evidence based care – Reducing unnecessary intervention – Ensuring informed choice – Developing “multiprofessional” care pathways
  14. 14. 13 PRINCIPLES OF CARE • Ascertain the patient’s needs and expectations of labour and care • Avoid interventions where labour is progressing normally • Ensure 1-to-1 care is delivered wherever practicable • Avoid leaving the woman alone • Where necessary provide a means to summon help and a time when staff will return • Allow and encourage the involvement of birth partners • Allow and encourage women to ask for analgesia at any stage • Allow women to drink and eat lightly except where specific risks preclude it
  15. 15. 14 BIBLIOGRAPHY Slide Principle Source(s) 1 UofAbereen – KCDN http://www.abdn.ac.uk/dugaldbairdcentre/projects/kcnd.shtml 2 NICE Pathway, Normal Labour & Birth http://pathways.nice.org.uk/pathways/intrapartum-care/normal-labour-and-birth 3

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