Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Clinic of the labor obstetric


Published on

Published in: Education
  • Be the first to comment

Clinic of the labor obstetric

  1. 1. - Consist of 4 layers of smooth muscle cells Stratum submucosum – thin layer,prediominantly longitudinal bundle Stratum vasculare – outside stratum submucosum many blood blood vessels gives spongy appearance,longitudinal bundles Stratum supravasculare – mainly circular bundles,some longitudinal bundles Stratum subserosum – outermost,thin layer of longitudinally oriented fiber bundles
  2. 2. Each myometrial cell has proteins plasma membrane involved in the process of ion transport and compose the receptor sites for endogenous and exogenous substances. Besides containing the normal cellular organelles, the smooth muscle cells of the myometrium contain myofilaments consist of actin and myosin. The interaction of these two proteins with calcium and adenosine triphosph ate (ATP) is the pathway that causes the smooth muscle cell to contract. The cell membrane also contains gap junctions that allow communication from cell to cell and provide synchronization during labor. The transmembrane junction consists of two protein hemichannels connexons. Each of them composed of six connexin subunit protein. Synchonization of myometrium smooth muscle cells cause powerful waves of myometrial contraction During labor
  3. 3. - During the process of labor, The myometrium contracts by a positive feedback effect on the "Ferguson reflex"), - Strong contraction of the myometrium are influenced by the action of the hormone oxytocin secreted by the posterior pituitary and hormone prostaglandins from placenta. -Contractions of the uterus after the cervix has been stimulated. -During labor, the urge to push is created by the Ferguson reflex. -The urge to push is caused when the baby is pressed onto the Ferguson Plexus of nerves. - These contractions expel the fetus from the uterus into vagina and also constrict the blood supply to the placenta. -After delivery, the myometrium contracts to expel the placenta and reduce blood loss; where the crisscrossing fibres of middle layer compress the blood vessels.
  5. 5. 1. Feto-placental contribution : - CRH  Pituitary, ACTH  Fetal adrenal gland,glucocorticoid  accelerated production of estrogen and prostaglandins from placenta  reduce progesterone production 2. Increase oestrogen (increase excitability of myometrium membranes and increase synthesis of Prostagladin) 3. Increase Prostaglandin (maintain labor) 4. Decrease Progestrone (increase contractility) 1. Uterine distention : - Stretching effect of the myometrium by the growing fetus and liquor amnii on the uterus.
  6. 6. REGULAR CONTRACTION false labour, It should be infrequent, irregular, and involve only mild cramping. - Contraction occur when the uterine muscles tighten and relax. - When true labor begins, the pituitary gland releases oxytocin. Oxytocin is a hormone that stimulates contractions. - True labor contractions are different from Braxton Hicks because they make labor progress. - Contractions usually start in the back and move around to the front. The contractions can be felt as a cramping or tightening sensation.
  7. 7. PASSING OF THE MUCUS PLUG -The cervix is "plugged" with a thick piece of mucous that helps protect fetus during pregnancy by blocking the entrance to the uterus. - As cervix effaces and dilates, the mucus plug will be released. - The mucus is discharged into the vagina and may be clear, pink, or slightly bloody. Time to labor? -Few days to hours.
  8. 8. BACK LABOR - "Back labor" refers to the pain and discomfort that laboring women experience in their lower back - A frequent cause of back labor is the position of the baby. Positions such as occiput posterior (when baby is facing the mother’s abdomen) can cause pressure from the baby’s head to be applied to the mother’s sacrum (the tailbone). - The result can be intense discomfort during labor.
  9. 9. Starts with Regular uterine contractions and ends with beginning of cervical dilatation and effacement. -Increase velocity of cervical dilatation in short duration (4 hourts) from 3cm to 7cm . Decrease velocity of cervix dilatation from 7cm to maximum dilation (10cm) and to full effacement : maternal os - It occurs because. the head descend and is in contact with the cervix.It gives force to cervix to dilate more (because presenting part of fetus 9.5cm and cervical dilatation only 7cm) - Cause cervix to dilate until full dilatation - Uterine contractions become intensively increase – more frequent, longer, and stronger.
  10. 10. - During active labor,the uterine divisions that are initiated phase 2 of parturition (Preparation of Labor) become increasely evident. - During contraction : - upper segment becomes firm - lower segment becomes softer,distended and more passive - Physiological retraction ring is formed between the upper and lower segment of the uterus. - Functions of lower and upper uterine segment during 1st stage of labor : the upper segment contract,retracts and expels the fetus.In response to these contractions,the softened lower uterine segment and cervix dilate and thereby form a greatly expanded,thinned out. - Fetus can pass through lower segment. - The upper uterine segment does not relax to its original lentgh after contraction,it becomes relatively fixed at shorter length (retraction) : to maintain and gain expulsive force of fetus
  11. 11. - Cervical effacement occurs because of increased myometrial activity during uterine preparation for labor just after cervix is ripened. - The cervix gradually softens, shortens and becomes thinner. It is called cervical effacement. - The muscular fibres at about the level of the internal cervical os are pulled upward,or ‘taken up’,into the lower uterine segment.The condition of the external os remains unchanged. - The presenting part, applied to the cervix and forming lower uterine segment - Because the lower uterine segment and cervix have lesser resistance during a contraction,the uterine contraction cause pressure on the membranes and hydrostatic action of amniotic sac in turn dilates the cervical canal. It is called cervical dilatation.
  12. 12. - Start when cervical dilatation is complete and end with the expulsion of the fetus head of fetus descend passes through the muscular birth canal PUSH (voluntary movement) occurs. the head of fetus pressed on the muscle of pelvis causing increase sensitivity on the stretch receptor on pelvic muscle and cause mother to have the urge to push the fetus out from the vagina As the fetal head continue descend, the vaginal opens and the fetal scalp appears. At first, it appears slit-like then becomes oval and then circular. This is called crowning. As she continue pushes, using her abdominal muscles to aid the involuntary uterine contractions, the fetus is pushed out of the birth canal.
  13. 13. - Occurs immediately after delivery of the fetus.Happen 30 minutes to prevent excessive bleeding  There are 4 classes of blood loss:   > 500 ml = high blood loss  1L = mild bleeding  - 250-300 ml = average blood loss > 1.5 L = severe bleeding Two separate phases are involved: • placental separation the placenta descent to the lower segment and finally expulsed with the membrane • placental expulsion occurs by being forced out by the effective contraction and retraction of the uterus with the voluntary contraction of abdominal muscles.
  14. 14. -Occurs from the moment of the birth until 6th weeks (If prolongation occur,it is called delay period) -Events occur during this period : 1. There is sustained uterine contraction to prevent postpartum hemorrhage 2. Lactogenesis (breastfeeding) 3. Uterine involution and cervical repair ( to enable the reproductive organs to return to non-preggy state) 4. Resumption of ovulation 3 phases of postpartum period : -The initial or acute period involves the first 6–12 hours postpartum. This is a time of rapid change to occurs such as postpartum hemorrhage, uterine inversion, amniotic fluid embolism, and eclampsia. -The second phase (subacute postpartum period) lasts 2–6 weeks. the changes are less rapid than in the acute postpartum phase and the patient is generally capable of selfidentifying problems. The third phase (delayed postpartum period) can last up to 6 months. Changes during this phase are extremely gradual, and pathology is rare.
  15. 15. 1. IDENTIFICATION OF LABOR To differentiate True and False Labor Characteristics True Labour False Labour Contraction Regular and gradually short interval Irregular and unchanged interval Cervical Dilatation Yes No Discomfort Back and abdomen Lower abdomen 2. CERVICAL EXAMINATION - Cervical effacement - Cervical dilation - level of station (distance between fetal part in birth canal and inshial spine)
  16. 16. 3. VAGINAL EXAMINATION The functions of a vaginal examination are to: • Identify the fetal presentation and position 4 movements of vaginal examination: 1) Insert 2 fingers into vagina 2) Fingers directed posteriorly and then swept forward over the fetal head toward maternal symphysis. During the movement, the fingers should cross the saggital suture 3)The position of 2 fontanels are ascertained.the fingers are passed to most anterior extension of saggital suture , and fontanel there is examined and identified. Then with a sweeping motion the fingers pass along the suture to other end of head until the other fontanel is felt and differentiated. 4) The station, or extent to which the presenting part has descended into the pelvis, can also be established at this time. 4. DETECTION OF RUPTURED MEMBRANE - Diagnosed when amniotic fluid is seen pH determination of vagina fluid Indicator used : Nitrazine Vaginal fluid pH Amniotic fluid 4.5 – 5.5 7.0 – 7.5
  17. 17. Monitoring fetal well-being during labor -Monitoring the fetal heart rate by using Cardiotocography (CTG) at least every 30 minutes in first stage and then every 15 minutes during second stage.
  18. 18. Subsequent Vaginal Examination Intravenous Fluids -An intravenous infusion system is advantageous during the immediate puerperium to administer oxytocin prophylactically and at times therapeutically when uterine atony persists. -Moreover, with longer labors, the administration of glucose, sodium, and water to the otherwise fasting woman at the rate of 60 to 120 mL/hr prevents dehydration and acidosis.
  19. 19. PARTOGRAM a graphical representation that record the observation and information from the monitoring of the mother and fetus. Consists :  Maternal status  Fetal heart rate  Dilatation & descent  Uterine contractions
  20. 20. analgesia -The pain of childbirth is likely to be the most severe pain that a woman experiences during her lifetime. -Analgesic that we use : Meperidine, 25-50 mg IV every 1-2 hours or 50-100 mg IM every 2-4 hours Fentanyl, 50-100 mcg IV every hour Nalbuphine, 10 mg IV or IM every 3 hours Butorphanol, 1-2 mg IV or IM every 4 hours Morphine, 2-5 mg IV or 10 mg IM every 4 hours As an alternative, regional anesthesia may be given. Anesthesia options include the following: Epidural (common) Spinal Combined spinal-epidural
  21. 21. ACTIVE MANAGEMENT Active management of labour (AML) is a structured protocol for the management of all parturients in labour with the aim of reducing prolonged labour. Its aim was to keep labour to fewer than 12 hours and operative delivery rates to a minimum. Two of its components are performed : -Amniotomy -Oxytocin When dilation is not increased by 1cm per hour,amniotomy is performed.After 2 hours,high dose oxytocin infused if still not dilated. ARM, (Artificial rupture of the membranes) AMNIOTOMY -breaking the membranes that surround the baby and releasing the amniotic fluid before it breaks naturally itself. -This is performed with the use of a long sharp hook similar to a crochet hook that is inserted through vagina and cervix and used to make a small nick in the membranes allowing the waters to escape. Patient will be required to lay on her back with her legs open while this procedure is preformed. -ARM’s are used to either help start labour before it is ready to started itself, or speed up a labour that is not moving fast enough for either the care provider or the mother.
  22. 22. PREPARATION FOR DELIVERY • • Positions that a woman may adopt during childbirth Once the cervix is fully dilated and the woman is in the expulsive phase of the second stage, encourage the woman to assume the position she prefers and encourage her to push Most widely used is dorsal lithotomy position. POSITIONING FOR DELIVERY
  23. 23. PERINEUM CLEANING -Need 6 swab balls -Clean sequentially as shown by the numbers -Clean according to the direction shown by the Arrows -Delivery must be sterile and antiseptic procedure CREATE A STERILE FIELD AROUND THE VAGINAL OPENING
  24. 24. EPISIOTOMY • Note: – Not a routine procedure and are considered preventing tear – Associated with • an increase of 3rd & 4th degree tears • subsequent anal sphincter muscle dysfunction. Considered only in: Do not decrease • perineal damage • future vaginal prolapse • urinary incontinence – • – complicated vaginal delivery • breech • shoulder dystocia • forceps • vacuum – scarring from female genital mutilation or poorly healed third or fourth degree tears – fetal distress.
  25. 25. ASSISTING WITH DELIVERY • • • Ritgen Maneuver is performed As crowning occurs, place a hand on the top of the baby’s head and apply light pressure Instruct the mother to focus on her breathing. Have her “pant like a dog” to help her stop pushing and prevent a forceful birth. DELIVERY OF THE HEAD • • • Ask the woman to pant or give only small pushes with contractions as the baby’s head delivers To control birth of the head, place the fingers of one hand against the baby’s head to keep it flexed (bent) Continue to gently support the perineum as the baby’s head delivers DELIVERY OF THE HEAD
  26. 26. DELIVERING OF THE SHOULDERS • • The side of the head are grasped with two hands and gentle traction is applied until anterior shoulder appears Upward movement until posterior shoulder is delivered SUCTION THE BABY’S MOUTH AND NOSE • Once the baby’s head delivers, ask the woman not to push • Suction the baby’s mouth and nose Nuchal Cord If the cord is around the neck, attempt to slip it over the baby’s head Feel around the baby’s neck for the umbilical cord
  27. 27. ASSISTING WITH DELIVERY As the head emerges, the baby will turn to one side (for easier passage of shoulders through birth canal) Check to see if the umbilical cord is looped around the baby’s neck. If so, gently slip it over the head Use a clean towel to catch the baby BABY DELIVERED FIRST BODY CONTACT OF MOTHER AND BABY AND CORD CLAMPING CLAMPING, CUTTING AND TYING OF UMBILICAL CORD
  28. 28. Expectant management • Talk to the woman and tell her that you will deliver her placenta • Wash your hands and put on your sterile gloves • After having the signs of placental separation, hold the clamp close to the perineum with one hand. • Deliver the placenta by putting one hand just above the pubic bone. • Tell the mother that she can strain when there is uterine contraction 4 signs of pacental separation : -Uterus becomes globular and firm -Sudden gush of blood -Uterus rise in the abdomen and placenta pass down into vagina -Umbilical cord protrudes farther out of vagina
  29. 29. Expectant management • Gently guide the placenta downward and outward by holding on the cord. • Be gentle because a hard pull can tear or break the cord and even worst, turn the uterus inside out • As the uterus stays in place and the cord gets longer , continue to guide gently until the placenta is delivered • When the bulk of the placenta is out,hold it with your two hands • Rotate the placenta like twisting a rope until delivered so that the fetal membranes will come out.
  30. 30. Expectant management • Feel the uterus from the abdomen and massage it to keep it contracted. • Inject an oxytocin drug intramuscularly to control bleeding. • The best time to inject oxytocin during the 3rd stage of labor: A. After the delivery of the baby B. After the delivery of the placenta
  31. 31. • Repair episiotomy • Controlled cord traction • Massage of uterus
  32. 32. • Went to medical university followed by 3 years of internship • Specialized in pregnancy and birth with different complications. • Majority of Certified Nurse Midwives • Midwife usually only available for woman who are healthy and with low-risk pregnancies. • Able to share more on emotions • Available for home birth • Normally only provide medical advice • Usually don’t provide home birth • Cannot perform C-Sections care. • Able to perform C-Sections.