Normal Labour, DeliveryNormal Labour, DeliveryandandPostnatal CarePostnatal Care
AIMS• Understand the process of normal labour• Understand what Active Management of theThird Stage of Labour (AMTSL) is and it’simportance• Knowledge of evidence based practices
When is a Woman in Labour?• Diagnosis of Labour 2-3 uterine contractions in 10mins Progressive shortening and thinning of thecervix during labour and Cervical dilatation 4cm or more dilated
Normal Labour• Stages of Labour First Stage: onset of labour pains to full dilatationof the cervix Second Stage: full dilatation of the cervix to thedelivery of the baby Third Stage: starts after the delivery of the babyending with the delivery of the placenta Immediate postpartum (‘Fourth Stage’): frequentmonitoring in the one hour following delivery
Supportive Care• Many providers continue to use, untimely,inappropriate and/or unnecessary interventions,leading to complications• Example: immobilising women, not allowingeating and drinking
Supportive Care• Supportive care during labour is the mostimportant thing to help the woman toleratelabour pains and facilitate the progress oflabour
Supportive Care• Support from a birth partner or companion.• Good communication and building trust withstaff.• Encourage walking around and changingpositions frequently.• Encourage adequate intake of food and drinks• Monitor maternal and fetal wellbeing usingthe partograph
Care that is of no proven benefit• Routine shaving of the pudendal area.• Giving an enema.• Routinely cutting episiotomy for delivery.• Application of fundal pressure
Second Stage• Once the cervix is fully dilated, encourage thewoman to assume the position she prefers topush only with a contraction. Squatting, sitting and standing positions maymake pushing easier Avoid routine catheterization which may lead toinfections. When delivery is imminent the women may beput in dorsal lithotomy position for the actualconduct of delivery
Second StageDelivery of the head: Control birth of the head to keep it flexed. Gently support the perineum as the baby’shead delivers. Feel around the baby’s neck for the umbilicalcord:- if the cord is loose, slip it over the baby’s head- if the cord is tight clamp and cut it.[!] NO routine episiotomy
Second StageCompletion of delivery :• Allow the baby’s head to turn spontaneously.• Deliver one shoulder at a time - anterior thenposterior.• Support the rest of the baby’s body as it slides out.• Dry and wrap baby, assess breathing• Ensure the baby is kept warm and in skin-to-skincontact on the mother’s chest/abdomen.
The classical expectant management• Wait for the natural forces of labor to bringabout 3rdstage contraction and placentalseparation• Look for the signs of placental separation• Controlled cord traction to expel the placentaand membranes• Optional administration of Oxytocics
Active management of 3rdstage• Oxytocic administration immediately afterdelivery of the baby so that the uterinecontractions and placental separation is notleft to the natural uncertain forces of labor• Controlled cord traction on perception of astrong uterine contraction with out waiting forthe actual signs of placental separation• Uterine massage to maintain the contraction
Active Management of the ThirdStageAs practiced• Palpate the abdomen to rule out the presence ofan additional baby(s)• Give Oxytocin: 10 units• Clamp and cut the umbilical cord• Controlled cord traction on perception of astrong uterine contraction with out waiting forthe actual signs of placental separation• Uterine massage to maintain the contraction
Controlled Cord Traction• Should be done only when the uterus isfelt to have contracted strongly• Make sure the bladder is empty• Hold the clamped cord in one hand andwith the other hand apply countertraction on the uterus. Keep slighttension on the cord and await acontraction.
Controlled Cord TractionCont• Pull downward on the cord to deliver theplacenta, applying counter traction to theuterus with the other hand• If it does not succeed at first attempt wait forsome more time for a stronger uterinecontraction• Stress on a complete examination of theplacenta for any retained placental fragments
Third Stage• As the placenta delivers, gently turn it untilthe membranes are twisted and slowly pullto complete the delivery.• Check the placenta to be sure none of it ismissing.• Examine the woman carefully and repair anytears to the cervix or vagina or repair theepisiotomy.[ ! ] NO routine packing of vagina while attempting a repair.
Immediate PNC - Mother• Routine observations• Regular checks for vaginal bleeding and contraction ofuterus.• Examine perineum for tears.• Pain relief• Encourage the mother to eat, drink and rest• Consider IUD insertion• Identify any signs of complications, stabilise and REFER
Observations• 1-2 hours: every 15 minutes• 3-5 hours: every 30 minutes• >5 hours: every 4 hours• Length of stay in health facility: Adviseobservation for 24hours
Immediate PNC - Newborn• Encourage early breastfeeding• Keep warm, check temp every 15min by feeling the feet• Examine for any malformation or abnormality > REFER• Care of the cord, check for bleeding• Give VIT K 1mg IM.• Delay baby’s first bath to beyond 24 hours of birth[!] Avoid separating mother from baby whenever possible. Do not leavemother and baby unattended at any time.[!] NO routine suction of throat and nose