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Normal labour

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NORMAL LABOUR BY Dr SHANZA AUROOJ

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Normal labour

  1. 1. Dr shanza aurooj FCPS part-II trainee Under Prof Dr Naila Ehsan
  2. 2. Table of contents:  Defination of labour  Female pelvis and fetal head diameters  Physiology of labour  Stages of labour  First stage of labour  Second stage of labour  Third stage of labour
  3. 3. LABOUR IS A CLINICAL DIAGNOSIS CHARACTERIZED BY REGULAR PHASIC UTERINE CONTRACTIONS INCREASING IN FREQUENCY AND INTENSITY RESULTING IN DILATATION AND EFFACEMENT OF UTERINE CERVIX,AND ENDS WITH THE DELIVERY OF THE BABY AND EXPULSION OF THE PLACENTA
  4. 4. THE BIRTH CANAL:  The bony pelvis  Joints & ligaments  Pelvic muscles
  5. 5. Represented by a prominent line starting from the upper border of pubic symphysis, passing over iliopectineal the anterior aspect of ala of sacrum, ending at the upper border of first sacral vertebrea called promontory  False pelvis: Above the pelvis brim,having no obstetric importance  True pelvis: Below the pelvic brim,related to child birth A typical female pelvis with optimal configuration for easy vaginal delivery is called gynecoid pelvis,It is comprised of 1. Pelvic inlet 2. Pelvic cavity 3. Pelvic outlet
  6. 6. Pelvic inlet: Anteroposterior diameter (true conjugate)=12 cm,from upper border of pubic symphysis to sacral promontory Obstetric conjugate Shortest AP diameter=11.5 cm,from posterior surface of pubic symphysis to sacral promontory Diagonal conjugate Measured from the lower border of pubic symphysis to sacral promontary=12.5 cm Transverse diameter: Between the farthest two points on iliopectineal line,largest=13 cm
  7. 7. The true conjugate can be measured only on radiographic films The obstetric conjugate is measured indirectly by subtracting 1-2 cm from diagonal conjugate.The diagonal conjugate is the most easily and commonly assessed. By deeply inserting the wrist, the promontory may be felt by the tip of the second finger as a projecting bony margin. the vaginal hand is elevated until it contacts the pubic arch. The immediately adjacent point on the index finger is marked.The distance between the mark and the tip of the second finger is the diagonal conjugate.
  8. 8.  Pelvic cavity: Lies between outlet & inlet,bounded in front by pubic symphysis and behind by sacrum  AP diameter : midlevel of pubic symphysis & junction of 2nd & 3rd sacral vertebrae=13 cm  Transverse diameter: Measured at the level of ischial spines(interspinous diameter)=11.5 cm
  9. 9. Pelvic outlet Transverse diameter: Between ischial tuberosities=11 cm Anteroposterior diameter: From lower border of pubic symphysis to coccyx = 13 cm
  10. 10. Caldwell moloy classification of female pelvis:  Gyneacoid pelvis (50%)  Anthropoid pelvis( 25%)  Android pelvis (20%)  Platypelloid pelvis(5%)
  11. 11. Round inlet & cavity with oval outlet,most suitable for vaginal delivery Oval inlet & outlet with round cavity,delayed engagement of head ,OCP Heart shaped inlet,narrow cavity (prominent spines)& oval outlet with narrow subpubic angle,most troublesome pelvis,persistent OCP & deep transverse arrest Kidney shaped.Flat inlet,reduced true conjugate,wide subpubic angle,delay in head engagement
  12. 12. Fetal diameters:  Fetal skull diameters  Transverse  Anteroposterior  Fetal body diameters  Biacromial (11.5-12cm)distance between the acromial processes of scapula,if large may cause shoulder dystocia  Bitrochanteric (10 cm) distance between the greater trochanters of femur
  13. 13. Bones of fetal skull:
  14. 14. Fetal diameters: biparietal diameter(9.5 cm),between two parietal eminence Bitemporal diameter(8cm),between the farthest points of coronal suture
  15. 15. SOB,from base of occipit to bregma.most favourable as it is shortest,fully flexed head in vertex presentation OPF,from occipital protruberence to nasion,slightly defled head,favours OCP SMB,from junction of chin &neck to bregma, hyperextended head with face presentation VM,from point of chin to centre of saggital suture,largest & most unfavourable,BROW presentation
  16. 16. PHYSIOLOGY OF LABOUR: oestriol oestradoil dehydroepiandrosterone pregnenolone cholestrol Placental oxytoxcin Prostaglandins Placental CRH hypothalamus Posterior pituatry oxytoxcin Oxytoxcin receptors SROM LABOUR hypothalamus anterior pituatry ACTH ADRENAL GLAND CRH DHEA CORTISOL Fetal lung maturity
  17. 17. Stages of labour: STAGES DEFINATION DIVISION DURATION First stage Begins with the onset of regular , phasic & co- ordinate uterine contractions & end s with full cervical dilatation(10cm) Latent phase: Begins at onset of labour & lasts till cervix is 3 cm dilated Active phase: Begins at 3 cm dilatation till cervix is fully dilated 8 hrs in Nulliparous,5 hrs in multiparous 5 hrs in nulliparous,2 hrs in multiparous Total duration is 14 hrs in nulliparous,7 hrs in multiparous Second stage Interval between full cervical dilatation & delivery of infant 2 hrs in nulliparous,1 hr in multiparous Third stage Delivery of the placenta & fetal membranes 30 minutes in either
  18. 18. First stage of labour: 0 2 4 6 8 10 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 hours of labour hours of labour Active phase Dilatationincms Latent phase Freidman’s graph of labour
  19. 19. Management of first stage of labour:  DIAGNOSIS  INITIAL EVALUATION  GENERAL MEASURES  DETERMINATION OF PROGRESS OF LABOUR  MATERNAL MONITORING  FETAL MONITORING  MAINTAINING PARTOGRAM  DOSE OF OXYTOXCIN  PAIN RELIEF DURING FIRST STAGE
  20. 20. DIAGNOSIS OF LABOUR: HISTORY • labour pains • Show • Sudden loss of fluid from vagina ABDOMINAL EXAMINATION • Uterine contractions • Frequency(3/10) • Duration(40-60 s) • Severity(pressure>80 mmhg) PELVIC EXAMINTAION • Cervical dilatation • Effacement • Consistency • position • Level of presenting part Diagnosis of labour is confirmed when in the presence of regular & painful uterine contractions,the cervix is more than 2 cm dilated or more than 80% effaced
  21. 21. INITIAL EVALUATION: BOOKED PATIENT Antenatal record review Admission test CTG Vitals/urine analysis Usual management& Monitoring of labour UNBOOKED PATIENT Detailed history/examinat ion Routine investigations(an tenatal visit) Usual management & monitoring
  22. 22. General measures: ENEMA/ GLYCERINE SUPPOSITORIES IV line position Oral intake Bladder care Prophylactic antibiotics
  23. 23. Determination of progress of labour Descent of the presenting part On P/A examination (Chricton’s technique)(number of fifths head is palpable) 5/5=free floating 4/5,3/5=entering brim 2/5=fixed,1/5=engaged On p/v examination(level of head in relation to ischial spine) -1,-2,-3 no of centimters above ischial spines,0=ischial spines & +1,+2,+3 below the ischial spine 1/5 0 Cervical dilatation Roughly assessed by fingers,1 finger=1.5 cm P/V examination Latent phase=3 hourly Active phase=hourly
  24. 24. • VITALS (4 hourly) • Intake/output chart • Level of hydration MATERNAL • Detection of passage of meconium • Fetal cardiac behaviour • Fetal blood sampling FETAL
  25. 25. DETECTION OF PASSAGE OF MECONIUM GRADE THREE Meconium dominates over liquor passed as semisolid material or black paste Immediate delivery is indicated GRADE TWO both liquor & meconium are drained in equal amounts giving it a dark green appearance Fetal distress,labour allowed in selected cases only GRADE ONE small amount of meconium staining liquor light green or Yellow LABOUR can be allowed to progress
  26. 26. Fetal blood sampling Normal PH=7.25-7.30 Suspicious=7.2 -7.25 abnormal=<7.2 in first stage <7.15 in second stage
  27. 27. Fetal cardiac behaviour Intermittent fetal heart rate monitoring Continous fetal heart rate monitoring Pinnard stethoscope Doppler heart rate detector(sonicaid) Performed after a uterine contraction every 15-30 min during first stage of labour CTG
  28. 28. Cardiotocograph is the graphical record of fetal cardiac behaviour & uterine contractions,measured by cardiotocogram
  29. 29. Admission test HIGH RISK CONTINOUS FETAL HEART RATE MONITORING INTERMITTENT FETAL HEART RATE MONITORING
  30. 30. ADMISSION TEST CTG:  Carried out for 20 minutes at the time of admission,good predictor of fetal condition for the next 4-6 hrs  The parameters assesed are  Baseline fetal heart rate  Variability  Acceleration  Deceleration  Contractions  The CTG is then classified according to FIGO classification as  Normal  Suspicious &  Pathological  Further monitoring is carried out on the basis of this classification
  31. 31. Baseline fetal heart rate=110-160/min Fetal tacycardia>160/min Fetal hypoxia Chorioamnionitis Hyperthyroidism Anemia Fetal tachyarrthmiasFetal bradycardia<120/min Mild100-120/min),OCP,post- date,transverse Severe (<80/min for >3 min),cord compression/prolapse,epidural,mater nal seizures
  32. 32. Normal variability is between 10-25 bpm³ Variability can be categorised as: 4 Reassuring – ≥ 5 bpm Non-reassuring – < 5bpm for between 40-90 minutes Abnormal – < 5bpm for >90 minutes Reduced variability: Fetal hypoxia,sleep,prematurity,co ngenital heart diseases
  33. 33. 180- 200/min I60- 180/min 130/min
  34. 34. Early decelerations
  35. 35. Reduced utero-placental blood flow can be caused by: ¹ Maternal hypotension Pre-eclampsia Uterine hyper-stimulation
  36. 36. Variable decelerations are usually caused by umbilical cord compression¹ The umbilical vein is often occluded first causing an acceleration in response Then the umbilical artery is occluded causing a subsequent rapid deceleration When pressure on the cord is reduced another acceleration occurs & then the baseline rate returns
  37. 37. Prolonged deceleration  A deceleration that last more than 2 minutes  If it lasts between 2-3 minutes it is classed as Non-Reasurring  If it lasts longer than 3 minutes it is immediately classed as Abnormal  Action must be taken quickly – e.g. Foetal blood sampling / emergency C-section
  38. 38. •A smooth, regular, wave-like pattern •Frequency of around 2-5 cycles a minute •Stable baseline rate around 120-160 bpm •No beat to beat variability •Severe foetal hypoxia •Severe foetal anaemia •Foetal/Maternal Haemorrhage
  39. 39. FIGO CTG pattern A. Normal - (1) Baseline 110-150 bpm (2) Baseline variability 5-25 bpm (3) No decelerations / sporadic mild deceleration of short duration (4) ≥ 2 accelerations during a 10 minutes period B. Suspicious - (1) Baseline 150-170 or 110- 100 bpm (2) Variability 5-10 bpm for > 40 min (3) Variability > 25 bpm (4) No accelerations > 40 min (5) Sporadic mild decelerations of any type (6) Variable deceleratopms Antepartum - (1) - (5) any one / combination Intrapartum - (1) - (4) & (6) any one / combination C. Pathological : Antepartum (1) Baseline < 100 or > 170 bpm (2) Variability < 5 bpm for > 40 min (3) repeated decelerations of any type (4) Sporadic noncurrent severe variable, prolonged or late decelerations (5) Sinusoidal pattern Any one or in combination
  40. 40. Interpretations of result:  Reactive/normal CTG: low risk,Intermittent fetal heart rate monitoring required  Suspicious CTG: High risk,require continous fetal heart rate monitoring  Abnormal CTG: High risk,require EmLSCS
  41. 41. PARTOGRAM  Partogram is a composite graphical record of key data (maternal and fetal) during labour entered against time on a single sheet of paper  Advantages  Provides information on single sheet of paper at a glance  Prediction of deviation from normal progress of labour
  42. 42. Patient’s data Fetal heart rate Liqour/membranes I C cervical dilatation Descent of presenting part Uterine contractions Frequency=no of contractions in 10 min Dots<20 sec,cross hatchin<40 sec,shaded>40 sec Oxytoxcin=5 u/1 l BP= 2hrly,PR=30 min.temp 2 hrly Drugs/IV fluids Urine(amount,an y + findings)
  43. 43. Systemic anelgesia Narcotic Pethidine,Pentazocine Fentanyl,Butorphenol Nalbuphine,mepiridine Non-narcotic: Benzodiazepam,barbiturates Penothiazine,ketamine Inhalation Entonox Enflurane isoflurane conduction Lumbar epidural analgesia Paracervical block Spinal anesthesia
  44. 44. Lumbar epidural analgesia:  Pain in first stage is transmitted through T11- L1,local anesthetic administration in the epidural space at this level reduces pain by 95% Procedure: 1. A preload of 500-1000 R/L or hartman’s solution is given to avoid maternal hypotension 2. Patient is put in left lateral position or made to sit at the edge of the bed 3. Local anesthetic is given in the lumbar region 4. Tuohy needle is advanced in the epidural space 5. Catheter is inserted through the needle, needle is withdrawn,punctured site is sprayed with an antibiotic & dressing applied 6. Bupivacaine is the drug given,10 ml initially then top up doses of 3-4 ml 2 hourly
  45. 45. PARACERVICAL BLOCK:  Blocks the sensory nerves from the uterus as they traverse the broad ligament close to each lateral fornix of vagina through blockade of paracervical ganglia  Given when cervix is 5-7 cm dilated,a 12.5 cm long needle is introduced in the lateral fornix,local anesthesia is given & lignocaine or bupivacaine is given
  46. 46. OXYTOXCIN FOR LABOUR AUGMENTATION • If the cervix is unfavoura ble (Bishop score <6) induction with vaginal prostaglan dins should be considered • Oxytocin to induce labour in women with history of previous caesarean should be discussed with the lead obstetricia n prior to use • Oxytocin should not be used within 6 hours of prostaglan din PGE2 • Oxytocin should not be used with dinoprosto ne PGE2) • Oxytocin to augment labour in a multigravi da should be discussed with the lead obstetricia n prior to use • Physiologi cal manageme nt of third stage is contraindi cated in women receiving oxytocin during labour PRECAUTIONS
  47. 47. CONTRAINDICAT ION Malpresentatio n: transverse or oblique lie, footling breech, brow presentation • Previous classical uterine incision • Cord presentatio n • Any other contraindicat ion to labour or vaginal birth • Spontaneous labour • Abnormal cardiotocogr aph (CTG) or known fetal compromise • Placenta praevia or vasa praevia • Active genital herpes • Persisting maternal fever
  48. 48. oxytocin to the woman and obtain verbal consent • Explain the anticipated outcome, benefits and risks of induction of labour with • Vaginal examination and Bishop Score to reassess indication and method of induction A normal cardiotocograph (CTG) must be recorded prior to the use of oxytocin P/A should be performed to detect fetal lie/presentation Document baseline maternal vitals/including uterine activity
  49. 49. EQUIPMENT REQUIRED: Volumetric pump IV tubing, Y extension set, IV pole and tapes • 10 units of oxytocin (Syntocinon®) for both multigravid and primigravid • 1000 mL flask of Compound Sodium Lactate (Hartmann’s Solution) or Normal Saline • CTG
  50. 50. Preparation & administration • Once the maximum has been reached and a further increase in the infusion rate is required it must be discussed with the senior obstetrician • Titrate the infusion rate as may be required to maintain 4 contractions in 10 minutes lasting 40-90 seconds each • Once 4 contractions in 10 minutes are achieved maintain the infusion rate • Increase the rate every 30 minutes aiming for 4 contractions in 10 minutes lasting 40 – 90 seconds each • Commence the oxytocin infusion at 2 milliunits/min (12 mL/hr) via volumetric infusion pump Add 10 units of oxytocin to a 1000 mL flask of Compound Sodium Lactate (Hartmann’s solution) or Normal Saline. Label flask and sign entries on the Intravenous Infusion Chart
  51. 51. mls per hour of oxytocin infused in measures of milliunits/minute in a solution of 10 units of oxytocin in 1000ml ml/hr mu/min Time(minutes) 12 2 0 24 4 30 36 6 60 48 8 90 72 12 120 96 12 120 120 20 180 144 24 210 168 28 240 192 32 270 10 units of oxytoxcin in 1000 ml R/L consist of 10 mU/ml
  52. 52. Calculating Flow Rates/drop rates for Infusion Pumps Calculating Flow Rates for Infusion Pumps in mL/hr: 1oooml/4=250 ml/hr Calculating Flow Rate in Drops per Minute Microdrip: 60 gtt/mL Macrodrip: 20gtt/mL 15 gtt/mL 10 gtt/mL 36 ml/hr*15÷60=9 drops/min
  53. 53. Standard regime of oxytoxcin for augmentation of labour REGIMEN STARTING DOSE(Mu/m in) Incremental increase(mU /ml) Dosae interval(min ) Maximum dose(mU/ml ) Low dose 0.5-1 1-2 1 2 30-40 15 20 40 High dose 6 6,3,1 15-40 42
  54. 54. OBSERVATION/MONITORING Continuous (CTG) is indicated with commencement of oxytocin infusion Uterine contractions should be assessed carefully for a 10 minute period at 30 minute intervals. Contraction frequency and duration should be reconciled with uterine activity recorded on the CTG • Strength of contraction is a subjective assessment requiring manual palpation (correlated with how the woman perceives her contractions • Support and pain relief options should be offered to women accordingly • Record the units of oxytocin in the flask (ie 10 units) • Record the rate of infusion in mLs/hr (ie 12) at the beginning of each set of observations • Enter the rate of infusion in mLs/hr at the end of each set of observations For example: 12 /24
  55. 55. Complications • Uterine hyperstimulation • Ruptured uterus - especially in multigravida and women with a previous caesarean • Water intoxication with high dose regimen or prolonged periods of use
  56. 56. Monitoring Mechanism of labour Mangement • Pain relief • Delivery procedure
  57. 57.  Done on same lines as in first stage  FHR:  Intermittent counted immediately following every second contraction to detect dip in HR  Continous  Meconium  Fetal scalp PH
  58. 58. FETAL LIE:  Relationship of the long axis of fetus to long axis of uterus,normally it is longitudinal
  59. 59. ATTITUDERelationship of the fetal head & trunk to the limbs,normally it is flexion flexed deflexed extended hyperextend ed
  60. 60. PRESENTATION Presentation is the part of the fetus present in the lower pole of the uterus or in the pelvic brim
  61. 61. POSITION Position is determined by selecting a denominator on presenting part & several points on maternal pelvis, the relationship between denominator & these points is then determined Symphysis pubis sacrum Sacroiliac joints Iliopectineal lines occiput
  62. 62. ENGAGEMENT When the presenting part has passed plane of the pelvic brim and is less than 2/5th palpable abdominally,head engages usually in LOA or ROA position with saggital suture occupying the transverse diameter
  63. 63. FLEXION Uterine contractions push the fetus downwards,while the cervix resist to this change resulting in increased flexion of the head
  64. 64. INTERNAL ROTATION At the pelvic inlet,head enters in OL position to occupy the larger transverse diameter At the outlet,the head has to rotate to occupy the larger AP diameter & comes to occupy occipitoanterior position by rotating through 90 degree
  65. 65. EXTENSION After internal rotation the occiput lies under the pubic arch and to be born safely,it has to go extension so the sinciput sweeps forward as the neck extends & intoitus is distended,this is the right time to give an episiotomy
  66. 66. RESTITUTION Alignment of the head to the shoulders is called restitution EXTERNAL ROTATION The internal rotation of the shoulder to come to lie in AP diameter of the outlet is viewed outside as external rotation Anterior shoulder is delivered from under the pubic arch followed by posterior shoulder with lateral flexion of the trunk and delivery of trunks & buttocks DELIVERY OF SHOULDERS & BODY
  67. 67. CONDUCTION ANALGESIA EPIDURAL SPINAL PUDENDAL NERVE BLOCK CAUDAL BLOCK (low epidural block) SADDLE BLOCK (low spinal anesthesia) LOCAL ANESTHESIA
  68. 68. PUDENDAL NERVE BLOCK
  69. 69. PATIENT PREPARATION PERINEAL SUPPORT DELIVERY OF HEAD OXYTOXCIN ADMINISTRATION DELIVERY OF SHOULDERS & TRUNK MUCUS CLEARANCE SUCTION & CORD CLAMPING DELIVERY OF PLACENTA INFANT CARE
  70. 70. Third stage of labour  After the delivery of baby marked reduction occurs in the size of uterus due to contraction & retraction causing placental separation,the separated placenta is delivered spontaneously by maternal efforts by SCHULTZ METHOD MATTHEW DUNCAN METHOD
  71. 71. Signs of placental separation  Lengthening of cord  Gush of blood  Uterus  Becomes hard  Mobile from side to side  Height rises to umbilicus
  72. 72. ACTIVE MANAGEMENT OF THIRD STAGE : CONTROLLED DELIVERY OF PLACENTA OXYTOXIC DRUGS
  73. 73. OXYTOXCIC DRUGS  OXYTOXCIN:  Promotes rhythmical contraction of uterus  Effects are noticeable after 3 min of IM injection,40-60 sec of IV injection  5 units of oxytoxcin produces contraction for about 15 min  Ergometrine:  Promotes prolonged contraction with retraction  effects noticeable after 7 min of i.m injection,40-60 sec of IV injection  Syntometrine:  Combined form of 5 units oxytoxcin & 0.5 mg ergometrine  Oxytoxcin induces early contraction,while ergometrine prolongs it,but ergometrine should be avoided in PIH,CVS disease,Chronic HPT These are given after excluding the second twin
  74. 74. Time of administration  IM is carried out crowning of head or after delivery of head  IV administration is carried out at the delivery of anterior shoulder or after the delivery of infant  Too early administration results in precipitate labour,while too late results in Postpartum hemmorhage
  75. 75. Controlled delivery of placenta  Brand Andrews method:  Umbilical cord is held taught at the vulva in one hand while uterus is pushed upward with the other hand placed above the symphysis pubis
  76. 76. • Crede’s method: – Cord is fixed with the lower hand & upward traction is applied using on the uterus using abdominal hand – After delivery of placenta,check for the completion of placenta

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