Group II IIIIIIIIIIIIIIIIIIIIIII (2).pptx

GROUP ASSIGNMENT
TOPIC:
1.Antenatal care contact schedule in Rwanda
2.labor and its stage and management
GROUP 2 MEMBERS:
Dukuzeyezu Dative : 023/09/MDW/1584
Nsanzurwimo Eliabu: 023/09/MDW/1674
Ishimwe Jean Remy: 023/09/MDW/1595
Mukantambara Veronise: 023/09/MDW/1594
Nzayomaze Jean De Dieu: 023/09/MDW/1579
Rwibutso Dollar Joyeux: 023/09/MDW/1607

ANTENATAL CARE CONTACT SCHEDULE IN RWANDA
1 INTRODUCTION
• Good Antenatal Care (ANC) is important for the health of
the mother and the development of the fetus. ANC
provides a platform for important healthcare functions,
including health promotion, screening and diagnosis,
disease prevention and management of complications
during pregnancy, childbirth and postpartum period. It is
the time to offer nutritional counseling, identify and
prevent low birth weight deliveries and risks of stunting
at a later stage.

Table 1: The New Schedule
ANC Schedule
for the new model of
eight contacts
Contact Weeks
1st
Trimester
1st
Contact As soon as
the woman suspects
she is pregnant: up to
12 weeks
2nd
Trimester 2nd
Contact 20 weeks
3rd
Contact 26 weeks
3rd
Trimester 4th
Contact 30 weeks
5th
Contact 34 weeks
6th
Contact 36 weeks
7th
Contact 38 weeks
8th
Contact 40weeks

Initial contact regardless of gestation
Contact 1 at 8- 12 weeks
• Maternal Assessment
Full History, clinical estimation of GA,
Complete physical examination,
abdominal palpation,
TB screening,
screening for intimate partner violence(IPV)
Screen for patients at high risk for preeclampsia(twin, chronic
hypertension, pregestational diabetes)

• Fetal Assessment
Refer to the gestational age
• Counseling
Nutrition, diet and physical activity, rest, HIV&STI test, Adherence to
medicines prescribed,
Avoid: caffeine intake, alcohol, tobacco and substance abuse
Use of ITNs;
Danger signs; Emergency preparedness Early stimulation of the HIV,
Syphilis,HBV,urine dipstick, Malaria.

Hemoglobin ASB(Gram stain or Culture)
Blood group and Rh
FBC Cervical cancer screening Ultrasound Iron and Folic acid
TT/TD(tetanus Toxoid), Treat or advise about relief of common
physiological symptoms,
Combination prevention: PrEp1, condom, VMMC for men; Maternal
weight/height measurement,
MUAC Blood pressure measurement, Male involvement , STI screening.
 Common physiological disorders including STIs;
complications of early pregnancy
Complete ANC card and give to woman;
Fill ANC register

• Investigations
HIV, Syphilis,
HBV,
urine dipstick,
Malaria
Hemoglobin
 Blood group and Rh
FBC Cervical cancer screening

• Radiological tests
Ultrasound
• Preventive measures
Iron and Folic acid, TT/TD
Treat or advise about relief of common physiological symptoms
Combination prevention: PrEp1, condom, VMMC for men.

Contact 2 at 20 weeks
Ask the mother if she has experienced any problems/changes since
last visit
Clinical estimation of GA,
Physical examination,
Symphysis fundal height measurement/abdominal palpation, Tb
screening , screening for IPV

FHR/Fetal heart sound auscultation after 20weeks
Enquire about quickening
Counseling
Nutrition, diet and physical activity, rest, HIV &STI test
adherence to medicines prescribed,
Use of ITNs; Danger signs; Emergency preparedness; Early stimulation of
the baby
Family Planning

• Investigations
urine dipstick
HIV, Syphilis
Retest for those who were negative or not tested in the first contact,
HBV, Malaria
Ultrasound if not yet done .

Anthelmintic(single dose Mebendazole 500mg)
Fe and folic acid, Calcium
 Combination prevention :PrEp, condom
VMMC3for men

Contact 3-at 26 weeks
Ask the mother if she has experienced any problems/changes since
last visit
clinical estimation of gestational age, Physical examination,
Symphysis fundal height measurement/abdominal palpation, TB
screening, screening for IPV. Ask about fetal movement , rule out
premature rupture of membranes (PROM)
FHR auscultation
Ask about fetal movements

• Counseling
Nutrition, diet and physical activity
Rest, HIV &STI test, adherence to medicines prescribe
Avoid: caffeine intake, alcohol, tobacco and substance abuse
Use of ITNs
Danger signs; Emergency preparedness Early stimulation of the baby.
Family Planning
• Investigations
Urine dipstick, Malaria test
Check Hb ; Check ASB

Ultrasound if indicated
Preventive measures
IFA, Calcium
combination prevention (PrEp, condom VMMC for men)

Maternal Assessment
Ask how the mother is doing, clinical estimation of gestational age,
Physical examination,
Symphysis fundal height measurement/abdominal palpation, TB
screening, screening for IPV. Ask about fetal movement, rule out
premature rupture of membranes (PROM)
Fetal Assessment
FHR auscultation
Ask about fetal movements

• Counseling
Nutrition, diet and physical activity, rest, HIV &STI test, adherence to
medicines prescribed
Avoid: caffeine intake, alcohol, tobacco and substance abuse
Use of LLINs; Danger signs; Emergency preparedness; Early
stimulation
Of the baby
Family Planning

Investigations
Urine dipstick
 Malaria test
Check Asymptomatic bacteriuria
Ultrasound if indicated
IFA, Calcium
 combination prevention (PrEp, condom VMMC for men

Contact 5 at 34 week
Maternal Assessment
Ask how the mother is doing
Clinical estimation of gestational age
 Physical examination
Symphysis fundal height measurement/abdominal palpation
TB screening, screening for IPV.
Ask about fetal movement, rule out premature rupture of
membranes (PROM)

Fetal assessment
FHR auscultation, ask about fetal movements
Counseling
Nutrition, diet and physical activity rest, HIV &STI test, adherence to
medicines prescribed
Avoid: caffeine intake, alcohol, tobacco and substance abuse
Use of LLINs; Danger signs; Emergency preparedness; Early
stimulation of the baby.
Family Planning

• Investigations
Urine dipstick, Malaria test
Check Asymptomatic bacteriuria
IFA, Calcium
 combination prevention (PrEp, condom VMMC for men

Contact 6at36 weeks
Maternal Assessment
• Ask how the mother is doing, clinical estimation of gestational age,
Physical examination, Symphysis fundal height
measurement/abdominal palpation, TB screening, screening for IPV.
Ask about fetal movement, rule out premature rupture of
membranes (PROM)
Fetal assessment
FHR auscultation, ask about fetal movements

• Counseling
Nutrition, diet and physical activity, rest, HIV &STI test
Adherence to medicines prescribed
Use of ITNs; Danger signs
 Emergency preparedness
Early stimulation of the baby
Family Planning

Investigations
Urine dipstick, Malaria test Check HB
IFA, Calcium
combination prevention (PrEp, condom VMMC for men

Contact 7 at 38 week
Maternal assessment
Ask how the mother is doing, clinical estimation of gestational age,
Physical examination, Symphysis fundal height
measurement/abdominal palpation,
TB screening, screening for IPV. Ask about fetal movement ,rule out
premature rupture of membranes (PROM).
Fetal assessment
FHR auscultation and ask about fetal movements

• Counselling
Nutrition, diet and physical activity,
 rest, HIV test, Avoid: caffeine intake, alcohol, tobacco and substance
abuse, IPV: Use of ITNs; Danger signs, Emergency preparedness.
Investigations
Urine dipstick, HIV and Syphilis retest for those who were negative,
Malaria test.
IFA, Calcium, combination prevention (PrEp, condom VMMC for men).

• Maternal assessment
Ask how the mother is doing Last,
 Clinical estimation of gestational age, Physical examination,
Symphysis fundal height measurement/abdominal palpation, TB
screening, screening for IPV. Ask about fetal movement ,rule out
premature rupture of membranes (PROM),
Ask about symptoms of labour.
• Fetal assessment
FHR auscultation and ask about fetal movements.

Counselling
Nutrition, diet and physical activity, rest, HIV test, Avoid: caffeine intake,
alcohol, tobacco and substance abuse, IPV: Use of ITNs; Danger signs,
Emergency preparedness.
IYCF, Breastfeeding, Breast care, FP/HTSP, Birth planning; EIMC, Early
stimulation of the baby; Counsel on admission if no signs of labour at 41
weeks.
Investigations
Urine dipstick, Malaria test
Radiological tests
Ultrasound if indicated
Preventive measures
IFA, Calcium, combination prevention (PrEp, condom VMMC for men).

PROVIDING ANC SERVICES
History taking
The service provider should undertake a comprehensive history
including:
• Identification: Names, age, home address, contact address, phone
number, next of kin and his/her address and phone number;
• Obstetric and Gynecological history: number of previous
pregnancies and outcome of each; previous cesarean sections,
problems and complications including bleeding;

• Medical history: hypertension, asthma, convulsions, heart diseases,
diabetes, tuberculosis, and other past and current medical problems;
current medications including use of medications and
herbal/traditional remedies, drug history including allergies
• Family history: e.g., genetic disorders
• Pregnancy and delivery history: gestation, term pregnancy, premature
deliveries, recurrent abortions, still births/death immediately after
birth, postpartum hemorrhage in the past, previous retained
placenta, c/sections, ruptured uterus, pre-eclampsia/eclampsia, grand
multipara pregnancy (> 6 pregnancies);

Maternal and fetal assessment
• Maternal screening forms part of the routine assessment of the
pregnant woman, where the provider must do the following:
• Ask about the mother’s concerns;
• Clinical estimation of gestational age;
• Examination head to toe;
• Abdominal palpation;
• Pelvic examination if necessary;

• Screen for Pre-eclampsia, Anemia and Asymptomatic Bacteriuria, TB,
Malaria, HIV, Syphilis, Hepatitis, gestational diabetes, substance abuse
and IPV as appropriate for contact;
• Measure gestational age through a Symphysis fundal height (SFH).
• Undertake an ultrasound examination at appropriate gestation as per
the guidelines;
• Nutritional Assessment: Height measurement should be performed at
the first visit and BMI should be calculated as a baseline assessment
for all pregnant women. Symptoms of diabetes to be assessed; if
presence of symptoms, plasma glucose to be measured (fasting, one
hour, two hours).

• Blood pressure monitoring at each visit;
• Test mid-stream urine for protein;
• Inquire about fetal movement from 20 weeks ;
• An Ultrasound scan is to be done for every pregnant woman before
24 weeks to identify the following: gestational age, fetal viability,
anomalies (multiple pregnancies, etc.). In case of complications such
as antepartum hemorrhage mal-presentations, IUGR, an additional
ultrasound may be performed.

Fetal assessment
• Fetal heart rate (FHR) must be monitored in all pregnant women. A
normal FHR is 110 – 160 beats/minute; while an Abnormal FHR is
<110 b/m or >160 b/m; enquire about fetal movements from 20
weeks.
Laboratory investigations
• Hemoglobin: Hemoglobin testing as a routine practice will be
performed to detect anemia in pregnancy. At health center and
health post, hemoglobin testing will be done using a hemoglobin
meter.

• Urine dipstick: urine culture testing is the most accurate means of
detecting asymptomatic bacteriuria. However, in health centers and
health posts, dipstick tests will be used; if positive, refer for
confirmation in hospitals. Dipsticks will be also used for testing sugar
and protein in urine.
• Counseling and testing for HIV and Syphilis;
• Test for Malaria and TB;
• Screening for Hepatitis B.
• At hospital level, the full blood count will be used as the method for
diagnosing anemia in pregnancy.
• Midstream urine culture will be used for diagnosis of asymptomatic
bacteriuria
• Blood group and Rhesus test.

PREVENTIVE MEASURES
Introduction
• Healthcare providers must ensure that all pregnant
women get all recommended preventive measures in line
with the 8 contact schedule, including treatment of
asymptomatic bacteriuria, prevention of: tetanus,
nutritional anemia, HIV, intestinal worms and malaria in
pregnancy (refer to the essential package for ANC
interventions).

Treatment for asymptomatic bacteriuria
(ASB)
• Defined as bacteriuria in the absence of specific symptoms of acute
urinary tract infection
• Refers to the detection of a high number of bacteria in a urine
sample.
• Urine culture is the gold standard for accurate diagnosis.
• The choice of antibi¬otics should be based on culture and sensitivity
results.

• First choice
• Nitrofurantoin 100 mg (per os and four times daily) for 7 days (avoid in first
trimester and near term)
• Alternative
• Amoxicillin 500mg TDS (Three times daily) PO for 7 days
• Co-amoxiclav (Augmentin) 625mg TDS PO for 7 days

Tetanus toxoid vaccination
Tetanus is an acute disease caused by an exotoxin
produced by Clostridium tetany.
Neonatal infection usually occurs through the exposure
of the unhealed umbilical cord stump to tetanus spores
Neonatal disease usually presents within the first two
weeks of life and involves generalized rigidity and painful
muscle spasm
If there is no evidence of previous tetanus diphtheria (Td)
immunization, two doses at least one month apart in
each pregnancy should be administered.

Iron, Folic Acid, calcium & other supplementation
• Folic Acid, calcium & other supplementation
• During pregnancy, women have additional requirements
for all nutrients and micronutrients.
• Prescribe a daily dose of oral iron (60mg) and folic acid
supplementation (400mg
• =0.4 mg) to prevent maternal anemia, puerperal sepsis,
low birth weight, and preterm birth.

• If a woman is diagnosed with anemia during pregnancy,
her daily elemental iron should be increased to 120 mg
until her Hb concentration rises to normal (Hb 110 g/L or
higher) Thereafter, she can resume the standard daily
antenatal iron dose to prevent recurrence of anemia.
• Advise mothers to take vitamin C (e.g. citrus fruits) and
vitamin A rich foods (e.g. orange fresh foods such as
mangos, whole milk, butter, egg yolk, palm oil) when
taking iron supplements since this will enhance iron
absorption. It is also recommended to decrease the
amount of tea which inhibits the iron absorption.

• Rapid SMS can be used to remind pregnant women to take
their supplements and to assist them to manage associated
side-effects.
Deworming
• Give Mebendazole (500 mg) once during second or third
trimester of pregnancy to every woman
Malaria in Pregnancy
 Provision of ITNs and counseling on other malaria prevention
measures
 Case identification and management in addition to prevention
using ITNs and other general prevention measures.

Recommended further readings
1. Obstetric care protocol in Rwanda,2020.
2. American academy of pediatrics. (2017, July 31). Essential care for small babies.
Retrieved from https://shop.aap.org/essential-care-for-small-babies-ecsb-action-plan/
3. Bansal, M. C. (2013). Bleeding in first trimester. Slideshare. Retrieved from
https://www.slideshare.net/drmcbansal/bleeding-in-first-trimester
4. Kinzie, B., Gomez, P., & Chase, R. (2004). Basic Maternal and Newborn Care: A Guide
for Skilled Provider. Retrieved from
https://books.google.rw/books/about/Basic_Maternal_and_Newborn
5. Laerdal Global Health. (2014, September 30). Essential care for every baby. Retrieved
from https://shop.aap.org/helping-babies-survive-hbs-essential-care-for-every-baby-
action-plan-wall-posters-single/

LABOUR, STAGES AND
ITS PHYSIOLOGY

Contents
• Definitions
• Normal and abnormal labour
• Causes of onset of labour
• False labour pain and true labour pain
• Stages of labour
• Physiology of first stage of labour
• Physiology of second stage of labour
• Mechanism of normal labour
• Physiology of third stage of labour

Definition
• Series of events that takes place in the genital organ in an effort to
expel the viable products of conception out of the womb through the
vagina into the outer world is called labour.
• It may occur prior to 37 completed weeks, when it is called preterm
labour.
• Delivery is the expulsion or extraction of viable fetus out of the
womb.

Normal labour (Eutocia)
• Labour is called normal if it fulfills the following criteria:
• Spontaneous in onset and at term.
• With vertex presentation
• Without undue prolongation
• Natural termination with minimal aids
• Without having any complications affecting the health of mother
and/or baby.

Abnormal labour (Dystocia)
• Abnormal labour (Dystocia) Any deviation from the definition of
normal labour is called abnormal labour.

Date of onset of labour
• It is unpredictable to foretell precisely the exact date of onset of
labour.
• Calculation from Naegele‘s formula is only a rough guide.
• Based on the formula, labour starts approx. on the expected date in
4%, one week on either side in 50%, 2 weeks earlier and 1 week later
in 80%, at 42 weeks in 10% and at 43 weeks plus in 4%.

Causes of Onset of labour
• 1. Uterine distension
• 2. Feto-placental contribution
• 3. Oestrogen
• 4. Progesterone
• 5. Prostaglandins
• 6. Oxytocin
• 7. Neurological factors

Oestrogen
• Increase the release of oxytocin from maternal pituitary.
• Promotes the synthesis of receptors for oxytocin in the myometrium
and decidua.
• Accelerates lysosomal disintegration in amnion cells resulting in
amnion cells resulting in increased prostaglandin synthesis.
• Stimulates the synthesis of myometrial contractile protein ---
actinomyosin through cAMP.
• Increases the excitability of the myometrial cell membranes.

Progesterone
• Increased fetal production of dehydroepiandrosterone sulphate
(DHEA-S) and cortisol inhibits the conversion of fetal pregnenolone to
progesterone.
• Progesterone levels therefore fall before labour.
• It is the alteration in the oestrogen: progesterone ratio rather than the
fall in the absolute concentration of progesterone which is linked with
the prostaglandin synthesis.

Prostaglandins
• Prostaglandins are the important factor which initiate and maintain
labour.
• The major sites of synthesis of prostaglandins are --- amnion,
chorion, decidual cells and myometrium.
• Synthesis is triggered by –rise in oestrogen level, glucocorticoids,
mechanical stretching in the late pregnancy, increase in cytokines,
infection, vaginal examination, separation or rupture of membranes

Oxytocin
• Oxytocin receptors are increased in the uterus with the onset of labour.
• Oxytocin promotes the release of prostaglandins from the decidua.
• Oxytocin synthesis is increased in the decidua and in the placenta.
• Vaginal examination and amniotomy cause rise in maternal plasma
oxytocin level (Ferguson reflex).

Neurological factor
• Both α and β adrenergic receptors are present in the myometrium;
oestrogen causing the α receptors and progesterone the β
receptoors to function predominantly.
• The contractile response is initiated through the α receptors of the
post ganglionic nerve fibres in and around the cervix and the lower
part of the uterus.

False labour pain Features
• 1. Dull in nature and usually confined to the lower abdomen and
groin.
• 2. Continuous and unrelated with hardening of the uterus
• 3. Without any effect on dilatation of the cervix. 4. Usually relieved by
medications.

Pre labour (premonitory stage)
• Begins:
• Primigravida: 2 or 3 weeks before the onset of true labour.
• Multigravida: few days prior.

Features of prelabour
• Lightening
• Cervical changes
• Appearance of false pain

True labour pain Features of true labour pain
• Painful uterine contractions (labour pain) at regular intervals
• Contraction with increasing intensity and duration
• Show
• Progressive effacement and dilatation of the cervix
• Formation of the ―bag of waters‖.

Stages of labour
• First stage of labour
• Second stage of labour
• Third stage of labour
• Fourth stage of labour

First stage of labour
• This starts from the onset of true labour pain and ends with full
dilatation of cervix. It is in other words, the ―cervical stage‖ of
labour.
• Its average duration is 12 hours in primigravida and 6 hours in
multigravida.
• There are two phases of first stage of labour:
• Latent phase
• Active phase

Phases of first stage of labour
• The latent phase: is the time between the onset of labour and 3- 4 cm
dilatation and cervix becomes fully effaced. It usually lasts between 3
and 8 hours, being shorter in multiparous women.
• The second phase: is the active stage and describes the time between
the end of latent phase (3-4 cm dilatation) and full dilatation (10cm). It
is also variable in length, usually lasting between 2 and 6 hours. Again
it is shorter in multiparous women.

During active phase
• Cervical dilatation during the active phase usually occurs at 1cm/hour
or more in a normal labour.

Second stage of labour
• It starts from the full dilation of the cervix and ends with expulsion of fetus
from the birth canal.
• It has got two phases
• 1. Propulsive phase-starts from full dilatation upto the descent of the
presenting part to the pelvic floor
• 2. Expulsive phase- is distinguished by maternal bearing down efforts and
ends with delivery of the baby.
• Average duration is 2 hours in primigravida and 1 hour in multipara.

Third stage of labour
• The third stage begins after the expulsion of fetus and ends with
expulsion of placenta and membranes; it also involves the control of
bleeding.
• A third stage lasting more than 30 minutes should be considered
abnormal.

Fourth stage of labour
• The fourth stage begins with the delivery of the placenta and
ends two hours later.

Physiology of first stage of labour
• Uterine action Fundal dominance:
• Each uterine contraction starts in the fundus near one of the
cornua and spreads across and downwards.
• The contraction lasts longest in the fundus where it is also most
intense, but the peak is reached simultaneously over the whole
uterus and the contraction fades from all parts together.

Polarity
• Polarity is the term used to describe the neuromuscular harmony that
prevails between the two poles or segments of the uterus throughout
labour. During each uterine contraction, these two poles act
harmoniously.
• The upper pole contracts strongly and retracts to expel the fetus; the
lower pole contracts slightly and dilates to allow expulsion to take
place. If polarity is disorganized then the progress of labour is
inhibited.

Formation of upper and lower uterine
segments
• The upper uterine segment, having been formed from the body of
the fundus, is mainly concerned with contraction and retraction; it
is thick and muscular.
• The lower uterine segment is formed of the isthmus and the cervix,
and is about 8-10 cm in length. The lower segment is prepared for
distention and dilatation.
• The muscle content reduces from the fundus to the cervix, where
it is thinner.

Formation of upper and lower uterine
segments cont…
• When the labour begins, the retracted longitudinal fibres in the
upper segment pull on the lower segment causing it to stretch; this
is aided by the descending presenting part.

The Retraction ring
• The ridge forms between the upper and lower uterine segments;
this is known as the retraction ring.
• The physiological ring gradually rises as the upper uterine
segment contracts and retracts and the lower uterine segment
thins out to accommodate the descending fetus. Once the cervix
is fully dilated and the fetus can leave the uterus, the retraction
ring rises no further.

Cervical effacement
• Effacement refers to the inclusion of the cervical canal into the lower
uterine segment.
• It takes place from above downward; that is, the muscle fibres
surrounding the internal os are drawn upwards by the retracted upper
segment and the cervix merges into the lower uterine segment.
• The cervical canal widens at the level of the internal os, where the
condition of the external os remains unchanged.

Cervical dilatation
• Dilatation of cervix is the process of enlargement of the os uteri
from a tightly closed aperture to an opening large enough to
permit the passage of the fetal head. Dilatation is measured in
centimeters and full dilatation at term equates to about 10 cm.

Show
• As a result of the dilatation of the cervix, the operculum, which formed
the cervical plug during pregnancy, is lost. The woman may see a blood
stained mucoid discharge a few hours before, or within a few hours
after, labour starts.
• The blood comes from the ruptured capillaries in the parietal decidua
where the chorion has become detached from the dilating cervix.

Formation of fore water
• As the lower uterine segment forms and stretches, the chorion becomes
detached from it and the increased intrauterine pressure causes its
loosened part of the sac of fluid to bulge downwards into the internal os,
to the depth of 6-12 mm.
• The well flexes head fits snugly into the cervix and cuts off the fluid in
front of the head from that which surrounds the body.
• The former is known as ‗forewaters‘ and the latter the ‗hindwaters‘.

General Fluid Pressure
• While the membranes remain intact, the pressure of the uterine
contractions is exerted on the fluid and, as fluid is not
compressible, the pressure is equalized throughout the uterus
and the fetal body; it is known as ‗general fluid pressure‘.

•Physiology of second stage of
labour

Uterine action
• Contractions become stronger and longer but may be less frequent, allowing
both mother and fetus regular recovery periods.
• The membrane often rupture spontaneously towards the end of the first stage
or during transition to the second stage.
• The consequent drainage of liquor allows the hard, round fetal head to be
directly applied to the vaginal tissues. This pressure aids distension.
• Fetal axis pressure increases flexion of the head, which results in smaller
presenting diameters, more rapid progress and less trauma to both mother and
fetus.

Uterine action continued
• The contraction becomes expulsive as the fetus descends further into
the vagina.
• Pressure from the presenting part stimulates nerve receptors in the
pelvic floor ―this is termed the ‗Ferguson reflex‘ and the woman
experiences the need to push.
• The mother‘s response is to employ her secondary powers of
expulsion by contracting her abdominal muscles and diaphragm.

Soft tissue displacement
• As the hard fetal head descends, the soft tissues of the pelvis
becomes displaced.
• Anteriorly-Bladder
• Posteriorly- Rectum
• The levator ani muscles
• Perineal body

Soft tissue displacement
• The fetal head becomes visible at the vulva, advancing each contraction
and receding between contractions until crowning takes place.
• The head is then born.
• The shoulders and body follow with next contraction, accompanied by
gush of amniotic fluid and sometimes of blood.
• The second stage culminates in the birth of the baby.

Presumptive signs of second stage of labour
• Expulsive uterine contraction
• Rupture of forewaters
• Dilatation and gaping of the anus
• Appearance of the rhomboid of Michaelas
• Show
• Appearance of presenting part

LIE
• It refers to the relationship of the long axis of the fetus to the long
axis of the centralized uterus or maternal spine.

Presenting part
• Is defined as the part of the presentation which overlies the internal
os and is felt by the examining finger through the cervical opening.

Attitude
• The relation of the different parts of the fetus to one another is called attitude of the
fetus. The universal attitude is that of flexion.

Denominator
• It is an arbitrary bony fixed point on the presenting part which comes in
relation with the various quadrants of the maternal pelvis.
• The following are denominators of the different presentations- occiput in
vertex, mentum in face, frontal eminence in brow, sacrum in breech and
acromion in shoulder

MECHANISM OF LABOR
• As the fetus descends, soft tissue and bony structures exert
pressures which lead to descent through the birth canal by a series
of movements. Collectively, these movements are called the
mechanism of labour.

Principles common to all mechanism
• Descent takes place
• Whichever part leads and first meets the resistance of the pelvic floor
will rotate forwards until it comes under the symphysis pubis.
• Whatever emerges from the pelvis will pivot around the pubic bone.

Six considerations for normal labour
• The lie is longitudinal
• The presentation is cephalic
• The position is right or left occipitoanterior
• The attitude is one of the good flexion
• The denominator is the occiput
• The presenting part is the posterior part of the anterior parietal bone.

Cardinal movement
• Engagement
• Descent
• Flexion
• Internal rotation of the head
• Extension of the head
• External Rotation/Restitution
• Internal rotation of the shoulders
• Lateral flexion

Engagement
• The mechanism by which the biparietal diameter—the greatest
transverse diameter in an occiput presentation—passes through the
pelvic inlet is designated engagement.

Descent
• This movement is the first requisite for birth of the newborn. Different
in nulliparous and multigravid women.
• Throughout the first stage of labour the contraction and retraction of
the uterine muscles allow less room in the uterus, exerting pressure on
the fetus to descend.
• Following rupture of the forewaters and the exertion of maternal
effort, progress speed up.

Flexion
• As soon as the descending head meets resistance, whether from the
cervix, walls of the pelvis, or pelvic floor, then flexion of the head
normally results.
• Suboccipitobregmatic diameter (9.5 cm) is substituted for the longer
occipitofrontal diameter (10 cm). The occiput becomes the leading
part.

Internal rotation of the head
• During contraction, the leading part is pushed downwards onto the pelvic
floor. The resistance of this muscular diaphragm brings about rotation.
• Occiput gradually moves toward the symphysis pubis anteriorly.
• Whichever part of the fetus meets the lateral half of this slope will be
directed forwards and towards the center in a well flexed vertex presentation
the occiput leads, and rotates anteriorly through 1/8th of a circle when it
meets the pelvic floor.
• This causes a slight twist in the neck as the head is no longer in direct
alignment with the shoulders.

Internal rotation
• The anteroposterior diameter of the head now lies in the widest
(anteroposterior) diameter of the pelvic outlet.
• The occiput slips beneath the sub-pubic arch and crowning occurs when
the head no longer recedes between contraction and the widest
transverse diameter is born.
• Of flexion is maintained, the suboccipito bregmatic diameter, usually
distends the vaginal orifice.

Extension of the head
• Once crowning has occurred the fetal head can extend, pivoting
on the suboccipital region around the pubic bone.
• This releases the sinciput, face and chin, which sweep the
perineum and are born by a movement of extension.

Restitution
• The twist in the neck of the fetus that resulted from internal
rotation is now corrected by a slight untwisting movement.
• The occiput moves one-eight of a circle towards the side from
which it started

Internal rotation of the shoulders
• The shoulders undergo a similar rotation to that of the head to lie in the
widest diameter of the pelvic outlet, namely anteroposterior.
• The anterior shoulder is first to reach the levator ani muscle and is
therefore rotates anteriorly to lie under the symhysis pubis.
• It occurs in the same direction as restitution, and the occiput of the
fetal head now lies laterally.

Lateral flexion
• Almost immediately after external rotation, the anterior shoulder
slips beneath the subpubic arch and the posterior shoulder passes
over the perineum.
• After delivery of the shoulders, the rest of the body is born by
lateral flexion as the spine bends sideways through the curved birth
canal.

Physiology of third stage of labour
• Third stage of labour
• This stage begins immediately after delivery of the fetus and involves
the separation and expulsion of the placenta and membranes,
involving the separation, descent and expulsion of placenta and
membranes and control of hemorrhage from the placenta site.
• The third stage usually lasts between 5 and 15 minutes, but any
period upto 30 minutes is considered to be within normal limits.

Mechanical factors
• As the neonate is born, the uterus spontaneously contracts around its
diminishing contents.
• The uterine fundus now lies just below the level of the umbilicus.
• Thus, by the beginning of the third stage, the placental site has already
diminished in area by about 75%.
• As this occurs the placenta becomes compressed and the blood in the
intervillous spaces is forced back into the spongy layer of the decidua
basalis.

Mechanical factors
• Retraction of the oblique uterine muscle fibres exerts pressure on the blood
vessels so that blood does not drain back into the maternal system.
• The vessels during this process become tense and congested. With the next
contraction the distended veins burst and small amount of blood seeps in
between the thin septa of the spongy layer and the placental surface,
stripping it from its attachment.
• As the surface area of the placental attachment reduces, the relatively non
elastic placenta begins to detach from the uterine wall.

Schultze method
• Separation usually begins centrally so that retroplacental clot is
formed.
• Increased weight helps to strip the adherent lateral borders and peel
the membranes off the uterine wall so that the clot thus formed
becomes enclosed in a membranous bag as the placenta descends,
fetal surface first.
• This process of separation is associated with more shearing of both
placenta and membranes and less fluid blood loss.

Matthews Duncan method
• The placenta may begin to separate unevenly at one of its lateral
borders.
• The blood escapes so that separation is unaided by the formation of
a retroplacental clot.
• The placenta descends, slipping sideways, maternal surface first.
• This process takes longer and is associated with ragged, incomplete
expulsion of the membranes and a higher fluid blood loss.

Separation of fetal membranes
• The great decrease in uterine cavity surface area simultaneously throws
the fetal membranes—the amnion, chorion and the parietal decidua—
into innumerable folds.
• Membranes usually remain in situ until placental separation is nearly
completed.
• These are then peeled off the uterine wall, partly by further contraction
of the myometrium and partly by traction that is exerted by the
separated placenta, which lies in the lower segment or upper vagina.

Homeostasis
• Retraction of the oblique uterine muscle fibres in the upper
uterine segment through which the tortuous blood vessels
interwine- the resultant thickening of the muscles exert pressure
on the torn vessels, acting as clamps, so securing a ligature
action.

Homeostasis cont…
• Vigorous uterine contraction following separation-this brings the
walls into apposition so that further pressure is exerted on the
placental site.
• There is transitory activation of the coagulation and fibrinolytic
systems during, and immediately following placental separation

Recommend further readings
• Maternity and women’s health care 11th Edition,2016.
• Gisin, Poat, Fierz, & Frei, 2013; Melchart, Jack, &
Kashanian, 2011).
• American Academy of Pediatrics [AAP] & American
College of Obstetricians and Gynecologists [ACOG], 2012.

NONPHARMACOLOGIC PAIN
MANAGEMENT IN LABOR

Introduction
• Relieving or reducing pain is important
• Techniques she usually finds helpful in relieving
stress(Pain) and enhancing relaxation (e.g., music,
meditation, massage, warm baths) may be very effective
as components of a plan for managing labor pain.

Relaxation and Breathing Techniques
Focusing and Relaxation Techniques
• By reducing tension and stress, focusing and relaxation
techniques allow a woman in labor to rest and conserve
energy for the task of giving birth.
• Attention-focusing and distraction techniques are forms of
care that are effective to some degree in relieving labor pain
(Jones et al., 2012).
• Some women bring a favorite object such as a photograph or
stuffed animal to the labor room and focus their attention on
this object during contractions. Others choose to fix their
attention on some object in the labor room. As the contraction
begins, they focus on their chosen object and perform a
breathing technique to reduce their perception of pain.

Imagery
• With imagery the woman focuses her attention on a
pleasant scene, a place where she feels relaxed, or an
activity she enjoys. She can imagine walking through a
restful garden or breathing in light, energy, and a healing
color and breathing out worries and tension. Choosing
the subject for the imagery and practicing the technique
during pregnancy enhance effectiveness during labor

Breathing Techniques
• An undesirable reaction to this type of breathing is
hyperventilation.
• The woman and her support person must be aware of
and watch for symptoms of the resultant respiratory
alkalosis: lightheadedness, dizziness, tingling of the
fingers, or circumoral numbness.
• Having the woman breathe into a paper bag held tightly
around her mouth and nose may eliminate respiratory
alkalosis. This enables her to rebreathe carbon dioxide
and replace the bicarbonate ions.

• The woman also can breathe into her cupped hands if no
bag is available. Maintaining a breathing rate that is no
more than twice the normal rate will lessen chances of
hyperventilation. The partner can help the woman
maintain her breathing rate with visual, tactile, or
auditory cues.

1.Effleurage and Counterpressure
Effleurage (light massage): is light stroking, usually of
the abdomen, in rhythm with breathing during
contractions.
It is used to distract the woman from contraction pain.
As labor progresses, hyperesthesia (hypersensitivity to
touch) may make effleurage uncomfortable and thus less
effective.

2.Counterpressure
• Counterpressure is steady pressure applied by a support
person to the sacral area with a firm object (e.g., tennis
ball) or the fist or heel of the hand.
• . Pressure can also be applied to both hips (double hip
squeeze) or to the knees (Burke, 2014).
• It is especially helpful for back pain caused by pressure of
the occiput against spinal nerves when the fetal head is
in a posterior position.

3.Touch and Massage
• Touch can be as simple as holding the woman’s hand,
stroking her body, and embracing her.
• Head, hand, back, and foot massage may be very effective
in reducing tension and enhancing comfort.
• Combining massage with aromatherapy oil or lotion
enhances relaxation both during and between
contractions.

4.Application of Heat and Cold
• Warmed blankets, warm compresses, heated rice bags, a
warm bath or shower, or a moist heating pad can
enhance relaxation and reduce pain during labor.
• Heat relieves muscle ischemia and increases blood flow to
the area of discomfort.
• Heat application is effective for back pain caused by a
posterior position or general backache from fatigue.

• Cold application such as cold cloths, frozen gel packs, or
ice packs applied to the back, the chest, or the face
during labor may be effective in increasing comfort when
the woman feels warm.
• Cooling relieves pain by reducing the muscle temperature
and relieving muscle spasms (Burke, 2014).
• One or two layers of cloth should be placed between the
skin and a hot or cold pack to prevent damage to the
underlying integument.

5. Acupressure and Acupuncture
• can be used in pregnancy, in labor, and postpartum to
relieve pain and other discomforts.
• Pressure, heat, or cold is applied to acupuncture points
called tsubos.
• Acupressure points are found on the neck, the shoulders,
the wrists, the lower back including sacral points, the hips,
the area below the kneecaps, the ankles, the nails on the
small toes, and the soles of the feet.

• These points have an increased density of neuroreceptors
and increased electrical conductivity.
• Acupressure is said to promote circulation of blood, the
harmony of yin and yang, and the secretion of
neurotransmitters, thus maintaining normal body
functions and enhancing well-being (Gisin, Poat, Fierz, &
Frei, 2013; Melchart, Jack, & Kashanian, 2011).

• Acupuncture is the insertion of fine needles into specific
areas of the body to restore the flow of qi (energy) and to
decrease pain, which is thought to obstruct the flow of
energy.
• Effectiveness may be attributed to the alteration of
chemical neurotransmitter levels in the body or to the
release of endorphins as a result of hypothalamic
activation. A trained certified therapist should do
acupuncture.

6.Transcutaneous Electrical Nerve Stimulation
(TENS)
• Involves the placing of two pairs of flat electrodes on
either side of the woman’s thoracic and sacral spine (Fig.
17-5)
• These electrodes provide continuous low-intensity
electrical impulses or stimuli from a battery-operated
device. During a contraction the woman increases the
stimulation from low to high intensity by turning control
knobs on the device. High intensity should be maintained
for at least 1 minute to facilitate release of endorphin

7. Water Therapy (Hydrotherapy)
• Bathing, showering, and jet hydrotherapy (whirlpool
baths) with warm water (e.g., at or below body
temperature) are non pharmacologic measures that can
promote comfort and relaxation during labor (Fig. 17-6).
The warm water stimulates the release of endorphins,
relaxes fibers to close the gate on pain, promotes better
circulation and oxygenation, and helps soften the
perineal tissues

• Most women find immersion in water to be soothing,
relaxing, and comforting. While immersed, they may find
it easier to let go and allow labor to take its course
(Gilbert, 2011).

8.Intradermal Water Block
• An intradermal water block involves the injection of small
amounts of sterile water (e.g., 0.05 to 0.1 ml) by using a
fine needle (e.g., 25 gauge) into four locations on the
lower back to relieve low back pain.
• An increase in the level of endogenous opioids
(endorphins) produced by the injections

9. Aromatherapy
• Aromatherapy uses oils distilled from plants, flowers,
herbs, and trees to promote health and to treat and
balance the mind, body, and spirit.
• These essential oils are highly concentrated, complex
essences, and are mixed with lotions or creams before
they are applied to the skin (e.g., for a back massage).
• Oils can tone the uterus, encourage contractions, reduce
pain, relieve tension, diminish fear and anxiety, and
enhance the feeling of well-being.

10. Music
• Music, recorded or live, can provide a distraction,
enhance relaxation, and lift spirits during labor, thereby
reducing the woman’s level of stress, anxiety, and
perception of pain.
• Music can help to create a more relaxed atmosphere in
the birth room, leading to a more relaxed approach by
health care providers (Burke, 2014).

11.Hypnosis
• Hypnosis is a form of deep relaxation, similar to
daydreaming or meditation (see www.hypnobirthing.com).
While under hypnosis women are in a state of focused
concentration and the subconscious mind can be more
easily accessed.

PHARMACOLOGIC PAIN MANAGEMENT
• Pharmacologic measures, especially epidural analgesia, to
relieve their pain during labor and birth.
Sedatives
Sedatives relieve anxiety and induce sleep.
Metoclopramide (Reglan), an antiemetic, has been found
to effectively potentiate the effects of analgesics.
Therefore, its use is recommended, rather than
promethazine (Hawkins & Bucklin, 2012).

• Benzodiazepines (e.g., diazepam [Valium], lorazepam
[Ativan]), when given with an opioid analgesic, seem to
enhance pain relief and reduce nausea and vomiting.
Because benzodiazepines cause significant maternal
amnesia, however, their use should be avoided during
labor.

Analgesia and Anesthesia
Anesthesia encompasses analgesia, amnesia, relaxation,
and reflex activity.
The term analgesia refers to the alleviation of the
sensation of pain or the raising of the threshold for pain
perception without loss of consciousness.
The type of analgesic or anesthetic chosen is determined
in part by the stage of labor of the woman and by the
method of birth planned

Pharmacologic Control of Discomfort by Stage
of Labor and Method of Birth
First Stage
 Opioid agonist analgesics(Meperidine Hydrochloride (Demerol)
Opioid agonist-antagonist analgesics
 Epidural (block) analgesia
 Combined spinal-epidural (CSE) analgesia
 Nitrous oxide

Second Stage
Nerve block analgesia and anesthesia
Local infiltration anesthesia
Pudendal block
Spinal (block) anesthesia
Epidural (block) analgesia
CSE analgesia
Nitrous oxide

Vaginal Birth
 Local infiltration anesthesia
 Pudendal block
Epidural (block) analgesia and anesthesia
Spinal (block) anesthesia
CSE analgesia and anesthesia
Nitrous oxide

Cesarean Birth
Spinal (block) anesthesia
Epidural (block) anesthesia
General anesthesia

Nerve Block Analgesia and Anesthesia
• A variety of local anesthetic agents are used in obstetrics
to produce regional analgesia (some pain relief and
motor block) and regional anesthesia (complete pain
relief and motor block).
• Most of these agents are related chemically to cocaine
and end with the suffix -Caine.
• Examples of common agents given are bupivacaine
(Marcaine), chloroprocaine (Nesacaine), lidocaine
(Xylocaine), ropivacaine (Naropin), and mepivacaine
(Carbocaine).

• Rarely, people are sensitive (allergic) to one or more local
anesthetics. Such a reaction may include respiratory
depression, hypotension, and other serious adverse
effects. Epinephrine, antihistamines, oxygen, and
supportive measures should reverse these effects.

Local Perineal Infiltration Anesthesia.
• Local perineal infiltration anesthesia may be used
when an episiotomy is to be performed or when
lacerations must be sutured after birth in a woman who
does not have regional anesthesia.
• Rapid anesthesia is produced by injecting approximately
10 to 20 ml of 1% lidocaine or 2% chloroprocaine into
the skin and then subcutaneously into the region to be
anesthetized.

Pudendal Nerve Block.
• Pudendal nerve block, administered late in the second
stage of labor, is useful if an episiotomy is to be
performed or if forceps or a vacuum extractor is to be
used to facilitate birth. It can also be administered during
the third stage of labor if an episiotomy or lacerations
must be repaired.
• Although a pudendal nerve block does not relieve the
pain from uterine contractions, it does relieve pain in the
lower vagina, the vulva, and the perineum .
• A pudendal nerve block should be administered 10 to 20
minutes before perineal anesthesia is needed

N.B
Pudendal block does not change maternal hemodynamic or
respiratory functions, vital signs, or the FHR. However, the
bearing-down reflex is lessened or lost completely.
Spinal Anesthesia
In spinal anesthesia (block), a solution containing a local
anesthetic alone or in combination with an opioid agonist
analgesic is injected through the third, fourth, or fifth
lumbar interspace into the subarachnoid space.

Epidural Anesthesia or Analgesia
(Block).
• achieved by injecting a suitable local anesthetic
agent(e.g., bupivacaine, ropivacaine), an opioid analgesic
(e.g. Fentanyl, sufentanil), or both into the
epidural(peridural) space.
• Injection is made between the fourth and fifth lumbar
vertebrae for a lumbar epidural block.
• Pidural anesthesia and analgesia is currently the most
effective pharmacologic pain relief method for labor

Advantages of an epidural block are numerous:
The woman remains alert and is more comfortable and
able to participate.
 Good relaxation is achieved.
 Airway reflexes remain intact.
Only partial motor paralysis develops.
Gastric emptying is not delayed.
 Blood loss is not excessive.
Disadvantages of epidural block: orthostatic hypotension
and dizziness, sedation, and weakness of the legs.

Side Effects of Epidural and Spinal Anesthesia
Hypotension
Local anesthetic toxicity
Lightheadedness
Dizziness
Tinnitus (ringing in the ears)
Metallic taste
Numbness of the tongue and mouth
Bizarre behavior
Slurred speech
Convulsions
Loss of consciousness

Fever
Urinary retention
Pruritus (itching)
Limited movement
Longer second stage labor
Increased use of oxytocin
Increased likelihood of forceps- or vacuum-assisted birth
High or total spinal anesthesia

Fever
Urinary retention
Pruritus (itching)
Limited movement
Longer second stage labor
 Increased use of oxytocin
Increased likelihood of forceps- or vacuum-assisted birth
 High or total spinal anesthesia

Recommended further readings
• Maternity and women’s health care 11th Edition,2016.
• Gisin, Poat, Fierz, & Frei, 2013; Melchart, Jack, &
Kashanian, 2011).
• American Academy of Pediatrics [AAP] & American
College of Obstetricians and Gynecologists [ACOG], 2012.

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